CSTE’s AEF Program: 20 Years of Training the Next Generation of Applied Epidemiologists

Pop Quiz: What do Finding Nemo, the Safari internet browser and iTunes all have in common? All three are celebrating their 20th anniversary this year.

CSTE is pleased to add the Applied Epidemiology Fellowship (AEF) to that list of milestone anniversaries! Since 2003, AEF has guided recent graduates through the expanding field of applied epidemiology. In 20 years, CSTE has placed 519 fellows in 45 states and the District of Columbia, 27 local, three territorial, and one tribal jurisdiction. AEF participants receive two years of on-the-job training at a state or local health department under the guidance of two experienced mentors. During the program, all fellows work in public health emergency responses and 70% of fellowship graduates remain in the governmental public health sector.

In celebration of these two decades of shaping the next generation of epis, we spoke with two fellows, past and present, on what led them to AEF, their experience in the program, and the doors it has opened for their careers.

Note: These interviews have been edited for length and clarity.

Past Fellow – Ellyn Marder, DrPH, MPH, Tennessee

Ellyn Marder was an AEF fellow from 2012 to 2014, working at the Tennessee Department of Health. After graduating, she worked as a surveillance epidemiologist for CDC and is now a Senior Epidemiologist in Washington state. Ellyn has a BS in chemical science from Florida State University and earned an MPH in epidemiology from Emory University in Atlanta.

Q: Was there a certain “aha” moment you had that led you being interested in epidemiology?

In college, I really kind of struggled to figure out what it was I was interested in. I liked the concept of public health, I loved science, but I was a little lost at how to apply it. My advisor suggested I take population health courses. Through being exposed to all of these different concepts, it drove me to epidemiology, where I could still bring in the science and understanding of diseases and transmission mechanisms, but really use my skills best working with data.

Q: How did you become interested in applying for CSTE’s AEF Program?

I interned at CSTE when I was in my MPH program at Emory. So, I became really familiar with the CSTE staff and members as I attended work group, subcommittee calls, other meetings, and worked on projects with the staff. The more I learned from members and staff about what kind of work was happening at the state and local level, I just became really excited to have that experience myself. So very luckily, I was able to apply to AEF and be accepted.

Q: You completed your fellowship at the Tennessee Department of Health. What did you work on and what was a typical day like?

A lot of what I did was outbreak investigations, whether those were from animal contact, restaurants or widely distributed food products where those were usually multi-state outbreaks. I was doing patient interviewing, designing case control studies, collecting the data, analyzing the data, and helping inform any kind of public health measures we needed to take, what testing we should be doing at the lab. Did we need to get receipts to find out what did consumers buy at Costco or wherever else it was? What food item on this restaurant menu could have made them sick? And then doing case finding, calling everyone who maybe dined at a restaurant that day to ask them if they also got sick so that we could figure out what was causing the illness.

Q: What lessons did you learn during your time in the AEF Program?

I think the biggest lesson is I gained so much confidence in my skills and expertise as an epidemiologist. I have phenomenal mentors and support at the state health department who gave me opportunities to try things, advice for when something wasn’t working, and then praise when something did that really showed me where I could provide value throughout my career. And that really has just driven everything I do. I know where I can provide value in different meetings, in different context. I have that expertise and because of the confidence that they instilled in me, I know there’s so much that I can contribute now and I’m excited to contribute it.

Q: What advice do you have for someone thinking about applying to AEF?

Do it a hundred percent. If I could go back, I would be a fellow. I tell everyone that every day. I think the fellowship provides such a unique opportunity to be on the ground, learn from renowned experts at state health departments, contribute in such a meaningful way while learning so much about what you’re going to enjoy in public health to help shape your career. I think anyone considering it, even folks who aren’t sure about the direction they want to take, I think the AEF fellowship just provides such a great foundation and a starting place for what public health can be for your career.

Current Fellow – Hannah Lund, MPH, Pennsylvania

Hannah Lund is a current fellow at the Pennsylvania Department of Health where she specializes in infectious disease. Hannah has a BA in Biology from Southwest Minnesota State University and earned an MPH in epidemiology from the University of Nebraska Medical Center.

Q: Was there a certain “aha” moment you had that led you being interested in epidemiology?

