ORGANIZING FOR SUCCESS
I had already been associated with the CDC for fifteen years when I was appointed its director. Before, I had always focused on specific problems. Now, I had to think of the entire organization, to ask what we were doing and what we should be doing. What did good stewardship come down to on a daily basis?
The National Institutes of Health (NIH) was seen as the research arm of the Public Health Service. The CDC was seen as the delivery arm of public health. Early on, I fortunately met with Don Fredrickson, director of NIH, to discuss how best to position the two agencies when we testified before Congress. I told him that I respected the traditional differences but had also noticed that the most productive employees at the CDC were not only focused on delivery but also always asking how to improve on what they were doing. Therefore, they were involved in research, looking for better tools and better ways of using those tools, and expanding what was known. Dr. Fredrickson said the same was true at NIH: the best researchers were involved in seeing their innovations and discoveries used. Therefore, they were involved in delivery to improve on the research findings and to guide future research. We concluded that there should be no sharp line between the two agencies and that, within the overall understanding that the CDC was in delivery and NIH in research, we would encourage employees in both organizations to combine research and delivery.
Implementing the tools and resources to improve the public’s health is easy to understand. However, a daily concern revolved around doing the right things and doing them right. What were the right things? Originally, we were charged with targeting infectious diseases, but the mandate was slowly expanding. Our objectives were threefold: we were charged with (1) eliminating premature death, (2) eliminating unnecessary suffering, and (3) improving the quality of life. Eliminating death is not achievable, but defining premature deaths and preventing them can be achieved. The definition continues to change as tools improve, so the CDC’s objective was always evolving. Eliminating suffering is also not achievable, but defining what is not acceptable, what is unnecessary suffering, is crucial. Finally, beyond death and physical suffering, there are the problems inherent with poverty, gender bias, illiteracy, unemployment, mental illness, and other social determinants that reduce the quality of life. Public health seeks to alleviate those problems. The tools for achieving these goals with infectious diseases are applicable to many conditions, so it is no surprise that the purview of the CDC continued to enlarge.
Evolution is a word fraught with emotion for many. Because the original task of the CDC was focused on communicable diseases, the staff included many microbiologists, and microbiologists have a front row seat to observe evolution. Viruses and bacteria are continuously changing to adapt to a new environment. Antibiotics were very useful when first introduced. However, bacteria develop countermeasures, often through mutations, to survive in the presence of an antibiotic. Soon those strains predominate, and the antibiotic or antimalarial drug became less useful and, in some cases, totally useless.
But one need not be a microbiologist to understand evolution. When my grandson asked me, “What is the best argument for evolution?” I answered, “The Westminster Dog Show.” It is obvious at a glance that dogs have a spectrum of sizes, shapes, looks, and abilities; yet, they have all developed from the DNA of wolves. To make it even more interesting, apparently the wolf group that evolved into modern dogs is extinct. It could not continue to survive as it was.
Many of my teachers emphasized that we are a mixture of nature and nurture. They always maintained that the environment in which we grew molded our basic genetic material, but that environment could not alter the DNA itself. But now, in the twenty-first century, we are learning that the environment can indeed alter DNA, inserting another ingredient into evolution.
Public health itself evolves, and soon it became necessary for the CDC to enlarge the area of concern from only communicable diseases to chronic diseases, such as cancer, heart disease, strokes, and diabetes. Rei Ravenholt (see chapter 5) had argued over the years that death certificates list the obvious clinical causes of death but that they should also list generic causes of the clinical condition, such as tobacco, alcohol, or diet.
Public health advocates kept enlarging their areas of interest. Violence was increasingly seen as a public health problem together with environmental toxins and workplace exposures. Over time, most health problems were found to have public health components. Dr. Yemi Ademola, my classmate from Nigeria in Tom Weller’s class at Harvard, used to say, “There is no field of knowledge beyond the interest and concern of public health practitioners.”
In 1993, J. Michael McGinnis and I published a paper in the Journal of the American Medical Association (JAMA) on the actual causes of death in the United States (1). Our conclusion was that, instead of listing heart disease, cancer, and stroke, the actual causes were tobacco (400,000 deaths a year), diet and activity patterns (300,000 deaths), and alcohol (100,000 deaths). These three factors accounted for 40 percent of the deaths in this country.
Yet even that approach is inadequate in explaining death patterns in this country. We need a new article on the causes behind the causes, in an attempt to determine the proportion of deaths due to poverty, lack of education, gender bias, unemployment, and other social determinants of health. The WHO and the CDC have both published on the social determinants of health and deaths, and in 2014, the faculty at Emory University added to the list by editing and publishing a book on religion as a social determinant of health (2).
Structure
Structure follows function, and during the early years of the CDC, with its focus on communicable diseases, the structure followed skill sets. Laboratory programs used bench scientists, who were working on understanding organisms, researching better ways of detecting them, following patterns of resistance to antibiotics, discovering the causes of outbreaks, and finding and characterizing pathogens never before seen.
