Julie Louise Gerberding became the Director of the US Centers for Disease Control and Prevention (CDC), and the Administrator of the Agency for Toxic Substances and Disease Registry on July 3, 2003.
In 1977, she earned a BA magna cum laude in chemistry and biology followed by an MD at the Case Western Reserve University in Cleveland, Ohio in 1981. Following an internship and residency at the University of California San Francisco (UCSF) she served as Chief Medical Resident before completing her fellowship in clinical pharmacology and infectious diseases at UCSF in 1988. In 1990, she earned an MPH degree at the University of California, Berkeley. While on the faculty at UCSF, she was Director of the Prevention Epicenter, a multidisciplinary service, teaching, and research programme that focused on preventing infections in patients and their health care providers. In 1998 she joined the CDC as Director of the Division of Healthcare Quality Promotion, National Centers for Infectious Diseases (NCID), where she developed CDC's patient safety initiatives and other programmes to prevent infections, antimicrobial resistance, and medical errors in health care settings. Before becoming CDC Director, Gerberding was Acting Deputy Director of the NICD, where she played an important part in leading the CDC's response to the anthrax bioterroism events of 2001.
Gerberding is also an Associate Clinical Professor of Medicine (Infectious Diseases) at Emory University, and an Associate Professor of Medicine at UCSF. She is a member of a number of notable societies, and is a fellow of the Infectious Diseases Society of America. Gerberding served as a member of NICD's Board of Scientific Counsellors, the CDC HIV Advisory Committee, and the Scientific Programme Committee of the National Conference on Human Retroviruses. She has also been a consultant to the National Institutes of Health, the American Medical Association, CDC, the Occupational Safety and Health Administration, the National AIDS Commission, the Congressional Office of Technology Assessment, and the WHO.
Her editorial activities are extensive. As well as sitting on the editorial boards of a number of reputable journals, she has served as a peer-reviewer, and has authored or co-authored more than 140 publications and text book chapters, as well as contributing to a number of guidelines and policies relevant to HIV prevention, post-exposure prophylaxis, management of infected health-care personnel, and health-care-associated infection prevention and control.
TLID: Having had an ambition to be a doctor at an early age, did you have any idea where your career was going to lead?
JLG: No, I had no idea that I would be in public health or at the CDC, but I did recognise at a pretty early age that medicine was my passion. No matter what I was doing, I would always in my heart still be a clinician.
TLID: What drew you into infectious diseases and epidemiology?
JLG: Actually, it was very fortuitous. When I began my internship at UCSF, the very first AIDS patients were being admitted to the hospital, and so my training was very much integrated with the evolution of the AIDS epidemic in San Francisco at the time. I don't think that anyone who worked there could have developed as a young professional without being involved or being invested in the tragedy that was unfolding all around us, not just in our patients, but in our neighbourhood, and among our colleagues and friends. So, my infectious disease interest evolved out of my compassion and passion for the toll that HIV infection was taking, and the world I was really developing my professional horizons in.
TLID: Was making the transition into public health a natural progression for you?
JLG: My early academic career was based at the San Francisco General Hospital within the University. It is an urban hospital so the patients there have all the problems that public health is supposed to address. Early on I don't think I really ever recognised the dichotomy between health care and public health because in that kind of a melting pot, it is all linked together. Sometimes it surprises me that people see them as such dichotomous career paths, such dichotomous aspects of health promotion and health protection.
For 2 weeks every year, I go back to the wards of San Francisco General where I take care of patients. I went back there last year, and kept an inventory of the problems that my patients had. I had patients with cancers that were diagnosed very late in the course of the disease that should have been detected earlier, or prevented through risk-factor reduction. I saw AIDS patients who were diagnosed many years after infection so were unable to take advantage of the prevention strategies and antiretroviral therapy. I saw people with alchoholism, and tobacco complications like emphysema. I am used to taking care of a hospital full of patients who had all of the health problems that we at the CDC are passionate about preventing in the first place
TLID: You are the first female director in the CDC's 57-year history. Why do you think it has taken so long for this to happen?
JLG: I don't have an answer for that. I can say that the CDC evolved out of the military, so it started out as an organisation that was almost entirely composed of men. And as leaders evolved through the history of the CDC, it took many years of progress before women achieved leadership positions within the agency. A pipeline is everything, sometimes it just takes a while for the pipeline to open up to get people in the very top positions.