I was a junior in college in undergrad, and I was majoring in biology, and I wasn’t really sure what it was that I wanted to do, and I happened to just pick up a book and I read about what they were doing. It was a former EIS officer who went on to work at CDC for several years, and he outlined how he got into public health, and the investigations he did while in EIS, and then working for CDC, and I was like, “Wow, that sounds like something I would really like to do.”

Q: How did you become interested in applying for CSTE’s AEF Program?

My career counselor at University of Nebraska was outstanding. She told me about a lot of different paths you can take leaving the MPH program here and mentioned CSTE’s AEF. We also had a PhD student who was a former CSTE fellow. I had the chance to hear her speak about her AEF experience, what she did and how it helped her. And after that day, I thought, “Oh, that seems like something I would really like to do.”

Q: Your fellowship is at the Pennsylvania Department of Health. Walk us through a typical day?

I’m in the Infectious Diseases team, but don’t have a specific focus. I am really spread out through everywhere. Somebody has a project, and they need help on it, my supervisors ask, “Hannah, do you want to do this?” So, I’ve helped with hepatitis, I’ve helped with some environmental projects with wastewater, influenza and vectorborne. I’ve done some COVID stuff. I’ve really just been kind of spread throughout and it’s been great, because I get to experience all these different things, and I get to see what I like and I don’t like.

Q: What are your future career goals?

I would say a dream job would be working with enteric diseases. I have really enjoyed doing interviews for any enterics outbreak. I like to stay busy and always have things going on, and that’s something that is busy year-round. Everything has its season, but there’s always something happening. And so, I think that would be my dream job.

CSTE established the Applied Epidemiology Fellowship (AEF) in 2003, closely modeled the program after the Center for Disease Control and Prevention’s (CDC) Epidemic Intelligence Service (EIS) program, which uses a mentorship model to train recent graduates in the expanding field of applied epidemiology. To learn more about AEF, please visit the newly refreshed and relaunched AEF website for more information – www.cstefellows.org.

Michigan Epi Jim Collins Reflects on His Career and What ‘Community’ Means to Him

By Ben Warden, CSTE Staff

Welcome to National Public Health Week 2023! In recognition of today’s theme, Community, we’re kicking the week off by interviewing Jim Collins, MPH, RS, Director of the Communicable Disease Division of the Michigan Department of Health and Human Services (MDHHS). Jim is also the CSTE Surveillance and Informatics Steering Committee Vice Chair. He discussed his career as an epidemiologist and what ‘community’ means to him. Note: This interview has been edited for length and clarity.

Q: What led you to being interested in epidemiology?

A: Back in the early '80s there wasn't much in the news about epidemiology. I was attending Alma College, a small liberal arts school in Michigan, and took a microbiology class that touched on the transmission dynamics of various infectious diseases. It was interesting to me and illustrated a connection between biology and math. At the time, I just wasn't sure where I wanted to go with it. I did know one thing; I've always wanted to see if I could make a positive difference. When I started reading about epidemiology, it made a lot of sense for the work I wanted to do. After graduating from Alma College, I decided to continue my education with an MPH program at the University of Michigan School of Public Health.

Q: What was the landscape for young epis back then?

A: When I finished graduate school, the job market for epidemiologists was not nearly as open as it is right now. At the time, I knew I wanted to go into a career focusing on infectious disease, recognizing it would be challenge.  A lot of folks thought infectious disease was passé because of antibiotics and other medical advancements. As we’ve since learned, infectious disease epidemiology will always be an important and dynamic field and that’s one of the reasons that I’m glad to be part of it. 

Q: How did you come to join CSTE?

I was an epidemiologist at the local level for about eight years, but I didn’t learn about CSTE until I worked at the state level. Our State Epidemiologist at the time, Dr. Matthew Boulton, recruited me to come work for the state and encouraged my involvement with CSTE.

Throughout my career at the state health department, our administration has continued to promote engagement with CSTE. I believe they agree that it contributes to our national public health voice and allows for information sharing that serves the greater good of the department and country.  I’ve found that to be absolutely true and I'm grateful for it.

Q: Take me through a typical day?  

