Mark Pendergrast

"Pendergrast is an affable guide on a wondrously labyrinthine tour. He explains complex phenomena with remarkable clarity, in a relaxed tone, and with a sense of humor." —Philadelphia Inquirer
"Mark Pendergrast, the ultimate free-lance journalist with an eclectic mind, writes about deceptively narrow topics that in fact have figured in world history for millennia." —Atlanta Journal-Constitution
Mark Pendergrast speaks at universities, schools of public health, business conferences, management seminars, and psychological meetings. His presentations are tailored to his audience but are always entertaining, thought-provoking, and challenging. Contact him to arrange an event. Click here for links to speeches, TV, and radio appearances. Click here for comments on his presentations.

Not a reliable blogger. I apologize for not having kept up with my blog essays. I’ve been too busy writing other books! But if readers would like to be in touch to encourage me to write about a particular issue related to what I’ve written, feel free, and I might rise to the challenge. Meanwhile, I hope you enjoy my older blogs below. –Mark Pendergrast

The Movie “Contagion”: Lessons We Can Learn

November 4th, 2011

As I watched the blockbuster bio-thriller Contagion, I was struck by how realistic it was in many ways. That isn’t surprising, since many epidemiologists, including those from the Centers for Disease Control and Prevention (CDC) in Atlanta, served as advisors. The film was based on a simple premise. What if a new, deadly virus that kills one out of four people it infects were also easily transmissible from human to human?

I knew more about the subject than most people in the audience, because I spent five years researching and writing Inside the Outbreaks, a history of the Epidemic Intelligence Service (EIS). EIS officers have served as the front-line CDC disease detectives since the organization was founded in 1951 in the midst of Cold War fears of bioterrorism. In the film, EIS officer Erin Mears, played by Kate Winslet, is sent to investigate the epidemic in Minneapolis, where she contracts the disease herself and dies a few days later. In reality, only one EIS officer has died in the line of duty, and that was when a terrorist blew up an airplane during the Biafran War in Nigeria. But there have been several close calls, as EIS officers have caught the diseases they were investigating.

Winslet’s portrayal of an EIS officer is essentially accurate, though she would not have been sent alone to handle such a major outbreak. More than half of EIS officers are female nowadays. They usually enter the two-year program in their early thirties, often with a masters in public health. Most are, like the Erin Mears character, compassionate, driven, idealistic, and courageous.

There are four main lessons we can glean from the film.

Lesson 1: We are an invasive species. At the film’s end, a bulldozer dislodges infected fruit bats (the source of the pandemic virus) from tropical trees. It is true that as people invade and disturb habitats, we are more likely to encounter new pathogens. That’s probably how the AIDS epidemic began, with transmission of a simian virus to humans. We are, after all, animals, living in a complex web of other living beings, so it isn’t surprising that zoonoses (diseases that spread from other animals to humans) are so common. And as humans proliferate — there will probably be 10 billion of us swarming the earth by 2050 — we offer a tempting target for infectious diseases.

Lesson 2: Bioterrorism is overrated. In the movie, officials of the Department of Homeland Security tell CDC epidemiologist Ellis Cheever that they suspect the new virus is a bioterror weapon intended to disrupt the Thanksgiving weekend and spread more quickly as people travel to be with their families. Cheever informs them, “Someone doesn’t have to weaponize the bird flu — the birds are already doing that.” Indeed, fears of bioterrorism, which helped to create the Epidemic Intelligence Service in the first place, are overblown. Yes, bioterrorists could spread deadly pathogens such as anthrax, but mad scientists are less likely to create a deadly viral mutation that is easily transmissible between humans. Nature is far better at such achievements. The next pandemic will not be man-made, at least not intentionally.

Lesson 3: People panic. The film is at its strongest in showing how people are likely to react during a pandemic when insufficient drugs or vaccines are available. How will they be distributed? Who decides who will get them first? What kind of looting and violence is likely to ensue? Contagion offers a chillingly plausible scenario. We are woefully unprepared for such panic-driven behavior.

Lesson 4: Rumors on the internet can kill. In Contagion, blogger Alan Krumwiede, played by Jude Law, convinces 12 million frightened internet followers that the government can’t be trusted. The CDC is lying, he writes. Their new vaccine is useless or even harmful. Instead, Krumwiede promotes a homeopathic remedy made from the forsythia plant. He pretends that he has contracted the virus and that he cured himself, thereby making himself wealthy, even as he misleads the public.

These are important lessons, yet Contagion also falls short in a number of ways. While it is far better than most Hollywood biopics, it focuses more on the social consequences of a worst-case scenario than on the science.

For one thing, it doesn’t teach us much about how epidemiologists work, probably because such logical, seemingly plodding methodology doesn’t suit the media. I have some painful personal experience in this regard. When Inside the Outbreaks was published in 2010, it was optioned for a television series, and an experienced Hollywood writer was hired to script a pilot show, in which a platoon of soldiers in basic training dropped like flies. It turned out to result from the intentional poisoning of beef jerky in a vending machine at a bar. The EIS officer in the script figured it out purely by serendipity.

I objected: “What is startlingly missing from the script is the EIS officer asking what they ate. This is very likely to be a foodborne outbreak of some sort. So she is looking for a common food. She should be doing a case-control study, asking the sick men what they ate and where they were, as well as soldiers who didn’t get sick but were as similar as possible in all other ways (i.e., who went on the same march, were in the same barracks, etc). Then when the case-control study pointed to the bar, but not to a particular food, she could have her Eureka moment, seeing the vending machine, finding out what was in it, and going back and redoing the case-control study with the right questions about whether they ate anything from the vending machine, and what it was. One of the vital points of epi is not only to use the right methodologies but to ask the right questions.”
The script writer responded: “It is to be assumed she asked what they ate, since she’s also asking deeply idiosyncratic and minute questions. But honestly, ‘What did you eat?’ is very boring and had to be avoided.” The pilot show was never made. Although I wanted my book to be the basis of a TV show, in a way I was relieved.

To his credit, Scott Burns, who wrote the screenplay for Contagion, included some explanation of how the virus was transmitted (by breathing droplets or by touching the same objects as those infected), but the movie did not focus on epidemiology, the methodology of disease detectives. Only at the end of the film do viewers get a quick glimpse of how the virus was transmitted, from fruit bats to pigs to people. Somewhere in the middle of the movie, there is a glimpse of the phrase “Nipah virus” on a CDC document, but otherwise moviegoers would have no idea that this is in fact the real-life virus on which the fictional MEV-1 virus was based. And the film offers no clue as to how anyone figured out its origin or transmission route.

In Inside the Outbreaks, I wrote about the first terrifying Nipah virus epidemic that began in 1998 in Malaysia with pigs who began to twitch, cough, bite at their bars, and lose their footing. Their urine turned bloody. Then they collapsed and died. Pig farmers developed fevers, becoming lethargic and disoriented. Some fell into a coma and died. A desperate farmer advertised on the Internet, selling sick swine on the cheap to farms 50 miles away, where over 200 farmers contracted the disease. When CDC labs found a new virus in spinal fluid from patients, they named it Nipah virus, after a village where the fire sale pigs had been sent, and it was designated a Biosafety Level 4 pathogen, equivalent to Ebola.

“People left their farms, their pigs, everything they owned. Whole villages just fled,” recalled EIS officer Mike Bunning. The outbreak was finally brought under control at the end of May 1999, by which time a million pigs had been sacrificed and 108 out of 280 identified human cases had died. The EIS case-control study indicated that direct contact with sick pigs was a primary risk factor.

The EIS officers suspected that Malaysian bats might serve as the reservoir for Nipah virus and helped to capture a variety of them, including the giant fruit bats known as flying foxes. Sure enough, Nipah antibodies were eventually found in the flying foxes. A dead bat or its feces might have fallen into a feed lot, or bats may have dropped contaminated, partially eaten fruit into pig pens.

In the ensuing years, Nipah virus jumped to Bangladesh and neighboring parts of India, often killing 75 percent or more of its victims, but there was no evidence of person-to-person transmission — it always required contact with a pig. Mike Bunning thought the actual mortality in Malaysia may have been near that figure, since many Chinese laborers who died were buried secretly to avoid the slaughter of their pigs. “If Nipah had been communicable between humans,” Bunning observed, “The world as we know it today would be different.”

I don’t know if anyone involved in Contagion read my book, but Bunning’s final chilling comment summarizes the basic premise of the film. Rather than a 75 percent mortality rate, the movie assumes a 25 percent rate, but that is still appallingly high. The film shows how quickly such a contagion could spread in the jet age.

Yet this doomsday scenario is unlikely to occur, though it is still possible. The most horrific viruses, such as Ebola or Nipah, tend to be dead ends in human beings. They evolved in order to take advantage of other hosts, such as fruit bats. It is a freak of nature that humans happen to succumb so quickly and horribly. If these viruses mutate in order to become easily transmissible between humans, they are also likely to become far less lethal. Why? Darwin told us. Evolution favors survival, and a virus that kills off too many hosts will not survive for long. Still, a lot of people could die before the virus fully adapted to humans.

