GLOBAL HEALTH
Sharing Our Science
Global health interests were high at the CDC. The original tropical disease specialists influenced this atmosphere, and soon Robert Kaiser, an early EIS officer (class of 1959) and tropical disease expert, was in charge of a massive malaria program, funded by USAID. The program worked with a WHO plan to eradicate malaria. This program—in conjunction with the smallpox eradication activities, the posting of D. A. Henderson (also an EIS officer and epidemiologist) from the CDC to the WHO, and Alexander Langmuir’s global interests—attracted globally inclined people to the EIS and other programs at the CDC.
However, the restrictions were significant. The CDC was expected to justify all global activities on the basis of improved health for Americans or as a response to a different funding agency, such as the USAID or the WHO. With these restrictions, Dave Sencer asked me to form a committee to advise him on how the CDC could best serve global health. Dave Sencer viewed health as one entire entity; he realized that what is good for the world is ultimately good for the United States. This perspective prompted him to detail many people to the Smallpox Eradication Program: he saw that the ultimate way to protect Americans from smallpox was to get rid of the disease everywhere. This strategy not only protected Americans but also was financially successful. The money that the United States contributed for smallpox eradication is recouped every three months. This is because adverse reactions to the vaccine that require hospitalization are absent, and approximately seven deaths a year, as the result of smallpox vaccine, are prevented. In the thirty-five years since smallpox was eradicated, the United States has seen its investment returned 140 times and avoided more than 225 deaths and literally thousands of vaccine complications.
This was the background for forming a group to advise Dr. Sencer on what the CDC could do to improve global health. The global health committee provided a specific recommendation. Because the CDC would probably never be a big funder for global health (this changed with AIDS and Ebola), the committee suggested that we identify the most important places in the world where global health decisions are made and then offer some of the CDC’s best people on secondment to those places. The committee emphasized that assignments should go to people that the CDC valued and would want back. The committee concluded that the single most important decision-making place for global health was the WHO headquarters in Geneva, Switzerland. Further down the list were the WHO’s regional offices, UNICEF, UNDP, and the World Bank. Sencer immediately began planning to offer a limited number of people the opportunity to work with the WHO in Geneva. The assignment of D. A. Henderson from the CDC to the WHO had already provided a precedent. Henderson headed up the WHO Smallpox Eradication Program for eleven years at WHO headquarters, always as an employee of the CDC. The ground rule with Henderson and those who followed was that the person would answer day to day to the WHO and not to the CDC. It was the only way of making the CDC employees a true gift to the WHO for the period that they were there, rather than a loan with conflicting loyalties.
The strategy worked. The WHO became even stronger when Rafe Henderson from the CDC was seconded to head up the Expanded Program on Immunization; Mike Merson, also a former EIS officer, was sent to direct the Diarrheal Disease Program and later the HIV/AIDS Program; and Jonathan Mann, another former EIS officer, was posted to work on AIDS. The WHO thus received strong management from people who could afford to do bold things. The CDC benefited by having staff acquire experience in global health decision making. The concept is still viable. Some WHO programs are funded outside its usual budget. Similarly, the WHO could have public health experts and managers assigned from various countries, who were not part of the WHO’s personnel count, to augment its staff. The WHO must have the final word on agreeing to the assignee and the authority to terminate assignments not in its best interest.
When I became director, I wanted to continue to strengthen the global health contributions of the CDC. I felt that, for each disease or condition, a global view—rather than a domestic versus international view—was needed. Those working on respiratory viruses or enteric bacteria should see their field globally. For that reason, having the entire organization steeped in global health, rather than having a special program for global health, is best.
This commitment required specific attention to global aspects. The CDC had many international visitors for meetings and to take training courses. For many years, Ed Najjar did a superb job in facilitating international visitors’ encounters with the CDC. Likewise, the CDC needed someone to coordinate all of its relationships with the WHO, UNICEF, the World Bank, and many other international agencies.
This led to our attempts to recruit Dr. Don Hopkins as deputy director for these global activities. Don was much sought after. He was a pediatrician who had global public health training under Dr. Tom Weller at Harvard. Harvard was offering Hopkins a position to stay with Weller’s department. Hopkins had done an outstanding job on smallpox eradication while working in Sierra Leone and India; he was a self-starter, a good worker, and keen to improve global health. He was also being courted by Peter Bourne, who was working in the Carter administration.