A: I am the Director of the Communicable Disease Division at the MDHHS, the state health department. Michigan has a population of about 10 million people. A little over 100 people in my Division work on communicable disease issues, exclusive of HIV. There is still a daily component in my job focused on the COVID-19 response, and I don't see that changing in the immediate future. We talked about how dynamic the field of infectious disease epidemiology is. While we continue to respond to COVID-19, on a different front, we're also actively working on an outbreak of blastomycosis in the Upper Peninsula that's associated with occupational exposures. I don't think there are many typical days in infectious disease epidemiology, but that's one of the many reasons I enjoy it.

Q: Today’s theme for National Public Health week is Community. How does a sense of community help you in your work?

A: In terms of CSTE, there are so many opportunities to learn from partners from across the country that are doing the same work, but in different environments.  After every call or meeting, I leave with at least some notion of how to do our jobs better. I think you must be open-minded to these teaching moments from the community of CSTE colleagues in order to move the field of infectious disease epidemiology forward. Having a community of like-minded people with similar objectives, that share the same passions, the same hopes, the same aspirations, helps tremendously. It's a community that ranges in age, experience, and perspectives. I'm probably on the upper end of the age range for the community we're in, but I think my experience can help contribute. There's so much collective knowledge out there in CSTE and that’s a major aspect to what makes it valuable and productive.

I've been doing this for about 35 years now, but I am still incredibly passionate about public health and epidemiology. I still love the work we do, and I think it's very important.

CSTE celebrates February 2023 as Black History Month

In recognition of Black History Month, CSTE spoke with Heather Butts, Assistant Professor of Health Policy and Management at the Mailman School of Public Health at Columbia University in New York. Ms. Butts shared a few unsung Black epidemiologists and their contribution to modern day epidemiology.

Past is Prologue: What Untold Stories of Black Epis Tells Us About Today

Heather Butts is an Assistant Professor at Columbia University and accomplished author. After her first book, African American Medicine in Washington, D.C.: Healing the Capital During the Civil War Era, was published in 2014, she received a curious question from a reader.

“I like your book, but why should we care about this now?”

It’s a sentiment often asked of historians and academics. Professor Butts answered it not with pie-in-the sky platitudes, but with a hardwired belief in how the past can inform today.

“Part of the book was about morphine use during the Civil War and finding that connection between trauma, coping and addiction,” she said. “There’s a direct line from that to what we’re seeing with the rise of the opioid crisis during the COVID-19 pandemic.”

Connecting the dots between past and present is a large part of Professor Butts’ class, “The Untold Stories in U.S. Health Policy History,” which covers the contributions of Black Americans to the history of healthcare, including epidemiology.

“We benefit from these individuals works, and yet they go unnamed,” she said “Their stories are not told. So, we benefit from what they've done for us, but we don't benefit from knowing who they are, and if we knew who they were, we might be able to benefit even more from what they've done.”

In the spirit of Black History Month, Ms. Butts spoke to CSTE about a few unrecognized Black epidemiologists and  the impact of their contributions to modern day.

In 1965, Bernard Challenor was the first Black American appointed to be an Epidemiological Intelligence Service Officer at the CDC. He also worked at the World Health Organization, where he led efforts to vaccinate for and eradicate smallpox.

“[Dr. Challenor] was one of the premier individuals at the School of Public Health at Columbia,” Professor Butts said. “His history and what he accomplished is so underknown that his niece actually contacted me to learn more about him. The reason why I teach the course is really for people to have a better understanding of who some of these individuals are.”

Another underknown name is Rebecca Crumpler, who some claim to be the first Black American woman to earn a medical degree in the U.S. In 1883, she wrote the Book of Medical Discourses, which provided early guidance on maternal and child health.

“Her contributions over 150 years ago to the field of maternal and child health stay with us today,” Professor Butts said. “We just don't know that they’re from her. And that’s problematic.”

Another untold story Professor Butts talked about was Vivien Thomas, a laboratory supervisor who developed a surgical procedure, the Blalock-Taussig shunt, used to treat blue baby syndrome. While doing his work, he was technically classified as a janitor and paid as one.

“It’s distressing,” she said. "You have this Blaylock-Taussig-shunt, and really it should be called the Blaylock-Taussig-Thomas-shunt, or maybe it should be called the Thomas-Blaylock-Taussig-shunt. It’s concerning that we don't know these stories and that they’re just not fully formed.”