“Successful” pathogens don’t kill the majority of their victims. They cause communicable diseases such as polio, diphtheria, tetanus, pertussis, influenza, yellow fever, measles, rubella, rabies, hepatitis, meningitis…. the list goes on. All of these bacteria and viruses have something else in common. All have vaccines that can save lives. That is why, to me, the most upsetting part of Contagion was not the virus itself, but the con artist Krumwiede who profits by scaring people away from an effective vaccine.

We don’t need a fictional pandemic to demonstrate this kind of scenario. It has been happening for years, as rumors that vaccines cause rather than cure diseases are rampant on the Internet. Although all vaccines cause adverse reactions in some people, the truth is that they have prevented millions of people (mostly children) from dying. Because of a vaccine, smallpox, an ancient killer, has been eradicated.

Yet paranoia over government-sponsored health programs has prevented many people in the United States and elsewhere from protecting themselves and their children. As long as enough people are immunized, infections are unlikely to spread rapidly, but as a large susceptible population develops, epidemics, illness, and deaths become inevitable.
It is impossible to prove a negative, so one cannot prove that vaccines do not cause autism or other ailments. Epidemiology is a science of probability, not proof. But an overwhelming array of epidemiological studies provides evidence that vaccines do not cause autism or the other ailments that fear-mongers claim. So let me end this essay with a plea for support for vaccinations. Anti-vaccine misinformation on the Internet is more prevalent and powerful than the staid official policy presented on the CDC website. But there are other well-informed websites about current dangers from vaccine-preventable diseases, such as Meningitis Angels (, Parents of Kids with Infectious Diseases (, and Families Fighting Flu ( In addition, Voices for Vaccines ( provides science-based information. Also, check out the well-researched, informative books by pediatrician and vaccine specialist Paul Offit. The fact that Dr. Offit has received hate mail and death threats for telling the truth and trying to save lives is evidence of the passionate misinformation out there.

Japan’s Tipping Point blog 2 — Tetsunari Iida and ISEP

November 4th, 2011

This is my second blog about Japan’s current energy situation and its future, about which I wrote in my short book, Japan’s Tipping Point: Crucial Choices in the Post-Fukushima World. In my first post, I explained how I came to Japan to study Eco-Model Cities and renewable energy policy two months after the earthquake/tsunami/Fukushima meltdown. I asserted that Japan is a kind of “canary in the coal mine” for the rest of the world, since it is facing the same issues that we all face, only sooner and more starkly. Japan has no fossil fuel, and it has scrapped plans to build more nuclear power plants. It therefore must ramp up renewable energy efforts, energy efficiency, and lifestyle changes.

The comments that my first blog inspired turned into a vituperative argument over the benefits and perils of nuclear power, with interpersonal attacks that added much heat but little light. So let me address the nuclear power issue briefly: The subtitle of my book referred to the “post-Fukushima world” because nuclear policy in Japan and other parts of the world has undergone a seismic shift following the meltdown, with a subsequent surge in interest in renewable options. I did not intend, however, to focus on nuclear power in my book, and I don’t want to focus on it in my blogs, either. My underlying assumption is that nuclear power in Japan will not be a viable alternative in the future. Even pro-nuclear Japanese experts such as Takao Kashiwagi, a professor at the Tokyo Institute of Technology, admit that Japan will not build any more nuclear plants for at least two decades.

Particularly in Japan, nuclear power plants are hazardous since the country sits on top of fault lines that make earthquakes and tsunamis a constant danger. All of Japan’s nuclear plants are located on the ocean’s edge for access to water as a coolant. I am not a fan of nuclear power for many reasons. Human beings who run nuclear power plants make mistakes, and in Japan there is a long history of cover-ups of such mistakes. Etc. But really, can we move on from this issue? For the purposes of discussion, I would simply like to assume that nuclear power is not a viable option for Japan’s future. In the book, and in my blogs, I want to focus on renewable energy. I propose to deal with each form of renewable energy one at a time in future blogs — geothermal, solar photovoltaic, solar hot water, wind, biomass, hydro/tidal — as well as food, energy efficiency, and lifestyle.

In this blog, I’ll talk about Tetsunari Iida and Tokyo’s Institute of Sustainable Energy Policies (ISEP) that he founded and continues to lead. A trim, short, self-assured man of 52, Tetsunari Iida seems to lack all pretension despite his current celebrity. He doesn’t appear to be a radical, even though his opponents think he is. He told me with pride how in the late 1990s he had criticized TEPCO, the Tokyo Electric Power Company, about its nuclear plants, while simultaneously working with the utility as a partner on a wind turbine project in Hokkaido. “I believe in dialogue,” he said, “not confrontation.” He comes across as a mild-mannered man with a sense of humor and a large dose of common sense.

Iida grew up on a farm in western Japan. His octogenarian father still sends him a package of home-grown vegetables every month. He heats his home, just to the north of Tokyo, with a wood stove. Iida started his career as a nuclear engineer. I asked him what led him to quit in 1992, expecting him to cite the Chernobyl meltdown, but he said he wasn’t really worried about safety issues in those days. He hated the groupthink atmosphere in which it wasn’t permissible to question any aspect of nuclear energy policy. All of his papers were censored. “It was a kind of soft fascism,” he said. He fled to Sweden, where he studied renewable energy. After shuttling back and forth to Japan, he returned to his native country in 1998 and founded ISEP two years later.

Since then, he has become the chief Japanese gadfly of nuclear power, while advocating strenuously for renewable energy. He has helped to found several green mutual funds, offering a small return to idealistic investors who want to support wind and micro-hydro. But until 3/11, he was mostly a voice crying in the wilderness, largely ignored by bureaucrats, governing politicians, and the mainstream media.

Now that has changed. “All of a sudden our voice is taken up more centrally,” he told me. He is constantly in demand for interviews on TV, radio, and in print. “Within the last month, ISEP has become one of the most well-known organizations in Japan. I now have deep connections in the cabinet and with both political parties.”

In his talks, Iida shows a slide in which Japanese nuclear power and fossil fuel use gradually dwindle to nothing by 2050, while renewable energy increases to account for 50 percent of current use. The other 50 percent will supposedly be covered by energy savings and efficiencies. By 2020, ISEP proposes that renewables will contribute 30 percent of Japan’s power supply and energy efficiency 20 percent, with coal and oil at 15 percent, liquid natural gas 25 percent, and nuclear power 10 percent. That scenario assumes no new nuclear reactors and a 40-year life for existing nuclear power plants, which will slowly be phased out. Iida would prefer to see all nuclear plants closed by 2020, however, with their energy share replaced temporarily by natural gas.

The ISEP plans for renewable electric generation capacity are fairly specific. Hydro currently supplies eight percent and is to be brought up to 14 percent by 2050. Wind will blow up from 0.4 percent to eight percent, solar from 0.3 percent to 14 percent, geothermal from 0.3 percent to eight percent, and biomass from 1.1 percent to six percent. While those are ambitious goals, they are perhaps feasible. But how is the other 50 percent in energy savings and efficiency going to be achieved? Iida is vague about that. He talks about switching to LED lights and installing better house insulation. He seems to think that the Japanese can drastically reduce their energy consumption without significantly modifying their lifestyles. I don’t see how that is possible.

Nonetheless, of all the people I interviewed in Japan, Tetsunari Iida was among those who impressed me the most, and I hope that his sudden rise to celebrity means that his message will be heeded. He tries to remain optimistic even as he observes that the Japanese energy policy has relied on a kind of “political delusion without rationality or evidence.” He believes that 3/11 marks the third drastic turning point in modern Japanese history. The first was the Meiji Restoration of 1868, in which Japan opened its doors to the outside world. The second was the defeat that ended World War II. Iida says that a mass delusion and blind faith in military might and the emperor led to the disastrous war, and no one was allowed to question it. “But after the war, everyone questioned it.” The same kind of unquestioning allegiance to nuclear power drove him to oppose it, and now, in the post-3/11 world, he hopes that Japan will throw itself into a massive energy shift.

Japan’s Tipping Point — blog 1

November 4th, 2011

In 2010, I published a book on public health (Inside the Outbreaks), and as a follow-up, I concluded that the overarching threat to the world’s public health that we face in the coming decades is climate change/peak oil.

In researching that story, I got an Abe Fellowship for Journalists that allowed me to go to Japan to study renewable energy and specifically to visit several so-called Eco-Model Cities in Japan. I already had my plane reservations when the earthquake/tsunami hit. I nearly didn’t go, but things had calmed down by May 11, which is when I showed up.

I have just completed and published a short ebook as a result of the trip, called Japan’s Tipping Point: Crucial Choices in the Post-Fukushima World. It is a small book on a huge topic. In the post-Fukushima era, Japan is the “canary in the coal mine” for the rest of the world. Can Japan radically shift its energy policy, become greener, more self-sufficient, and avoid catastrophic impacts on the climate?

