The Centers for Disease Control and Prevention is attempting to reform itself following its many missteps and overreaches in response to Covid-19. The CDC’s failures were so numerous and undeniable that the agency’s director, Rochelle Walensky, had little choice but to admit the obvious in an email she sent to her staff detailing her plans for the agency. “In our big moment,” she wrote this past August, “our performance did not reliably meet expectations.”
By now, everyone knows that the CDC, despite its legion of experts and billions of dollars and years to prepare, failed during the pandemic. It failed in the task of adequately informing the American citizenry of facts, failed to rally the medical community, and failed to protect the public from illness and death. But few people understand why, and they will get no help from the CDC’s efforts to explain its failure. The CDC does not understand where it went wrong and what changes it needs to make as it undertakes to reform itself. What’s more, the direction of its new efforts makes it highly probable that the agency will keep making the same mistakes again and again.
_____________
In her email, Walensky stated: “For 75 years, CDC and public health have been preparing for COVID-19.” But preparation and actual readiness are two different things. And when the SARS-CoV-2 pathogen appeared in late 2019, the CDC immediately made a number of errors that betrayed a lack of readiness. In fact, the biggest mistake was made in the years preceding the appearance of SARS-CoV-2. During that time, the CDC shifted its focus from the spread of communicable diseases to behavioral-health issues. So when a new and serious communicable disease hit, the agency was caught off guard.
The change in focus was a political response to shifting winds. The CDC, along with much of the public health community, had begun to view its proper mission as addressing health challenges caused by human behaviors, such as smoking and poor eating. Some of the agency’s new concerns are barely even connected to disease. For example, the CDC currently lists among its priorities “reducing racial disparities in public health,” dealing with “the public health consequences of the climate crisis,” and looking at “the social determinants of health conditions in the places where people live, learn, work, and play.” We’re talking here about an organization originally founded in 1946 to combat malaria, not to play fashionable social politics.
It’s clear, looking back, that the CDC’s failure to understand its mission and priorities was reflected in the earliest blunders of the pandemic. The agency demanded that it, and it alone, be in charge of developing the diagnostic test for the disease. But the test it generated proved too flawed to be of use. That didn’t stop the CDC from using its position of trust and authority to demand that it continue to develop the test and, with enforcement help from the Food and Drug Administration, to prevent nongovernmental actors from developing tests of their own.
The lack of effective testing in the spring of 2020 meant that the U.S. was behind the curve from the very beginning. This was a fundamental error on which further missteps were piled. Testing is the first priority in pandemics because it is the most critical line of defense. It is the very thing that makes possible an orderly and fair system of tracking, tracing, and isolating infected individuals. The U.S. has typically been competent at controlling disease spread via this method. For instance, our mostly effective response to the Ebola outbreak of 2014 stemmed from our strong system of infection controls, which allowed tracers to find infected individuals and limit disease exposure. SARS-CoV-2 made this kind of response difficult to reproduce because of its asymptomatic, airborne spread, but that only made more urgent the timely development of a working test. Other nations were able to create tests in impressive time, including Japan, Thailand, and South Korea. The U.S. government, under the auspices of the CDC, failed miserably.
Another tone-setting mistake made at the start of the pandemic was the mask debacle. When the CDC’s then-director, Robert Redfield, was asked in February 2020 whether healthy people should wear masks, his answer was an emphatic no. Only later would we learn that this answer had been delivered based not on validated research but rather on expedience. Redfield and other government officials wanted to discourage everyday Americans from buying masks to maintain a supply for frontline medical workers. And they hid their concern. In April, two months after dismissing the effectiveness of masks, the CDC suddenly shifted gears and recommended mask use with an institutional passion. It also took charge of mask guidance, which would continue to shift perplexingly throughout the course of the pandemic. To this day, there is precious little evidence that mask mandates were effective against Covid-19 or that the states that imposed them did a better job than other states of limiting the spread of the disease. But the CDC, once it had dug in, became fanatical on the issue.
The entire saga, spread out over two years, contributed to the substantial erosion of public trust in the agency’s claims, pronouncements, and recommendations.
The CDC also embarrassed itself—and did untold harm—in its handling of school closures. Even in early 2020, it was clear from data that, unlike the 1918 influenza virus, Covid-19 was far less harmful to children than it was to adults. Yet CDC experts joined in on popular anti-science groupthink and shut down schools without sufficient regard for the devastating impact on children’s education and emotional health, and with no options for low-income parents or those with special-needs children. Not only was this initial decision wrong, but the CDC would advocate keeping schools closed long after rational psychologists and terrified parents demanded they be reopened for the good of kids who were falling behind and suffering psychologically. In August 2022, studies would reveal that test scores for reading and math had dropped dramatically for U.S. nine-year-olds.
