The reorganization of elements of the Department of Health and Human Services has resulted in the recall of the Centers for Disease Control and Prevention (CDC)/Center of Excellence staff members Joel Selanikio and Gary Rhyne. (See "A Job Well Done," p.60)

Dr. Selanikio, an epidemiologist with the CDC and a Commander in the US Public Health Service, was seconded to the Center of Excellence beginning January 1998 until his departure in January 2002. He now works as a senior health advisor for the newly created Office of Public Health Preparedness in Washington, DC. Robin Hayden interviewed Dr. Selanikio in January 2002 as he packed his bags for a new life in the US capital.

RH: Joel, where were you on Sept. 11th of last year?

JS: I was attending a meeting at the World Health Organization (WHO) in Geneva. I'm originally from New York City (NYC) and I have lots of friends who worked in the World Trade Center. So obviously it hit me the same way it hit most people in the [U.S.]. I was just incredulous. The greater effect has been that the government is now in the process of realigning a lot of its assets, such as me, to better assist in the war against terrorism.

RH: What led to your transition from the Center of Excellence?

JS: I got back shortly before the first anthrax case was confirmed in Florida. This is a very rare disease, so perhaps this was a natural occurrence, but it soon became clear that the anthrax had been intentionally introduced. CDC had to reassign its personnel on an emergency basis. On October 11th I flew to Washington DC and began my role as chief of operations at the Emergency Command Center for the Secretary of Health and Human Services.

During the anthrax epidemic, in the thick of things, we were working all the time. My role was to know what was going on with the investigation  for Secretary Tommy Thompson. So if someone were to ask him, he would know what happened to a sample, who is processing that sample, what are the results, how reliable are the tests, how many cases do we have, what hospitals are they in, all that information.

RH: You must have done a very good job, because you've been requested by Thompson to work for Dr. D.A. Henderson. Can you tell me about Dr. Henderson and what your new role entails?

JS: Sure. First, I was chosen not only for doing a good job but also for being willing to work eighteen- to twenty-hour days for two months straight!

D.A. Henderson is essentially a giant within the field of public health. He is probably best known for heading up WHO's program to eradicate small pox. Within the natural [environment], with the exception of a couple of samples, there is no small pox, in large part thanks to this guy.  

Most recently, Henderson was the director of the Center for Civilian Bio-Defense Studies at John Hopkins University. I can't imagine finding someone else who is better suited to direct all of the Department's efforts with regard to responding to bio-terrorism or public health emergencies. That is a tremendously positive step – assigning one person to be able to coordinate and direct the entire enterprise.

RH: While the number of cases has decreased to zero, we still need to prepare for that kind of attack in the future, so how is your role evolving?

JS: Well, I think you have certainly hit on the key task. With regard to terrorism, it's better prevented than responded to. There is a tremendous amount of preparation. It's difficult to do, because for example, local hospitals need to be prepared to deal with large groups of people who might be affected. Economics has been driving the hospital system to become more and more competitive, cutting loose every bit of what we call ‘surge capacity', [the] additional capacity to deal with sudden, unexpected upturns in demand.

RH: So this is an unintended consequence of our health policy.

JS: Exactly. I think it is normal for people to want to spend most of their money on the things they do most often. Hospitals want to spend their money on taking care of patients who are there every day. They don't want to put [money] toward building special rooms or bringing on additional staff to deal with things that may or may not happen in the future. That's the way the market is supposed to work, and I think that's fine for the health system to work this way.

Obviously, the US Federal Government has additional goals beyond economic competition. [It] and our office has to ensure that the local hospitals will be able to respond. So do how we give an incentive to the hospitals to build in that surge capacity? It's very difficult. All of the health care institutions have to be incentivized in the same way because, otherwise, someone is going to hold back and gain a competitive edge by not putting money in.

We are anxious to release [federal] money into the hands of local hospitals and communities to build response at that level. But we are still in the process of determining what the local communities think.

