In a rare act of bipartisanship, Congress passed a law to deal with this potential problem. Physicians are now required to make a diagnosis before prescribing Dormigen. A doctor has to at least make some conjecture as to why your chest is covered with open sores. Then you get your gel caps. Yes, physicians still cut corners, offering vague, incomplete, and often inaccurate diagnoses (e.g., “tropical disease”), as I would if I were an overworked general practitioner with twelve and a half minutes to spend with each patient. Still, some information is better than none.
The same law requires that if a physician prescribes Dormigen without a firm diagnosis—if he or she really cannot identify the underlying illness—the symptoms have to be entered into a federal database. Doctors hate it; so do the anti-government folks. Big Brother now knows if you have a rash on your penis. Like many federal regulations, this one is imperfectly observed and poorly enforced. Nonetheless, on that snowy March evening in Natick, Dr. Helen Spellings typed a few vague lines into the Dormigen Prescription Without Diagnosis (DP-WoD) database at the end of her shift. The salient key words of the undiagnosed illness were “healthy male,” “nonresponsive fever” and “flu-like symptoms.”
In Tampa, Florida, at about the same time that Dr. Spellings was typing those vague symptoms into the DP-WoD database, Tom Elliott, a management consultant from San Francisco, was spiking a fever as he prepared to give a presentation to the board of directors of a large auto parts manufacturer. Elliott did not seek medical attention, as far as we know. Our best guess is that his fever was around 102 as he rushed through his PowerPoint slides. He mentioned in passing at the beginning of his presentation that he was not feeling well. He later sent a text to his daughter saying he felt miserable—so bad that he was not sure he could tolerate the five-hour flight home. Elliott went back to his room at the Marriott Courtyard, presumably to rest. A hotel employee found him unconscious that afternoon when she went to clean the room. By the time Elliott was transported to a hospital, his major organs had shut down. He died less than an hour later. Tom Elliott was forty-three and healthy. As far as we know, he was the first fatality of the Outbreak.
Elliott’s death, and what little could be pieced together of his symptoms, were entered in a different federal database, the Fatal Infectious Disease Surveillance Instrument (FIDSI). This database has been around longer; doctors take it much more seriously. Public health officials pay attention when otherwise healthy people die from unknown causes. On the same day that Tom Elliott died in a Florida hotel room, six other people died with similar symptoms: five middle-aged men and a female lacrosse player at the University of Vermont. But to spot that pattern, someone has to be looking for it.
10.
“WHAT DO YOU MAKE OF THIS?” TATIANA BOROVSKY ASKED her supervisor.
She had walked down the hall at the CDC on a Monday morning clutching a handful of papers and some rough statistical analysis she had done earlier that morning. The public would eventually know her simply as “Tatiana” after stories described her as the “discoverer” of the Outbreak. I suppose it was technically true, in the sense that Tatiana Borovsky was the first person to notice a statistical anomaly, the mathematical manifestation of an epidemic. If I were to be less generous, I would point out that the first person to discover it is raining is not necessarily a genius. The data, like raindrops, tend to fall on your head.
Tatiana was tall—nearly six feet—and exotic-looking. One has to wonder if she would have received as much attention if she had been a balding, middle-aged man, like her supervisor. She had an intriguing backstory, including family that hailed from the Balkans and Syria. (Her provenance tended to shift, depending on the news story.) Tatiana had long legs, long jet-black hair, and exotic if not necessarily beautiful features. As you may remember from some of the news stories, she also had a proclivity for skinny-dipping while on holiday at various destinations on the Black Sea. One lesson from the Outbreak is that if you are lanky, reasonably good-looking, and prone to post topless photos on the Internet, you are likely to garner undue attention. Tatiana walked down the hall on that Monday morning with data showing an increase in unexplained deaths that was two standard deviations above the norm. If one does a Google search of “Tatiana Borovsky and two standard deviations” the topless photos come up, along with a succinct explanation of what a standard deviation is, using breasts as a teaching tool. One standard deviation is significantly larger (or smaller) than normal. Two standard deviations is very unusual—as the photos illustrate. Very clever, I suppose. (To be clear, I never visited this site while using my government computer.)
“Probably just noise,” Tatiana’s supervisor said as he perused the data. “But those are big numbers.” He had a small, windowless office with pleasant but artless photos of his second wife and their blended family. He most likely did not take photos of himself swimming naked, and if he did, no one would want to see them. “Check all the databases,” he told her. “See if anything turns up in the OECD numbers.”
This was basic epidemiological detective work. You look for patterns. The more data you have, the easier it is to spot them. Suppose six people driving the same kind of pickup truck die in traffic accidents in six different states. A police officer at each accident scene will investigate the crash and fill out the paperwork. Why would any one of those officers—just one person examining one crash site—suspect that the brakes on that particular pickup truck were faulty? Each report gets filed away. Maybe it ends up in a state database, one piece of a jigsaw puzzle. No one can do the puzzle without seeing the other pieces. But when a mid-level bureaucrat at the National Highway Traffic Safety Administration—Tatiana without the legs and exotic looks—gets a weekly report showing a cluster of fatal crashes involving a T-370 pickup, she is going to put down her coffee and walk that report down the hall. Someone is eventually going to take a look at the brakes on the T-370.
Tatiana did that. The rhetoric about her as “the hero” and “the Syrian savior” was not merely overblown; it was ridiculous. She had only one basic responsibility, which was to gather reports and look for anomalies. She was not a paper pusher, more of a paper catcher. The oddity she spotted was 107 unexplained deaths from flu-like symptoms in the previous week. All were otherwise healthy people. Most were under age fifty, including eight college students. Even in the era of Dormigen, there are periodic spikes in unexplained deaths. Most of them turn out to be statistical noise, but as Tatiana’s supervisor rightly observed, 107 was a curiously high number for unexplained deaths among healthy people. Each of those deaths was its own tragedy; together they may have been the pieces of a more interesting puzzle. Or maybe not.