We invited Don and his wife, Ernestine, to see the programs at the CDC. I had no idea that he disliked heights when we put him on one of the top floors at the Peachtree Plaza Hotel. Only years later did I discover that he had spent an anxious and often sleepless time during that visit. However, the potential at the CDC overcame the clumsy attempt at hospitality, and Don helped to put global health on the permanent agenda at the CDC.
The CDC global health story has many high and low points. A low point was the climate of racial unrest, which made housing difficult for scientists from other countries, particularly those from Africa. But this in turn led to a high point, in 1972, when the United Methodist Church, the Episcopal Church, the Evangelical Lutheran Church, the Presbyterian Church, the United Church of Christ, and the Atlanta Archdiocese Council of Catholic Women developed Villa International. Villa International is near the CDC and Emory University and offers short-term residence to persons of all faiths and from all parts of the world. It provides individual rooms but also a communal kitchen, which allows people to cook the foods they prefer. Since opening in 1972, Villa International has hosted more than 23,000 guests from 146 countries. While originally founded to host international guests of the CDC, the villa is open for scholars and researchers with short-term programs at other institutions, especially Emory.
Some events were particularly challenging. Soon after I became director of the smallpox program, David Sencer called me at home at dinnertime. He told me that the smallpox program would be accused of racism on the 10 p.m. news. His suggestion was that I go to the station and be prepared to appear on the news program to defend the program.
First, I had to know the issues. We were conducting a smallpox and global health–training program at the time, which included a dozen visitors from Nigeria. I was told that a local African American dentist had been in discussions with a number of the visitors, and he was charging discrimination. Specifically, he charged that their per diem rate was lower than that for Americans attending the training program and that the visitors were being housed in a roach-infested, second-class hotel.
There was no time to assemble all of the details before the news show, but I concluded that a white employee attempting to say that we were not involved in discrimination would look inappropriate. I called our new equal employment officer, Frank Miller, and begged for his help. Frank was an outstanding athlete (and a football teammate of Rev. Jesse Jackson in earlier years). Frank was new in this job, but he had a stellar reputation as a capable public health advisor with the Venereal Disease Program.
Frank agreed to appear on the program, and he provided a calm response and denied any discrimination. Years later, he told me that he did not know me at the time and was never sure why he had come to my rescue, but he did not regret it.
The event soon became even more painful when the CDC received a call from a viewer saying he intended to shoot the first African walking out the front door of that hotel. Once again, good people rose to the occasion. The Emory Inn, across the street from the CDC, called to say it would offer accommodations to the entire Nigerian delegation at the same prices as at the hotel in which visitors were then staying. Suddenly, the housing and the transportation concerns were solved.
It took some days to sort out the problem. In the end, it turned out that the Nigerian attendees were getting a higher per diem than the American attendees, not lower, because they were being paid by USAID, while Americans were subject to the rates provided by the CDC. Second, only three of the attendees were offended. They were physicians who were uncomfortable being treated the same as the nonphysician public health workers from Nigeria. These physicians pointed out that they would have received special treatment in their country or other countries, including limousines for the trip from the airport. One was especially offended that he had been picked up by a CDC smallpox employee in a pickup. Finally, it turned out that the delegation had been given the choice of accommodations and had selected that hotel in an attempt to save money, allowing them to return home with more gifts.
The local dentist received the publicity he sought, the three physicians seemed satisfied that they had made their point regarding their importance, and the remaining members of the delegation were deeply embarrassed and apologetic. I was subjected to questioning by the US Public Health Service (PHS) in Washington, DC, and was successfully defended by a senior PHS administrator, Paul Ehrlich, who later became the surgeon general. Figuring out the lessons learned in this incident was difficult. We could not treat the physicians differently from the rest of the delegation, but it pointed out the minefields when working with other cultures.
Despite such problems, dealing across cultures continued to be one of the true joys of working at the CDC. Over the years, we hosted visitors from dozens of countries, learned from their perspectives, and grew in our understanding of the world.