TLID: In the past few years infectious diseases have never really left the spotlight. Since 1999 we have had West Nile virus, the anthrax attacks, severe acute respiratory syndrome (SARS), monkeypox in the USA, and now bovine spongiform encephalopathy (BSE). How hard has it been for the CDC to get the balance right between surveillance and prevention of everyday infectious diseases, and defending against a bioterroist attack, or the threat of an emerging infectious disease?
JLG: The capabilities that we as an agency need in order to respond to emerging terrorism threats are the same capabilities that we need to respond to any other infectious disease problem. The response requires globalisation, and incredible connectivity across the whole health system, both domestically and internationally. Today, there is particular emphasis on the connectivity with the veterinarian communities since 11 out of the last 12 emerging infections that we have been dealing with have come from the animal kingdom. And then there is a requirement for speed. When you create an organisation that is global in focus, highly connected and integrated with other necessary sectors, and fast, those capabilities serve you very well for terrorism as well as for any emerging infectious disease threat.
TLID: Do you think there has been a delay in fostering a stronger interaction between human health and animal health?
JLG: We are very cognisant of the incredible need to integrate with the veterinarian community in all levels of health. Examples include the avian influenza problem, monkeypox, and BSE. Wherever you look animals are more and more involved in human health. One of the many things we are doing at the CDC to deal with this issue, is to appoint a special adviser to our NCID. We have created a new position, for a veterinarian to advise the Director of the centre. We are already linking our surveillance systems together. It started back in food safety but now increasingly we have to be able to share information at all levels of the interaction. The CDC has many veterinarians, but in the past we have tended to use them primarily as people who are responsible for the health and safety of the animals that we work with. And now we recognise that the veterinarian community here is essential for understanding the human-animal interface, and we are developing a number of new programmes to build on those needs.
TLID: Is there a danger that the public health system (in the USA at least) is nearing burnout with the routine surveillance and the additional support and resources required to respond 24/7 to a new emerging disease. Do you think a new mindset in public health is needed?
JLG: Absolutely not, these are challenging times, no doubt about it. But what we are learning to do organisationally, and certainly what the Secretary of Health and Human Services Tommy Thomson is doing in the USA, is to move into the new normal. We can't look back and say, “I wish we could go back to the good old days when this problem did not emerge this fast, or have these kind of far-reaching implications”. Because the good old days are over. This is the new normal, and our agency and the public health agencies across the USA are really adjusting to that. More than $2 billion dollars has been put out in the last 2 years, primarily for preparedness in the context of terrorism. This investment has led to the expansion of people's capabilities to respond to other health events. One of the most rewarding things that has happened to me in the past year is what I learned when I visited various health departments. For example, I went to Beaver Valley, Pensylvania, where there had been an outbreak of hepatitis A in the community Lancet Infect Dis 2003; 4: 7. People there said, “thank goodness for the preparedness investment” because we were able to communicate rapidly with all the people in the system who needed the information, and we were able to distribute vaccine to the population at risk much faster than we ever would have been able to do if we hadn't had the terrorism preparedness investment. I think the new normal and investments are helping our overall capacity to deal with emerging health threats even at the very local level.
I think it is challenging and whenever people are faced with consecutive or contemporaneous challenges, there is certainly stress involved. What we at the CDC are trying to do is to provide the framework for adaptation and overall improvement, and if I can harken back to the connectivity issue, the speed aspect, globalisation, and the recognition that SARS may be in Hong Kong today, it could be in Toronto tomorrow, and in the USA the next day. We just have a different world that we have to come to grips with. But once people make that transition and begin to plan and organise around it, we really do evolve around it very quickly. I don't want to minimise the challenge but I think we are up to it.
TLID: What have been your biggest achievements in medicine and public health, and the most memorable moments for you in your career so far?
JLG: My most memorable moments, and those that are the most valuable to me personally, are not visible to the public. They are the kind of things that happen at the bedside, the human connections that you make with individual patients. Recently when I was back on the wards of San Francisco General I had a patient who was homeless and had been beaten. He had a staphylococcal infection in his chest wall that was very painful. Someone from the press asked him what it was like to have the director of the CDC as a doctor caring for him. The patient replied, “what is CDC?” And then they talked a little bit, and the patient said “oh monkeypox”. It turned out that the patient was from Ghana and although he was homeless, he read the New York Times, and he knew that monkeypox had been imported from Gambian rats that had been exported from Ghana. He said it was a small world. And that theme, “a small world” is what I have been using as a metaphor for globalisation, connectivity, and the speed framework for the new normal. But going back to that patient, he brought that metaphor down to a very person-to-person level. When I went back to see the patient later, he was happy to know that I had work outside patient care at San Francisco General Hospital, but he also expressed how incredibly grateful he was for the care he was receiving and the quality of the interaction. To me that is ultimately what being a clinician is all about. Whether you are working on rules to prevent the importation of monkeypox, or you are at the bedside of somebody who is suffering from the problem, it is the whole spectrum; that's what I love about it. I have the privilege of seeing health from the entire spectrum of health promotion and disease care. I have the heart of a clinician. Even when I am talking about SARS, or prevention, or the virology of influenza, I still always in my mind see the people who are affected by exposure to the illness, and so I try and bring that perspective, the humanitarian perspective, no matter what I am doing.
