Behind the MRSA Epidemic: Q&A with Maryn McKenna, author of Superbug
Maryn McKenna has lived inside the "hot zone" for much of her reporting career. She honed her craft at the Atlanta Journal-Constitution, where she was much admired for her coverage of the Centers for Disease Control and Prevention. It takes skill to persuade any large government agency to give up some of its secrets, but McKenna did just that and turned them into fascinating stories. She has since taken the enviable career path of writing books. Her first, Beating Back the Devil, was about the CDC's Epidemic Intelligence Service. And, in March, Free Press published her book Superbug: The Fatal Menace of MRSA, about methicillin-resistant Staphylococcus aureus. The book is as frightening as a Dario Argento film and as well-researched as a Ken Burns documentary. You can read about all of her projects on her blog, Superbug.
I reached her at her office in Minneapolis. The interview has been edited for space and clarity.
Q: When do you think was the first time as a reporter that you had occasion to write about MRSA?
A: The first time that sticks in my mind was at the Journal-Constitution, where I worked for 11 years. I was the only person in the US assigned to fulltime coverage of the CDC. After the anthrax attacks I got an agreement to embed with a new class of their Epidemic Intelligence Service. Those are young doctors and PhDs who give the CDC two years of their lives and 24 hours every day, being told to get on the plane to somewhere at a moment's notice in exchange for this amazing credential that pretty much makes their careers in public health. I ended up at an investigation being conducted by one of them in collaboration with the Los Angeles public health department of a cluster of severe MRSA infections.
Guys were reporting infections that started like a spider bite: small, hot pimples. And then the pimples would break down and become massive abscesses. When they did a case control study, it turned out the victims were gay and all went to sex clubs. The question immediately was whether this was a skin infection behaving like a sexually transmitted disease. The guys go into sex clubs, take their clothes off and are just wearing a towel so they are probably picking this up from each other. But, in these clubs, there also were all kinds of workout equipment. So what was happening also could be like transmission in a gym. The question was: Does someone have an infection around their genitals because they sat down naked on a gym bench or because they had sexual contact with someone else?
In the first days of the AIDS epidemic, all of the major California cities struggled with how to handle sex clubs. San Francisco shut down its bath houses, but LA never did. The LA public health department had managed to work out something with these clubs to keep them just safe enough, doing HIV counseling and things like that inside the clubs. So they were really worried about appearing to turn punitive. They didn't want the clubs to shut off access to this population that was the target of all these other public heath activities. Immediately, this investigation wasn't just about the disease but about the whole cultural context of the disease. And that's what interested me most. It's what has always interested me. What are the cultural forces that are colliding to make this happen right now? The story of this is told in my first book, Beating Back the Devil. It turns out that the hypothesis that it was like transmission in a gym turned out to be correct. It was being spread by these men taking their clothes off and sitting on benches. It was the surfaces, not primarily the sex, making it happen.
Q: This is kind of like the USC football team a few years ago.
A: Yes. That story is told in Superbug, in the sports chapter.
Q: So what was it about MRSA that made you think you had the makings of a book?
A: On the one hand it was a really interesting disease. Drug-resistant staph was thought of as a hospital-acquired infection, but these skin infections were putting people in the hospital. On top of that, it was enmeshed in this whole complicated cultural context. I wrote that up as a chapter in my book on the EIS and noted it down as something I would save string on. Three years later, I ended up leaving my job and got a Kaiser Fellowship to look at emergency room crowding. Every month, I spent eight overnight shifts in ERs around the country. In every shift, no matter where I was, I saw someone who had MRSA. And it was more of a big deal than just a little spider bite. The ER physicians were really accustomed to it. It was one of the things they saw all the time, but to me, coming in fresh, it was, "Whoa, this is really interesting." The fellowship was only part-time, and so I was starting to freelance, and an editor at Self magazine, which has really great health coverage, offered me a story about whether community-associated MRSA, as opposed to MRSA picked up in a hospital, was an underreported threat to women and children. At that point, it had mostly been reported in football teams and prisons and gyms. I wrote the story that, yes, it was an underreported threat to everyone, and it ran in February 2007. The Today Show picked it up, and the Montel Williams show picked it up. A ton of people contacted me and emailed me to say, "Thank God. This thing has changed my life."
Q: What do you mean by that? That MRSA had changed their life for the worse, I'm guessing.
A: Basically. Either because they had gotten it as a hospital infection and it was unbelievably costly in terms of health care dollars and their time and their emotional investment. Or they got this out on the community and didn't know where to turn.
Q: Why don't people know where to turn?
A: There's not really any patient movement, at least not a national patient movement. There are some groups in states. It's a challenging condition to find information about, because the syndromes it causes are so diverse. Some of the community manifestations can recur. You can have 6, 7 recurrences even if you are doing everything right. It can also ping pong between humans and their pets. And there are really ugly manifestations where it causes necrotizing fasciitis, the flesh-eating disease. It can also set up the lungs for bacterial pneumonia. In one chapter, I describe two kids in San Diego who had something called necrotizing pneumonia from combination of MRSA and flu. One child survived and the other one died a really awful death.
Q: How are people finding you?
