Lisa M. Lee, PhD ’98, MS
Lisa M. Lee has some big shoes to fill. In the tradition of JHSPH greats Alexander Langmuir (MPH 1940) and D. A. Henderson (MPH 1960), she has worked as an epidemiologist, surveillance scientist and public health ethicist for more than 20 years at the local, state, and federal levels. She spent her career from 1998 to 2012 at the Centers for Disease Control and Prevention, where she led the Surveillance Science Advisory Group, which advises CDC on the science of public health surveillance, and the Institutional Biosecurity Board, which monitors dual use research of concern. As a senior epidemiologist with the CDC Division of HIV/AIDS Prevention, she led national HIV/AIDS surveillance activities including development and implementation of a new national HIV incidence and viral resistance surveillance system. She also served as the lead scientist on the national HIV prevention initiative, Advancing HIV Prevention.
In April 2012, Lee seized the opportunity to devote her full time to ethics, as executive director of the Presidential Commission for the Study of Bioethical Issues. Created by President Barack Obama in 2009, the commission “seeks to identify and promote policies and practices that ensure scientific research, health care delivery, and technological innovation are conducted in a socially and ethically responsible manner.” When she first arrived as a student at the Bloomberg School, Lee was originally interested in learning methods to measure morbidity and mortality. She wanted to understand both the numerator and the denominator—not just health outcomes, but also the population context in which they occur. She pursued a PhD in Population Dynamics (now part of Population, Family and Reproductive Health), which provided a strong basis in population measurement and sampling, and enjoyed learning demography from Stan Becker and Young Kim.
Another important mentor was Biostatistics professor Helen Abbey, who “would sit patiently with us eager youngsters and help us figure out what we’d learned in lecture. She instilled the importance of evidence in all of us, and not over-interpreting data. So many days I engage with how to accurately and appropriately use evidence and data.”
Lee’s advisor was Ron Gray, famous for his work with Maria Wawer on HIV epidemiology and prevention in Rakai, Uganda. Gray called his protégée “unquestionably an innovative leader in public health,” as well as “an outstanding public health scientist who has made major contributions to our understanding of the HIV epidemic in the USA.”
Today, Lee calls herself “a very proud Hopkins grad” who is “immensely appreciative of what I learned as a student and how I apply it as a professional. I’m constantly thinking, ‘this is where my Hopkins experience is coming into play.’”
As the lead editor of Principles and Practice of Public Health Surveillance, 3rd edition (Oxford University Press, 2010), Lee drew from her experience at CDC as Chief Science Officer in the Office of Surveillance, Epidemiology, and Laboratory Sciences. Lee mused on the changes and continuities since the days of Langmuir and Henderson: “The idea that every new technology is going to dramatically change public health surveillance is a little off-target. We’ve consistently practiced it despite major changes in technology. In the early days, it was all written by hand and delivered via U.S. mail. Then we did reporting by telephone, then computer, and each time we asked, ‘will this change everything?’ I think fundamentally, the system in this country has stayed the same, especially the ethical principles, regardless of the technology. Privacy was also a major concern for people in the paper age. What has changed is one of the seven steps: how we collect the data. I used to sit in the basement of hospitals reviewing stacks of patient charts. Now that’s extremely rare.”
Of her career trajectory from epidemiology and demography to HIV to bioethics, Lee observed, “I started working in HIV in the mid-1980s. It didn’t take long for the ethical issues to start lapping at my ankles. Working with reproductive epi and HIV/AIDS, I needed a framework other than just epi and demography. These issues required dealing with diverse groups of people and ensuring justice and equity for people who have little social capital. At CDC, we had to consider two important priorities: individual autonomy as well as what’s best for a community, and that required an ethical lens. It was the perfect opportunity for me to combine scientific and ethical work.”
Lee emphasizes that the 11-member commission “has to remain agile and flexible. The commission can determine what topics it thinks are important—they have their fingers on the pulse of what matters in bioethics.” The first report Lee worked on as executive director was close to her heart: Privacy and Progress in Whole Genome Sequencing. She consulted with Dr. Debra Matthews, Assistant Director for Science Programs for the Johns Hopkins Berman Institute of Bioethics. Lee said that working on the report “brought together for me public health data collection and privacy/justice issues. We had to determine how to collect data to advance science in a way that is respectful and minimizes intrusiveness.”
Lee, who served as Associate Editor for the Journal of Pediatric Infectious Diseases, says medical countermeasures (MCM) in pediatric research presented the commission with its hardest ethical questions to date. MCM is a catchall term for the use of federally-regulated drugs and products in response to chemical, biological, radiological, and nuclear attacks. Some are already FDA-approved, such as doxycycline against the spread of bacteria, but others are not yet approved, and studying them raises additional ethical questions. The commission’s report dealt with how to ethically manage the government’s obligation to protect children from research risks as well as its obligation to ensure that the country is prepared to care for the population in the case of a bioterrorist attack.
Lee described pediatric medical countermeasure research as “this troubled place where we have to decide how to reconcile the tension between putting children at risk while still developing effective immunization methods.” The challenge, Lee stated, was that “in a vacuum of information, without knowing the probability that the need for countermeasures might arise, can we conduct research for which we hope never to use the results?”
Lee noted proudly, “we’re the first presidential commission to webcast all our work. Anyone who’s interested can be involved. Last year a bioethics class watched the live meeting webcast and skyped in to talk with some of our members. It’s extremely rewarding to be involved in a public bioethics approach, talking about things that affect us all.”
The commission does sometimes hear individuals with unorthodox opinions, and its website provides an easy way for anyone interested to submit comments or questions. “The beauty of a pluralistic society,” Lee explained, “is that we get many different opinions. The commission is extremely committed to evidence-based decisions. Those ‘tails of the bell curve’ are important, because they help us see where the edges are. In a democratically deliberated process, it’s important to consider all perspectives. Everyone must come to the table willing not only to voice their perspective, but also to listen to others and find similarities that allow us to come to consensus or compromise and move the ball forward.”
For her path breaking leadership in health care ethics, Lee received the 2014 Pellegrino Medal from the Healthcare, Ethics and Law Institute at Samford University in Birmingham, Alabama. Her Pellegrino Medal talk was titled “Requiring Immunizations for Health Care Workers: Fair and Just?” Whereas most discussion about immunization ethics centers on older people or young children, Lee chose an example where the entire community’s welfare was very much at stake: immunizing adult health professionals in order to protect their patients. Even though immunization is “one of the most amazing public health successes, it works best when everyone does it. Like stopping at a four-way stop,” Lee said, “benefits accrue to individuals only when everyone participates—that is herd immunity. The clinical ethics framework doesn’t quite fit to justify requiring workers to be immunized; it is too focused on the individual. We have to involve public health ethics as well to get to the place where we can wrestle with the ethical considerations of requiring healthy workers to be immunized to protect vulnerable patients. Then it’s a matter of adding justice: equity and opportunity for all people.”
Currently, Lee is interested in the intersection of bioethics pedagogy and public health ethics, and is urging schools of public health to do more in these areas. “We [in schools of public health] have so much to offer in terms of enriching the ethical decisionmaking processes of professionals in our field. Infusing ethics into all aspects of public health research, policy, and programs can broaden individual disciplinary approaches and improve our practice. More than interpreting a two-by-two table or the most sophisticated multi-level statistical models, our decisions about what to do must include the question of what is right for this community?”
By carefully balancing the questions of what’s right for the community with what will keep the most people healthy and safe, Lee is following in the legendary footsteps of her CDC forebears—and creating some big shoes of her own for those who will follow her.