Japan is at a crucial tipping point and I discovered that I had been naive in thinking that the country was ready to make a massive change. The Japanese boast of their eco-services for eco-products in eco-cities and yet they rely primarily on imported fossil fuel and nuclear power, live in energy-wasteful homes, and import 60% of their food. That may be changing in the wake of the Fukushima nuclear disaster. Maybe. But as I documented, Japan lags far behind Europe, the United States, and even (in some respects) China in terms of renewable energy efforts. And Japan is mired in bureaucracy, political in-fighting, indecision, puffery, public apathy, and cultural attitudes that make rapid change difficult.

Yet Japan is also one of the most beautiful countries in the world, with friendly, resilient people who can, when motivated, pull together to accomplish incredible things. As an island nation, Japan offers a microcosmic look at the problems facing the rest of the globe. And as Japan tips, so may the world.

The Impact of the EIS

December 2nd, 2010

Thursday, Dec. 16, 1 p.m., Foege Auditorium, University of Washington, Seattle, WA. Mark Pendergrast will speak about the history of the CDC’s Epidemic Intelligence Service and its impact on public health, based on his book, Inside the Outbreaks. EIS officers are the front-line disease detectives of the CDC, and EIS graduates are among the leaders of the world of public health (including Bill Foege, for whom the auditorium is named). The presentation is free and open to the public. Located in the Foege Building, southeast corner of Pacific Street and 15th Ave NE in Seattle.

Speech on coffee history and culture

December 2nd, 2010

Tuesday, Dec. 14, 2010, 7 p.m., Starbucks Olive Way store, 1600 East Olive Way, Seattle, WA. Mark Pendergrast will be speaking about his book, Uncommon Grounds, which has just come out in a revised, updated edition. The presentation is free and open to the public. 206-568-5185.

Elder Education Enrichment talk

August 10th, 2010

Monday, November 2, 2010, 2 p.m. – 3 p.m., at Faith United Methodist Church, Dorset Street, South Burlington, VT. Mark Pendergrast will talk about Inside the Outbreaks and the work of the Epidemic Intelligence Service.

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August 10th, 2010

League of Vermont Writers meeting

August 9th, 2010

Saturday, September 18, 2010, 9:30 a.m. – 10:30 a.m., Bishop Booth Center at Rock Point, Burlington, VT. Mark Pendergrast will speak to fellow members of the League of Vermont Writers about the process of researching and writing Inside the Outbreaks, as well as commenting on the current perilous state of publishing. For other speakers and information the event, see Members $38. Non-members $42. Morning Danish and beverages plus lunch included.

Burlington Book Festival

August 9th, 2010

Saturday, September 25, 2010, 1 p.m. – 2 p.m. Main Street Landing Performing Arts Center, Burlington, VT. Mark Pendergrast will talk about Inside the Outbreaks, followed by a book signing, as part of the Burlington Book Festival. For other authors, see

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August 6th, 2010

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August 5th, 2010

The Living Room, Colchester

May 27th, 2010

Tuesday, June 22, 2010, 7:30 p.m. — Mark Pendergrast will speak about Inside the Outbreaks and offer a slide show and video clips of his research trip to Africa at the Living Room on West Lakeshore Drive in the little mall opposite Mazza’s General Store (  Entrance fee is $10, with half of the money going to the Living Room and half to the CDC Foundation to support the work of the Epidemic Intelligence Service.  Unlike most book-related events, this literary evening offers an intimate setting — i.e., like a living room — and a more leisurely, in-depth presentation. There will be a 15 minute break for wine and cheese around 8:30 p.m., followed by a more wide-ranging informal chat about Pendergrast’s other books, the process of research, writing, and getting published, the uncertain future of the book, etc.   Limit of 30 people.  Advanced ticket reservations suggested through the Living Room website.  This will be the first of a series of such literary evenings on alternate Tuesday nights, hosted by Pendergrast.

Unitarian Universalist Church in Burlington

May 27th, 2010

Sunday, May 30, 11:30 a.m. — Mark Pendergrast will speak about Inside the Outbreaks at the Unitarian Universalist church at the head of Church Street, on Pearl Street in Burlington

Jimmy Carter Presidential Library & Museum speech

May 26th, 2010

Wednesday, September 8, 2010, 7  p.m. — In the Theater of the Carter Library & Museum (located at the Carter Center,, Atlanta native Mark Pendergrast will speak about Inside the Outbreaks, his history of the Epidemic Intelligence Service, the front-line disease detectives of the CDC.  Presentation will include photos and video clips.  Books provided by Acappella Books,

Decatur Book Festival

May 26th, 2010

Sunday, September 5, 2:30 p.m.- 3:30 p.m. — Mark Pendergrast will be speaking at the Decatur Book Festival ( at Decatur High School in Decatur, GA, about Inside the Outbreaks and his other books.

Global Health Council Conference

May 20th, 2010

Tuesday, June 15, 12:45 p.m. – 1:30 p.m., Omni Shoreham Hotel, Washington, DC  — Mark Pendergrast will be speaking about Inside the Outbreaks in the “Speaker’s Corner” in the Exhibition Hall of the annual Global Health Council Conference.  He will discuss the history and impact of the Epidemic Intelligence Service and will look at likely future trends and problems faced by public health practitioners.

Smallpox Eradication

May 16th, 2010

May 17, 2010

Smallpox Eradication – 30th Anniversary Celebration

On Monday, May 17, 2010, a statue was unveiled at the World Health Organization headquarters in Geneva, in honor of the thirtieth anniversary of the certification of smallpox eradication.  The last wild case of smallpox actually occurred in Somalia in 1977, though the last actual case (and death) occurred in 1978 because of a laboratory leak in the UK.  WHO waited until 1980 to certify that the hideous disease was truly eradicated.

Smallpox, which had an enormous impact, afflicting people from Egyptian pharaohs to modern times, was a scourge that disfigured and killed millions – probably billions.  The campaign to rid the world of this virus (except in freezers where it is kept for study) is a shining example of how coordinated global effort can have a lasting impact.

I documented the involvement of Epidemic Intelligence Service officers in the smallpox eradication effort, particularly in West Africa, India, and Bangladesh.  EIS officers and other international epidemiologists were vital to the endgame in Asia in 1975.  One chapter of Inside the Outbreaks, “Target Zero,” documents that incredible time.  Here is the final section of that chapter:

The Legacy of Smallpox Eradication

Epidemic Intelligence Service officers always relied heavily on people around them.  Nowhere was that truer than in the smallpox eradication effort.   Epidemiologists from all over the world deserve credit for the success of the effort, but the greatest heroes were the Indians and Bengalis who devoted themselves to the cause.

It was not always easy for EIS officers to return to normal American life after the intensity of smallpox eradication.  The urgency of their task and the immediacy of the results were addictive, and it gave them a perspective on what really mattered.  “It was a very humbling experience,” Wilbert Jordan recalled.  “It made me appreciate what I had.  I made myself a vow that if I ever got back to America and heard myself complaining, I would kick myself in the ass.”

But it was also jarring to return and be treated like a regular person.  “I was a superstar in India,” Jordan said.  Wynn Hemmert had reverse culture shock when he came home to his wife and two small children.  “I was sort of a sick stranger for a while.  My wife looked at me, obviously thinking, What happened to you?

Mostly, though, they came back with an overwhelming feeling of pride and accomplishment.  “It was almost a religious experience,” Walt Orenstein said.  “It was so dramatic to see the disfigurement, the dead children, and to know you were getting rid of it.”  For Rick Greenberg, “Everything else in my life goes back to this moment in India, what we accomplished.  It was a wonderful thing.  You almost felt the earth should have stopped.”

Many veterans of the smallpox eradication crusade went on to become leaders in the world of public health.  They brought a self-confident, can-do attitude, a refusal to accept that anything was impossible, a sublime impatience with stodgy bureaucracy or indifference to suffering.  “We were cocky and arrogant, we smallpox warriors,” Stan Music said.  “We became tough to deal with sometimes.  We knew you could overcome any obstacle if you just pushed hard enough.”

Sometimes that pushiness in India and Bangladesh amounted to intimidation and coercion.  “We overstepped,” Steve Jones admitted.  But the crusaders were, after all, trying to save lives, trying to rid the world of an ancient scourge.  A few years later, Bill Foege called smallpox eradication “an incarnation of Gandhian ideals” which led to “non-violent social change [and] a better world.”

D. A. Henderson summarized his approach to supervising field epidemiologists:  “Give them running room, some support, and some back-up.  Ask them questions, make them think about what they are doing, but by God give them the room to move, then you have great things happen.”

Don Francis, writing back to his colleagues about his 1973 smallpox eradication efforts in Sudan, wrote about qualifications an EIS officer should have. “I think what the EIS course teaches us all is how to fly by the seat of our pants and come out on top.  Just give all graduates a bit of baling wire, a piece of bubble gum, and a slide rule, and send them off.”

