UCSF's influence extends far beyond the city limits of San Francisco.

Walter Orenstein, director of the National Immunization Program at the Centers for Disease Control and Prevention (CDC), worked nonstop last winter to respond to the early onset of a particularly lethal form of the flu.

Orenstein, who served two years of his pediatric residency at UCSF during the early 1970s, is among more than two dozen former or current UCSF affiliates or alumni who are making a difference at the CDC, working to protect humanity from the world's most deadly public health threats. From the top down, the CDC team includes UCSF-trained and -educated health professionals engaged in guarding against everything from anthrax exposure to zoonotic diseases at the nation's leading public health agency.

Orenstein says the UCSF-CDC connection is understandably strong. "There's a real interest in prevention and a real commitment to the intellectual pursuit of disease prevention and public health programs," he says. "UCSF helped in fostering that interest and commitment."

After some 23 years at the CDC, Orenstein says he sees a real change in the way the agency operates since Julie Gerberding, an associate professor of medicine who began as an intern in June 1981 and rose through the ranks at UCSF, became its director in July 2002. "Julie is really focused on trying to get timely messages out to the public and health professionals," Orenstein says. "We're being much more responsive, improving our preparedness and response mode, and we're much more sophisticated in dealing with emerging threats."

That's reassuring news, given that the CDC is facing extraordinary health hazards. Unlike her predecessors, Gerberding and the CDC team are confronting a world forever changed by the September 11, 2001 terrorist attacks in the US and the ongoing dangers posed by the war on terrorism. "If you want to transform an organization or a culture, it sometimes takes a crisis," Gerberding said on her last visit to UCSF. "We've taken on new responsibilities and new requirements as we've gone forward."

Gerberding calls the atypical barrage of public health threats - whether natural phenomena or man-made - the 'new normal,' and she is spearheading a profound transformation at the CDC to prepare it for the 21st century. The goal is to study complex public health problems from a variety of perspectives and to constantly translate that scientific knowledge to protect and save lives.

Importantly, the CDC has established readiness teams and systems to ensure that highly skilled investigators are ready to respond to any public health emergency. The CDC's transformation also involves improving coordination, communication and cooperation among its many divisions, sister agencies within the Department of Health and Human Services, and across the US government, health care organizations and public health allies at local, state, national and international levels. Under Gerberding's direction, the CDC also is promoting across-the-board collaboration within the agency and with its many partners around the world. Breaking down arbitrary and obsolete barriers, is after all, the cornerstone of scientific success at UCSF, where Gerberding spent years as an infectious disease expert.

Says CDC Medical Officer Danny Feikin, who served his residency in internal medicine at UCSF: "Going to investigate an outbreak with other epidemiologists or working on a big outbreak, like anthrax or severe acute respiratory syndrome (SARS), reminded me of the team approach and cooperation and the rapid pace of my UCSF residency."

Gerberding, who earned a master's of public health degree from UC Berkeley in 1990 and first joined the CDC in 1998, was promoted to director a year and a half ago, in part because of her outstanding leadership of the CDC's response to the anthrax attacks of 2001.

In the months following the anthrax incidents, the CDC moved quickly to establish a communications command center so that teams could establish direct links across the US government and with its many public health partners around the world. And the CDC deployed teams of dedicated disease detectives, including Michelle McConnell, to dangerous zones in search of answers.

Fresh from finishing her pediatric residency at UCSF, McConnell went to the CDC in 2001 as one of the nation's 148 Epidemic Intelligence Service (EIS) officers sent on domestic and international health investigations. "While an EIS officer in the Division of HIV/AIDS, I was called upon to work on the anthrax attacks and was one of the first people sent from CDC to New Jersey to assist with the identification of most of the cases of anthrax there." McConnell is currently working on two presidential HIV/AIDS initiatives: To prevent mother-to-child transmission and to develop an emergency plan for AIDS relief.

Tim Uyeki, who joined the the CDC as an EIS officer in 1998, says he still maintains connections with his UCSF colleagues working at San Francisco General Hospital, where he was an attending physician for five years before being appointed a UCSF assistant clinical professor of pediatrics. "I find returning to SFGH each year to be highly stimulating, challenging and refreshing," he says. "I believe that it is very important to have clinical experience on the 'front lines' as well as the national and international public health perspective at CDC."

Uyeki also has been called to the frontlines of bioterrorism. He worked in the CDC's emergency operations center in Washington, DC, during the anthrax investigation and was part of the CDC's first response group to be vaccinated against smallpox in November 2001. Uyeki was also the first CDC staff member to go to Hanoi, Vietnam - the first country to declare an outbreak of SARS - in March 2003 after working to control the largest Ebola outbreak ever in northern Uganda in 2000. Last winter, he monitored severe illness and deaths among children with the flu in the US as part of the CDC's influenza branch.

As Feikin, a medical officer in the CDC's respiratory diseases branch, emphasizes, most health threats are not caused by terrorists. "Although the core of the CDC is still intact and we still do very exciting and important work, the 'militarization' of the institution and the focus on bioterrorism ... distract us from our focus on the real burden of diseases that are still killing 99.9 percent of people in the world."

For his part, Mark Lobato, a medical officer in the CDC's Division of TB Elimination, aims to reduce the impact of tuberculosis worldwide. The nation has made great progress tackling TB in the US, with the CDC reporting in March 2003 a ten-year decline in TB cases and the lowest-ever reported number in the nation. But the constant pressure of immigration keeps Lobato and his colleagues busy. Worldwide, the TB situation is grim and getting worse, compounded by the HIV epidemic, which is fueling TB rates. Today, one-third of the world's population is infected with the bacterium that causes TB. In sub-Saharan Africa, TB is the number-one killer.

A 1989 graduate of the UCSF School of Medicine, Lobato has long been interested in public health. He trained as a pediatrics resident at UCSF, worked at the state TB program and served a pediatrics infectious disease fellowship before joining the CDC in 1994. Lobato says the CDC-UCSF connection often goes both ways, since people come and go to scientific centers of excellence.

"Moving to the CDC seemed like a good way of combining my interests of medicine, caring for people and having an effect on a larger population, especially in the field of prevention," he says. At the CDC, Lobato applies the skills and knowledge he gained while training at UCSF. "What you learn at the local level makes your work more applicable, more real. The purpose of our program is to help local TB programs understand and to prevent TB in this country."

One continuing problem in combating TB is half-hearted patient compliance; those who stop and start medication remain infectious, eventually build drug resistance and can become untreatable. "Fortunately, we've seen a decrease in multidrug resistance with more aggressive monitoring of the patient," Lobato reports. In fact, direct observation by a doctor who watches the patient taking medication has become the standard practice since the mid-1990s.

Further success requires more federal funding. Without continued intervention, the CDC predicts that the number of new TB deaths worldwide by 2020 will swell to 35 million. "I think it is an important lesson to learn that until TB is virtually eliminated, we'll need to pay for prevention and intervention programs."

But Lobato remains optimistic. "After nine years with the CDC, I thoroughly enjoy it," he says. "We face a lot of challenges and there's always something to do. But at the end of the day, you know you've done your part to improve the world."