TLID: We have seen an early onset of the influenza season. And now an initial study from the CDC has shown that the 2003–2004 influenza vaccine was largely ineffective against influenza or influenza-like illness. Can you comment on the study, what can we draw from it in relation to the current season, and what future studies are planned?
JLG: Unfortunately we can't draw anything from that very preliminary study. It did not really say anything about the efficacy of the vaccine against influenza. It only said that in the population of people investigated there didn't seem to be an impact on influenza-like illness. But we know that most of the influenza-like illness was not caused by influenza, so naturally the vaccine isn't going to be very effective in that context. So we have a lot of work to do before we can really estimate the efficacy of this year's vaccine against influenza per se. We carried out the study midway through the epidemic just to give us an indication of what might be happening. If most of the influenza-like illness had been due to influenza A, we might have had enough power in that particular study to make the evaluation, but there is no way of knowing that when you start. We have to do more work and we have other studies in progress that will be more reliable in helping us get that information.
TLID: The USA has had its first case of BSE. One criticism was that the US Department of Agriculture was not sufficiently open or forthcoming about BSE; and indeed lack of openness was specifically criticised by the UK's BSE enquiry. Do you think the US will have to relearn the lessons from the European experience?
JLG: The USA has been working very closely with the European Community since the problem first emerged there. And we have been building our BSE programme with the knowledge gained from the European experience. So this is certainly not something just starting now. The US experts who have been looking at ways to reduce the risk in the USA are well aware of the European experience, and drew upon that data as well as the input from many experts in Europe. So this is an on-going collaboration, and again an evolving problem. We all learn as we go, and I am sure that is the model we all want to continue to use to address this problem.
TLID: Monkeypox was introduced into the USA through importation for the pet trade of live animals, and there is a risk that new diseases could be imported in the same way. Does the CDC intend to continue, or even broaden, the current ban on trade in certain live animals?
JLG: We want to frame our decisions about importation on the best available science. What we want is evidence-based recommendations, and in the case of monkeypox importation bans, we used the best available science. We had obvious documentation of a health threat, we knew the animal species that were involved or could be involved. It did seem like common sense to restrict importation until such time when we have better means of control. Likewise we made the decision to restrict the importation of civet cats, not because we have proved that civet cats are the source of SARS, but because there is compelling information that the viruses in civet cats are very similar to the human SARS coronavirus, and it just made sense to try and reduce the possible importation of viruses via civet cats. So we have to balance science in what we know about the reservoirs of important human diseases, with common sense. And at the same time, we recognise that there are people who for whatever reason desire these animals to be imported, so there's a need to have the least amount of restrictions that we can without jeopardising human health.
TLID: Have there been any changes or events in the infectious-disease specialty that you thought you would never live to see?
JLG: AIDS was such a paradigm shift because before the recognition of this whole new global epidemic, many credible experts around the world were signalling the end of the era of infectious diseases. They really believed that with antibiotics and vaccines we could shut the book on infectious diseases. In fact many credible experts were suggesting that it not even be a career path because there was no future in it. But guess what, new diseases can emerge. They can emerge in very profound ways. And I think unanticipated by me at that point in my career was the recognition that this is another part of the new normal. Diseases are emerging and spreading and they are coming at us fast and furious. And certainly I don't think anyone anticipated what the world of emerging infections would really be all about.
TLID: Work aside, how do you disengage yourself from your daily role; how do you unwind at the end of the day?
JLG: There are two things that I can definitely count on for relaxation. One is to dive, I love scuba diving. There is something about being suspended in the water, the total relaxation and quiet that is absolutely unsurpassed. But unfortunately there is no ocean in Atlanta, so I don't get to do that as often I did on the west coast. So, what I do rely on here on a more regular basis is gardening. I have a very large garden. I have learned to garden since being at the CDC, so I am kind of a novice, but I love it. There is something so rewarding about putting a tiny little plant in the ground, and by the end of the summer you have a glorious blossoming garden. It is a miracle, and reminds me how growth, serenity, and great beauty can be achieved all at once.