A: Mostly through my blog, which is called Superbug, but the URL is www.drugresistantstaph.blogspot.com. I keep all my comments moderated, so if someone comments on my site, it's like sending me a personal note. Some of them just find my email and email me directly.
Q: This is one of the big challenges for health reporters. People call you all day and night with their sad stories. How do you keep track of people and how do you decide who will be part of a later story or book?
A: I built a database of people that I wanted to know more about and keep track of. Let's say you start out with 50 people. I go through the first round and could knock out 20 of them. They didn't have what they thought they had. Or they had a time that was emotionally difficult but not really medically complicated. They didn't enjoy what happened but nobody did anything wrong. Those are all reasons to sink people down on the list because they are not dramatic stories. Then, of the ones left, I would say, "Are you willing to share your medical records?" Or "Can you put me in touch with your doctor?" All the stories in the book are corroborated by medical records or someone involved in the case, in most cases by multiple sources.
Q: Why weren't you able to get the medical records in all cases?
A: Sometimes, it was just too complicated to physically receive them, but a doctor would walk me through them on the phone. You could hear them going through the charts. There's a guy in chapter three who had a hospital infection in an abdominal incision. They had to open him up and keep on going back through his abdominal muscles to the point where he started to get hernias. He had something like 12 hernias, eight surgeries and four or five doctors. I got one of his doctors who came in fairly late in the game and he walked me through the guy's chart, encounter after encounter, describing the surgeries and the recoveries. Some people didn't really understand what they had until I talked with their doctors. There's a woman who is the main case in Chapter 13, a case of community MRSA occurring in a maternity unit. She hadn't really processed the full implications of her case, even though she was a medical reporter. I was able to tell her she had the community strain of MRSA, and nobody else had told her that.
Q: Why would these doctors want to talk with you? Weren't they worried about being sued?
A: When there were a range of sources, I tried to go for ones whom I thought would know about the case but would not have reasons not to talk to me. If a doctor had been sued by the patient he would not have talked to me. But in most of these cases, the patients viewed the doctors I was speaking to as people who had saved their lives.
Q: Still, doctors don't like to talk too much about their cases because they might open themselves up to a problem down the road?
A: I did tons of networking and saved every single email. I have a computer with a really big memory. I have literally thousands of emails that I've tried to sort and tag and so forth. I found the parents of those children in San Diego, the two families, and the head of the pediatric infectious disease unit at the hospital through the Infectious Diseases Society of America, the specialty society for ID physicians. They think there ought to be changes in how pharmaceutical companies are supported in antibiotic research, and they want to help get these stories out there. I said to them, "I'm looking for cases," and they surveyed their membership and found doctors in various cities who saw MRSA cases. The San Diego cases were ones where everything came together. The families were willing to talk. The specialist physicians were willing to talk. And the hospitals were willing to let me in.
Q: So there wasn't a lawsuit in those cases?
A: There were lawsuits filed after I interviewed the families, which I believe are still ongoing. These were both community infections. And so in both cases the kids were taken first to primary-care doctors or clinics and those local physicians didn't realize this was MRSA. For good reason, I have to say: The national recommendations for treating pneumonia didn't even take up the potential of cases being caused by MRSA infections until the year that one of these kids died. This is one of the cultural things that is so interesting. Among the lessons of this ongoing epidemic is, when something authentically new happens, how do you recognize it, and how do you prove it to the rest of medicine? The doctors at the University of Chicago who first recognized the community epidemic wrote it up and JAMA refused to publish their paper for 18 months. Eventually the folks at the University of Chicago bulldogged them until they got the paper published. But JAMA published it with kind of a skeptical editorial saying maybe it is something but maybe it isn't. As it turns out, the U of C people were right and JAMA was wrong. Now there is a new epidemic of MRSA emerging linked to agricultural antibiotics. And, once again, there is a lot of pushback.
Q: Hantavirus, SARS, bird flu, swine flu. All of these have turned out to be less serious than everyone thought. What makes MRSA different? How do you take care when reporting and writing about it to not create another bogeyman?
A: I think about this a lot. I covered the CDC, and before that I was a public heath investigative reporter in Boston and Cincinnati. Most of my career has been frightening people about health problems. Culturally, we have a weird appetite for scary disease stories. Look at the success of Richard Preston's books. But most of these things that we love to frighten ourselves with aren't actually that great a threat to us. There has never been a case of Ebola here. SARS barely happened in the US. We have plague in animals in the Southwest, but we don't have anything like the Black Death. MRSA is almost the mirror image of those stories: It is something that really is a direct threat and yet somehow we have failed to perceive it. When you follow the breadcrumb trail of findings through the medical literature, you find that it kills 19,000 people a year and may send 7 million to primary care doctors. I think we should be more frightened than we are. I think we need to be doing more to grapple with it on a policy level. We certainly need better surveillance that would help detect the full dimensions of the epidemic, because medicine and public health don't talk to each other. The public health physicians are not talking to the primary care physicians who see a kid who did a bad football tackle and now has a fever because he has community MRSA. And the people how are finding it in livestock are not talking to anyone in the public health community. Because we have these silos, we are prevented from recognizing how great the burden from MRSA truly is.