In addition, officers should know how to repair Landrovers and learn foreign languages.  “Tolerance must be part of the curriculum” – tolerance for eating raw camel’s liver, incredible heat, horrible roads, and cultural differences.  Add to that “the ability to enjoy something in all this chaos,” including scenes of great beauty, wonderful people, and “finally seeing one of the most wicked diseases disappear from the faces of children.”

Politics & Public Health

May 9th, 2010

May 9, 2010: I have spoken to several Rotary Club groups about Inside the Outbreaks. Rotary International clubs have given over $850 million to support global polio eradication, which is tantalizingly close to succeeding.  I covered a great deal about polio in my book, from the Salk vaccine to the present eradication effort.

But that’s not why I’m writing this.  It’s to lead into a frustrating phone conversation I had recently.  One Rotarian in charge of programming told me, “Our members wouldn’t be interested in hearing from you because they are primarily interested in politics.”  This flabbergasted me.  I blurted out, “But public health is politics!”  I couldn’t convince him, but it is true.  The more I researched the history of the Epidemic Intelligence Service, the more I found that politics influenced what impact EIS officers could have.  The CDC (of which the EIS is a subset) has no regulatory power.  It can only make recommendations.  Thus, for instance, when EIS officer Karen Starko first documented that aspirin caused most cases of Reye syndrome – a horrible affliction that killed thousands of otherwise healthy children – the FDA quickly moved towards insisting on a warning label for all aspirin-containing medicine for children.  The powerful aspirin industry lobby interceded and managed to block the label, insisting on more delaying studies for another five years.  In the meantime, nearly 300 more children died of Reye syndrome.  Once aspirin was finally removed from children’s medications, Reye syndrome became an extremely rare disease in the United States.

It is clear that legislation (i.e., politics) is a potent public health tool.  Putting high taxes on cigarettes and keeping ads for them off television are good illustrations.  Yet our legislators are generally not terribly well-informed about public health issues.  So here is my sermon for this Sunday – I would like some public health veterans – perhaps EIS alums – to run for public office, nationally and locally.  One of the few criticisms I have of these folks (whom I admire a good deal on the whole) is that they aren’t vociferous enough about what they discover and what urgent issues we face.  The CDC led the way in documenting foodborne E. coli O157:H7, for instance, but it took citizens’ groups to push successfully for new legislation for beef inspection, which the USDA has implemented.

I have heard inspirational public health speakers such as Bill Foege and Nils Daulaire, and I found myself thinking, I would love to vote them into office, any office.  I want more people to hear them.  I want them to have more clout.  Foege is too old now, I’m afraid, but Daulaire, who for years headed the Global Health Council and has now been tapped by President Obama as his new Director of the Office of Global Health Affairs, would be a good candidate.  Instead of waiting to be appointed, how about public health experts running for president next go-round?

A Generation Without Smallpox, Tewksbury, MA

May 9th, 2010

Monday, May 17, 2010, 2:00 – 5:00 p.m. — Mark Pendergrast will attend and sign copies of Inside the Outbreaks at “A Generation Without Smallpox,” at the Old Chapel, Tewksbury Hospital, 365 East St., Tewksbury, MA 01876.  This event celebrates the 30th anniversary of the certification of smallpox eradication and will feature those who helped make it happen.  For more information, contact Marilyn DelValle, 781-774-6733,

May 3, 2010 — In Kenya

May 3rd, 2010

Making a Difference in Kenya

January 31, 2006, Homa Bay, Kenya. After Niger, I traveled to Kenya, where I visited three rural elementary schools with Ciara O’Reilly.  A five-foot tall, 100-pound blonde Irish native, the 31-year-old EIS officer presented quite a contrast to the Africans she served.

[That is to introduce this blog post and get your attention!  I must apologize to my blog followers (not sure who is reading this — drop me a line!) for not posting for a couple of weeks.  Life has been hectic, with book signings, interviews and travel.  And it is continuing.  So I am cutting and pasting again from Inside the Outbreaks from the chapter on my African sojourn, this time in Kenya.  I introduced the Safe Water System in a previous blog.  You will see its impact here.]

After earning a Ph.D. in Food Microbiology, Ciara began with the CDC Foodborne and Diarrheal Diseases Branch in August 2004.  Just before I met her in Kenya, she had spent two days aboard a cruise ship in the Caribbean, where norovirus was spread by passengers’ vomitus.

The transition from the luxurious cruise ship to African poverty was jarring, but Ciara had been to Kenya the previous year to set up a diarrhea study, so she knew what to expect.  “Kenyans are better able to appreciate small things than we are,” she told me.  “If something good happens, they have such joy.”

At one of the schools we visited, children stood on the barren school grounds to sing songs and recite poems they had written for their Safe Water Club.  Though many were barefoot, they wore the school uniform – boys in white shirts and blue shorts, girls in blue dresses with white collars – and there was indeed joy on their faces, even though a storm had recently ripped the corrugated roof from their school building, built from bricks they had made themselves, and even though many of them were AIDS orphans.

Ciara and Matt Freeman, a young epidemiologist with the Center for Global Safe Water at Emory University, were there to assess the impact of the Safe Water System (SWS), which had been implemented by CARE (with funding from Coca-Cola) the previous summer in 45 primary schools in Nyanza Province in western Kenya. Ciara and Matt had trained local enumerators to administer questionnaires to randomly selected students and their parents/guardians.

Diarrhea from polluted water kills over two million people annually, mostly children in developing countries.  The SWS teaches people to treat their drinking water with dilute bleach and to dispense it from spigots in narrow-topped containers too small for hands to reach in.·

This school had two sources of water. The better one was a river down the dirt road, a half-hour away.  The other was a ten-minute walk, but it was foul and  stagnant.  We were looking at the latter when an old man told us that people who drank this water went loco and got diseases.  As he spoke, several emaciated cows ambled up and waded in to drink.

At the schools, I watched children stop at a hand washing station after leaving latrines, as they had been taught.  They drew water to drink from brown narrow-topped clay pots with metal spigots, and they demonstrated how they added a capful of WaterGuard, the dilute bleach solution, to treat new water.

The next day, I walked through the dry scrub with Elvis, a Luo-speaking enumerator, as he visited parents or guardians in their small mud homes, questioning them about their knowledge of WaterGuard and the Safe Water System.  The third house was very small, with a bare double-bed foam mattress leaning against the wall.  The woman in the house was a recent AIDS widow with seven children.  Her husband had had three wives, but one of them, with six children, had also died. The third remaining wife was childless.  So these two women had 13 children to care for and were very poor.  Yet this woman still managed to buy WaterGuard for their water.

Over the next few days, I helped Ciara and Matt enter data from the questionnaires into laptops.  “Now you know what being an EIS officer is really like,” Ciara told me, referring to the tedious job in oppressive heat.  Some of the surveys were heart-rending: an 86-year-old woman caring for three AIDS-orphaned grandchildren; two adults, 11 children, all sleeping in one room.  An enumerator’s comment on the last situation:  “The family is very desperate and I really wondered how they manage their daily bread.”

As I walked the single paved street of Homa Bay every morning and evening, I encountered women carrying 20-liter plastic buckets of water on their heads – water retrieved from a pool, ditch, or rivulet.  Children riding bicycles carried jerry cans of water.  All polluted.  Ciara told me about a local “control” school she had visited that did not have the SWS program.  “A teacher showed me a bucket of water they drank.  Scum floated on top of the brown water, and sediment coated the bottom,” she said.  With most people earning less than a dollar a day, even the pennies needed for WaterGuard were hard to come by.

When the data from Ciara’s survey were tabulated, they told a positive story.  Student absenteeism in the intervention schools had dropped by 35 percent, while in non-project control schools it had risen by 5 percent.  More parents had heard about WaterGuard than during a baseline survey, though only a few more actually used it at home.

My final day in Kenya, I drove with Ciara over terrible, dusty roads one more time, to visit hospitals and clinics where she was conducting a baseline study of what caused diarrhea in another area of Nyanza Province.  One hospital was located in Siaya, hometown of Barack Obama’s father.· Stool samples from the hospital were tested twice a week at the CDC lab in Kisumu to determine what had caused diarrhea and what sort of drug resistance had developed.  In Bondo District Hospital, the drinking water was not treated with WaterGuard, and about 15 children a month died there.

Ciara’s study found that in children under five, three bacteria – Shigella, Campylobacter, and Salmonella – together accounted for about half of the pathogens identified.  The other half was caused by rotavirus, which is impervious to WaterGuard.· Ciara also found that the bacteria were highly resistant to three common antibiotics, but responded to others.

Since the time I followed Ciara in Kenya, she has graduated from the EIS but stayed on as a staff member in the same branch.  She helped to launch the Global Enterics Multi-Center Study (GEMS), which will expand the Kenyan diarrhea project to eight locations worldwide in an unprecedented prospective case-control study to determine what diarrheal pathogens are killing children under five, and to what drugs they are susceptible.

