Front & Center

By Terri L. Rutter

For 23 straight years, HSPH graduates manned the helm of the nations's premier public health agency.

Like the man who would be king, James Goddard, M.P.H.’55, hoped one day to be surgeon general. But he needed a high-powered administration job first to strengthen his resume. As the nation’s first Civil Air Surgeon, he was responsible for the medical licensing of some 300,000 pilots a year as well as the investigation of human factors errors in major aircraft accidents. After clashing with the faa’s top administrator, Goddard was summoned by Surgeon General Luther Terry, who gave him three choices for a placement that would earn him the star he needed to someday put him in line for Terry’s job. His last choice was director of the Communicable Disease Center (CDC) in Atlanta, Georgia. And that’s where Terry sent him. At age 39, this brash midwesterner was the youngest person to ever hold the job.

When Goddard arrived at CDC headquarters at 1600 Clifton Road in Atlanta, Georgia, in 1962, the 16-year-old agency had already gained a reputation for the skill with which its Epidemic Intelligence Service (EIS) officers, under the direction of hard-edged Alexander Langmuir, tracked down the cause of outbreaks of infectious disease. The eis had cut its teeth during the early years of the Cold War by preparing for the possibility of biological warfare. The anticipated attack never happened, but eis officers learned much about how to respond to and solve infectious disease outbreaks around the country. In 1955, EIS officers tracked a polio outbreak to a vaccine produced at the Cutter Laboratories in California that had been contaminated with live virus. The CDC’s reputation for expert epidemiology was reinforced two years later when the agency joined an international effort to trace the source of a deadly outbreak of Asian flu.

"Our epidemiology was the best in the world," says Goddard today.

Established in 1946, the CDC was a direct descendant of the U.S. Public Health Service’s Malaria Control in War Areas (MWRA) program. MWRA was created during World War II to protect American troops from the mosquito-borne disease malaria, which was endemic in the southern U.S. states where some 600 military bases were located. Under the direction of its intrepid leader, Joseph Mountin, MWRA quickly brought the malaria threat under control by digging drainage ditches and spraying generously with the larvicide DDT. By 1943, the anopheline mosquito that carries malaria had virtually disappeared from the United States. Encouraged by this success, Mountin expanded MWRA’s scope to include battling the louse-borne disease typhus and the tropical diseases brought home by servicemen returning from the war. After the war, Mountin argued successfully for the creation of a federal agency to monitor and control infectious disease outbreaks nationwide. Congress responded by creating the CDC.

Veterinarian James Steele, M.P.H.’42, went to the CDC during its first year of operation, as director of the agency’s Veterinary Public Health Division. "It was the first of its kind," says Steele of the division, which investigated the transmission of animal diseases to human beings, including rabies, salmonella and the bird-borne disease psittacosis. Steele’s division served as the model for similar efforts at the World Health Organization and the Pan American Health Organization.

In the 50 years since its founding, the CDC has grown many times over, in terms of budget, staff, and complexity. What began as a small group of mostly engineers and entomologists has expanded into a complex army of nurses, epidemiologists, biologists, physicians, veterinarians, and behavioral scientists, among others. The CDC has become the world authority on communicable disease–sending teams of eis microbe hunters around the globe, usually within a day’s notice of an outbreak. With the who, the CDC was a major player in the eradication of one deadly disease–smallpox–and is participating in the strategic planning for the eradication of two others: polio and Guinea worm disease. In recent years, the CDC has broadened its focus to include chronic diseases and injury control. In 1992, CDC added the word "prevention" to its name to reflect this broader focus.

"The CDC is one of the most exciting places that anyone can work," says William Foege, M.P.H.’65, who directed the organization from 1977 to 1983. "People could do things there that they could never do any place else."

