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THE NEW ENGLAXI)JOURNAL OF MI-2DICL'~E .Marth 10, HEALTH POLICY REPORT The Centers for Disease Control TnF. Centers for Disease Control (CDC), a respect- ed federal agency that enjoys a worldwide reputation for its successful assaults against infectious disease, has broadened its programmatic scope to include disease that is related to the environment, occupational health hazards, and the promotion ofhealth. The CDC's new charter, which will inevitab[y make it a more contro- versial agency, stems fi'om a congressional mandate; the zeal of its director, Dr. William H. Foege, for a broad definition of disease prevention; and the strong support &two recent secretaries of Health and Human Services--Republican Richard S. Schweiker and Democrat Joseph A. Califano, Jr. -- for health pro- motion. The support of Schweiker and Califano has helped to bolster disease prevention and health promotion as promising nonpartisan concepts-- though occasion- ally not without controversy, as Califano's anti-smok- ing campaign demonstrated. Although there is broad support in Congress for both concepts, translating this support into public-policy thrusts has only begun. Payment for personal health services to eligible per- sons will consume more than 90 per cent of the $76.5 billion in federal health outlays in 1983, and spending for biomedical research will take much of the rest of this mammoth pot. Nevertheless, disease prevention and heaIth promo- tion are acquiring a constituency within government circles and in the private sector. Reflections of this growing interest abound, but little attention is pai.d to it, because the steps involved are incremental, they do not involve large sums of money, they are generally voluntary-- we Americans do cherish our freedom, even to harm ourselves--and they usually invoIve routine processes rather than technologic break- throughs. 8chweiker provided a good example of the kind of steps he was prepared to take on behalf of prevention, or as he characterized it in this instance "wellness," when he discussed his department's "ac- complishments" on February 25, 1982, in testimony before the House Appropriations Subcommittee on the Departments of Labor, Health and Human Services, Education, and Related Agencies. ~re began by .setting up a new national health agenda, with wellness at the top of the list. We are setting up at the NIH [National Institutes of Health] a basic research program in the ~ellness area .... We have set up a task force to work with medical schools; instead of just dealing with acute care, the). will help train patients" and providers in the area of health promotion. We are working with the Advertising Council of America to identify wellness as one of their national campaigns in the coming year. We have begun a sodium-labeling program on a voluntary basis at the FDA .... Finally, we are trying to encourage the kind ot'thlngs reported in the N~w York 7~,me~ a few months ago. It was reported that about 500 corporations put on wellness programs. In a private-sector action, the Health Insurance As- sociation of America and the American Council of Life Insurance (ACLI) announced on January 19 that they were encouraging the nation's life and health insur- ance companies to "begin concentrated efforts to pro- mote smoking cessation and prevention at the work- site." The action followed a report on "the dangers of cigarette smoking and the need for worksite cessation programs" that was written by Dr. Charles Berry, former chief medical director of the U.S. space pro- gram, and Dr.Jonathan Fielding, director of the Uni- versity of California at Los Angeles Center for Health Enhancement. Schweiker became president of the ACLI February 4. Another important development was the publication last year of a compendium of stud- ies and conferences sponsored by the Institute of Medicine to examine thoroughly linkages between health and behavior? The growing interest in disease prevention and health promotion is not a well-coordinated phenom- enon. It is a movement that does not have a well- recognized national leader and that is taking shape at a restive time in the evolution of the American health- care system. Indeed, rhetoric on behalfofits concepts runs far in front ofactual commitments to pay for their costs. In the public sector, the CDC represents the closest thing we have to a national force that is promot- ing the control and prevention of disease. This report will focus on the CDC and discuss the status &its most important missions. Dr. William H. Foege, who has been director of the CDC since 1977 and affiliated with the agency since 1962, is highly respected in the world of disease control for his role as one of the architects of the successful program to eradicate smallpox throughout the world. One of the most emphatic points he made in a recent long inte.rview was that the private