And CARE (with funding from many public and private organizations) has begun to implement the Safe Water System in an additional 200 schools in Nyanza Province.  Some schools will also get latrines, while others will, in addition, get a borehole well or rainwater harvesting.  The idea is to see which interventions are cost-effective and sustainable.  It is a three-year project, and there are plans to expand it to 1,500 more schools.

The programs were nearly derailed by ethnic violence in Kenya following the disputed presidential election of December 27, 2007.  “Kisumu looks different these days,” Ciara emailed, “with many buildings burnt to the ground.”   Still, she had managed to train staff for the prospective diarrhea study and was preparing to launch it.  A power-sharing agreement between the incumbent Mwai Kibaki and his opponent Raila Odinga was hammered out in late February, and Kenya settled back into an uneasy peace.

That February 2008, EIS officer Sapna Bamrah, 34, arrived in Kenya to assess the impact of the violence on AIDS and tuberculosis health clinics, where 180,000 people had been taking antiretroviral drugs.  As an EIS officer, Sapna Bamrah had already ventured to Azerbaijan to look at mortality surveillance from land mines, to Vietnam to study the impact of Pur, a water treatment product made by Procter & Gamble, to Nepal to assess the nutritional status of Bhutanese refugees, and to Swaziland to conduct a randomized survey of rape and molestation of young girls.  Now in Kenya, she found that while many health clinics had been temporarily closed or abandoned, the system was beginning to recover more quickly than had been feared.

I interviewed Sapna Bamrah in August 2008, a month after she completed her EIS service and remained with the CDC.  She acknowledged that “sitting on committees, wearing a uniform, and following rules and regulations has little to do with public health,” and that politics sometimes subverted science.  But Bamrah concluded:  “For every moment I am frustrated, I am continually inspired and amazed at what people in the EIS and in this agency are doing.  The average American has no idea the amount of energy spent in the United States and the world by people who really believe in protecting the public.”

  • · See Chapter 17.
  • · Six months later, in August 2006, then-Senator Barack Obama came to Siaya to visit his grandmother.  At the CDC outpost in Kisumu, at the request of EIS alum Kayla Laserson, Obama and his wife Michelle publicly submitted to HIV testing to encourage locals to do the same.
  • · Later in 2006, two oral rotavirus vaccines were found to be safe and effective, though getting them to poor children around the world is another matter.

Phoenix Books and Cafe, Essex, VT

April 15th, 2010

Wednesday, May 26th, 2010, 7 p.m. —  Mark Pendergrast will discuss Inside the Outbreaks followed by a signing at Phoenix Books and Cafe in the Essex Shoppes & Cinema Mall, 21 Essex Way, Essex, VT 05452.  Phone:  802-872-7111.

In the world’s poorest country

April 14th, 2010

April 14, 2010

I have been too busy writing a speech and dealing with other deadlines (plus putting in new raised bed gardens and planting my snow peas — perhaps the subject for a future blog in conjunction with food-borne outbreaks I will avoid this way) to write a new blog, so here is an excerpt from Chapter 22 of Inside the Outbreaks called “L’Experience Fait La Difference.”  This quotes from a journal I kept in Africa, and I may in the future put in some of that journal here.  But for now, welcome to Niger:

Jan. 25, 2006, Niger, West Africa.  After sleeping in a tiny mud hut, covered by my bednet, I arose and used the toilet – a four-square inch hole in the floor.  Then I watched the village stir and come to life.  Children drove donkey carts.  A goat excreted by the dirt roadside.  Women laughed and greeted one another as they got cook fires started in front of their adobe homes.  A barefoot man in a blue satin robe and a white pillbox hat sat on a bench next to another whose head was swathed in a bright yellow turban.  I was in the town of Tera, the middle of nowhere, but which, in comparison to the remote villages, seemed like the Big City, with its gas station, cell phone tower, Coca-Cola poster, and single restaurant.

After two years of research and hundreds of interviews, I was finally out in the field, following second-year EIS officers Natasha Hochberg and Melto “Jamie” Eliades in Niger, the world’s poorest country by United Nations criteria.  The prior month, public health personnel had attempted to distribute insecticide-treated bednets to every household in the country with a child under five, along with vitamin A and oral polio vaccine drops.  Hochberg and Eliades were training and directing a team of locally hired “enumerators” who would visit randomly selected villages throughout the country to assess how successful the distribution had been.  I would tag along for the first week of the project, then fly to Kenya to follow another EIS officer.

The hanging bednets, which can repel mosquitoes within a 30-meter radius, were intended to prevent malarial mosquitoes from biting children and their families.  This program had a very personal meaning for me.  During a brief visit to Niger in August 2003, my friend Liz Lasser, who worked for an international health organization, had been bitten by a mosquito carrying the Plasmodium falciparum parasite.  She hadn’t bothered to take anti-malarial medication.  A vibrant, idealistic woman of 49, she developed fever, chills, and body aches.  Her lungs filled with fluid, and she died of pulmonary edema shortly after entering a hospital near her home in England.

Each year over 500 million people become infected with malaria, for which there is (as yet) no effective vaccine.  Nearly three million die, most of them young children in sub-Saharan Africa.  Almost everyone in Niger has contracted malaria repeatedly.  Having developed partial resistance, those who survive to adulthood usually have milder — but still painful — symptoms.  The Niger villages I visited were in the southern part of the country, compounds of mud huts with thatched or pueblo-style roofs set on an arid plain surrounded by millet stubble and scrub bush, reachable by red dirt tracks or brown sand.

Trim and nearly six feet tall, Natasha, 31, was a Harvard graduate who had gone on to medical school.  She had worked in clinics in Peru and Honduras, then matched with the CDC Parasitic Diseases Branch in July 2004.  Her father, Fred Hochberg, had served as an EIS officer in the early 1970s.

Natasha was the lead EIS officer in Niger, keeping track of nine teams, getting enough gas, and dealing with money problems, glitches with the palm pilots with built-in Global Positioning Systems (GPS), and more.  An intense perfectionist and worrier, she drove herself hard.

Jamie Eliades worked in the CDC Malaria Branch.  In Tera the night before, he and I had eaten at the Restaurant L’Amitie (Friendship Restaurant), a shack of sticks with woven mats for roof and walls. We enjoyed our chicken and couscous, though I didn’t drink the water.  (Natasha opted out, having once contracted typhoid from African fare.)

At 6’ 6”, with a relaxed manner and easy smile, Jamie, 37, was a “gentle giant,” according to Natasha.  After a residency in emergency medicine, he had earned a masters degree in public health and eventually applied for the CDC program.  By the time I met him, Jaime had been to 55 countries.  He had helped with the first national bednet distribution and assessment in Togo, later volunteering for Niger as well.

He was a calming influence.  “It’s good to have opposite personalities on a team,” he explained, finishing his meal.  As we left the restaurant, I took a photo of its misspelled sign announcing:  Specialite Afro-Eropenne, L’Experience Fait La Difference.  Yes.  Experience Makes the Difference could be the motto of my trip, or for that matter, of the EIS.

That day, after hours of rough driving, we had visited the village of Zoribi.  As the interviewing team was choosing random huts and conducting the survey in Djerma, the local tribal language, a young mother carrying her daughter had approached Natasha to ask for help, pointing at the child’s grotesquely swollen heel.  Natasha gently examined it and answered her apologetically in French.  She advised her to go to the nearest health clinic to get antibiotics, since we didn’t carry any.

Why can’t someone give this poor little girl some medicine? I later wrote in my journal.  I know that the argument is that we are doing public health, doing a bednet and polio vaccine survey, not primary health care.  And if we get involved with trying to take care of everyone, we will go nuts and be diverted.  But…

Later I gave Natasha a small amount of money and asked her to get it to the local health clinic for treatment of the girl’s foot.  She thanked me and said, “You know, I get so wrapped up in our program, and so stressed out, sometimes I need a reminder that we can stop and help just one person.”  One out of every four children in Niger dies before the age of five.  It is through public health programs such as immunization, clean water, proper nutrition and vitamins, and bednet distribution that most of those deaths might be averted.

Since I would have been a distraction if I had gone into the huts during surveys, I stayed outside in the villages, where the children crowded round me.  Most of the girls wore headscarves, bracelets, and traditional clothes, while the boys wore drab castoff Western tee-shirts and shorts.  Most children smiled and laughed, pushing closer; a few shy kids hung back.  They were beautiful.  Intelligence and curiosity shone from their eyes.  Over a quarter of the children die here, I thought.

To engage them, I sang, “If You’re Happy and You Know It, Clap Your Hands.”  They began to clap.  Then I gestured to them encouragingly, asking for a chanson, and after some hesitation one little girl sang in Djerma.  Two children began to dance, stomping their feet, leaning in and circling one another, as the others sang and clapped around them.  Finally, a man shouted at them, and they left, apparently ordered back to work, fetching water or carrying firewood.

One woman invited me into her hut.  Like most of the women, she wore a startlingly bright traditional dress of white, yellow, blue and red, a shiny purple head scarf, two necklaces of tiny shells, and big hoop earrings.  She proudly showed me the filter she used to keep guinea worm copepods· out of the water that she stored in carefully stacked clay pots, though she had no visible bednet.

