This article was originally published in our May 1994 issue.
The Centers for Disease Control has been reinvented. Once, it was home to a vigorous little band of independent-minded researchers who expanded the agency from a World War II malaria control operation into a potent strike force designed to track down and eradicate infectious disease anywhere on earth. But that was before CDC itself came under the microscope of politics, before it had a billion-dollar budget, before politicians and engineers decided to redefine what constitutes infectious disease, before social agendas were given more attention than social diseases.
In the early years of CDC, teams field-tested Jonas Salk’s polio vaccine; its epidemiologists helped eradicate smallpox and brought numerous Third World plagues under control. Later, agency task forces sounded the alarm on AIDS, solved the puzzles surrounding Legionnaires’ disease, toxic shock syndrome, and last year’s deadly outbreak of hantavirus on Native American reservations in the Southwest. But about a decade ago, the politicians began to move in on CDC. Things may never be the same.
The winds of change swept in under the aegis of the Reagan administration when the CDC director became a political appointee. They continued to blow through the Republican ’80s and now into Bill Clinton’s chunk of the ’90s with the appointment of Dr. David Satcher, president of little-known Meharry Medical College in Nashville.
The first evidence of political meddling at CDC came in 1980, in the aftermath of a study of aspirin’s effect on children; the most recent when CDC scientists determined urban violence was a disease and decided to find a way to vaccinate society against it.
In 1980, five separate teams of medical researchers turned up evidence that aspirin given to children recovering from flu or chicken pox could trigger Reye’s syndrome, an often fatal illness. Statistically, none of the studies was conclusive; taken together, the evidence was overwhelming. In Atlanta, William Foege, director of the Centers for Disease Control, rushed to publish a warning in CDC’s MMWR (Morbidity and Mortality Weekly Report), an influential newsletter circulated to public-health offices, hospitals, and medical professionals around the country.
Pharmaceutical manufacturers, fearing lawsuits and loss of profit, moved faster. They insisted the research was inconclusive, lobbied the FDA, promised new information was forthcoming (there was none), warned CDC its vaunted reputation would be ruined. Weeks went by as Foege slogged through the bureaucratic morass. When Secretary of Health Richard Schweiker backed CDC, Foege went ahead and published the reports, believing he’d won. He was wrong. “The aspirin manufacturers got to the Reagan White House,” he says. Five years would pass before warning labels were put on aspirin bottles.
Dozens of innocent children died because of the delay. No one realized it at the time, but CDC had been infected with a debilitating disease: a plague of politics that would spread unchecked for a decade. Minorities and women suffered, then the poor and outcast. And finally, the agency’s own researchers. It metastasized into many forms—the politics of AIDS, pressure groups, party affiliation, the religious right, race, gender, correctness, diversity—but its focal point was the CDC director’s office, where politics would twist public health policy decisions again and again.
After Foege, the CDC directorship became a de facto political position, in retrospect a disastrous departure from the independent-minded researchers who’d guided the agency from its modest malaria-control origins.
The line separating political appointee from partisan ideologue proved thin. Even though the agency came under the authority of the Department of Health and Human Services in the early ’70s, the pressure on the CDC didn’t begin to build until after Ronald Reagan took office in 1980. It came from conservative right-to-lifers who’d helped sweep the Republicans into power. Surgeon General C. Everett Koop, a pro-lifer (he would later incur right-wing wrath for promoting condom use as a protection against AIDS), visited Bill Foege in Atlanta. CDC routinely monitored death and illness associated with abortion. “I told him,” remembers Foege,
“‘No matter what else we talk about, abortion will come up. Why don’t we get it out of the way?’” Koop demanded the right to review first drafts of abortion studies “for scientific credibility.”
Scientific credibility was quickly strained. “Every one of the surveys [on sexuality] we tried to get going was canceled,” says Dr. Mary Guinan, then a researcher in the division of sexually transmitted diseases. “They didn’t want to know about pregnant women with HIV infection because someone might choose to have an abortion. We’re talking about preventing AIDS in children, and they didn’t want to deal with it?”