Epidemiology was another major focus and enlarged greatly with the recruitment of Alexander Langmuir. Statistical programs expanded to support the epidemiologic and laboratory work. At that time, the CDC was small enough that much of the structure was informal and did not require a “structural adjustment.” A management expert studying the CDC in the 1960s defined it as a mom-and-pop operation that seemed to work fine.
The problems arose with new outbreaks to be investigated. Each outbreak required a matrix management ad hoc approach, which depended on early guesses as to the organism involved. The problems were always worked out, but there was a cost in efficiency.
As the complexity of public health increased, the CDC was forced to define the high-priority areas of concern. The agency needed to determine what function it should play and how it should be structured to fulfill that function.
I did not face these questions alone. The CDC had a staff of thousands, but beyond that, we all bring with us the input of thousands of others, for we are all truly connected and in the struggle together. John Donne was correct when he wrote (3):
No man is an island,
Entire of its self,
Every man is a piece of the continent,
A part of the main.
The implications go beyond the idea of human connections. A million ancestors have influenced my DNA, just since the Renaissance. Even more have influenced my social DNA.
Social DNA includes the influence of many, directly and, even more, indirectly. Some of the most obvious are those we regard as mentors, people who have had an influence on our thoughts, beliefs, way of working, and sense of responsibility. The list of mentors seems endless. (For my partial list, see the appendix.)
Advice from the Past
Every new position, as medical student, intern, EIS officer, medical missionary, smallpox worker, refugee health coordinator, and now the CDC director, initially made me anxious. Was I prepared? Could I find the right people to provide guidance? How would we choose priorities, develop strategies, and measure our performance? Would we have the courage to acknowledge mistakes, and would we learn from those mistakes?
The wisdom of historical people is invaluable not only because their ideas were often the end product of everything they had learned but also because those ideas could be evaluated in the context of what happened after these people have lived, a perspective obviously denied to them. And so I went back, before going forward. It was similar to the thirty-six hours taken during the Nigerian famine relief operation to absorb the wisdom of the past before being certain about my next steps.
What continued to surprise me was the consistency of the conclusions of great people regarding what constitutes the best ways to live and the consistency of our resistance to adopting their recommendations. They repeatedly praised knowledge and science, while, at the same time, warning of the limitations of science. They consistently promoted social justice, while the world continued to promote slavery and bias. It is easy to get discouraged when faced with the economic inequities in the world, despite the pleas of Amos the prophet. And so I reviewed notes made over the years that provided advice on public health before the discipline even existed.
Polybius was a reminder to me that the world is an organic whole, with everything affecting everything, and that the voices of 100 billion people who have preceded us were still speaking to those who would listen.
Confucius reminded me to emphasize morality and the Golden Rule as a basis for the CDC’s responsibility to improve life for all and to be cautious about the power inherent in teaching others how to be healthy. The itch to teach is a part of the itch to rule; scratch the one and find the other. There is a strong need for a social conscience in this organization called the CDC. Imhotep, apparently the first scientist that we know by name, a physician and the builder of the Step Pyramid, would urge us to combine art and science in every endeavor and in every scientist.
The echo of Euripides’s songs attacking slavery, gender bias, and aristocracy was a reminder of the need for social equity and urged me to use the CDC’s facilities for the poorest people in the poorest countries. Through 2,500 years of history, I could imagine him preaching about the social determinants of health.
That mission was enforced by Arnold of Villanova, physician to James II. I read of his diplomatic missions, where he was shocked by the health, misery, and exploitation of the poor. He did not mince words. He condemned the wealth of the clergy, and, despite being pursued during the Inquisition, he repeatedly warned the king that unless he protected the poor from the rich he would go to hell.
At a time of increasing specialization, I remembered Averroes, the great Islamic philosopher, lawyer, and physician, who saved for us the works of Aristotle. He was the first to recognize that an attack of smallpox confers immunity and argued for the integration of knowledge from medicine, philosophy, physics, psychology, law, theology, and astronomy.
Roger Bacon would say that he saw the CDC coming 700 years ago. He seems to have seen everything else—cars, airplanes, submarines, and telescopes. But his warning is still clear 700 years later. Science has no moral compass, so scientists must cultivate one.
Rabelais would repeat the ten words that he has Gargantua saying to his son, “Science without conscience is but the ruin of the soul.” This should be on the wall of every science department.
Francis Bacon would utter his legendary words, “Knowledge itself is power.” But despite his zest for knowledge, Bacon subordinates it to morality. “Of all virtues and dignities of the mind, goodness is the greatest,” he wrote.
Benjamin Franklin would be absolutely delighted by the science from the CDC. He once said, “O that moral science was in as fair a way of improvement … and that human beings would at length learn what they now improperly call humanity.” Franklin lost his son to smallpox, and he would have had a special interest in the CDC.
