My name is Dr. Celeste. I am the county epidemiologist — and when the health commissioner shifted the epicenter of an E. coli outbreak fifty miles from the actual contamination source, I had already uploaded the patient-mapping data to the CDC.
The health commissioner shifted the epicenter of an E. coli outbreak fifty miles on a map to protect a corporate farm, telling me he was just managing the panic.
My name is Dr. Julia Patel.
I am a state epidemiologist.
Edward Sloane altered the PDF map on the state server.
He did not know I kept the raw GIS shapefiles and the FASTQ sequencing data on an offline local machine.
You can move a circle on a screen.
You cannot alter a genome.
I work out of the state epidemiology unit on the fourth floor of the state public health building.
I came in on a Tuesday morning to a cluster of seventeen reported cases of severe hemolytic-uremic syndrome across four adjacent counties.
The cases had a common gastroenteritis prodrome.
The cases had been admitted to four different hospital systems across the preceding eleven days.
The patient ages ran from eleven months to seventy-three years.
Three of the patients had died.
The state lab had cultured Escherichia coli O157:H7 from stool samples of fourteen of the seventeen patients.
The state lab had run a basic pulsed-field gel electrophoresis profile on the isolates and had returned an “indistinguishable” pattern for thirteen of the fourteen culture-positive cases.
The state lab had not yet run whole-genome sequencing on the isolates.
I requested whole-genome sequencing on all fourteen culture-positive isolates at nine fifteen on Tuesday morning.
I requested the data be returned to me as raw FASTQ files rather than the state lab’s standard summary report.
The state lab returned the raw FASTQ files at four forty on Wednesday afternoon through the internal data transfer queue.
I downloaded the files to a state-issued USB external hard drive.
I walked the external drive across the corridor to my office.
I closed the door.
I unlocked the steel cabinet beside my desk.
I lifted out the local workstation.
The local workstation was a custom tower built for me by a contract genomics laboratory three years ago when I had been on temporary detail to the federal Centers for Disease Control’s Atlanta campus.
The local workstation ran a current-generation thirty-two-core processor, two hundred fifty-six gigabytes of error-correcting memory, and four terabytes of NVMe storage in a redundant array.
The local workstation ran a Linux distribution that I had installed and configured myself.
The local workstation had no network card installed.
The local workstation was air-gapped from every state network and every commercial cloud.
I had paid for the local workstation out of a federal training stipend at the end of the detail.
The state had been disinclined to authorize the purchase under state procurement rules.
The state had been content to let me bring the workstation back from Atlanta as personal equipment that I voluntarily made available to my state duties.
The state had not objected.
The state had also not asked questions about it.
I powered on the local workstation.
I plugged the external hard drive into the front USB port.
I ran the genomic sequence alignment pipeline against the published reference assemblies for E. coli O157:H7 outbreak strains in the state laboratory’s archived reference library.
The alignment pipeline ran for forty-three minutes.
The pipeline returned a high-confidence match against a specific archived reference strain.
The archived reference strain carried a distinguishing plasmid that I had not seen in the state lab’s standard PFGE pattern summary.
The plasmid was a one-hundred-fifty-thousand-base-pair virulence plasmid carrying both Shiga toxin variants and a specific tellurite-resistance cassette.
The tellurite-resistance cassette was a recent and rare marker.
The tellurite-resistance cassette was present in fewer than thirty published E. coli O157:H7 genome assemblies in any global database that I could query against my local archive.
The tellurite-resistance cassette had been documented twice in the previous decade in romaine lettuce traceback investigations conducted by the federal Food and Drug Administration.
Both of the romaine traceback investigations had identified the same corporate farm.
The corporate farm was Mossvale Greens Cooperative, a one-thousand-eight-hundred-acre operation in the western county of our state, the single largest leafy-green grower in the state by acreage and by revenue.
Mossvale Greens Cooperative had been a major political donor to the current state administration in the prior election cycle.
The chief executive of Mossvale Greens Cooperative had appeared at a ribbon-cutting ceremony with the governor at the opening of a new automated wash-line facility nine months earlier.
I ran the GIS pipeline next.
I loaded the case residential addresses and the recent grocery purchase locations into the spatial analyst.
