Officials at the U.S. Centers for Disease Control and Prevention (CDC) were bewildered when Richard Horton, editor of The Lancet, on 11 February published criticisms of the institution's Center for Global Health that he received from an anonymous letter writer. But CDC kept mum. When Horton ran complaints made by two more unnamed critics of the CDC center on 3 March, CDC Director Thomas Frieden and the head of division under attack, Kevin De Cock, decided to take on the critics point by point, which they do in a rebuttal (PDF) that yesterday appeared online in The Lancet.
CDC formed the Center for Global Health 18 months ago to bring together five large programs working in this arena. In addition to HIV/AIDS—De Cock's specialty—the center has divisions that focus on parasitic disease and malaria, global disease detection and emergency response, health-systems strengthening, and global immunization. The center has a budget of more than $300 million, employs 1100 staff members, and has people on the ground in 55 countries.
The first letter writer urged that an "objective evaluation" of the program take place, asserting that the center needed a change of direction and "increasingly looks like a major missed opportunity." Excerpts from the next two letters, which appeared under the headline, "Is CDC a science-based organization," were harsher still, suggesting that a congressional investigation "might be in order." As Horton noted, the letters "raise questions about leadership, management of resources, proper use of the CDC's authority and power, and the scientific rigour of CDC research."
None of the complaints offer specific examples, and several of the harsher attacks are opinion that can neither be proved or disproved: staff morale is "quite low," there are "huge amounts of tension and confusion," "there is no strategic direction … other than spending monies at lightning speed," and employees have not spoken out about the waste "for fear of losing their jobs." But other broadsides are questions of fact. Contractors working overseas allegedly deliver "poor quality products and services thanks to minimal guidance and appropriate oversight." There supposedly is a "duplication of efforts," a rivalry between CDC and the U.S. Agency for International Development that undermine in-country programs, an "inappropriate" use of funds. "We were surprised and perplexed," De Cock says, adding that "no evidence for the assertions being made was presented."
The CDC's rebuttal, measured in tone, recounts the center's accomplishments in training field epidemiologists, working with ministries of health in many countries, and helping countries combat health emergencies. The center has aided efforts to combat HIV/ADS, malaria, cholera, cryptic liver disease, plague, measles, lymphatic filarisis, and polio. Frieden and De Cock also note that CDC last year began a review of the program.
De Cock accepts that there's room for improvement in his organization. "We don't claim to be a perfect organization," he says. And he acknowledges that tensions exist with other U.S. government organizations. "It's no secret that intragovernmental collaboration across different agencies can be challenging," he says.
The waste allegations, he asserts, are baseless. "If you do global health, you have to travel," he says. "People fly economy class unless they have a health reason." He characterizes the assertion that an evaluation of the center is "long overdue" as absurd. "Long overdue?" he asks. "When should this evaluation have been done? We're 18 months old."
Horton says the letters came from CDC staffers who raised their concerns internally but were ignored. "They have felt that their only recourse has been to contact us," says Horton. "It seems to us that it is the responsibility of CDC to listen to the questions senior staff raise and to address those questions appropriately. According to our correspondents, that has not been done in this case."
De Cock strongly rejects the idea that there's a culture of repression and intolerance for dissent. "We're committed as a scientific agency to open debate," he said. "I'm committed to that." From his perspective, this is a "golden moment" in CDC's global health efforts as it's "a core priority for the agency."