Albert Schweitzer would remind us that ethics goes beyond people to include animals, plants, and the environment. He would caution all those with any power to be mindful of the destiny that they are creating for others. This remains vital for everyone who will ever work in the CDC’s buildings.
Einstein, standing before the Caltech student body (4), said, “It is not enough that you should understand … science … Concern for the man himself and his fate must always form the chief interest of all technical endeavors … in order that the creations of our mind shall be a blessing and not a curse to mankind.” But the quote from Einstein that I have used the most over the years is, “Nationalism is an infantile disease. It is the measles of mankind.”
The physicist Richard Feynman famously said that time moves in only one direction—that, for example, it takes very little energy to scramble an egg, but all of science is incapable of reversing that simple process. This underscores the importance of the CDC’s mission to use science for prevention.
The drumbeat of history could not be ignored: the wisest people of the past agree on the need for social justice, and that means global social justice.
There was no end of advice from the past, but it was also important to get advice from the present. So, with these lessons from unmet mentors firmly ingrained, we sent out a letter to national, state, and local health officers, as well as to academic institutions and many others, asking for their input on what they regarded as the most important tasks that the CDC should pursue. More than 400 people returned thoughtful responses. Seth Leibler took responsibility for organizing the responses into eighteen different categories. The traditional areas of public health, infectious diseases, sanitation, water safety, health education, and immunization were frequent subjects of the letters. But an expansion of interests was becoming evident. Violence, substance abuse, chronic diseases, genetics, mental health, and disaster relief were also well represented.
We then formed a committee—the Red Book Committee—based on the color of its final report. We asked the members to look at the responses and, on the basis of what was known about suffering and death in this country, to tell us what they thought the CDC’s highest priorities should be. All committee members were from outside the agency because the group was advising the CDC, and we did not want insiders influencing the direction their recommendations would take. The one exception was Don Millar, who acted as secretary for two reasons: first, to be the interface with the CDC for any questions the committee might have and, second, to be responsible for the report’s acceptance and use at the CDC.
One interesting development was the Red Book Committee’s concern that mortality statistics are difficult to interpret because infants and children who die young have equal power in analysis to 90-year-olds who die; thus, children’s deaths may not highlight the potential for prevention activities—as they should. From the committee’s inquiry came a new approach, still used today, namely, that of premature deaths. How many years are lost before a given age because of early death? It might seem logical to use the median age of death as the cutoff for premature death. The problem is that it would change each year, so it was decided to select an age and continue to use that. What age should be chosen? There were good arguments for selecting age 70 or even 75, but in the end, 65 was selected because global statistics often use that as a standard, and the committee wanted to be able to compare the United States to other countries.
After much discussion, the committee prepared a report on the priority areas it felt should especially concern the CDC.
The CDC followed the publication of the report with two retreats at Berry College in North Georgia, an off-site location close to Atlanta. The retreats were designed to give top management an opportunity to speak for or against the priorities. In the end, the CDC’s top managers accepted them all and added a few more. It was agreed that budget requests to the Public Health Service would reflect an annual review of priority areas. The important result was a priority list that had support from all.
Reorganization
Agreeing on how the CDC should be structured was much more difficult. The basic result was an agreement that the CDC should reorganize from an expertise orientation to a health-outcome orientation. For example, we should have a Center for Infectious Diseases that would contain all the expertise needed in laboratory sciences, epidemiology, statistics, social sciences, and other areas for the center director to be able to achieve infectious disease goals. There would be a center for environmental health, one for occupational health, and eventually one for chronic diseases and injury control. Matrix management would still be required for problems that were unclear at the beginning of an investigation, but the new structure made the CDC much more efficient.
With an agreement on a new structure, a new problem arose. Scientists working in the laboratory were concerned that they would not have the same supervision if a bench scientist did not supervise them. One can read that as a lack of confidence in epidemiologists to understand the lab scientists’ needs. A large portion of the laboratory force would be in the new Center for Infectious Diseases. Bench scientists had been supervised for so long by people with the same background that they could not easily accept supervision by others. Soon I learned that a number of top scientists were seeking employment in other places, including academic institutions or state laboratories.
It was crucial to have a center director of the Center for Infectious Diseases who could bring a new group of people together in a functioning unit. By the time the first director stepped down, it was hoped that employees of the Center for Infectious Diseases would have worked so effectively that the tension between bench scientists and epidemiologists would have eased. Dr. Walter Dowdle was a virologist, highly respected in the lab but also by epidemiologists. He had a special interest in influenza, and because this was an annual problem, he had worked closely with epidemiologists to determine which strains of virus should be incorporated into the influenza vaccine each year.
I talked to Walt about the position, but he was not interested because he enjoyed bench science. I had always avoided talking people into positions; I thought it important for people to follow their passion, not someone else’s desire. Despite that basic belief, I went back to Walt and tried again. I failed. On the third try, he agreed to give it a try, and it solved all of the problems that were brewing. Bench scientists stayed, and Walt had the ability to make a new center work. Best of all, he came to enjoy it. After he retired from the CDC, he continued to work on polio eradication and was successful in developing a global laboratory network capable of isolating, defining, and following polio lines of infection as the world organized to eliminate polio from the globe.