Professor Butts stressed that even though these individuals may not officially be known or trained as epis, the work they did contributed to the field. She also draws a line between her historical perspective and the epi method.

“Epidemiology to me is history in real time,” she said. “It’s we see the trends, they happen over time, and if we can take a moment to learn from them, we can see everything old is new again.”

Too many stories of Black History, especially in regards to public health, have slipped through the cracks. Recognizing them is not just about knowing the past … but to also glimpse into the future.

“I think if we can know where we came from, we can have lessons not only to where we are now, but where we are headed, where we could be going,” Professor Butts said.

“To me, that's why knowing our history, our complete history, our full history, it's so critical. It's so instrumental.”

Professor Butts received her Bachelor of Arts from Princeton University. She was a history major, concentrating in American and African American Studies. She received her Juris Doctor from St. John’s University School of Law, her Master of Public Health from Harvard University and her Master of Education from Teachers College, Columbia University.

She is also the co-founder or H.E.A.L.T.H for Youths, Inc. a nonprofit organization that focuses on college readiness and preparation. Her organization partners with 25 programs each year to help more than 1,000 students achieve their dream of going to college.

Read more about Professor Butts and her class, The Untold Stories in U.S. Health Policy History

CSTE President Angela Dunn had her “Public Health” epiphany as a young medical student. During an ER shift, she encountered a young man with late-stage Hodgkin’s lymphoma. He had no health insurance and was essentially told there was nothing the doctors or staff could do for him.

“I understood at that moment that I needed to go into more of a public health policy realm to affect change for people rather than just one-on-one patient care,” she said. “I knew that my interest and skill set would be better used at ensuring people like this gentleman got the care they needed and were diagnosed early so that they could go about their lives in a healthy way.”

Angela saw epidemiology as a natural transition from the clinical sciences she was studying, due to its data-driven methodologies and the detective-like mindset it takes to succeed at the job.

“[Epidemiology] really does speak to the science side of my brain, but then also that desire to make a bigger change at a larger population level really excites me,” she said.

After many years as Utah’s State Epidemiologist, Dunn is now the Executive and Medical Director of the Salt Lake County Health Department. A longtime member of CSTE, she was elected President in June 2022 for the 2022-23 term.

Like the CSTE Presidents before her, Angela has developed and crafted a few presidential priorities to spotlight during her term. Her first priority, “Formalizing Cross Jurisdictional Partnerships,” focuses on maximizing CSTE’s ability to bring together epis to share best practices experiences to help each other out.

“Having that group of people be able to say, ‘Well, here's how I deal with it,’ is really important,” Angela said. “But beyond that, it really is just that sharing of best practices within applied epi across state lines, because when we're able to bounce ideas off each other, that's how we make sure we're all practicing the best public health we can.”

The genesis of this priority came from the isolating early days of the COVID-19 pandemic, where Angela, then still a State Epidemiologist, noticed how much her and her colleagues in other states relied on each other to both keep up morale and share resources.

“It was nice knowing that there was a group of people out there that definitely had your back and understood what you were going through.”

If the community of epis is at the heart of Angela’s first presidential priority, then the community at large is at the heart of her second priority, “Equipping Epidemiologist to Practice Epidemiology WITH Rather Than ON Communities.”

Traditionally applied epidemiologists are very disease focused, describing how a particulate disease could spread, risk factors, etc. However, Angela feels that COVID-19 highlighted that since its typically the same communities that are at the highest risk for many public health diseases, epis need to “work with” communities and not just “talk at” them.

“As epidemiologists, we don't want our data to just sit unused in a spreadsheet,” Angela said. “We want it to be used to improve the health of the community. To do that, the communities must trust what we're doing. It's about incorporating a community perspective into our applied epidemiology, so that we can bring the whole community up and not just talk about one disease.”

While Angela admits her priorities are lofty, she is certain they are achievable in part due to the expertise and resiliency of CSTE members. One story from her pre-COVID days as the Utah State Epidemiologist specifically came to her mind that connects those attributes with both of her priorities.

