Dr. Georges Benjamin
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SUSAN DENTZER: And now, as you said, the world is very, very different. What’s changed just in the past days, weeks?
DR. GEORGES BENJAMIN: Well, one of the things we had in place before we had a basic surveillance system, we had infection control practitioners who gave us a lot of the information I just talked about. If you had a case of meningitis, you’re in the hospital, these are nurses who–in general, who went around the hospital and looked for disease. They’d go to the ER. They’d go to the lab. They’d look at the intensive care logs. And then they would, as a separate step, report back to the health department if they found something.
In addition to that, we had those cards I talked about, and we looked at those–we would look at those–those maps and those patterns.
Now, we’re moving in terms of minutes. Things are happening very, very quickly. Information is [inaudible] very fast. We have several different types of systems out there to try to look for sick people. We have what we call syndromic surveillance, and we’re looking for people with things like rash or gastrointestinal or stomach problems, people that are coming in with overwhelming bacterial infections of all kinds. And we’re measuring those things, and every day we sit down with that data. So data that we used to spend hours and days and weeks kind of pondering over and hypothesizing, we’re now having to look at that data and make decisions about whether or not there’s a blip, right away, every single day.
In addition to that, you have overlaid a call that comes in and says there was a sick patient in Hospital A or a sick patient in Hospital B, and then you’ve got to run over there and try to figure out what’s going on. Actually, a lot of times–the first time, as you pick up the phone and you call to verify actually there’s a patient there–and you get lots of rumors. We spend a lot of time doing rumor control because right now every sick patient who comes into a hospital who might be perceived to have any relationship to anything, certainly some of them are postal workers, but a lot of them are not. And they’re people who are concerned about their health.
And so we’re–we’re going around trying to find out first whether or not these reports are true. They’re also coming in from very, very non-traditional sources in many cases. They’re coming in from the press. They’re coming in from just phone calls from politicians who have heard. They’re coming in from people on–on the street who are calling to say they’ve heard. They’re coming in from union workers and union leadership.
So there are lots of pieces of information that have to come in, and all these things have to be filtered in order to decide which ones to pursue first and which ones to pursue second. And that’s virtually an onerous task.
SUSAN DENTZER: Give me an example, if you would, of a rumor that you had to, in effect, dispel that came across your plate recently.
DR. GEORGES BENJAMIN: Oh, we’ve had a couple rumors. We’ve had people that allegedly had skin anthrax, and we’ve had to go back and look and see whether or not they did or not. And in one case, actually, you know, the case actually turned out to be biopsied, and there was nothing there. But our initial thought was this is probably not the disease process, didn’t sound like it, but there was a lesion on a–on a hand. The good news is that wasn’t.
We had a couple situations where we had sick people allegedly at a hospital, and we’ve gone to the hospital and we couldn’t find sick people. Those kinds of things. Those were the easy ones.
SUSAN DENTZER: And these were reports that were called in by whom?
DR. GEORGES BENJAMIN: I think one was one called in by a physician. Another one I think was basically a press call, where the press was calling to find out whether or not we had someone sick.
In fact, I had one of the reporters who covers me who actually called me at home to–to say whether or not–he had heard that we had an anthrax case and Maryland was about to announce one. Well, the truth is, of course, we were not about to announce one, and I was–I was doing the reverse. I was trying to pick his brain to find out what he knew, because I certainly didn’t know. And the good news is it was not a case. This case actually turned out to be in another jurisdiction. It was not a case of anthrax at all, but it was someone who was–they were concerned about, and the good news is that that case was ruled out as well.
SUSAN DENTZER: You talked about the fact that in this particular case involving Brentwood, it really straddles three different jurisdictions: Maryland, Virginia, and D.C. Are those jurisdictions cooperating well together? Are those jurisdictional issues being bridged at this point?
DR. GEORGES BENJAMIN: Yeah, I think so. Let me add the fourth jurisdiction, that’s the Federal Government, because that’s an important component of all the things that we’re trying to do. I think so. I actually spent a whole day, and my good buddy DR. GEORGES Ivan Wachs (ph), who’s the health commissioner for Washington, D.C. I spent the whole day in his office talking with him, talking to CDC staff, trying to understand and coordinate some services with them. It was a good day because I got a good feeling for some of the things that they’re doing.
Prior to this, we had had a working relationship with those jurisdictions for the presidential inauguration and the IMF meeting, the International Monetary Fund meeting, and we, of course, planned to beef up our surveillance activity for that meeting. Unfortunately, September 11th occurred and we had to turn that system on a lot sooner than we had intended to do so.
SUSAN DENTZER: And let’s just say a word about the extra surveillance that that entailed.
