We focused the evaluation on five essential leadership positions at CDC or state or local health departments: CDC director, CDC center director, state epidemiologist, FETP resident advisor, and CEFOs. Though there are many other positions of leadership at CDC, we selected these five essential leadership positions based on the more readily available data sources.6 These selected positions represent varying degrees of leadership, and all these positions were also included because the structure and demands of the jobs require unique skills of critical thinking and evidence-based decision-making, particularly around surveillance, epidemiology, and statistics analysis, that EIS seeks to instill in its graduates to address public health needs at the national, state, local, territorial, tribal, and international levels.
CDC directors lead the largest public health organization in the United States, with the main objectives of improving national and global health security, reducing the largest causes of morbidity and mortality, and supporting and strengthening the collaboration between public health and healthcare systems.7 CDC center directors organize and oversee the work of their respective centers within CDC.8 Although there are other important leadership positions at the division, branch, and team levels of CDC, the historical records are not easily traceable due to CDC’s multiple reorganizations. State epidemiologists oversee state- or territory-wide programs for the surveillance, prevention, and control of diseases, coordinate epidemiologic investigations and surveys, and manage intervention services.9 State epidemiologists also coordinate disease surveillance and research activities of federal, state, and local officials in their jurisdictions, and communicate with media sources and public officials through conferences and policy briefs. FETP resident advisors are epidemiologists placed in countries around the world to provide technical and epidemiological assistance to ministries of health. Resident advisors are responsible for planning and organizing the implementation of FETPs in their host countries in a manner that best supports epidemiologic needs of the host country or region, as well as supervising and mentoring their trainees.10,11 CEFOs are federally funded CDC epidemiologists placed in state and major metropolitan health departments to strengthen their health departments’ emergency preparedness and capacity for effective public health response.12
First, we constructed a dataset with the names of people who have held each of the five selected positions. For several reasons the evaluation focused on positions held from 2000-2016 for all positions except for the CDC Director. First the CEFO program was established in 2001 the attacks of September 11, 2001so this time period included all the positions of interest. Second data was readily available through that period for all positions. Finally, for the position of CDC director we were able to obtain data dating back to 1953, so this position was evaluated across a longer time period than the rest.
Using the History section of the online CDC webpage, “About CDC 24-7” (https://www.cdc.gov/about/history/pastdirectors.htm), we found the tenure dates and names of all CDC directors and acting directors who served the agency during 1953–2016 (the first four directors who served during 1942–1953 were not included because they started their tenure before the first EIS class finished the fellowship). To compile names of CDC center directors, one investigator directly inquired with points of contact for each CDC center and the National Institute for Occupational Safety and Health and requested names and tenure dates of every director during 2000–2016. We also reviewed past CDC organizational charts, obtained using the Internet Archive (San Francisco, CA, https://archive.org/web/). For this evaluation, we defined CDC center directors as the people listed by name in CDC’s organizational chart during their respective term of service, including directors of CDC coordinating centers, institutes and offices that were not horizontally related to the office of the director in the organizational chart.13 To compile names of state epidemiologists who served during 2002–2016, we used information posted on the Council of State and Territorial Epidemiologists (CSTE) web site using the Internet Archive. The Internet Archive had copies of CSTE’s web site dating back to 2002. To compile the list of state epidemiologists who served during 2000–2001, we used appendices of MMWR Surveillance Summaries (https://www.cdc.gov/mmwr/indss_2018.html), which listed state epidemiologists for those years. We obtained a list of names and tenure dates of Resident Advisors who served during 2000–2016 from an administrative database maintained by FETP at CDC’s Center for Global Health. We acquired names and service dates of all CEFOs serving during 2001 (year in which the CEFO program began) through 2016 from CDC’s Center for Preparedness and Response, which oversees CEFOs. For all types of positions, those designated as acting or interim were not included (i.e., people serving in the role temporarily in between terms of officially hired or appointed people).
We used an internal electronic dataset of all persons who participated in the EIS fellowship since 1951, stored in CDC’s Fellowship Management System. Data elements included the first and last name of each officer, fellowship start year, host site assignment, and professional category (physician, nurse, scientist, nurse, or veterinarian). Professional categories were assessed in the following order which prioritized and individual’s clinical degree (with the finalized assignment being the first category that characterized the officer): physician, veterinarian, nurse, or doctoral scientist. For example, a physician who also had a scientific doctoral-level degree would be considered a physician.
To match names of those identified as serving in the selected leadership positions with the names of EIS alumni, we first used a probabilistic matching program14 in SAS® version 9.1 (SAS Institute, Cary, NC). The program compared first and last names in EIS’s alumni list with first and last names in lists of persons serving in each leadership position and calculated complex agreement patterns that allow for possible typographical errors. The edit distance proportion was used to develop match scores indicating the likelihood that the two records were a match. Records with match scores >0 were categorized as possible matches. Possible matches were reviewed manually. Finally, unmatched records in lists of persons serving in leadership positions were also reviewed by the authors and other EIS program staff to identify known matches that were not identified by the matching program due to last name changes or differences in name conventions (e.g., Bill vs. William). We characterized EIS alumni who had served in selected leadership positions by professional category, type of EIS assignment (CDC vs state or local health department), and geographic location of the leadership position (for state epidemiologists, resident advisors, and CEFOs). In rare instances when the EIS officer changed assignment type during the fellowship, the assignment type at the end of the fellowship was used for purpose of this analysis. Several people in the sample served multiple times in the same type of leadership position (e.g., served as CEFO in multiple states); each person was counted only once for each type of leadership position. If an individual served in more than one type of leadership position they were counted for each category they served in. This project was reviewed by CDC and was deemed non-research, as it was considered a program evaluation that included only retrospective analysis of existing data.