Foege’s tenure at CDC falls roughly in the middle of a continuous, 23-year stretch in which graduates of the Harvard School of Public Health held the post of director. Beginning with Goddard and continuing through Donald Hopkins, M.P.H.’70, who served as acting director in 1985, the string of alumni directors includes David Sencer, M.P.H.’58, Foege, and James Mason, D.P.H.’67. Much of the CDC’s growth, and some of its greatest successes, can be traced through the leadership of these five HSPH graduates–the ones Foege calls the "true believers."

Goddard broadened the vision for the CDC," says Steele of the man who began the legacy. "He was the watchdog for new things on the horizon."

Among other achievements, Goddard almost single-handedly introduced the CDC to the age of electronic computing. The IBM 610 that Goddard secured for the agency occupied a room 18 feet long and 20 feet wide–a true dinosaur compared to modern computers. The EIS officers "grumbled and grumbled" as they were sent to the IBM training courses to learn the language of entering data and outputting results on multivariate outcomes, says Goddard. A year later, however, they were as enthusiastic about the emerging technology as he was.

Goddard also enlarged the agency’s Medical Audiovisual Branch, which produced hundreds of training films for state health departments and public health laboratories and produced informational literature and films for the public, including adult comic books about venereal disease prevention. In her history of the CDC, Sentinel for Health, Elizabeth W. Etheridge illustrates the bold independence for which Goddard was known.

Feeling frustrated at how long he had to wait for clearance from Washington for materials produced by the CDC, Goddard asked an assistant to gather and take a picture of all the videos, books, brochures, and other materials produced in a single year; the collected materials covered a long table. He had the picture enlarged to poster size and presented it at the next meeting. When his superiors recognized the amount of time required to review each piece, they resigned their stance on the subject, and Goddard never had to wait for clearance again.

Goddard was also a friendly, easygoing man from Ohio who spent every Friday roaming the halls, sticking his head into laboratories and offices just to say hello. He also apparently played a mean game of bridge in the dining room during lunchtimes.

In 1966, Goddard left the CDC–"the best assignment I had in my career in public health service" he says–to serve as commissioner of the U.S. Food and Drug Administration. He left the director’s chair open to the man he had chosen to be his deputy, fellow HSPH graduate David Sencer, M.P.H.’58. Sencer was "the brightest man I’ve ever worked with," says Goddard, adding that Sencer wanted the head position at the CDC"so much he could taste it."

In Sentinel for Health, Etheridge notes that the hallmark of David Sencer’s 11-year reign as head of the CDC was growth. Sencer took in federal offices whose funds were being cut–such as the Office of Pesticides and the Foreign Quarantine Office–and reorganized them by cutting inefficient and wasteful procedures and making changes in redundant staffing.

"Sencer was an organizing, implementing kind of person," says James Curran, M.P.H.’74, who went to the CDC` in 1971 as part of the Sexually Transmitted Disease Division.

Sencer was also known for his amazing capacity to remember details and his thorough knowledge of the agency. "That guy knew everything there was to know about the CDC," says Donald Hopkins. "He knew so many people by name; he has a phenomenal memory."

"When he moved to the big corner office on the second floor of 1600 Clifton Road, the man and the institution were fortuitously matched at a time when it was possible to get something done," writes Etheridge.

In 1966, Sencer’s first year as director, the CDC and who launched the global Smallpox Eradication Campaign. Four years later, Sencer put fellow HSPH alumnus William Foege in charge of the campaign. Foege would eventually succeed Sencer in 1977, the same year the last case of small pox was registered.

During Sencer’s watch, the CDC also implemented the nation’s first successful family planning research project, which included the surveillance of birth defects. This eventually grew into the Birth Defects Monitoring Program, which garnered support from the March of Dimes. Sencer also scanned the U.S. Public Health Service and decided that sectors such as the National Clearinghouse for Smoking and Health, (which insiders called the "Smokehouse") and the National Institute of Occupational Health and Safety might be more appropriately administered by the CDC. Both were primarily concerned with prevention and, says Sencer, "the same sorts of skills used in communicable disease control" could be applied to monitor the health effects of tobacco and workplace safety issues. Thus in 1972, Sencer says he "waged a little campaign" and successfully acquired the two offices.

