The evolution of epidemiology: Reflections from Monto & Martin

0:00:41.2 Emily Martin: I was thinking about something as I was driving in today. Have I told this story when the first time I met you? I don't think you know this story.

0:00:46.9 Arnold Monto: I don't know this story.

0:00:48.0 EM: It was when I was a grad student and it was the first time I had a talk. I had an abstract selected for a talk and I was in the IDSA ready room trying to upload my slides for my talk. And you sat down next to me and you could not get the computer to work. Like you could not get your slides uploaded. So I scooched over to work on your slides big...

0:01:08.3 AM: This is when you were in Washington.

0:01:10.0 EM: This is when I was in Washington. And so I opened your slides and it loaded above and I saw who you were 'cause I didn't recognize you by looks. And I was like, "Oh. And I just got," I didn't say anything. I just made sure that your slides worked and then I scooched back over to my computer. But it was probably like five years before we had ever worked together.

0:01:26.7 AM: Yeah.

0:01:30.7 Host: Hello and welcome to Population Healthy, a podcast from the University of Michigan School of Public Health. Join us as we dig into important health topics, stuff that affects the health of all of us at a population level. From the microscopic to the macroeconomic, the social to the environmental, from cities to neighborhoods, states to countries and around the world.

0:02:01.2 Host: The University of Michigan School of Public Health has been at the forefront of shaping public health research and practice since 1941. We're particularly proud of our connection to two of the most recognizable names in the history of epidemiology Thomas Francis Jr. And Jonas Salk. Francis founded the Department of Epidemiology here at the University of Michigan School of Public Health. He was also the first person in the US to isolate the influenza virus and was one of the leading minds behind the creation of the very first flu vaccine. When Salk came to the University of Michigan in 1941 to pursue postgraduate work in virology, it was Francis who taught him the methodology of vaccine development. Salk's work at Michigan ultimately led to his polio vaccine. Francis conducted the largest field trials in history proving that Salk's Polio vaccine was safe, potent, and effective. Today we sit down with two contemporary University of Michigan epidemiologists, who over the course of their time at Michigan Public Health have made their own significant marks on the field and continue to do so.

0:03:00.6 Host: Arnold Monto, professor Emeritus of Epidemiology and Global Public Health is a world renowned expert in respiratory infectious disease and influenza. He's been a cornerstone of our faculty for over 55 years. Emily Martin, an associate professor of epidemiology at the School of Public Health, has played a crucial role in addressing recent infectious disease emergencies through her work on respiratory viruses and vaccines. These colleagues have collaborated on numerous infectious disease studies from flu to RSV to COVID and beyond. They sat down with us to reflect on the evolution of the field and science of epidemiology from their view here at Michigan Public Health.

0:03:39.5 EM: So let's talk some history.

0:03:41.2 AM: The Francis era was a very different one because there were a number of people who were leading lights in the field and everybody knew their names. And now, other than Dr. Fauci and other people like that, I don't think the public really recognizes the names of leaders in the epidemiology field the way they did at that point. Remember we had Dr. Francis, who was the founding chair of the Department of Epidemiology and we're sitting in a building named after him, and his student was Salk. And the closest one of his colleagues who he had a lot of differences in opinion with was Saban. And there were many other people. This was the year of, let's say, vaccine development at the point. It was the measles vaccine and things like that, which were developed by, again, leaders in the field whose names were almost household words for the public.

0:04:56.4 EM: And so Salk, so Jonah Salk, Dr. Francis's student.

0:05:02.9 AM: And he went to Pittsburgh...

0:05:03.0 EM: And then he went to Pittsburgh.

0:05:02.9 AM: Where he developed the vaccine using the technology he learned here.

0:05:08.1 EM: And was still...

0:05:09.0 AM: Because it was the same technology that was used to develop the inactivated flu vaccine.

0:05:14.9 EM: So how did you start working with Dr. Francis? 'cause you're not from No Michigan originally.

0:05:21.8 AM: No, I was...

0:05:21.8 EM: I mean you've now been here.

