Public Health, Politics and Pandemic Preparedness
We are often told that the Public Health establishment will play a key role in responding to a pandemic. If so, how are they likely to perform? We can get some estimate of the quality of their response by assessing how good a job they have done in preparing for a pandemic.
The public health establishment is strongly hierarchical. The lead agency is the World Health Organisation (WHO). The top US agency is the Centers for Disease Control and Prevention (CDC). In the US, there are State Health Agencies. The actual providers of public health are at the County and City level. The hierarchical nature of these relationships is illustrated by the pandemic alert phase levels. The WHO establishes what level of alert is appropriate at any given time. Most nation-states base their responses on information they receive from the WHO. States receive their alert information from the CDC and counties and cities receive their information from the State public health agencies. Thus, the smallest public health organisation in the US ultimately depends on the information provided by the WHO.
The public health establishment is surprisingly political. Although the general public thinks most in public health are acting as scientists or physicians, this is not the case at any but the lowest levels. In fact, the decision-makers are almost always career politician/bureaucrats who may or may not have any training in medicine or science. Appointment to key positions in public health is dependent on keeping politicians happy, not in serving the public interest.
The mix of rigid hierarchy and politics has produced a public health system that is not responsive to the public and which does not function as if the health of the public is the primary objective.
Dr. Margaret Chan's appointment as Director-General of the WHO illustrates the ugly reality of politics in public health and the potentially catastrophic outcome we can expect as a result. Dr. Chan was a public health official in Hong Kong during the SARS outbreak. She was judged by the Hong Kong legislature to have failed in her responsibilities and publicly rebuked. She is thought to have been more concerned with protecting the reputation of the Chinese Communist Government in Beijing than in saving lives of her fellow Hong Kongers. An impartial observer might have thought this would end her career in public health. Instead, she was appointed Pandemic Flu Czar at the WHO. After the unexpected death of the then Director of the WHO, Dr. Chan launched an aggressive campaign to become the next Director-General. She assiduously courted the Chinese Communist Party leaders and received their strong backing. Although there were many rumors of bribes and other unsavory practices, Dr. Chan became Director-General of the WHO. Under her leadership, international cooperation on pandemic surveillance has reached new lows. The head of the Indonesian Heath Department, Dr. Supari, has publicly declared her unwillingness to share sequences or even acknowledge confirmed human cases. Further, Dr. Chan is alleged to have accused the US of "stealing" sequences from the WHO. Dr. Supari, a member of the WHO Executive Board, has accused the US of using these sequences for the production of biological weapons. Dr. Chan has not denied any of these charges. The damage to the reputation of the US in the undeveloped world is likely substantial. Further, Dr. Supari's conspiracy theories may well have discouraged other countries from reporting their cases and providing critical samples.
In the US, the most powerful member of the public health establishment is Dr. Gerberding, Director of the CDC. The Director of the CDC is appointed by the President and answers to the Secretary of Health and Human Services (HHS). Dr. Gerberding is widely considered to be the worst Director of the CDC in its entire history. Five past Directors of the CDC have taken the unprecedented step of publicly criticising her performance. Many have accused her of gutting the science base of the CDC while rewarding professional "risk communicators". And how have they done? One of them, Dr. Sandman is famous for suggesting that the public put pandemic preparedness on the "backburner". Although an TV ad was created to urge people to prepare, almost no-one has seen it. The HHS pandemic site advocates stockpiling food and other essentials for 2 weeks, but again, almost no-one in the general public is aware of this. Dr. Gerberding's mismanagement of the CDC has not gone unnoticed by the US Senate. Senators Grassley and Coburn have publicly criticised her performance.
One would think with this sort of track record, that Dr. Gerberding's chance of being reappointed to her position in the next administration would be low. In fact, she has made it clear that she would like to be retained:
At the disease centers, Dr. Gerberding is said to be interested in keeping her job.
But Dr. Jeffrey P. Koplan, who preceded Dr. Gerberding as director of the disease centers, is leading the Obama administration’s C.D.C. transition team. Dr. Koplan has publicly criticized Dr. Gerberding’s leadership.
Although we can hope that Dr. Koplan will favor a new Director for the CDC, he will not make the decision. President-elect Obama will, perhaps with input from Senator Daschle, who he has selected as Secretary of HHS. Comments by some at CDC Chatter indicate that the Senator has a good working relationship with Dr. Gerberding and may favor her retention. Also in Dr. Gerberding's favor is her team of "risk communicators" who may have been using their considerable skills to smooth her path. I have found it quite remarkable that political blogs that are intensely critical of almost all of President Bush's administration have been largely silent on Dr. Gerberding's performance. This includes high-profile blogs with experts in public health and pandemic preparedness.
At this point, it is difficult to know what is going on behind the scenes. One can hope that a qualified public health official will be chosen as Director of the CDC. My own preference, Dr. Roz Lasker, has shown a refreshing willingness to engage in genuine conversation with the public about pandemic preparedness.
There is little we can do about Dr. Chan's position as Director-General of the WHO. However, we have a small window of opportunity in which we can make our voice heard regarding the next Director of the CDC. President-elect Obama has created a website to solicit suggestions from the public about the transition: http://change.gov/. I would urge everyone with an opinion about the CDC's leadership on pandemic preparedness to express it at this site. Whether you voted for President-elect Obama or not, we all have a stake in the CDC's leadership.
This may be our last chance to influence the selection of a public health official who will be making life or death decisions about pandemic preparedness. Let's not waste it.
Friday, December 19, 2008