The CDC continued to be a place of wonder. Combining good science with a strong drive for social justice attracted an unusual group. I once remarked that, walking down the hall, it sometimes appeared that we had hired the campus radicals of the 1960s. We had activists who often could not believe that they were working for the government they had recently condemned. But as noted elsewhere, whatever your feelings about government, it is the only institution that represents all of us. No church, social organization, or service club can do that. Therefore, government is the only place that can provide actual social justice for all. It is a revelation for social activists when they finally discover that.
The Workforce
The workforce also evolved and became a combination of several cohorts. There were the scientists, often working in the laboratory, striving to find better ways to study organisms or to detect chemicals in the environment. The scientists tended to be academic in their perspectives, and while some would move on to academic settings, some remained at the CDC for their entire careers. Notable examples included the late Charles Shepard, who focused his disciplined mind on less-studied organisms, such as the bacterium responsible for leprosy. Joe McDade focused on rickettsia and was the scientist to discover the organism that caused Legionnaires’ disease. Joe was a leader in forming the online scientific journal Emerging Infectious Diseases. In recent years Olen Kew, a gifted virologist, has brought cutting-edge science to the understanding of polioviruses. I believe he actually understands how the poliovirus thinks. Walter Dowdle became a legendary figure, as noted. He worked in the laboratory on influenza viruses and became an encyclopedia of knowledge as this virus changed its appearance in a constant attempt to remain relevant and to avoid the threat of whatever influenza vaccine was currently deployed.
A second grouping involved managers. Scientific knowledge is weak in its original state. It must be used to be powerful. As the management consultant Peter Drucker once observed, that means it has to degenerate into work. Management is the work tool that allows knowledge to change the outcomes in public health. Many of the original managers came from the Malaria Control Program of World War II. These were gradually replaced by managers who learned their trade as field-workers in the field of sexually transmitted diseases. This group combined blood-drawing skills with interpersonal skills, honed while interviewing individuals about their sexual activities, and detective skills, refined in finding contacts of persons with a sexually transmitted disease. Their work helped them to develop skills as diplomats and salespeople. Imagine getting a person to share the name of a sexual contact with the reassurance that the information would not become public. These workers had to convince people that they could be trusted.
The venereal disease workers became unusually adept as problem solvers, and they moved on to become accomplished managers of many programs at the CDC. Their ability to keep secrets was profound. Following the death of a famous person with AIDS, identified by news reports as being gay, I chanced to be at a meeting with a dozen of these workers. After the public disclosure, they were free to talk, and it was soon apparent that half of the people in this meeting knew the true situation, had contacted this person regarding other sexually transmitted diseases, and had never shared this knowledge, even with their fellow workers. It was from this background that the late Bill Watson emerged to become deputy director of the CDC and a leader of such integrity that he had the respect not only of the managerial cohort but also of all others in the organization.
There were several other cohorts in the mixture. One consisted of EIS officers, who were recruited for two-year terms as one of the draft options in the CDC’s early days. Therefore, at the beginning of EIS, they were all men. Many spent their two years at CDC headquarters; others were assigned to states, cities, counties, or academic institutions. Many stayed beyond their two years, some for entire careers. The CDC had to become even more professional, hiring cutting-edge experts in scientific, training, and managerial fields to support these officers as they investigated outbreaks. The officers, in turn, kept a continuing stream of new ideas coming into the CDC.
Finally, the CDC had an enormous support staff; secretarial support, janitorial services, glass washing, engineering, and computer expertise were among the services provided by over 160 different occupational groups. While the scientists, managers, and EIS officers tended to be recruited from national labor pools, the support staff tended to be recruited from the Atlanta area.
Equal Employment Opportunities
Atlanta in the 1950s and 1960s, as in the rest of the country, was working through the great social changes of the civil rights era. Atlanta had a stability not found in some cities because of its fair-minded and inspirational leaders in the African American community, such as Martin Luther King Jr., Andrew Young, Benjamin Mays, and John Lewis. In the white community, people such as business and civic leader Ivan Allen Jr. led Atlanta through turbulent times when segregationist Lester Maddox was in his political prime. Ralph McGill, editor of the Atlanta Constitution, was a strong influence; he featured continuing editorials and articles on the importance of rights, fairness, and diversity not only in Atlanta but also in the rest of the country.
The CDC did not escape the tensions of those years. At one point, an underground newspaper, the Plantation News, was published, which complained about the bias inherent in the CDC’s hiring practices. Dave Sencer, director of the CDC at the time, wanted no discrimination and sought an approach to equal employment opportunity that was both fair and transparent. A large percentage of the total workforce came from the local community and the CDC needed to make it a representative workforce. Sencer asked me to head up a committee to advise him on the most effective way of making sure that our intentions of equal opportunity were matched by actions.
