Introducing Backstories in Epidemiology: True Medical Mysteries

by Lloyd F. Novick, MD, MPH

Dr. Lloyd F. Novick

Introducing Backstories in Epidemiology

The September-October 2018 issue of the Journal of Public Health Management and Practice includes an article entitled “Mystery in the Pines.” It recounts a large typhoid epidemic in the Catskill Mountains written by editorial board member and former New York State health official, Gus Birkhead. This article is the first in a collection of historic narratives called Backstories in Epidemiology. Compiled and edited by John Marr, Carole Novick, and myself, this series is written in the spirit of the classic Eleven Blue Men and Other Narratives of Medical Detection by Berton Roueché (1965, Berkeley Medallion, New York). Roueché wrote for the New Yorker for nearly 50 years. His true stories of medical detection originally appeared there in a column called “Annals of Medicine,” first published in 1948. Roueché’s stories provided an introduction to epidemiology for many public health professionals. In fact, the Centers for Disease Control and Prevention lists his book as a suggested resource for teachers and students. It is our intention in developing Backstories in Epidemiology to provide an updated collection of medical mysteries.

In each of the next several months, a new true medical mystery story will be posted here on JPHMP Direct. Following the case format used in JPHMP, actual situations with protagonists identified by name are used. After publishing our first six cases on a monthly schedule here on DIRECT, we will welcome submissions from other epidemiologists who adhere to our story format and provide new mysteries of medical detection for our readers.

Introducing Backstories in EpidemiologyRead Backstories in Epidemiology: True Medical Mysteries

We are publishing these stories not only because of their interest but also because of their importance to practitioners and students of public health and health professions at all levels. With the explosive growth of public health education at high schools and community colleges, we believe there is a broadening audience for this type of content. Following our case format, each narrative is accompanied by questions for the reader.

Available on JPHMP Direct

Offered this month on JPHMP Direct is  “The World’s Deadliest Poison,” written by John Marr and Marcus Horwitz. It is an account of botulism in a New York City family that results in two fatalities. In the months to follow JPHMP Direct will post stories to include “It’s all in the Bottle,” an apparent outbreak of TB in a Virginia state prison for women; “Bad Blood: The Gift of Giving,” a malaria outbreak in New York City; “Appendectomy Masquerade,” an epidemic initially attributed to appendicitis in upstate New York; “The Babies are Dying,” newborn deaths in a West Virginia rural hospital nursery; “Clam Aches,” an outbreak at a church picnic from Maine clams; and “Of Bites and Men: The Most Dangerous Urban Animal,” a story revealing that the number of human bites exceeds shark bites.

Two additional investigative medical mystery cases authored by John Marr can be found in JPHMPs 21 Public Health Case Studies in Policy and Administration, published in 2017 by Wolters Kluwer. “It Takes a Village” describes an outbreak of amebiasis in men living in the West Village in the 1970s, presaging the AIDS epidemic. “Typhoid Moishe” looks at a typhoid epidemic spread by a Hasidic rabbi officiating at Bris ceremonies (circumcisions). The latter case has a contemporary epilogue found in recently reported transmission of Herpes Simplex by rabbis at these events

Epidemiological approaches have undergone many changes since the publication of Roueché’s cases and the stories we are publishing with this collection. Yet, while investigations have been greatly aided by technology, the pathways to solutions still are routed in human curiosity and hard work.

For example, in “Mystery in the Pines,” Birkhead mentions that the New York State Health Department used cards to keep a registry of known typhoid carriers. Marr also mentions cards in his case about human bites in New York City. Today, computerization has greatly facilitated disease reporting and outbreak investigation. In-depth studies using GIS technology (geographic information systems) became available in the mid-1990s, which has replaced sticking pins into a map to chart disease occurrence. GIS systems now can be used to link database information with maps to provide for spatial analysis. In “Mystery in the Pines,” a bacterium was recovered from a typhoid carrier and also from the putative vehicle of infection (orange juice). Current technology utilizes genetic typing of the isolates of the bacteria from the carrier and the bacterium recovered from the vehicle of infection, although this was not available at the time. However, even currently used techniques to obtain DNA fingerprints of bacterial agents of infectious diseases frequently cannot discriminate between all bacterial strains of the same outbreak, making it difficult to trace the spread of the disease. A recent solution to this problem is the application of next-generation whole-genome sequencing techniques, which allows all available genetic information of each clinical isolate to be determined. The availability of comparatively cheap whole‐genome sequencing technologies in the last few years enables monitoring all changes in a bacterial genome and providing maximum discriminatory power between two isolates.

Call for Submissions

We hope our readers find Backstories in Epidemiology to be rewarding reading. As editors and chapter authors in this series, we have found this to be an enjoyable and worthwhile endeavor. The majority of the cases in the Backstories of Epidemiology collection have so far occurred in the 1970s and 1980s with two occurring in the 21st Century. While all of these cases do update Roueché’s work by an average of more than 30 years, we are seeking additional contemporary cases. We believe this is possible, even realizing some of the current challenges of the format that captures real situations and identifies protagonists (not those individually affected).

If you would like to contribute a backstory from an actual epidemic, please contact the editor for consideration at

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Lloyd F. Novick, MD, MPH, is the Founding Editor and Editor-in-Chief of the Journal of Public Health Management and Practice and Professor Emeritus of the Department of Public Health at the Brody School of Medicine, East Carolina University. Follow him on Twitter. [Full Bio]