When Dr. James Mason, a Mormon and close friend of Utah Senator Orrin Hatch, was named director in 1983, politics moved inside CDC’s walls. Mason, a willing instrument of the conservative ideology being trumpeted in Washington, quashed research on abortion and the efficacy of condoms—information, given the context of the escalating AIDS epidemic, that might have saved thousands of lives.
Through the ’80s, politics clearly delayed the nation’s mobilization against AIDS, contributed to the government’s head-in-the-sand approach to safeguarding the nation’s blood supply (a debacle that resulted in 6,000 transfusion-related AIDS cases), and escalated the continuing war of words over condoms, birth control, sex education, needle exchange (to protect IV drug users against HIV), Agent Orange, credit for discovery of the AIDS virus, and other controversies. All too often CDC research was ignored or twisted in the process.
Dr. William Roper, an ambitious Alabama health officer who rose to head the White House Office of Health Policy Development, became director in 1990; he was a personal friend of George Bush and kept on his spotless desk a red telephone that staffers joked was linked directly to the White House. High-profile and well-connected, Roper increased CDC’s budget, changed the agency’s name to the Centers for Disease Control and Prevention, hired hundreds of new employees, and continued channeling resources into so-called behavior-based problems, such as occupational safety, chronic illness, and injury prevention.
Unfortunately, say CDC insiders, Roper was careful to distance himself from “no-win” issues, particularly the bitter controversies swirling around the federal government’s response to AIDS. An odd thing for a man whose public-health agency spends more than a quarter of its budget battling an epidemic that has already killed more than 200,000 Americans.
In 1993, Roper was undone by the same hardball politics that had elevated him. Bill Clinton’s men fired him and appointed Dr. David Satcher. Significantly, Satcher is a good friend of Vice President Albert Gore. In his first address to CDC’s 7,000 employees last fall, and in public statements since, Satcher stressed the importance of combating social ills like teen violence and drug abuse through outreach programs and community networks. “Partnership with schools, churches, and community organizations,” he said, “can really get out there and contact the people we need to reach.” It remains to be seen whether the speech—which has become the centerpiece of Satcher’s agenda—will prove a clarion call for a culturally diverse, more effective CDC, or a stale restatement of Democratic Party rhetoric.
Even with good intentions and strong guarantees from Washington, the 53-year-old Satcher has his work cut out for him inside and outside the agency. A no-nonsense administrator who saved financially troubled Meharry Medical College by forcing through a merger with a Nashville hospital, Satcher must try to get a handle on a bloated agency infamous for its lax management.
CDC works because it is driven by a staff of highly educated and idealistic epidemiologists and researchers. Hardcore CDC cadre still carry keychains decorated with miniature kegs of Watney’s Red Barrel beer, a reference to London’s John Snow Pub, named for a pioneering 19th-century epidemiologist who tracked a cholera epidemic to a water pump near where the pub now stands.
Behind the faceless buildings on Clifton Road and the forbidding maximum biological containment laboratory, CDC is the most public of government agencies. Epidemic Intelligence Service (EIS) officers scattered around the country track down outbreaks of measles, whopping cough, TB, syphilis, gonorrhea, HIV, and other infectious agents. They poke into restaurant food poisoning and people’s bedrooms with equal zeal. (Many diseases can be sexually transmitted.)
Unintentional injuries resulting from bicycle spills and car crashes and house fires are targets of CDC investigators, as are chronic illnesses such as cancer and heart disease, by far the leading causes of death in the United States. A CDC team was on the ground in the aftermath of the 1992 Los Angeles riots, painstakingly gathering or reconstructing information—opinions, preconditions, flash points (negative attitudes toward Korean merchants for example)—that might help defuse or predict future upheavals.
Staffers are overworked and underpaid, but CDC has been a place where JFK’s “Ask not what your country can do for you . . .” challenge still echoes in the corridors. An esprit de corps, all too often missing from government and the private sector, has always defined the agency.