At every village, Natasha and Jamie first visited the village elder.  Because both of them towered over everyone, they usually squatted respectfully, explaining their mission.  I was impressed with their ability to organize and train the teams (in sessions back in Niamey), plan this difficult survey of a vast and sparsely populated country, and maintain a sense of humor.

“Jamie and I made a great team,” Natasha told me after the survey was completed.  “I tend to be compulsive, that’s how to get work done.  He’d tell me it was OK to give the teams a day off.”  There had been multiple flat tires, gas crises, cell phone inaccessibility, disgusting lodging, and software problems, but the teams actually finished ahead of time.

The effort revealed that 87 percent of the surveyed children under five had received polio vaccinations during the December 2005 campaign, and that 64 percent of the households with young children had received a bednet.  Yet only 15.4 percent of the children had slept under an insecticide-treated bednet the previous night, presumably because the January-February survey took place during the dry season, when mosquitoes are not a big problem.

In September 2006, EIS officer Julie Thwing led teams that repeated the random assessment during the rainy season, finding that 55.5 percent of children under five had slept under an insecticide-treated bednet the previous night.  Though not the official 80 percent goal, this was a dramatic improvement.  From 2006-2009, ten other African countries have conducted similar bednet distribution campaigns in conjunction with immunization drives.

The bednet surveillance project in Niger is typical of the unsung work of EIS officers.  It would have received little notice if I had not tagged along.

  • · Guinea worm disease (dracunculiasis) involves a life cycle in which worm larvae are ingested by fresh-water copepods.  When a person drinks water with  Guinea worm copepods, female worms grow up to three feet long, emerging with painful ruptures.  The worm releases her larvae into water, and the cycle begins anew.  In 1985 the CDC/EIS joined a worldwide effort to eradicate the disease.

Colchester VT Rotary Club talk

April 13th, 2010

Thursday, May 20, 2010, Noon. Mark Pendergrast will attend a Rotary Club luncheon at the Hampton Inn, Colchester, VT, at noon, followed by a talk about his book, Inside the Outbreaks.  Address:  Hamton Inn, 42 Lower Mountain View Drive, Colchester, Vermont 05446  Tel: 802-655-6177

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Tall Tales Book Shop, Atlanta, GA

April 13th, 2010

Friday, April 23, 2010, 7 p.m. Mark Pendergrast will speak at Tall Tales Book Shop about Inside the Outbreaks, followed by a book signing.  The store is located at 2105 Lavista Road, #108, Atlanta, GA  Phone:  404-636-2498.  Email:

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Body Count Man

April 5th, 2010

April 6, 2010

Instead of a regular blog, I am going to post the beginnings of an article that I have never been able to sell.  It is a profile of Les Roberts, one of the EIS officers I wrote about in Inside the Outbreaks, primarily about his nightmare experience in the cholera-ridden refugee camps of Goma following the Rwandan genocide in 1994.  He went on to specialize in the epidemiology of war — specifically, in estimating the number of people killed.  Hence I called this profile “Body Count Man.”  If any readers want to help me place this important article, let me know!

The Body Count Man

by Mark Pendergrast

We all know that statistics can lie in any number of ways, but the controversy over the number of Iraqis who have been killed since United States forces overthrew Saddam Hussein in 2003 is astonishing.   Some “experts” say that the figure is less than 100,000, while others aver that over a million Iraqis have died a violent death.

Media outlets have tended to err on the low side.  The most widely cited figures have come from the website Iraq Body Count (, which says that there have been around 85,000 deaths as of February 2008.  The IBC website features a plane unloading bombs with a quote from General Tommy Franks:  “We don’t do body counts.”  The implication is clear – this is an anti-war site that aims to tell it like it is.

Yet the British IBC organizers base their figures primarily on media reports, supplemented by severely deflated official figures.  They make no attempt to do any kind of scientific population-based estimate.  They have never sullied their shoe soles with the dirt of Iraq.  So what we have is a kind of circular tail-chasing logic in which the media parrot back figures derived from inaccurate media reports.

The British medical journal, The Lancet, published the findings of a US-Iraqi team of epidemiologists, whose random cluster surveys for the periods of September 2004 and May-July 2006 indicated much higher numbers of violent deaths – 100,000 and 600,000 respectively.  The Lancet reports were derided by supporters of the war in Iraq.

The Iraqi government commissioned its own study specifically to counter the Lancet conclusions, examining the same time period (through the summer of 2006), and coming up with only 150,000 violent deaths.  Published in late January 2008 in the New England Journal of Medicine with the imprimatur of the World Health Organization, this latest survey has been widely hailed as more accurate because of its larger interview base, but it is flawed for a number of reasons – most notably because it shows no increase in violent deaths from 2004 to 2006, while all other studies and reports indicated escalating death tolls over that time period.

The raging controversy, with attendant innuendo and smear campaigns, has been quite an eye-opening experience for Les Roberts, the Johns Hopkins epidemiologist in large part responsible for the Lancet studies.  His story is a case study of a public health scientist who, in attempting to change the world for the better, has put himself in harm’s way both literally and politically.

* * * * * * * *

On September 18, 2004, Professor Les Roberts, 43, was listening to All Things Considered through the satellite radio built into the TV set in his Baghdad hotel room.  He heard a familiar voice.  Martha Foley, a commentator for North Country Public Radio, was describing an exquisite fall day in upstate New York and how she had picked blackberries with her granddaughter.  Roberts smiled, picturing the far-off scene as he looked at bombed-out buildings through the sliding glass door to his balcony.

Many years ago, as an undergraduate at St. Lawrence University, Roberts had reluctantly agreed to accompany his workstudy boss to Martha Foley’s house for dinner, though she had not invited him.  As they pulled into the driveway, he had seen her look out her kitchen window, spot him, go to the sideboard, and pull off an extra plate.  By the time they got to the kitchen, another place had been set, and she never mentioned that he was an unexpected guest.  Roberts subsequently referred to such instances of invisible grace as “Martha Foley moments.”

Roberts could use such a moment now.  As the world’s premier expert on mortality in war-torn countries, he had come to Iraq to help conduct a random survey of 33 community clusters throughout the country, with the goal of estimating the number of civilian deaths before and after the March 2003 invasion.  Since 1992, he had worked in Bosnia, Rwanda, and the Democratic Republic of the Congo at the height of their genocidal conflicts.  He had witnessed people being killed, had seen starving children, had been tortured by nightmares.  He was used to dangerous situations.  But he had not been prepared for the level of anti-American sentiment here.

After accompanying his Iraqi interviewers a few times, it had become clear that his very presence was a threat to their lives, so he had sequestered himself in this hotel room, descending briefly to the lobby at 5 a.m. each day to use the internet to contact his wife and to email precious data to colleagues.  In the evening, his driver brought each day’s interview results along with some humus, fruit, or roasted chicken.  Going over the questionnaires, Roberts would call his six Iraqi interviewers on his cell phone to ask for clarifications.

Fearing that he might be kidnapped at any moment, he wedged the top of a chair against the door handle, then shoved a bureau and ottoman against the chair, hoping to gain enough time to leap from his third floor balcony.  He occupied himself by entering new survey data in his laptop, working on a draft of the final paper, watching BBC World News and Al Jazeera, doing 200 sit-ups and push-ups, and thinking.

As Martha Foley talked about her granddaughter’s blackberry-smeared face, Roberts watched two American helicopters approach an unseen target less than a mile away.  As they circled it, he could hear the pop-pop-pop of machine gun fire and could see the spent shell casings falling to the ground.  As Foley described making blackberry pie, thick black smoke billowed from the unseen target, as the helicopters continued to circle, flying in and out of the smoke in a surreal scene.

“It was a schizophrenic moment,” Roberts recalls.  “Into my ears and into my eyes were coming two facets of America that couldn’t have been further apart.  One was about nature, tradition, love, and nurturing.  The other was about anger, aggression, and violent technology.  It occurred to me that both Martha and the gunner were like people I went to high school with.”

* * * * * * * * * *

Roberts was born and reared near Syracuse, New York.  His father repaired furnaces, while his mother raised four children.  Young Les was an alarmingly fearless child, the first to jump off a ledge into water without knowing how deep it was.  He was raised Catholic, with heavy sermons on sin.  “Most of my life is driven by guilt,” he observes.  After graduating from Saint Lawrence University with a physics degree, he taught high school in Mattapoisett, Massachusetts.  “I was the only teacher under 30.  It was quite a poor school.  I was a terrible disciplinarian but good at getting them excited – why the sky was blue, things like that.”

In June 1984, when the financially strapped school laid him off after a year, Roberts decided to join his brother in Kenya, where he was on an exchange program.  A month later, his brother went home, but Roberts stayed, trying unsuccessfully to find a teaching position.  “Everywhere I went, as a white guy from the North American suburbs, I didn’t fit in.  Everyone wanted a bribe.  I got malaria.  I was an idiot and took no prophylaxis.  I was staying in Mrs. Roche’s Guest House in Nairobi, where tourists could pitch tents for $5 a night.  I had spikes of fever, couldn’t tell which way was up or down in my tent.”