0:05:23.6 AM: I was, this goes back to the era when there was still a doctor's draft. This is actually pre-Vietnam. And at the point when I entered the field, there was a required military service for physicians. And there was not required military service in the general population until the Vietnam War came along. The way people did their national service and prepared themselves for their careers at the same time was to find a position in which they could do both. And what I did was I went and was working at a National Institute of Health Laboratory in the Panama Canal Zone, which was very interesting because that's where I learned how to work with the respiratory viruses. Because what we were doing was showing that those viruses, which had only recently been identified were ubiquitous. They were in the tropics as well, even though common coals we think that there's something that is associated with cold weather.

0:06:37.4 AM: And we showed that it was present in the tropics. I started doing some studies in a local community to show this. And in Michigan, the Tecumseh study was actually looking at health and disease in an American population already. But didn't have an infectious disease element in it, which is kind of funny because Dr. Francis, who was an infectious disease epidemiologist, was the founder of that study. And that's how I got recruited to come to Ann Arbor to try to set up a community study in a US population. And we thought we were gonna have the vaccines for all these viruses quite promptly.

[laughter]

0:07:26.0 AM: Such as RSV.

0:07:26.7 EM: As as RSV.

0:07:27.8 AM: And the RSV vaccine has only been available now.

0:07:32.4 EM: If you think about that, going from Tecumseh and we're like finishing up the results of the first RSV community vaccine study...

0:07:43.6 AM: Yeah.

0:07:43.8 EM: All of these years later. Right?

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0:07:47.3 EM: I mean, you've always had a really good relationship with a lot of people in the media and you do a lot of either public comments for newspapers and things like that, but you also do a lot of informal work just educating people in the media. And I've done some of that too, and I've been impressed the degree to which we've been able to build these relationships, but then help reporters understand the science so that they make good calls.

0:08:13.8 AM: But one of the things that has happened in the media is there are fewer and fewer health reporters, people who really understand. And it's really surprising. This is in part a result of the total revolution where we don't have newspapers anymore. So you have to go to very, very circuitous roots to find out what's going on in Ann Arbor.

0:08:43.0 EM: So you've always kind of been, I mean, since I've known you've always kind of been the explainer, the flu explainer for a lot of, the news station. Does the interview with you every year about what to expect from flu season, everything. Was that something that you intended that you sought out to have that role? Or did you just sort of land in it and you had a knack for it and you became the local flute.

0:09:07.5 AM: Well, in epidemiology, we need to take advantage of situations. And one of the problems we have in epidemiology is that the funders also change their interests. And it's very hard to keep a steady research agenda going with the kind of funding that we have. And that's a real problem. I think it even more in epidemiology than in other areas where with cardiovascular disease, for example, there it is a clinical entity. There's always something of importance going on. And it is usually consistently funded. But until recently, we've had a great deal of trouble doing epidemiologic studies, infectious disease epidemiologic studies. We had a period where when antibiotics came in there was a feeling that all problems had been solved. Really? Antibiotics would take care of everything.

0:10:12.0 EM: You got pushback for being infectious diseases and...

0:10:14.7 AM: Yeah. And I was told I should become a cardiovascular disease epidemiologist. I was wasting my time working on infectious disease. And things were difficult at times. And now we've had one outbreak after another. Remember we went from 1977 through the occurrence of H5, and that really changed things. Up to that time, it was pretty quiescent in terms of interest in respiratory infections because there was gradual development, but no major development and no major pandemics or no pandemics. One of the things Dr. Francis did say was that in each pandemic, and he had been through several, people were drawn to work on flu who didn't have a history of working in flu, and they reinvented things that were actually known from previous pandemics. And we've seen that recently.

0:11:20.4 EM: And now you've seen that evolution happen over time. And we're both thinking a lot about bird flu right now or avian flu or cow flu as the case may be. We're recording this in end of July, beginning of August. Where do you think this is? It's hard to say where it's going, but yeah. Where do you think this is going?

0:11:45.4 AM: Well, I have a feeling we're still gonna be dealing with it at about the same level, because things have really more or less stabilized. There's a lot of new cases of human avian influenza, but they're associated with a true avian outbreak in Colorado. And apparently the appropriate handling of an outbreak did not occur. They said they were actually circulating the air in the place where the chickens were being kept because it was very hot. They were having a heat wave and a fan was operating.

0:12:24.4 EM: Interesting.