And often we shared humor. One visit of note included Dimitri Venediktov, deputy health minister in the Soviet Union. Venediktov was well known in global health circles, often representing the Soviet Union at international conferences. The Bulletin of the World Health Organization recounted, in October 2008 (1), his role in organizing the Primary Health Care conference in Alma Ata. This meeting established basic primary health care as a goal for all peoples of the world. David Tejada de Rivero, assistant director general of the WHO, related how Venediktov appeared at his home in January 1976 to say that the Soviet Union would provide $2 million to have a conference on primary health care in the Soviet Union. The previous May, delegates to the World Health Assembly had promoted such a meeting, but resources were not available.
Venediktov offered funding, the meeting was held, and it became a watershed moment in global health in promoting the idea of primary health care for all people in the world. It also resulted in tension between the WHO, which was promoting this concept, and UNICEF, which was promoting specific interventions under the name GOBI (for growth monitoring, oral rehydration, breastfeeding, and immunization). This tension interfered with basic health approaches because countries could not afford to offend either the WHO or UNICEF, and yet they were offering different visions on the road forward in global health. This tension continued until 1984, when the Task Force for Child Survival was formed, providing a common platform for immunization and then other programs of the two agencies.
Venediktov visited the CDC with his chief microbiologist, Viktor Mikhailovich Zhdanov. It was Zhdanov, who, as the deputy minister of health for the Soviet Union in 1958, called on the World Health Assembly to undertake an initiative to eliminate smallpox from the world. He left the Ministry of Health in 1961 to return to research. At the time of his visit to the CDC, his early efforts were being celebrated because smallpox had been eradicated.
Venediktov and Zhdanov were briefed by programs throughout the CDC and expressed their great respect for the work being done. But nothing intrigued them as much as the discovery of the Legionella bacterium. They both exclaimed that finding new human pathogenic viruses was expected, but to find a new human pathogenic bacterium took them completely by surprise.
On their final night at the CDC, we held a banquet at nearby Stone Mountain Park (site of the world’s largest bas-relief carving), complete with Southern cooking. This was considered an important event by our government, and so Julius Richmond, the surgeon general, came in from Washington, DC, along with two State Department officials. Near the end of the dinner, I arose to offer the first toast. I suggested we toast the Soviet Army. The State Department officials blanched, the Soviet visitors suddenly appeared apprehensive, and only Dr. Richmond seemed relaxed.
I went on to explain that Bill Watson, deputy director of the CDC, had been a prisoner of war outside of Dresden in World War II. I explained the importance of Bill Watson for the health of Americans and indeed the health of people around the world. I then said it was his successful liberation by the Soviet Army that had made this all possible. The State Department officials began to breathe again, everyone cheered the Soviet Army, and the guests relaxed.
Dr. Venediktov then arose and said, “Americans bring out the competitive best in us. We have been greatly impressed with your accomplishments in isolating Legionella. We have agreed that we will now return home and attempt to find another human bacterial pathogen.” He paused for a long moment before adding, “Even if we have to create it in the laboratory.”
The success of the smallpox eradication effort improved the standing of the CDC. Requests continued to increase for consultation and for training of officers from other countries. Finally, the contribution that the CDC had sought to provide for years, namely, an expansion of both the CDC and the EIS to other countries, was achieved.
In 1976, Canada established the first Field Epidemiology Training Program (FETP) outside the United States, modeled after the EIS program at the CDC. In 1980, David Brandling-Bennett, a former EIS officer and tropical disease expert (later deputy director of the Pan American Health Organization, and even later an early scientist at the Bill & Melinda Gates Foundation), arrived in Thailand to initiate the first FETP outside of North America, at the request of the Government of Thailand. With initial funding from USAID, the program immediately demonstrated its value. Scientists in the program investigated infectious disease outbreaks, helped to characterize resistance patterns of antimalarial drugs, and became the gold standard for similar programs that developed in ensuing years in Asia. As in the United States, the program strengthened the entire public health infrastructure.
