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What is the weakest link?

Year: 1981
Setting: Club Med in Haiti
Position: Tropical disease specialist at the Pitie-Salpetriere hospital in Paris

Club Med is experiencing an outbreak of acute gastroenteritis on one of his sites in Haiti and is facing a class-action lawsuit threat from a group of American tourists. The CEO calls professor Mac Gentilini at the Pitie-Salpetriere hospital in Paris who sends me to investigate the situation. My visit follows one by a team from the U.S. Centers for Disease Control and Prevention, which drew conclusions that were questioned by the club.

On the way from the airport to the resort and around the club property, shantytowns and villages exhibit a dismal level of poverty. Although water supply does not seem to be a problem, clean water is scarce and sometimes far way. We arrive at the resort, which is surrounded with a high, barbed-wire fence. Inside the perimeter, luxury abounds from exquisite food to posh accommodation and high-tech recreational activities. The contrast is striking!

After conducting a survey, I identify the likely source of contamination (confirmed later by bacteriological analyses of the samples I took): Local cooks check in for work in the morning but some of them systematically bypass the shower and hand-washing steps before handling food. I learned later that my findings as to the source of the contamination were the same as the CDC's, but my recommendations for correcting the problem were different. My recommendations were adopted and solved the problem.

In an unrelated matter, as I was checking the nurse logs I found an unusually high number of acute otitis media in the children staying at the resort. After a quick investigation, I find out that the daily treatment of the pool with antiseptic is erratic due to disruption in shipments. I write my report with recommendations to tackle these issues, and I am happy to leave the lawsuit matter to other specialists!

Lesson for the doctor: When carrying out epidemiological research, always look for the weakest link.

Yann Meunier, MD, is the health promotion manager for the Stanford Prevention Research Center. He formerly practiced medicine in developed and developing countries throughout Europe, Africa and Asia. Each week, he will share some of his experiences with patients in remote corners of the world.

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