Turning Point

t first glance, it's hard to tell whether the main campus of the Centers for Disease Control and Prevention in Atlanta is a factory, an office park or a construction site. Two squat, white smokestacks belch steam into the air; low-slung brick buildings stand cheek-by-jowl with sleek, cast concrete office towers; mounds of dirt rise between thickets of yellow cranes, while hard-hatted construction workers mill about. The whine and buzz of drills and heavy equipment is incessant.

The CDC's buildings themselves bespeak an agency in transition. The CDC has worn many hats since its inception 57 years ago-tracking malaria, hunting global viruses, preventing workplace injuries, measuring environmental toxins, combating chronic disease. Now the agency is struggling to master its toughest role yet as one of the lead players in the nation's war on bioterror.

It's a tall order for an agency that has been neglected as long and as badly as the CDC. Out of sight in Atlanta, the CDC often escapes the notice of Washington policy-makers. It has suffered chronic funding shortfalls and a decaying physical plant. In some of its labs, plastic tarps are jury-rigged to protect costly equipment from ceiling leaks. And crumbling labs aren't the CDC's only problem. The 2001 anthrax attacks revealed serious gaps in the agency's crisis preparedness. Officials were faulted for failing to communicate quickly and clearly with state and local public health providers, CDC's main constituents. The agency also took heat for public communications gaffes-though the Health and Human Services Department also shouldered the blame for muzzling top CDC scientists.

The CDC also bumped heads with law enforcement officials. In at least one case, the Federal Bureau of Investigation withheld crucial evidence from the CDC. The anthrax episode left the agency embarrassed and demoralized, particularly after the departure last March of popular CDC Director Jeffrey Koplan, a Clinton administration holdover who had headed the agency for three and a half years.

Since then, the CDC has received kudos for responding decisively to last summer's outbreak of West Nile virus. Much of the credit goes to new CDC Director Julie Gerberding, an agency insider and infectious disease expert who was HHS Secretary Tommy Thompson's top choice. Gerberding has acted swiftly to patch up relations with state and local health providers, ramp up the agency's communications and emergency response capacity, and win over influential allies in Washington.

Gerberding is convinced that the CDC's twin challenges-preparing for bioterror attacks while shoring up the nation's public health system-are synergistic. "We wouldn't have a good bioterrorism response system without that infrastructure," she says. "And at the same time, our terrorism preparedness response is enhancing our overall capacity." But the CDC still faces a rocky road.Some public health providers warn that the war against bioterrorism is robbing resources needed to research other urgent health threats. The CDC's expanded role also subjects it to fresh scrutiny and criticism. In addition to its state and local public health partners, the CDC must answer to a whole new set of national security and law enforcement constituents. The new Homeland Security Department may help by improving coordination between agencies and clearing up muddled lines of communication. Or it may cause confusion and duplication, as some analysts warn.

As it shoulders homeland security responsibilities, the CDC faces a host of other pressing challenges. Global travel has made Americans newly vulnerable to infectious diseases such as West Nile and malaria. Drug-resistant and hospital-borne infections are a growing problem. And the CDC is preparing to face its biggest test ever: inoculating up to 10 million emergency responders against smallpox.

"It's really an agency that, five years from now, could be a lot worse, or it could be a lot better," says Paul C. Light, director of the Brookings Institution's Center for Public Service. "It's really at a crossroads."

BEGGAR AT THE GATES

This is not the first time the CDC has had to reinvent itself. When it first opened as the Communicable Disease Center in 1946, its mandate was to track malaria in troops returning from World War II. In the 1950s it opened its Epidemic Intelligence Service, launching its global reputation as a crack hunter of diseases such as the Ebola and Hanta viruses. In recent decades the CDC has broadened its mandate to include promoting occupational safety and seat belt use, and fighting child abuse, smoking and chronic illnesses such as heart disease.

Through it all, the CDC has been asked to do much with little. Its budget in 1950 was a mere $7.4 million. Between 1980 and 1990, a time of fast expansion at the CDC, the budget jumped from $273.5 million to $1.1 billion. By 2001, it had grown to about $5 billion, thanks in part to Koplan's skillful lobbying on Capitol Hill. In fiscal 2002, following the Sept. 11 terrorist attacks, CDC got its biggest budget increase ever, to $7.6 billion. But the CDC budget remains paltry compared with some fellow health care agencies. The National Institutes of Health's fiscal 2002 budget, for example, was a whopping $23.6 billion. Unlike the CDC, NIH is right under the noses of Washington policy-makers. NIH also has powerful allies among a broad range of health care advocacy and industry groups-something the CDC has lacked.

In part, the CDC has suffered because the public is more interested in finding miracle cures than in preventing illness. The CDC's prevention mandate, along with its unique relationship with state and local public health providers, set it apart from other health-related federal agencies. But prevention, by definition, tends to be invisible. "Unfortunately, when they are successful in preventing episodes and nothing happens, of course there's nothing to mark [their success]," notes former HHS Secretary Dr. Louis Sullivan. Sullivan blames the agency's problems not on its staff and leaders but on a lack of funding. "They have been working, frankly, with one hand tied behind their back," he says.