There are key goals that we need to address universally. For example, the National Pharmaceutical Stockpile is a program administered by the CDC that keeps trucks laden with antibiotics, antidotes, bandages, and other medical supplies at certain locations within the U.S. The goal of the program is to reach X percentage of the population within 12 hours. For the first time, these were deployed after the attacks and, in fact, were shown to work. On Sept 12th, there were very few planes in the air. The only non-military planes were the stockpile planes that were trying to get those drugs and antidotes to NYC, anticipating that there might be a follow-up biological attack.

Even within the stockpile [example], there are many communities in the U.S. that are not prepared. It's great if a plane or a truck shows up in your city with 8 billion bandages or 2 million doses of small pox vaccine. The question is, how do you administer that? Do you have people there who even know how to take the vaccine and give it to someone? There has to be training, preparation, exercises. People need to rehearse these issues and possibilities to make sure the system will work as intended. I think NYC worked exceptionally well and that's because it had been exceptionally well prepared for terrorist attacks and anticipated being the target for a long time.

The most useful thing is for us to assume we are all targets. Each of us needs to talk with our local hospital systems via the legislature and our political representatives. And make sure that we will be prepared, for example, to accept supplies from the stockpile, or to respond in other ways to a radiological, chemical or biological attack.

RH: How long do you think this effort will take?

JS: I don't think there is an end date. As the president has said, we are involved in a war… [however] as time removes us, [we] go back to business as usual. Psychologically people need to do that. While that is true for the general population, we do want the people who are in charge of planning for these events to be on a state of high alert all of the time.

Part of it is preparing for response and part of it is making sure that everyone understands that there is a consequence for attacking the U.S. I'm hoping that we will have fewer people who are willing to attack us now that we have shown that we are interested in pursuing those who attack us and fighting back.

There needs to be a system in place if you are going to take billions of dollars and try to apply it to solve a problem. You need a system to route that money toward where it needs to be. You need a bureaucracy to do that. At the same time, bureaucracies tend to get set in their ways and this is definitely not a situation in which we can be set in our ways. The government is taking the threat very seriously and if there was ever, within the federal government, a 'business-as-not-usual' time, this is it.

RH: Earlier you and I made a comparison, in attitude, to the mindset of the military as far as preparation to fulfill its primary role as defender of the country. But then the military does operations other than war, as they call them, which could be humanitarian assistance or disaster relief...

JS: Or it could be running Tripler Army Medical Center for families and service members.

RH: Right. Which is a training hospital so that doctors are being trained at the same time and so on. But yet the military is prepared at any time to be ready for its primary role. So is this the kind of mindset you are trying to engender?

JS: Exactly. And the Department of Health and Human Services does a tremendous amount of good work, but it's not the Department of Defense. Not only in terms of budget but also mindset. You've really hit the nail on the head when you say that there is a job Number One that needs to be done: to be prepared to respond to these emergencies. Once we are pretty sure that we are as prepared as we can be, it's fine to move onto other tasks. Right now, we are working very hard to get ready.

RH: What projects were you working on at the Center of Excellence?

JS: I was posted about eighteen months ago to COE as research director in the medical unit. We've been looking at issues in refugee health, something that COE concerns itself with quite a bit. We have been trying to figure out better ways to do assessments in camps. There is a lot of information you need to know - their state of health, what the vaccinations are, a lot of different health data needs to be collected. Currently, all that data is collected on paper. The medical unit is developing a hand-held technology model that will enable us to get that information more quickly. Up until September 11th, that's what I was doing.

RH: Where do you see the hand held program going?

JS: There is a tremendous potential application for data gathering tools within the fields of public health and public health emergencies. Certainly within private industry, people are adopting hand held computers as fast as possible. There are a tremendous number of physicians around the country using hand held computers. I think within the public health community for a lot of different reasons that has not so much been the case. There is more money in clinical medicine than there is in public health. And people are more reluctant to change within the field of public health.

I will continue to work in conjunction with COE's Dr. Tom Hasling to show what you can do with hand held computers. In September 2000 we went to a refugee camp on the Thai-Burmese border and were able to collect [the same] information on the nutritional state of the refugee children that was being collected on paper. We were able to perform that task in a fraction of the time and with better accuracy.

It's really a no-lose situation. You have an inexpensive device that you can bring in to perform an essential function you are already doing, but in a fraction of the time, with less effort, better accuracy and better data.