I ran a clustering algorithm against the supplier distribution network for romaine and spring mix product moving through the regional grocery chain in the preceding fifteen days.
The clustering algorithm returned a tight spatial vector converging on a single source farm.
The source farm was Mossvale Greens Cooperative.
I exported the shapefiles.
I exported the alignment outputs.
I exported the case summary table.
I locked the external hard drive in the steel cabinet.
I went home.
I came into the office at six the following morning.
I opened the state public health website.
The state public health website now carried an official outbreak alert.
The official outbreak alert had been issued by the office of the state health commissioner, Dr. Edward Sloane, at four forty the prior afternoon.
The alert displayed a map of the affected region.
The epicenter on the map sat over a rural intersection approximately fifty miles west of Mossvale Greens Cooperative.
The epicenter had been moved.
The alert advised consumers to avoid consuming “leafy green produce of uncertain origin from regional retail outlets” within a “broadly defined western county warning zone.”
The alert did not name Mossvale Greens Cooperative.
The alert did not name any single source.
The alert did not request a recall.
I walked down the hallway to Edward Sloane’s office at seven fifteen.
The office door was open.
Edward Sloane was at his desk.
Edward Sloane waved me in with a coffee in his hand.
Edward Sloane said, Julia.
Edward Sloane said, the genomic link was too tenuous to panic the public and destroy the agricultural sector.
Edward Sloane said, we broadened the warning zone.
Edward Sloane said, it is safer this way.
Edward Sloane took a sip of the coffee.
Edward Sloane lied to my face.
I did not respond to Edward Sloane in his office.
I went back to my office.
I closed the door.
I sat at the desk for a long count.
I thought about the seventeen patients.
I thought about the three who had died.
I thought about the patient in the children’s hospital on the south end of the regional medical campus, an eleven-month-old who was still in the pediatric intensive care unit on continuous renal replacement therapy.
I thought about the romaine and spring mix product still on the shelves of every grocery store in the state.
I thought about the harvest crews still in the field at Mossvale Greens Cooperative cutting product for the next distribution cycle.
The product harvested this week would reach store shelves on Saturday.
Saturday was three days away.
I unlocked the steel cabinet.
I powered on the local workstation.
I opened the alignment outputs.
I opened the shapefiles.
I opened the case summary table.
I assembled a standard federal Centers for Disease Control submission package.
The federal submission package required raw FASTQ files for each isolate, the alignment outputs against the federal reference library, the GIS shapefiles for the case spatial distribution, the supply chain traceback documentation, and the state laboratory chain-of-custody records for the original cultures.
I had all of the data on the local workstation.
I had all of the chain-of-custody records as scanned PDFs in a folder I maintained for federal liaison purposes.
I assembled the federal submission package in approximately four hours.
I burned the federal submission package to two encrypted external hard drives.
I burned a paper printout of the case summary table, the alignment output, the shapefile rendering, and the supply chain traceback to a hard copy that I locked in the steel cabinet.
I burned a second paper printout that I put in my work bag.
I called the federal Centers for Disease Control’s Atlanta operations center at eleven forty-five.
The operations center was a number I had used during my Atlanta detail to coordinate cross-jurisdictional outbreak response.
The operations center duty officer was a woman I knew from the detail, an epidemiologist named Brenda Carrington who had been my office neighbor for the eleven months I had been in Atlanta.
I told Brenda I was looking at a state-level outbreak with seventeen confirmed cases and three deaths converging spatially and genomically on a single source farm.
I told Brenda the state health commissioner had broadened the warning zone fifty miles west of the actual source and had declined to issue a single-source recall.
I told Brenda I was prepared to submit a complete federal package through the federal Epi-X secure portal that afternoon.
Brenda asked if I had authorization from the state health commissioner.
I told Brenda I did not.
Brenda asked if my submission would carry my personal credential or my state credential.
I told Brenda my personal credential.
Brenda said, Julia.
Brenda said, federal Epi-X accepts submissions from any credentialed epidemiologist with a public health emergency designation.
Brenda said, your federal credential from the Atlanta detail is still active.
Brenda said, the submission is going to trigger a federal review within four hours of receipt.
Brenda said, the federal review is going to override state authority on this outbreak.
Brenda said, you understand what that means for your state career.
