Expecting the unexpected

By Julia Puppe

It is September 11, 2007. I am talking with Dr. Julie Louise Gerberding, Director of the CDC, in her office in Atlanta. “I’m sure everyone is thinking about where they were on September 11, 2001,” Gerberding says pensively. “The people I’ve encountered today on my way into work have all said pretty much the same thing, whatever their particular memory was. And we’d say simultaneously that it seems like such a long time ago – so much has happened. And yet, it seems like it was yesterday. I don’t think any of us have really fully taken in what the profound implications of those events were for the United States.”

Six years ago, Gerberding had just taken on the role of Acting Deputy Director of the National Center for Infectious Diseases (NCID). “I joined the CDC shortly before 9/11 and found myself right in the midst of anthrax and terrorism attacks without really planning to be in that position,” the 52-year-old remembers, adding: “But obviously, I consider it a huge honor to have had this opportunity and my current role of service to CDC. I’m sure it’s the most important thing I will ever do in my life.”

Leaning back in her chair, Gerberding describes her role in the bioterrorist threat after September 11 as modest. She was working under the leadership of Dr. James Hughes, Director of the National Center for Infectious Diseases, and a scientist with plenty of experience in public health emergencies. “I learned a great deal from Jim, which served me very well as we emerged out of the anthrax attacks and stepped into the West Nile outbreaks that were marching across the US and then, of course, the SARS global outbreak,” Gerberding recalls.

“The most important thing I learned – one I try to contribute in whatever situation I’m working in, whether it’s an emergency or something more mundane – is that we have to constantly remain in learning mode. The second we become arrogant or have any thought that we’re infallible is the moment when we become extremely vulnerable to faltering or making a mistake,” she adds.

A powerful woman

Gerberding would have every reason to feel infallible. In August 2007, she ranked amongst Forbes’ “100 Most Powerful Women” for the third consecutive year. Still, she hasn’t gotten used to it. “I am always surprised when the rankings come out because many days I feel like one of the least powerful women in the world,” she admits. “But it is important to reflect upon the fact that CDC is a public health agency. We’re a government organization and the fact that we would even be considered as having a contribution to be in the running to make a list like this says a lot for how important CDC really is. I feel very honored to be the visible leader of the organization, but clearly I wouldn’t be on the list if the CDC wasn’t an extremely effective agency that really made a difference in people’s lives.”

There’s little doubt that CDC has become the backbone of the US health protection efforts. July 1, 2006 marked the 60th anniversary of the agency’s establishment. Dr. Joseph W. Mountin, founder of the original Communicable Disease Center, as it was called, was a visionary public health leader with high hopes for this small and, at that time, relatively insignificant branch of the Public Health Service. Today, CDC is the nation’s premiere health promotion, prevention, and preparedness agency and a global leader in public health.

Gerberding has put her personal stamp on CDC since becoming the organization’s Director in 2002. However, she doesn’t see herself as the shaper of CDC. Her responsibilities, Gerberding explains, have been to work collectively across the leadership group to articulate the CDC’s vision in the context of a new millennium. “We’re working in a whole new world, a very flat one – the world of globalization. We have much bigger problems in the health arena than we appreciated when CDC started as an agency 61 years ago. We’ve got the big problems of climate change and ideologic conflict that create the stage for terrorism, social instability and poverty. And we have a problem globally of extreme poverty, the lack of the resources and access that millions and millions of people need to appreciate even the most basic elements of public health.”

Global networking

The world we face is a one of high expectations, Gerberding expresses. The public increasingly expects flawless performance from its organizations and institutions. “They want things in real time. They want them conducted with perfection. There’s very little tolerance for learning or for mistakes. The last frame of that is the speed imperative, where we have to be as fast as the Internet. Governments don’t always work that fast. We have to modernize our organization to be able to maximally protect people’s health in the context of the uncertainties in the environment that we’re working in,” explains Gerberding.