Here, too, years of political meddling and destructive in-house competition have taken a toll. “Ten years ago you could walk in and ask anyone, even the maintenance staff, what CDC’s mission was,” says Dr. Joyce Essien, a former CDC program director now at Emory University’s School of Public Health. “There was a sense of family, of purpose, a clarity as to what one’s contribution could be. Today, people are just doing a job.”
Essien, who holds both M.D. and M.B.A degrees, learned her CDC laboratory program was being dismantled and her position essentially terminated as she was about to receive an Equal Employment Opportunity award in front of a crowd of cheering employees. “It was not an atypical kind of incident,” she says bitterly. She spent the next six months opening mail for her new boss.
Morale plummeted when conservative ideologues in Washington demanded that Dr. Ward Cates, head of CDC’s abortion surveillance program, be fired because he published findings that abortion was essentially a safe medical procedure. Cates was spared, then assigned to study sexually transmitted diseases. Other researchers were asked to provide studies that could show a link between birth control pills and cancer.
Dr. David Grimes, now a professor and vice chairman of the department of OB-GYN and reproductive sciences at the University of California, San Francisco, and other CDC scientists were driven away, their politically unpopular (i.e., abortion-related) work suppressed as unsound. “There was even an attempt to get scientific evidence that showed condoms didn’t work,” remembers Dr. Guinan. “The thinking went, ‘If it’s only 99 percent effective, then how can you give them to kids?’”
With the onset of AIDS, the “Just Say No” posturing and political pandering became criminal. “They dealt with sex as a moral issue,” continues Dr. Guinan. “You don’t want to ask children if they’re having sex? Well, they were having sex. They were getting pregnant. The reality is there are health risks associated with sex. And we, as public officials, needed to advise people how to protect themselves from fatal illness.”
In the ’80s, as CDC expanded into a bigger, more complex and entrenched bureaucracy, other problems developed. As of this writing, CDC has lost its authority to hire employees. It was suspended last year after the federal Office of Personnel Management (OPM) uncovered a “total breakdown of staffing operations.” A report cited hundreds of violations, including the appointment and promotion of unqualified or preselected candidates, sloppy record keeping, and other abuses.
“There was no rhyme, reason, or rationale as to the way people were selected,” says regional OPM director Ronald Brooks. “There have to be guarantees that the best applicant gets selected rather than somebody’s friend.”
In private, some CDC administrators play down the OPM charges as “overblown,” a result of the agency’s rapid growth. Since 1990, CDC staff jumped 15 percent; its budget grew almost 50 percent to more than $2 billion. “The violations have been documented,” says Satcher. “So, it is, in fact, very serious. I also think there’s a serious commitment to correct the problems. I guarantee there is.”
Women staffers are frustrated by a good-old-boy network they say routinely fills senior positions with males. Black employees have filed a complaint with the Equal Employment Opportunity Commission, alleging discrimination in hiring, promotions and training. Blacks make up nearly 40 percent of CDC’s employees but less than 9 percent of its managers.
“People ask me if I think there’s a glass ceiling for women and minorities at CDC,” says Mary Guinan. “It’s cement!” Guinan, an 18-year CDC veteran, is no disgruntled employee. She was one of the epidemiologists depicted in last year’s HBP blockbuster And the Band Played On. Her tenure as CDC’s associate director for science from 1986-87 made her the highest ranking woman ever to work at the agency.
When pressed about such inequities, Satcher’s hard-nosed side emerges. “The people advising me,” he says, “will not be part of the problem. I want policies and procedures at CDC to be so clearly defined and so well carried out that when I violate them, my actions will indict me.”
