Friday, November 26, 2004

Powell and Gerberding: Administration Aqueducts

The resignation of Colin Powell as Secretary of State has brought a mixed reaction from progressives. dKos and Atrios are glad to see him go. The estimable Juan Cole of Informed Comment saw him as an important moderating force, as did The Washington Note (Steve Clemons). I confess to being in the former category. Colin Powell was not only duplicitous with the public (assuming he had private reservations, which if he didn't, makes additional reasons to be glad he's gone) but he carried (a lot of) water for the Administration. He was always the "good soldier." Some see that as a virtue. Few of them would cut the German General Staff any slack for the same thing. Yes, I know, comparisons of Bush with Hitler are odious. Even I don't believe Bush is a Hitler. But that fact just underscores my point. Disagreeing with Bush can get you ostracized, marginalized or fired. Disagreeing with Hitler got you dead or in a concentration camp. Okay, enough said. This blog is about public health, right?

Which brings me to Julie Gerberding, current Director of CDC. An infectious disease/HIV specialist who came to CDC in 1998, Gerberding was Acting Director of the National Center for Infectious Diseases during the anthrax attack of 2001. To say that CDC did not distinguish itself in that episode would be an understatement. For one thing, it propagated inaccurate information on the dose needed to infect, continually maintaining that number was in excess of 10,000 spores when the available science indicated it was far smaller. A seminal paper by Meselson et al. in 1994 suggested that as few as 9 spores might be sufficient to infect 2% of those exposed. It turns out that it was about 2% of the Brentwood mail facility that contracted inhalational anthrax from spores of weaponized anthrax contained in loosely sealed postal envelopes. If they had understood that so few spores might produce serious or lethal disease when a large population was exposed as at the mail facility, CDC might have accorded them the same kind of exposure assessment (nasal swabs) they did Congressional staffers and treated them prophylactically with cipro. Not only did NCID (under Gerberding's direction) miss the boat, but CDC leadership allowed itself to be cowed by, and subordinated, to the criminal justice system (in this case the FBI) in handling a public health crisis and in communicating with the public.

To be fair, there are some important ways that Gerberding is an improvement as CDC Director Apparently she learned important lessons about public communication from that debacle. She herself, in contrast to her former boss, the former Surgeon General or the low-wattage Secretary of HHS Tommy Thompson, is an impressive and articulate communicator. She doesn't go beyond the science, which she represents reasonably accurately, and she doesn't try to spin it. Her performance in the SARS episode was good and was what we should expect from a public health official at that level. So what's my complaint?

Same as Colin Powell. She seems to have carried a lot of water for the Bush Administration. CDC, a once proud and effective public health agency, has itself become marginalized and morale is at an all time low according to long-time employees. Again to be fair, one told me he thought she was doing her best within the Administration in private to fight for public health. Shades of Colin Powell. At that level, fighting for public health has to be done publicly and you have to be prepared to lose your job. Being fired over public health priorities would in itself be a valuable contribution. She isn't going to be out on the street living in a Kelvinator box. She'll have an easy time landing an academic or other position.

Moreover, much of the loss of agency morale is said to be traced to poor management. Gerberding has put in place a wholesale reorganization of CDC that has disconcerted and upset many. Leaving aside its virtues as an organization chart (and there is much to criticize here), she did it by fiat with little or no preparation within Congress or the agency. Major changes like this, which must have been in the works for awhile, need a great deal of attention to getting everyone onboard, and if, in that process, modifications need to be made, they can be. I am told that none of that was done.

The latest agency dust-up is the admission that a much bally-hooed CDC paper in JAMA with Gerberding's name on it was inaccurate (PubMed abstract of paper here). The paper made news because it said that obesity was poised to overtake cigarette smoking as the major cause of ill health in this country The gist of the JAMA paper was that the biggest causes of disease in the US are "modifiable behavioral risk factors" (read "life-style"):
These findings, along with escalating health care costs and aging population, argue persuasively that the need to establish a more preventive orientation in the US health care and public health systems has become more urgent.
The burden of this "preventive orientation" will fall on individuals to change how they live. Apparently the role of the fast food industry, agribusiness, the automobile culture or urban design is not part of CDC mandate.

Gerberding is not only failing to fight publicly for her agency (which has had budget woes) but is actively promoting the Administration's emphasis on self-reliance as a "preventive measure." She is not only carrying water for this Administration. She is a one-person aqueduct.