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CDC, an institution synonymous around the world with publichealth, will be 50 years old on July 1. The Communicable DiseaseCenter was organized in Atlanta, Georgia, on July 1, 1946; itsfounder, Dr. Joseph W. Mountin, was a visionary public healthleader who had high hopes for this small and comparativelyinsignificant branch of the Public Health Service (PHS). Itoccupied only one floor of the Volunteer Building on PeachtreeStreet and had fewer than 400 employees, most of whom wereengineers and entomologists. Until the previous day, they hadworked for Malaria Control in War Areas, the predecessor of CDC(Figure_1), which had successfully kept the southeastern statesmalaria-free during World War II and, for approximately 1 year,from murine typhus fever. The new institution would expand itsinterests to include all communicable diseases and would be theservant of the states, providing practical help whenever called.
Distinguished scientists soon filled CDC's laboratories, andmany states and foreign countries sent their public health staffsto Atlanta for training. Any tropical disease with an insect vectorand all those of zoological origin came within its purview. Dr.Mountin was not satisfied with this progress, and he impatientlypushed the staff to do more. He reminded them that except fortuberculosis and venereal disease, which had separate units inWashington, D.C., CDC was responsible for any communicable disease.To survive, it had to become a center for epidemiology.
Medical epidemiologists were scarce, and it was not until 1949that Dr. Alexander Langmuir arrived to head the epidemiologybranch. He saw CDC as "the promised land," full of possibilities.Within months, he launched the first-ever disease surveillanceprogram, which confirmed his suspicion that malaria, on which CDCspent the largest portion of its budget, had long sincedisappeared. Subsequently, disease surveillance became thecornerstone on which CDC's mission of service to the states wasbuilt and, in time, changed the practice of public health.
The outbreak of the Korean War in 1950 was the impetus forcreating CDC's Epidemic Intelligence Service (EIS). The threat ofbiological warfare loomed, and Dr. Langmuir, the most knowledgeableperson in PHS about this arcane subject, saw an opportunity totrain epidemiologists who would guard against ordinary threats topublic health while watching out for alien germs. The first classof EIS officers arrived in Atlanta for training in 1951 and pledgedto go wherever they were called for the next 2 years. These"disease detectives" quickly gained fame for "shoe-leatherepidemiology" through which they ferreted out the cause of diseaseoutbreaks.
The survival of CDC as an institution was not at all certainin the 1950s. In 1947, Emory University gave land on Clifton Roadfor a headquarters, but construction did not begin for more than adecade. PHS was so intent on research and the rapid growth of theNational Institutes of Health that it showed little interest inwhat happened in Atlanta. Congress, despite the long delay inappropriating money for new buildings, was much more receptive toCDC's pleas for support than either PHS or the Bureau of theBudget.
Two major health crises in the mid-1950s established CDC'scredibility and ensured its survival. In 1955, when poliomyelitisappeared in children who had received the recently approved Salkvaccine, the national inoculation program was stopped. The caseswere traced to contaminated vaccine from a laboratory inCalifornia; the problem was corrected, and the inoculation program,at least for first and second graders, was resumed. The resistanceof these 6- and 7-year-olds to polio, compared with that of olderchildren, proved the effectiveness of the vaccine. Two years later,surveillance was used again to trace the course of a massiveinfluenza epidemic. From the data gathered in 1957 and subsequentyears, the national guidelines for influenza vaccine weredeveloped.
CDC grew by acquisition. The venereal disease program came toAtlanta in 1957 and with it the first Public Health Advisors,nonscience college graduates destined to play an important role inmaking CDC's disease-control programs work. The tuberculosisprogram moved in 1960, immunization practices and the MMWR in 1961.The Foreign Quarantine Service, one of the oldest and mostprestigious units of PHS, came in 1967; many of its positions weresoon switched to other uses as better ways of doing the work ofquarantine, primarily through overseas surveillance, weredeveloped. The long-established nutrition program also moved toCDC, as well as the National Institute for Occupational Safety andHealth, and work of already established units increased.Immunization tackled measles and rubella control; epidemiologyadded family planning and surveillance of chronic diseases. WhenCDC joined the international malaria-eradication program andaccepted responsibility for protecting the earth from moon germsand vice versa, CDC's mission stretched overseas and into space.
CDC played a key role in one of the greatest triumphs ofpublic health: the eradication of smallpox. In 1962 it establisheda smallpox surveillance unit, and a year later tested a newlydeveloped jet gun and vaccine in the Pacific island nation ofTonga. After refining vaccination techniques in Brazil, CDC beganwork in Central and West Africa in 1966. When millions of peoplethere had been vaccinated, CDC used surveillance to speed the workalong. The World Health Organization used this "eradicationescalation" technique elsewhere with such success that globaleradication of smallpox was achieved by 1977. The United Statesspent only $32 million on the project, about the cost of keepingsmallpox at bay for 2-1/2 months.
CDC also achieved notable success at home tracking new andmysterious disease outbreaks. In the mid-1970s and early 1980s, itfound the cause of Legionnaires disease and toxic-shock syndrome.A fatal disease, subsequently named acquired immunodeficiencysyndrome (AIDS), was first mentioned in the June 5, 1981, issue ofMMWR. Since then, MMWR has published numerous follow-up articlesabout AIDS, and one of the largest portions of CDC's budget andstaff is assigned to address this disease.