and public sectors alike make a distinction between financing health serv- ices on the one hand and paying for health promotion on the other. Health-care services and health promotion are held to different standards, play by different rules, lfl should develop a new surgical technique, funding is available for it even before it is found effective. If someone develops a new drug, once it is proven safe and effective and it is licensed, insurance programs cover the cost. But there is no requirement that a drug demonstrate a positive cost-benefit ratio. For disease-preventlon methods, it is a different story. Take the polio or measles vaccine as examples. Not only did their safety and cy have to be proved, but because they are prevetation techniques they had to show a positive cost-benefit ratio. Once that was proven, we had to justify the funds for these vaccines every year, placing them in competition with other programs For funding, even though we could prove that a measles or polio vaccination returned $ tO for every $1 spent. I view this dichotomF between health-care services and prevention techniques in the United States as simply absurd. The basic social value is that health is a priority, but attend to it only after you have lost it. The roots of American public-health policy derive from 18th-century efforts to control epidemics. The nation's public-health structure x.,ery much reflects the evolution of the distribution of powers between the TI06971893

605 states and the federal gnvertmlrnt as set forth in tttr Constitution. Local boards of htmlth and, later, state health departments were de- veloped to perform community dis- ease-control and prevention tasks that individual practitioners, by themselves, were incapable of Tab',~ 1..-qea.~iaq #dminis:ral-.¢ ,; Ftsc~l 1984 BJdget Request for the Centers for Di~eas,: Conlrol, a~ Compa:e. ;.¢,r.h Those cf the Two Previous Fiscal Years. (Dollar Ar~ount~ in Thous~nd~.l llV'..', pF~2 1983 1984 no. doing. The federal role that evolved "" " o" Grants a6 35,419 was one of asslStltl~ the state and Direct opcratid'ns 17. 7,483 local health agencies with money, Immunization qflalified professionals, and techni- ~rant~ ~, 27,8t7 cal assistance. D,,irect operations 12:. 6,898 As World War II came to an end, Infectious dlseasc~ 57'~ 28.526 the Communicable Disease Center Chronic and environmental .t2,~ 28,020 (as the CDC was called initially) disease prevention was created as a technical arm of Oecupatinnal safety and the Public Health Service. Its win- health Research 73 t 53,008 cipal mission ~as to aid states in the Training - 5,913 control of communicable diseases. "Scientific/technical services 40 3,137 Initially, its focus was the eradica- Epidemic services 85i 32,839 tion of only one disease ~ malar- Buildings and facilities--- 2.499 ia ~ in the 14 traditionally malar- Program management 84 2,583 ious states extending from Virginia Toua obligations ".'3566234,142 to Texas. The CDC was formed from the administrative and personneI struc- ture of the Office of Malaria Control in War Areas, which had its headquarters in Atlanta. Today, the CDC's Atlanta headquarters makes it unique among federal agencies, virtually all of which are directed from offices in Washington. CDC's Atlanta base has helped insulate the agency from some of the political maneuverings that from time to time consume other federal programs with headquarters in Washington. Ironically, the CDC employed a larger staff-- 4000 persons -- to track malaria than it does today to con- trol and prevent a multitude of diseases- testimony to society's current penchant for limiting government. The CDC currently employs about 3600 people. Dr. Alexander D. Langmuir, who created the CDC's highly regarded Epidemic Intelligence Serv- ice, wrote several years ago of an interesting bureau- cratic struggle that pitted the new agency against the National Institutes of Health over the issue of the CDC's right to mount a broad epidemiologic service program. 463 40,000 463 40,510 172 7.692 172 7,968 99 27,428 9(1 30,482 125 11.858 125 11,407 604 34,882 642 34,417 453 24,809 432 24,305 733 49,545 733 52,288 -- 5,760 -- -- 40 2,179 40 2,332 851 41,699 859 46,030 -- 12,602 -- 17,370 84 ~ 84 ~ 3615 261,244 3640 270,023 The issue with NIH was long lived and sometimes bitter. NIH officials rightly claimed that over the previous halt-century the Na- tional Hyglenie Laboratory had a brilliant record of investigating epidemics and providing solutions .... We at CDC countered with our new congressional charter that charged the agency with serving the ~tates in the control of communicable disease, which certainly included the provision ol'epidemic aid on request. When the NIH offi~als were asked if they would accept responsibility for answering all such requests, they replied, "Certainly not. Only the interesting ones." This issue wa~ re~olved by a simple agreement that whichever agency received an epidemic aid request would dear the situation with the other before sending out a team ofepidemiolo- glsts.