I told Brenda I understood.
Brenda said, send it.
Brenda hung up.
I logged into the federal Epi-X secure portal from a terminal in the federal liaison reading room on the second floor of the state public health building.
The federal liaison reading room had its own dedicated federal network drop separate from the state network.
The federal liaison reading room had been installed two years earlier as a condition of a federal grant.
The federal liaison reading room was not subject to state network monitoring.
I uploaded the federal submission package to the federal Epi-X portal at two forty-seven in the afternoon.
The federal Epi-X portal returned a submission receipt with a federal case number and an automatic acknowledgment from the federal Centers for Disease Control’s outbreak response branch.
The acknowledgment estimated a federal preliminary review window of approximately three to six hours.
I logged out of the federal Epi-X portal.
I walked back to my office on the fourth floor.
I closed the door.
I sat at the desk.
I waited.
I worked on a separate technical report on an unrelated influenza surveillance project for the next four hours.
I did not check the state outbreak alert page on the state public health website.
I did not check my email.
I did not check my phone.
At six fifty-two in the evening my desk phone rang.
I picked up the phone.
The caller was a federal epidemiologist with the federal Centers for Disease Control’s outbreak response branch.
The federal epidemiologist said, Dr. Patel.
The federal epidemiologist said, the federal preliminary review has been completed.
The federal epidemiologist said, the federal Centers for Disease Control is federalizing the outbreak investigation effective seven o’clock this evening.
The federal epidemiologist said, the federal Food and Drug Administration is issuing a Class One nationwide recall on all product harvested by Mossvale Greens Cooperative within the last twenty-one days effective concurrently with the federalization.
The federal epidemiologist said, the federal press office will issue a public alert at eight o’clock.
The federal epidemiologist said, the federal Centers for Disease Control’s outbreak response branch chief will be in your office at nine tomorrow morning to formally assume the state-level investigation under federal authority.
The federal epidemiologist said, thank you for the submission.
The federal epidemiologist hung up.
I sat at the desk.
I called the state health communications office and confirmed that Edward Sloane had scheduled a state press conference for ten the following morning to provide an update on the western county warning zone.
I called a reporter I knew at the regional newspaper who had covered the state public health beat for the previous nine years.
The reporter was a man named Cooper Llanes.
I told Cooper there would be a federal alert at eight o’clock that evening and a state press conference at ten the next morning.
I told Cooper to come to the state press conference with a paper copy of the federal alert in hand.
I told Cooper to read the federal alert into the record at the press conference.
I told Cooper not to mention my name.
Cooper said, all right.
Cooper hung up.
I went home.
I did not sleep.
The state press conference was held in the state public health building’s main lobby in front of the state seal mounted on the east wall.
The lobby had been arranged with a single podium at the front, a row of three folding chairs to the left of the podium, and a press riser at the back with seating for approximately thirty reporters.
The press riser was approximately two-thirds full at nine fifty-eight.
I sat in the second row of the press riser.
I had taken a personal day from the state and was attending in my private capacity as a state resident.
Cooper Llanes sat in the front row of the press riser.
Cooper had a printout of the federal alert in a manila folder on his lap.
The federal alert had been published on the federal Centers for Disease Control public website at eight o’clock the previous evening.
The federal alert had named Mossvale Greens Cooperative as the source of the outbreak.
The federal alert had attached a Class One nationwide recall notice from the federal Food and Drug Administration.
Edward Sloane walked to the podium at ten oh four.
Edward Sloane was wearing the same charcoal suit he had worn at the staff meeting the previous Wednesday.
Edward Sloane carried a thin black folder.
Edward Sloane set the folder on the podium.
Edward Sloane opened the folder.
Edward Sloane greeted the press.
Edward Sloane said, good morning.
Edward Sloane said, the state department of public health continues to monitor a cluster of foodborne illness cases in the broadly defined western county warning zone.
Edward Sloane said, we are monitoring the general region.
Edward Sloane said, there is no need for a targeted recall at this time.
Edward Sloane said, we expect the cluster to resolve as routine grocery turnover cycles refresh leafy green inventory through normal supply chain replacement.
Edward Sloane said, we ask consumers to remain vigilant.
Edward Sloane invited questions.
Cooper Llanes raised his hand.