In those days, the Public Health Service was recommending weekend sensitivity sessions that included employees and their managers. The idea was that everyone could discuss their feelings, complaints, and concerns openly, with no adverse implications when they returned to work on Monday. Sensitivity sessions relied on compartmentalizing thoughts and emotions—workable in theory but difficult in fact.
I went to the American Management Association and asked what experiences their members had in implementing equal employment opportunities and whether they could draw conclusions from those experiences. The association had a database of companies that had tried a spectrum of activities. The most successful approaches had relied on managerial approaches rather than on sensitivity approaches. If achieving a diverse workforce was part of the expectations for managers and was reflected in the evaluation performed by supervisors, and if performance ratings and promotions took that into account, success was more likely. In later years, I realized this was the basis for an observation that “it is easier to change a mind than a heart.”
Over forty-two years later, I have gone back to our committee report. It recommended that Dr. Sencer should approach equal opportunity in hiring as a problem to be solved by an organization of problem solvers. Three training sessions were recommended. The first was a series of meetings, starting with Dr. Sencer and all staff reporting to him, and continuing through programs, branches, sections, units, and subunits. The purpose was to establish the philosophy that the CDC was going to solve this problem but that the solutions would come from the programs and move up. The second series of meetings went in reverse, from subunits to the center level, listing the commitments made by each program. Dr. Sencer would not set the goals for the CDC until he had heard from the programs. The purpose was for each manager to make a commitment on the basis of the program’s present profile and how the manager thought it could change in three, six, nine, and twelve months. Each manager’s plan and commitment would be presented and merged with other commitments as the meetings progressed back to the director’s level.
Our assumption, which turned out to be correct, was that the composite plan, reflecting the decisions of managers, would provide targets even higher than if Dr. Sencer started with center-wide targets.
A third series of meetings from subunits to the center level allowed each area to review its commitments now that a plan for the entire CDC existed. This series of meetings also offered a chance for comments to be directed to the center director. These meetings also detailed plans for evaluation, determining what would be measured, how often, and how the results would be distributed. When the third round was complete, the commitment made by each program became clear. Quarterly evaluations would be based on numbers of employees by sex and race at each salary level and within each occupational category, changes in number over time, shortcomings in commitments, and a summary of new hires in each category.
This plan seems so logical at this point in history but, interestingly, the Public Health Service was wary of the approach. However, because of that community’s respect for Dr. Sencer, they gave a provisional six-month approval, with a promise to review the results at that time.
At six months, the review, by the office of the assistant secretary for health in the Public Health Service (HEW), was favorable, and the approval was extended. The CDC continued to make good progress in providing opportunities for women and minorities.
Some years later, after I had become director of the CDC, an administrator from the Public Health Service requested a time to talk to the senior staff. He presented a plan for equal employment opportunities for the CDC to implement along with the rest of the Public Health Service. As he was discussing the plan, I realized it was the CDC plan from some years earlier that had been given provisional approval, six months at a time. I sent a note to Carol Walters, who was attending the meeting, asking whether she could go to the files and get a copy of our original plan, which she did. When the Public Health Service administrator finished, I told him he could count on us and then showed him a copy of our original plan, the provisional approval by the Public Health Service, and a summary of how it had worked out. Satisfaction is the word that came to mind.
Daily Operations
Epidemiology can be reduced to the concept of acquiring numerators and denominators to determine a rate and then interpreting that rate. Similarly, public health can be reduced to surveillance systems to acquire information on the health of the public and the use of that information to make decisions that enhance the health of all. Every daily activity in some way supports that core. The surveillance system is then used to determine the impact of the activities to make midcourse corrections. The process continues to be repeated.
Some outbreak accounts have already been related. But what happened at the CDC on a daily basis? Much of the activity involved developing and maintaining usable national and global surveillance systems. This resulted in a continuing flow of information on every health condition imaginable. Originally, the information systems were geared to infectious diseases. Over time, similar systems developed for the entire expanding range of public health. Beyond the conditions reported by all, certain states had special interests in other diseases, and as state epidemiologists make the decisions regarding what they report, there are parallel reporting systems. In addition, state laboratories and many medical laboratories report directly on organisms they have isolated. Current and former EIS officers around the country and around the world are in daily contact. Then and now, there is a whirlwind of activity in the labs and offices as people work on analyzing data, developing new tests, testing the thousands of samples coming to the CDC, and reporting back information to all who need to know. The parallel in clinical medicine involves taking the history of a patient and conducting physical and laboratory examinations. In public health, the surveillance system is continuously taking the history of a community, state, nation, or the world.