That is beginning to change. President Bush and Vice President Dick Cheney have visited the CDC, the first sitting president and vice president to do so. Health and Human Services Secretary Tommy Thompson visits the CDC more often than any previous health secretary. Gerberding also parks herself at her HHS office in Washington one to two days a week. Her agency is in the throes of an ambitious, $1.4 billion, five-year master plan to build new labs and facilities, something only the federal government has deep enough pockets to fund. The idea is to consolidate the CDC's scattered Atlanta operations into two main campuses that will boast new research labs, the state-of-the-art Emergency Operations Center, and the Global Communications and Training Facility.

"CDC right now has over 20 different locations in Atlanta where our scientists are housed," says David Fleming, the agency's deputy director of science and public health. "It's very, very difficult to coordinate program lines across scientists, between laboratories and epidemiologists and public health professionals, when everybody is in different places."

A visit to the CDC's Chamblee campus on Atlanta's outskirts reveals just how decrepit its facilities are. "Occasionally when I give a tour, the termites will actually swarm," says Dr. Jim Pirkle, deputy director for science at CDC's National Center for Environmental Health. At Chamblee, located some 10 miles from CDC headquarters, scientists work in old army barracks never intended for scientific research. The pipes leak, the power goes out, halls are cluttered, and lab workers leave food out for stray cats to control the vermin.

But right next door in a building opened in July 2002, Pirkle proudly shows off a brand-new environmental toxicology lab where ceiling filters keep the air so pure that visitors must clean their shoes before entering. "If you look up at the ceiling, there's no water dripping in," Pirkle marvels. "The air conditioning works. And we have power. The power works every day, and it works all night." It's one of two shiny new labs recently opened at the CDC. However, the vision for a new CDC exists largely on paper. Handsome site plans and architectural drawings hang on bulletin boards throughout CDC buildings. But so far, the master plan is only about one-third done. By the agency's own admission, the majority of its scientists are working in substandard space.

Moreover, the funding to complete the master plan on time is in jeopardy. To stay on schedule, the agency must receive some $250 million a year between now and 2005. The money came through for fiscal 2002, but for the coming fiscal year, Bush has requested only $110 million for the master plan. CDC allies in Congress are lobbying for the full $250 million. But with Republicans now in charge of both chambers, the president is likely to prevail.

AWKWARD DANCE PARTNERS

The CDC's state and local public health counterparts are in even more dire straits. State and local hospitals don't have enough beds to handle day-to-day emergencies, let alone to absorb additional patients in a crisis. Regional laboratories lack basic equipment, and there are too few public health professionals trained in public health, let alone in bioterrorism response. All this makes the CDC's efforts to repair the broken state and local public health system just that much harder. Along with HHS, the CDC has been working closely with states to administer a $1 billion federal grant, approved by Congress after the terrorist attacks, to help them improve their public health emergency preparedness.

But even as public health providers snap up federal dollars, many face sudden state budget shortfalls. Some fear they will end up treading water-adding health workers in one department, only to ax them in another. Inoculating health care and emergency workers against smallpox will stretch health departments still further. "If you add more things onto a foundation that's not very strong, you risk the whole thing kind of crumbling," warns Dr. Jo Ivey Boufford, a professor of health policy and public service at New York University's Robert F. Wagner Graduate School of Public Service. She recently co-wrote a report on the future of American public health. "While the bioterrorism money is very important and helpful, it doesn't deal with the entire infrastructure need," it said.

Compounding budget problems is lingering confusion over the historically rocky state-federal health care partnership. The anthrax episode revealed vastly differing expectations of the CDC from state to state, says Dr. Elin A. Gursky, a senior fellow at the ANSER Institute for Homeland Security in Arlington, Va. Gursky recently completed an analysis of CDC's anthrax performance. She found that while some state officials were happy to let the CDC take over, others felt a need to protect their turf.

Gerberding is sensitive to such criticisms. One of her first moves as CDC chief was to spend several weeks visiting local health departments, experts and constituent groups, trying to get a sense of how outsiders regard the agency. "We must have a customer service mentality here," says Gerberding. "We're here to serve people, we're here to serve health departments, we're here to serve the health delivery system. If we don't have accurate information about what those individuals or groups need, we can't possibly address their needs."

Gerberding has taken steps to improve coordination within the CDC. She tapped immunization expert Joseph Henderson to be the agency's point man for bioterror matters. His title is associate director for terrorism, preparedness and response, a new position. In January, Gerberding tapped five top CDC officials to serve on a new executive leadership team to help her better manage the agency. Gerberding also revamped the agency's PR structure and instituted a new emergency communications plan.

