November 28, 2006

Time: Troubles at the CDC

What Ails The CDC: Staff turnover, morale problems and charges of mismanagement couldn't have come at a worse time for the guardians of U.S. public health
Time Magazine
Sunday, Nov. 19, 2006

Julie Gerberding was still a deputy director of the Centers for Disease Control and Prevention (CDC) in 2001 when someone started mailing anthrax spores to newsrooms and politicians' offices around the country. A telegenic personality who connected easily with journalists, Gerberding quickly became the public face of the CDC--a rare cool head among a parade of increasingly confused health bureaucrats. The fumbling she witnessed behind the scenes convinced her that the CDC's troubles extended beyond the need for better communications. She made her case to Tommy Thompson, then Secretary of Health and Human Services (HHS), and within a year was appointed director of the agency--the first woman to hold that job--with a mandate to radically reshape the CDC.

Five years later, Gerberding finds herself in the public eye once again, but this time she's under attack. The massive reorganization she ordered--combined with painful budget cuts in key divisions--seems to be tearing the agency apart. Six directors of the CDC's eight primary scientific centers have left. Researchers are sniping at one another in public and on the Internet. The agency has been targeted by three different congressional probes. And a blistering report, leaked last week, by an outside consultant who studied the agency's response to Hurricane Katrina found chaos and mismanagement at the very top.

Nobody is claiming that the CDC has become another governmental basket case like FEMA--at least not yet. Indeed, the speed with which this past summer's outbreak of lethal food poisoning was traced to spinach tainted by runoff from a particular herd of cows in California is testimony to the CDC's continuing expertise. But the bad publicity comes at the worst possible time for the agency and its director. Congress is wrapping up its final budget for 2007, and the Administration is starting to draw up a preliminary budget for 2008. If lawmakers believe that Gerberding is floundering, her institution's budget will suffer.

That's the last thing the U.S. needs. As the nation's premier guardian of public health, the CDC is responsible for researching, tracking and counteracting newly emerging infectious diseases like West Nile and SARS. Doctors rely on it to develop unbiased recommendations on a wide range of medical issues from when to vaccinate children to how best to battle obesity. It also directs funds to individual state and local public agencies to shore up their own community health efforts.

Ironically, it is increased CDC funding mandated by Congress for high-profile threats like bioterrorism and flu pandemics that has drained money from areas of public health that may actually be more pressing. Among the hardest-hit programs: AIDS prevention (down 19%), tuberculosis control (down 16%) and preventive-health block grants for outbreaks of West Nile disease and other unexpected events (down 17%).

But what really troubles the most vocal critics is their sense that the CDC's devotion to pure science--a long-established mandate to follow the trail of medical evidence wherever it leads--has been sabotaged. AIDS specialists today feel that they are being constrained not to say anything positive about condoms, while others complain that more cash bonuses are being given to administrators than to researchers. "It's the policies and the direction of the institute I'm most concerned about," says Dr. Brad Woodruff, an epidemiologist in the organization's Maternal and Child Nutrition Branch. Woodruff is particularly incensed that the agency's new jet, which is supposed to be for medical emergencies, was used by HHS Secretary Mike Leavitt to make promotional appearances on behalf of President Bush's Medicare drug plan.

The centerpiece of Gerberding's reorganization was her decision to replace the agency's 11 often insular centers with four coordinating bodies that would, in theory, respond to emergencies with more agility. Closer contact between infectious-disease and environmental experts, Gerberding says, has already resulted in faster tests for detecting botulism.

But some within the agency complain that the main difference they have seen so far is that their work is more likely to be second-guessed. "Scientists feel less empowered to make decisions," says Dr. Stephen Cochi, who has worked at the CDC for 24 years, currently in the Global Immunization Division. "There's more bureaucratic filtering." Decisions that were routinely made in Atlanta, he and others say, must now be approved by higher-ups in Washington. Requests for anything but emergency travel have to be made 90 days in advance.

As in so many other internecine battles, it can be hard to tell where the whining stops and the real problems begin. The CDC was due for a major overhaul, and it's human nature--even among scientists--to resist change. What started off as hallway grumbling, however, has grown into an ugly public ruckus, thanks to an unofficial employee blog and a few well-directed Freedom of Information requests from the Atlanta Journal-Constitution.

Through it all, Gerberding has stood firm. "The CDC was not broken," she says. "The reason to undergo this [reorganization] is that the world was changing so dramatically." As for charges of political interference, she is unapologetic. "This is a public-health agency, and by its very nature, we're never going to satisfy every single constituency," she says candidly. "I tell [Administration officials] this is the science. This is the recommendation. What they do with it is beyond my control."

Not everybody blames Gerberding for the turmoil. "I don't think anyone denies that there's a morale problem at the CDC," says Dr. Georges Benjamin, executive director of the American Public Health Association. But he attributes much of the upheaval to government-wide belt tightening rather than to Gerberding's reorganization, noting that core programs at the CDC have been cut 4.5% in each of the past two fiscal years. He and other experts believe that the agency needs at least $15 billion a year to do all the jobs it has been assigned--nearly twice the current budget of $8.5 billion.

Perhaps the most immediate problem is the number of senior-level people who are leaving. Part of that is an unavoidable function of aging--40% of the CDC's 9,000 employees will be eligible to retire in 2008. But there's also speculation that older scientists are being pushed to leave early. Either way, "you don't replace the experts at CDC easily," says Robert Keegan, deputy director of the agency's Global Immunization Division. "Management has said they've enacted better emergency standards, but until there's an emergency, you don't know."

State and local public-health officials are keeping a close eye on all the drama. "The most difficult organization in the world to change is a successful organization [like the CDC]," says Paul Halverson of the Arkansas department of health and human services. "If you're a company that is losing money every month, then it's easy to see the need to make a change." Of course, in this case, it's not just money but lives that are at stake.
With reporting by Greg Fulton / Atlanta, Alice Park / New York

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