Government Service as a Public and Personal Good

First Government Position

My first experience of government service came through an entry-level assistant director position at the National Cancer Institute (NCI), where I worked on the Community-Based Cancer Control Program. Today, we would call the model community-based participatory research. It was there that I was mentored by Ruby Isom, DrPH, who was a graduate of the University of North Carolina at Chapel Hill School of Public Health’s Health Education Department. Ruby was a gritty, direct woman who came out of Appalachia by way of military service and had no difficulty telling us what we did well and not so well. She was tough, no one was coddled, we learned how to take feedback, and we all improved under her guidance. To this day, this was some of the toughest, most meaningful, beneficial, and lasting feedback I ever received. The programs on which we worked were among the first large investment programs at the NCI charged with evaluating impact. We invited a number of public health and evaluation greats, like Carol Weiss, PhD, and Lawrence (Larry) Green, DrPH, to advise us. Dr. Lester Breslow, a physician and then dean of the UCLA School of Public Health, was one of the principal investigators. We were building the science of community-based intervention, although we did not call it that at the time, and we lacked notions of evidence-based interventions.

Working at the NCI, 3 years after graduating with an MPH degree, gave me opportunities to gain a macro-level, national perspective that has forever informed my world view. What I mean by that is that I learned how the NCI worked by being there, observing and trying to navigate it. I saw individual grants as a package rather than only the work of individual principal investigators and their research teams. I experienced the organization’s constraints and understood why we could not give every group what it wanted. Moreover, I gained a strong sense of accountability regarding taxpayer funds and the importance of focusing on impact. Legislators, on behalf of citizens, expect that federal funding produces value, and they should.

Recognizing that I needed additional academic preparation, I left the NCI to study at, then, the Johns Hopkins School of Hygiene and Public Health, under Professor and Chair, Larry Green, DrPH, who reinforced the value of public service when he left Hopkins to serve as first director of the Office of Health Information, Health Promotion, Physical Fitness, and Sports Medicine for the Department of Health and Human Services, creating the first Healthy People efforts, with J. Michael McGinnis, MD, MA, MPP. To this day, Larry is one of my most significant mentors, and a colleague and friend. (See Green, 2016, for Larry’s own reflection on government service.)

I graduated from Hopkins with a DrPH and went to work first at the Fox Chase Cancer Center, in Philadelphia, PA, and then at Duke University School of Medicine. Fox Chase was a wonderful organization, with outstanding people and services, and substantial collaboration across the basic, clinical, and population sciences. One Saturday, a group of us took a 26-mile walk on the Delaware Canal. (It had not started out as 26 miles!) The group was representative of the interdisciplinary collaboration that was special about Fox Chase then; it included a couple of epidemiologists, a clinical scientist, Barry Blumberg, a Nobel Prize scientist who had done the fundamental work that led to the HBV vaccine, and me. Barry regaled us with fascinating stories about his career and discoveries. He knew the name of every tree and flower along the way. Through those years, with the mentorship of Dr. Paul Engstrom and colleagues (including Tracy Orleans, PhD), we built an intervention research program, contributing innovations in behavioral research, including the application of stepped care, from hypertension, to mammography and smoking cessation, and the development of tailored interventions. We designed and tested what were shown to be effective, even cost-effective, interventions. Once we had finished the trials, it was left to us to find organizations to sustain them, a time-consuming, frustrating task that was not always successful. That experience drove some of what I did when I went to the NCI. I was determined to institutionalize methods for sustaining effective interventions.

I moved to Duke University after 10 years at Fox Chase. While at Duke, I was asked to serve on an NCI evidence-review committee about the effectiveness of mammography for women of different ages, particularly women in their 40s. Partly as a result of the exposure our report received, I was appointed by President Clinton to chair the National Cancer Advisory Board, becoming the first woman and behavioral scientist in that presidentially appointed role. We worked through some difficult issues, including highly contentious debates about mammography (Meissner, Rimer, Davis, Eisner, & Siegler, 2003; Rimer & Bluman, 1997; Rimer, Halabi, Strigo, Crawford, & Lipkus, 1999), when we concluded that there was a rationale for recommending mammography for women in their 40s.

I worked closely with the new director of the NCI, Richard Klausner, MD, one of the most charismatic people I have ever known. After several reviews of the Institute’s cancer control programs (e.g., see NCI, 1997), Klausner decided it was time to reorganize these programs. He asked me to create and lead a new Division of Cancer Control and Population Sciences (DCCPS), ultimately, with more than $400 million per year in budget authority. Klausner believed that fundamental work on prevention and the clinical aspects of prevention were different and should be placed in a separate division, the Division of Cancer Prevention. DCCPS should include strong epidemiologic research, surveillance, and health services research, and, for the first time, basic biobehavioral research as well as a larger portfolio of behavioral research. He also put survivorship research in the new division. Having recently received the center grant of my dreams, I told Klausner on three separate occasions that I could not possibly leave Duke. Then, one night when we had a National Cancer Advisory Board meeting, he drove me to the Jefferson Memorial, reminded me about Kennedy and public service, and about how a new division could influence the future of cancer control far more than could I or any individual scientist. I said yes.

