CDC chief puts agency in overdrive

ATLANTA-It's easy to see why Dr. Julie L. Gerberding, the new chief of the Centers for Disease Control and Prevention, calls her agency's emergency operations center "an embarrassing physical space." The center, which acts as a 24-hour communications hub for national health emergencies, is anything but state-of-the-art.

Although a snazzy digital wall clock records the time in zones around the world, and a dozen or so health experts bustled about on a recent day tracking the West Nile virus, the place has an unmistakably thrown-together feel. In the single open workroom, computers are plunked down on tables, blackboards adorn one wall, and directional signs are printed out on office paper.

It's little wonder that Gerberding's first move after taking over as CDC director in July was to speed up the construction of a more modern operations center. Within two years, Gerberding wants to open the doors to a permanent, cutting-edge command center for emergencies. In the meantime, she's hustling to get the CDC's staff into an interim operations center by Oct. 31. The interim center, to be housed in a sub-basement, will boast some $4 million worth of satellite phones, videoconference equipment and other high-tech devices.

Gerberding is so eager to speed things along that she authorized construction crews to work on the interim center 24 hours a day, seven days a week. "24/7 construction is not something you do lightly," acknowledged Gerberding during a recent interview with National Journal at the CDC's Atlanta headquarters. But Gerberding hasn't been taking anything lightly during her three months as CDC director. As the first woman to head the nation's leading public health organization, she has been on overdrive since day one.

For Gerberding, 47, directing the $6.8 billion agency, with its 8,600 employees in 11 institutes and divisions, swamps any other challenge she has faced during more than two decades as a doctor, research scientist, and infectious-disease expert, including four years at the CDC. She steps in at a time when the CDC, an agency of the Health and Human Services Department, is under greater public scrutiny than at any other point in its 56-year history. After being long neglected by policy makers in Washington, the CDC is now a lead player in national defense.

It's a new and somewhat uncomfortable role for the CDC. Established in 1946 to track malaria in troops returning from World War II, the agency made its reputation hunting down natural killers such as smallpox, Legionnaires' disease, and the Ebola virus. More recently, the CDC has turned its attention to chronic illnesses such as heart disease, and to preventing injury and exposure to environmental toxins.

But thrust onto the front lines of the war on terrorism, the agency has stumbled. Last year's anthrax attacks exposed alarming weaknesses in the nation's public health system and at the CDC. The agency was faulted for responding too slowly, and for failing to communicate effectively with medical providers and the public. Gerberding's task is to pick up the pieces and essentially reinvent the agency from the ground up.

At the same time, the war on terrorism could distract the CDC from other, equally urgent threats. Insidious new germs are spreading domestically, spurred in part by global travel. Drug-resistant bacteria are emerging more quickly than scientists can develop medications to fight them. The AIDS virus infects 14,000 new people a day worldwide. And obesity and diabetes are becoming national epidemics.

The CDC faces these multiple challenges at a time when its physical plant is literally falling apart. The agency recently unveiled two gleaming new laboratories to research infectious diseases and environmental pathogens. But most of its labs remain inadequate. In some, plastic tarps protect equipment worth hundreds of thousands of dollars from ceiling leaks. Other labs are infested with rats, mice, or termites.

Gerberding has no illusions about the magnitude of the challenge she faces. On the eve of the October 4 anniversary that marks one year since the CDC confirmed that anthrax had been unleashed in the U.S. mail, Gerberding is in a race against the clock. Her agency is better prepared than it was a year ago, but it is still not ready. Asked to describe her reaction to being tapped by President Bush to head the agency, Gerberding replied, "I was honored, and thrilled-and a little intimidated."

An Unlikely Warrior?

Gerberding is a somewhat surprising choice to head the CDC. She was less well-known than some other candidates, including Dr. Robert Redfield, a former Army physician and controversial AIDS vaccine researcher. Nor is she a particularly forceful or flashy leader. Outwardly low-key, approachable, and even soft-spoken, Gerberding has a reputation as a "people" person-the kind of doctor who would give a frightened patient a hug.

But Gerberding is also known for being cool and decisive under pressure. She impressed HHS Secretary Tommy Thompson during last year's anthrax crisis when she quietly assumed a central role in coordinating the CDC's response. As acting deputy director of the CDC's National Center for Infectious Diseases, Gerberding emerged as an unflappable spokeswoman at a time of near-chaos.

