It has been a tough month for patients, providers and those who approach medicine from the “all hands on deck mentality.”  We have seen the foundations for a repeal of the Affordable Care Act, the potential selection of Robert Kennedy, Jr to a “vaccine safety” commission, and an expansion of a new political hegemony that appears to distrust science.  Yes there are some in the healthcare field that embrace the changes proposed by the new administration, but many others recoil at the potential setbacks and dangers inherent with these major shifts in policy.  Healthcare is at a crossroads, but without a clear compass or leader – it is hard to know what comes next.

As Tom Freiden, MD, MPH has stepped away from his post, I see a potential vacuum left behind.

From an Infectious Diseases perspective, he and his agency helped the country deal `with a variety of unexpected issues, including pandemic H1N1 swine influenza, drug resistant gonorrhea, Carbapenemase-resistant enterobacteraciae (CRE), Exserohilum rostratum, the expansion of dengue fever (including to Hawaii), and more recently the newest mosquito-borne virus Zika.  Among these and many others, I have no doubt that his legacy will be linked in no small part to Ebola.  This outbreak was not only fluid but required difficult decisions.  None of us will ever know what it was to like to send young Epidemiologic Intelligence Service (EIS) Officers and staff into harm’s way, or to become the focus of the country and media’s attention when mistakes were made.  I often wonder if he slept at all when faced with such a checkboard of challenges: unending grim mortality reports from Africa, the decision to bring Americans home to be treated in specialized units despite public fears, not bending to congressional pressure for limiting travel which was neither necessary nor rational, and of course, the missteps in Dallas.  I have no doubt he has regrets.  One can read about the CDC’s own overview and come to your own conclusions.

no-mans-land
The CDC Director is often left in no-man’s-land: whatever they do is criticized.  It takes bravery to lead.

Being CDC Director is like sitting in no-man’s-land.  Raise the alarm too early or inappropriately, and you will have wasted resources and engendered mistrust by having “cried wolf.”  Too late, and you will be chastised for not taking a threat seriously, being unprepared, and costing more dollars for cleaning up the mess.  Was it easy to get the support for Zika prevention? No.  Was it speedy?  No.  Success is less visible than any singular mistake – particularly in an era of instantaneous news – it is a losing gambit regardless of what you do.  It is both a thankless job and one that requires courage.

In remembering Dr. Freiden’s legacy, I hope people also harken to the CDC’s less colorful efforts to understand his impact.  During his tenure, there were major efforts to bring opiate addiction and antibiotic resistance to the mainstream. The CDC/World Health Organization’s Global Health Security Agenda, efforts to develop more outposts for outbreak detection and intervention, and those to enhance vaccinations internationally get little fanfare in America, but are of critical importance to making the world safer.  I highly doubt that most realize that the million hearts initiative (co-organized with the Centers for Medicare & Medicaid Services in 2012) was both ambitious and important to the nation, or that it provided additional focus on women’s heart health. Some of this may have begun before his time, but it all happened on his watch.

We also saw the CDC enhance public education, including expansion into social media. Many of us follow CDC on twitter on mutiple handles (ex. @CDCflu or @CDC_AMD). Did any of you download and play with the CDC’s “Solve the Outbreak” app (available for apple or  android)?  It is an excellent entry point for students to live the life of an EIS officer.  They organized inumerous webinars and dedicated personnel who gave time to train others in the community.  These are important efforts that all directors approach, allowing further expansion of the influence of the agency to improve public health, but one that felt  more visible during his tenure (although this perhaps this is more a reflection of my job).

I have seen the CDC as a place that many colleagues praise their experiences and the leadership within the organization.  It is a name we trust. I know people at the CDC respected Dr. Freiden’s intellect.  His dedication to improving and protecting the public was clear every time he spoke.  Dr. Freiden wasn’t perfect as a leader – no one is.  He wasn’t the astute communicator, as his predecessor Julie Gerberding or perhaps the more recognized physicians like Dr. Sanjay Gupta from CNN, but he was a staunch supporter of public health.  He was also lucky to worth with a White House that supported the agency.  I worry his public service will be remembered only for Ebola and not for the breadth of the CDC’s accomplishments.

What will come of this venerable agency and who will be selected to take charge?  It is important that in remembering Dr. Freiden’s accomplishments, we must assure that the new director is a highly qualified public health proponent that embraces science, prevention, transparency and education.  It also must be someone who is willing to evaluate the effects of the new healthcare policies of the new administration.  Understanding how policy shifts can affect the number of uninsured americans, teen pregnancy, HIV incidence, vaccination rates, and cervical cancer are just a few important ones that are clearly at risk.  This individual also must also be willing to present those data in an unvarnished way to the American public.  They must protect public health from becoming politicized and be focused on assuring there is adequate funding to support both prevention, surveillance and research efforts of the institution.   I hope that the new director will have an ability to talk comfortably and candidly to the public, to help communities understand the benefits of their work and assure there is a strong voice that speaks against those with anti-science agendas.  I know that immunosuppressed patients and providers throughout the world are paying attention.

The CDC Director is a position of critical importance to the public health community, and I am encouraged that the superb  and supremely qualified Dr. Anne Schuchat, is currently the CDC’s Acting Director.

Is it too audacious to hope that this becomes permanent?

Featured image taken from NBC news article here. Thanks to a friend and colleague for editorial support. 

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