Julie Gerberding: On the Public Health Frontline

In the spotlight: Dr. Julie Gerberding is three years into a comprehensive reorganization of the U.S. Centers for Disease Control and Prevention

Dr. Julie Louise Gerberding, 51, has been director of the U.S. Centers for Disease Control and Prevention – the federal public-health agency based in Atlanta and known internationally simply as “the CDC” – since 2002. A South Dakota native, she began her medical career in San Francisco in the desperate early days of the HIV/AIDS epidemic. The experience of pursuing a medical mystery amidst panic and intense publicity has proved useful at the CDC; she rose to prominence during the 2001 anthrax-letter attacks and has steered the agency through the SARS epidemic, the Indian Ocean tsunami, Hurricane Katrina and preparations for an influenza pandemic.

The 9,000-person CDC and Gerberding’s performance as director have attracted unusual scrutiny lately. Employees who object to a comprehensive reorganization that she launched in 2003 have taken their case to the internet, prompting inquiries from several members of Congress. In a wide-ranging interview in December with freelance writer Maryn McKenna for Georgia Trend, she discussed her tenure, her agency’s challenges and her vision for its future. Here are highlights from that conversation.

GT: We are speaking at a time when CDC has been getting a lot of attention from the media and from Congress. How does it feel to be in the midst of that?

Gerberding: CDC is doing a spectacular job protecting health. When there are lenses cast on various aspects of the organization, we take that seriously. But I think we are learning to put that into context and remember that the most important thing is that we have a big job to do and we really need to concentrate on getting it done to the best of our ability.

GT: How do you measure whether you are doing something well?

Gerberding: The whole organization of CDC is increasingly focused on results. We are measuring excellence in four areas. Excellence in service, which is where we measure our ability to have an impact on health. Excellence in science: It is important to know we are not doing science for science’s sake, but because it is the knowledge we need to protect people’s health. The third domain is excellence in strategy and workforce, and innovation: We really need to put a lot more emphasis on the public health of the future, not just the public health of this crisis or this year. The last area is excellence in systems. Our intent is to publish a scorecard every quarter of where we are: red light, yellow light, green light, a total of 16 individual measures that we will be reporting to the public across CDC.

GT: Much of the public thinks of the CDC as an organization that responds to disease outbreaks, though that is only part of what the CDC does. How do you measure your response?

Gerberding: The most important measure of success in an outbreak is how long does it take you to solve it. For some time we have been measuring – in the case of a food safety issue for example – from the time the first case is recognized to the time that the product is recalled from the market. That is an important time interval because all of the days in between those two time marks are days when people are continuing to be exposed and may be getting sick and in some cases even dying.

In terms of our preparedness planning we are looking more specifically at: time to detection; time from detection to reporting – how long does it take for the local health department to know something has happened, how long does it take for the state to know, how long does it take for the CDC to know; the time to a decision for action, to contain or control or stop the problem; and ultimately the relationship between the onset of the event and the resolution – how long did this outbreak last from the standpoint of the citizens who may have been affected.

We have been able to show with food safety over the past few years that overall the time from the first case to the recall [of a food product] has consistently been decreasing. That is important because food safety outbreaks are like looking for needles in a haystack.

GT: The reorganization of the CDC is one of the things you are most identified with. How is that going, and how are you feeling about it now?

Gerberding: It is important to understand that CDC is not reorganizing; CDC is trying to transform our agency into one that is better positioned to respond to a whole new set of challenges.

The first challenge might be described as the challenge of extremes: extreme climate, extreme poverty on a global scale, extremism – the ideological conflict that is going on in more and more parts of the world. Also the extremes of age, with more and more people living longer and longer, and the extremes of our lifestyle, including poor nutrition and the incredible obesity epidemic. Those are big problems. They require us to think about solutions in new ways, because they are global, they are hard to solve, and they take far more than just CDC to make a difference.

We are also working in an environment where increasingly the individual consumer is in charge of decisions. We need to have things available to people where they need them, when they need them, and on a personalized basis how they need them. And we need to be fast.

Something that is very important to understand is that we are in an environment of finite resources. Our budget has gone up wonderfully for urgent threats – but for realities like obesity, tuberculosis or syphilis, our budget has been reduced by, in some cases, 12 to 14 percent over the past five years. We have more to do some things, but we are going to have to do some other things with less money than we have had before. CDC has to be better, faster and cheaper; and the only way you can be better, faster, and cheaper is if you innovate.

What we are doing is learning how to adapt to the new world that we are living in, which is not going to allow us the luxury to do things that don’t have high impact or that don’t achieve results on an accelerated time frame. I don’t think we could have been successful doing that with the old organizational structure, the old management style, of CDC.

GT: A transformation is an ongoing process, whereas a reorganization might have a finite end. Does that mean you are in a process that doesn’t end?

Gerberding: Usually, when people say “reorganization,” they are talking about the structure of the organization. The structural reorganization has been challenging at CDC, but it is really the least important thing we are doing. The real process that we are undergoing here is the hard work of asking ourselves: What are the most important things we should be concentrating on to accomplish [our goals]? And how can we bring people together across the CDC to get that work done fast?