0:12:25.2 AM: And that would clearly stir up any material droppings and things like that, because in birds flu tends to be a gastrointestinal disease and it's in the dropping. So that may be why there were human cases, but the interesting thing is, we're worried about H5 because it has the potential to cause severe disease. And we have only seen mild disease in the United States associated with the H5 cases, even the ones that were associated with a typical avian outbreak.

0:13:02.8 EM: Yeah. The fan thing is interesting. It's like my favorite live market study where they identified the de-feathering machines is having like spewed the virus and then it gets carried away by the ventilation. One of the things that worries me is that the reservoir is going to be so established now given that just the number of bird populations that have it, the number of domestic animals and wild animals and mice and all sorts of things that they have been finding the virus and it seems that it's just established and it's gonna be something that we are gonna have to deal with periodically in the US.

0:13:41.7 AM: It's a real transformation.

0:13:43.8 EM: Yeah.

0:13:43.8 AM: Because we really haven't had it in North America, the highly pathogenic H5N1 until fairly recently. They've had it in Europe, they've had it especially in Asia and to a lesser extent in Africa for a long time and they do see these flareups. So I think you're right. It's going to be new but the dairy cattle thing is a really new phenomenon.

0:14:12.5 EM: Yeah.

0:14:13.0 AM: It's quite clear that it hasn't been seen before because people have looked in various parts of the world. They're very aware of H5N1 and it appears to have been a single origin in Texas according to molecular work that some of our colleagues have done, and it's therefore probably the result of a mutation which allowed this to happen.

0:14:40.4 EM: Right. There's a lot of unknowns here 'cause we don't know how the cows are infecting the cows, but what you know from flu and previous emergences, zoonotic emergences, what do you think about vaccine landscape and the antiviral landscape and whether do you think the US is ready to make those decisions? Do you think we're not ready to make those decisions? I mean, based on we've made those decisions correctly and incorrectly in the past.

0:15:07.6 AM: Well, there doesn't seem to be a whole lot of discussion about how to handle this. Usually you get NIH meetings and things like that and in a situation like this, decisions are often made on the fly and sometimes they're correct and sometimes they're not. I suspect that what is going to happen is that the disease will continue and there will be modifications of what was actually done in the 2000s when we first were afraid of H5N1.

0:16:00.5 EM: Can we talk about some old outbreaks?

0:16:02.2 AM: Yeah.

0:16:02.7 EM: What is kind of similar and different now compared to some old classic emergences that I teach about but wasn't here for, but Michigan was involved in. It does seem for all of the advancements and for how incredibly fast we get to the sequence. Now the tools, we've talked about this, like the strategies have not changed that much since 1968.

0:16:24.8 AM: Well, 1968 was a clear pandemic. It was associated with the swapping of a couple of segments, particularly one segment into the existing human flu virus from birds and the concept evolved then that the influenza pandemics were gonna result from the swapping of a segment of the virus from birds and that's how things were gonna happen. And then we've had a couple of pandemics since, or one pandemic and one pseudo pandemic. And people forget about the pseudo pandemic in 1977. And in 1977, a virus which had been extinct we thought, for 20 years came back and it came back in a form that was very similar to the virus that had been seen 25, 30 years before. It was an H1N1 virus and everybody said it was a weird situation. Up to that time, we only have one type A virus circulating.

0:17:38.2 AM: And that's when we did some studies here, which showed that antivirals did work in preventing a transmission because it particularly hit younger people, older people because the virus had been around previously were not as susceptible. Young people were totally susceptible. We had university outbreaks with a great deal of not very severe illness, but clear febrile illness and that's when we showed how you can control an outbreak with antivirals. Now we didn't know what was gonna happen, but the virus has continued and not only that, a variant of the virus was responsible for our most recent flu pandemic.

0:18:26.0 EM: Yeah.

0:18:26.0 AM: Which...

0:18:26.2 EM: The 2009.

0:18:27.6 AM: Nobody really expected.

0:18:29.2 EM: And then that impacted the exposure to the 1977 virus impacted how people responded to the 2009 pandemic, like how aggressive it was in 2009.

0:18:40.0 AM: Exactly.