In 2019, many Utah residents were visiting a camp in Jackson, Wyoming, when a rabid bat exposure occurred. In a very timely matter, Angela had to work and share resources with the Wyoming State Epidemiologist (whom she knew from CSTE) to identify all the individuals at risk, as well as work with the community to disseminate facts and not induce panic. During that time, communication between the two states was easy thanks to the connections that CSTE fosters. That efficiency also translated working with the community in a constructive manner.

“That's part of the bread and butter of applied epidemiology,” she said. “Working across state lines is to be able to work quickly, and that happens better when you know the people on the other side.”

“And honestly, it's because CSTE brings us together.”

Angela Dunn, MD, MPH is Executive Director of the Salt Lake City County Health Department, and CSTE President for the 2022-2023 term. For information on CSTE’s Presidential Priorities Award, which is given at the CSTE Conference, please visit https://www.cste.org/page/presidential-priorities-award.

April is known as a month of “firsts” – the first flowers of the year bloom, the first days of warmer weather and the first baseball game of the year is played. April 2022 also saw a first for CSTE as it hosted its first Preventative Medicine Fellow, Dr. Hariharan (Hari) Athreya. 

Concurrently with his CSTE Fellowship, Dr. Athreya is finishing up a Fellowship in Preventative Medicine at Emory University. He’s passionate about providing global and community health and addressing health inequities. During his time at CSTE, he graciously sat down for an interview.

Q: Was there a certain “a-ha” moment where you became passionate about Public Health as a career?

A: If I had to pick one, it would be my experience with AmeriCorps during college. I saw that if I cared about social determinants of health and where people were living and how they were living like I was doing … then I would need a public health degree. But to be able to do that I think coupling that with a medical degree would offer the most ability to leverage my skillset and my interest in science. That experience showed me the importance of community health and trying to understand where people are living before just trying to fix them when they come to clinics, and I think that really showed me the importance of public health.

Q: Describe wanting to branch out beyond a traditional medical education to include public health?

A: Early in my medical education I was having a hard time grasping how little it allowed us to be out in the community and understand what was going on with our patients. And I think that medical education can sometimes be siloed in that we don't really understand the context of what we're giving or the context of the people that we're trying to help. And I remember in our medical school I think we only had one half-hour session on what public health meant and didn't feel like that was enough.

I started a program, GoodEats, that raised awareness of how social determinants of health affect clinical outcomes. It was born out of an attempt to help teach fellow medical students and myself about social determinants of health and how that was not just only affecting the patients in our community that came to see us, but how that was impacting our own ability to function as students and learners and be able to be present for our patients.

Q: What’s an average day like for you? 

A: My day to day varies a lot. With CSTE, there's a lot of information to absorb and that's been great. I attend a couple different group meetings daily and then sometimes ad hoc events come up, for instance today there is a White House briefing on the new data modernization initiative.

So, the day is usually sprinkled with three or four meetings and then trying to work on projects that I've been assigned to, that's both continuing projects with CSTE and sometimes projects that have been ongoing. Right now, I'm working on a project around screening for opioid use disorder in primary care clinics, working on a paper on air quality standards and how that affects preventative medicine physicians, doing different data analysis projects for the Georgia Department of Public Health.

Q: What programs or areas of CSTE’s work have interested you the most during your Fellowship?

A: I just sat in on a meeting with the health equity division of CSTE and I think that’s the most interesting [area] to me right now. And then informatics, i.e., the work that Annie Fine (CSTE’s Chief Science and Surveillance Officer) is doing around data modernization and why it's important. There is a balance necessary in trying to improve data systems that will be key for the future. It seems that working on the very local level right now, data is such a challenge to deal with. The questions around how to handle it moving forward is very interesting.

Q: Managing burnout has become a major issue for all health care workers. What have you learned, especially during the pandemic, that has helped you?

A: I think everybody who worked in direct patient care got burned out at some point during COVID, and it's how you pick yourself up from that. For me it was a lot of just trusting or being able to talk to the people around you, and share your experiences, and share your frustrations, and then together kind of resolve to find a better way to do it next time.

I think the answer to that question is one, making sure that you have people you can talk to and be open and vulnerable with when you do feel burned out or low, and then moving on to try to build a better public health infrastructure to avoid feeling burned out in the first place.

Dr. Hari Athreya is preventative medicine fellow at Emory University School of Medicine. He served as CSTE’s first preventative medicine resident in Spring 2022.