ON BUDGETS AND BURGLARS
Real stories are often so much more interesting than the accepted accounts of how something happened. Polybius, several thousand years ago, said that the world is an organic whole, where everything interacts. This is a Polybius story.
The story began during my last year as director of the CDC. It was the last budget cycle for me as director. On Monday, I was to attend a meeting with Health and Human Services (HHS) secretary Richard Schweiker.
The budget process starts each year with the CDC’s submitting, to the Public Health Service, the budget that the agency believes is required for the next year. The Public Health Service will inevitably remove some items entirely and reduce the request for other items in its attempt to balance the requests of all agencies. The Public Health Service then submits a budget for all of the agencies to HHS.
That department does its own review, usually removing more items, and almost never increasing a request. HHS then submits a consolidated budget to the White House. The White House (actually the Office of Management and Budget) makes decisions based on the entire federal government and sends its decisions back to the department. HHS then makes some changes, sending its conclusions to the Public Health Service. It, in turn, makes decisions, and the results are sent to the agencies, including the CDC. Every step up and down the line tends to remove requests that we felt were important when originally included. But we learned to accept the decisions.
However, one final opportunity existed to redress the most distressing reductions. This Monday meeting would be a chance, the last chance before the budget went to Congress, for the Public Health Service to make the agency’s appeals to restore the program cuts that it found most appalling. It was an important meeting.
My family had spent the weekend out of town and returned home on Sunday night. I was well versed in the appeals that the CDC was seeking and therefore was not especially stressed in preparing for the meeting. I could do it with a few hours review that evening. But our calculations were immediately disrupted when we reached home that night. We had been burglarized. We called the police, and by the time they had left, and we had settled down, it was after midnight. I was up at 4:30 a.m. to get to the early-bird flight to Washington, DC. I was not feeling good because of sleep loss but also because of the violation inherent with a burglary.
A meeting was held first at the Public Health Service level to give us our marching orders. The instructions were a complete surprise. We were told that agency heads would not be allowed to speak, an approach I could not recall ever having been used in previous years. We were there only to answer questions if called on by the secretary. The budget professionals would handle the entire appeal process. My immediate thought was, Why are we even here?
Second, we were told that any attempt on our part to reinsert a capital project would result not only in the loss of that project but also in a loss of an equivalent amount of money from the remaining budget. This was hardball. The Reagan administration had decided that fiscal responsibility required no new building projects, no matter how important they were. This meant that our hopes for a Class-IV laboratory at the CDC would not be presented. I was informed of the three appeals the CDC would be allowed, but I had no input into the process.
We went to the secretary’s meeting. NIH was the first agency reviewed. This is the largest agency in the Public Health Service, and, in truth, it is the best known and most watched by Congress. Any illness in congressional members, their families, or friends becomes a reason to provide an increase in appropriations. That is the reason much more money goes into research for cancer and heart disease than malaria, or other problems that involve far more people globally. The NIH appeal process went according to the rules. The director never said a word. What a waste of his time, I thought.
The CDC was next. Within the first minutes, the budget professionals got confused and could not figure out why they were having trouble reconciling two numbers. I sat on the sidelines and watched them try to stay in control. Secretary Schweiker listened for a few minutes and then with a bemused look said, “Bill is sitting right here. Couldn’t we just ask him?” He then turned to me and said, “Why don’t you present the CDC appeals?” It took me totally by surprise, but it was now out of the hands of the Public Health Service budget people.
I presented the first two appeals in a matter-of-fact way and then came to the third, and last, appeal. It concerned the immunization program. The White House had reduced the amount that we had requested. I believe that immunization is the foundation of public health. Vaccines allowed the modern era of public health to develop. Immunizations have a positive benefit-cost ratio, meaning that if you don’t fund them, you have decided to continue having the problem but are spending more than prevention would have cost. It is an emotional issue with me. And I got emotional.
I told the secretary about the burglary. I told him that I still felt violated and upset when I got on the plane that morning but finally came to some accommodation with what had happened. I decided that the burglar knew I had more than he did and was trying to equalize the situation. But, I continued, as I looked at this last appeal, it brought back all of those feelings of having been violated, and it made me angry. The White House, I said, has now made a decision to “steal health from the American people. And no one seems to have the courage to stand up and say this is wrong.”
The secretary turned to his budget officials and with no hesitation said, “Give him all three appeals.” He then turned to me and asked, “Did you know it was going to be this easy?” I, of course, said no. He then asked, “If you had known it was going to be this easy, what would have been the fourth thing on your list?” The truth is that my fourth item would have actually been my first appeal, but we had been given firm instructions about not trying an end run on capital projects. However, I had never been offered an opportunity like this.
I looked at my boss, Ed Brandt, assistant secretary for health, and saw him put his head in his hands. He knew what I would ask for, and I had been ordered not to do that.
I went ahead. I told the secretary about Class-IV laboratories,a which deal with lethal agents for which we lack vaccines or treatment. I explained how the number of such agents had continued to increase and that the CDC had the capacity to deal with only one agent at a time. If a new suspicious agent came in, it meant closing down and cleaning the lab and then, after several days of effort, starting with the new unknown agent. The number of agents had increased but so had our diagnostic techniques. Everything was increasingly complicated, and we had our hands tied at the CDC.
Emerging Infectious Diseases Laboratory, the CDC, 2005. This facility was constructed to triple the agency’s capacity to conduct research and provide responses involving pathogens that require the highest levels of safety precautions. The Biosafety Lab-2 (BSL-2), BSL-3, and BSL-4 laboratory spaces provide the appropriate degree of containment for microorganisms under investigation. Photo from the CDC
The United States had only recently dealt with a problem of a person’s putting poison in Tylenol bottles in drugstores. To make my case, I said to the secretary, “If we would be faced with a viral equivalent to the Tylenol problem, it would take less than an hour for the country to realize that we had no capacity to deal with it.”
The secretary turned to his budget officers and said, “We have to at least try.” It was about a week later when the secretary called me at home at night. He was calling from the White House, and he was as elated as a schoolchild. He told me that he had just gone head-to-head with David Stockman, director of the Office of Management and Budget.
“You will get your new lab,” Secretary Schweiker said to me. He then told me that the administration was interested in speed; therefore, they were going to add it to the current year’s budget so it would not even have to be defended at the next congressional budget hearings. The secretary had understood the importance of this budget request. Suddenly, an important issue that appeared doomed a week earlier was on a fast track.
Inside a Class-IV laboratory at the CDC, 2007. Photo from the CDC
It is not an understatement to say that this lab has become absolutely essential to the CDC mission. Later, this became obvious when the CDC was dealing with Ebola virus, HIV, and West Nile viruses simultaneously.
Some years later, when I was executive director of the Carter Center, Jim Mason, the director of the CDC, invited me to attend the dedication of the new Class-IV laboratory building. It is a wonderful place, which provides for state-of-the-art diagnostic testing on multiple agents at one time. It provides great flexibility in investigating our most serious and dangerous agents.
At the dedication, I heard, along with the rest of the audience, speeches about the logic behind the building and how it had come into being. And I thought to myself, These people have no idea at all. We owe this building to two fumbling budget masters and an unknown Atlanta burglar.
a Now known as BSL-4 laboratories.