"She was up all the time," said Dr. Tanja Popovic, chief of the CDC's new epidemiological investigations lab, who worked closely with Gerberding during the anthrax investigation. "She was always available. You could call her at any time of the day. I actually never saw her lose her cool."

When then-CDC Director Jeffrey Koplan abruptly stepped down on March 31, Thompson installed Gerberding as one of four acting principal deputy directors to keep the agency afloat. Then he began lobbying the White House to put her in charge. It was not an easy sell, said Kevin Keane, assistant HHS secretary for public affairs. "They obviously didn't know much about Julie at the White House," Keane said. "So he had a great deal of work to do to educate them as to what her talents were, and why she would fit."

But Thompson was persistent. He had been burned before in his efforts to fill numerous vacancies throughout HHS. His No. 1 choice to head the Food and Drug Administration, food-safety expert Lester Crawford, was made deputy commissioner, but was never installed as chief.

Gerberding's gender may have had something to do with her selection. All of the other heads of health agencies under Bush are men. Her big selling point, however, appears to have been her skills as a communicator. Those who know her say that Gerberding has a knack for explaining complicated scientific concepts in plain language, and for getting along with multiple department heads and constituent groups.

The medical community greeted her appointment with a sigh of relief. Some had feared that Bush would pick a CDC head with a background in politics, not science. One possible candidate, for example, was former Rep. Tom Coburn, R-Okla., a socially conservative obstetrician. But Gerberding, who is married with one stepdaughter, is a scientist to the core. She's so apolitical that she declined to tell NJ her party affiliation.

Raised in Estelline, S.D., the daughter of a teacher and a law enforcement officer, Gerberding knew at age 4 that she wanted to be a doctor. She went on to earn her B.A. in chemistry and biology at Case Western Reserve University in Cleveland. She did an internship in internal medicine at the University of California (San Francisco) and served as chief medical resident at San Francisco General Hospital.

Her hospital work in San Francisco in the 1980s ended up shaping her career. The AIDS epidemic was just coming on the scene, and Gerberding developed a passion for fighting infectious disease, particularly HIV. She gained prominence for being among the first to help write guidelines to protect hospital workers from contracting the virus.

She also became the first woman to receive tenure in her department at the University of California, where she ultimately headed the university's Prevention Epicenter, a multidisciplinary program to prevent hospital infections. On joining the CDC in 1998 as director of its Division of Healthcare Quality Promotion, she continued her focus on hospital safety, tackling areas such as drug-resistant infections and medical errors.

She took over the CDC at a difficult time. Morale had suffered after the departure of Koplan, who was tremendously popular. Speculation was rampant that Koplan had left because of fallout from the anthrax crisis, or because of clashes with Thompson. In an interview, Koplan denied the rumors, saying simply that it was "time to move on." Koplan was a holdover from the Clinton administration and had served just over three years in the position.

Gerberding has big shoes to fill, but she has been warmly received so far. "She's very, very smart-and that's probably one of the most important characteristics that a CDC director needs," said Dr. David Fleming, the agency's deputy director of science and public health. "But she is a quick study and articulate as well, and that doesn't always go with being smart," he said.

Good News, Bad News

Gerberding's communications skills may be the medicine that the CDC needs most. At the time of the anthrax crisis last fall, the agency was excoriated for a host of communications failures. State and local medical professionals were unsure of whom to turn to for solid medical information. Agencies at various levels didn't coordinate messages, prompting citizens to wonder who was in charge.

Notwithstanding the professional performance of Gerberding and many others on the CDC staff, agency officials were faulted for being inaccessible to the news media and for giving out conflicting information. For their part, some at the CDC were frustrated that Thompson had seized the microphone and was funneling press queries through his office.

"I'm proud to say we learned many lessons," said Gerberding of the anthrax investigation. "One very critical lesson was communication. We needed to prepare people for the fact that we didn't have all the answers. We're used to having all the answers; at least our scientists want to have all the answers before they go forward with public information. And in a time of crisis, that doesn't work."

The CDC's new modus operandi, said Gerberding, will be to admit it up front when the story is incomplete. "We have to prepare people for the expectation that ... we'll tell them everything we can tell them today, and we'll make the recommendations based on that knowledge today," she said. "But tomorrow it may be different."

To combat confusion within the CDC, Gerberding has tapped immunization expert Joseph M. Henderson to fill a new position: associate director for terrorism, preparedness, and response. Henderson, whose previous experience includes 10 years tackling nuclear, biological, and chemical warfare with the Air Force, will coordinate all CDC terrorism response activities.

