Medical Super Sleuths

THEIR CHASE SCENES TAKE PLACE UNDER MICROSCOPES and their offenders are usually bacterial, but it’s not stretching it too far to say that doctors Charles and Robert Haley are super sleuths after the proud tradition of Sherlock Holmes. As epidemiologists-Charles for Dallas County and Robert for Southwestern Medical School-the brothers are essentially medical detectives. Their victories aren’t in Lazarus-style healings, but in meticulously piecing together scraps of information to determine the causes and effects of mysterious diseases.

What do epidemiologists do? A rather crude parallel that describes their livelihood goes something like this: suddenly, one by one, a group of million-dollar race horses charges off a cliff into a rocky, fast-flowing river below. The most gallant M.D.s dutifully rush to the scene and climb about taping legs and administering horse pills.

It’s an epidemiologist who first looks up from the growing mound of dead horses and exclaims, “Lordie, they’re still jumping- we’ve got to stop those fools.”

Day-to-day tracking of public health statistics isn’t always that spectacular, the Haleys are quick to admit. But, Charles says, ’If people don’t know we’re here, we must be doing a good job,” Charles became the county health department’s first epidemiologist when he accepted the position in July 1984. He may be biased, but he says he thinks the decision to hire an epidemiologist showed forward thinking on the part of the department and an important commitment to a disease prevention program based on a scientific monitoring of the whole population. The health department had traditionally maintained a more clinical approach to public health, emphasizing direct observation and treatment of individual patients.

Charles took the job after completing a fellowship in clinical infectious disease at Parkland in 1984. Before that he’d done another fellowship in hospital infection control and worked four years with the Centers for Disease Control in Atlanta (CDC). Both brothers did internal medicine residencies at Parkland after graduating from Southwestern Medical School. Robert spent ten years with the CDC, eventually completing a multimillion-dollar study on hospital infection control as chief of the CDC’s hospital infection branch. He joined the faculty of Southwestern in 1983.

The brothers approach their field from entirely different angles. Robert, who is forty, is chiefly an academician as director of epidemiology and preventive medicine at the health science center. His job allows him to be the dreamer of the pair, constantly pondering new theories for improving disease control. Charles, thirty-six, has to keep his feet on the ground as a watchdog for public health. He says he works to translate the useful information gathered by academicians such as his brother into practical public policy. “Together;’ Charles says, “we want to build a good health information system, to define problems with some degree of precision, to use funds well and efficiently so that the health department can do more than just issue birth and death certificates.”

In Charles’ cramped, civil-servant-style office in the health department office near Parkland Hospital, a large map of Dallas County covers much of one wall. Using the reports of communicable diseases submitted by doctors, Charles can plot the wavelike movement of influenza across the map as it begins to appear in localized outbreaks in November, fades during Christmas holidays, and resurges in mid-January. Charles can also point to the pockets in Pleasant Grove where infant mortality seems particularly high and to the Village-Vickery area where suicides are most numerous. (Despite the sound of the word, epidemiology is not confined to the study of epidemics. The field includes the study of all diseases; homicide, suicide, and even drunk driving, can be studied epidemiologically.)

Both brothers are interested in the current 10 percent to 20 percent increase of tuberculosis in Dallas. Robert theorizes that the increase, which is particularly evident among the homeless, may be due in part to changing immigration patterns, better tracking of the disease, and possibly the incidence of AIDS, since tuberculosis is the type of infection an AIDS victim is likely to acquire.

Although Charles says the resurgence of tuberculosis is as big a problem as AIDS, 90 percent of his time is spent keeping abreast of the newest Findings in AIDS research and helping to bring those findings in a practical way to the community. “We know almost all there is to know about TB,” he says, “but the book isn’t written yet on AIDS.” Epidemiologists all over the nation send their AIDS research results to the Centers for Disease Control, which works to compile and interpret the data.