People just need to be shown this is possible. Aside from simply demonstrating this, we are working on technologies and software program tools to make it easier for people to utilize this [tool] in the field…ideally we get someone to say, "I saw what you did in Thailand. We'd really like to go ahead and do the same thing ourselves, how do we do it?"

Right now the state of the software tools that are available to make a new questionnaire, a new survey, or a data-gathering instrument, are somewhat limited. It might not be easy for someone who doesn't have a computer background. One of the things that Tom is working on is developing a program that will make it much easier for the general population and certainly public health practitioners, to be able to go into the field and design their own data gathering instrument. They can buy a Palm Pilot for US$100 now, get the software from us for free and design their own questionnaire. A lot of barriers to automating those processes are removed.

RH: And civilians, militaries, non-governmental organizations and other institutions could make bulk purchases and be able to do assessments very quickly?

JS: Well sure. I think one of the reasons that people haven't computerized field data gathering is, for one, it's expensive. Laptops are expensive: you're spending at least US$2,000 per unit. Plus, in the field there is no electrical outlet. There are tons of reasons why that mode of computing doesn't work in a field setting. And for exactly those same reasons, a hand held computer like a Palm Pilot or a pocket PC is perfect for those applications. They don't require much electricity. They are much less expensive. Instead of spending $2,000 on a laptop, you can buy 20 Palm Pilots. Another expense would be software. We are developing inexpensive or free software that would plug that hole.

The hand held unit will also enable people to be able to think creatively and gather information they are not yet gathering, because the barriers to gathering that information will fall as it becomes less expensive and frankly less difficult, less time consuming. The typical process is you are working twelve hours a day in the hot sun, then you go back to your base with information you have written on paper and you start typing into the computer. You're very tired at the end of the day. You make a lot of mistakes.

With the hand held computer, once you've entered [the data], it's entered. Once this is widely adopted it will really revolutionize our ability to monitor populations and to serve those populations.

RH: You started the hand held project because you thought it would have real impact in the field. In your new role, how to you expect to make a difference?

JS: At the end of some period of years, [the U.S.] will be better prepared to respond to a biological terrorist attack. Certainly Secretary Thomson is adamant that we are better prepared in two months than we are now, and that we'll be better prepared two months after that.

RH: How do you measure that preparation?

JS: That's an excellent question. Most branches of the government are not used to putting projects in place where we expect to measure the result in 2 or 4 months. Usually the time span is much longer. This is not a typical government project. This is a life or death issue for the American people. And what should we count as improvement? What are the things that we can measure, to figure out, in fact, if we are meeting our goals? The Secretary has said again and again that he wants to be better prepared in March than we were in January; he wants to be better prepared in June than we were in March. Well, again, we have to go out and measure something.

A lot of work I have done has to do with gathering information - measurement - determining if there is a result or not. That background has already made me useful within the Office of Public Health Preparedness. My own particular strengths are, as you know, within public health but also within the application of information technology to public health. We have to process a tremendous amount of information, [such as] early warning surveillance systems that keep track of what everybody is going to the emergency room for in the entire U.S., and are there any unusual patterns of illness being seen. People are trying to develop real time systems to measure that kind of thing. This is information gathering, information technology and that's exactly the topic that I have concentrated on within my career in CDC.

RH: So you see information as the lynchpin to measuring success?

JS: You're going to be able to find people within D.A. Henderson's office who know more about smallpox that I do, and people who know more about nuclear weapons technology and responding to nuclear attack than I do. I am one of the better-placed people within that office to discuss issues of information technology and how we can apply it to knowing if we are better prepared than we were a month ago, to putting in place these early warning systems, or even evaluating early warning systems that are looking to us for additional funding.

The object here is not just to get the money out. The object is to get the money out in a way where we can again measure how well are doing. This is not an academic exercise. So, I'm positive that I will have a particular role to play within the office. And I think that they feel the same and I think that's why they have yanked me from Hawaii.

RH: You are needed elsewhere.

JS:  Apparently so.

RH: Everyone at the Center will miss you and I know that I speak for them when I say that Joel. Thank you.

JS: My pleasure.

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