Ep 75: Building Trust Before Crisis

with Denise Cardo, M.D.

May 18, 2022


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Denise Cardo, M.D.
Director, Division of Healthcare Quality Promotion (DHQP), National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)

Dr. Denise Cardo is the director of the Division of Healthcare Quality Promotion (DHQP), National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention (CDC). Dr. Cardo joined CDC in 1993 as a medical epidemiologist and, after holding several leadership positions in DHQP, she was selected as division director in 2003. Dr. Cardo leads CDC activities to prevent infections and antimicrobial resistance in healthcare settings, sepsis, and to promote healthcare safety. She has been involved in several CDC responses to emerging infection threats, including to COVID-19. In addition, she has served as CDC Acting Deputy Director for Surveillance, Epi and Lab systems (OSELS) and as CDC Acting Deputy Director for Infectious Diseases (DDID). 

Prior to joining CDC, she had a distinguished career in the division of infectious diseases at one of Brazil’s prestigious medical institutions, Escola Paulista de Medicina, where she received her medical degree, completed her residency and fellowship, and joined the faculty as associated professor of infectious diseases. She also did a sabbatical at the Hospital Epidemiology Program,  University of Tennessee, Memphis. 

Dr. Cardo has been involved in healthcare epidemiology and infection prevention for several decades and is internationally recognized as an expert and leader in the area.  Her interests include patient safety, prevention of healthcare-associated infections, antimicrobial resistance, sepsis, and public health-healthcare interactions to promote health.  She is the author of several research and reviewed papers including book chapters and has received several awards for her work.


I don't accept excuses for not doing something that needs to be done.



[00:00:18] Julie Gerberding, M.D.: Welcome to our next episode of Her Story, a chance for us to have conversations with some of the most amazing women in the healthcare industry and beyond. And today, I couldn’t be happier than to be able to introduce our guests, Dr. Denise Cardo. Denise is the Director of the Division of Healthcare Quality Promotion at the US Centers for Disease Control and Prevention. And she has an amazing leadership story to tell us, but she’s also right now still on the front line of the activities at the CDC, including those related to the pandemic. So, this is your moment Denise and I would love, maybe just start with telling people a little bit about what your division is, the Division of Healthcare Quality Promotion DHQP, because not everyone even understands that healthcare quality is a really important part of public health. So tell us your story.

[00:01:16] Denise Cardo, M.D.: First I’m happy that you were saying that it’s my division because there was a while where you would say it was yours. But at the Division of Healthcare Quality Promotion at CDC, what we do is everything to really have an impact in people’s lives in terms off of protecting the patients and healthcare personnel, not just from infections they may get when encoutering healthcare systems, but also other diverse events, including vaccine safety. So we started as a small division and it has grown to a division that not only we have the MDs, PhDs, the labs, but also we have a huge number of partners that can help us having backed. So that’s the way we work. We measure what we do by infections or other adverse events that we can prevent and are preventing and the lives that we save. And really with the focus, not just public health, the focus of health. And that’s the main thing that we do.

[00:02:31] Dr. Julie Gerberding: So Denise, you mentioned these partnerships and I think one of the characteristics that I admire most in your leadership style is your approach to kind of that horizontal leadership, the partnerships, the respect, the inclusion. Tell us where that came from. Were you born being a collaborator, or is this something that you evolved and developed over the course of your career?

[00:02:57] Dr. Denise Cardo: I don’t know if I was bored, but I think I started working with other people in my life when I think about that and enjoying that, enjoying really working together to have an impact. And I think I even ended up in this field when I was in Brazil because I wanted more just being by myself, taking care of one patient and really seeing how we could add all this different strategies in ways to have more impact. And what we do, I think for me, it’s not just deciding which partners for the sake of, is this a nice partner or not? It’s which partners will really make a difference for us to achieve what do we need to achieve?

[00:03:46] Dr. Julie Gerberding: The strategic partnerships.

