A month after Dr. Jeffrey Koplan stepped down as CDC director, no replacement has been named and no official list of candidates has emerged.

Health and Human Services Secretary Tommy Thompson has not indicated the identities of any favorites. His spokespeople say he intends to act within weeks, but agency-watchers in Washington have picked up no evidence that he is conducting a formal nationwide search.

A new director will have to overhaul the agency to fight bioterrorism, muscle more money from an administration determined to trim the CDC's budget and take the heat of being national spokesperson in any possible future bioterror attack.

In the absence of outside candidates, interest is focusing on the agency's transition team: Dr. David Fleming, acting director; Dr. Julie Gerberding, acting deputy director for science; and Dr. James Hughes, longtime director of the National Center for Infectious Diseases, whom Thompson named co-leader of the CDC's bioterrorism wing.

Handicappers are intrigued by Gerberding. An HIV researcher who headed efforts by the Atlanta-based Centers for Disease Control and Prevention to combat infections occurring in hospitals, she emerged during the anthrax crisis as an unruffled communicator the agency used frequently to brief the media. Insiders suggest her gender would appeal to an administration whose last two health choices, Dr. Elias Zerhouni for the National Institutes of Health and Dr. Richard Carmona for surgeon general, are male.

In a conversation last week, Gerberding dismissed speculation about the interim team's future.

"Both David [Fleming] and myself recognize that this is a time of tough transition for the CDC," she said. "We're trying to stay focused solely on what the agency needs right now."

Wishes and worries

In addition to the members of the transition team, other names are circulating. On examination, some are a wish list; others represent possible administration choices who unnerve the CDC rank and file.

On the list of names that provoke anxiety are: > Dr. Thomas Coburn, co-chair of the Presidential Advisory Council on HIV/AIDS. A family physician and Oklahoma Republican congressman from 1995 to 2001, Coburn is a social conservative who memorably scolded NBC in 1997 for showing the Holocaust movie "Schindler's List" because it included nudity and violence. > Dr. Robert Redfield of the Institute of Human Virology at the University of Maryland. An AIDS vaccine researcher and career Army physician, Redfield clashed with AIDS treatment advocates over whether to collect names of those who tested positive, rather than using anonymous identifying codes. > Dr. Antonia Novello, the New York state health commissioner, who was U.S. surgeon general under the first President Bush.

On the wish list, assembled by CDC employees and public health experts, are: > Dr. Ed Thompson, state health director for Mississippi who belonged to a personal advisory committee assembled by former director Koplan and has testified before Congress in favor of expanding the CDC's ability to monitor chronic diseases. > Dr. John Lumpkin, an emergency physician and African-American who is state health director in Illinois. He has served on several federal and national panels and chairs the National Committee on Vital and Health Statistics, a group that has proposed building a nationwide electronic health-tracking system. > Gail Cassell, a microbiologist from Alabama who is vice president of infectious diseases at drug-maker Eli Lilly and Co. She is the former chief of the American Society of Microbiology and chaired the CDC's board of scientific councilors.

Falling somewhere between the two lists, as someone whom CDC employees both respect and are unnerved by, is Michael Osterholm, Thompson's special representative on the CDC transition team. Osterholm knows public health well --- he was state health director for Minnesota and now heads the University of Minnesota's Center for Infectious Disease Research and Policy --- but over the years he has been a frequent critic of the CDC.

Reached in Minnesota, Osterholm declined to comment. He reportedly has said he is not a candidate.

Key credentials

The thread that links the wish-list candidates is knowledge of the structure of public health. "The CDC is the most important federal partner to state and local public health practice in this country," said Dr. George Hardy, executive director of the Association of State and Territorial Health Officials. "My bias is for them to choose someone who has worked in public health."

If public health experts are having trouble saying which person should be CDC director, they have no difficulty listing the qualifications that person should have. "We think it needs to be a physician," said Thomas Milne, executive director of the National Association of City and County Health Officials. "It ought to be someone who has the technical knowledge, and the ability to think on his feet and to deal well with [other agencies] and the press."

In the wake of the anthrax attacks, the ability to communicate clearly has become a key credential for the next director. With President Bush's proposed 2002-03 budget cutting funds for many CDC programs, the ability to advocate in front of Congress has become equally important.

Congress recently doubled the budget for the National Institutes of Health and should do the same for the CDC, the NIH's sister agency, said Dr. Barry Bloom, dean of the Harvard School of Public Health.

"Bioterrorism awakened America to how weak our public health system is," Bloom said. "The CDC needs a leader who can really communicate the message of the value of public health, both to political leaders in Washington and to the public at large."

Political pitfalls

There is a further complication. The White House will expect the new director, as head of the agency leading the U.S. response to bioterrorism, to work with its national security team. That suggests the administration wants someone with whom it is ideologically comfortable: a conservative, or at least a centrist.

But among career public health workers, conservatives are relatively hard to find. The profession attracts people with a liberal bent, ones who feel that intervention is an appropriate role for government.

Federal conservatives, in contrast, have criticized the CDC for years for intervening too much. In their view, CDC research into gun violence, sexually transmitted diseases, obesity and other problems with a social component strays from the agency's original mission of protecting against infectious diseases.

Career CDC workers reply that the mission has shifted because the problems have: More Americans now die of chronic, noncommunicable diseases than infectious ones.

Nationally, one well-known public health leader tends to the conservative side: Dr. William Roper, dean of the School of Public Health at University of North Carolina and a member of the White House staff under the first President George Bush. He was CDC director from 1990 to 1993.

Those familiar with the CDC fear the consequences if a new director were chosen for political allegiance rather than public health expertise.

"An outsider will have to gain the trust of people on the inside, and then advocate for programs with the administration," said Dr. James Curran, dean of the Rollins School of Public Health at Emory University and former chief of AIDS programs at the CDC. "It's easy to be politically loyal, but it's not easy to be knowledgeable about staff and resources if the CDC is foreign land."

From Healthy.net