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Tensions Between CDC, White House

Health Officials Say Low Morale Could Threaten Agency's Ability to Handle Crises

By Susan Okie

Washington Post Staff Writer

Monday, July 1, 2002; Page A15

The federal Centers for Disease Control and Prevention in Atlanta has been weakened and demoralized by tensions with Bush administration officials in Washington, according to a number of current and former officials at the nation's top public health agency.

The low morale is causing deep concern among public health experts around the country that the problems will hinder the CDC at a crucial moment -- when the agency should be leading the nation's effort to counter bioterrorism and other health threats.

The tensions stem from a variety of factors, including fallout from widespread criticism of how federal health officials handled last fall's anthrax attacks, the absence of a CDC director since March, efforts by the new administration to change approaches to controversial issues such as sex education and HIV prevention, and a campaign to exert more control over the CDC from Washington, health experts said.

"The absence of leadership . . . and the micromanagement of things, from press releases to travel authorizations, have created a hunkered-down mentality among the CDC staff I've talked to," said Willard Cates, president of Family Health International, a North Carolina research organization that works closely with the CDC.

Top officials at the CDC and at the Department of Health and Human Services, which oversees the agency, deny that there is a crisis at the CDC and attribute any tensions to the normal process of adjusting to a new administration.

"We are in a transition period . . . [but] the agency is moving forward," said David W. Fleming, acting CDC director. "There is a long-standing esprit de corps, and that never changes. . . . People are doing what they need to be doing."

As the federal agency responsible for protecting public health, the CDC takes a lead role in responding to epidemics and health emergencies. Its work has ranged from eradicating infections once common in the United States, such as smallpox and measles, to investigating outbreaks of food poisoning and fighting re-emerging diseases such as tuberculosis, or newer ones such as AIDS and West Nile encephalitis.

In the past, the CDC has often acted with considerable autonomy from Washington, even though some of its programs to prevent disease and injury touch on politically sensitive issues, such as condom promotion and gun control. Indeed, the agency, which has more than 8,000 employees, has long had a reputation for attracting health activists and is viewed as a headstrong outsider by many in the Washington health bureaucracy.

Since taking office, HHS Secretary Tommy G. Thompson has moved to centralize control over the department's 11 agencies, including the CDC. Criticism of health officials for giving conflicting advice during last fall's anthrax outbreak apparently strengthened the determination of Thompson and other officials to rein in the agency.

A number of CDC employees said that, in recent months, they have frequently been exhorted by HHS officials to make sure that the department speaks with "one voice," an approach that some fear may stifle scientific debate, especially on controversial topics.

Contact with the media is strictly monitored by the HHS press office. Many people interviewed for this article declined to be identified, saying they did not want to get themselves or colleagues into trouble.

"The whole issue of speaking with one voice has become a major problem, because it means that one voice will be a political voice," said a former CDC official. "Technical agencies remain credible if they are free to act on the basis of the best scientific information available, and not on the basis of what is the most politically favorable option."

Other factors have also contributed to the tension between the CDC and HHS, sources said. D.A. Henderson, who joined the department last November as head of HHS's new Office of Public Health Preparedness and is currently Thompson's principal science adviser for public health preparedness, once worked at the CDC but reportedly feuded with the agency on various occasions later in his career.

HHS officials have ordered audits of many CDC programs and are requiring departmental approval for decisions, such as the hiring of top staff members and travel by employees to scientific conferences, that in the past were usually made within the agency.

Workers given the task of responding to departmental audits are taken away from other public health activities, a CDC employee said. "The approach could have been to say, 'Here is Secretary Thompson's view of this,' " the employee said. "Instead they say, 'We're going to do an audit. Make sure you do things the right way. We're not going to tell you what the right way is. Guess what we're thinking.' "

International travel requests, as well as domestic trips by more than five CDC employees to the same destination, now require departmental approval, generally at least six weeks in advance. Kenneth Castro, director of the CDC's division of tuberculosis elimination, said similar rules on overseas travel were enforced at times during the Clinton administration. He said the long lead time sometimes makes it difficult to send CDC experts to international meetings.