[00:03:48] Dr. Denise Cardo: Strategic partnership. And it has been an evolution, Julie. Many partners, it’s not that I thought, oh, it’d be great to include them, like the patients and the families, the patient families that have had something bad happen to a loved one while the person was in healthcare. Initially, I thought, oh, it’s important to know, but I never thought to sit together and plan together. And so it’s something that has evolved. And that’s what I tell people. I’m also a patient and a family member, but when I’m working, I don’t wear that hat. So it’s really bringing people with different perspectives and different responsibilities and accountabilities to move forward. It’s not easy because many of the partners initially won’t like you, or even in the process will not like you, but that’s okay.

[00:04:44] Dr. Julie Gerberding: Well, there’s always a transactional investment necessary to bring partners together and to get everybody aligned around a common strategy or at least a common objective. And I’ve seen you do that time and time again. But you also are a negotiator. I know this from watching some of the complex negotiations that have gone on with the advisory committee that takes the CDC science and translates it into infection control recommendations, for example, infection prevention guidelines in hospitals. How do you think about that negotiation process? You’ve got partners, you want to please everybody, and yet it’s not possible to do that.

[00:05:26] Dr. Denise Cardo: Now that you mention that I am a good person at negotiating, I think it’s a good way to describe a lot of what I do, especially because, many times, my work is behind the scenes. And one thing I learned is that there is a kind of a process that is know, like, and trust. It’s not because you know somebody, you can trust. And it’s not because you like, you can trust. And vice versa with people regarding to dress. So I may not have the partners came because of opportunities. But also because of us be open to challenges and have any impact. I remember being meeting many years ago in which the partner. I was criticizing everything we were doing and everything that the professional societies were doing. And then at one point I said to him, I said, do you really want to make a difference in people’s lives? So let’s see how we can do it. And there were painful meetings that I had to say, whoa, let’s respect each other here. But it was a way to move forward. Did it work out? No, it didn’t. But it was a good way for us to listen to what the person was thinking and to really see also how to manage expectations of other partners. So I feel partnerships is like a partnership in life. Don’t take anything for granted. Always listen. And the main thing is to have common goals and clear expectations of what to do. And this you need to kind of develop this prior to any crisis. And when people say to me, why you guys worked so well with CMS doing COVID response, it’s not because I called them and they said, oh, we like you. It’s because it was a work that we’ve built for a long time. So even when there was something that they were not comfortable with, we were able to sit down and talk and say, okay, so how do we move forward so we can really protect people in this situation? Many times it was not easy for my division. They would say to me, you are selling us. We’re doing what the partners want. And I’m like, no, we’re doing with the partners what we are supposed to do.

[00:08:05] Dr. Julie Gerberding: What’s right for the patients.

[00:08:07] Dr. Denise Cardo: The patient. But it’s a process. You have to really stop and think a lot. When I’ve looked at my computer, I have a few things for me all the time like pause, relax, breathe. But, I also have this, listen to learn, not to respond, because my reaction many years ago would be, somebody would say something, a partner that I would justify and then why we were doing it. And I learned, listen to learn and don’t create excuses. But also I don’t accept excuses for not doing something, then it should be that. So it’s a very interesting negotiation. And then you learn who you can work with and who you need to partner with, but not really work together.

[00:08:59] Dr. Julie Gerberding: There’s a lot of incredible wisdom that you’ve pulled through in your varied leadership experience. BUt I want to go back to Brazil because you don’t always talk about yourself, but those of us who know you know that you’re incredibly connected to your family. I’ve had the privilege of meeting your wonderful mom. And you have a family background in healthcare. Your father was a psychiatrist. So you were brought up in somewhat of a medical environment. When did you know you were going to go to medical school and how did that story get started?

