Extending the professional memory: four samples of environmental health history.

I find words interesting--discovering new meanings and etymologies, and learning about words that have almost vanished from our vocabulary. The English language is absolutely fascinating. If you let it, it can also be a bit intimidating.

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In this column, I will be discussing four words as they apply to public health--four words that some environmental health professionals may never have heard of or perhaps have forgotten. These four "oldies but goodies" refer to some drastic measures that have been used in the past to solve environmental and health problems and that can still be of use in what I like to call "public health sleuthing." The goal of this vocabulary lesson is to revive knowledge of some public health traditions that may help you, in future situations, identify sources of infectious disease and control their spread.

Quarantine, DOT, Moore swabs, nitrites: Do they mean anything to you? When I was a newly employed sanitarian back in the late 1960s, one of these words stirred memories of qualitative analysis in chemistry class, one was something from back in the dark ages, and the other two meant absolutely nothing to me. Remember, this is coming from a sanitarian (as in: Sanitarian in Training with a temporary license) who a week before he was hired didn't know anything about public health, environmental health, or the sanitarian profession. In fact, this sanitarian didn't get a thermometer until a month before taking the state licensing exam for sanitarians. The exam was proctored by none other than Dr. Ben Freedman, the author of the Sanitarian's Handbook. At the time, I didn't know about that either. But I digress. Here are the words.

"Quarantine"

The word "quarantine" was coined in Italy in 1403: "una quarantine di giorni." It referred to the 40-day isolation period imposed on ships entering port cities to prevent the spread of contagious disease, specifically the bubonic plague. It is fortunate for us that the number 40 was chosen; it is greater than most incubation periods. The number was not chosen because of good science, however; but because of its special connotation in religion (the flood, Lent, etc.), and it was adopted as a divinely inspired period. The translation is in fact "isolation." I have seized products--which we refer to as quarantine--but I have never experienced "quarantining a person or a population" in my 35 years of public health (hospital isolation excluded). If you remember back to Dustin Hoffman and the movie Outbreak, the word begins to take on ominous overtones. I have never seen the yellow quarantine flag of the U.S. Public Health Service flown in my lifetime, and thank God for that. Maybe some of you have seen that flag with the Public Health Service insignia flying on a ship or over a town or village, but not too many, I bet. If anyone reading this has had such experiences, I would like to hear from you, especially if it involves the United States.

Anecdotally, I have heard that some states don't even use the term "quarantine" in their public health laws. But in light of the possibility of bioterrorist events and of global transmission of new or re-emerging diseases, the concept of quarantine is seeing a resurgence in both practice and codes.

Will we ever have to use quarantine as a tool to stop the spread of a contagious disease? No one knows, and we all pray that it won't happen. If quarantine is ever used, will the public accept it? Are we capable of enforcing it? Are we sufficiently knowledgeable to handle a quarantine situation with compassion and good science? These are just a few things to think about in relation to this archaic word quarantine.

"Moore Swabs"

Is this term in your public health vocabulary? If it is, do you know what a Moore swab is used for? For those of you who have never had the excitement of a disease hunt, I'll try to explain. One day early in my career, I was told to unfold 10 gauze pads, stack them one on top of another, tie a 10-foot length of cord around the middle of the stack, tighten the cord so as to divide the gauze into two sections, and wrap it in grocer's brown paper. I was told to make 12 of these bundles and take them to the public health laboratory to have them sterilized in an autoclave. Once they were sterilized, the fun began. The health department sanitarians and public health engineers had isolated the carrier of an infectious agent to a public-housing project, and our job was to go to each sewer cleanout from each section of that housing project and insert the swabs into the sewer so that they would be in direct contact with the effluent. After two days, we had to retrieve the Moore swabs and put them in sterile jars for transportation to the microbiology lab. We also had to replace the ones we had just removed. Nothing happened for some two and a half months, and then Bingo!--we isolated an infectious organism to a four-unit section of apartments. Now all we had to do was to visit the four apartments and get the inhabitants to voluntarily submit stool samples to the public health nurses at the clinic. This was done, and two people were found to be carriers without any overt symptoms. Case solved!

Yes, the Moore swabs strike again--an old tool that easily can be applied to new situations. This technique can be useful for tracking enteric-disease organisms found in sewer systems. If you ever have the opportunity to be part of a hunting team, do so. You'll get loads of experience in real public health detective work.

"DOT"

No, DOT does not stand for "Department of Transportation," but for "directly observed therapy." The prerogative of directly observed therapy is something that health departments, under their police power, can invoke when someone has a contagious disease and will not take the appropriate medicines or will not take the medicines for the prescribed length of time. For example, DOT has been used in today's world, albeit sparingly, in cases where a person has an active case of tuberculosis and will not willingly take medication. This can be done on an outpatient basis with the police involved, or it can be done by a confinement order in a medical inpatient situation. Radical? Yes, but sometimes necessary. As sanitarians, we need to learn the enforcement nuances of this tool and its limitations.

"Nitrites"

Every year within a week or two of Mardi Gras, we used to visit our meat markets, take samples of suspicious bright red-looking ground meat, and submit the samples to the lab for analysis for nitrites. Just a minute amount of this material can turn brown, old, dried-up-looking ground meat into fresh-looking ground meat. We also used to test itinerant vendors' products with a bit of malachite green solution and destroy the products if we found them to be adulterated with nitrites. Those were the days!

Well, now you know! I hope your vocabulary and memories have been stimulated by this trip back--as they like to say--to the basics. It's all part of our learning curve.

James Balsamo, Jr.