In 1950, the first national surveillance system for a single disease, malaria, was established. International treaties had identified a small number of diseases—including smallpox, cholera, plague, and yellow fever—as reportable. The states were expected to report those diseases, but it was largely a passive system. In 1950, the first active surveillance system was established for malaria. It was a surprise when reported malaria cases were tested to find that malaria had quietly disappeared from this country. The second surveillance system was developed in 1955 because the polio vaccine from Cutter Laboratories was causing disease. The surveillance system quickly identified the problem and was able to exonerate vaccines from other manufacturers. The third system was developed in 1957 for influenza. Thereafter, surveillance systems mushroomed, and the CDC always had a point person responsible for each reportable disease.
While public health workers continue to identify the systems as surveillance systems, the word often conjures up the thought of CIA activities. In reality, the programs are attempts to develop disease intelligence systems, but surveillance has become the operative word.
The systems, over time, went from infectious diseases to everything imaginable in the area of human health and welfare. Systems now exist for all of the chronic conditions, including heart disease, stroke, and diabetes, but surveillance systems also now exist for tracking factors leading to those problems. Surveillance of weight, blood pressure, smoking rates, and other predictors of health problems is common. Disease problems resulting from occupational or environmental exposures are tracked as well as the chemicals and toxic substances thought to be involved. The data bank has become increasingly sophisticated.
A parallel is seen globally. Famine used to be detected after it was obvious that children were starving. Now surveillance systems exist for rainfall, crop cover, and market prices, providing information on what might happen long before malnutrition is detected. The system for famine detection is now so robust that starvation can be attributed to conflict or political problems rather than to lack of information on the nutritional status of the population.
Collecting the data is only a start. Data must be analyzed to understand the meaning of the information. Analyses are ongoing at different levels and at different speeds. For example, a report of a suspected case of smallpox, cholera, or anthrax leads to immediate analysis and action. Smoking rates, on the other hand, are tracked over time.
Response
Public health is characterized by action. Analysis must lead to some response, either immediate or in the future. While this is widely accepted today, the development of surveillance evolved from archiving, which is simply recording events, to an academic approach, where the events might be analyzed and reported but with no response. Modern public health surveillance uses the entire cycle of collection, analysis, response, and then restarting the cycle with the new information collected.
William Farr was a pioneer in the development of surveillance systems. In the early 1830s, he qualified as a doctor in London and while in practice he became interested in medical statistics. He began working in the General Register Office for England and Wales and developed a system for recording causes of death. This allowed comparisons according to the deceased’s occupation, age, and geography.
In 1849, a cholera outbreak in London took the lives of 15,000 people. By examining data from that outbreak, Farr developed theories on how cholera spread. This is the same outbreak that was studied by John Snow, who concluded that the disease was spread by contaminated water. Snow was correct, but Farr thought the disease was spread by air (i.e., the miasmic theory), and he showed over the years that death rates decreased with elevation above the river. For him, this was proof of the theory of air as the vehicle. Although Farr did not accept Snow’s theory, Farr helped Snow by providing the addresses of the people who had died, allowing Snow to develop spot maps of the deceased. Years later, Farr’s doubts were overcome by good data, and he concluded that Snow was correct in his interpretation, showing once again that doubt and uncertainty provide the basis for sound scientific conclusions.
Now surveillance systems are much more intensive. Many reports are automatically generated as organisms are identified. Google has raised the possibility of estimating influenza activity even earlier than the CDC by analyzing the requests for information on influenza symptoms and the geographic location of those inquiries. However, the “noise” of the Google approach does not make the information more reliable. Real-time analysis of laboratory results, with instant reporting as part of the diagnostic process, will reduce delays and will speed up the analysis. It is possible to foresee a day when urine and stool analysis in public toilets, as well as air analysis in buildings and real-time reporting of individual patient isolations, will provide part of the evaluation of the health of people in the aggregate.
Having reached preliminary judgments about disease patterns, the CDC shares the information in a variety of ways. Informally, report providers are in a constant dialogue.
The Importance of Partnerships
The CDC routine has always involved a weekly publication, the MMWR. This provides raw data on a wide variety of diseases, commentary and explanations, and summaries of the science for various conditions. Raw data allow readers to do their own analyses and to keep the system transparent.
At one point, as part of reducing government spending, the administration declared that the CDC must stop sending out the MMWR for free. I was concerned about the government’s inability to understand that this newsletter was an important part of public health administration, an efferent arm to the surveillance cycle. It is an essential part of transparency to provide information back to those who have provided it, to those who can improve health by having that information, and, in a broader sense, to all who fund public health, that is, the public.
But what I initially regarded as a mistake by the White House and a major problem for public health turned out fine for reasons I had not anticipated. George Lundberg was the editor of JAMA from 1982 to 1999. A pathologist by training, Lundberg was one of those people interested in everything. To be editor of a journal that encompassed all things medical and beyond was a great job fit. Lundberg visited the CDC as part of his information gathering, and when he heard about the White House decision to stop free MMWR distribution, he offered to publish the newsletter’s contents as a part of JAMA. Suddenly, the MMWR’s circulation went far beyond the original mailing and could be found in every medical library and in most physicians’ offices. It was an important marriage of public health and clinical medicine.