After he recovered, Roberts saw a thief grab a woman’s necklace, chased him 20 blocks and caught him.  The police threw them both in a car.  “As we drove to the station,” Roberts recalls, “the guy in the front seat bashed the thief in the testicles with a club.  No one had even asked me what happened.  I realized the police were far worse than the guy I had caught.  I didn’t know what I was doing.  Everything I touched I messed up.”

Roberts decided he needed a specialized technical skill.  Every day he saw women carrying huge buckets of polluted water on their heads for miles.  “It seemed so crazy.  Meanwhile we could put a man on the Moon and spend money on Pet Rocks.”  He returned to New York to teach high school for a year near Syracuse, saving enough to enter the Tulane School of Public Health and Tropical Medicine, where he earned a masters in public health.

“At the end of my Tulane time, all I knew was that I didn’t know much.”  He went on to earn a Ph.D. at Johns Hopkins in environmental engineering, specializing in sanitation engineering and diarrhea prevention.  For his dissertation, he spent a year in Peru proving that chicken coops helped prevent the spread of disease.  Just before he left in May 1991, a cholera epidemic struck Peru – the first reappearance of the dreaded diarrheal disease in South America.

He met two Epidemic Intelligence Service (EIS) officers dispatched to Peru from the Centers for Disease Control to study cholera.  They told him about the two-year training EIS program which required that the disease detectives keep their bags packed, ready to go anywhere in the world to battle an outbreak.

Intrigued, Roberts applied and joined the Epidemic Intelligence Service in July 1992.  The EIS is a two-year CDC program which requires that disease detectives keep their bags packed, ready to go anywhere in the world to battle an outbreak.  With the EIS, he worked on cholera control in Malawi, assessed the health crisis in war-torn Bosnia, then documented the 1994 Rwandan genocide and worked in the mass cholera/dysentery outbreak in Goma, Zaire, among Rwandan refugees.  With the International Rescue Committee (IRC), he conducted mortality surveys in the Democratic Republic of the Congo.

In late August 2004 he snuck into Iraq to help conduct the first nation-wide mortality survey.  In Bosnia, Rwanda, and the Congo, Roberts had witnessed people being killed, had seen starving children, had been tortured by nightmares.  He was used to dangerous situations.  Still, he was not prepared for the level of anti-American sentiment he encountered in Iraq, nor did he realize that his very presence would imperil his team of Iraqi investigators.  But his most painful learning experience would come later, when his hard-won mortality estimates, published in The Lancet, were dismissed by the Bush administration and most of the U. S. media, and then undermined by the WHO/Iraq government report.

In contrast, Roberts’ previous work in the Democratic Republic of the Congo had a major impact.  In 2000, that survey estimated 1.7 million Congolese deaths.  These numbers, cited by Kofi Annan, eventually led to doubled aid and peace talks.  During his subsequent 2001 Congo survey, which estimated 2.5 million deaths, Roberts’ foot was shattered when it hit a hidden log as he rode a motorcycle along a narrow jungle path.  He had to continue anyway.  (His foot is still deformed.  Every step hurts.)

When the IRC leadership decided to accept money from the U. S. government just prior to the Iraq invasion in March 2003, Roberts resigned in protest, since he felt that it compromised the mission’s objectivity and tacitly provided “humanitarian” cover for the war.  With $40,000 from Johns Hopkins and other sources he decided to go to Iraq to study mortality on his own.  Through email, he arranged to work with Farzad (a pseudonym to protect him), a professor at Baghdad’s most prestigious medical school.

On August 22, 2004, Roberts flew to Jordan, where he found an expatriate Iraqi taxi driver willing to take him to Baghdad.  The driver advised him to give him his passport and lie on the floor in the back of the SUV when they got to the border.  There, the driver happened to encounter an old military friend, who took one look at the American passport and said, “Are you crazy?  Put that away!  Good luck, I don’t know you, go.”  So Roberts entered Iraq without having his passport stamped, a circumstance that would come back to haunt him.

When Roberts arrived in Baghdad unannounced and called Farzad’s cell phone, the Iraqi doctor was astonished that he had made it across the border from Jordan.  “Only Allah could have done this for you,” he said.  Unable to afford the secure luxury high-rises other Americans stayed in, Roberts rented a room in a small local hotel, where he tried to dye his light brown hair and beard black, then looked in the mirror.  “My hair was black black black.  My beard, tinged with grey, looked sort of blue, my thicker mustache remained brown and grey,” he recalls.  “I looked ridiculous, like a chocolate rainbow.”

The following day, he donned a long white Arab robe and flip-flops to meet his survey team.  As soon as Roberts got out of the car, Farzad burst out laughing.  From then on, he wore nondescript Western clothing, as did most Iraqis, and carried a fake ID saying that he was Dr. Abdul Salam from the Bosnian National University, so that he could have blue eyes, look European, speak no Arabic, and still not be seen as an American.

Farzad had recruited six interviewers, two of whom were women.  Five had medical degrees, one a near-Ph.D., and all spoke English.  Farzad had arranged for them to do test interviews in one of Baghad’s safest neighborhoods.  For the only time, Roberts stood with them during the interviews.  “I wanted to see their body language,” he says.

Two interviewers refused to ride in a car with him.  Roberts wanted them to ask to see death certificates in order to remove any doubt about mortality reports.  “No way,” the interviewers said.  “People will think we don’t believe them.  They might pull out a gun and shoot us!”  After two days of practice, during which the questionnaire was refined, they split into two teams, one led by Roberts, the other by Farzad.  Then they began to interview the first household clusters.

* * * * * * * *

The art of mortality survey epidemiology is not rocket science, but it is nonetheless a science, involving a fair amount of math, probability theory, and gumshoe experience.  In an ideal world, each death would be counted as it occurred.  But in the chaos of a war-torn country, what is the quickest, most efficient way to estimate mortality?  It turns out that 30 is a kind of magic number.   For any given population – refugee camp, city, region, or nation – you need to sample at least 30 clusters of people to achieve statistically reliable results.  These clusters should be chosen at random, but areas with greater population are allocated more clusters, which is why Roberts had chosen seven clusters in Baghdad itself.

Within each cluster, you need to sample at least 30 random households.  So, in total, the surveyors needed to visit 900 or more houses around Iraq.  Each team carried a Global Positioning System to find a predetermined random point.  From there, the three members on each team would interview the 30 households closest to that GPS point.  To make sure at least 30 locations were visited, Roberts had chosen 33 clusters throughout Iraq.

The Baghdad cluster interviews went well, as did the first few outside the city.  Roberts accompanied his team to the eighth cluster in the city of Balad, 50 miles north of Baghdad.  Entering town, he encountered two huge pictures of the anti-American Shi’a cleric Muqtada al-Sadr and his father.  The first random spot chosen by the GPS turned out to be the governor’s home.  Waiting in the car with his driver, Roberts watched his two interviewers go into the house.  A few minutes later, a police car pulled up.  Roberts watched as the police took his two interviewers away.  They will be killed, he thought.

After an hour and a half, the two interviewers returned unharmed.  The team completed its 30 households and drove back to Baghdad.  But Roberts never accompanied them again, realizing that it would only put the surveyors in danger.  He sequestered himself in his hotel room, descending briefly to the lobby at 5 a.m. each day to use the Internet to contact his wife and to email precious data to colleagues.  In the evening, his driver brought each day’s interview results along with something to eat.  Going over the questionnaires, Roberts would call the six Iraqi interviewers on his cell phone to ask for clarifications.

Fearing that he might be kidnapped at any moment, he wedged the top of a chair against the door handle, then shoved a bureau and ottoman against the chair, hoping to gain enough time to leap from his third floor balcony.  He occupied himself by entering new survey data in his laptop, working on a draft of the final paper, watching BBC World News (and occasionally Al Jazeera), doing 200 sit-ups and push-ups, and thinking.

Les Roberts barely got out of Iraq because his passport was not stamped.  This first survey estimated that 100,000 Iraqis had been killed since the war began.  The results, published in The Lancet just before the U. S. elections in November, were ignored or dismissed as overestimates.

* * * * * * * * * *

In May-June 2006, Roberts helped from afar (without returning to Iraq, since his colleagues insisted it was too dangerous for him and for them) as the same Iraqi team conducted another mortality survey.  This time, it revealed that an estimated 600,000 Iraqis had suffered violent deaths since the invasion.  Again, the study was published in The Lancet.  Again, it was ignored.  “If these assertions are true,” the Iraq Body Count website argued in dismissing the results, they implied “incompetence and/or fraud on a truly massive scale by Iraqi officials” as well as “an abject failure of the media.”  Roberts would certainly agree.

Now, despite the recent WHO/Iraq government report, Roberts remains quite sure that the mortality in Iraq since the invasion is well over a million deaths.  He is skeptical of the claims that violence in Iraq is down by half.  While violence may have been reduced in Baghdad, no one is tracking what is going on in the rest of the country.  No one wants to know.

