Doc Martin’s medical case notes

January 18, 2015

This week’s blog is a departure from what I normally do. There is not one theme to this week’s post. Rather I will be looking at a couple of stories relating to medicine have heard a couple of fascinating podcasts recently. It is from these that I got the ideas for this week’s post.

The first story comes from the excellent Freakonomics podcast. It was about how the CIA organised fake vaccination drive to get Osama bin Laden’s family DNA. Dr Shakil Afridi was recruited by the CIA to do a number of vaccination drives in Pakistan. Afridi was in the pay of the CIA, and in 2011 they asked him for help in capturing America’s number one terrorist target Osama Bin Laden. The means was a hepatitis B vaccination campaign in Abbottabad. They wanted him to gain access to houses in an area where they thought the terrorist might be present. Indeed they had one particular house in mind and their goal was to obtain DNA from the fugitive al-Qaida leader’s family.

The doctor went to Abbottabad in March, saying he had procured funds to give free vaccinations for hepatitis B. Bypassing the management of the Abbottabad health services; he paid generous sums to low-ranking local government health workers, who took part in the operation without knowing about the connection to Bin Laden. Health visitors in the area were among the few people who had gained access to the Bin Laden compound in the past, administering polio drops to some of the children. Afridi had posters for the vaccination programme put up around Abbottabad, featuring a vaccine made by Amson, a medicine manufacturer based on the outskirts of Islamabad.

The CIA were not able to confirm that Bin Laden was hiding there. We now know that he had been living there and on May 2nd 2011 he was killed by U.S. forces. The Pakistani government, who had been kept in the dark about the operation, was furious and went in search of any locals who had collaborated with the Americans. The CIA gave Afridi money and recommended that he escape to Afghanistan. The doctor felt that he was safe and decided to stay. However, he was picked up by the notorious Pakistani secret services, the ISI. The CIA director at this time, Leon Panetta demanded that Afridi be released. However, as of 2014, Afridi is still in prison.

I have no doubt about the collusion between the Pakistani government and terrorists. Moreover, I can understand the desire to get Bin Laden. Nevertheless the decision to use a vaccination campaign as a cover for an intelligence-gathering operation was a deeply flawed one. Everyone involved in vaccine campaigns was under suspicion. Save the Children were forced to close down their anti-polio vaccination campaign in Pakistan. The Pakistani Taliban banned polio vaccinations entirely. And they began to target health workers in the country. 65 health workers administering polio vaccines in Pakistan have been murdered since the end of 2012. Consequently polio is on the rise in this troubled country. In 2014 there were 214 cases of the disease, the highest figure in 15 years. All of these unintended consequences were highly foreseeable. At the end of the Freakonomics piece they make a nice point. In the US there are, as in the UK, a lot of people paranoid about vaccines. Now the CIA has exported the problem. Couldn’t they have sent a fake cable TV guy, or an encyclopaedia salesman?

One of the most fascinating cases in medical history must be that of Mary Mallon, better known as Typhoid Mary. Born in 1869 in Cookstown, County Tyrone, Ireland, Mary emigrated from Ireland to the United States at the age of 15. She became the first

first documented case of an asymptomatic carrier of the pathogen associated with typhoid fever United States. In her capacity as cook she worked for a number of affluent families, many of whose members would subsequently be afflicted with typhoid.

One family hired a sanitary engineer named George Soper to investigate. He believed Mallon might be the source of the outbreak and set out to find her. When he finally approached Mallon about her possible role in spreading typhoid, she refused to provide him with blood, urine and stool samples. Put yourself in Mary’s shoes. You feel perfectly healthy and then one day a man accuses you of infecting people with this illness and making strange demands. You probably wouldn’t welcome him into your home. Indeed, she chased the investigator out of the building wielding a serving fork.

Soper would need to find alternative evidence, compiling a five-year history of Mallon’s employment. Of the eight families for whom Mallon had worked as a cook, members of seven claimed to have contracted typhoid fever. The health authorities declared her to be a carrier and under sections 1169 and 1170 of the Greater New York Charter, Mallon was held in isolation for three years at a clinic located on North Brother Island. Mary Mallon never believed that she was sick or dangerous. Here is a letter she wrote while she was “imprisoned” on the island:

“When I first came here I was so nervous and almost prostrated with grief and trouble. My eyes began to twitch, and the left eyelid became paralyzed and would not move. It remained in that condition for six months. There was an eye specialist [who] visited the island three and four times a week. He was never asked to visit me. I did not even get a cover for my eye. I had to hold my hand on it whilst going about and at night tie a bandage on it.

… I have been in fact a peep show for everybody. Even the interns had to come to see me and ask about the facts already known to the whole wide world. The tuberculosis men would say “There she is, the kidnapped woman.” Dr. Park has had me illustrated in Chicago. I wonder how the said Dr. William H. Park would like to be insulted and put in the Journal and call him or his wife Typhoid William Park.”

Eventually, it was determined that disease carriers should no longer be kept in isolation and that Mallon could be freed if she agreed to stop working as a cook and take reasonable steps to prevent transmitting typhoid to others. After being released Mallon found employment as a laundress. Unfortunately this paid less than cooking and after changing her name, she soon returned to her old profession. For the next five years, she worked in a number of kitchens in restaurants inns and a sanatorium. The inevitable result was further cases. It was only after another major outbreak at a New York maternity hospital. 25 people were infected and two died. I did feel some sympathy for her the first time she was quarantined, but now she was wilfully putting people’s lives at risk. Mallon was arrested and spent the rest of her life in quarantine back on the island. On November 11, 1938, she died of pneumonia at age 69. An autopsy found evidence of live typhoid bacteria in her gallbladder. We do need to put the cased in context. At the time Mary was being quarantined, there were hundreds of men who were also asymptomatic carriers. Indeed many of these worked in catering. But Mary was the only one on the island. She was undoubtedly a scapegoat. The authorities had to seen to be doing something.

I had head about this case before but I was reminded about by Patient Zero, a programme in the excellent Radiolab series.  In medical science patient zero refers to the initial patient in the population of an epidemiological investigation. The etymology is interesting it was originally patient used for patient O (standing for out of California), referring to Gaëtan Dugas, a superspreader of AIDS. The letter O was later misinterpreted as a zero. In fact, Mr. Dugas was not patient zero. According to the programme, the origin could be in 1908 from an African man who had eaten an infected monkey. Who knows if this true? And then we would to know who chimp zero was.

With the recent outbreaks of Ebola, plagues are very much back in the news. Before the virus wreaked havoc in West Africa and spread around the planet, Ebola struck a toddler named Emile Ouamouno, who is said to be the first person to contract the disease in the current outbreak almost a year ago. He is patient Zero. What is worrying is how far the disease has spread this time. Ebola has been around since the 1970s, but previous outbreaks have tended to be confined to small areas. I remember an interview with Desmond Morris before the Cold War was over. He said that he was far more worried about some kind of plague than a nuclear Armageddon. Let’s hope that neither of these catastrophes befalls us.

House MD – 177 Episodes in 7 minutes

January 18, 2015

It’s been just over two years since my favourite TV doctor abandoned our screens. Here is a compilation from YouTube.