A major CDC goal is to close what has become a yawning gap between public health officials on the one hand, and medical practitioners, such as family doctors, pediatricians and hospital workers, on the other. During the anthrax crisis, many doctors relied on the news media to stay abreast of events. The CDC has set up an emergency telephone hot line and is making better use of its Internet Health Alert Network, which sends daily e-mails to health care providers. During the West Nile crisis, the hot line received some 700 calls a day.

"We want [practitioners] to know how to reach their public health counterparts, and we want their public health counterparts to be responsive when they are reached," says James Hughes, who directs CDC's National Center for Infectious Diseases. In the event of an outbreak of disease, whether from terrorism or natural causes, he notes, it's clinicians in the field who are in a position to first spot unusual symptoms.

The CDC has set out to patch up relations with law enforcement officials, with whom it clashed repeatedly during the anthrax episode. When an anthrax-filled letter was sent to the office of then-Senate Majority Leader Tom Daschle, D-S.D., for example, the FBI sent samples collected from the letter to Army labs at Fort Detrick, Md., for analysis-not to the CDC. As a result, CDC scientists were not in a position to observe firsthand that the anthrax was of a fine, military grade that could spread easily. For public health officials in Maryland, the home of two postal workers who died from anthrax inhalation, that was a crucial-yet missing-piece of information.

"It would have been very helpful to know that the particle size of the anthrax was such that it could cause inhalation anthrax," says Georges Benjamin, Maryland secretary of health at the time, and now executive director of the American Public Health Association. "Nobody clearly said that."

Gerberding admits that the public health and law enforcement sectors "have different cultures. We have different traditions of sharing information. Public health's very open; law enforcement is naturally more contained with their information, because they don't want to jeopardize those criminal prosecutions. We have had very little opportunity to work together."

That strained relationship will be put to the test as the Homeland Security Department opens its doors. The new department will take over the CDC National Pharmaceutical Stockpile, and it will set priorities for CDC scientists working on bioterror. Some critics fear that the CDC's medical expertise will be lost in the shuffle, particularly given that the new department's anti-terror mandate is essentially one of law enforcement.

The administration's controversial new bioterror surveillance network also is thrusting new law enforcement responsibilities onto the CDC. The computer network reportedly will track and monitor patients' health data in eight major cities in a bid to spot disease outbreaks. The health monitoring network began at the Defense Department but was moved to the CDC after critics raised medical privacy concerns.

DANGER AHEAD

CDC's efforts to smooth lines of communication and authority already are paying off, say state public health secretaries. During the West Nile outbreak, Gerberding activated the CDC's Emergency Operations Center, now housed in an interim facility, as a sort of dry run for a future catastrophe. The CDC moved swiftly to get factual information out to the states and calm public fears, say state health officials. In contrast with the anthrax crisis, state officials were able to track the investigation as it unfolded, and there were no mixed signals from federal agencies. "Not only has communication improved," says Florida Health Secretary Dr. John O. Agwunobi, but the CDC "has begun to speak for and on behalf of states in Washington."

But one complaint lingers regarding the CDC and West Nile: The agency could only react to the crisis, not prevent it. Some public health experts warn that the CDC has not been aggressive enough in asking what the next outbreak will be, where it will take place, and how to prevent it. A significant risk of the war against bioterrorism is that it will distract the CDC from fighting global diseases and chronic, day-to-day health threats. "It's very important to keep these acute threats to our security and well-being in balance with the daily killers," said Koplan, now vice president for academic and health affairs at Atlanta's Emory University.

Nothing illustrates this tension more than the administration's controversial new smallpox vaccination plan. The CDC is working closely with states to implement President Bush's goal that 1 million service members and health care workers get the vaccine.

The next phase-offering the vaccine to up to 10 million firefighters, police officers and other emergency responders-could stretch state and local public health departments to the breaking point. Many state and local health officials already have used up much of the bioterrorism preparedness money released last year. Some have warned that the added cost of smallpox inoculations, which as of yet have not been accompanied by any additional federal dollars, will force them to cut basic services.

To make matters worse, many hospitals have refused to participate in the smallpox plan, concerned that the vaccine's risks outweigh its benefits. Some union leaders even have called on the administration to halt the plan until better safeguards are in place. The CDC is scrambling to respond with educational videos, brochures, satellite training courses and information sheets for health care professionals at all levels.

But the controversy underscores the management and communications nightmare that CDC would face in an emergency requiring mass vaccination for all Americans in the event of an emergency. The vaccine is unusually dangerous and risky. The last time the CDC attempted to direct a mass inoculation-during the swine flu epidemic of 1976-the public backlash was so great that the then-CDC director was forced to resign.

"You can't tell [people] to line up and get vaccinated . . . unless there's a level of trust, that supports that kind of initiative," says Gursky, of the ANSER Institute. "So people have to trust government. And I think we have to regain some ground"

At CDC headquarters, the steel beams and concrete skeletons of laboratories under construction furnish solid evidence that the agency is on the road to repair. The only question is whether the CDC's grand improvements will be complete in time for the next emergency.