Edward Sloane recognized Cooper.
Cooper opened the manila folder.
Cooper held up the printout.
Cooper said, Dr. Sloane, the federal Centers for Disease Control issued a federal alert at eight o’clock last night.
Cooper read directly from the printout.
Cooper read the federal alert’s first paragraph identifying Mossvale Greens Cooperative as the confirmed source of the outbreak.
Cooper read the federal alert’s second paragraph announcing the Class One nationwide recall of all Mossvale Greens Cooperative product harvested within the previous twenty-one days.
Cooper read the federal alert’s third paragraph confirming that the federal Centers for Disease Control had federalized the investigation effective seven o’clock the previous evening, superseding state authority on the outbreak response.
Cooper finished reading.
Cooper said, Dr. Sloane.
Cooper said, can you reconcile the federal alert with your statement just now that there is no need for a targeted recall.
The lobby went quiet.
Edward Sloane stared at Cooper.
Edward Sloane stared at the manila folder.
Edward Sloane stared at the state seal mounted on the east wall behind the podium.
Edward Sloane did not answer.
A second reporter from a regional television station raised a hand.
The second reporter said, Dr. Sloane, did your office receive notification of the federal federalization at seven o’clock last night.
Edward Sloane did not answer.
A third reporter from the wire service raised a hand.
The third reporter said, Dr. Sloane, why did the federal Centers for Disease Control federalize this investigation.
Edward Sloane did not answer.
A fourth reporter said, Dr. Sloane, are you stepping down.
Edward Sloane closed the thin black folder.
Edward Sloane stepped back from the podium.
Two of Edward Sloane’s communications aides walked from the row of folding chairs to the podium.
The aides flanked Edward Sloane.
The aides walked Edward Sloane briskly off the press riser through the east doors of the lobby toward the elevator bank.
The doors swung closed behind them.
The lobby stayed quiet for a long count.
The state seal on the east wall was uncovered.
The press riser sat with thirty reporters facing an empty podium.
Cooper Llanes folded the federal alert printout back into the manila folder.
Cooper stood up.
Cooper walked out of the lobby through the south doors.
I sat in the second row of the press riser for another long count.
I stood up.
I walked out of the lobby through the south doors.
I did not look back at the podium.
I did not look back at the state seal.
I walked across the parking lot to my car.
I drove home.
I did not go back to the office that afternoon.
The federal Centers for Disease Control’s outbreak response branch chief, a woman named Dr. Hadia Onuora, arrived at the state public health building at nine o’clock the following morning per the previous evening’s phone call.
Dr. Onuora set up a federal command post on the third floor of the state public health building in a conference room that the state had reluctantly cleared overnight.
Dr. Onuora ran the federal investigation from the conference room for the next sixty-one days.
Dr. Onuora’s investigation traced the contamination event to a single irrigation event at Mossvale Greens Cooperative’s east field block on a specific Tuesday morning eighteen days before the first reported case.
The irrigation event had drawn from a surface water reservoir that had been contaminated by overflow from an upstream cattle operation following a rainfall event eleven days before the irrigation event.
The federal investigation issued findings.
The federal Food and Drug Administration suspended Mossvale Greens Cooperative’s interstate commerce authorization for fourteen months pending compliance remediation.
The state attorney general opened an inquiry into Edward Sloane’s office under the state public records and false statements statute.
The state attorney general’s inquiry was ongoing nine months later.
The state legislature held a public hearing on the state public health department’s outbreak response protocols four months after the federalization.
The state legislature passed a statutory amendment to the state public health code six months after the public hearing.
The statutory amendment required the state health commissioner to issue any source-identification information to the public within forty-eight hours of confirmation by either the state laboratory or a credentialed federal partner laboratory.
The statutory amendment further required that any state public health alert issued during an active outbreak attach the underlying source-identification data as a public-record exhibit.
The statutory amendment became law.
Edward Sloane resigned his position as state health commissioner approximately two weeks before the statutory amendment cleared the state senate.
The state department of public health transferred me at the end of the sixty-one-day federal investigation.
The transfer paperwork moved me from the state epidemiology unit on the fourth floor to a windowless office on the second floor in the state public health department’s historical surveillance archive.
The historical surveillance archive was a single-person desk job.