~ Even the Reagan administration has never seriously questioned the view that the tasks performed by the GDC constitute an appropriate role for the central government, although in the early stages of develop- ment of the President's fiscal 1984 budget a zealous middle-level professional at the Office of Management and Budget recommended sharp reductions in spend- ing for the agency. For a guide to what the CDC re- gards as important, one can refer to the administra- tion's new budget, which provides a picture of its spending priorities. Table 1 outlines the CDC's fiscal 1984 budget and compares it with those of two pre- vious years; it provides no insight, however, into how much infighting took place between the CDG, the De- partment of Health and Human Services, and the Of- fice of Management and Budget before this spending level was arrived at. The CDC's 1984 budget was subjected to sizable swings during the course of its development. The budget that Health and Human Services initially sub- mitted to the ONce of Management and Budget sought $375.7 million for the CDC--a sharp pro- posed increase, given the grim fiscal environment in which the department's policies are shaped these days. But the Office of Management and Budget, aggressive- [y in pursuit early in the budget cycle ofcuts anywhere they could be found, at first allowed only $215.8 mil- lion for the CDC -- a figure well below the agency's fiscal 1983 spending level. Schweiker, demonstrating his commitment to pre- vention, appealed the CDC's low budget allowance (and a number of other health items) to the White T106971894

House. Sd,weikcr's plea on behalf of the CDC was persuasive, but perhaps more compelling was a White House decision that taking a few million dollars from such agencies as the CDC and the FDA could not begin to erase the massive federal deficit. In any event, when the budget was unveiled it contained a request for $270,023,000 for the CDC in fiscal 1984. Although the dollars involved are relatively small, the budget scramble involving the CDC is neverthe- less intense at times. For example, the CDC fought for six years through Republican and Democratic admin- istrations for funds to build a new virology laboratory to replace its existing obsolete facility. This year, the initial budget proposal of the Department of Health and Human Services included funds for the laborato- ry. But the Office of Management and Budget re- moved the funds in its first crack at the department's budget. Ultimately, though, the administration's new budget included the $15.6 million necessary to build the laboratory. Since 1981, the CDC has been forced to eliminate or curtail a number of activities because of the adminis- tration's relentless pursuit ofbudget savings; Congress has largely accepted these cuts. For example, CDC employment has been reduced by 500 people (tempo- rary positions only), its $14.5-million rat-control grant program was eliminated, funding for occupational- health and safety actiyities was reduced from $81 mil- lion to $55 million (from 1981 to 1982), and four of its categorical grant programs--health education and risk reduction, prevention oflead-based-paint poison- ing, fluoridation, and health incentive grants-.- were consolidated into the preventive-health-services block grant, thus shifting from the CDC to the states deci- sion-making authority over' the way these monies are allocated. One policy change that has led to what has been perhaps the loudest outcry was the agency's decision to discontinue free distribution ofits widely read Mor- bidity and Mortality Weekly Report (MMWR), the major communication ]ink between the CDC, state and local health departments, other federal and international agencies, and the medical community about the cur- rent status &some 46 diseases ofpublic-heahh impor- tance in the United States, When the CDC distributed the publication free, cir- culation was 110,000. Now that an annual charge of $70 has been imposed, circulation has dropped to about 12,000, although another 10,000 copies are still distributed free to organizations that have a vital role in maintaining the public's health and that provide data for the weekly report. The MMWR cost the CDC about $1 million a year to publish free. By not expend- ing funds for the free distribution of the MMWR, the CDC was able to save the jobs of 30 members of the agency's work force. Many of the CDC's prog÷am activities have been developed aud are being implemented within a context created by two key government documents: Healthy People: The Surgeort General's Report off Health Promotion and Disease Prevention, published in 1979, and Promoting Health~Preventing Disease: Objectives.for the Nation, pub- lished in 1980. The 1979 report reviewed methods of • preventing the most