Bearded, bespectacled David Satcher grew up on a rural Alabama farm with eight brothers and sisters. He barely survived a childhood battle with whooping cough and went on to earn a PhD in chromosome genetics. His folksy manner and easy reminiscences don’t hide the steel in his personality. Satcher, a Black man, appreciates the link between public health and social justice. Overwhelmingly, it is minorities and the poor who go unvaccinated, who are victimized by everything from violence to tuberculosis and malnutrition. A pillar of public health theory is that it can address this imbalance.
“You don’t take a position like this and then find out where people stand,” Satcher says, acknowledging the pressures that come with the job. “You have to be confident that the assistant secretary for health, the secretary, and the president are all committed to allowing CDC to function as it should function—beyond political, cultural and religious differences. If I were not confident, I wouldn’t have taken the job.”
Given the pervasive, even intrusive scope of CDC endeavors and the scientific certainty with which its pronouncements are made, it may only be a matter of time before those whose verities are moral, religious, or political again try to throttle the agency.
Sex is once again the lightning rod. In January, CDC launched an $800,000 campaign promoting condom use to prevent the spread of HIV, the virus that causes AIDS. The ads included a TV spot that depicted an animated packet of condoms jumping in bed between a writhing couple and another containing the following exchange between an overheated, hastily undressing young man and woman: “Did you bring it?” “I forgot it.” “Then forget it!”
Health and Human Services Secretary Donna Shalala said the ads were long overdue. “What we have lacked until now is the political will.” But within days, the Family Research Council, the National Conference of Catholic Bishops, and a raft of conservative commentators had begun lambasting CDC, Shalala, and the Clinton administration in radio spots, editorials, and op-ed page blasts.
“We want a balanced message,” says Shepherd Smith, president of Americans for a Sound AIDS/HIV Policy, a middle-of-the-road organization. “A tiered message beginning with the optimal medical message of abstinence, which is prevention, going down to the least optimal, which is risk-reduction message involving condoms.”
Smith attended a meeting in Washington where the controversial ads were prescreened. “I didn’t consider them balanced,” he says. “Each speaker got up and said abstinence is the best message, then went on to speak about condoms. There was absolutely nothing on decent refusal skills, nothing on negotiating sexuality. It was all done on the assumption that kids are going to be sexual and therefore have to put on a condom.”
In Atlanta, the Reverend Gerald Durley, president of the Concerned Black Clergy, argued the CDC’s campaign not only doesn’t say no, “It says, ‘go ahead.’” Other conservatives blamed Shalala for the ads, an eerie restatement of liberal complaints during the Reagan and Bush administrations. In February, caught off guard by the virulence of the response, Shalala wrote a letter to friendly newspapers—including the Atlanta Journal-Constitution—thanking them for their support in the condom campaign while at the same time stressing that “young adults need to know that the surest way to prevent AIDS is to refrain from having sex. That is a message we, as health educators, have a commitment to emphasize.”
“We’ve moved into a much more public arena,” says Dr. Mark Rosenberg, director of CDC’s National Center for Injury Prevention and Control. “From doing scientific research to being responsible for applying that research to real-life problems. AIDS is a highly politicized issue with very strong interests on one side or another. You’re not gonna keep the politicians’ hands off.”
To counter that (and the pressure of special-interest groups ranging from the radical AIDS activists of ACT UP to the conservative Family Research Council), CDC is attempting to form outside alliances. “It is much easier to do research and remain apolitical than it is to put prevention programs in place,” continues Rosenberg. “They may require legislation or regulation. The money needed for such programs is much larger. This forces us to have alliances with community and other advocacy groups.”
Somehow, the agency must also come up with the right combination of human resources—psychologists, social workers, counselors, etc.—to operate effectively in the target communities. “Given the mission of CDC,” says Satcher, “and the populations with which we must deal effectively, diversity is critical to the success of our program.”
Over the last months, Satcher has been emphasizing the challenge of a disease that is stealing years of productive life from millions of Americans. A disease that is in many cases more deadly than any infection: violence.