"Sencer had a real grasp of the important public health issues of the time and how they should be dealt with," says Curran.

Although Sencer was widely considered "a leader’s leader," his tenure ended with controversy, which eventually led to his resignation.

In January 1976, four isolates of what turned out to be swine flu–the killer of some 20 million people during a worldwide epidemic in 1918–were discovered among soldiers stationed at Fort Dix, New Jersey. One soldier died and 500 others were believed to have been exposed. When word of the outbreak reached the CDC, Sencer called the first of many high-level meetings; all present agreed something had to be done.

Sencer presented a memo to the Ford administration in which he outlined four options for dealing with the potential threat of swine flu: option four, calling for the vaccination of the entire population in time to avert another potentially deadly epidemic of swine flu, was the one he recommended. He gained nearly unanimous consensus from his colleagues at the CDC, including the Advisory Committee of Immunization Practices and the Public Health Service. The vaccine champions themselves, Jonas Salk and Albert Sabin, conferred with President Ford and agreed that a widescale vaccination effort was in order.

On October 1, 1976, the first swine flu vaccination shots were given. On December 16, Sencer announced the swine flu vaccination program was being suspended following 54 reported cases of Guillain-Barré syndrome, believed to somehow be linked to the vaccine. Two weeks later, Sencer was asked to resign. He also took the brunt of the criticism. "David was the fall-guy on swine flu," says Goddard today. "He got a bum rap."

"I would say over and over again, this was the right thing to do," says Sencer in a video tape produced in 1983 by the CDC, part of an oral history of the agency.

Critics pointed to Sencer’s memo as the incendiary piece of paper that sparked the whole vaccination effort. In the CDC video, Sencer says all he did was present the facts in the name of the public interest: "We didn’t pull out people lying in the streets and tear-jerking things. We tried to present [the situation] as accurately as we could and say that this was good preventive medicine, and if you believe in good preventive medicine, you sell it."

In his introduction to The Swine Flu Affair: Decision-Making on a Slippery Disease by Richard Neustadt and Harvey Fineberg, Joseph A. Califano points to the good that was accomplished by the swine flu affair, namely the huge number of people vaccinated, the development of a successful influenza surveillance program, and the ability of that system to track down the negative side-effect of Guillain-Barré. "In these terms, it may go down as a qualified success," wrote Califano, who was then hew secretary and who commissioned Neustadt and Fineberg to write the book so that the administration could understand the lessons to be learned from it.

The year William Foege assumed the directorship of the CDC, the last case of smallpox had been eradicated from the world. He had been anticipating and planning for this event since he was a student at the School of Public Health. "It’s one of those things that is not just a once in a lifetime opportunity," he says, "but it has to be done once in the entire history of the world." And, he adds, "its benefits accrue forever."

Foege’s involvement in the eradication of smallpox began in a missionary medical center in Nigeria, where he helped devise the "search and containment" strategy that proved so essential to the program’s success. Instead of vaccinating everybody in the world, as was the original plan, limited stocks of vaccine were used to inoculate people living in villages already experiencing a smallpox outbreak, as well as the entire communities of a few surrounding villages. The system was efficient, but most importantly, it was also effective.

In 1967 Nigeria’s six years of post-colonial turmoil finally erupted into civil war, and Foege was evacuated. He returned to the CDC, where in 1962 he began a two-year stint as an EIS officer. When he came back in 1967, he went straight to the Smallpox Eradication/Measles Control Program and in 1970, Sencer named him director of the program. Six years later, Foege replaced Sencer as CDC director.

During Foege’s first year as CDC director, he chose an ambitious project: identify the leading causes of morbidity and mortality in the country and devise means of prevention. He organized what he called the "Red Book Committee," which included, among others James Mason, who would succeed Foege as CDC director. What they found was that injury, including everything from automobile accidents to homicide, was the leading causes of premature morbidity and mortality. The solution, says Foege, was obvious: prevention.

