Kevin M. De Cock, MD, has been tapped to lead a new center focused on global health at the U.S. Centers for Disease Control and Prevention. A longtime leader in international health, Dr. De Cock has been at the forefront of the battle against the HIV/AIDS epidemic for more than a decade. As director of the World Health Organization’s Department of HIV/AIDS from 2006-2009, he oversaw all of WHO’s work assisting low- and middle-income countries to scale up treatment, prevention, and support programs. He is now finishing up a stint as Director of CDC’s Kenya office before he moves to Atlanta to launch the CDC’s new Center for Global Health. In this Q&A, he talks about the vision for this new center and the challenges ahead.
Q: You are about to take the helm of a new center within CDC that will amplify the agency’s work on global health. Why did CDC leaders feel this new center was needed and what are the objectives?
A: When the CDC’s director, Dr. Tom Frieden, took up his functions in the middle of last year, he did two things. Firstly, he defined global health as one of CDC’s core priorities. And I think the significance, the symbolism, of that is considerable. Although CDC has done international work since its inception, it’s really the first time a CDC director has so explicitly named global health as one of his priorities. And to match that rhetoric, he also decided CDC’s work in global health should be consolidated and therefore created a new center.
The creation of the new center does mean that CDC has to think more ambitiously and more strategically about its role in the world, in the hugely changed international diplomatic environment that is so different from just ten years ago. We will be thinking about science and public health priorities and how best to do our work in the 40 or 50 countries where we are engaged. We will work to get a better impact, a more measurable impact, and one that can be communicated more clearly.
Kevin DeCock who lead a new Center for Global Health at the CDC
Q: You have a long history of working on the global HIV response both in Kenya with CDC and with the WHO. Many of us are concerned that the Administration’s Global Health Initiative, with its welcome expanded reach, will in fact come at the expense of the robust response envisioned for HIV and TB through the Lantos-Hyde Act. Already we see evidence of this in less than ambitious treatment targets for HIV and TB. What is your own assessment of this? Are you concerned about a loss in momentum toward HIV treatment targets that you helped craft, such as Universal Access by 2010?
A: I think that’s a very relevant question. I have no doubts about the commitment of the Administration to building up the impact of PEPFAR I. And as far as PEPFAR II is concerned, the funding remains huge and the targets remain ambitious and the work is very extensive.
Now at the same time, there’s no doubt that we have to look to the longer term future and begin to think more deeply about how does the long-term global response get funded? It’s unrealistic for one country to fund the whole response to the pandemic, which is likely to stretch into decades to come.
Actually, it’s a coincidence that you asked this, because we’ve been discussing these sorts of questions for Kenya yesterday and today. And I think we’re okay for the time being. But obviously with 33 million people infected with HIV, and with around 4 or 4.5 million on therapy right now and others waiting to become treatment eligible, the costs of HIV/AIDS are going to increase and we do need to think about innovative methods of financing—sharing the burden more broadly; getting other donors involved, such as emerging economies; getting affected countries themselves to take up some of the costs, which some of them could; and making the response more efficient and effective. I’m not so worried about the immediate short term, but I certainly think some deep thinking is required about the longer term.
Q: Similarly, the tuberculosis treatment targets detailed in the Administration’s GHI consultation document was considerably lower—roughly half—of the goals laid out in Lantos-Hyde. Do you have concerns about a pullback on fighting TB, particularly with the rising threat of multidrug-resistant TB (MDR) and extensively drug-resistant TB (XDR-TB)?
A: I think tuberculosis is always at risk of getting forgotten. The history of TB funding has always been cyclical. It rises when TB seems to get out of control, then the response is funded, the cases come down, and then people’s attention gets drawn elsewhere. That’s been a phenomenon, including in the US, over many years. So I do think there’s a need to continually remind people about tuberculosis. And although I think we’ve done reasonably well addressing TB within the context of the AIDS epidemic, there’s still enormous work to do.
As far as MDR and XDR, these are very important issues. We need better surveillance data, but XDR has been most severe in a limited number of places and MDR also is not a huge problem everywhere. The real answer to drug-resistant TB is prevention and better functioning programs, since it is poorly functioning programs that are at the root of MDR and XDR TB. I think the response under the GHI is fairly robust, but tuberculosis does need continuous advocacy to ensure it’s kept on the front burner and policymakers continue to pay attention to it.
Q: What role will the CDC play in the Global Health Initiative? We noted last week the appointment of Amie Batson as the point person for the GHI at USAID, but certainly our physician members see CDC as a critical player in global health. Will there be a similar liaison from the CDC? And if not, how will the agency ensure that its voice is heard in this new approach to global health?
A: The discussions are ongoing about the governance of the GHI–those discussions are unfinished. But let me reassure you that the director of CDC, Dr. Frieden, is paying the utmost attention to this issue and has been intimately involved … And as this new center is stood up, he’s been paying extraordinary attention himself to global health issues and these Washington discussions. The CDC will be represented at the highest levels.