Technology, the CDC Director says, is enabling her organization to respond to the speed imperative. The Internet, health alert mechanisms, secure communication systems and cell phones are the means to communicate rapidly across the world at the push of a button. It is technology, amongst other things, that helps to hold a huge institution such as the CDC together. Gerberding calls it a “network.” In order to effectively keep all the 12 scientific centers, national centers of excellence and a whole host of supporting offices and programs together, internal communications need to be strengthened. “In addition,” Gerberding says, “you have to strengthen the incentives for people to plan across the boundaries of their traditional organization units. And you have to reward them for that kind of innovative behavior. Most importantly, you need to have a centralized strategy. Make sure everybody in the system understands the strategy and then allow them the freedom and the opportunity to make their independent decisions and self-aggregating way at the front line of the work that they need to do.”

Health protection

The CDC has two main portfolios of responsibility in its mission of health protection. Gerberding explains: “One has to do with the urgent threats, the terrorism attacks, the emerging infectious diseases, the natural disasters that are increasingly part of our responsibility. But we also have responsibility for the urgent realities, the chronic diseases, the injuries and the disabling conditions that affect the lives of people everywhere, every day. We’re really in a position where we have to balance our work in both of these areas to try to create appropriate focus not only on the things that affect people everywhere, every day, but the things that could affect anyone, anytime, at any place.”

In response to urgent threats, Gerberding explains, the CDC’s principles are to expect the unexpected, to have an open mind and to challenge the dogma. “In 1981, I was a young doctor in San Francisco. As we were taking care of the very first patients with AIDS at San Francisco General Hospital, we had no idea that we could possibly be dealing with a new infectious disease. We were attributing this condition to all sorts of things, undiagnosed cancer or drug exposure, some kind of a toxin. It was a long time before people allowed the possibility that this could actually be an infectious disease that we’d never seen before. That lesson has taught me so much about having an open mind,” Gerberding emphasizes.

Learning from the past enabled the CDC to solve the mystery around SARS a lot quicker after it was first reported in Asia in 2003. Samples came in and were distributed across the organization’s infectious disease laboratories, where scientists were able to nail down the cause of the outbreaks and provide guidance for surveillance, clinical and laboratory evaluation, and reporting.

Today, the CDC has the capabilities to detect pathogens in the environment even before individual human beings are exposed to them. With air sampling protocols, for example, the organization is searching for terrorism threats. But even if humans or animals have been exposed to a threat, there’s protection at the point of care. “You want a rapid diagnostic. You want it highly sensitive and specific. And you want it to be available on clinical specimens that don’t require you to have to culture the material or process it in any way before you get a result. In some dimensions we’ve been able to achieve that. For example, we have rapid testing for HIV infection now. But for some of the other important organisms, particularly other viruses, we have a way to go before we truly have rapid, sensitive and specific point-of-care testing.”

Molecular biology, Gerberding believes, will make the next 10 years the decade of diagnostic development. “We’re rapidly transferring what we learn about molecular constructs of pathogens into tools that allow us in a multiplex way to diagnose and distinguish one from another very quickly.”

Challenges

The biggest challenge in the world of infectious disease prevention, in Gerberding’s view, is the single-stranded RNA viruses, which evolved very quickly. The two prototypes are HIV and Hepatitis C infection. “We have an equivalent challenge with influenza, which also constantly evolves and transforms itself into immunologically distinct viruses. And so until we can really nail universal vaccines for that category of pathogens, we’re vulnerable to some pretty serious infectious disease threats.”

In terms of antimicrobial susceptibility, Gerberding continues to say, the lesson to learn is that if you use it, you could lose it. “Anytime you use a drug you are creating a context for bacteria and viruses to become resistant to it. And they evolve far faster than we do. And they certainly evolve faster than our pharmaceutical companies can work to keep up with their drug development. We have to start thinking about different strategies for pathogen treatment. Instead of trying to kill or eradicate the pathogen, we need to think more about a laser approach. How can we neutralize the damage that it does? Or, how can we disrupt its ability to initiate the cascade of pathogenesis so that maybe we can tolerate living with the bacterial virus in harmony.”

