Tuesday, April 14, 2009

THE US NEEDS AN IMPROVED CDC-What Went Wrong and What Can Be Done?

The US Centers for Disease Control(CDC), almost synonymous with US public health, is clearly one of the most important health agencies in our federal government. Comprised of 7coordinating Centers with approx 8,800 total employees and a budget of approx $8.8 billion dollars the CDC is also one of our largest federal health agencies. While both its vision statement and mission statement are commendable, in recent years its seems to have gone “off track” and like, most of our federal agencies, and requires at the very least significant improvements- at best and, what this writer recommends, a major overhaul

This brief essay will explore my personal opinion as to where the CDC went wrong and suggest some solutions.

DOING GOOD MEDICAL SCIENCE IN THE ERA OF DEREGULATION AND INFLUENCE OF RELIGIOUS AGENDAS

First and foremost is the CDC attempting to fulfill its good mission in an almost 30 year period of emphasis on deregulation and excessive emphasis on partnering with the for profit sector. While this pressure has been felt by all of our health agencies it seems to me that since public health efforts do not generally generate profits perhaps this trend may have differentially impacted the CDC? However personally I do not know to what extent the CDC’s programs have been directly affected by this trend other than by anecdote. The US GAO (Government Accountability Office) has published a limited number of reports on the CDC. Then there is The CDC Foundation which describes and applauds the CDC's public/private partnerships in some detail.(note Board of Directors). Now I believe that public/private partnerships are both necessary and desirable as long as strict conflict of interest and disclosure rules with teeth in them are enforced which I suspect has not been the case in recent decades. Also, bio-medical science, generally, in our federal agencies has also been regrettably influenced by unscientific religious agendas especially in President George W Bush’s 8 year administration (2000-2008)

THE FAILURE OF THE EXCESSES OF REDUCTIONISM -SINGLE ORGANISM-SINGLE DISEASE MODEL

Because the CDC history if filled with a remarkable historical legacy of major infectious disease success stories the agency is still very much populated by professionals who are thoroughly wedded to a reductionistic infectious disease paradigm. So we have CDC virologists and bacteriologists who are very “pathogenic organism” oriented by training, experience and temperament. This paradigm has resulted in a series of failures in managing and communicating such risks as West Nile, Lyme Disease, Mad Cow Disease (BSE), SARSs, the Seasonal flu and the Pandemic flu to name a few. More recently we have witnesses the mismanagement of pathogenic organism contaminated foods such as tomatoes, peanut butter products and pistachio nuts. Dr. Marc Siegel in his remarkable and prescient book entitled FALSE ALARM-The Truth About The Epidemic of Fear describes in some detail these failures. Referring to an epidemic of fear he cites the concept of “the bug de jour” which grabs what he calls the media megaphone only to turn out to be a “false or exaggerated alarm” which then dies off to be replaced by yet another needless scare. Also he provides numbers of US cases of these diseases compared to very real and present disease to back up his thesis. One example of this is the methods the CDC reports even seasonal flu deaths (25-30,00 annual deaths) or in the recent Salmonella peanut butter products deaths (less than 10 deaths) failing to advise the public that in both cases these deaths are most often in the frail and elderly who were likely to die from something else shortly. A CDC spokesman, Mr. Curtis Allen told Insight Magazine in 2004, "There are a couple problems with determining the number of deaths related to the flu because most people don't die from influenza - they die from complications of influenza - so the numbers [of deaths] are based on mathematical formulas. We don't know exactly how many people get the flu each year because it's not a reportable disease and most physicians don't do the test [nasal swab] to indicate whether [the symptoms are caused by] influenza." Also the most serious danger of predicting "epidemics that never happen" is what some have called “the boy who cried wolf phenomenon” meaning that if you scare the public enough on issues that never become reality then the public finally becomes desensitized and complacent which in the event of a every real event leaves us very dangerously vulnerable.

THE EMPHASIS ON PREVENTION-THE CDC’s “P” THAT NEVER OCCURRED.

Recognizing the enormous toll that individual health behaviors like smoking, overeating and a sedentary life style has on the health of American’s in 1992 the CDC to its credit changed its name to the Center for Disease Control and Prevention. However for a variety of reasons that emphasis on health promotion, while still recognized as on of its 7 coordinating centers – The Coordinating Center for Health Promotion- has gotten short shrift over the years with limited progress to show for all its efforts. Also the budget for Health Promotion is approx ½ of the budget for infectious diseases within the agency. Even though the name change occurred in 1992 but, by law, the well known three letter acronym CDC was retained. (sort of tells you something about the agencies priorities?)

THE DIVERSION OF RESOURCES AND MISMANAGEMENT OF BIOTERRORISM RISKS AND VACCINE PROGRAMS-CDCs COMPLICITY

Without question bioterrorism needed to be taken seriously by our nation as we became increasing aware of terrorism but most especially after the 9/11 attack and a month later (Oct 2001) the mailing of letter laced with anthrax spores which resulted in the death of 5 US citizens with 17 others sickened but scared most (over 300 million) Americans. The fact is, however, with the exception of a salad bar and coffee creamer contamination with Salmonella by a small disgruntled religious sect in The Dalles, Oregon in 1984 (751 ill – 0 deaths) our nation has never been attacked by a biological weapon from an external enemy in recent times. The 2001 anthrax letters, conversely, were sent by a mentally ill US ARMY scientist. Furthermore the two most important vaccine programs under Operation BioShield signed into law by President Bush in 2004 ($5.6 billion over 10 years) in our war against Bioterrorism –namely Anthrax and Smallpox Vaccines- were grossly mismanaged resulting in failures of both vaccine programs at great cost to the nation. While the CDC should not be solely blamed for these vaccine program failures since the FDA and DoD were involved the CDC was complicit in and contributed to their failures. The fact that the last case of Smallpox in the US occurred in 1949 and the World Health Organization declared Smallpox eradicated in 1976 begs the question of what the Government knows that we citizens don’t.

