CDC Arms With Behavioral Science in War on Disease and Injury

Of the ten leading causes of death in the United States today, seven are directly tied to human behavior (e.g., tobacco smoking, poor eating habits, lifestyle). What is more, half of all premature deaths are also attributable to human behavior, according to research. This is the modern landscape of morbidity and mortality in the United States today, and it is vastly different than that of 50 years ago when the US Government established the Centers for Disease Control and Prevention (CDC) to combat the primary killers of that era, infectious diseases. In response, the focus is changing a bit at CDC, especially at the top levels of management, as behavior’s role becomes increasingly understood.

The current-day line-up of primary killers and robbers of health are behavioral in origin. Word to this effect is spreading from numerous well-documented reports issued by the Institute of Medicine as well as more than one US Surgeon General, among other sources in the federal public health service agencies. These reports all attest to the integral role of that ever-modifiable phenomenon we call “behavior.” Within their pages lies an attempt to correct our national bias toward naively attributing most all disease exclusively to traditional factors (e.g., our genes, our individual physiology) that are, in practical terms, often beyond our control and that are treatable only by what medical philosopher Lewis Thomas called expensive “palliatives.”

Change at CDC

To date, these reports and related behavioral/psychological research also serve to reveal just how close the link is between behavioral factors and one’s health or propensity to illness. Further, they are creating an intellectual environment that is facilitating changes at CDC. “CDC is making a special effort to create an environment conducive to behavioral and social scientists’ pursuit of research that will advance CDC’s mission,” says CDC’s director, David Satcher. (Satcher was appointed CDC director by HHS Secretary Donna Shalala in November 1993.)

One way in which Satcher hopes to achieve this goal is through CDC’s establishment of the Behavioral and Social Science Working Group, whose goals are to: (I) further the understanding and use of behavioral and social sciences; (2) promote and ensure excellence in such research; (3) facilitate communication, collaboration, and partnerships among CDC behavioral and social scientists and with outside organizations; (4) encourage CDC’s recruitment and retention of behavioral and social scientists; and (5) further professional development and advancement of these scientists within CDC.

Behavioral and Social Sciences Coordinator

A second major step CDC has taken to foster a behavioral scientist-friendly environment is its recent appointment of a senior-level psychologist, Marjorie Speers, in the office of the CDC director to guide and encourage high-quality science at the agency. Speers, an experimental psychologist and epidemiologist by training (at Yale University), is the first behavioral scientist to hold this newly created position in the CDC. Appointed in November 1995, Speers is the Behavioral and Social Sciences Coordinator in her broader role as Deputy Associate Director for Science.

Last year, Congress became convinced of the potential importance of behavior in the fight against chronic as well as infectious diseases and mandated that a status report be completed by CDC on efforts being made by that federal agency in the areas of behavioral and social science research. Speers is spearheading the drafting on that report.

As the nation’ s lead agency within the US Public Health Service (PHS) in the Department of Health and Human Services (HHS), CDC is responsible for promoting health and preventing disease, injury, and premature death.

Efforts that increase our level of sophistication in understanding the degree to which individual behavior can both determine illness onset and influence the course or severity of illness have tremendous potential for reducing healthcare expenditures. Further, since its mission has been broadened (see accompanying box on historical highlights) over the past decade to include injury prevention and control, women’s health, and a behavioral science coordinator, CDC has become a potentially powerful focal point for influencing the “health” of behavioral science research and its contribution to alleviating the incidence and prevalence of preventable illness and injury.

Evolving Mission, Health Through Prevention

Operating with a $2-billion-plus annual budget, CDC consists of six centers, an institute, and six program offices (see accompanying box). Three primary aspects distinguish it from the other health agencies (e.g., the National Institutes of Health) that Observer readers often encounter in these pages. First, its emphasis is on primary prevention, rather than treatment, of a wide variety of health problems; second, CDC concentrates on effecting its mission through populations rather than individual patients and therefore epidemiology is central to its activities; and finally, CDC works very closely with a wide range of agency partners (e.g., state and local governments, other federal agencies) and utilizes collaborative agreements more than grants or contracts to accomplish these collaborations.

The focus of CDC has necessarily had to keep pace with the ever-shifting primary causes of premature death and disability. So, while malaria, typhus, and plague were the impetus for CDC’s birth (as the Communicable Disease Center) in 1946, the CDC has had to adjust its focus to meet the ever-shifting primary causes of illness, injury, and death.

Our nation ‘s penchant for more traditionally biological explanations and approaches to disease is understandable, given that a few short decades ago, communicable diseases- while still an ever-present, continuing threat-once were our primary health concern. But as these diseases have come under control, health science has been forced to become more sophisticated in its understanding of the modern complexities in disease vectors and illness origin and their maintenance in human populations. Consequently, the centrality of behavior as a key component in disease transmission and in injury is becoming more commonplace.

For example, as drug researchers race to keep antibiotics a step ahead of microbial adaptations to formerly powerful medicines, the role of doctors’ drug education and knowledge and prescription practices have come under scrutiny as have patient attitudes toward medicine, including their inappropriate demands for drugs to treat any and all illness, and their treatment compliance behaviors. (See the January 1997 Observer article on the National Institutes of Health November 1996 symposium on patient self-report in relation to healthcare delivery and epidemiology.)

Similarly, as heart disease has become the leading cause of death in the United States, associated medical costs eat up some $48 billion per year, but behavioral change (e.g., learning to control one’s fat intake, exercising, reducing other risk factors in one’s lifestyle) becomes a pivotal component in terms of potential to influence our national healthcare expenditures.

The public’s underutilization of the many cost-effective vaccines for preventable disease causes some 50,000 to 70,000 adults lives annually, but behavioral science has a key role to play in helping the public achieve a higher level of appreciation for the value and importance of these treatments, as well as their safety and efficacy.

The vision of CDC (Healthy People in a Healthy World Through Prevention) is achieved, according to CDC, by promoting health and quality of life, and by preventing disease, injury, and disability. Eight primary activities- in collaboration with CDC’s partners throughout the nation and the world- are used to achieve this vision:

• Monitoring health status and trends;

• Detecting and investigating health problems;

• Conducting research to enhance prevention;

• Developing and advocating sound public health policies;

• Implementing prevention strategies;

• Promoting healthy behaviors;

• Fostering safe and healthy environments; and

• Providing leadership and training.

To provide readers with a better sense of CDC’s current thinking about its mission, in relation to behavioral science, Observer Editor Lee Herring interviewed Speers. Her remarks begin on the next page. (See also the accompanying article on page 9 on CDC’s efforts to combat sexually transmitted disease. It features the research program of APS Fellow Martin Fishbein, a CDC psychologist and professor at the University of Illinois-Urbana-Champaign.)