[00:09:36] Dr. Denise Cardo: As you said, my dad was a physician and he was a psychiatrist, but he also worked as a generalist in the ED for 20 years. So I was very exposed socially to his friends, especially those friends that worked with him at the emergency department. So that was what I learned growing up. It’s like being a physician and enjoy what you’re doing. Complain, but enjoy. And so I thought that’s what I want to do. And people would ask me why not this? I’m like, I have no idea what the other thing is. So my father got concerned when I said I wanted to be a physician. He’s like, oh my God. You’ll just know what being a physician. You don’t know what it’s like being another professional. But then I said, no, that’s what I want. And then I also learned meeting my dad’s friends. And some were much younger than my dad. I learned that it was not just meaning being one thing. You could do so many different things because they had all different backgrounds, all different specialties. So I thought this is interesting. It gives them an opportunity for. And so I decided I wanted, and I was very young because in Brazil you have to make that official decision. So I was like 17 when I had to pick my big path to entering in the medical school. And then I liked it. I got like, I liked everything. That was my problem. When it was genetics, I thought, oh my God, look at this. When it was anatomy, whoa, my God. And I learned that I like to learn. So doing my training, I also did a lot of extra things to learn a little bit more. And it was like deciding what I want for my specialty was my exclusion. So like, do you want to be a surgeon that is just going to be there doing things? No. Do I want to do this? No. So I went to internal medicine. And then I didn’t like the patients, not I didn’t like. I had a very hard time dealing with patients with chronic underlying conditions that didn’t have hope in their lives, to a point that I even had to ask for help from the psychiatrist that was dealing with patient physician relationship when I was a resident, because it was very hard for me. So I thought, you know what? I probably should go to infectious diseases because you just decide and that’s it.

[00:12:31] Dr. Julie Gerberding: And you treat and they get better.

[00:12:33] Dr. Denise Cardo: Yes. But this was 1980. Okay. And then 1982, I’ve got my first patient with AIDS. And then I thought, I cannot believe this is happening to me. And I was really depressed and thinking, God, I don’t have anything to offer. There was no treatment at that time. So that’s when I saw the opportunity of learning about nosocomial infections. And I volunteered. I had no idea. And then I thought, oh God, I can help people with this. And it was HIV times. People didn’t want to take care of patients. So it was a good thing for me to say, look, you can take care. That’s when I got involved. And then I changed my career in a way. At that point, I had left at the academic medical school to just work as a clinician. And then I was invited to come back. And that’s when I did my master degrees. I became an associate professor. I became a reference for the country in terms of how to do surveillance, universal precautions. I led several things that they asked me to lead. But I didn’t want to have an official position in leadership. So I was always helping because I was like, oh, I’m not sure. And then it became something I really enjoyed doing and continue to have medical activities for a long time, but I really enjoy it. And when I came to CDC, I had a very high position. I always remember telling people, I had two secretaries to help me. And I was invited to come to CDC and I had to answer the phone when the secretary was having lunch because we had to have somebody and I remember thinking, okay, why did I decide to come? But Julie, it was not that I decided, oh, let’s try something different. I was not happy when I was there. There was a lot of things I couldn’t do. And I saw that as an opportunity to do. But I was tenured so I could keep my job for two years there. So I’m not the one that is like, oh, let’s change everything.

[00:14:51] Dr. Julie Gerberding: When you went to the university in America, I mean, you transitioned from one country to the other. How did you get the courage to be able to do that because that’s a big, big transition.

[00:15:03] Dr. Denise Cardo: Yes. For people in countries outside the US, we do see an opportunity, especially, if you have a position in academics, going to another country to do a sabbatical is a very important way to move forward. But it wasn’t common at that time for a woman to come by herself. And so it was not hard for me to get the government to sponsor me. But it was hard for me to think about being by myself and not liking it. Not liking not being by myself, not liking the program. And I always thought, oh my God, I’m one of the first female professors who are going to do this by herself. If I don’t like the program and decide to comeback, everybody will say, see, that’s what happened. A woman by herself cannot handle anything. And so I said, I just went for six months, and then I ended up staying for one year. But it was a way for me, for the first time of my life. I’m not close to my family. I like in a place with a different language. And the first time I was not the majority because I was a woman, a white woman, in Brazil. Then I became a Latina with an accent. And so that for me was very hard because I always had everything perfect. And so it was a lot of struggle. But then after a while I learned there was a role for me and then I went back to Brazil. They offered me to stay. I said, Brazil is my…went back. And that’s when I was not doing what I wanted. And that’s when I accepted the offer from the CDC.