The MMWR is only one form of communication for the CDC. Dialogue with workers in the field, articles published in the scientific literature, and employee interviews by journals, newspapers, radio, and television to explain findings are all important. These activities are augmented by countless speeches at countless meetings by hundreds of CDC workers to provide real-time information and dialogue.
A component of responsiveness is providing accurate information to the press (and now, of course, social and other online media). Many organizations attempt to control, at a central point, information released to the press. We took a different approach and told the staff we were comfortable with anyone’s talking to the press. We wanted the most knowledgeable people providing the information rather than a spokesperson providing information from talking points. But we had one caveat: tell us what you said so that we don’t contradict you. People will talk off the record if this approach isn’t used; this way, the front office knew what was being said. We never once got into trouble because of this open approach.
Direct Public Health Response
Daily public health activities are the responsibility of local health departments. Vaccinations, collection of water samples, inspection of restaurants, investigations of outbreaks, and the like are all activities of state, county, and city health departments.
However, the CDC becomes involved as a resource and a provider of skills, consultation, and supplies. For example, the announcement in April 1955 that the Salk vaccine protected against polio led to a federal program to provide polio vaccine to all children in the United States. New vaccines were added to that program, and today it is a massive program that covers many vaccines provided through the CDC to state and local health departments. A part of accepting the vaccine is an agreement on how the vaccine will be used, age groups to receive the vaccine, and standards and evaluations of the immunization program. While the CDC does not routinely administer vaccines, it is heavily involved in the entire immunization program and maintains records on cases of vaccine-preventable diseases. It also provides federal employees to assist states in executing programs, and it offers help in investigating outbreaks of these diseases.
The same is true for many conditions. Investigators are assigned for sexually transmitted diseases, tuberculosis control, environmental health programs, occupational health, and, increasingly, for chronic diseases. Although these investigators are federal employees, they are supervised by state and local health departments. In recent years, the CDC has also assigned hundreds of workers to foreign countries to assist in executing programs for malaria, AIDS, immunization, and training in epidemiology or laboratory sciences.
Speeches
I found myself expected to give many speeches a week, at times two or more a day, and made the unhappy discovery that I could not read a speech prepared by someone else. If I had not written it, I did not understand it well enough to actually give it.
Yet there is scarcely time to write speeches amid the numerous expectations of the CDC director. I used to say that every week felt like test week in medical school with more information than can be easily digested. I had to find an efficient way to prepare talks. And so I developed a system of preparing with the minimum effort possible. I would have a separate file for each speech scheduled over the next few months, and I would go through the files for a half-hour, early each morning. It became an efficient way to update thoughts on multiple subjects. Additional benefits were that this process helped to clarify what I needed to know to convey an idea to an audience, caused me to reach out to the experts in the field, and provided both contact with employees throughout the CDC and a better understanding of what they were doing. So speeches became a way to convey information to others but also (following the medical school test week comparison) forced me to study what was likely to appear on the next test.
On my retirement, I found my files actually contain thousands of speeches. I also found that the market for old speeches is limited (see sidebar).
The Hazards of Giving Speeches
Three stories about my speechmaking always make me smile. The first: Every speaker has a nightmare story of following an exceptional speaker. I wrote this account shortly after my own experience:
I was asked to speak at the thirtieth anniversary of the Indian Health Service. I did a fair amount of research and was impressed by the reduction in infant mortality and the improvement of other indices in its thirty-year history. Indeed, I became more excited about the results in light of no attempt to change the basic living patterns, a basic tenet of many overseas development programs. Even though the Navajo dwellings, or hogans, were still common and despite the lack of running water or bathrooms, the health indices were improving. There were important lessons here for the developing world.
I traveled to Aberdeen, South Dakota, and met up with the Weltys, both physicians, before my talk. They had arranged for my invitation to be on the program. The turnout was good, and I looked forward to speaking.
The speaker preceding me was William Mervin “Billy” Mills. Mr. Mills was a Sioux hero, who had won a gold medal in the 1964 Olympics in Tokyo, running the 10,000-meter race, the only American who had ever won that event at the Olympics. And what a speaker he was. He showed the actual film clips of his race. Of course, everyone knew, even before he started speaking, that he had won, but as the film went on, he narrated his thoughts as the race was progressing. This included the thoughts he had of dropping out and the decision to take the lead for one lap and then drop out. He could always use an excuse of a twisted ankle. He thought he would feel OK about that decision as he would show what he could do, but he would not have to do it beyond a lap. The Sioux Nation would be proud that he led the world for that one lap. But as he took the lead, giving a great fright to the other runners, he found that he felt fine and that he had enough energy to do it for another lap. He kept playing that game in his mind, lap after lap. He could feel fine dropping out at the completion of the next lap. He had a strong desire to show what a Native American could do. He had pride in his heritage … a pride that increasingly made it impossible to give up. But he also had pain that was eating away at his resolve, and he described the depths of determination that countered the pain.
