Internal Dissension Grows as CDC Faces Big Threats to Public Health

The Centers for Disease Control and Prevention is being roiled by internal dissension as the nation's top public health agency is facing such unprecedented threats as bioterrorism, a potential flu pandemic and the obesity epidemic, say current and former officials and several outside experts.

The Atlanta-based agency has been thrown into turmoil by a combination of factors, including the upheaval of a drawn-out restructuring, the departure of dozens of its most respected scientists, concerns about political interference and a pending budget cut of nearly $500 million, they say.

Although the impact remains a matter of debate, the uproar is causing widespread alarm among public health authorities, and some say the deep discord may have already contributed to several recent crucial missteps, including confused messages during this winter's flu vaccine shortage, an embarrassing error in a highly publicized estimate of obesity's toll, and a failed program to vaccinate hundreds of thousands of front-line health workers against smallpox to prepare for a possible bioterrorist attack.

Last week, an independent panel of the National Academy of Sciences criticized the CDC for failing to provide clear leadership in the smallpox vaccination campaign and suggested that political "constraints" imposed by Washington played a role.

The tumult has been exacerbated, say some current and former agency employees, by CDC Director Julie L. Gerberding's management style. Her critics say she tends to squelch open discussion and has failed to protect the agency from the specter of deep budget cuts and undue influence from Washington.

Taken together, the turbulence at the agency has created a "crisis of confidence" and an atmosphere of fear in which employees feel "cowed into silence," wrote one top CDC official, Robert A. Keegan, in a widely circulated memo to Gerberding and other top leaders.

"I think there is a crisis," added Keegan, deputy director of the global immunization division, in a phone interview. "Clearly there is a real problem with morale. People are feeling tired and frustrated and don't know where we're headed."

Leadership Disputes Claims

The claims of widespread discontent and demoralization are disputed, however, by the agency's leadership and other CDC employees and supporters outside the agency.

"There are always people who have a hard time accepting change, and we are interested in ideas in how we help people deal with that," Gerberding said in a recent phone interview. "But there are a lot of people in the agency who are excited about this and have jumped in with both feet."

Although difficult in the short term, the changes will forge a much more efficient, modern agency, she and her supporters say.

"We have a responsibility to really learn how we can do our jobs and accomplish our health protection mission in a world that has undergone some pretty profound changes," Gerberding said.

Founded in 1946, the CDC has grown into an $8 billion agency with more than 9,000 employees who play crucial roles in all aspects of public health: stanching the spread of AIDS, investigating disease outbreaks, protecting workplace safety, reducing domestic violence, vaccinating children and guarding against bioterrorists.

The main source of unhappiness at the agency stems from the Futures Initiative, the first major reorganization of the CDC in decades. Launched in June 2003, the plan is designed to transform the agency by shifting responsibilities, consolidating functions, fundamentally redrawing lines of authority and making the agency much more nimble in a crisis. One of the biggest changes would create four powerful coordinating centers intended to break down barriers that prevent the CDC's many centers, programs and offices from working efficiently together.

But the reorganization has dragged on for nearly two years, leaving many employees exhausted, disillusioned and impatient, Keegan and others said.

"Are we seeing efficiencies?" Keegan asked. "It doesn't feel more efficient. There's frustration that after two years we're still waiting for a payoff."

Some employees say much of the restructuring has been confusing, misdirected and counterproductive. One controversial change, for example, moves responsibility for vaccine safety out of the National Immunization Program.

"CDC folks are a very dedicated bunch . . ., [but] it's gone from dedication to make change to being aghast at the process and the changes being made," one senior official said. Among the 34 people interviewed for this article, this official and a number of other current and former CDC staff spoke on the condition they not be identified because of their intense loyalty to the agency and, in some cases, because they fear retribution.

"Growing Pains"

Other employees said the reorganization has been open, inclusive and positive.

"This is exactly what the agency needs to be doing," said Richard Goodman, a 27-year veteran who co-directs the agency's public law center. The complaints, he said, are just "growing pains."

But her critics said Gerberding has let the process drag on too long while jumping too quickly into the spotlight on high-profile issues, reeling from one crisis to the next, and relying too much on a close coterie of top aides.

"I would describe it as a kind of Alice in Wonderland environment where the CDC director is like the Queen of Hearts," the senior official said. "You know, 'Off with their heads.' It's a very autocratic and unpredictable environment."

An internal report on the widely publicized statistical mistake in the obesity study found that some scientists had questioned the calculations but did not push their concerns because "they did not feel it would make any difference," because Gerberding was one of the study's authors.

By some estimates, nearly 40 top managers have left or are planning to, motivated partly by dissatisfaction with the changes and partly by the coincidence that a generation of CDC officials is becoming eligible for retirement. The result is that many top jobs have been filled by officials in an acting capacity, including five of the CDC's seven long-standing centers plus the National Immunization Program and the newly created National Center for Health Marketing.

The reorganization and departures come against a backdrop of complaints by some that the agency's historical independence has been seriously compromised. The AIDS prevention program in particular has been dogged by controversy, with scientists arguing that too much emphasis was being put on promoting abstinence, instead of condom use and sex education.

"There's an ideological focus that's inconsistent with the science," said Margaret Scarlett, who left the CDC's AIDS program in 2001 after 15 years with the agency. "Political ideology is being substituted for science."

National Academy Criticism

In its report, the National Academy panel said the smallpox vaccine effort fell far short at least in part because the agency failed at answer key concerns about the program's necessity and safety.

"The ability of the Centers for Disease Control and Prevention to speak authoritatively as the nation's public health leader, on the basis of the best available scientific reasoning, was severely constrained, presumably by the top levels of the executive branch," the panel wrote.

Gerberding immediately rejected the critique. In an earlier interview, she had disputed the charges that the agency has allowed politics to influence science, that she has failed to protect the agency from damaging budget cuts, stifled dissent or that any of the problems have hampered the agency's work.

"I think we'll get through this difficult period of change and end up in a situation where we're concentrating on our job, which is to protect people's health," she said.

Gerberding acknowledged that some people may be leaving because they are unhappy with the changes but said there is a new generation of qualified scientists waiting to move up.

"It's very sad to see some of our revered leaders move on," she said. "But it's also an opportunity to bring in newer and younger people. It's healthy sometimes to get new people with new ideas."

Current and former officials disagree on whether the turmoil is affecting the CDC's performance, but one informal analysis circulating inside the agency suggests the number of new research projects and published scientific papers has fallen as retirements have spiked.

Outside authorities were mixed in their assessments.

"The CDC is going through a change that's long overdue," said Michael Osterholm, a leading infectious-disease expert at the University of Minnesota.

Others, while saying they remain highly supportive both of the agency and the need for change, said the depth and duration of the discord was unusual and alarming.

"There's a very intense malaise and demoralization among the CDC staff," said Alfred Sommer, dean of the Johns Hopkins Bloomberg School of Public Health. "The CDC is our thin gray line when it comes to public health, and so you've got to be concerned."

Local, state and national public health leaders said they are especially worried that the reorganization is affecting their ability to work with the agency and that the budget cuts would mean a loss of hundreds of millions of dollars for programs to boost bioterrorism preparedness, immunize children, promote good health habits and fight chronic health problems.