common diseases for specific age groups and identified 15 priority areas, including the following five preventive health services: family plan- ning, pregnancy and infant care, immunizations, care for sexually transmitted diseases, and high-blood- pressure control. The second report listed prevention goals for 1990 that are specific and quantifiable objectives for each of the 15 priority areas. These recent reports built on earlier attempts to identify specific preventive meas- ures appropriate for population subgroups. Instead of recommending an annual physical examination for everyone, specific professional services have been rec- ommended for various age groups? Within this framework, the CDC has made dramat- ic progress since 1977 in reducing through vaccination the incidence of seven preventable childhood diseases and the number ofdeaths attributable to them. In his recent book, Califano told how the national effort to immunize all ch.ildren was rekindled. The childhood immunization program began the way many things began in Carter's Washington, with a phone call from the Presi- dent's wife. Early in the administration, Mrs. Carter called me. She and the President had dined with Senator Dale Bumpers and his wife the night before. "Betty has some ideas about immunizing children and I would like for you to scc her." I callcd Mrs. Bumpers that day and she came to my office on Fcbruary 18, 1977. She explained how "when Dale was governor of Arkansas, we organized everything from the National Guard to the churches and schools to get children immunized. If you get everyone going, it'll work," she said.~ By the fall of 1981, 95 per cent of children entering school for the first time had proof of immunization against diphtheria, measles, pertussis, polio, rubella, and tetanus, and 90 per cent had proof of immuniza- tion against mumps. Table 2 compares the maximal and current morbidity and mortality due to these dis- eases, as reported May 7, 1982, by the GDC to the Senate Labor and Human Resources Subcommittee on Investigations and General Oversight. As shown in Table 2. Comparison of Maximum and Current Morbidity and Mop tality Due to Vaccine-Preventable Diseases In the United States. MAXIMUM 1981 MAXIHUM NO. OF PROVISIONAL NO. OF 1978 Diphtheria 206,939 (1921) 4 IS,000+ (1921) 4 Measles 894,134 (1941) 3032 6986 (t934) 11 Mumps * 152,209 (1968) • 4729 55 (1952) 3 Pertussls 265,269 (I934) 1189 7518 (1934) 6 Pollo (paralytic) 21,269 (1952) 6 ' 3145 (1952) 1 Rubella "]" 57,686 t1969) 2060 53 (1964) 10 Tetanus :l: 601 (1948) 60 I7253 (1933) 32 • First reportable in 1968. IR~t relmrtabl¢ in 1966. ~:Fi~sl ~cportable in 1947. T106971895

Vol. 308 No. l0 HEALTH POLICY REPOR [" 607 the table, there has been a striking reduction in mor- bidity and mortality from all the vaccine-preventable diseases. The national immunization effort is coordinated by the CDC, but it is actually implemented at the state and local levels. The CDC administers a categorical grant program that provided state health departments (and, because of historical circumstances, a few local health departments) with $27.4 million to purchase vaccines as wel! as to provide stafffor educational and promotional activities, surveillance and investigation, and program management. The CDC conducts from i5 to 12 thorough evaluations each year of individual state immunization programs. -' The national effort to immunize children against preventable diseases involves an interesting mixture of the public and private sectors. Although there is con- siderable variation in different parts of the country, the CDC estimates that about half of all children receive their immunizations through the private sector- mostly in phy.sicians' offices m and half receive them through the pu.blic sector, primarily in local health- department clinics. Another reflection of the stepped-up campaign on behalf of immunization is the fact that all 50 states have enacted laws requiring children to be immunized before they enter school. In 39 states the laws apply to children from kindergarten through 12th grade; thus, children moving from one school to another are re- quired to show proof of immunization. Dr. Alan Hinman, director of the CDC's Immuni- zation Division, said in an interview that the agency has made an effort over the past five years to "equal- iz~" the effectiveness of the 50 state programs. The "major varlations" that once existed between state progra.ms no longer exist, Hinman said, pointing as evidence to the overall national rate of 95 per cent of all children entering school with proof'of immuni- zation. Hinman said he regarded CDC's "major challenge" in hi~ sphere as maintalnlng'progress toward universal immunization. We have made really incredible prog.ress in the last five years, progress that is reflected in the morbidity levels. An acid test of the effectiveness of an immunization program is its success with measles, a highly con- tagious illness that will seek out and find a program'n faults. Last , week [the week of Jan. 17 to 22], for the first time since measles became a reportable disease we did not have one ease reported. The CDC has been less successful in controlling venereal diseases. Rcp. William H. Natchcr (D-Ky.), chairman of the House Appropriations Subcommittee on the Departments of Labor, Health and Human Services, Education, and Related Agencies, asked the CDC's director on March 1, 1982, what evidence the agency had "that the federal investment in this pro- gram (venereal-disease grant program) is working?" Foege responded: Since the initiation of federal ~sistance and ~orts to corttrol venere- al disease, the reported ~a.