Government Service: The Power to Transform

Klausner was right about the reasons I should go to the NCI. In my prior positions, my colleagues and I had created and tested cancer control interventions that were effective and improved cancer-related outcomes. In self-reflective moments, I knew those interventions alone were not going to shift the cancer burden dramatically. Our new division, DCCPS, would have the resources to redirect fields and shape how research was conducted. That could be huge.

It was a heady time; the economy was good, President Clinton was in his heyday, and the National Institutes of Health (NIH) budget was doubling. I remember a very hot Washington day when colleague and former Hopkins classmate, Michael Ericksen, ScD, then leading the Office of Smoking and Health at the Centers for Disease Control and Prevention (CDC), and I waited in the Rose Garden for President Clinton to announce the decision to regulate tobacco under the Food and Drug Administration’s authority. We were two Hopkins graduates from the same cohort, participating in an exciting, game-changing moment. We knew that it was a turning point for big tobacco, and that this act, in itself, could save millions of lives.

Yet there was another side of government service, the intrusion of politics. At a meeting Vice President Al Gore attended, he told me that we, at the NCI, only should talk about youth smoking, because it was less contentious than adult smoking. We found workarounds, but it was disappointing how often politicians wanted us to toe the line to their positions, even when the result was a diluted message.

At DCCPS, with deputy director Robert Hiatt, MD, PhD, who came from Kaiser Permanente, we created a new vision for cancer control and population sciences (Hiatt & Rimer, 1999), developed program innovations, changed what people studied, put efforts into place that influenced not just the NCI but also other NIH institutes and cancer organizations, and we developed tools that enabled citizens, organizations, and legislators to get a more accurate picture of the cancer burden. We influenced what was fundable and the mechanisms that were used for funding. It was transformative and incredibly satisfying.

We supported research collaborations that brought numbers (of studies, samples, investigators, mutations) to bear in answering questions about genetics, new models for health services research, including economics, transdisciplinary research, communications research, team science, and dissemination of evidence-based interventions. As an example, beginning in 1999, initially, in a groundbreaking partnership with the Robert Wood Johnson Foundation and National Institute for Drug Abuse (NIDA), we funded Transdisciplinary Tobacco Research Centers (TTURCs; Hall et al., 2012; Morgan et al., 2003; Turkkan, Kaufman, & Rimer, 2000). Although the transdisciplinary concept had been developed earlier (e.g., as reported by Rosenfield, 1992), it was new to the NIH and NCI. In fact, when we presented the concept to the NCI’s Board of Scientific Advisors, one of the members suggested that we had made up the word. Nevertheless, the Board of Scientific Advisors approved the request. TTURCs were a new way of studying and influencing tobacco and nicotine use—bringing together basic, behavioral, statistical, health services, epidemiologic, and other scientists who would gain transdisciplinary understanding about addiction through the combinations of scientists at the table and the kind of work they did (see NCI, n.d.-d). TTURCs have made powerful advances in understanding addiction and demonstrated the value of transdisciplinary methods (Rimer & Abrams, 2012). With funding from the Robert Wood Johnson Foundation, we studied how researchers and others collaborated in these transdisciplinary settings and examined processes and outcomes associated with TTURCs. We also facilitated the study of team science by a group within the division, using new methods (some contributed by William Trochim, PhD) to understand how effective teams were created and how to enhance the functioning of such teams (Croyle, 2008; Hall et al., 2012; National Academy of Sciences, 2005; Stokols et al., 2010; Trochim, Marcus, Masse, Moser, & Weld, 2008).

Having reinvigorated the study of tobacco use, we recognized that communications research needed a similar injection of energy and innovation and created and funded Centers of Excellence in Cancer Communications Research (CECCRs; NCI, n.d.-b). We also studied the process of collaboration within these centers, contributing to lessons learned about team science. Later, a similar model was used to study diet and energetics (see NCI, n.d.-c).

Under the leadership of Gary Kreps, PhD, and Brad Hesse, PhD, the Health Information National Trends Survey (HINTS) was developed and became the definitive survey on cancer-related communication, still active and valuable today (see http://hints.cancer.gov/), with emphasis on wide access to the data and a track record of asking important, interesting questions.

Reflecting on my and others’ experiences as researchers, and with growing calls to ensure that the results of research benefit people, we created the first unit at the NIH focused on the dissemination of evidence-based interventions, led, initially, by Jon Kerner, PhD, and now by David Chambers, PhD. We partnered with the CDC in supporting the Task Force on Community Preventive Services (see http://www.thecommunityguide.org/) for its work in reviewing the evidence on interventions, many of which were relevant to cancer control and population sciences. We developed Cancer Control P.L.A.N.E.T. (NCI, n.d.-a), a resource for collecting highly curated evidence-based interventions that could be downloaded and used by anyone. Over time, the focus evolved to implementation science (see http://cancercontrol.cancer.gov/is/; Sivaram, Sanchez, Rimer, Samet, & Glasgow, 2014). It took the platforms of government, with the status, scale, and resources of the NIH, to institute the new programs we created, internally and externally. Federal service can allow government teams, in partnership with the extramural community, to shape, influence, and achieve and sustain impact on a scale rarely possible in individual academic careers.