Away from their graphs and tables, the Haley brothers are great spinners of “war stories,” the best of which-fortunately for us-occurred elsewhere. While with the CDC in Atlanta, they kept dop kits and spare shirts packed, ready to take with them on the next plane out to investigate an unusual disease outbreak anywhere on the globe. Charles traveled to the island of Mauritius, an American and Soviet monitoring station in the Indian Ocean, to investigate an unexplained outbreak of typhoid fever about a month after a cyclone hit there in 1980. After a twenty-four hour trip, he arrived at the airport tired and disheveled and was surprised with a VIP welcome by the American embassy. After only ten days’ investigation Charles pinpointed the outbreak’s source; after the cyclone, a crossed connection between a water main and the sewage system had backed up the sewer behind the home of a boy who had been diagnosed with typhoid fever before the storm. Hospital officials had treated and discharged the boy from the hospital to make room for those injured in the cyclone. By an unfortunate coincidence, the worst foul-up in the sewer and water lines occurred behind this young man’s home.

Another interesting case for Charles came in 1977, It was his first assignment while assigned to Berkeley. California as an officer for the Epidemic Intelligence Service. He received a call from a panicky health officer in San Jose who said a local hospital had just received a report of a case of the bubonic plague-the same black death that wiped out a third of Europe’s population during the Middle Ages.

Tests on the blood serum specimen the official sent Charles confirmed the grim findings. Since the bacteria that cause this rare infection are carried by fleas and rats, Charles took a small mammal specialist with him to San Jose in hopes of locating the animal carrying the disease. They arrived after the victim, a veterinarian, had died- more than half of the time bubonic plague brings death within a couple of days. Examination of the body showed no flea or rat bites, leading Haley to fear the man had died of pneumonic plague-a more serious threat to the general population since it can be contracted through inhalation.

Since the infection could be transmitted through coughing and the deceased man had not been in isolation, Charles worried that many others had been infected. To his relief he learned that the victim had tried to take a bus to the hospital, but it was too crowded- he’d had to drive himself. The man lived alone, so the number of traceable exposures since the probable time of infection was limited to those in the hospital emergency room at the time of his admission. Charles located all but one of those he knew had come in contact with the man. He began monitoring their temperatures and administering tetracycline.

The missing person who had been exposed was a nurse who had left on vacation. Charles issued an all-points bulletin for her apprehension; the nurse and her husband were driving to British Columbia when they noticed flashing police lights in their rear view mirror. The officer didn’t dare approach the woman, so he shouted the alarming news through a bullhorn: “You have been exposed to the plague.” She immediately followed him to a nearby hospital.

The widely publicized case generated some hysteria among the people of San Jose. Amazingly, no more cases occurred; the man had apparently been the victim of an isolated carrier. Charles still believes the man suffered from a bubonic infection, and that a tiny flea bite was simply not detected. Since all the animals the veterinarian had handled in the two weeks before his death were examined except those that had died or been put to sleep, Charles assumes that the culprit had been cremated before he had a chance to examine it.

Both Haleys compliment Dallas for providing the support and funding necessary to take a sophisticated approach to epidemiology. Robert is currently involved in the study of hospital-acquired infections, which include pneumonia, surgical wound infections, and renal and urinary tract infections directly responsible for 2,000 in-hospital deaths annually and indirectly responsible for an additional 60,000 deaths each year. The preventive program Robert recommends could reduce those numbers by at least one-third through increasing staff trained in infection control. Hospital-acquired infections are a modern problem, he says, a drawback of new, invasive medical procedures (such as chemotherapy and immuno-suppression for transplants) that bypass the body’s normal defenses.

Robert and Charles Haley come from afamily of four sons-all doctors-whosefather and grandfather were physicians.Charles says: “Both of us have our eyes openfor problems to study in a scientific mannerand translate to programs that will meaningfully affect public health.” Most of thetime, the brothers say, their efforts dovetailbeautifully.