~e~ of syphilis have declined from art all- time high of 575,.593 reported cases in 1943 to 71,474 in 1981, a reduction of more than one-half million cases. During this sonic period, infant deaths due to syphilis have declined 99 per cent; first admissions to mental hospitals with syphilis psychoses, all other deaths from syphilis, and reported cases ofcongenital syphilis have declined by 98 per cent. Beginning with fiscal 1972, when federally assisted state and local gonorrhea-control programs were imple- mented, the increasing incidence of reported cases of gonorrhea began to slow from 10.7 per cent in fiscal 1973 to 3.1 per cent in 1976 to essentially stable levels since 1977. Although gonorrhea remains the number one reportable disease, the case rate of 445.8 per 100,000 population ( 1,009,686 reported cases) for fiscal 1981 is a 6.6 per cent reduction from the rate o£477.2 reported in fiscal 1976. Paralleling this decrease in gonorrhea rates has been a dramatic 49 per cent decrease from 1973 to 1979 in the rate of visits o£patients with pelvic inflammatory disease to private physicians' offices. This leveling off and decline occurred in the face ofsocial changes which placed more people at risk for venereal disease. Recently, the incidence ofsyphilis has been increas- ing. Asked for an explanation, Foege said the CDC is concentrating its limited resources on eliminating gon- orrhea. "That i's a trade-off we have agreed to make. The dollars are better spent on ~onorrhea," Foege said, noting that the gonorrhea rate has dropped about 4 per cent in the past year. The CDC is also limiting its oversight ofgenital herpes, which th.e agency declared an epidemic in March 1982. Foege said the CDG and the NIH were concentrating their resources on devel- oping a vaccine to use against herpes. "We will have a vaccination," he said,.without predicting when. As the nation's strike force against disease epidem- ics, the CDC is oftencalled on to move rapidly in certain situations. The list ofepidemi.cs is long, and the work of the agency is generally lauded, though the CDC came up with something of a black eye and its former director, Dr. David Sencer, was fired by Cali- fano in 1977 for his role in the government's swine-flu immunization program. In his recent book, Califano wrote that President Carter called him on Sencer's behalf to ask what he intended to do with Sencer. He told Carter he intended to replace Sencer and added: Sencer isn't running the Center well. He's largely responsible for the swine-flu program, and in the last few years the immunization of children has dropped sharply. We need new leadership just to revive our immunization program~ to say nothing ofall the other potential of the center,s Now, the CDC is faced with a new problem, charac- terized by the agency's Dr. James W. Currarr as "the most complex new medical disorder to come along in a very, very long time.".Curran coordinates the CDC's Task Force on Kaposi's Sarcoma and Opportunistic Infections, a group formed to combat the current epi- demic ofserious illnesses associated with defects in the body's immune system. The diseases have been cate- gorized in the literature as "acquired immune deficien- cy syndrome" (AIDS). The ODC, which is reporting an average of three new cases a day, has initiated epidemiologic and labo- ratory investigations to determine the cause of AIDS and a means for prevention and control. The CDC is working with the National Cancer Institute and other T106971896