Not surprisingly, violence has roared to the top of the political agenda, displacing healthcare reform. After a series of horrifying murders last December (six New Yorkers killed and 17 wounded on a commuter train; three workers and a police officer murdered in an unemployment office in California; four shot to death in a pizza parlor in Denver; a school superintendent murdered in Michigan), President Clinton declared in a national radio address that the country was in the grip of an “epidemic of violence.”
Statistics support what every citizen knows in his heart. In the United States, violent crime increased 560 percent between 1960 and 1991. Murder jumped 170 percent; rape, 520 percent; aggravated assault, 600 percent. For teenagers the risk of being killed by a firearm has jumped 77 percent since 1985.
In Georgia, and surely the rest of the country, only 25 percent of the population believe the federal government’s crime-fighting efforts are moving in the right direction. In Washington, a new task force is scrambling to coordinate anti-violence efforts underway within the U.S. Department of Health and Human Services, Justice, and Education.
David Satcher and his cohorts believe CDC can help control the wholesale slaughter by applying the same techniques that have worked so effectively against most killer micro-organisms. “Violence is a problem for which you can identify precursors, preconditions, or risk factors that more likely lead to it,” he says. “You can develop strategies, monitor the outcome.”
At its best, CDC works painstakingly, its epidemiologists like good detectives examining tens, hundreds, even thousands of cases, looking for patterns, then scientifically determining causes, risk factors, interventions, conclusions. A tremendous problem with children poisoning themselves disappeared after research led to introduction of childproof packaging. The cost-to-benefit ratio of smoke detectors turned out to be 1-to-20. Bicycle helmets have been shown to reduce the risk of serious head injuries by 85 percent.
The research on homicide is even more interesting. Most people feel that violent death most likely awaits them in carjackings, muggings, or convenience store crossfires. In fact, studies show most murders involve no other felony. It’s mostly people who know each other who are arguing, drinking, escalating, and Bam! Somebody’s dead. “More police,” says Rosenberg, “is not going to do anything about arguments in the home. . . . The question is not, ‘Are we going to address firearms as a public health problem?’ but ‘How are we?’”
CDC critics, including the National Rifle Association, have complained that gun control is not a public-health problem, that the agency is neither objective nor scientific, just anti-gun.
“We took firearm injuries away from the political, philosophical debate and put it on scientific ground,” counters Rosenberg, who began working in CDC’s violence epidemiology branch more than a decade ago. The research is shocking: If you keep a gun in your home, for every time it is used to kill an intruder, it is used 43 times in a murder or unintentional homicide or suicide of someone who lives in the house.
“Our response to gun control is not all-or-none,” says Rosenberg. “We didn’t have to ban cars to make them safer. We can change behaviors, modify the environment. Reduce the number of guns, control access to them, how they are stored and carried, do away with automatic weapons.”
Violence and risky sex are behaviors that may prove more resistant than any virus or bacteria, embedded as they are in the American psyche, reinforced as they are in broken homes, on street corners, and in the virtual reality of video and movies. Violence is more prevalent in America than alcoholism. Homosexual men may have reduced their risk of exposure to AIDS by modifying their sexual behavior, but the population of young heterosexual males David Satcher is targeting has been especially resistant to other public health messages.
The problem may lie beyond the reach of the CDC’s determined epidemiologists. There is increasing evidence of a genetic link to aggressive behavior. Broken homes, broken families, deprivation, drugs, and poverty may alter the balance of chemicals deep in the brain and trigger aggression. These are highly charged issues. Recently, the Reverend Jesse Jackson’s singling out a violent subpopulation he labeled “Bad Black Brothers” triggered a backlash among some African Americans worried about the dangers of negative stereotyping.
In leading CDC, David Satcher must be sensitive to these and a thousand other issues. He must be aggressive and thick-skinned, political but never partisan. “We’ve got to continue to reinvent ourselves,” he says. If CDC doesn’t, there are a lot of folk out there who will.
Vincent Coppola was an Atlanta magazine contributing editor.
This article was originally published in our May 1994 issue and reprinted in our January 2021 issue.