Gerberding herself has given numerous interviews and has started holding press conferences at CDC headquarters in Atlanta, a new practice for the agency. The press conferences follow a "telebriefing" format that enables reporters nationwide to watch and ask questions, as in a telephone conference call.

Gerberding has also gotten Thompson to sign off on an emergency communications plan for the CDC, making it less likely that her agency and the HHS will veer off in different directions. She has expanded her communications staff, which has set out to improve service to a broad audience that includes medical clinicians and policy makers.

A major hurdle Gerberding faces is the CDC's physical isolation. "You have a geographic divide that's very real," said HHS's Keane. "They're in Atlanta, and we're in Washington. So you can't just walk across the street, and sit down at a table, and work on issues in the same way that the FBI and the Department of Justice could, for example." Gerberding has handled that problem by spending one to two days a week in her office at HHS. "Her presence makes a difference," Keane noted.

Such tactics also help explain why she has kept the peace with officials at HHS and other agencies-a difficult task with so many players on the bioterrorism field. "She manifests a nice balance between having very good leadership abilities as well as being a team player," noted Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases.

Gerberding has also made herself visible on Capitol Hill. "Just as soon as she received her appointment, she didn't waste any time," said Rep. Saxby Chambliss, R-Ga. "She came to the Hill and set up meetings with critical members of the [Georgia] delegation and critical members of Congress."

To get a better sense of how the CDC looks from the outside, Gerberding has visited local health departments, medical experts, and constituent groups. The news from the field has been good and bad, she conceded. States have expressed appreciation for the CDC's willingness to deploy personnel locally. But Gerberding said she has also learned that the CDC needs to be "more proactive in providing information and tools for the front-line clinicians, who are very often the first line of public health."

Public health experts agree that the CDC must build better relationships with health experts in the private sector and with practicing physicians, as well as with academic medical institutions. The field of public health and the day-to-day practice of medicine have become too segregated, argued Gail Cassell, vice president for scientific affairs at Eli Lilly, a Gerberding ally who lobbied for her appointment. "It's a necessity that they be better integrated, starting today," Cassell said.

Still, some observers see progress in the CDC's handling this summer of the West Nile virus. Gerberding seized on the outbreak, the worst ever nationally, as an opportunity to practice the procedures that would take effect in the event of a terrorist attack. The CDC is implementing its emergency communications plan during the outbreak. The emergency operations center, underequipped though it is, is also in full swing.

"We've chosen to use this as an example of the kind of event that CDC needs to be planning for," Fleming explained. "So in essence, [we're] practicing on West Nile for a larger infectious disease threat, [a] bioterrorism threat."

Also paying dividends is a grant program of close to $1 billion, authorized by Congress earlier this year, to improve emergency response at state and local public health departments. CDC and HHS officials have toiled to get the money out as swiftly as possible.

"One good sign is, during the West Nile outbreak, how quickly state after state was able to identify those cases and take action," said Mohammad Akhter, executive director of the American Public Health Association. "If it wasn't for September 11, and if it wasn't for the CDC's preparedness, we probably would have missed some of those cases. This is a very good sign that the nation is better prepared than it was a year ago."

Not There Yet

Still, big problems loom for the CDC. A major open question is how a Homeland Security Department will work with the agency. In theory, at least, scientists studying terrorist biological or chemical agents would remain at the CDC, but Homeland Security Department officials would set their priorities.

"The Homeland Security Department is not taking on essential public health services," Gerberding said. "They are taking on the role of coordinating the intelligence, coordinating the large-scale response community."

But Gerberding has also repeatedly emphasized that the war on terrorism and on other public health threats are inextricably linked. Her philosophy as director is that the anti-terrorism effort must be built on a strong public health infrastructure-and that fighting terrorism, in turn, will better prepare the CDC to combat other health threats. Establishing a new department undercuts this dual approach, some public health experts warn.

"It's extremely difficult to separate out the skill set and people who would do a bioterrorism event from those who would do a naturally occurring outbreak," Koplan noted.

A larger danger for the CDC may be that its consuming focus on terrorism will distract it from other illnesses, and from its long-term prevention mandate. "CDC is at great risk of having their portfolio knocked out of balance by the tremendous energies now being placed on terrorism," said Louis Z. Cooper, president of the American Academy of Pediatrics. "And that's a real concern to many of us."

