Incoming CDC Director Needs a Global Perspective

At a meeting last week I was asked to predict which cases would be included in the 2020 edition of Millions Saved: what large global health successes might unfold over the coming decade or so? I had no ready answer. Would it be a great victory against malaria, achieved through bednets, better and more accessible treatment, and even a vaccine? Or a successful, sustained and well-targeted program to fight malnutrition, including eliminating deficits in low-cost but essential vitamins and minerals? Perhaps a dramatic reduction in the rate of suicide, homicide and other types of violence, achieved through the application of a science-based public health approach? Or even a coordinated global response to an avian influenza epidemic or another infectious disease that is yet to hit the headlines? Though all are possible, none of these potential successes is in any way assured. What I can predict with complete confidence is that any of these or other future global public health achievements will likely owe considerable credit to the U.S. Centers for Disease Control and Prevention (CDC).The CDC has provided technical expertise, training and other capacity building efforts, and "shoes on the ground" for a large number of world-changing global health programs in the past, from the eradication of smallpox to the reduction of measles deaths in southern Africa. Today, it is integral to the work of the President's Emergency Plan for AIDS Relief and the President's Malaria Initiative. Beyond disease-specific programs, CDC personnel -- now more than 200 in 54 countries -- have worked tirelessly and usually without fanfare to contain disease outbreaks, transfer technical skills in epidemiology, surveillance and health promotion to counterparts in developing countries, and establish evidence-based technical norms and standards that have international applications. And some of CDC's domestic health functions, including those dealing with recommendations about vaccines, have profound international ramifications. Just follow the debates about mercury-containing preservatives in childhood vaccines and you'll see what I mean. In short, it is one of the most important global health assets that the U.S. has, and as the world shrinks through interconnectedness, that role has to grow.With the pending departure of Dr. Julie Gerberding as CDC's Director, the incoming Obama administration will have choices to make about who steps into the job. Given recent critiques, there's no doubt that observers (as well as CDC staff) will first and foremost be looking for reassurance that the incoming director will insist that the science and evidence-based public health policy must trump ideology and politics. That's the bare minimum. We should also be looking carefully at the understanding of and commitment to global health.These qualities should include a continued willingness to offer up the agency's talents for the "development" mission, largely manifested through participation in aid-funded health programs. The CDC's role in that area needs to be carefully thought through, in light of the experience of the PEPFAR and PMI programs, which have dwarfed with money and political visibility many of the CDC's other, longer-standing global health efforts. The new director, working with the Office of Global Health Affairs at the Department of Health and Human Services, will need to work out the complex details of constructive partnership with USAID and others who have "development" as their primary mission.But to tap the CDC's full potential, its attention to global health should focus more dollars and staff time on establishing and strengthening the professional and inter-institutional bonds with public health agencies around the world. While some of that work can be done in the context of PEPFAR and PMI, it's a much broader agenda. The aim is to share the benefits of U.S. technical strength, yes; but also to acquire knowledge and connections that are vital for dealing with the cross-border health problems that will arise in the future -- the next SARS, or the expanding challenge of antibiotic resistance. Ideally, the CDC also would commit to help reduce the causes of ill health that we ourselves export, whether through our carbon footprint or the hegemony of fast food.This is a tall order, but as the U.S. redefines the nature of our citizenship in the world, how much the new CDC leader knows, thinks and cares about global health will certainly determine the number and kinds of successes that we will be able to point to in 2020.