[00:17:07] Dr. Julie Gerberding: You are so admired. You’re admired by professionals above our level. You’re admired by your peers, by the partners, the stakeholders, and so forth. But you’re also very much admired by women and particularly Latina women. How do you engage with younger, Latino, up and coming people and how do you see yourself as a role model or a mentor? And maybe follow that with just, what’s the most important advice you got and what’s the most important advice you try to pass on to those women?

[00:17:43] Dr. Denise Cardo: I will start with the most important advice that I got, that the person who gave me the advice had no idea that it was really helping me. It was when I was still in Memphis and I wanted to do everything to lose my accent because I didn’t want people to say to me, where are you from? And I’m like, I do my best. And then they know I’m not from here. And then my boss at that time said to me, Denise, when you were in Brazil and somebody who is from another country, they come and they speak perfect Portuguese. Do you know that they are not from there? I say, oh yeah. He said that’s the same thing. Take advantage of that. And so that was very important for me because I decided that this could be something that would make me different. And my joke was, if I’m in a conference call, I don’t need to introduce myself. So I had to myself deal with that to be, not try to be, I need to speak the right English, but not the English without an accent because that’s me. So that was very important, Julie. Also very important in the way, I know it sounds so superficial and so silly, but the way I dress and everything, it was like, yes, I do like to wear specific bright colors. I do like to do this. I am not ashamed to say that I like to dance or to do this, but it was a process. I learned that I had to be careful when I was among people who didn’t know me, that they would say, oh, she’s just a Brazilian. So I had to really do that and know how to do so don’t think it was right from the beginning.

[00:19:45] Dr. Julie Gerberding: So you grew into yourself in a way. You embraced your own identity and your own personhood.

[00:19:53] Dr. Denise Cardo: Yes. And so I think I have been helpful to young women overall, at least at CDC. One of the jokes that one person who came to work for me is I was at the advisory committee once in DC. And they said something and I had to, I didn’t agree. And I had my lipstick in my hands, and I’m telling all these guys, I didn’t do it on purpose. And she’s like, oh, I want to work for that one. So, is that a good thing? No, it’s not a good thing, but I just, I learned not to do bad. But so it has been a very interesting concept. For Latinas, I decided that I want to be helpful to women overall because, even as women, we still have challenges. As Latina, it’s harder. But also African-American, especially because of Ken.

[00:20:56] Dr. Julie Gerberding: Your husband, Ken, was African-American.

[00:21:01] Dr. Denise Cardo: And I learned that the way people treat you, it’s really different. So it has been interesting because many of the women, especially at CDC, that are reaching out to me and said, can you be my mentor? I’m like, I’m not a mentor. But I learned mentor doesn’t mean just having a book that you follow to mentor. It means like talking about yourself, about how to handle a few things, and listening to what they are facing. But I think more than anything else, Julie, what I learned is not just mentoring and talking. I learned that we need to empower ourselves. I’ve been in situations. I always say, don’t take anything for granted. You said people respect me, but not everybody. So there are people who still have a challenge of dealing with women in a leadership role, especially a Latina or an African-American woman. And I faced that a few years ago. And when I faced that, I didn’t know what to do. And I thought, should I say, why are you not talking to me? Why are you just talking to the man who worked for me? I’m the division director. And then I thought, no, I’m not representing myself. I’m representing a program. And I have to be careful. On the other hand, how do I help women in those situations? And that’s when I start telling, not just myself, but many of the leaders in my division, if you are in a situation like that, you have to say, ask her, because she knows. Let’s ask that person because that person knows. So don’t expect us to say, I will say something. No. So I’m learning also how to, in my mentoring of people overall, how to show the role, they play to really empower and respect Latinas, African American women Asian, especially with COVID, we saw lots of…so how you make this as part of the expectation from everybody. So it’s been very interesting, but it’s a dream.

