Don’t read this blog. Instead, close your door, unplug your phone, and click on this link, which will transport you to a lecture hall in downtown Washington, where five former directors of the Centers for Disease Control and Prevention (CDC) met recently to discuss the agency’s legacy and its future.

You can read here that these esteemed lions warn that the CDC’s reputation and effectiveness are threatened by politically motivated manipulation of science. Or that globalization brings to our doorstep increased risks to human well-being not only from disease but also from poverty, environment, behavior, and other nonmedical determinants of health. Or that the public health infrastructure is underfunded and inadequate.

But you already know all of that. What can be learned from this rare dialogue between William Foege, James Mason, William Roper, David Satcher, and Jeffrey Koplan is knowledge of a higher order. The historic, global campaign to eradicate smallpox, spearheaded by the CDC, happened on Foege’s watch during the 1970s but was a touchstone for all five in this dialogue. What the smallpox campaign represents to them is leadership, collaboration, commitment — and success. But in the expanding universe of global health, the challenges grow greater, not less; and while the dedication of public health professionals is undiminished, the CDC’s capacity to sustain its functioning at the level of the smallpox battle is fragile and uncertain.

With limited resources, Koplan said, difficult dilemmas arise in balancing priorities between shorter-term and more tangible threats such as avian flu or bioterrorism and long-term health promotion goals such as stemming epidemic levels of obesity and diabetes or curbing tobacco consumption. Satcher emphasized the importance of international collaboration in tackling global public health challenges, and moderator Barbara DeBuono, the former New York state health commissioner, noted a parallel interdependence on the domestic front between the CDC and state and local health agencies. But the domestic infrastructure is weakened by perennial budget neglect, and Foege told an embarrassing anecdote about CDC personnel’s recently being required to obtain political clearances to meet with World Health Organization officials. “Politics trumped science in a way that I never thought would happen after the smallpox eradication program,” he lamented.

Yet in a manner that was characteristic of the directors’ collaborative habits of thinking and discourse, DeBuono and Roper went on to develop another side of the politics-and-health theme. DeBuono, who managed the contentious launch of mandatory Medicaid managed care in New York, noted bluntly that politics often drives policy at the state and local level and that public health officials “have to understand the political environment and how to navigate that successfully.” Foege acknowledged that despite the apparent need for a church-state type of separation, the relationship is nuanced and “very confusing.” Roper went further. “The reason public health is such a consequential area is precisely because it is the intersection of science and politics. There’s a proud tradition of political action in the name of science,” he said. “Politics is the way we make decisions in a free society.”

The panel received a heartfelt and spontaneous standing ovation from students and faculty of the George Washington University School of Public Health and Health Services. A poignant question from one of them begged the luminaries for advice on how to keep from being overwhelmed by the magnitude of the challenges and the neglect and obscurity that often shrouds their chosen field. Mason first and then the rest all responded — without a hint of theatrics — that the opportunity to do some good in the world far outweighed the moments of frustration and doubt. “I think dreamers go into public health,” Mason said, to applause. “I can’t think of anything that is more satisfying.”

Health Affairs’ most recent issue on public health can be found here.

Tags: Public Health