This was not just a matter of misjudgment. At the start of the Biden administration, the CDC formed a wildly inappropriate connection with Randi Weingarten, head of the American Federation of Teachers. The group was a key donor to and ally to Joe Biden’s presidential campaign, and Weingarten’s influence appeared to shape the CDC’s back-to-school guidance of February 2021, which recommended, among other things, “Universal and correct use of masks” and “Physical distancing” of at least 6 feet, conditions that would make it exceedingly difficult for many schools to open. In the run-up to that guidance, the AFT sent an email to the CDC reading, “Thank you again for Friday’s rich discussion about forthcoming CDC guidance and for your openness to the suggestions made by our president, Randi Weingarten, and the AFT.”
By then, after more than a year of shutdowns, parents from across the political spectrum had justly concluded that the teachers’ unions had no interest in the education of children (and likely never did). As Weingarten saw it, if she could keep her union members fully paid without working, she was doing her job. That she consulted with Walensky on the issue, and had a baleful influence on the novice director, will long be a black mark on the CDC. And although the agency came under an enormous amount of criticism at the time for all this, Walensky’s outline for reform in 2022 makes no mention whatsoever of rethinking this kind of unethical political input.
Finally, there were the eviction-moratorium orders. This order was originally implemented by the CARES Act in the early stages of the pandemic on a temporary basis. After the initial 120-day period expired, the CDC both extended and expanded the scope of the order, without legislative authority to do so. Even when rebuked by the courts, the CDC continued to push on stopping evictions. This is another bureaucratic imbroglio that has not been mentioned in the retrospective effort to revamp the agency. Its absence means that there is nothing in the works to prevent similar mission creep, distraction, and unconstitutional power grabs in the middle of future pandemics.
All of these were significant missteps that contributed to the spread of the virus and exacerbated its social and economic costs. The new CDC reform and restructuring outline gives little indication that the agency has come to terms with the nature of its missteps. The full plan is not out yet, so one might hope for some improvements. But what we have seen, in the form of Walensky’s email to CDC staff, provides a worrying blueprint.
First, the very people Walensky is relying on to assess and reform the agency come largely from within the CDC or Health and Human Services. The CDC says that it will consult with some sources outside the agency, but the leaders of the exercise appear to be internal. If the problems of the pandemic response make nothing else clear, it’s that the CDC needs a significant outside perspective, including voices from the private sector who would be willing to call out the CDC on its many mistakes. Much of the bungling since early 2020 has come from internal efforts to manage bad news cycles in lieu of squarely fixing problems. A largely self-directed cleanup effort could mean more of the same.
The next cause for suspicion is that Walensky’s email talks about the development of an equity office at the CDC. How exactly would the creation of an equity office address the many failures of the agency’s SARS-CoV-2 response? It wouldn’t. In fact, it’s an idea in keeping with the CDC’s problematic instinct to put energy and resources toward political trends that have little to do with the controlling disease.
Walensky’s plan to better disseminate information is a worrisome example of this politicizing trend. She said in an interview that the CDC needs to “become more versatile in how we speak to the American public.” Elaborating, she complained: “We have not historically been challenged by social media and disinformation.” But this conflates two things. Social media may challenge CDC assertions, but those challenges are not necessarily inaccurate just because they come from social media. And while there is some information out there that is disinformation, we have also seen articles and tweets taking issue with the CDC on legitimate grounds. In failing to make these important distinctions, Walensky compounds the concerns of those who question some of the CDC’s conclusions.
The main thrust of Walensky’s plan is its bias in favor of CDC “action” in future pandemics. As Walensky herself said, “my goal is a new, public health action-oriented culture at CDC that emphasizes accountability, collaboration, communication, and timeliness.” A legitimate line of mainstream criticism holds that the CDC is more of an academic institution than an elite pandemic-fighting unit. Walensky’s expressed desire to make it a more effective pandemic-response entity is, therefore, understandable. But an endorsement of more “action” in and of itself is not necessarily going to solve the CDC’s problems. Indeed, much public trust was squandered each time the CDC took actions that made little scientific or practical sense. If a bias toward action means moving more quickly on bad ideas such as eviction moratoriums, mask flip-flops, and prohibitions on private test-development, it will simply multiply the agency’s mistakes.
_____________
So what would an effective restructuring and reform plan actually look like? First, it would make room for a much larger role for the private sector in responding to public health emergencies. Many if not most of the failures of the SARS-CoV-2 response can be fairly placed on government’s shoulders. The successes, however, have largely come from private industry—this includes the development of a vaccine in record time. While the government assisted in funding the vaccine work, it wisely did not develop a vaccine, as the CDC had tried and failed to do with early Covid tests. The CDC, FDA, and HHS, in general, have a wariness of the private sector that can limit the potential for cooperation. Operation Warp Speed, the effort that produced a working vaccine, was a success only because it eschewed the traditional mistrust that prevails when the government works with private industry. For this reason, a serious CDC reform plan would explicitly recognize that the private sector is the most likely future source for cures, therapeutics, vaccines, and other key pandemic countermeasures.
