The Centers for Disease Control and Prevention has performed poorly during the COVID-19 pandemic, and CDC Director Rochelle Walensky promises wholesale changes in the agency. She publicly admits, “We are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications.”
That is a welcome and rare degree of candor from a public official in the face of public malfunction, but her promised reorganization will not necessarily guarantee a better response to future pandemics. A larger budget and bigger workforce are likely, and these alone do not automatically make for a more effective organization. To address the inevitable pandemics of the future, here are six things a reconfigured CDC should do:
Clarify the role of medicine versus public health during an outbreak. A major problem during COVID-19 was the blurred line between medicine and public health. There is inherent overlap, but the role of public health in a pandemic is to identify the problem’s scope through means such as testing, then recommend control measures. The role of medical doctors is diagnosis and treatment of infected patients. The CDC should clarify these two roles, which became confused during COVID-19.
Refocus on infectious diseases. The CDC was founded in 1946 to combat malaria, then endemic in the Southeast U.S. Domestic malaria was soon effectively eradicated, and the agency’s mission expanded to fight other infectious diseases including polio, rabies, tuberculosis, smallpox and rubella. While the CDC has been quite successful in controlling these diseases and some noncommunicable problems such as cancer clusters and lead poisoning, this success has not transferred over to noninfectious conditions such as obesity and gun violence. The COVID-19 failures suggest a needed return to and redoubling of efforts in addressing serious infectious disease outbreaks.
Have its place identified in the chain of command during outbreaks. The CDC is an investigative and advisory agency, not a rule-making regulatory body. There was a problem during the pandemic with its relationship to other health agencies and personnel: National Institutes of Health, Food and Drug Administration, the U.S. Department of Health and Human Services, surgeon general and state health departments. A pandemic requires strict lines of authority. During World War II’s Manhattan Project, when the atomic bomb was developed, one individual, Leslie Groves, was responsible for every facet of the program. His expertise was neither scientific nor technical, but coming from the military, he was adept at management and organizational control. The White House should name this type of individual above all agencies, with primary responsibility during future outbreaks, who can delineate the exact role of the CDC in relation to the other organizations in pandemic control.
Improve surveillance of outbreaks. Surveillance is key to public health. The CDC came late to the realization of community transmission from asymptomatic or mildly symptomatic people and underestimated the importance of adequate indoor ventilation. An essential part of a CDC restructuring should be the early identification of outbreaks and how and where they spread. Because wastewater surveillance, using new molecular identification, has proved effective in isolating the location of new COVID-19 variants, the CDC should consider an expanded national wastewater surveillance program.
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Improve information technology. In a new outbreak, astute clinicians usually identify the initial cases, but with supercomputers and tech companies such as Google, Apple and Microsoft at its disposal, the CDC can institute a rapid early warning system. It should have the capability of incorporating into its databases the results of home testing, an emerging feature of pandemic management. Outside experts from other disciplines such as finance, adept at identifying complex trends, may be valuable serving as consultants.
Employ honest communication.Public communication by the CDC has been disastrous during COVID-19. Some mistakes are being repeated with monkeypox. (Alarm spread among the broad public about a disease with fairly discrete risk factors, while those most at risk — including men who have sex with men — were not informed effectively.) Messaging should be understandable, simple and direct and include what is known and what is not known about an outbreak. No agency should withhold information out of fear the public will misuse it. If and when that happens, it’s usually because officials bungled the crafting or delivery of the message.
There is a place for political considerations in public health messaging, but ideology should never compromise clear communication. To inform journalists and the public, the CDC should consider employing messaging specialists from outside medicine. Finally, and this is crucial, the CDC should listen to and not suppress dissenting voices, who turned out to be right on some COVID-19 issues. Where all think alike, no one thinks very much.
Plenty of actors besides the CDC deserve blame. Two major operational models of American medicine were ineffective. Walensky admitted the CDC became too attached to the academic model of teaching and university-associated hospitals, where publishing studies in medical journals — a long, arduous process — was prioritized over managing a rapid disease outbreak. Likewise, large hospital networks, where profit is the goal, did no better than the academic model in dealing with a public health emergency.
A Yoruban proverb says that yesterday’s truth is often tomorrow’s folly. COVID-19 has demonstrated that much of what we believed in early 2020, we now know was wrong. This should prompt the entire American medical community to do what the CDC is doing: reexamine its beliefs and deployment of its resources before the next pandemic arrives.
Dr. Cory Franklin is a retired intensive care physician. Dr. Robert Weinstein is an infectious disease specialist at Rush University Medical Center.
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