11 groups to pool information and share each agency's plans for investigations and research. Meanwhile, the CDC finds itself embroiled in a po- litical controversy over what steps it should recom- mend to control the disease. The National Hemophilia Foundation has asked that immediate steps be taken to screen out homosexuals and others who run a high risk of falling victim to AIDS from among potential blood donors. (One theory being pursued by investigators is that AIDS is transmitted through blood products.) However, the three leading blood-collection groups -- the American Red Cross, the American Association of Blood Banks, and the Community Council of Blood Centers-- said January 13 in a joint statement that they would not ask potential donors whether they were members of the groups at high risk for AIDS. Foege, noting this "polarity in the [blood] community," said the CDC was working to strike a compromise that would assuage the involved interests and still provide a .higher degree of protection for users of blood products. Some of the CDC's most formidable future chal- lenges lie in areas outside its traditional domain of c/~ntrolling and preventing infectious diseases. Specifi- cally, the agency has been delegated responsibility for dealing with the health-related aspects of diseases re- lated to the environment and of occupational salary and health. In the former area, the agency is workiug to implement the health-related applications of the Comprehensive Environmental Response, Compensa- tion and Liability Act of 1980, or as it has become more commonly known in the environmental sphere, the "Superfund." The "Superfund" law provides the federal govern- ment with the funds and authority to respond to actual and threatened spills or dumping of hazardous sub- stances and to make those responsible liable for the costs of cleaning up. The fund closes a gap in toxic- waste control by allowing the federal government to take immediate action against any spillgr dumping for which no responsible party can be found. Most recent- ly, the CDC has been working with the Environmental Protection Agency and other agencies in Times Beach, Mo., where residents have been threatened by dioxin- contaminated roads. Dioxin is one of the most danger- ous chemicals known to man. The CDC has also become the central government actor in another unfolding drama irlvolving Agent Or- ange, the dioxin-based herbicide used widely in Viet- nam. The CDC has signed an interagency agreement with the Veterans Administration (VA) to conduct an epidemiologic study to determine whether veterans of the Vietnam conflict suffered long-term adverse health effects from dioxins produced in the manufacture of herbicides. Dr. Vernon N. Houk, acting director of the CDC's Center for Environmental Health, s-ald in an interview that over a five-year period the agency would engage in "the largest epidemlologlc study ever under- taken," involving 30,000 veterans. The GDG's agree- ment with the VA calls for two separate but parallel studies. One study will compare the health of three groups of Vietnam veterans who differ in their pre- sumed level of exposure to Agent Orange. The second study will compare the health of a group of Vietnam veterans with that of a group of Vietnam-era veterans who did not serve in Vietnam. The VA has been widely criticized for dragging its feet in getting started on the study, which Congress mandated more than three years ago. One administra- tion representative, who asked not to be named, said the "mood" of the executive branch is "to press ahead on the study with a reputable agency." The CDC, he said, "will be lending the VA some of its white hat." Finally, the CDC also faces a substantial challenge in developing closer working relationships with the National Institute for Occupational Safety and Health (NIOSH), which has felt something like a forgotten stepchild since it was placed in the CDC in 1973. Rep. David R. Obey (D-Wis.), an influential legislator who is a member of the House panel that handles the CDC's annual appropriation, has sought--thus far unsuccessfully -- to transfer NIOSH to the NIH be- cause of a strongly held belief that the CDC has ne- glec~ted research dealing with occupational safety and health. Except for Obey, who is generally troubled by Foege's stewardship, the CDC and its director enjoy high standing on Capitol Hill. Foege is the only perma- nent director of a Department of Health and Human Services health agency who held his post under Presi- dent Carter and has remained under the Reagan ad- ministration. Despite the importance of the CDC's work in disease prevention and health promotion, until more private physicians emphasize the importance of these concepts in their encounters with patients, treat- ment will remain the overriding priority of the medical model, a priority that can be sustained only at a tre- mendous cost to society. REFERENCES I. Hamburg DA, Elliott GR, Patron DL. Health and behavior:, frontiers of research in the biobehavioral sciences. Washinglon, D.C.: National Academy Press, 1982. 2. Langmuir AD. The Epidemic Intelligence Service of the Cenler for Disease Control. Public Health Rep. 1980; 95:470-7. 3. B~-eslow L, Somers AR. The Lifetime Health-Monitoring Program: a practical approach to preventive medicine. N Eagl J Med. 1977; 296:601-8. 4. Califano JA.~r. Governlng America: an insider's report from the White House and the CabineL New York: Simon and Schuster, 19g1:179. 5. Idem. Governing America: an insider's r~port from the White Hous~ and fl~¢ Cabinet. New York: Simon and Schuster, 1981:174. T106971897