A true CDC reform effort would also entail a significant move away from behavioral health and back toward the agency’s original communicable-disease focus. One reason that the CDC has wandered off course is that Congress does not authorize the CDC as it does other key agencies. This is because the CDC was originally created via executive action, not legislative language. Some specific actions are authorized, and Congress does appropriate funds for CDC activities, but the lack of authorization limits Congress’s ability to create an overall mission for the CDC, to conduct oversight, and even to control the director, as it is not a Senate-confirmed position. A congressional authorization with an emphasis on the agency’s role in stopping communicable diseases would help get the CDC back on track.
The agency’s behavioral-health focus is a problem for a number of reasons. First, and most obvious, is the matter of resources. Even after the pandemic, its $10.7 billion 2023 budget request calls for spending approximately $3.6 billion on chronic-disease prevention, environmental health, and occupational safety and injury prevention. This is more than it will spend on communicable diseases ($3.5 billion).
Consider how this misallocation plays out in terms of available hands. The CDC has 21,000 employees and contractors. During the pandemic, the agency reported that its “base field presence” included upwards of 500 staff and more than 7,000 personnel “actively supporting the response.” Why, at the height of the biggest public health crisis in a century, was only one-third of available personnel working on the response? What exactly were the other 14,000 people doing?
That the agency now views behavioral health the same way it views communicable diseases reveals a deep misunderstanding of its own role. The CDC was originally tasked with stopping pathogenic threats, be they natural or man-made. Yes, bad behaviors kill millions of Americans. But using tobacco or eating unhealthily are personal choices that present a categorically different challenge from that of a pandemic. Furthermore, a serious pandemic could have civilization-altering, or even -ending, implications. In the face of such possible consequences, relevant government agencies must be clear on the nature of their mission.
In fact, the CDC’s obsession with behavioral health was arguably at the heart of its faulty approach to Covid-19. Here’s how. The U.S. government typically has a set of go-to responses to pandemics. These include international monitoring; testing, tracking, tracing, and isolating; and distribution of medicine and equipment from the strategic national stockpile. In response to Covid, all of these defenses failed. We were too trusting of Beijing to realize that Chinese officials were wildly untruthful about what was happening in Wuhan. The testing failed for reasons outlined above. And when the virus hit, the strategic national stockpile, despite billions in spending, contained no effective countermeasures for coronavirus.
Faced with the failure of its three lines of defense, the CDC (and the public health bureaucracy) decided that Covid mitigation was primarily a behavioral challenge. It focused on non-pharmaceutical interventions (NPIs) to deal with the emerging crisis. In a technologically advanced society such as ours, NPIs are supposed to be a last resort, but we were left with them as the only available tool. The CDC’s behavioral recommendations included social distancing, mask-wearing, and school closures. And just as the CDC takes a moralistic view of what it considers to be unhealthy behaviors that lead to chronic disease, it took a moralistic view of those who did not comply with its recommendations regarding SARS-CoV-2.
The more the CDC lectured the public about what it deemed appropriate behavior, the more it alienated Americans who harbored legitimate as well as illegitimate doubts about the agency’s recommendations. What’s more, the lack of clarity in the science about SARS-CoV-2 meant that the CDC couldn’t provide much credible evidence that its approach was the right one. Even comparing states that went in a restrictive direction with those that were more lax made for a fairly muddy picture. In fact, a National Bureau of Economic Research study found that “the correlation between health and economy scores is essentially zero, which suggests that states that withdrew the most from economic activity did not significantly improve health by doing so.” Thus, public trust in the CDC eroded.
For this reason, any viable CDC reform plan must look to close the trust gap that opened up during the pandemic. The University of Chicago’s Harold Pollack, a liberal public health expert, has written cogently about the public health community’s unfortunate inability to speak to people with a conservative mindset. The CDC and other public health entities are obsessed with all kinds of diversity—except diversity of thought. Finding a way to reach out to Americans of all political stripes must be an essential element of any serious reform.
And that’s a daunting task. But a good first step would be for the CDC to acknowledge its actual failings. As it stands, the reform effort is being steered by insiders who believe that the agency was not interventionist and political enough in its response to Covid. It’s not at all clear that the reforms the CDC is pursuing will solve its manifold problems. And those problems will probably yield more-tragic results than those we’ve already witnessed should we someday get hit with a pathogen even worse than SARS-CoV-2.
We want to hear your thoughts about this article. Click here to send a letter to the editor.