Foege called for the CDC to become the "conscience for prevention," and he championed the application of epidemiology to study injury. But he faced strong opposition, particularly from within the department, where it was believed that injury was a problem for law enforcement, not for public health. Publication of the 1983 Institute of Medicine report "Injury in America: A Continuing Public Health Problem", in which Foege played a key role, began to change minds. Two years later, the CDC created an injury epidemiology and control division, and in 1993, the National Center for Injury Prevention and Control was developed, thus lending the same legitimacy to injury as communicable disease.

"Injury in America really set the stage for the development of injury control as a scientific field," says Mark Rosenberg, director of the CDC’s National Center for Injury Prevention and Control. Rosenberg credits Foege with unifying the various government agencies into one central agency that would address all phases of injury: prevention, as well as the acute care and rehabilitation of injured people. "He helped to clarify the vision, and he continues to play a critical role in guiding and inspiring workers in this field around the world."

On June 5, 1981, two years before Foege left CDC to go to the Carter Center, where he would eventually be named executive director, a report that is now known as "Document Zero" appeared in Morbidity and Mortality Weekly Report, the CDC’s digest of disease outbreaks and trends. Simply titled "Pneumocystis Pneumonia–Los Angeles" this brief article described the deaths of five homosexual men from a rare pneumonia found predominantly in people whose immune systems were severely compromised.

"No one had any idea of how big this problem was going to be," says Foege. It would take two more years for this problem to be given a name–acquired immune deficiency syndrome, AIDS–by which time it was well on its way to taking an enormous international toll on human life. For many at the CDC, including Foege’s successor, Mason, it would become an all-consuming interest.

Curran, who would become head of the CDC’s AIDS program, said each director lent his individual skills and strengths to the AIDS issue. "Foege tried to get people to take AIDS seriously," he says. "He was supportive of us at a time when the government was trying to cut funding. When we needed resources, he would find additional resources," says Curran.

When Mason came on board, AIDS had been diagnosed in recipients of blood transfusions and hemophiliacs, so there was much more public attention being given to it. "Mason," says Curran, "took responsibility for managing all the attention and making sure people had the right concerns."

"What was hidden was so much greater than we could see," says Mason about the emerging AIDS pandemic that was taking so much of the CDC’s attention when he assumed the directorship in 1983. "And the CDC was more aware of this than others early in the epidemic."

That same year, the CDC’s National AIDS Hotline was established to handle the growing number of calls for information. Meanwhile reports of heterosexual women who had contracted AIDS from male partners exploded the belief that the disease was strictly confined to homosexual men. Like his predecessor, Mason spent much of his time fighting Congress for more AIDS funding–unfortunately, he says, much of it came from the CDC’s infectious disease budget. "It had to come from somewhere; we couldn’t appropriate it fast enough," he says. He also became involved in writing public policy on AIDS.

Directing the CDC was an event that Mason admits was "not even in his wildest dreams" when he was a student at the School, where he received his D.P.H. in 1967. In 1958 Mason faced two choices to fulfill his military obligation: the navy or the public health service. Just as he was about to sign on the dotted line for the former, a position opened up at the CDC. He took it.

"It was a fantastic two-year period," says Mason about his stint in the EIS, where he rose to the position of chief. "I felt guilty calling it military service."

In 1962 Mason came to the School as part of the CDC’s career development program. He says he was so impressed by Professor of Tropical Public Health Tom Weller and his department that when Weller asked him if he was interested in working towards a doctoral degree in tropical public health, Mason didn’t hesitate. As a student, he co-authored a paper with Weller and Professor Andrew Spielman describing a technique for direct monitoring of natural transmission of mosquito-borne viruses. Over the next five years, Mason shuttled back and forth between the CDC, where he served in different administrative capacities, and the School.