Although CDC succeeded more often than it failed, it did notescape criticism. For example, television and press reports aboutthe Tuskegee study on long-term effects of untreated syphilis inblack men created a storm of protest in 1972. This study had beeninitiated by PHS and other organizations in 1932 and wastransferred to CDC in 1957. Although the effectiveness ofpenicillin as a therapy for syphilis had been established duringthe late 1940s, participants in this study remained untreated untilthe study was brought to public attention. CDC also was criticizedbecause of the 1976 effort to vaccinate the U.S. population againstswine flu, the infamous killer of 1918-19. When some vaccineesdeveloped Guillain-Barre syndrome, the campaign was stoppedimmediately; the epidemic never occurred.
As the scope of CDC's activities expanded far beyondcommunicable diseases, its name had to be changed. In 1970 itbecame the Center for Disease Control, and in 1981, after extensivereorganization, Center became Centers. The words "and Prevention"were added in 1992, but, by law, the well-known three-letteracronym was retained. In health emergencies CDC means an answer toSOS calls from anywhere in the world, such as the recent one fromZaire where Ebola fever raged.
Fifty years ago CDC's agenda was noncontroversial (hardlyanyone objected to the pursuit of germs), and Atlanta was abackwater. In 1996, CDC's programs are often tied to economic,political, and social issues, and Atlanta is as near Washington asthe tap of a keyboard (Figure_2).Adapted for MMWR by Elizabeth W. Etheridge, Ph.D., from her book,Sentinel for Health: A History of the Centers for Disease Control.Berkeley, California: University of California Press, 1992.
Editorial Note
Editorial Note: When CDC's name changed in 1970, from theCommunicable Disease Center to the Center for Disease Control, CDCscientists were poised to accept new challenges. The most notableof the agency's many achievements in the following 10 years was itsrole in global smallpox eradication, a program that finallysucceeded because of the application of scientific principles ofsurveillance to a complex problem. In the realm of infectiousdiseases, CDC maintained its preeminence, identifying the Ebolavirus and the sexual transmission of hepatitis B, and isolating thehepatitis C virus and the bacterium causing Legionnaires disease.The Study of the Effectiveness of Nosocomial Infection Control(SENIC) was the most expensive study the agency had ever undertakenand proved for the first time the effectiveness of recommendedinfection-control practices. Other studies included identificationof the association of Reye syndrome with aspirin use, the relationbetween liver cancer and occupational exposure to vinyl chloride,and the harmful effects of the popular liquid protein diet.
The 1980s institutionalized what is considered to be acritically important scientific activity at CDC -- the collaborationof laboratorians and epidemiologists. The decade began with thenational epidemic of toxic-shock syndrome, documentation of theassociation with a particular brand of tampons, and the subsequentwithdrawal of that brand from the market. CDC collaboration withthe National Center for Health Statistics (NCHS) resulted in theremoval of lead from gasoline, which in turn has markedly decreasedthis exposure in all segments of the population. The major publichealth event of the 1980s was the emergence of AIDS. CDC helpedlead the response to this epidemic, including characterization ofthe syndrome and defining risk factors for disease.
CDC became involved in two very large epidemiologic studiesduring the 1980s. First, the Cancer and Steroid Hormone Studyconducted in collaboration with the National Cancer Instituteassessed the risks for breast, cervical, and ovarian cancersassociated with both oral contraceptives and estrogen replacementtherapy. Second, at the request of Congress, CDC undertook a seriesof studies of the health effects of service in Vietnam on veteransand their offspring, which led to a landmark contribution of thelaboratory -- the development of a serum test for dioxin able tomeasure the toxicant in parts per quadrillion. This decade alsointroduced scientifically based rapid assessment methods todisaster assistance and sentinel health event surveillance tooccupational public health. Epi Info, a software system for thepractice of applied epidemiology, was introduced and now has beentranslated into 12 languages for tens of thousands of usersglobally. Finally, during the 1980s, NCHS was moved to CDC, furtherenhancing CDC's information capabilities to meet national needs.
The 1990s have been characterized by continuing applicationsof CDC's classic field-oriented epidemiology, as well as by thedevelopment of new methodologies. For example, the disciplines ofhealth economics and decision sciences were merged to create a newarea of emphasis -- prevention effectiveness -- as an approach formaking more rational choices for public health interventions. In1993, the investigation of hantavirus pulmonary syndrome requireda melding between field epidemiology and the need for sensitivityto and involvement of American Indians and their culture.Similarly, the response to global problems with Ebola virus andplague underscore the importance of adapting these newmethodologies. Other major CDC contributions to the world's healthinclude global polio eradication efforts and efforts to preventneural tube defects. Finally, in October 1992, Congress changedCDC's official name to the Centers for Disease Control andPrevention, to recognize CDC's leadership role in prevention.Today, CDC is both the nation's prevention agency and a globalleader in public health. As the world enters the new millennium,CDC will remain the agency ready to address the challenges to itsvision of healthy people in a healthy world through prevention.
Editorial Note by: Office of the Director, Epidemiology ProgramOffice, CDC.
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