0:18:41.9 EM: So my students never believe me when I teach about the 1977 pandemic, and I've now found some written histories about where that virus came from. I'm trying to put myself in your shoes in 1977, when this virus started circulating, like who knows where it came from?

0:19:00.5 AM: Well, we called it the Russian flu because, or AUSSR was the strain that we worked with, but China was closed at that time. And basically, we only learned about what was going on when it came into the Siberia, which was part of the USSR at the that time and we called it the Russian flu. But subsequently, we've learned that there were outbreaks in China before that time. So there have been multiple...

0:19:27.3 EM: It's a mystery.

0:19:30.1 AM: Hypotheses of where it came from, especially since it was very close to a previously seen virus.

0:19:36.9 EM: Interesting. And is that the outbreak? Now, there was an outbreak that you found out from Dr. Francis?

0:19:44.7 AM: Oh, that was in 1968.

0:19:47.3 EM: That was '68.

0:19:47.4 AM: He happened to be in Hong Kong at the time, and it was not until it hit Hong Kong that the outbreak was recognized. Ann Arbor has always had various individuals very much interested in flu in the epidemiology department. And he sent a cable.

0:20:04.1 EM: I was gonna say, 'cause he didn't send an email. So how did he get these vaccines?

0:20:10.1 AM: He sent a cable which said, "A severe disease to be seen in Hong Kong may be pandemic action," because you had to pay by the word. So it was a very terse cable that he sent.

0:20:26.5 EM: I feel I wanna make this visual compilation of all of the first emails that have been sent in the flu group over decades as different outbreaks have happened. You know what I mean? I'm interested to know how working with the community has changed over time, over your career compared to your first studies in Panama and then your studies as you got to Ann Arbor, but then watching that evolve through all the years that you've been in Michigan.

0:21:00.7 AM: Well, there have been a lot of changes in the world over the last 50 years, many for the better in terms of the technology. And at the same time, the population has become a lot more sophisticated about the technology, using the technology and being familiar with a lot of things that really were considered...

0:21:27.7 EM: Kinda like niche topics.

0:21:28.8 AM: Something associated with moonshots and things like that. It was really different. But at the same time, the population has become much more suspicious that many of these things are being done for other reasons than to move science or the world forward. And we used to be able to do studies much more easily with very little inducement, except to talk about how this would benefit the overall population. For example, we studied how vaccinating school children in Tecumseh in the 1968 pandemic would prevent transmission in the community herd immunity. And we actually studied this in 1968, and the community, 85% of the children were vaccinated. One of the good things that has developed is that we have a better system for getting informed consent, because people really didn't have the explanations for what the dangers for new innovations being used in them. We didn't have a fixed system. And what we used at that time was simply a request that was signed by the parents to have their children vaccinated. So we did have signed informed consent, but was done in a very informal way.

0:23:00.4 EM: But it's akin to how the polio trials were really a national endeavor, in a way that we don't see these days quite as much. We did see some of that sentiment during the COVID vaccine trials, but not to the same degree.

0:23:16.1 AM: And then they changed.

0:23:16.3 EM: A fervor around.

0:23:19.3 AM: And then it changed.

0:23:19.5 EM: Yeah. And then it changed. Yeah.

0:23:19.7 AM: At first everybody was eager to get the vaccine and then it changed.

0:23:26.2 EM: Yeah. Did you wanna talk a little bit about the history of the polio trials?

0:23:28.7 AM: Well, the polio trials, the ones that were done in Ann Arbor were the trials of the inactivated polio vaccine. And they were called the Francis Field Trials initially, and they came to Ann Arbor in an indirect way because, and the other thing that's changed is that there was little government support of the trials. This was done by through contributions for the March of Dimes.

0:23:58.0 EM: Yeah. It's philanthropic. Well, philanthropic, but it was everybody giving a little. Yeah.

0:24:04.0 AM: Exactly. And only gradually has the government been heavily involved in research programs.

0:24:11.0 EM: I think the kids these days would call it crowdsourcing. It's crowdsourced. What about your time?

