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Harvard Forum Questions Former CDC
Directors About How To Fix The Agency
CNN Asks Similar
Questions To Current & Former Senior Level CDC Officials
Five former CDC
directors (Bill Foege, Bill Roper, Tom Frieden,
Julie Gerberding, and Robert Redfield) serving as far
back as 1977 and as recently as 2021 were questioned about the
failures and challenges observed at the CDC during the pandemic and
asked for their views about how to fix the agency.
The interviews took
place virtually as part of a Harvard School of Public Health year long
series entitled Public Health On The Brink. According to Harvard, the
series will examine the urgent challenges facing public health today
and explore the most promising ideas for rebuilding and revitalizing
the field.
CDC Review
The Harvard event
event took place on April 5, just as Rochelle Walensky, the
current CDC director, announced a month long review of the agency’s
structure and processes due to begin on April 11, 2022. That review,
according to Walensky, is designed to make CDC more adaptable while
maintaining its existing gold standard processes to protect the health
of Americans. The former CDC Directors expressed support for
Walensky’s review by outsiders and for making it relatively quick.
During the event, the
former Directors identified several key problems which became apparent
during the pandemic, some of which have been longstanding challenges
in how the agency functions.
Science & Politics
The first challenge is
how well the agency manages the tensions created by the fact that both
science and political considerations are inherent to public health and
should play roles in public policy setting. To think that political
considerations should be kept out of public health is a naïve notion,
said Bill Roper. Instead, science should be used to guide the decision
making and both scientists and politicians should work together
constructively as required by good decision making in democratic
societies.
Foege agreed that we
should not separate public health from politics. Instead the question
is how do we incorporate politicians into the process of creating
solutions. They don’t exist just to give us money, said Foege. That
said, Roper was firm in insisting that CDC’s mission is to be a
science agency, not a political one. And Redfield was clear that more
independence for CDC is needed.
Tension
Managing this tension
between science and politics in our currently dysfunctional political
system was acknowledged to be especially difficult. Redfield, who led
CDC under the Trump administration, disagreed with Foege’s assertion
that many of the lessons learned by public health over the years were
disregarded during his tenure at the head of CDC in the Trump
administration. Redfield stated that CDC strove to maintain the public
health messages despite substantial pressures emanating from political
appointees in the administration. Redfield’s proposed solution for the
future is to assure the structural independence of the CDC Director.
He would make the job a 7-10 year term appointment similar to what is
done with the FBI Director.
Just how to maintain
the constructive working relationships called for by Foege and Roper
while achieving the independence and scientific integrity that all the
former directors want was not fully clarified during the forum.
Senate Confirmation
The former directors
had different opinions about whether or not the CDC Director position
should be one that requires Senate confirmation. Frieden called it “a
dangerous idea”. Doing so would add credibility for the person
appointed, according to Roper, but given the state of our political
system at the moment, such a requirement could make matters worse,
according to Gerberding.
Real Time Data
A second challenge
that became more evident during the pandemic is CDC’s lack of real
time data. Redfield said he was particularly bothered by the fact that
current information about COVID 19 was to be found at a medical school
(Johns Hopkins) rather than at CDC. He believes the agency needs to be
the hub of real time data if CDC as the public health response agency
is to actually execute a public health response. A prime reason for
CDC’s delay in obtaining real time data is due to the fact that CDC
obtains its information from state and local health departments. There
is no single standardized data collection system, and individual
states can opt out or delay providing information. Fixing this problem
would require revamping the information collection system to modernize
it and giving CDC the authority to make reporting mandatory. According
to Roper, the nation must answer the question—who is driving the
system?
Resources
A third major problem
identified by the former directors is the under-resourced and
unsustained level of funding at CDC and in public health generally.
Redfield said he believed he was at the top public health agency when
he arrived but was shocked by what he learned about funding. He stated
that the greatest threat to US security today is not China, Russia, or
North Korea. He believes that our greatest threats are our public
health vulnerabilities and the potential for pandemics. As a result,
he believes that public health funding must be made more proportional
to the threat. We don’t cut military spending in peace time and should
not cut public health funding after emergencies. As one director
pointed out, no war has ever produced the number of deaths caused by
the COVID pandemic and so health security spending should be adjusted
to reflect this threat.
According to Foege,
public health professionals always have to be beggars, and poor people
think differently than rich people, he said. For example, if we go 20
years at an airport without accidents, we don’t cut funding for
safety, he said. We do cut in public health. It’s not the same
mentality.
Investment
Gerberding pointed out
the need to talk about the money for public health not so much as a
cost but as an investment. As it stands now, if something is to
qualify as an investment, it must repay the costs in the same year.
According to Gerberding, any outyear benefits don’t help to offset the
initial costs. The approach requiring “annual accounting” needs to
change, she said.
In support of this idea, Foege pointed out that the US currently
recoups its investments in smallpox eradication every 3 months and has
repaid 160 times what the US invested. Likewise for immunizations
which can return 10 dollars for every dollar spent, he said.
Trust
The session also
addressed the loss of trust in CDC and the need to reestablish it.
This loss was poignantly described by the interviewer who read a
question from an audience member. She had lost all faith in CDC and
felt as if she had lost her religion. She said she felt completely
betrayed.
Roper pointed out that
the loss of trust is not restricted to CDC but extends to other
institutions. He called for giving advice with more humility by
acknowledging that any advice given is based on what is known today
and that this advice can change tomorrow if the information changes.
People may want permanent answers from the powers on high, but that is
not possible using a scientific process. Gerberding recalled that
during her tenure she created the term “interim guidance” to help
communicate the lack of permanence and prepare readers for the
possibility of change in guidance. People can handle uncertainty and
ambiguity, she said.
Closing
Redfield reiterated
the need for a structurally independent CDC to avoid political
pressures and to build trust in the advice given.
Asked again about
trust and what is the one thing each former director would recommend
to regain trust, the answers were increased transparency, a
structurally independent CDC Director, and more frequent
communication.
CNN Report
Interestingly, the
problems and solutions
identified by
the former CDC
Directors were
different from those highlighted recently following interviews by CNN
of twelve current and former senior level CDC officials and four
outsiders who have worked for the agency. The principal ideas which
emerged from these interviews about needed CDC reforms were:
1. Get CDC scientists
out of their silos to broaden their perspectives, including sending
them to work in state and local health departments.
2. Practice for a
pandemic to increase readiness and gauge who can work well under
stress.
3. Learn to “keep it
simple, stupid” in order to communicate with real people.
4. Escape the
“strangleholds” on communication from the White House and get CDC’s
voice back.
5. Get a more modern
data system.
6. Temper expectations
of what can be achieved from the CDC month long review because of the
fundamental nature of some of the existing challenges and the lack of
flexibility in the CDC budget. According to a current CDC officials,
it has 150+ individual disease and risk factor specific lines leaving
minimal to no flexibility throughout the year to respond to
emergencies
To listen to the
Harvard forum, visit:
https://bit.ly/3KPtrA2
To read the CNN
report, visit:
https://cnn.it/3rvY71t
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