Q: Some advocates have argued that CDC has suffered as an agency because it is far from Washington’s reach in Atlanta. What plans do you have to engage with the Washington community of policy makers, program implementers and advocates on global health?
A: That question has some validity, but there are some advantages also to being in Atlanta. One of the original reasons CDC was put in Atlanta was to deal with malaria in the southern United States in the early 1940s. Two advantages of not being in Washington are 1) it has allowed the agency to develop a very strong technical focus and identity, because being away from the political spotlight, I think an emphasis has been put on its technical work and 2) it’s allowed the agency to grow and occupy more physical space, which in D.C. frankly might have been quite difficult.
On the other hand, meetings in Washington get called, sometimes on short notice, and there isn’t always someone to fly up from Atlanta and so we miss out on discussions. We do have an office in Washington, with a Washington-based director. There’s a deputy for the agency for policy in Washington, who has just been appointed. And for global health, we also have a deputy director for policy and communications position that will be Washington based. We are recruiting as we speak.
Q: There was new evidence presented at CROI last month about the benefits of HIV treatment as prevention. How do we educate policymakers about the broader community benefits of HIV treatment, including the reduced transmission of HIV and TB?
A: Policymakers pay attention to data if they are explained to them in the right way, and we are beginning to see pretty persuasive data on HIV treatment as prevention, especially with discordant couples, where one person is infected and HIV treatment prevents the second person in the couple from becoming infected. To my mind, there’s only one direction this debate is going—it’s towards early treatment and more widespread treatment. It is giving a biological and biomedical justification for the aphorism that treatment and prevention are inseparable. It’s a very important and emerging theme in HIV/AIDS work.
The role of HIV treatment as prevention, the impact at the community level of widespread treatment on HIV transmission, and the question of when to start treatment for the individual, and the impact that would have on individual health and on TB at the community level–these allied questions are, to my mind, the most important research priorities in HIV medicine today.
Q: On drug-resistant TB, there’s a lot of excitement about new diagnostics in the pipeline that could lead to faster, better tests for drug-resistant strains of TB. If such a vital tool comes to market soon, will the US have the resources to help get it out widely to the field?
A: If new tools become available, such as diagnostics, that are shown through research to improve outcomes or to make interventions more effective, more efficient, then they do get adopted and sometimes remarkably quickly. We’ve certainly see that within HIV medicine. You have to be impressed with the scale of up therapy and rapid HIV testing. There is also a movement in programs in lower and middle-income settings towards laboratory strengthening and an interest and emphasis on point-of-care tests, be they for malaria , TB or HIV. But the technology has to be developed first, has to be refined, and has to be evaluated.
Q: You haven’t officially transitioned into your new job yet and are wrapping up things in Kenya as we speak. What kinds of successes has the CDC seen in Kenya and what challenges remain for your successor there?
A: CDC has had a very interesting history in Kenya. It was in 1979 that the first D.C. assignee arrived here and he was sent to initiate collaborative malaria research. And up to and until the early 2000s, the agenda was almost exclusively research, which CDC always tries to link to policy development and programs.
But with the advent of PEPFAR, and subsequently our work in emerging infectious and global disease detection, we’ve become much broader. Our research has had direct impact on health policy. For example, malaria research on the efficacy of insecticide-treated bed nets was extremely important. In HIV, the clinical trial of HIV treatment to prevent mother-to-child transmission through breastfeeding contributed to a change in international guidelines.
As for what comes next, we have been very infectious-disease oriented. It is time that we begin to extend our work—and this is mandated actually through the GHI—to non-communicable disease priorities, including tobacco use, salt intake, hypertension, diabetes and injuries. And we have to address maternal and child health and extend our work to neglected tropical diseases. These will be the challenges moving forward.
Q: When you get to Atlanta, what will the new center’s structure look like and what will its portfolio include?
A: It will be structured like other centers within the CDC, with an office of the director that has central functions like policy and communications. Currently there are 4 operational divisions in the new center. The first one is the division of global HIV/AIDS, the operational arm of the CDC for PEPFAR implementation. A second division is focused on parasitic diseases and malaria. Third, there’s a division called global disease detection and emergency response, which does international work on emerging infectious diseases, response to outbreaks, international surveillance and response to humanitarian emergencies. And fourth, a division that deals with health system strengthening and is well known for its work in field epidemiology training. We will have to work towards better integration of all CDC’s work in global health.
There is of course a great deal of work in other aspects of public health with global implications done in other parts of the agency, for example our work on immunizations. Whether those will move into the new center is under discussion, but the important point is that the new center will do all it can to support all of CDC’s international work. And perhaps that summarizes the identity we seek – a global public good for public health.
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