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The Disease Detective
An Interview With Dr. Jeffrey Koplan
By Daniel Berman |
Dr. Jeffrey Koplan was director of the Centers for Disease Control and Prevention (CDC) under Presidents Clinton and Bush, from 1998 until March 2002. Under his tenure, CDC played a critical role in containing and investigating the several anthrax attacks of late 2001. Dr. Koplan began his career in public health in the early 1970's as one of CDC's Epidemic Intelligence Service officers - the "disease detectives." He has been instrumental in the fight against a variety of serious health concerns including infectious diseases, cancer, tobacco, and other chronic illnesses, and he served as Assistant Surgeon General from 1989 to 1994. Dr. Koplan is an alumni fellow of the Yale Corporation and is currently the vice president of academic health affairs for the Woodruff Health Sciences Center at Emory University.
I recently spoke by telephone with Dr. Koplan about his views on some of the most important public health issues in America today.
Dan Berman: A New York Times article last week addressed a report by the Center for Strategic and International Studies on the unpreparedness of America for a biological attack. It cited a lack of coordination between agencies and laboratories, problems with information flow and established hierarchies of authority, unanswered legal questions, and unreadiness to deal with large-scale disease containment. What changes have been implemented since the anthrax scare in 2001?
Jeffrey Koplan: First, you need to understand that America was, and is, as well prepared as any country in the world. But it's not a question of the government being prepared just for bioterrorism. . . If you have a first rate, well-functioning public health system established, you're going to be in a position to deal with whatever comes up, whether it's an intentional attack or something completely different. If you have a poorly funded, badly organized system, you're going to have problems. It's not a quick fix. You need adequate staff, adequate funds, and they've got to be there for a truly modern public health system. Then whether it's West Nile or SARS or bioterror, you'll have the mechanisms in place to deal with them effectively.
DB: Many of the policies adopted since 2001 seem to have been directed outside of the United States - rooting out terrorism in Afghanistan, now of course the war in Iraq. Considering how easy it is for biological agents to be moved knowingly or even unwittingly on an airplane, are there weaknesses in the public health systems of other countries that you think pose a particular danger to the United States?
JK: We need a presence in every country, even ones that aren't our allies right now. I don't use those words lightly. I mean every country. Every country needs to be your friend in public health because you don't know where the next thing's going to come from. That includes North Korea, that includes Cuba. . . Any actions by a government that politicize public health, or by which the U.S. is perceived as acting unilaterally about public health, are dangerous.
DB: In the year between the SARS outbreak and the recent avian flu, especially considering the accusations of official cover-up and delay, have we seen China make changes in how it deals with public health?
JK: It shouldn't be a surprise to anyone that when you're struck by a catastrophic event, that's when you find out where your weak links are. They've done a lot to improve their laboratory work and their epidemiological capacity. . . One thing I can tell you definitely is that they reported more new cases of SARS after the initial round of infections, and they did it promptly. But in a country of that size, in a country where so much is closed, it's going to be a while until the culture changes - the political culture, and as a result the public health culture.
DB: Moving on, I read the 2001 Surgeon General's "Call to Action to Prevent and Decrease Overweight and Obesity." Clearly this was recognized as a serious problem at least several years ago. When did the gravity of the problem really dawn on us? Have we seen this coming for quite some time?
JK: It's been coming on steadily for some time now. I've been writing papers on the need for increased physical activity for the past twenty years. In 1999 I presented to Congress. . . I told them that we're getting little to no funding for it. If you look at the statistics of rates of the population who are obese, you see a steady, unrelenting increase in every city in the country. What remains almost shocking is that it doesn't seem to stop. It goes up again and again, in every state, in every socioeconomic group. It is the upsizing of America.
DB: With tobacco, it seems to me that one of the key elements in American society's turn against smoking was the anger and the betrayal felt by the American people when it came out that these companies for so many years had been, quite simply, blatantly lying to the public. And to the extent that they had lied under oath before Congress, criminally lying. So my question is, do you think that a movement against obesity. . . can really take shape without that kind of sensationalism, that criminal element, to give it a jump start?
JK: There are many parallels between tobacco and obesity. . . Up until the 1950's, people thought, "Oh well, it gives you a cough." Cigarette companies advertised that they had the healthiest product. They showed doctors smoking.
But most people who were against smoking were, of course, not smokers, and it was the smokers who were most likely to feel personally injured when it came out that these companies had lied. . . It was the reports about secondhand smoking that changed the social stigma of smoking, and that changed the societal norm. When people started to realize that smoking wasn't harmless to others, and in particular when people started to see all the harm being done to kids, that's what really changed things. And the same thing will happen with obesity.
DB: So what you're telling me is, it's not going to be those people who are suffering serious health consequences because of their obesity who will be responsible for changing the trend, but rather it'll be those people who are not obese?
JK: That's exactly what I'm telling you. It'll be the person sitting in economy who's pressed up against the wall of the plane. It'll be the person who sees his health insurance costs going up and up and up to cover the increasing costs to everybody of rampant obesity.
DB: There seems to have been quite a remarkable movement against transfats only last year - and I say this because usually you'll have a debate among the medical community, butter or margarine, and you'll hear it back and forth for ten years. But transfats became notorious almost overnight and Congress took action on labeling. What explains the intense reaction, and are there lessons that we can learn from that about how to change public opinion about what's healthy?
JK: It's not just that this product is good or this product is bad, you need to create a more informed consumer. . . People are going to go, "Don't mess with my chocolate. Don't mess with my steak. Don't tell me that butter's no good." You try to keep the public as up-to-date as you can; you tell them whenever new studies come out. The downside to that is when you have to change your advice, especially if it's the next year, you look like a fool. But for those of us in public health that's something we get used to. You tell them it's not just cholesterol, it's saturated fats. Then you learn there are transfats and you tell them about it. It's a little bit like learning a complex foreign language that never ends.
DB: We have an article in this issue about needle exchange programs for intravenous drug users and the importance of police cooperation in these sorts of programs if they're going to succeed. When you were directing CDC, were there any issues of public health policy that were particularly contentious, either under the Clinton administration or under Bush, that might not have received the attention in the U.S. media that you felt they deserved?
JK: All public health issues are politically contentious. When I started in public health thirty years ago, the political issues could be fairly well classified: there were environmental issues, and tobacco, and things relating to reproductive health. But over the past thirty years, everything has taken on a political dimension. You wouldn't think of an infectious disease outbreak as a political issue. But whether you have a Republican in office or a Democrat, someone's going to ask questions and someone takes the blame. . . For that myriad of health issues that are politically contentious, if you have a more conservative group in power, they'll start getting slugged by the liberals, and if you have a more liberal group in power, they'll start getting slugged by the conservatives.
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