Dr. Richard E. Besser, on April 27.
Dr. Richard Besser isn't one for easing into a new job. Before becoming the acting director-general of the Centers for Disease Control and Prevention (CDC), the trained pediatrician was the head of the CDC's emergency response office, a position he took in 2005, hours before Hurricane Katrina hit. Now, just a few months after being named the CDC's interim head — in lieu of a political appointment from President Barack Obama — Besser has been thrust into the role of the government's public health commander-in-chief, guiding the agency through what could be the first new influenza pandemic in decades. That has meant long days at CDC headquarters in Atlanta and lots of time in front of TV cameras, explaining to a worried country why hand-washing is so very important. He spoke with TIME's Bryan Walsh about deciding whether to make an H1N1 flu vaccine, the lessons from Katrina and how to straddle the line between reassurance and alarm.
TIME: The CDC and federal government have been very careful to try to protect public health and manage concern without hyperstimulating fear. How do you strike that balance?
Besser: It's critically important that people trust you during a public health crisis. And to engender that trust, people have to feel that you're going to be open and honest and tell them what you know. And, so, our approach here has been to try and do that, do it on a regular basis, tell people what you know, what you don't know. We want to let people make some decisions for themselves with that information. So we've tried to be out with the media as much as possible, to be able to share the information. And I think it's been an effective approach because people are turning to us for information. We have more than 87 million hits on our website. I think we were number 17 on YouTube over the weekend with over a million views and we're tweeting. I think that's it — I always get that term wrong. I think there is, every few seconds, a tweet on this topic. It's clear that, if you can give people something to do, something real to do that could help improve their health and reduce their risk, that's very empowering during a difficult situation. (See pictures as the swine flu hits Mexico.)
TIME: Talking about the public response, people are wondering why the U.S. has not sealed off the border, or attempted to close it, with Mexico. I know the CDC and the government have been against that. Why do you think it's a bad idea?
Besser: That's been a question that has come up many times. The first definitive case of H1N1 was not diagnosed in Mexico, but in San Diego. So at the time that the outbreak was first diagnosed, it was already in the U.S. Our pandemic planning, overarching planning that was done largely around avian flu, had approached or looked at [an outbreak that] would originate off our shores. Then you could send in a team and attempt to contain it, if it were in a small area. Once it moved out of a small area, it's impossible to contain influenza. Those factors together really push against a border strategy.
In addition to that, there is modeling data that shows even if an outbreak starts far away, if it's not contained, a border strategy will gain you 10 weeks, at most, in terms of distributing and standing surveillance. Once it's inside your borders, that's not effective — by the time you know it's there, it's likely to be in many places. So all along, I've been trying to get a message out that the virus is likely all over. We're finding it in many parts of the country.
Another overarching strategy is that we want to direct our resources toward interventions that are likely to influence people's health. A border strategy doesn't meet that criterion by any means.
TIME: Even though the first case we saw was in the U.S., H1N1 really got out of control in Mexico. Does this indicate that when emerging infections are concerned, the U.S. is only as safe as the help we give to other countries?
Besser: It depends on the type of illness. You know, influenza is one that if it's originating in a small village in Mexico, you might think about trying to contain it in that setting. Even that's very optimistic, though, given how easily influenza spreads from person to person. Once it reaches an urban environment in any country, your ability to contain it is pretty much nil. But your other point that countries need to beef up their public health capabilities around the world — definitely. We as a global community are only as strong as our weakest link.
TIME: Similarly, do we need to improve communication between the veterinary health and human public health sectors, to make sure that if vets see something unusual, they inform their counterparts in public health immediately and find those diseases faster?
Besser: If you look at where emerging infectious diseases come from, they tend to come from the interface of animal and human health. We have a facility here — the National Center for Zoonotic, Vector-Borne and Enteric Diseases that's addressing those issues. Because, you're right, the better connection we can have between the two, the better our ability to pick up infectious diseases more quickly.
TIME: The H1N1 flu virus could disappear now but return in a more dangerous form in the fall at the start of the next flu season. What should we do to prepare between now and then?
Besser: There are a number of preparatory measures we are undertaking, including the possible decision to produce a vaccine for H1N1. And that will be very important because should we decide to produce one, we want to make sure everything has been put in place that allows that to happen quickly. The other thing we want to do is look very closely and carefully at what takes place in the Southern Hemisphere during its upcoming flu season. How will this virus do compared to the others out there? That's an important question. Will it be mutating, in terms of its resistance? Right now the virus can be treated with Tamiflu and Relenza, and we want to make sure it stays that way or we want to know if it changes. And as the virus changes, we want to make sure we have a handle on it, and whether the vaccine we would want to produce would be effective if this strain potentially comes back next fall.
TIME: What's the deadline to make a decision about producing a vaccine?
Besser: There isn't a fixed date — it's really a couple of months from now. We are going through the possible vaccine strain and the manufacturers are working to complete a seasonal flu vaccine. The strategy is to complete the seasonal vaccine and then, should we desire, switch production to the H1N1 vaccine.
TIME: So far, we have been fortunate that this virus hasn't caused much severe illness, but, obviously, that could change. How prepared are state and local health agencies, which have suffered from budget cuts in the recession, for a truly severe pandemic?
Besser: There is very little surge capacity right now in our health care system. You have to plan for how you would handle a surge, but right now there is very little excess capacity. It points to the importance of health reform and increasing access to care, and making sure that people have a trusted medical source they can turn to for information. One of the reasons we work so hard on community control measures is not that you can stop the flu from spreading eventually, but if you slow it down, it can reduce the burden on your health care system at any one time. And that is something that will be a problem whenever we face a major crisis, and should this virus come back strongly in the fall it would be an issue.
TIME: Speaking of disaster response, you were in charge of the CDC's response to Hurricane Katrina. What are the lessons from that experience, and how might they be applicable to what we're facing with a pandemic?
Besser: There are so many lessons from Katrina. We as a public health community tend to focus on the response. But another vital part is how we make our communities healthier to begin with. Looking at the individuals who suffered the most during the hurricane, you could see that those with underlying medical problems were at greater risk.
The other big lesson from Katrina is that it pays to be prepared. But it's also very difficult to stay prepared because the longer you go between events the more you'll see complacency. We are very fortunate in our response to H1N1 that state and local health agencies have been exercising a plan for a response to a pandemic for many years. We have labs that are able to receive our test kits and are using those to test for the virus locally. You can't put a price tag on preparation for a pandemic.
TIME: As worrying at the spread of a new flu virus must be, it must also be a little bit exciting — as someone who is trained in disease response — to be handling what could potentially be the first pandemic in over 40 years.
Besser: What's really gratifying is to see the incredible work going on at CDC and around the country and to see that the efforts that have been undertaken are paying off and they are paying off in terms of the impact on people's health and lives.