A Division That Continues to Innovate and Inspire

I am deeply proud of the people we hired—including some who never expected to work for government but were compelled by the opportunity to be part of something bigger than their own work; who understood the potential to influence the future of science, to create tools used by millions of individuals, and, by their collective efforts, to affect the health of millions and millions, not just in the United States but around the world. These are the ultimate reasons for federal service. Together, current director Dr. Robert Croyle and his outstanding team continue to reflect on, revise, redirect, innovate, invent, and reinvent key features of DCCPS and its priorities and programs (see http://cancercontrol.cancer.gov/bb/index.html).

I am grateful that researchers, including Drs. Neeraj Arora, Robert Croyle, Russ Glasgow, Brad Hesse, Robert Hiatt, Jon Kerner, Bill Klein, Scott Leischow, Joe Lipscomb, Glen Morgan, Bryce Reeve, Julia Rowland, Steve Taplan, Vish Viswanath, and many others joined DCCPS (some after I left the NCI). They were outstanding leaders and colleagues who have left their amazing imprints—some still in their NCI positions today. Bob Croyle continues to lead the division—one of the most effective leaders anywhere. None of the work would have been done nearly as well without the daily excellence of NIH employees like Ellen Moul, Arlene Sanchez, Stacey Vandor, and Bob Vollinger; Drs. Rachel Ballard Barbash, Nancy Breen, Brenda Edwards, Eric Feuer, Helen Meissner, Deborah Winn, and so many others. Colleagues like Dr. Dinah Singer, division director for Cancer Biology, became trusted confidantes and friends. To name a few people is potentially to dishonor the hundreds of others without whom the day-to-day life of the organization would not flourish. There are so many outstanding employees at the NCI and NIH that it would be impossible to name them all. And while I use the word “we” as a convention, it was often they who turned vision into reality. I left the NCI a year into the next administration, when I consistently found myself uncomfortable with their style and positions.

Over the years since I arrived at the NCI in 1997 to work under Dr. Richard Klausner, there have been several subsequent NCI directors, all committed to accelerating progress against cancer, some more effective than others. I particularly admire Harold Varmus, MD, under whom we worked when he was the NIH director from 1993 to 1999. I had the privilege of working with Dr. Varmus again when I was appointed to chair the President’s Cancer Panel in 2011 (staffed by another great group of NIH employees, led by Abby Sandler, PhD). Varmus is brilliant and incisive and was a real inspiration and guiding force for our work on accelerating HPV vaccination (President’s Cancer Panel, 2014).

Government Service as a Public and Personal Good

It is with gratitude and nostalgia that I look back on the years I worked at the NCI—and the community of people, internal and external to the NCI and NIH, who made such a difference. It was a privilege to lead the DCCPS. Working in multiple sectors, including government, can produce value for individuals and their organizations—and benefit the public’s health. I emerged from government service with an even stronger commitment to delivering measurable impact. Working for government teaches these lessons, and the lessons can be applied to public universities, especially. Understanding that citizens and legislators expect us to deliver impact is not something that is in the DNA of all faculty members, but it is helpful if some feel the call to impact in a visceral way.

Working for the NIH benefited me, the NCI, and my current employer, the Gillings School of Global Public Health at the University of North Carolina at Chapel Hill. For example, by participating in multiple grant reviews, I absorbed many important lessons about how to write effective grants. The first grant I wrote after leaving NCI received an outstanding score. Running a division that was, in many ways, similar to the elements in a school of public health prepared me for being dean. I was steeped in the literature of many public health disciplines while at the NIH and approached my role as dean with curiosity about many fields and modest understanding of some.

It is exhilarating to translate ideas into effective national programs, and that is one of the most important reasons to work at the national level, but the NCI experience was not all positive. Soon after I began work there, I was nearly overwhelmed by the bureaucratic machinery and became pessimistic that I could ever learn to function within it. I learned that, rather than my mastering it, we needed administrative staff who adroitly knew how to do business effectively. And while there were so many remarkable people, there also were dysfunctional employees. The challenges involved in removing them were so daunting that few attempted to do so. Moreover, over time, the growing politicization of NIH became disturbing. Those of us in leadership were subjected to strong advice about what we could and could not discuss. To date, fortunately, most efforts to legislate behavior and speech at the NIH have failed.

What is the takeaway? While not for everyone, I encourage students and established faculty members to consider government service not only for lifelong careers but also, potentially, for more defined periods (e.g., through expert or visiting appointments). The perspective one gets from working for the NIH, CDC, and other government agencies can help in developing a larger view of science, research, and advocacy. Working in multiple sectors can provide the opportunity to refresh one’s thinking, get and generate new ideas, broaden experiences and networks, and apply one’s knowledge and skills on a larger stage to benefit the public’s health.

Alex Pattakos (2014) wrote, “Managing the public’s business has never been more important than it is today, and the pursuit of excellence in government at all levels has never been more needed to restore public confidence in our societal institutions.” That brings us full circle to John F. Kennedy, who so wisely charged a generation: “Ask not what your country can do for you—ask what you can do for your country.”