Georges Benjamin could not have picked a more turbulent time to take the reins at the American Public Health Association.
A little more than a year removed from the terrorist attacks on the World Trade Center and the Pentagon and the anthrax scare, worries about bioterrorist attacks and other public health crises were still pervasive, especially with outbreaks of severe acute respiratory syndrome making headlines. Questions abounded about the capacity of the nation's public health system to handle such emergencies.
Since Benjamin took over as executive director at the APHA on Jan. 1, 2003, problems with the flu vaccine supply and the threat of an avian flu pandemic have only further put the nation's public health system in the spotlight.
But for Benjamin, such high-profile threats are not what worry him the most. Rather, it's when all appears calm on the surface.
"When public health is working well, you don't notice it," he says. "As a result, we're often the last to receive funding."
John Nelson, immediate past president of the American Medical Association, put it this way: "What seems to happen, you keep getting asked to do more and (legislators) keep cutting your budget; and every time they cut your budget they don't take away what they've asked you to do, they add to it."
The oldest and largest public health organization in the country, the APHA is made up of more than 50,000 members from all sectors of public health, including laboratory workers, physicians and teachers. And as its name would imply, the association advocates for all areas of public health including the environment and anti-smoking campaigns as well as fighting chronic and infectious diseases.
Without trying to sound alarmist, Benjamin warns that even without a disaster, natural or man-made, the nation's public health system faces daunting challenges. For example, in less than a decade, about half of the nation's public health workers could be lost because of retirement. The nursing shortage has been well-documented and Benjamin says that despite funding increases for public health programs immediately after the Sept. 11 attacks, cuts in the president's budget proposal for 2006 will compromise progress made since the attacks. Included in Bush's 2006 budget proposal is a $470 million cut to the Centers for Disease Control and Prevention and a $454 million cut to educational and training programs for health professionals.
Despite political and legislative efforts to improve the public health system -- a wide-ranging network including such organizations as hospitals, the CDC, the National Institutes of Health, public health providers, community health centers and educators -- Benjamin says, "I've argued for some time that we really don't have a strategic blueprint for healthcare in America."
Diverse membership, agenda
An internist by training, Benjamin entered medicine almost by accident, he says. Working in emergency rooms during the early days of his clinical career exposed him to the difficulties that the nation's patchwork healthcare system faces. That experience, he says, clarified for him that he could do more for Americans' health as an advocate for changing public health policy than he could as a doctor.
Benjamin's role at the APHA, according to those in the public health arena, has been to not only advocate for a wide range of issues -- such as safe-sex practices, the uninsured and the need for more federal funding -- but also to navigate a diverse APHA membership with many different political leanings.
Says Patrick Libbey, executive director of the National Association of County and City Health Officials, "When you have so many disciplines and viewpoints, developing a vision is difficult."
At the same time, the 52-year-old father of two has had to attract the attention of lawmakers for an organization that had been functioning below the radar in a Washington landscape dotted by lobbyists, advocacy groups and public-interest organizations. While the APHA may be well-known within the healthcare community, in the halls of Congress, its identity was something of a question mark, observers say.
Now 2 1/2 years into Benjamin's tenure at the APHA, those in the public health arena have only good things to say about him and the job he's done advocating for public health issues.
"He's not a flamboyant leader. It's always about the issues with him," says John Lumpkin, vice president of the Robert Wood Johnson Foundation. "I think what has improved is, (the APHA) is considered now to be more of a mainstream organization."
Benjamin first got into medicine as a matter of serendipity. As a child, he was one of those youngsters who spent his free hours trying to figure out his world through a microscope. By the time he was in high school, he had mapped out his future -- he would study biology in college then become a gene splicer, he says.
"I understood very early on the potential of reorganizing genes and recombining genes," he says.
But while a student at the Illinois Institute of Technology, as he was assisting a doctoral student on a project, he remapped his life. The student's project was on sickle cell anemia, a disease that had killed Benjamin's brother. While on that project, he says, he found that he lacked the clinical knowledge to complete the project and had to research the topic in the university library. Eventually, a friend threw out the idea of medical school to Benjamin, and the proverbial light bulb went on.
After graduating from the University of Illinois College of Medicine, he worked on the clinical side for about a decade, becoming chief of emergency medicine at the Walter Reed Army Medical Center in Washington and chairman of the Department of Community Health and Ambulatory Care for the since-closed District of Columbia General Hospital.