The historical surveillance archive’s mission was to maintain a publicly available digest of state communicable disease trend data going back to nineteen seventy-eight.
The historical surveillance archive’s current backlog was a queue of historical influenza surveillance records from the nineteen ninety-five through two thousand seven flu seasons that needed to be re-coded into the state’s current data standards.
I had been in the historical surveillance archive for four months.
I had processed nine flu seasons.
I was working through the nineteen ninety-eight flu season.
The nineteen ninety-eight flu season had run from late September of nineteen ninety-seven through early May of nineteen ninety-eight.
The nineteen ninety-eight flu season had been a low-severity season dominated by a circulating H3N2 strain that had not undergone significant antigenic drift from the seasonal vaccine composition.
The nineteen ninety-eight flu season had not killed anyone of significant note.
The nineteen ninety-eight flu season had been the last flu season before the development of point-of-care rapid influenza diagnostic testing changed the surveillance landscape.
The nineteen ninety-eight flu season was data that did not matter.
I re-coded the data anyway.
I re-coded the data with the same care I would have given to live outbreak data.
I re-coded the surveillance records line by line into the state’s current data standard.
I checked the records against the federal Centers for Disease Control’s archived weekly surveillance reports for the corresponding weeks.
I cross-referenced the state’s records against the regional hospital systems’ archived emergency department visit data.
I corrected three transcription errors in the original state records that had survived three rounds of prior reformatting.
I closed the nineteen ninety-eight flu season at the end of the fourth week and moved on to nineteen ninety-nine.
The work was the work.
I do not feel triumphant about the outbreak.
I feel that the genome is the genome.
I feel that the spatial vector is the spatial vector.
I feel that the irrigation event is the irrigation event.
I feel that the cattle operation upstream of the surface water reservoir is the cattle operation upstream of the surface water reservoir.
I feel that the seventeen patients are the seventeen patients.
I feel that the three who died are the three who died.
I feel that the eleven-month-old in the children’s hospital is the eleven-month-old in the children’s hospital.
The eleven-month-old survived the acute renal failure and was discharged seventeen days after I sent the federal submission.
The eleven-month-old is at home now.
The eleven-month-old is approximately fourteen months old as I sit at this desk in the historical surveillance archive.
The eleven-month-old will not remember any of this.
The eleven-month-old does not need to remember any of this.
The eleven-month-old’s parents will remember it for her.
The federal investigation report names me twice in the appendix.
The federal investigation report names me once as the submitter of the federal Epi-X package that triggered the federalization and once as the state-level epidemiologist who developed the initial genomic alignment that identified Mossvale Greens Cooperative.
The federal investigation report does not name me in the executive summary.
The federal investigation report does not name me in the press release.
The federal investigation report does not need to name me anywhere.
The federal investigation report is the work.
The work is the federal investigation report.
The external hard drive sits in the steel cabinet beside my desk in the historical surveillance archive.
The steel cabinet was transferred with me from the fourth floor.
The local workstation was also transferred with me.
The local workstation is still air-gapped.
The local workstation is still functioning.
The local workstation has nothing to process at the moment.
The state has not asked me to look at any outbreak data since the federalization.
The state has not asked me to look at any data at all except the nineteen ninety-eight flu season and the seasons that follow it in the historical surveillance archive backlog.
The state may never ask me to look at outbreak data again.
I think about this in the historical surveillance archive at the end of each day before I close the workstation and lock the steel cabinet and walk out of the office.
I think about it on the drive home.
I think about it sitting on the back porch of my house in the evenings.
I do not feel betrayed by the state.
I feel that the state is the state.
I feel that the federal Centers for Disease Control is the federal Centers for Disease Control.
I feel that the genome is the genome.
I feel that the genome does not care which agency holds my badge at the security desk.
I feel that if the state asks me to look at outbreak data again I will look at outbreak data again.
I feel that if the state does not ask me to look at outbreak data again I will process the historical surveillance archive backlog through nineteen ninety-nine and two thousand and two thousand and one and the rest of the queue until the queue is empty.
I feel that the work is the work whether it is the nineteen ninety-eight flu season or the live outbreak.
I feel that the work holds.
The genome holds.
The spatial vector holds.