Beginning in 1968, mason, who is a Mormon, split his time between the CDC and administrative and clinical duties within the church’s health care delivery system–a job he kept, in one capacity or another for the next two decades. Today, Mason oversees the church’s humanitarian and missionary work throughout sub-Saharan Africa. His organization has bored water holes in the Congo, organized the distribution of clothing throughout the region, and provided food during civil uprisings.

"We’re helping people become self-reliant," says Mason.

When asked why he thought Harvard trained so many directors, Mason says that he and his predecessors share a common thread, which originated at the School: "All of us are really committed to excellence."

They also all believe in the importance of being guided by an organized database, and share a commitment to prevention. "We couldn’t allow the CDC to get caught up in the treatment paradigm."

While Mason says he supported Foege’s drive to move the CDC towards understanding the burden of injury and chronic disease, he is concerned that those pursuits not be followed at the expense of the surveillance and prevention of infectious disease. "The CDC’s future is to maintain its grip on communicable disease," says Mason. "You can’t let those go because they’re always waiting to bite you."

Hopkins, the last in the line of alumni directors, directed the Smallpox Eradication/Measles Control Program of the U.S. Public Health Service in Sierra Leone, West Africa from 1967 to 1969, and was a consultant on smallpox eradication programs in Ethiopia and India. Although he went to school at Morehouse College, a black private college located only a few miles from CDC headquarters, Hopkins says he had only "an inkling" of what the CDC was all about before joining the smallpox effort. In 1972, he came to the CDC as a medical officer hoping to work on malaria in Ethiopia. When President Nixon reduced funding for public health work overseas, Hopkins left the CDC for a three-year stint as an assistant professor of tropical public health at the School. He was invited back to the CDC in 1977 by Foege as assistant director of operations. Three years later he was named assistant director for international health, and in 1984, he became Mason’s deputy director. For most of 1985, while Mason served as acting assistant secretary for health in the Department of Health and Human Services, Hopkins assumed the responsibilities of acting director. That year, says Hopkins, was "the grand year of AIDS." On October 2, Rock Hudson died of the disease. Also that year, the serological test for HIV infection was developed and the CDC cosponsored the first International Conference on AIDS.

"Two thirds of my time as acting director was spent on AIDS," says Hopkins.

Hopkins stayed at the CDC for two more years before leaving for the Carter Center, where he returned to the work he loves–"real" tropical public health, specifically battling Guinea worm disease"–work for which he received a prestigious MacArthur Fellowship in 1995. When Hopkins retires at some point and is "sitting in a rocking chair somewhere" he says he’ll reflect with great satisfaction on his work to eradicate two devastating diseases: smallpox and guinea worm disease. As senior consultant since 1987 for the Global 2000 project at the Carter Center, Hopkins is in charge of the guinea worm eradication initiative, which is directly assisting programs in Ethiopia, Ghana, Mali, Niger, Nigeria, Sudan, and Uganda.

In June it was announced that yet another HSPH graduate, Jeffrey P. Koplan, M.P.H.’ 78, will take the helm at CDC. A former assistant surgeon general and the first director of the CDC’s National Center for Chronic Disease Prevention and Health Promotion, Koplan began his career as a foot soldier in the Center’s Epidemic Intelligence Service.

Even if Koplan’s appointment doesn’t initiate another 23-year stretch of Harvard leadership at the CDC, it does reaffirm the School’s continued relevance as a cultivator of professionals who consistently rise to the top of the field.

"Harvard has always been recognized as one of the premier schools of public health in the country," says Curran. In each of the leaders he has worked under–Sencer, Foege, and Mason–he recognizes a consistent quality: "a broad perspective of public health problems throughout the world and an ability to see public health problems as world-wide problems."

Perhaps this consciousness was bred at the School, or just as likely, these three and those who have preceded and succeeded them, came to the School because they had that feeling already.

"It’s not unique to the CDC or HSPH," says Foege. "There are a large group of people who see public health as more than a vocation; it is a consuming interest of life.

"I used to walk down the halls of the CDC and see the campus activists of the ’60s," he continues. "People who were concerned about social justice were there. That’s the base philosophy of public health."