AT DISEASE CENTERS, A SHIFT IN MISSION
25 Aug 2003
Source: The New York Times, September 10, 2002.
At Disease Centers, a Shift in Mission and Metabolism
By LAWRENCE K. ALTMAN
The Centers for Disease Control and Prevention is going through an uncomfortable metamorphosis, from an agency that focused on controlling naturally transmitted diseases to one heavily involved with bioterrorism and its possible effects on national security.
The anthrax attacks last fall shook public and professional confidence in the C.D.C., the federal agency in Atlanta responsible for protecting the nation's health. It was embarrassed by widely voiced assertions that it was inadequately prepared to deal with a bioterrorist attack and had failed to communicate, clearly and quickly, vital information to the public and to health workers. In the aftermath, the agency's director, Dr. Jeffrey P. Koplan, resigned.
"The place is different now," said Dr. Harold W. Jaffe, a senior official at the agency. "To be told that you are partly responsible for the security of this country is a big cultural change for the agency. People are accepting it, but they are not entirely comfortable with it."
Over the past year, the C.D.C. has funneled $914 million from its parent agency, the Department of Health and Human Services, to state and local health departments, nearly 10 times as much as the agency said it disbursed the year before. The money is being used to upgrade disease surveillance systems, improve communication with local doctors and hospitals and bolster the ability of a network of laboratories throughout the country to detect the microbes considered most likely to be used in a bioterrorist attack.
If these efforts succeed, they will also strengthen the nation's ability to deal with naturally transmitted diseases.
The improvements have already borne fruit against West Nile virus, said Dr. Mohammed Akhter, the executive director of the American Public Health Association, the Washington-based group that is the oldest and largest organization of public health professionals in the world.
A year ago, Dr. Akhter said, states like Louisiana might not have detected outbreaks as quickly as they did this year.
The centers' new director, Dr. Julie L. Gerberding, said some of the problems presented by the West Nile outbreak were similar to those the agency would confront in a biological attack, in that communities were threatened by a seemingly novel microbe. She said the agency was drawing useful lessons from its experiences with West Nile, and applying lessons it had learned in the anthrax outbreak.
Nevertheless, some public health leaders say the agency is moving too far in the bioterror direction, at the expense of its more traditional efforts -- cutting the sickness and death toll from the major killers of Americans, like heart disease, cancer and stroke, and holding infections like tuberculosis in check.
These efforts "are in the shadow of the bioterrorism attack efforts," Dr. Akhter said, "and in that sense, the C.D.C is sort of unbalanced."
Finding the right balance is a major challenge, said Dr. Gerberding, who worked on hospital-acquired infections at the centers until she became director. Bioterrorism is "a fairly urgent public health issue," she said in an interview, yet ordinary public health issues "are the backbone of the work we do and really reflect the problems that affect the lives of people every day."
Nevertheless, the anthrax attack jolted the agency into greater self-analysis. "The style of not wanting to make a decision until you have all the data gathered and you have the nice tied-up package was a deterrent to effective decision making on a day-to-day basis" in the anthrax outbreak, Dr. Gerberding said.
Now a "theme of learn as we go" prevails at the centers, Dr. Gerberding said. In the event of another bioterror attack, she said, the agency will tell doctors, local health officials and the public: "This is what we can figure out today. Tomorrow we'll adapt to any new information that comes in."
This practice makes some public health specialists uncomfortable. Public health specialists "are not used to practicing in a fish bowl," said Dr. Georges C. Benjamin, secretary of the Maryland health department and president of the Association of State and Territorial Health Officials, which works closely with the C.D.C.
But there is wide agreement in and out of the agency that lack of openness was a major problem in the anthrax outbreak. Particularly embarrassing to C.D.C. workers, hundreds of whom were investigating the anthrax outbreak, was that the government's leading scientific spokesman on the attack was the director of a rival agency, Dr. Anthony S. Fauci of the National Institute of Allergy and Infectious Diseases.