The federal Epi-X portal still accepts submissions.
The federal credential from the Atlanta detail is still active.
The federal credential expires in eleven months.
I will renew the federal credential in eleven months.
The federal credential will be active when I renew it.
The federal credential is the work.
The work is the work.
The work holds.
I closed the nineteen ninety-eight flu season folder at four forty-five on a Friday afternoon.
I opened the nineteen ninety-nine flu season folder.
I read the first weekly state surveillance report for the week ending September twenty-six of nineteen ninety-eight.
The report logged forty-one outpatient visits for influenza-like illness across the state in the reporting week.
The report logged zero hospitalizations for influenza.
The report logged zero deaths attributed to influenza.
The report logged a single positive influenza A H3N2 culture from a tertiary care hospital in the eastern part of the state.
The report logged the standard vaccine availability and clinic schedule for the upcoming season.
I read the report line by line.
I checked the report’s data against the federal Centers for Disease Control’s archived FluView report for the same reporting week.
The state report and the federal report agreed on every line.
I re-coded the report into the state’s current data standard.
I saved the re-coded report to the historical surveillance archive.
I closed the workstation.
I locked the steel cabinet.
I picked up my bag.
I walked out of the office.
I walked down the hallway to the elevator bank.
I rode the elevator down to the ground floor.
I walked across the lobby past the state seal mounted on the east wall.
I walked out the south doors of the state public health building.
The afternoon was warm and clear.
The state seal was the state seal.
The lobby was the lobby.
The work was the work.
I walked across the parking lot to my car.
I drove home.
I cooked dinner.
I sat on the back porch with a glass of water and watched the sky go from blue to orange to gray to dark.
I thought about the eleven-month-old who was at home now.
I thought about the nineteen ninety-eight flu season records that I had re-coded that week.
I thought about the federal credential from the Atlanta detail that was still active.
I thought about the local workstation in the steel cabinet beside my desk in the historical surveillance archive.
I thought about the federal Epi-X portal.
The federal Epi-X portal accepts submissions from credentialed federal partners every day of every week of every year.
The federal Epi-X portal will accept a submission from me on any of those days.
I do not have a submission to make this week.
I do not have a submission to make this month.
I may not have a submission to make for years.
I may have a submission to make tomorrow.
The genome will tell me when there is a submission to make.
The spatial vector will tell me when there is a submission to make.
The case summary table will tell me when there is a submission to make.
The work will tell me when there is a submission to make.
The work will hold until then.
The genome will hold until then.
The federal credential will hold until then.
The historical surveillance archive will hold until then.
The state seal in the lobby of the state public health building will hold until then.
The state seal does not care.
The genome does not care.
The work does not care.
The work cares about the work.
The work is the work.
The work holds.
The eleven-month-old is at home.
The eleven-month-old is the work.
The work holds.
I came back to the office on Monday morning at seven thirty.
I unlocked the door to the historical surveillance archive.
I powered on the local workstation.
I opened the nineteen ninety-nine flu season folder.
I started on the second weekly state surveillance report.
The second weekly state surveillance report logged thirty-eight outpatient visits for influenza-like illness across the state in the reporting week ending October third of nineteen ninety-eight.
The report logged zero hospitalizations.
The report logged zero deaths.
I read the report line by line.
I checked the report against the federal Centers for Disease Control’s archived FluView report for the same week.
The state and federal reports agreed on every line.
I re-coded the report.
I saved it.
I opened the third report.
This was the work this morning.
This would be the work this afternoon.
This would be the work tomorrow.
The work was the work.
The work held.
The federal credential held.
The local workstation held.
The eleven-month-old held.
The work held.
At lunchtime I walked down to the lobby and stood for a long count in front of the state seal mounted on the east wall.
The state seal was bronze cast and approximately three feet across.
The state seal carried the state motto in raised letters around its perimeter.
The state seal was the same state seal that had been on the wall behind Edward Sloane at the press conference seven months earlier.
The state seal had not changed.
The state seal did not need to change.
The state seal was the state seal.
The work was the work.
I went back upstairs to the historical surveillance archive.
I closed the door.
I sat at the desk.
I opened the fourth weekly state surveillance report for the nineteen ninety-eight through nineteen ninety-nine flu season.
I started to read.
