Defeating disease is in the DNA of the Centers for Disease Control and Prevention, the federal agency which, during its first decade of existence, oversaw the eradication of smallpox, the elimination of malaria and the eradication poliomyelitis as threats to the health of Americans.
But as the 75-year-old agency director acknowledged this week, the CDC has not evolved to keep up with the faster speed and higher stakes of germs in the modern world.
In the face of a historic threat – the emergence of a new virus that has killed more than a million Americans – “our performance has not reliably met expectations,” Dr. Rochelle Walensky told employees of the CDC in a call for change.
The arrival of monkeypox has already brought the creaking machinery of the agency under new criticism. Failure to improve could mean the extinction of a public health organization that has long been a model for the world, experts have said.
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Many of these experts have spent much of the COVID-19 pandemic barely suppressing their dismay at the agency’s half-hearted efforts to move beyond its initial missteps and regain Americans’ trust.
Now they have stopped trying to defend CDC performance.
“A botched response to the greatest crisis of our lifetimes,” said Laurent Gostinan authority on public health law in Georgetown.
A record of mistakes that resulted in “one of the greatest losses of this pandemic: trust in our public health agency,” said Dr. Richard Bessera former CDC director who is now president and CEO of the Robert Wood Johnson Foundation.
“A culture that was just arrogant and overestimated its ability to get it right,” said Kathleen Hall Jamiesondirector of the Annenberg Public Policy Center at the University of Pennsylvania and expert in science communication.
As the coronavirus swept the world, the agency’s renowned specialists blundered an early test to detect it. They have issued misleading and confusing guidance on the value of face coverings. They took months to recognize what outside scientists quickly gleaned — that the virus that causes COVID-19 spread primarily through the air. And they relied on epidemiological findings from Israel, Europe and South Africa instead of US data often difficult to extract from a patchwork of overwhelmed public health departments answerable to state politicians.
CDC statements on the basics — how long an infected person should self-isolate, who needed vaccines and boosters the most, how long immunity would last, and what should follow — were belated, garbled and subject to caveats incomprehensible to ordinary Americans. When new findings demanded updates to previous guidelines, they slipped into the news cycle intermittently and without context.
“To be frank, we are responsible for some pretty dramatic and pretty public mistakes,” Walensky said in a video released to the agency’s 11,000 employees. “We still suffer the consequences of these errors – from testing to data to communications.”
Neither the novelty of the virus nor political interference can absolve the CDC of mistakes made in the second and third years of the pandemic, she added.
“An honest and unbiased reading of our recent history will come to the same conclusion,” she said. “It’s time for CDC to change.”
Walensky’s sobering admissions followed a comprehensive review based on interviews with about 120 public health experts inside and outside the agency.
In meetings with senior advisers and public health officials, she heard of a culture of scientific self-absorption that hampered the agency’s central public messaging mission. CDC epidemiologists, he was told, acted with all the scientific conservatism and urgency of an academic medical journal.
“By the time they were done, the data could have been bulletproof,” said a senior CDC official who was not authorized to speak to the press. “But its actual relevance had passed.”
The CDC’s risk communications mission is meant to embody three commands: Be the first. To be right. Be credible. “Yet we’ve seen during COVID that the CDC isn’t first, and often significantly behind other sources of information — and misinformation,” Besser said.
Walensky’s first priority is to improve the CDC’s ability to deliver scientific knowledge about a health threat early, often, and authoritatively, especially to Americans who need it to protect themselves and their communities.
“No one can say their posts have been up to date, understandable, timely and calm,” Gostin said. “They always seemed to lead from behind.”
To a deeply divided public, the CDC’s shifts in direction were often interpreted as a lack of conviction or, worse, dishonest manipulation. Many have chosen easier, more frequently updated sources for their pandemic information.
But even scientists and public health experts — people who appreciated the scientific complexity of the CDC’s task — gave up leadership of the agency, Gostin said.
Walensky will try to win them back with a series of proposals to modernize the agency.
The initiatives are aimed at strengthening the agency’s workforce and its partnerships with health care organizations and state and county public health agencies. They would streamline CDC data collection and science sharing.
They would make the agency’s public health messaging faster and easier to understand when time is of the essence. And to avoid the kind of governmental dialogue that often made the CDC seem clueless, a “no-surprises posture” would become a key operating principle of agency communications.
Some changes, including the ability to transfer emergency funds, will require Congressional approval, a process which has already started. Others, including the creation of a new public communications office and an agency-wide focus on diversity, equity and inclusion, have just been put in place.
And then there’s the task of cultivating a habit of agility.
“Yeah, we’re going to move some boxes on the org chart,” Walensky told CDC employees. “However, I cannot stress enough that moving boxes will not modernize this agency or better prepare us for the next pandemic. Changing the culture will.
Certainly, the legal, budgetary and political restrictions under which the CDC has operated will continue to pose major challenges, Gostin said.
For decades before the outbreak of COVID-19, steady funding cuts drained the corps of public health workers at the county, state, tribal, and federal levels. Shrinking budgets have dried up the kind of laboratory capacity needed in the event of a sudden outbreak and delayed the introduction of new ways to monitor public health, from genetic sequencing of viral samples to sewage monitoring.
While the pandemic has underscored that these methods are here to stay, the CDC still needs money to build its laboratory capacity and a workforce capable of practicing 21st century epidemiology. After the billions spent on the pandemic, that might be a tough sell to a wary Congress, Gostin said.
The CDC also needs to find more efficient ways to commission data on emerging health threats, Gostin said. State and local governments — not a federal agency like the CDC — are responsible for implementing and enforcing measures to protect public health. A federal judge’s order this spring demonstrated that the CDC doesn’t even have the unchallenged authority to require masks to be worn on planes, trains and other forms of public transportation.
Nor, under the Supreme Court Reading of the 10th Amendment, can the CDC require state or county health departments to collect and share data of public health interest if they do not wish to do so.
This handicapped the CDC’s pandemic response. At various times, a wide range of states, including Florida and Texas, simply did not provide data on COVID-19 cases, vaccinations and deaths, leaving the federal agency guessing at missing numbers. or do their calculations without them.
If the CDC wants to avoid such blind spots in a future emergency, it will need to create surveillance systems by linking health systems and volunteer states and counties, as is the case with keeping tabs on the flu. And we will have to act quickly.
Lorien Abromswho teaches public health communication strategy at George Washington University, is optimistic about the CDC’s ability to overcome its track record of pandemic errors.
“Of course they can reform,” she said. “They came from a place of greatness. We used to lead the world in epidemiological intelligence. I really think we can get back to that.