By Lois Carlisle
Atlanta influences everything, including the nation's health. Since 1946, the Centers for Disease Control and Prevention (CDC) has spearheaded countless global health initiatives from its headquarters in Atlanta. Dedicated to saving lives and protecting the health of its citizens, CDC defends the health of people and their communities by controlling disease outbreaks, ensuring the cleanliness of food and water, preventing chronic diseases, researching how to improve worker’s health, and working globally to improve the health of all, among other issues.
From CDC’s origins as a malaria control unit to influenza surveillance of the mid-20th century and beyond, the research and analysis conducted across CDC's Atlanta campuses have a direct impact on public health around the globe.
The history of CDC is one of civic responsibility, meant to create a healthier, more empathetic society; and as citizens currently living through a public health crisis of historic proportions, it is important that we look to the past for renewed inspiration.
To understand how CDC has shaped Atlanta, we must begin in Philadelphia, in 1798. It was there that President John Adams signed An Act for the Relief of Sick and Disabled Seamen. This piece of legislation founded the Marine Hospital Service, the first federally regulated network of hospitals in the United States. Spanning the East Coast, these hospitals were dedicated to care for sick and wounded merchant seaman. A subsequent act in 1799 extended benefits of Marine Hospital Service to officers and men of the US Navy.
As one might imagine, post-revolutionary America was not known for its overt cleanliness. There were no regulations for trash disposal, slaughterhouses and their offage sprang up within city limits, and raw sewage flowed through the streets. Illness ran rampant across the country and the federal government became increasingly concerned about the health of its citizenry. In 1912, the Marine Hospital Service’s scope of work expanded—and so did its name, the Public Health Service (PHS)—to include noncommunicable diseases, field investigations, navigable stream pollution, information dissemination, prevention of diseases inside the country and assistance to the states; particularly through its program for the treatment of the most contagious diseases, such venereal disease and tuberculous.
One way it controlled the spread of germs was through quarantine. The PHS provided medical exams for federal employees, longshoremen and arriving immigrants. At sites like Ellis Island, the Public Health Service implemented an isolation policy for those displaying symptoms of communicable diseases. While PHS doctors didn’t play a role in deciding a person’s fitness to enter the country, they did help determine quarantine timelines to keep disease exposure risk rates low.
Throughout the 1920s and the 1930s the responsibilities of the Public Health Service grew to include the establishment of the National Institutes of Health, the creation of a separate Bureau of Narcotics, which was later changed to the Division of Mental Hygiene as well as investigations of disease and sanitation problems.
There’s a reason the Walking Dead wasn’t set in Washington, D.C.
These days, we may consider malaria a disease that only effects countries half a world away; however, that hasn’t always been the case. The universality of the first World War brought the world to our doors in the form of rationing, volunteerism, and disease. As millions of enlisted men left home and moved into newly constructed army bases across the American South, a different enemy appeared on the home front: malaria.
Carried by mosquitos who thrived in tropical climates, malaria continued to be endemic in many parts of the south, including military bases. A widespread disease in the American South for centuries, malaria posed a new kind of threat as it spread through training camps. With soldiers falling ill, malaria began to impact national security.
The widespread nature of this disease provided the PHS with its first large-scale venture into disease control within the United States. The PHS quickly learned that the fight against malaria was costly. The government, concerned about the health of its military in the middle of a global conflict, granted additional funding to the PHS for malaria studies.
At the very beginning of the United States involvement in World War II, the PHS established the Office of Malaria Control in War Areas (MCWA). It was headquartered in Atlanta, with field stations literally all over the country. In addition to the Emory Malaria Field Station on Ichuaway Plantation, there was the Henry Rose Carter Laboratory in Savannah, and many others throughout the Southern states and beyond. There was even a dengue fever control operation in Honolulu.
At the conclusion of the war, MCWA had assembled a highly competent group of disease control specialists with working relationships with the states. Dr. Joseph Mountin, the Chief of the Bureau of State Services of the Public Health Service and Assistant Surgeon General, recognized this and conceived of the “Centers” concept. Dr. Mountin envisioned several centers that would make available to state health departments certain highly specialized know-how that few states could afford to maintain on their own. He was a visionary public health leader with high hopes for this small and, at that time, relatively insignificant branch of the Public Health Service.
On July 1, 1946, the Surgeon General of the Public Health Service directed that the designation of the office of Malaria Control in War Areas in Atlanta be changed to the Communicable Disease Center. CDC was organized based on MCWA administrative model with headquarters offices located at Broad, Luckie, and Forsyth Streets in downtown Atlanta with a Laboratory Division at the Lawson Veterans Administration Hospital in Chamblee. One year later, recognizing the value of having a federal agency headquartered in the city, Coca-Cola President Robert W. Woodruff brokered an agreement with Emory University to sell fifteen acres of land off Clifton Road to the federal government for ten dollars.
Today, CDC has two major campuses in Atlanta: the Chamblee campus on Buford Highway, which houses the National Center for Environmental Health and the National Center for Chronic Disease Control and Prevention, among other areas; and the original campus on Clifton Road.