In the early 1980s, Secretary Richard Schweiker of the Department of Health and Human Services (HHS) attended the World Health Assembly. He asked me to send a paragraph to his speechwriter, offering US assistance in developing an EIS program for the WHO. Such assistance would have been an excellent way for the WHO to respond to health problems, train outbreak investigators from around the world, and strengthen its abilities to support such operations. A week later, Schweiker inquired about my paragraph. I said I had sent it. I re-sent it, but it still did not appear in his draft. The speechwriter did not want to include it. The secretary asked me to send it directly to him, and he included the offer in his talk. The offer was made to the WHO, but the organization did not accept it. Over the years, attempts were made to provide such a program. Rafe Henderson became an active promoter of the idea at the WHO. But the organization did not appreciate the potential of such a program, and the idea never achieved traction.
Despite the lack of enthusiasm at WHO headquarters, the concept spread to many countries. Such FETPs retained many attributes of the original EIS Program. The idea for all such programs is learning by doing. The number of persons trained each year is small, to allow for adequate supervision. In many programs, a laboratory component is part of the training so that epidemiology and bench science are combined. The CDC has now helped in developing over fifty such programs around the world. FETPs are country-owned programs, located within ministries of health, and are tailored to meet the public health needs of each country. They are a proud heritage of global health at the CDC.
The story isn’t complete without mentioning that, for all of its proven worth of openness and transparency, the CDC approach of emphasizing global health is not automatic. Its value must be earned every day. The new century saw a different approach: the new HHS coordinator for global health under President George W. Bush issued an order that all WHO contacts must be centered in his office. If the WHO wanted a CDC expert on a committee, to provide consultation or to attend a meeting, the WHO was no longer free to go directly to the CDC, as had been done for decades. The WHO had to make the request through the Washington, DC, HHS office, and the coordinator would decide who attended the WHO meeting. It was a blow to improved global health. It is the kind of decision that controls a process rather than focusing on outcomes. There were, of course, consequences in terms of health. At times, the American attendee would be selected for political rather than for scientific expertise. The ability to provide informal consultation to WHO decisions was hampered, the CDC knowledge of what was happening globally was delayed rather than gathered in real time, and the WHO felt hampered in getting the best advice possible. However, in 2009, the CDC was once again able to provide direct leadership in global health.
People are often critical of the WHO—and for very good reasons. But if it didn’t exist, it would have to be created. It operates with limitations that would not be tolerated by CEOs of other organizations. First, its “board of directors” consists of the ministers of health of all member countries. They meet annually, as the World Health Assembly, to decide on policies and programs and to review results. A board of 180 or 190 people is too unwieldy to be practical. In addition, ministers of health are generally political appointees, so they are not in office long enough to have a deep commitment to the WHO or to have an understanding of how to best support the organization for the benefit of the health of all people. Yet the practice has continued for more than sixty years. Practicality has ceased to be a consideration.
Second, at the formation of the WHO, the United States fought for it to have strong regional offices. This was done to protect the Pan American Health Organization, which had proved so effective in the Americas. It continues to be effective, but the WHO’s other regions have become examples of what happens when politics becomes more important than health. Regional directors can be voted in one term after another by providing benefits to key people in key countries. Global headquarters in Geneva often lacks the resources or authority to implement needed global programs. In short, the world ties the hands of the director general.
Third, resources are inadequate for the task. The WHO operates a global organization on a smaller budget than that of the CDC. The WHO’s annual budget for the entire world is about what diabetes costs the United States every week.
Fourth, in an attempt to represent the world, the personnel system tries to fill positions with an eye to balance. This isn’t always the same as competence. For some employees, this is the best job they have ever had, and they cannot afford to jeopardize their employment with brave actions. Safe decisions become important.
After seventy years of experience, it is time to stop and ask what has been learned over that time and how we can revamp the WHO to be a more responsive and efficient program and a true leader in the improvement of global health. We are at a point where available tools, organizational ability, and interest make global health equity an achievable objective. How do we make the WHO as good as its potential? We could be doing much better.
Finally, it should be stressed that, while the CDC was already strong in global health for many years, it has now become truly global in its outreach. With literally hundreds of people assigned around the world, it is a major player in all WHO programs. But the CDC also responded with fieldworkers and major responsibilities when President George W. Bush launched the President’s Emergency Plan for AIDS Relief (PEPFAR) with a commitment of $15 billion for five years (2003–2008). This program has had major success in treating AIDS patients throughout the world. It is a great and lasting legacy for President Bush.