Even as government leaders scrambled this year to stockpile the smallpox vaccine, for example, the CDC contended with an alarming shortage of routine childhood vaccines for diphtheria, measles, mumps, pertussis, rubella, and tetanus, among others. The crisis has largely abated, but CDC officials can't guarantee that it won't recur. The problem is that not enough drug manufacturers are making the vaccines, which are not lucrative to produce.

In the meantime, according to Cooper, the CDC's focus on terrorism made it harder to come up with a short-term solution. "Here we were, trying to create recommendations so that states and private doctors could ration existing vaccines, yet many of the people who could have helped in that process were pulled off to work on issues around terrorism," he said.

Gerberding insisted that the agency remains true to its long-term mission. "CDC is not focused on bioterrorism," she declared. "CDC is focused on public health. And detecting and responding to emerging public health threats is our core business. That is what we were founded on; that is what we have been doing for decades. And so biological terrorism, or chemical terrorism, or nuclear terrorism are just examples of one more public health threat that we need to identify and respond to."

Government resources, however, can stretch only so far. The budget squeeze on the CDC will only intensify in the event of continued economic recession or war. And when it comes to fighting over the budget pie in Washington, the CDC has historically lost out.

Nothing illustrates that better than a visit in the outskirts of Atlanta to the CDC's Chamblee campus, which houses the agency's National Center for Environmental Health, where scientists perform measurements on environmental toxins, such as lead in blood. At Chamblee, dilapidated, military barracks-style buildings, built after World War II, stand alongside a new laboratory that houses some of the cleanest, most antiseptically sealed research stations in the United States.

In the old buildings, which were built without central air conditioning, engineers have installed portable AC units in the ceilings. The trouble is, condensation from the units forced CDC workers to rig up complicated drip systems that include gutters from Home Depot and plastic tarps. Under this hodgepodge stand some of the best instruments in the world for making precise measurements. But because the air conditioning doesn't work properly, scientists need to cool one of the machines, which cost hundreds of thousands of dollars, with a $19 fan. A while back, the lab lost a $340,000 instrument when a pipe broke.

"If I was trying to attract a very advanced, top-notch scientist to do the threshold advance work we do, and he ... or she came in here and saw that, you can imagine that would not be very attractive," said Dr. Jim Pirkle, deputy director for science of the CDC's National Center for Environmental Health. "And it would not really matter what I said about what kind of support we get from the CDC."

On the other hand, the immaculate and gleaming lab next door might make a chemist drool. Here, visitors must clean and cover their shoes before entering, and filters on the ceilings purify the air. Light pours in from plate glass windows, and outside, a marble fountain splashes water into a kidney-shaped pool. "Moving 100 people into this building has been just fabulous for morale," noted Pirkle. Unfortunately, another 150 scientists at Chamblee are still working in the old labs.

At Chamblee and at the CDC's main campus in Atlanta, construction workers are toiling to remedy that disparity. The agency's ambitious, $1.4 billion master plan includes more new labs, a global communications and training facility that will act as a public gateway for the CDC, and a new emergency operations center.

But even in a best-case scenario, the master plan won't be completed until 2005. The plan initially extended over 10 years, but has been accelerated to a five-year time frame. To stay on schedule, however, Congress must appropriate $250 million a year for new buildings and improvements. The money came through in 2002, but for fiscal 2003, Bush has requested only $110 million for the master plan.

"I thought it was unconscionable for the administration to cut CDC [construction] funding by two-thirds," said Sen. Max Cleland, D-Ga., who is still negotiating on Capitol Hill for a higher amount. "That doesn't make any sense."

The CDC does receive some support from the private sector. The money to outfit the interim emergency operations center that Gerberding is so eager to open came from Atlanta philanthropist Bernie Marcus, Home Depot's co-founder. Marcus donated $3.9 million for state-of-the-art equipment after seeing the emergency command center that the CDC had slapped together in an auditorium during the anthrax outbreak.

Marcus and other Atlanta business leaders have set up a group dubbed the Friends of the CDC to lobby on the agency's behalf. A congressionally authorized nonprofit called the CDC Foundation is also raising money to help the agency and will administer Marcus's $3.9 million contribution.

Such efforts, however, will never fully fund the CDC's master plan. Ultimately, it will fall to Gerberding to convince policy makers that the CDC needs new buildings-now. Her own office offers something of a lesson in crisis management. While the outer vestibule has tastefully hung gold-framed prints of Grecian urns, the walls of her office are bare. It's hard to see how Gerberding will have the leisure to decorate them anytime soon.