Was the TB lawyer a pawn in a budget ploy?

The American Journal Constitution has a story today wondering if the notorious TB lawyer (see our posts here) that caused an international ruckus because he flew against medical advice (the evidence is a bit obscure on this point) may have been part of a CDC ploy to get increased funding for its TB program. I don't know the answer to that, but the fact it should even be raised and taken seriously in some serious quarters speaks volumes about CDC, its management and an air of desperation there:

Months before the Centers for Disease Control and Prevention made Atlanta lawyer Andrew Speaker the unwitting poster boy for drug-resistant tuberculosis, the agency and its advisers discussed a strategy to get more funding by publicizing the deadly strain of the disease, records show.


One strategy centered on publicizing the urgency of combating XDR TB -- a rare, new form of extensively drug-resistant tuberculosis. "The implications of XDR TB for TB control in the United States should be compiled and communicated as a strong advocacy tool to increase the TB investment," the minutes state.

Five months later, CDC's lab diagnosed Speaker as having XDR TB, and the agency issued a federal isolation order -- its first in more than 40 years -- and held a national press conference about how he possibly spread the disease aboard international flights.

The actions were in stark contrast to the private way the agency dealt with 100 other TB cases involving airline travelers, both before Speaker and after, including an incident last month when a severely ill drug-resistant TB patient flew from India to Chicago. (Alison Young, Atlanta Journal Constitution)

The TB program at CDC has been level funded for several years. In practice, this means it has been experiencing 4 - 5% cuts every year. So the program was naturally eager to boost its funding and after the publicity given this case it did get a 4% boost in the latest budget (which effectively means it is level funded after inflation). President Bush vetoed Congress's planned 9% boost. But if you are a TB person and you are looking down the barrel of the XDR TB gun, desperation is probably not too mild a word. XDR TB is an emerging problem major public health problem. Instead CDC Director Gerberding is talking about bioterrorism and obesity. If you in TB control this must seem like Alice in Wonderland. But even so, the suspicions being bruited about regarding the case of lawyer Andrew Speaker are extraordinary:

Dr. Alan Bloch, an expert in the airborne transmission of TB and measles, said he's wondered since last summer: "Was there a hidden agenda to use Andrew Speaker's case to get more money for TB control?"

Bloch, who spent 25 years at CDC before he retired in 2005, said the agency's response to Speaker seemed overblown, given that test results known to health officials and Speaker's lack of symptoms made him unlikely to spread the disease.

Bloch conducted the first national survey of drug-resistant TB and designed the expanded TB surveillance system that CDC used to identify the 49 XDR TB cases in the U.S. from 1993-2006.

Watching Gerberding's televised press conference in May, when she announced the CDC had issued the first federal isolation order since a 1963 case of suspected smallpox, Bloch said he assumed "this patient must be extremely contagious.''

"I had visions of a non-compliant patient who was the tuberculosis equivalent of Typhoid Mary, who was highly infectious. When I found out this patient did not meet other criteria for being a very infectious case, I was puzzled."

We wondered the same thing at the time but didn't accuse CDC of manipulating it for budgetary reasons. We don't have enough information now to settle that issue but from the outset this whole case had a bad odor to it (again, see you coverage, in many posts linked here). It isn't clear if or when we will ever know the answer. CDC is refusing to release any information on the case, even under valid Freedom of Information Requests. I assume the rationale is to protect the privacy of the miscreants.

I don't know who did what and for what reasons. But the atmosphere at CDC is one of general suspicion and a pervasive feeling among science professionals that management is too concerned with sucking up to the administration and too little concerned with CDC's mission. In such a setting people might make judgments in desperation they wouldn't otherwise.

I hate to see this happen to CDC. Whatever the truth of the matter, the fact it is even being talked about in this way says it's time for Director Gerberding to join her Bush administration colleagues Ashcroft, Gonzales, Rumsfeld, Thompson, etc., etc. in retirement. It must be very tiring carrying all that water. Take a rest.

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Given his family ties in the CDC, maybe an interesting question is:

Was he an unwitting pawn or a co-conspirator?

Considering how we was savaged you can be sure he was no co-conspirator -- if indeed this was the way the story went, which I am still agnostic about.

CDC has long been proud of its not being in Atlanta and it's relative insulation from "politics" in the past. CDCers also are proud of being "above" politics, even though politics are what make a lot of public health happen. Bottom line, people at CDC are too politically naive, if not willfully politically too stupid to have done this a stunt. Until here recent efforts at rehabilitation (the leak about what the administration had taken out of one of her speeches), Gerberding would have simply asked "ho high" when the Administration said "jump". This is simply the dumbest speculation about CDC that I've heard in ages.

Rich: That's what a lot of people used to think. But there has been a sea change around there according to what I've heard. Program folks see the games played at the upper levels and some of them might be tempted to loosen up at the program level. You never know. Desperation does strange things, especially when you figure you're going to bail anyway. If this has any truth to it, I surmise it was initiated at levels below JG.

But as I tried to make clear, while I am agnostic on the actual motives I am amazed at the speculation, which, as the quotes indicate, is being repeated at some reasonably high levels outside CDC.

It's a measure of how far the establishment has fallen in the past few years that we can rationally consider the possibility of a conspiracy with our very limited data.

By Caledonian (not verified) on 14 Jan 2008 #permalink

The ultimately bumbling quality of the whole TB thing is the only aspect that would suggest that it was done for political leverage. CDC continues to bleed taleneted senior and mid-level people (I was just talking to a couple of them yesterday). People are too busy activating exit startegies to do anything really strategic.

It's a measure of how far the establishment has fallen in the past few years that we can rationally consider the possibility of a conspiracy with our very limited data.

Posted by: Caledonian | January 15, 2008 12:11 AM

It's sad to see them on a downhill slide. From the info here it seems there is no way to make a conclusive judgment as to whether or not it was staged and then taken advantage of, or just happened and then was taken advantage of.
Dave Briggs :~)