Prevention

The CDC’s guidelines on the prevention of healthcare infections are clear: stay at home when posing an infectious disease threat to patients, cover nose and mouth when sneezing or coughing, and keep your hands clean. “Everything you need to know about preventing healthcare infections we learned in kindergarten,” comments Gerberding, adding: “Yet it is often neglected. Another point to remember is that vaccines aren’t just for patients. We have a responsibility for our own vaccination against influenza, hepatitis and other lifesaving vaccines that are recommended. Of course, some people have a medical reason for not being vaccinated, but aside from that, I think it should just be a matter of professional ethics that we protect ourselves from the illnesses that could pose a risk to our patients.”

That’s the healthcare worker side of the equation. But there’s also the practice. The single most significant source of healthcare associated infections are devices, says Gerberding. “We need to constantly challenge ourselves every time we see the patient. Does this patient have to have a Foley catheter today? Does this patient need an intravenous line? If there’s not a strong indication for the device then don’t use it because they are the underlying cause of the vast majority of healthcare associated infections.”

Education

Informing healthcare professionals is one of the CDC’s objectives. Educating the public is another. However, for Gerberding there is more than just the one public, and it is critical to understand exactly what the needs of various communities of the public are. “We have to learn to reframe our knowledge into terms and tools that people can use and apply in their own particular context. In computer science you would call that ‘user specified information,’” she explains.

CDC takes great care to ensure authenticity and integrity in its messages to the public. Today, people are bombarded with health information which is not always science-based. Some of it is advertising and some of it, Gerberding says, is “plain junk.” The average person surfing the Internet has a hard time trying to decide whether the information they’re looking at is reliable or not. Part of the process of building trust, Gerberding believes, is to let people know over a long period of time that you will tell the truth and update information as quickly as you can. To this end, the CDC is in the process of reinventing its web presence to make it even more useful to the individual consumer. “We’ve long targeted our public health partners and the medical community, but now we’re learning how to translate our science into information and tools that people can access directly on a global basis.”

Joining forces

Like many organizations, Gerberding admits, the CDC is struggling with globalization. Present in almost 50 countries, the institution has drastically expanded its international workforce. Consequently, it has to change its practices and mindset. “We have become a globally relevant force of health protection as part of a network that’s getting stronger and stronger as countries around the world begin to have the same transformational process. As we link up with the UK, Canada, China and public health agencies around the world, we’ve got a lot to learn from each other.”

Joining forces, Gerberding is convinced, will create a health protection system that’s greater than the sum of it’s component parts. “How we go about transforming ourselves to be able to do that scientifically, respond to new threats and disseminate information reliably and quickly, requires profound changes in the way we approach our business. Our biggest future challenge is to truly globalize all of our work in ways that provides the best possible health for all.”

As our interview comes to an end, Gerberding looks me directly in the eye and states: “You know, sitting here on September 11 of 2007, talking with you, I am thinking a lot about public health and what’s changed in the world that we live in today. And I think that the strengthening of preparedness as an important element of health protection is a critical evolution for public health agencies around the world. And I feel profoundly privileged to be a part of that process here at CDC. But it’s also important to recognize that this is a wonderful agency that has a workforce that constitutes an international treasure chest of expertise and passion, and is a source of great hope to people in the United States and people around the world.”

Health matters and agencies like CDC are increasingly critical not only to the health of a nation, but also to its security and economic prosperity. With a long list of momentous contributions to public health over the last 60 years, there’s a lot to be proud of at the CDC. But Gerberding won’t sit back and relax. Modest and introverted, she remains driven by the desire to learn rather than pretend to have all the answers.

BIO

Julie Louise Gerberding became the Director of the CDC and the Administrator of the ATSDR in 2002. Prior to that, she was Acting Deputy Director of the NCID, where she played a major role in leading CDC´s response to the anthrax bioterrorism events of 2001. She joined CDC in 1998 as Director of the Division of Healthcare Quality Promotion, NCID, where she developed CDC´s patient safety initiatives and other programs to prevent infections, antimicrobial resistance, and medical errors in healthcare settings.

Her background as an infectious disease expert and expertise in the field of antimicrobial resistance has served Gerberding well in her current role as CDC Director.