"Very often our overseas partners have only thought of a meeting three weeks ahead," he said. While the rules can be waived in emergencies, recently "there have been a couple of decisions that have been down to the wire. Those have been difficult."

Moreover, since the resignation of Jeffrey P. Koplan as CDC director in March, the agency has been run by a four-person interim team, leaving employees uncertain who will be the CDC's next leader. "If they appoint someone as the next head who is clearly a political hack, people will leave in droves," a former federal health official predicted.

In interviews, two of the CDC's interim managers disputed the claim that tense relations with HHS headquarters have damaged morale or affected productivity.

"I think the relationship . . . is actually in one of the most collaborative and professionally positive modes that I've seen in many years," said Michael Osterholm, a special adviser to the HHS Office of Public Health Preparedness whom Thompson appointed to the CDC management team.

Fleming, the CDC's acting director, said that rather than stifling scientific discussion, the department's emphasis on "one voice" has promoted greater interchange between the CDC and other federal health agencies. "Once policy decisions are made, it's all of our jobs to support them," he said.

It is common for a new administration to focus on high-profile activities such as travel and hiring, he said. Fleming said CDC and HHS officials are looking at ways to streamline the process.

Fleming acknowledged that many CDC programs have undergone audits but said they have not created problems. "We do a very good job here," he said. "The more that we can have people from the department or people from other parts of the government see what it is we are doing, the better off we're going to be."

The June 6 announcement that more than $900 million in federal grants would be made available to state and local health departments for bioterrorism preparedness is evidence that the CDC and HHS are cooperating efficiently, Osterholm said. States' plans for spending the money were evaluated within seven weeks by the CDC, the Health Resources and Services Administration and HHS headquarters.

"You can't cut through all the red tape if you have parties that aren't working closely together," Osterholm said.

But there is uncertainty at the agency over what impact the emphasis on bioterrorism preparedness -- and the administration's recently announced plan for a new Department of Homeland Security -- will have on the funding of public health programs. Under the proposal, much of the CDC's responsibility for protecting against bioterrorist attacks would be moved to the new agency.

Following the Sept. 11 attacks, Congress passed an emergency supplemental appropriation that boosted the CDC's fiscal 2002 budget to $6.8 billion. It included about $1 billion for terrorism preparedness to be distributed by the CDC to state and local public health agencies, as well as more than $1 billion for purchases of smallpox vaccine and drugs. The president's $5.8 billion budget request for the CDC for fiscal 2003 contains about $1.6 billion for the agency's bioterrorism efforts but would cut overall funding to other CDC programs by about 4 percent.

HHS spokesman William Pierce said the proposed budget contains money to expand the agency's infectious-disease laboratories in Atlanta and Fort Collins, Colo., as well as funds for needed building repairs, a new communications center and increased security. He said Thompson has been trying to consolidate research programs and reduce the duplication of efforts among various HHS agencies. In some areas, "that might mean less for CDC, but not less on health issues department-wide," he said.

Koplan, the former CDC director, said he was concerned about the impact of the proposed new department on the CDC's role. Much of the funding that the agency has received for bioterrorism preparedness is to rebuild and strengthen state and local public health departments, diagnostic laboratories and communications networks that are also critical to combating everyday diseases.

"There are elements of what we do at CDC that could be carved out" as exclusively related to bioterrorism, Koplan said. "There are many other things that naturally overlap. . . . The country needs to be prepared for both naturally occurring plague and the potential for bioterrorist use of plague."

Koplan and others said the CDC continues to attract highly qualified doctors and scientists. The key to its future will be whether it can keep them.

"Can it be improved upon? Always," Koplan said. "But I think it's got lots of talented, smart people who have done well by the country for many decades. I hope that they will be in an environment that encourages use of top-quality science to inform public health decisions."

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