In 1995, after working in Washington, first as the acting commissioner of public health and later as director of Emergency Medical Services, he was named deputy secretary for public health at the Maryland Department of Health and Mental Hygiene. In 1999, he was named secretary of the department. While there, he oversaw a budget of $5 billion, led the delivery of the state's health services and regulated Maryland's healthcare delivery system and its financing system, including Medicaid.
In late 2002, Benjamin was named executive director of the APHA, replacing Mohammad Akhter, who had held the position for six years. Benjamin was given a three-year term.
While Benjamin says he went to the APHA because "It just seemed to me time to begin to try to impact national health policy in a broader way," his departure from the Maryland health department was also the result of shifting political winds. In 2002, Gov. Parris Glendening was set to leave state government because of term limits. In November of that year, Robert Ehrlich was elected as the first Republican governor of Maryland in nearly 40 years.
But just as Benjamin was ready for change, so apparently was the APHA. While the association is one of the standard-bearers of public health, it has also been seen by some as historically having had very little legislative influence, particularly in comparison to the AMA and the American Hospital Association.
"My sense, prior to Georges, was that APHA worked at exercising its influence more within the public health arena and the policy points within the international and national health communities, and less so in the political dimension where public health is one of a number of issues and oftentimes not a major issue," Libbey says.
Nelson of the AMA put matters more bluntly, saying lawmakers care only about votes, and when it has come to public health issues, advocates have found it difficult getting legislators to act because public health issues -- except in times of emergencies -- generally don't translate to votes.
By Benjamin's own admission, the APHA hasn't been completely successful in getting Washington to understand the challenges facing the nation's public health providers. But observers say Benjamin has been effective in using his experiences as a state government official and a clinician to bring greater focus to those issues.
"I think he understands the systems in which he works, the policy systems, the administration systems, the legislative system, the public health system itself," Libbey says, and rather than focusing on specific legislation, the APHA is now concentrating on raising the profile of public health as an issue before Congress.
Benjamin offers a mixed assessment of the state of the nation's public health system, saying that even with the most basic programs, such as immunization efforts, government officials have stumbled.
"We're playing a shell game," he says. "We've put in place programs to immunize children but we don't keep up with the infrastructure costs" to meet future needs.
As Congress looks for $10 billion in cutbacks in Medicaid, Benjamin also expresses concern about the consequences if the reductions aren't done correctly. In particular, he points to recommendations from the National Governors Association to charge higher copayments to beneficiaries to access services. While the NGA says that beneficiaries need to be more aware of costs, Benjamin says forcing people who are already struggling financially to pay more for healthcare carries the risk that it will drive up costs if beneficiaries skip basic care, eventually leading to even more serious health problems.
"For most Americans in the program, that's going to be regressive. These individuals are very price-sensitive," he says.
Rather than cutting services, Benjamin says lawmakers need to look at savings from administrative costs, crack down on fraud and abuse in the program and cut prescription-drug costs. Like other organizations, the APHA would like to see the federal government negotiate directly with drug manufacturers for lower drug prices in Medicare and allow reimportation of prescription drugs from other countries.
Most of all, though, Benjamin sees the uninsured as the nation's leading healthcare problem. While the administration has offered proposals calling for expanding health savings accounts and community health centers, and reforming medical malpractice laws, Benjamin says such steps are only incremental and will do little to address the core problem.
On the uninsured, the APHA supports universal coverage, though not necessarily with the federal government as the payer.
"It's a leadership problem," Benjamin says. "We have to convince the public that this is something we have to address."
His term is set to expire at year-end, but Benjamin has verbally accepted an offer for another three-year stint at the association. Benjamin, a registered Democrat, says that he looks at his career in five-year arcs and when he decides to leave the association, he has not ruled out moving into a position in the federal government, but only, he says, for an administration that is committed to healthcare issues.
"If the right president came along, I'd be happy to go into federal government," he says.
"I've argued for some time that we really don't have a strategic blueprint for healthcare in America."--Georges Benjamin
Family status: Wife, Yvette; and daughters Kali, 21, and Stephanie, 25.
Education: B.S. in liberal arts with concentration on biology, Illinois Institute of Technology, 1973; M.D., University of Illinois College of Medicine, 1978
Previous jobs: Chief of emergency medicine at the Walter Reed Army Medical Center, Washington, 1983-87; chairman of the Department of Community Health and Ambulatory Care at the District of Columbia General Hospital 1987-90; acting commissioner for public health, D.C. Department of Human Services, 1990-91; director of Emergency Ambulance Bureau, D.C. Fire Department, 1990-91 and 1994-95; deputy secretary for public health services, Maryland Department of Health and Mental Hygiene, 1995-99; secretary, Maryland Department of Health and Mental Hygiene 1999-2002.