DR. GEORGES BENJAMIN: Well, that extra surveillance included beginning to look at what we call syndromic surveillance. Basically what we do is we have hospitals reporting to us things like the number of ER visits and ambulance runs and how many people come in–go in and out of the hospital. But we added to that looking for groups of different types of things, again, people who have overwhelming infections, people who have rashes, people who have neurological problems, look like they’re having a stroke, because that’s a sign looking for something like botulism, people who are coming in with gastrointestinal or stomach problems. All these things we wanted to–to lump in these categories, and then we kind of measure a baseline and then we start looking for blips.
Then if we get a blip, then we go back and look and see if that is a problem for us, and we then try to look at the individual cases and try to understand what that blip really means.
SUSAN DENTZER: In the case of the postal worker who died a few days ago at Southern Maryland Hospital, it appears that some omissions at least took place in terms of discerning whether he was potentially at risk for anthrax. Depending on the press account one reads, he either was asked about what his occupation was and when he said he was a postal worker, nobody asked where, or he perhaps was not even asked at all what his occupation was, at least when he initially presented with these symptoms.
Did the system break down?
DR. GEORGES BENJAMIN: I think what we’re going to be doing is doing a lot of second-guessing about that, about what happened there. We’re going to be doing that for a lot of things that have happened throughout this tragedy.
I don’t know if the system broke down or not. I think it’s too early to say. I can tell you that in any single case, it was obviously missed. I think the one fundamental thing is and the one that has not yet asked was it being missed, would it have changed the outcome. I don’t know. I don’t know. I hope that we will have a system in place throughout this country that’s going to pick up very early people like him and get them certainly into therapy. It’s a real tragedy. I think we’re all very sorry that that happened, and we just hope that, you know, we don’t have another one of those.
SUSAN DENTZER: A lot of criticism is being heaped now on the Centers for Disease Control for a variety of things. One is the decision not perhaps to evacuate a lot of the Brentwood facility, treat all the workers very aggressively early on. Another is a lot of criticism over the flow of information from the CDC to other public health authorities and, indeed, even to physicians.
What’s your assessment of how the CDC is doing at this point?
DR. GEORGES BENJAMIN: Well, we’re working very carefully and strongly with the CDC. You know, the retrospectoscope is a very, very powerful tool. Clearly, this has shown that the CDC needs a better infrastructure. Clearly, this shows that local–state and local health departments need a better infrastructure.
But it is a disaster. Anyone who does not think that this public health disaster–while the number of people certainly who have died is nothing like the tragedy in New York, this is a public health disaster. And it has to be viewed in that manner.
We are learning every day. We are learning every moment. We are readjusting what we do. And I think at the end of this, let’s be judged on how quickly we were able to readjust and move forward versus by that powerful tool called the retrospectoscope.
SUSAN DENTZER: We were talking about communication a moment ago. Tell me what communications you now have in place for physicians in this state. What are you telling them, what are you sharing with them that’s different from what you were sharing with them before?
DR. GEORGES BENJAMIN: Well, we’re talking much more aggressively with physicians. So when we get information on how to diagnose a particular disease process like anthrax or the type of therapy they should get, the antibiotics, or when we found out that the anthrax was sensitive to all the commonest antibiotics that we normally use, we sent that information to physicians. We actually sent that to the state medical society who could send it out very quickly to 1,500 physicians in our state.
They fax it basically to the physicians’ offices. In addition to that, we do send some e-mails to some physicians. We also send things to the medical directors at our hospitals and to the emergency departments at our hospitals.
There’s some places that also send them at night to the administrator of the day. That’s the person that’s up in the middle of the night kind of running the hospital, making sure things are going well, and you send that to that person to make sure that it actually gets to the hospital emergency department.
We also send the information to our infection control practitioners. This is kind of the ongoing information that we give people about anthrax, about how to diagnose this disease, as well as some of the others.
Some of the other things that we’ve done is we have basically a four-hour course, and, again, our bioterrorism coordinator, she goes around the state and she gives that course, and it’s kind of an hour of, you know, Bioterrorism 101, a couple hours of the clinical stuff, and then the last part of this, how do you adapt that to your facility or community, what does it mean to you, kind of a question and answer session.
We’ve done things such as–I think today was the first day for one of our lab class where we actually bring in laboratorians to teach them about some of the threat agents, you know, how to–how to culture them, how to identify them, what do they mean from a laboratorian perspective.
So we’ve done several things with both the laboratory community, the hospital community, and physicians. Last December, we had a class basically for CEOs of hospitals and security personnel to talk about biological terrorism, basically. We’ve, of course, then given the usual lectures around the state to–and medical grand rounds. And we’ve had other hospitals that bring experts in to talk about bioterrorism. Then the goal is to make sure that physicians will be able to identify the threat agents, to identify people who may be sick when they come in. It’s just an extremely thing to do. And that task obviously isn’t done yet.