Les Roberts teaches public health at Columbia University and Johns Hopkins and continues to agitate for change in American policy and to roam the world to try to prevent unnecessary deaths.


Dartmouth Bookstore event

March 31st, 2010

Tuesday, May 11, 2010, 6 p.m. — Mark Pendergrast will discuss his book, Inside the Outbreaks, and sign books afterward.  Dartmouth Bookstore, 33 North Main Street, Hanover, NH 03755-2098.  Phone:  603-643-2348.

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Flying Pig Book Store, Shelburne, VT

March 31st, 2010

July 22, 2010, 7 p.m. — Mark Pendergrast will be discussing his book, Inside the Outbreaks, at the Flying Pig Bookstore in Shelburne, Vermont, and signing books afterwards.  5247 Shelburne Road, Shelburne, VT 05482.  Phone:  802-985-3999.

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Vermont Edition on Vermont Public Radio

March 31st, 2010

Thursday, April 29, 2010, noon — Mark Pendergrast will appear on Vermont Public Radio’s “Vermont Edition” show to discuss Inside the Outbreaks, issues facing public health, and respond to callers on this live show.  Email your questions and comments to Vermont Edition any time to To call in during the live broadcast at noon call 1-800-639-2211.

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Barnes & Noble signing, Burlington, VT

March 31st, 2010

Thursday, May 6, 2010, 7 p.m. — Mark Pendergrast will be giving a talk about his book, Inside the Outbreaks, at the Burlington, Vermont, Barnes & Noble bookstore and signing books afterwards, at 102 Dorset Street, South Burlington, VT 05403
Phone:  802-864-8001.

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Diarrhea death toll

March 29th, 2010

March 28, 2010

In the United States, diarrhea is usually considered a nuisance, the subject of jokes.  But in the developing world, diarrhea kills some 2 million children a year.  It is the third leading cause of death in children under five, and the leading culprit is unclean water.  In 2006, I followed EIS officer Ciara O’Reilly in rural Western Kenya, near Lake Victoria, as she and her colleagues assessed the impact of the Safe Water System (SWS) in selected elementary schools.  In Inside the Outbreaks, in Chapter 22, I wrote about this trip.  Earlier in the book I explained the origin of this inexpensive, low-tech solution.  It started with horrendous cholera outbreaks in Africa and then in 1991 cholera leapt to Peru, the first appearance in Latin America in nearly a hundred years.  If untreated, cholera can kill within 24 hours due to dehydration.  (My book also relates the invention of “oral rehydration solution,” a life-saving drink, but that’s another story).  EIS officers discovered that even when water was properly treated to kill bacteria, it was often re-polluted when people dipped water out of storage containers, since their hands carried the germs.  So the CDC began to supply not only a dilute bleach solution (called WaterGuard in Kenya) but to provide narrow-mouthed water containers, the opening too small to allow a hand to enter.  There are spigots near the bottom.

As I saw in rural Kenya, the Safe Water System works.  Absenteeism and illness among students in the schools were down in contrast to the control schools without the program.  I also saw the source of the water some of the schools were drinking.  A ten minute walk from one school led to a stagnant pool of fetid water.  As we watched, emaciated cows, their ribs showing, came over to drink.  An old man, a member of the local Luo tribe, also came up and began to yell across the ravine, waving his arms and pointing at his head.  Our translator told us what he was saying.  The water made people sick, crazy in the head.  A local Catholic charity had promised to dig a well, but then the priest spearheading the effort was killed in a car crash, and it never happened.  Please help!

Obviously, the Safe Water System is a stop-gap measure.  In an ideal world, all people should be able to turn a tap and fill a glass with clean water.  But the huge cost of this infrastracture improvement is unlikely to be diverted from our spending on weapons, etc., in the near future.  So in the meantime, the SWS is a valuable tool.  After her two-year EIS service, Ciara O’Reilly, an Irish native, stayed on with the CDC in Atlanta and is working to bring cleaner water to the world.

Studies in seven countries on three continents have yielded a consistent result: use of the SWS decreased diarrhea risk by around 40% (though it does not kill viruses – rotavirus is a major child-killing cause of diarrhea, the subject of another blog perhaps).  Through partnerships with dozens of organizations from all sectors (private, NGO, UN, governments, community groups), the Safe Water System has been instituted in over 20 countries and protects three million people per month.  CDC and its partners are now trying to figure out how to get the SWS to more people — particularly the world’s poorest people.  The CDC has engaged schools, clinics, and HIV self-help groups to expand access to ever-more-remote locations.

April 2010 EIS conference

March 22nd, 2010

Wednesday, April 21, 2010, 12:30 p.m. Mark Pendergrast will give a presentation about the Epidemic Intelligence Service at the annual EIS conference on April 21, 2010, at 12:30 p.m. – 1:30 p.m.  It is held at the Crowne Plaza Hotel, Atlanta Perimeter at Ravinia in Atlanta, GA, just off the perimeter highway I-285, at 4355 Ashford Dunwoody Road.  Pendergrast will discuss the importance and evolution of the EIS, giving specific examples.  He will also discuss the process of research and writing Inside the Outbreaks.  The EIS conference is free and open to the public, and it is one of the best and most varied scientific conferences out there — and few know about it.  Anyone can register at   Note: On-line registration will close on April 5th.  For general information about the conference, see

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April 2010 EIS conference

March 22nd, 2010

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March 21, 2010 blog

March 21st, 2010

Welcome to my first blog.  (Actually, I wrote a different essay originally, but Amazon wanted to run it as an exclusive entry on their website for my book, so that’s where you can read it.)  I plan to write a new blog entry once a week (on Sundays), but we’ll see whether I can stick to that schedule.  My new book, Inside the Outbreaks, a history of the Epidemic Intelligence Service (a part of the CDC) is due out in April.  I just got a copy of the book, so it is off the presses.  It took over five years to research and write.  I wished that I could write it more quickly, but it was a complex story involving many different characters and diseases.  It certainly kept my attention the entire time.  Still, everyone I knew kept telling me that now would be the perfect time for the book to come out.  Hurry up!

Avian flu was exploding around the world!  Monkeypox had invaded America’s heartland!

Hurricane Katrina devastated New Orleans, and EIS officers descended.

Here in Vermont, an unusual number of people in a state office building in Bennington came down with sarcoidosis, a mysterious, still unexplained disease.

In Panama, EIS officers traced 46 children’s deaths to a liquid expectorant cold medicine contaminated with diethylene glycol sold by a Chinese firm as harmless glycerine.

Rift Valley fever struck in northeastern Kenya.

Cans of Castleberry’s canned Hot Dog Chili Sauce caused botulism in the United States.

A bizarre neurological illness in Minnesota slaughterhouse workers was traced to aerosolized pig brains.

Marburg and Ebola virus struck in Uganda, while Ebola killed in the Democratic Republic of the Congo, then hit Uganda.

Children across the U. S. played the “choking game,” in which they nearly strangled themselves in order to experience a brief euphoria caused by cerebral atoxia.  An EIS officer documented 82 resulting deaths.

A nation-wide Salmonella saintpaul epidemic sickened over 1,400 people in the United States and was finally traced to hot peppers imported from Mexico.

In April 2009 a completely new H1N1 influenza strain with genetic components from swine, birds, and humans emerged in the United States and Mexico.  The media called it “swine flu.”  Over the next few months, it spread throughout the world, creating a new pandemic.

And still I kept working on the book, and still my friends kept telling me that now would be the perfect time for the book to come out.

But guess what?  Now is the perfect time for the book to come out, and next week, and next year, and next decade.  One thing I have learned from my research is that nature (and human interaction with nature) will continue to provide surprise epidemics and public health problems on a regular basis.

When Alexander Langmuir moved to the CDC and then founded the Epidemic Intelligence Service in 1951, many of his friends told him he was crazy.  Antibiotics and vaccines would soon make infectious diseases obsolete.  He was focusing on a dying field.

That turned out not to be the case.  Bacteria quickly adapted to resist antibiotics.  Vaccines were useful but difficult, even in the United States, to get to all the children.  And vaccines would cause their own problems and controversies.

In addition, EIS officers have tried to deal with seemingly intractable problems caused by human behavior – smoking, drinking, poor diet, and lack of exercise are killing us more surely than microbes.

So, unfortunately, now is a great time for Inside the Outbreaks to come out, and the lessons to be learned from it will be applicable into the indefinite future.  In future blogs, I will deal with these public health issues in more detail.  I think I’ll write about the immense death toll of unclean water in my next entry.

Inside the Outbreaks signing in Atlanta Barnes & Noble

March 1st, 2010

April 22, 2010: Mark Pendergrast will be giving a talk and signing Inside the Outbreaks at the Barnes & Noble on 2900 Peachtree Road in Atlanta, Georgia, on April 22 at 7 p.m.  Please call 404:261-7747  for more information.

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