The audience was beginning to cheer, and they were on their feet as the film showed the end of the race. They could not be restrained. They continued to clap and cheer, and the moderator had trouble regaining order.
But at last the restless crowd was utterly spent and began to contain their enthusiasm and find their seats. Slowly the noise decreased. When all excess energy had been exhausted, the moderator said, “And now to review the last 30 years of Indian health care …”
The second speech-related story concerned a lecture I was to give at Johns Hopkins. I checked into the hotel the night before and worked on notes for the talk. When I was almost finished, I went to the lobby bar, ordered a beer, and continued to review my notes.
A talkative man took a seat near me, ordered a drink, and began asking questions, Where are you from? How long have you been here? When will you go home? I was polite but continued to work on my notes. He suddenly asked me, “Has anyone ever told you that you have a great personality?” I said, “No.” He responded, “Well, there is a reason.” But he continued and said, “I didn’t come here to talk to you anyway. I came to seduce the piano player.” With that he left and went across the room to the piano, where a young woman was playing. I returned to my notes and would have forgotten the episode except that he returned after ten minutes and said, “You are never going to believe this. She has a worse personality than you have.”
Finally, a story from a CDC staff meeting, when I was a director, that I am afraid has become legendary. Part of internal communications is to make sure that everyone knows what is going on. Before e-mail became ubiquitous, staff meetings were the principal way of making certain that everyone in a particular office had the same information, so such meetings were frequent. However, I realized the difficulty of keeping the meetings short and informative when Don Berreth, director of the Information Office, once fell asleep in a staff meeting and later said in his defense, “The only ones not sleeping were the ones not listening.”
The key to public health is appropriate response. That is more than analysis, communication, and support of the daily activities of state and local health departments. It often involves investigations or additional research. Much response is in the form of consulting. States, counties, cities, and foreign countries ask the CDC for advice on how to respond to a problem and then another group conducts the actual response.
Sometimes the request is more formal, for example, a state asking for assistance. In general, the federal government cannot conduct an investigation in a state without an invitation. In practice, this is usually easily arranged because the relationship between the CDC and state and local health departments is so close. In these cases, the appropriate CDC person summarizes the request, usually in less than a one-page report of what is known at that moment, who made the request, when and how the request was conveyed, and how the CDC responded. This is classified as the “EPI 1” document. When the investigation is completed, an “EPI 2” is written to summarize what was done, what was found, and the remedial action taken.
Dozens of such formal investigations are conducted each year, many by current EIS officers together with other CDC staff. In addition, EIS officers assigned to the field do many investigations within their area of assignment that are not formally documented at the CDC, as these officers are working under the supervision of the local health department. The agreement with states is that the officers can be withdrawn for short periods, after discussion with the state health department, for investigations undertaken by CDC headquarters.
In addition, the CDC has many officers assigned to positions in other countries, some through the WHO and some directly with agreements between governments.
The key message is that there should always be a response, just as one would expect in clinical medicine. There are times, as with individual patients, in which the response is watchful waiting, but even that is a response.
Finally, there are long-term efforts with the states to plan for the overall improvement of the public’s health. In the 1970s and 1980s, a great deal of time was spent developing standards for every aspect of public health. I frequently observed that baseball had better standards and rules than public health. Baseball fans knew the standards and rules, and daily newspaper accounts would mention them in baseball stories. Pitchers were traded on the basis of not meeting a standard. Games were lost because a rule had been violated. And baseball is only a game. Why couldn’t public health be that organized?
In 1978, the Public Health Service decided it was time to develop objectives for the health of the public, in addition to standards. Drs. Julius Richmond and Michael McGinnis were prime movers in the Public Health Service. Representatives from around the country were assembled to begin the process of determining health objectives for the year 1990. The first meeting was held at Emory University in Atlanta, Georgia, followed the next day by a meeting at the CDC. Experts in multiple areas developed more than 200 health objectives. The process is common now and has led to global health and development goals.
The process was so new in 1978 that many of our objectives were unrealistic. But in some ways that did not matter because the important result was that a process had been developed that has continued ever since, and that process continues to get better.
When these objectives were reviewed in 1990, approximately half had been realized, and a quarter had not, although progress was real in most areas. Interestingly, a quarter of the objectives were not even measurable because the measurement tools had proven deficient. But again, that fact served to provide a research agenda on how to improve the system.
This domestic effort to suggest objectives in health led to a similar global effort in 1988. Rafe Henderson, formerly a CDC smallpox worker in West Africa, was now director of the Expanded Program on Immunization at WHO. In March 1988, at a polio meeting in Talloires, France, hosted by the Task Force for Child Survival, he presented a paper on objectives for global child health.
This was a forerunner of the Millennium Development Goals (MDGs) developed by the United Nations. The MDGs will have similar frustrations because of targets not reached or measurement difficulties that hinder evaluation. But the result will be the same as for the health objectives for the nation: they will provide a process, transparency, and a system for future improvements.