SUSAN DENTZER: How are you communicating with the public about this?
DR. GEORGES BENJAMIN: Communicating with the public is difficult, and I’ll tell you why: Because we’re trying to balance not scaring them with informing them. And, you know, we’ve obviously sent out press releases to the public to inform them when we have critical information. But that’s been our biggest challenge.
The good news is we have been able to get the message out, I think, through multiple sources, through local health departments, we’ve had television interviews and radio interviews, that regardless of what’s going on, the risk to any single individual is very small. The fact that you had thousands and thousands of people who died last year from the flu and from pneumonia is an extraordinarily important message. That doesn’t minimize any of these people that have gotten sick or the ones that have tragically died from anthrax. We don’t want to do that. What we do want to do is kind of try to put in perspective so that people aren’t afraid, so they live their daily lives, so they do what they have to do. And for me as a health official, spend money so I can improve my budget, and so that I can continue to improve the public’s health. It’s a very, very important thing to do.
SUSAN DENTZER: Endless of all stripes have made the point that in this exercise that we’ve been through recently we see the fruits of a systematic underinvestment in public health–
DR. GEORGES BENJAMIN: Yeah.
SUSAN DENTZER: –over years if not decades. What is your assessment? Do you agree with that? Have we totally underinvested–invested in public health, and are we seeing that now?
DR. GEORGES BENJAMIN: The public health system is part of our national defense. We have underfunded it. We have undersupported it. And it must stop. It has gone on for years. It’s bipartisan. We’ve all done it. And we in the public health community have not asked for what we needed. We’ve been good soldiers. And that must also stop.
I think what we’ve learned from this very, very tragic event is how much the public health community–how important the public health community is to this country.
I saw a survey a few weeks ago, and I’m sorry I don’t remember who did it, that said that over 70 percent of the American public did not know they had been touched by the Public Health Service. Well, that must mean that they don’t recognize that the water that they drink and the food that they eat and the clothing, bedclothes they put their children in every night, and the safe cars that they drive were not influenced by public health people. And the fact that there are diseases that we have prevented all these years and the people that we’ve made healthy have been totally forgotten. People just don’t remember that.
The fact that, you know, vaccine-preventable diseases are dramatically down in this country, and so we have just not really paid much attention to public health, and we need to really turn that around very quickly to be part of–you know, to really understand that public health is an important part of our lives every day.
SUSAN DENTZER: Do you have enough resources to manage your department effectively in this crisis?
DR. GEORGES BENJAMIN: We are managing this–this crisis. I tell you, we are pulling resources from everywheres. But we are absolutely talking to our federal partners about enhancing our resources in order for us to do a much better job, and we are going to need to do that, us and every other state in the nation.
SUSAN DENTZER: What do you need enhanced at this point?
DR. GEORGES BENJAMIN: Oh, we absolutely need more funding for communication systems. We need more funding for our laboratories, for reagents, small equipment. We need more funding for people and epidemiologists to kind of actually do some of this disease work.
We certainly need more funding for some of the interactions, just simple things such as being able to make telephone calls that are necessary to talk from one person to another.
We need to spend money for planning, continued planning. You know, you just don’t plan once, and that has to continue as well.
This is going to be an intense effort that’s going to take a long time to build up this system. But it’s going to need adequate funding.
SUSAN DENTZER: You discussed earlier the lack of potentially press understanding, public understanding of the role of epidemiology in attacking situations such as this. Let’s talk about that. What do epidemiologists do in this situation? And what does the public need to understand about that?
DR. GEORGES BENJAMIN: Epidemiologists, if you think about a detective, that’s what they do. They take a great deal of disparate information, they put it together, and they come up with the picture. And they have to make decisions along the way about what to do. So they may start with a little bit of information, and they may have to make a decision or recommendation to the medical community to do something based on a little bit of information. And then over time they may get more information, and they may make a different recommendation. And then, of course, they will get more information and make a different recommendation.
In this problem, with the anthrax, that time line has been compressed, so we’re making a lot of very rapid decisions in a very short period of time. But think of an epidemiologist just like a detective who’s having to [inaudible] the lock or get a piece of information or take a scrap of information, a little bit of disease here, a little bit of disease there, and make some guess about what the next thing has to occur, you know, to help people, and, more importantly, what they have to do is then decide do we do something to protect the public’s health now or can we wait. And that’s a balance. And sometimes we win that balance and sometimes we lose that balance. And when we lose that balance, sometimes more people get sick.
And so we have to weigh that every time we make a decision. It’s a very, very tough–touchy decision to make, a very difficult decision to make.