The structural reorganization has distracted people, understandably, because structural reorganization is, where is your office going to be, who do you report to, how is your job going to change – things that affect people every single day. But we are seeing CDC settle down. The new leaders are in place, the new organizational structure is in place, the new work groups are formed.

There is one other major change in our way of doing business, and that is committing ourselves to truly engaging partners and the public. There is a great example in pandemic flu planning. Experts at CDC and elsewhere have told us that the people who would be at greatest risk of harm should be the first to receive vaccine or antiviral drugs. Typically seniors are at greatest risk from harm. But when we went out and asked the public about this, we heard: Protect the people that keep our communities functioning and safe during a pandemic, the police, the fire, the electrical company, the water sanitation department. And after that, many people said, protect the children. They were not approaching it from a medical framework; they were approaching it from a citizen values framework. It is very important that we understand and respect that.

GT: You have lost a substantial number of personnel to new jobs or retirement who were heads of the traditional centers, the science concentrations, at CDC. And some nonprofit analyses warn that the CDC and the whole federal health corps contains many workers nearing retirement age. Can you comment on the departures and on what you are doing to recruit your next generation?

Gerberding: The aging of the federal workforce is a problem for every single agency and it is one that I am very concerned about for CDC. Some 40 percent of our workforce is eligible to retire in the next three to four years. It is a tremendous challenge.

In terms of what has happened at CDC, we have been measuring common indicators of workforce attrition and stress that are widely used in other organizations and we are reassured. For example, absenteeism is usually a pretty sensitive marker for a stressed workforce and we have seen no change in days away from work. The retirement rate is going up, but the non-retirement attrition rate is stable and might even be decreasing.

People aren’t talking about the “brain gain,” the fact that we have been able to recruit extraordinary leaders who are already making a huge difference. We are also seeing extraordinary evidence of a strong pipeline of leadership within the CDC as bright young people move up into positions of responsibility.

I need to be candid that some people have left CDC because they are unhappy about the direction that we are changing. Experts in organizational change in and outside of government have said it is just about impossible to undergo a major reorientation of an agency without some people who had a stake in the old way feeling like there wasn’t room for them anymore. As disappointing as that may be, it is probably a necessary and expected part of any serious organizational change.

GT: The past five years have seen a series of national emergencies: the anthrax attacks, in which CDC’s response was criticized; SARS, for which CDC was praised; Hurricane Katrina, for which reactions have been positive and negative. What can you say at this point about CDC’s ability to respond to emergencies?

Gerberding: CDC was one part of the Katrina response, functioning under the authority of the Secretary [of Health and Human Services]; we were not independently operating or making decisions. We have received uniform high and ongoing praise from the health officers in all four of the affected states as well as multiple commendations from [those] who were in charge of those areas. I think on balance CDC performed its responsibilities during Katrina.

However, we have made an organizational commitment since anthrax that no matter what the emergency response success is, we have a responsibility to ask ourselves: What else could we have done? What went well? What can we improve? If you don’t question your capabilities and dig deep to find areas where you can improve, you will never get better.

The information reported [regarding] CDC’s Katrina response was the after-action report that we put together ourselves to examine potential problems and identify any we thought were important enough to concentrate effort on improving. That report did not contain a compendium of all the things that went really well and that we should be really proud of.

GT: You’ve been CDC director for almost five years. Are there things you are particularly proud of? Is there anything you regret?

Gerberding: Personally I am most honored to have created the team of leaders we have here. When we talk about leadership at CDC now, we are talking about a very big tent. It is not just the people in the senior leadership positions or the directors of our coordinating centers, it is the center directors, the division directors, the leaders of our special-interest employee groups, the leaders of our labor-management council. That is an extraordinary network and to be part of that network is an extraordinary learning experience for me.

What I would say I regret the most is that I don’t think I adequately prepared people for what a change process really entails. This is a very big organization, it is very distributed, and I wish we had done a better job with internal communication from the very beginning – both in terms of communicating expectations and what the road map ahead was, but also in communicating reassurance and normalizing this experience. Yes, this is hard and it may get harder, and there are going to be bumps in the road, but let’s keep in mind why we are doing this: We are being faced with really hard challenges and if we don’t make these changes we are at risk for not succeeding in our mission.

GT: Can you articulate a vision for CDC going forward from here?

Gerberding: As a nation we must understand that we cannot be putting our health resources into disease care without putting more of that portfolio into health protection. That makes health sense for families and individuals. It makes business sense to the businesses who can’t afford to continue to pay so much for health benefits. It makes common sense to moms and dads who know an ounce of prevention is worth a pound of cure. But right now what we believe and what we are doing are two very different things.

The most important driver for the CDC in the future is to contribute leadership to a health system that truly values health protection by promoting the best possible health, by preventing diseases and injuries and disability before they occur, and by preparing ourselves and our communities to contend with whatever the next threat is. The vision is that every family and every person in America is able to access the support, the tools, the programs, the services and the knowledge that will let them make the best possible choices about protecting their health.

Editor’s Note: Maryn McKenna, an independent journalist specializing in public health and health policy, is author of BEATING BACK THE DEVIL: On the Front Lines with the Disease Detectives of the Epidemic Intelligence Service (Free Press), a history of the CDC.

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