In 1947, the World Health Organization (WHO) gathered an international panel of experts to propose solutions to prevent pandemic influenza. The panel recommended establishing a collaborative body to collect and study influenza viruses, distribute information, and coordinate laboratory work on a global scale. The following year, the Global Influenza Programme was approved, and the World Influenza Centre was established in London to serve as a global reference laboratory. By 1952, the Global Influenza Programme comprised a worldwide network of laboratories called the Global Influenza Surveillance Network. The network still exists today under a slightly different name, the Global Influenza Surveillance and Response System, and continues its mission to protect the world from the threat of influenza. The GISRS has 144 National Influenza Centers designated by 114 Member States across the globe.
In 1956, WHO designated CDC as a Collaborating Center for Epidemiology, Surveillance, and Control of Influenza. One year later, a novel influenza virus emerged, triggering a pandemic. Similar to its work today, CDC took a leading role during this pandemic by facilitating influenza surveillance and epidemiological activities. CDC’s research guided the PHS as it developed state-by-state plans in response to the pandemic.
Under the system developed by the PHS, each state would receive an allotment of influenza vaccines determined by its population size, and vaccine manufacturers would distribute the vaccine through commercial networks. As pandemic influenza vaccines were initially limited, Surgeon General Leroy Burney determined that “priority groups” (those considered to medically high risk by a physician, healthcare workers, police, those in communication services, etc.) should receive a vaccination first. After this point, the priority system, in many instances, was not followed.
After the 1957 pandemic, the Advisory Committee on Influenza Research noted that excess deaths (more deaths than would be expected) occurred in pregnant women, elderly people, and people with chronic health conditions. To prevent these excess deaths from occurring in these groups in the future, the U.S. Surgeon General recommended in 1960 that people in the at-risk groups, people in close contact with people from those groups, and healthcare workers receive a flu vaccine annually and charged CDC with creating plan to educate professionals and the public about annual influenza vaccinations .
Each year, as part of the work undertaken as a WHO Collaborating Center, CDC monitors circulating influenza viruses for any changes in the viruses. CDC then takes this data and provides the information to other WHO Collaborating Centers for vaccine recommendations for both the northern and southern hemispheres.
CDC has an established role in facilitating vaccine recommendations—particularly when it comes to childhood illnesses and influenza. Prior to the 1960s, the distribution of vaccines and other life-saving medical treatments was limited. Communities who were most vulnerable to communicable diseases—particularly in the southern and western US—were oftentimes the communities with fewer public health resources.
Before 1962, no formal immunization program existed in the United States. Private practices and local health departments administered vaccines, paid for by out-of-pocket funds or provided by using state or local government funds. Then, in 1962, John F. Kennedy signed into law the Vaccination Assistance Act with the aim of achieving “as quickly as possible the protection of the population, especially of all preschool aged children. . .through intensive immunization activity over a limited period of time.” This bill allowed CDC to support intensive preventative vaccine campaigns across the country. As a result—and the annual renewal of funding to support state and local health agencies—most vaccine-preventable diseases have declined to historically low levels.
By studying the scientific and social history of past public health responses, such as those associated with the influenza viruses, one can become better prepared for future public health events, including pandemics — like the one we are facing today. Parallels can be drawn between every flu pandemic of the 20th and 21st centuries and the current COVID-19 outbreak.
Social distancing is not a new phenomenon—just a new title for a century-old technique. During the 1918 influenza pandemic newspapers, pamphlets, and educational campaigns called for closures of public parks, theatres, and schools. These practices, advised by the PHS, follow the same tenets that now guide our quarantine in 2020.
A century ago, like today, publications encouraged hygienic practices, like covering coughs and sneezes, wearing cloth facemasks, and washing hands with clean water. Also, like the 1918 pandemic, there are (at the time of publication) no vaccines or pharmaceutical countermeasures to combat COVID-19.
While it’s easy to compare COVID-19 to the 1918 pandemic, it’s important to keep two things in mind. First, CDC didn’t yet exist in 1919. We now live in a time when an entire federal agency is dedicated to the study and eradication of contagious diseases. Second, because of CDC’s work in establishing pandemic preparedness plans, we are better prepared than we were a century ago. In other words, we are much more prepared than we were a century ago.
Adapting lessons learned from the National Influenza Immunization Program in 1977, CDC (in partnership with other federal agencies) drafted the first U.S. pandemic plan. Prior to 1977, most infectious disease research being done in the US centered around containment, not prevention. The new pandemic plan put forth by CDC was forward facing—evaluating pandemic risk factors, containment policies, as well as strategies for prevention.
In 2005, the National Strategy for Pandemic Influenza was published providing a clear plan on what we should do during an influenza response. In subsequent flu outbreaks, CDC relied upon decades of pandemic preparedness plans to lead the response.
With the spread of COVID-19 and the implementation of social distancing and methods of communicating through a crisis, it’s clear that we’re living through a new age of history. Just as our understanding of communicable disease changed 100 years ago, it continues to grow and shift today. What Atlanta and CDC offer this brave new world is knowledge, tried and tested, and ever-expanding.
We would like to thank Louise E. Shaw, Mary Hilpertshauser and Heather Rodriguez from the David J. Sencer CDC Museum for their contributions to this piece. Their work in Atlanta is invaluable to both public history and public health communities around the globe.