[00:23:30] Dr. Julie Gerberding: We’re coming out of a pandemic. The world is in a state of crisis. Our health system’s fragility was demonstrated in the context of the pandemic. Our health workers are, in many cases, shattered with the stress and the responsibilities that they’ve been valiantly managing over the last several months. What is your outlook and how are you helping your division and your part of the health system evolve past our current state?

[00:24:03] Dr. Denise Cardo: Yes. And COVID, the pandemic, has been a learning process for all of us, a way for us to wake up for many things. And also to, for me, not to accept a few things that are happening. And one is how healthcare delivers care and how the crisis that all healthcare personnel face now that is like awful. So the way I see it, something that, especially in working with CMS, working with other groups, is having that as a goal for us. So it’s not just to put a band-aid in a specific thing. And that’s what I tell people. It’s not just a checklist for preventing infections. It’s a change. It’s a change in how to deliver care. And it’s not just within an institution. It’s across. And how to really have people who not only can do, but enjoy doing where they are doing. So that’s one piece that I’ve been vocal about, but not just from my division, I really feel, I think for my division, sometimes I feel I’ve done what I could. I see people who repeat and do what I do. So I’m like, yes. Perfect. I can think about other things. So that’s the focus I have right now. It’s not really with the details and the prevention of specific things. It’s, this is just a surrogate of how we improve it, but it’s really looking at more the system and for CDC. So I’ve been volunteering to really work CMS, and you’ll remember that because you started CMS, not just working with one disease, but how together we can work really to achieve a few things and also to address health disparities and `equity. So the way I see myself, Julie, I see myself not as engaged in infection control and prevention as much. I’m still. But I tell them I don’t need to be in all the meetings. You guys represent me. And I see myself more into strategy at a little, I don’t want to say higher level, but a more complex system. And that’s what makes me feel like I still could be helpful.

[00:26:43] Dr. Julie Gerberding: This is just a wonderful way to end this conversation, Denise, because you’ve kind of brought us full circle, really, starting with your need to feel like you could make a difference at a patient level and finding a way to do that and still take care of your own emotional context and your own emotional needs, but moving up and out in the world to the point where you’ve now become a true thought leader, a person who’s setting the stage for the future evolution that our health system needs and really concentrating on the longer term strategic outlook and not the operational implementation of the here and now. And that’s exactly why I wanted you to be on this program, because this is about a leadership journey and we are taking advantage of so many incredible women in our profession who are pushing the envelope. And I think if there’s one thing that I’ve learned in this conversation, other than the fact that you remain my most favored friend in all regards, that we should feel optimistic about the future because there are people like you who are seeing beyond the crisis and who are determined to try to provide a different system of care and to not give up or give in to the current realities, but also to forge the way ahead. So I just really want to thank you for making time. I know you’re extremely busy. This has been a rare privilege, and I think our audience will be really pleased with what you’ve said about the role of women in leadership, about the importance of being yourself, about the importance of listening, constantly learning and evolving and ultimately expanding your sphere of influence so that you really are setting the tone, not just for your division or the CDC or our nation, but in all of your work beyond that, which we didn’t even touch on today. So Denise Cardo, Director of the Division for Healthcare Quality Promotion. Thank you so much. And just please keep doing what you’re doing. We love it.

[00:28:51] Dr. Denise Cardo: Thank you, Julie. As always you play a fantastic role not just empowering women, but really motivating always. In the past, I remember saying that I learned a lot of things, but you were the one who took me to the prom and introduced me to society and saying, see, you are even better than most of them. So go ahead and do whatever. So it’s so important and that’s what I think is so critical. We show to people that things are possible and they may not be easy, but they are possible.

[00:29:32] Dr. Julie Gerberding: They are possible, and that is the art of the possible. So thank you. Thank you. Thank you.

[00:29:37] Dr. Denise Cardo: Thank you so much.

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