"That signaled a serious problem," said a centers official, speaking on the condition of anonymity.
In late August, Dr. Gerberding and senior staff members held a news conference to say the agency was better prepared to fight a bioterrorist attack than it was a year earlier. It was the first news conference ever at the centers' headquarters, Dr. Gerberding said.
"You would think an agency like C.D.C. should have had that skill of a news conference under their belts a long time ago, but it wasn't something that was considered important," Dr. Gerberding said.
Now, the agency is working to improve communications with federal and state governments, the public and the groups of medical specialists that are most likely to detect the first cases in an attack, like specialists in infectious diseases, emergency medicine and dermatology.
In the initial stages of the anthrax outbreak, when communication was most critical, the centers published little information in The Morbidity and Mortality Weekly Report, its chief means of communication to health workers.
Discussing the planned changes, Dr. John W. Ward, its editor, said: "We may be publishing the report more than once a week when we need to get information out more quickly. In times of emergency, we may publish daily."
Dr. Gerberding said she had also reorganized the centers' schedule of scientific and administrative meetings to avoid the duplication that she said was "extremely disruptive" in the anthrax outbreak. And she said she would streamline the operation of the agency's headquarters, which was so cumbersome that members of the anthrax investigating team often learned about developments in the case from news reporters.
The anthrax outbreak also exposed serious gaps in the centers' working relationships with its bosses in Washington and other federal, state and local agencies. Dr. Gerberding said she was developing closer ties with agencies like the National Institutes of Health and the Food and Drug Administration and with law enforcement and intelligence agencies.
In addition, Dr. Gerberding talks daily to her superiors in Washington and has visited them at least once a week, she said. She has also begun visiting state and local health departments, including New York City's.
Since the anthrax attacks, the agency has upgraded its emergency operations center. As part of that upgrade, technicians have adapted software to send a daily report automatically from the operations center to Washington so officials there have immediate access to the most recent information.
In a way, the current emphasis on bioterrorism brings the agency full cycle to the origins of its epidemiology program, which was started in 1951 out of concerns of biowarfare in the Korean War. The agency itself was established five years earlier, out of concern that troops returning after World War II might being exotic diseases to the United States.
Over the years, the centers have grown into an agency whose mission includes acting on infectious diseases, chronic and occupational diseases, environmental health and other problems. The agency has an annual budget of $6.6 billion that employs 8,254 people in Atlanta and at field stations around the country, up from 7,310 in 1996.
But though its epidemiologists have earned a world-class reputation as medical detectives, "parachuting" into the scene of an epidemic, learning its cause and helping local health officials control it, today they are learning to improve their coordination with different groups.
C.D.C. also has reached out to state and local health departments by holding more conference calls, something that did not happen as regularly a year ago, Dr. Akhter said.
In addition, the agency has begun to pay more attention to the way the public will react to reports of disease outbreaks, Dr. Akhter said, adding, "It is a very welcome shift."
Dr. Gerberding said the centers' staff was "often perceived as being very insulated, didactic and objective," but she added: "That perception is wrong. We are very humanistic and empathetic and truly care about the individuals who are affected by many of the health problems we investigate. But we often don't raise that to the level of corporate consciousness, we don't reward it, we don't reinforce it, and often we don't reveal it."
To underscore the importance of C.D.C.'s role and to help boost morale at the institution, George W. Bush and Dick Cheney became the first sitting president and vice president to visit the centers while in office, in November and July respectively.
Tommy G. Thompson, the secretary of health and human services, has made four visits, more than any of his predecessors, to the tangled web of C.D.C. buildings that abut Emory University.
"Their visits have had a profound impact on our sense of value and role in government," Dr. Gerberding said in an interview.
The government has long been criticized for inadequately financing public health. Dr. Akhter said creating a top-level public health system would require a sustained effort for about three years. "It cannot be done overnight," he said.