0:24:16.5 AM: But Dr. Francis got into the studies after it had been developed to a certain extent. So there were two designs that were used in the study. One in which the second grade students were given the vaccine. And the first and third grades were just observed to see whether there was a difference in the occurrence of polio in those grades. But Dr. Francis said there are a lot of potential for biases in this kind of design and he insisted on a placebo control trial. And this was a very large study. Not only that, he brought staff here to get this study done, because we didn't have computers at the time. They were using punch cards as a way to track who was vaccinated and who not so it was a lot of extra work that had to be done. And the interesting thing was that when the polio field trial was done, he had staff here that knew how to do community studies, and that's how the Tecumseh study of health and disease in an American population actually began 'cause the same people or some of the same people who had worked with him on the polio field trial stayed to work on the Tecumseh study.

0:25:51.5 EM: Thinking about like, the softer aspects of our work, like kind of outside the science, what things did you learn as someone had the opportunity to learn from Dr. Francis, what things did you learn from Dr. Francis that you've carried forward in terms of like how to think about problems or how to teach or mentor?

0:26:08.2 AM: Well, he felt that you need to keep an open mind. And one of the things he said to me was, and we just don't do it these days because we publish in a hurry. And he said...

0:26:23.2 EM: I know what you're gonna say that.

0:26:26.4 AM: He said, "Dear, when you write a paper, put it in a drawer for a month and then look at it again," 'cause sometimes, I've found that what I originally thought the data were telling me wasn't really the case.

0:26:41.1 EM: And that's advice you've given me several times and I've been trying to.

0:26:43.3 AM: And it's something that that we forget about that we have to keep an open mind and part of the issue and you've experienced as well. When we see something in a new development that agrees with our preconceptions, we're much more likely to accept it. If it doesn't, we start looking for the problems. Was there a coding error?

0:27:14.9 EM: Yeah. Why isn't this the answer that I wanted?

0:27:17.4 AM: And that's something we have to always keep in mind. We have to, and this is something that I learned from Dr. Francis. We have to question even things that look like they're correct. And I know you are very careful in terms of encoding and things like that. And that's a very important thing to follow. We're in a very strange world right now. We are in a polarized environment, and I think it is important that students realize that if they hear criticism of what they are doing, they should take it to heart, listen to it, and see whether it makes sense in terms of their background.

0:28:12.3 EM: And what they're trying to accomplish.

0:28:16.6 AM: And what they're trying to accomplish. They shouldn't dismiss it because, for example, we can't control infectious diseases. If half of our population believes that we're taking advantage of them, that it's not correct, that it is not the way to go, it is important to try to understand where they're coming from and to try to do something about it. I think right now, we are at a point where it may be impossible to get people, because they're working on beliefs and not on the basis of facts to change their minds, but we can hope that this is a passing phenomenon. We've really had consistency in people being interested in helping themselves by getting vaccinated, for example and this is a relatively new phenomenon. Remember, there was hope that we would have a vaccine before the 2020 election and it was delayed, and then people did want to get vaccine. We would hope that as people look at the facts, and at our situation, we will be able to change back to a situation we're all on the same side, because after all, we're trying to achieve the same goals.

0:29:53.7 EM: I think as part of that, it's so important for students to be immersing themselves in the literature, the old literature, like the literature from prior pandemics and from prior developments. The basis of your knowledge. You want that to be formed from what you're reading and what you're learning and not what you're hearing told to you from other people, like told you from social media or from videos or whatever. You want to be learning that core knowledge so that you know the science of how things worked and the facts. Thanks for having this conversation.

0:30:32.3 AM: Oh, thanks for.

0:30:33.6 EM: With me.

0:30:34.6 AM: I'm so glad that you're here to work with me and to continue some of the activities.

0:30:43.7 EM: Yeah. And I feel so lucky to have the opportunity and the platform at Michigan and working with you to be able to build some of this stuff.

0:31:00.2 Host: Thanks for listening to this episode of Population Healthy from the University of Michigan School of Public Health. Visit our website, population-healthy.com for more resources on the topics discussed in this episode, and to find more episodes. If you enjoyed the show, remember to subscribe, rate, and review wherever you listen to podcasts. Be sure to follow us on social media and consider sharing this episode with friends. Population Healthy is produced by Andrea Ferrell, Brian Lilly, and Chrissy Zameron, and hosted by Michael Kasiborski. Hope you can join us for our next episode, where we'll dig in further to public health topics that affect all of us at a population level.