WHAT CAN BE DONE? –A FIVE POINT PLAN

1)Like all US federal health agencies the CDC rules pertaining to collaborations with the for profit sector must be modified to allow for science driven policies and programs removed from the excesses of the profit motive. Also no CDC programs should be influenced by extreme religious views.

2)A new breed of infectious disease experts who understand a systems (holistic) approach to organism –host –environment interaction must be hired lest the reductionist model continue to fail

3)Much more of CDCs budget must be allocated to its Center for Health Promotion where the most significant public health benefits could accrue. A concerted effort and funding should be allocated to the worthy goals of the CDC’s Healthy People 2010

4)Or perhaps the entire Health Promotion program should be carved out of the CDC to free the CDC it to do what it does best?

5)While bioterrorism is important we must accurately perceive their risks, avoid profiteering off of unwarranted fear,and do much better with successful vaccination or other preparations as is necessary

REGAINING LOST TRUST-PERHAPS THE MOST IMPORTANT TASK

This nation needs a strong, well funded and vibrant CDC. Perhaps the greatest tragedy of the recent CDC, again like other US Health agencies, is that the US public has lost confidence and trust in it. The rebuilding of trust may take years but it must begin in earnest as soon as feasible

Whoever CDC’s new leaders are must recognize the gravity of lost trust and must be committed to addressing that immediately

I am personally confident that our new administration is committed to most of the issues I address in the essay. But I’m not sure they fully understand yet either the reductionism verses systems (holistic) approach to infectious disease management or the gravity of the failed bioterrorism risk perception and risk management programs.

One can only hope that we have enlightened leaders who are leading our nation’s health agencies that are ready for change to meet the very real and pressing public health challenges of the 21st century

Richard A. Lippin MD
April 14, 2009

10 Comments:

Anonymous Jayne Lyn Stahl said...

This is a wonderful, and insightful, post, Rick. You make some excellent points about the CDC, and health management, in general, in this country.

Principally, as you suggest, the CDC needs to separate science from religion, and put public health above the profit motive.

You assess the danger of a bioterrorist attack wisely, and argue for enlightened leadership. I share your optimism about the Obama administration which has already gotten off to an excellent start by signing executive orders allowing for embryonic stem cell research, as well as making it clear that medical treatment must not be politicized.

Bravo for this illuminating, and richly intelligent, piece.

5:44 PM  
Anonymous Sheldon Samuels said...

In pursuit of your worthwhile effort to promote holistic concepts of health and medical practice, with a spotlight on stress issues, you miss an important problem. CDC has regulatory functions.

It is the host of NIOSH, ATSDR, and CEH, which besides education and research perform semi-regulatory functions for EPA, OSHA, MSHA, FDA, federal agencies (such as DOD and DOE) and state health departments.

Historically, the predecessor to CDC lost the air, water, radiation, and noise programs to what became EPA because of conflicts of interest. CDC didn’t learn from that experience and both new [such as the CDC ‘Foundation’] and old conflicts persist. Budgets and functions are distorted to accommodate “customer satisfaction” programs and panhandling in the corporate community. The consequence is that essential programs such as providing criteria for new standards, industry-wide epidemiological-industrial hygiene studies, technical assistance to small business, and dose reconstruction for compensating nuclear weapons workers are not done, or not done well. Registers, such as the beryllium registry, are so out of date as to be worthless. The training of professional personnel – their oldest function in environmental and occupational health – is at best an after thought. Public environmental health education is nearly forgotten. Contract management is abhorrent.

Many of us in this field believe that CDC is not able to serve environmental and occupational health needs. It is time for another major reorganization: move semi-regulatory agencies out of CDC to become either independent agencies or agencies reporting directly to the Secretary of Health and Human Services or to the Secretary of Labor.


Sheldon W. Samuels [former Chief, Field Services, Air pollution Program, USPHS/EPA; Director Emeritus, Health, Safety and Environment, Industrial Union Department, AFL-CIO; Adjunct Professor of Public Health, Drexel University; Special Representative, Metal Trades Department, AFL-CIO; and Executive Vice President of the Ramazzini Institute (USA)].

12:30 PM  
Anonymous Dr. Rick Lippin said...

PS- Re- CDC Private/Public partnerships. Here is the link to CDC Foundation Officers and Board of Directors.

see- http://www.cdcfoundation.org/about/ourboard/index.aspx


I want to make it clear that I personally believe that these relationships are both desirable and necessary if conflict of interest and disclosure rules with teeth in them are strictly adhered to.

Dr. Rick Lippin
Southampton,Pa

10:14 AM  
Anonymous Anonymous said...

Great job -particularly in pointing out the focus/link between infectious disease and bioterrorism/fear.

You are going right at the defense link of the cdc to the military-industrial complex (Alexander Langmuir, arguably the "father" of the CDC, explicity articulated the rationale for the epidemic intelligence service as a resource for combating biowarfare agents spread in the US by the USSR)

With this rationale, he was able to put the CDC on the map after WWII and shape it's evolving out of the malaria control agency that was able to eliminate malaria from the south during WWII.

A very powerful essay - thank you for putting it out there - it is ironic, that, according to a formal organ of our government, the FBI, a US Army scientist was responsible for the anthrax event in the US - so, the very military-medical industrial complex itself, in its current form, is a public health threat.

Wild to have this all on the internet, but- when you have a governor of a state in the US essentiallysaying that "seccession" from the United States is a valid policy option for the citizens of his state to consider, we are certainly living in interesting times

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