We live in an age of decreased faith in institutions. We count on them for so much, and are therefore left wanting when they fail to perform. The instinct of the age is to criticize, and social media provides manifold platforms for doing so. But our goal should not be to tear down our institutions but to build them up, and to take advantage of opportunities to bolster key intuitions when we can.
One such opportunity is occurring right now at an essential public health institution, the Centers for Disease Control and Prevention (CDC). Few will disagree that the CDC’s performance was found wanting during the recent coronavirus pandemic, as the United States experienced disproportionately high levels of infections and deaths. For this reason, it was an encouraging sign when CDC Director Rochelle Walensky announced a one-month review of the organization in the hope of reforming her oft-criticized agency.
Walensky was careful in her statement announcing the review, but it was clear that she recognized the need for change, saying, “During the past year, CDC has worked to speed up data reporting and scientific processes throughout its pandemic response. Work is needed to institutionalize and formalize these approaches and to find new ways to adapt the agency’s structure to the changing environment.”
As the internal review is supposed to end on May 11, let’s hope that it will correctly identify some of the CDC’s top challenges. These challenges predated 2020, but the recent COVID-19 pandemic exposed them in a more visible way. Without the exposure of shortcomings during the coronavirus response, there was likely little chance that the Biden administration, or a traditional public health person like Walensky, would have engaged in a review like this. Yet such a review is badly needed, and she is to be commended for undertaking it.
The CDC has for many years sold itself as the premier agency protecting the nation from the potential impact of pandemic disease. It engages in a series of international monitoring programs, provides grants to states and local areas, sets up testing for new diseases, and in general promotes itself as the go-to agency for protecting against the emergence and spread of pandemics.
What the CDC has increasingly been focused on, however, has been behavior modification, efforts to change Americans’ behavior so as to improve their health status, rather than trying to prevent the spread of communicable diseases. Indeed, if you break down the CDC’s 2023 budget request, it calls for about $3.6 billion in spending on chronic disease prevention, environmental health, occupational safety and injury prevention—more than its approximative $3.5 billion domestic spending request for communicable diseases. However, when the CDC makes up an appeal for funding from Congress, it highlights the pandemic preparedness aspect of its mandate, which is its core mission, rather than its behavioral modification efforts, which are popular with the public health community but often controversial with the public.
The reason for the focus on behavioral modification is a simple one: Pandemics come around rarely, while poor health behaviors are a constant, especially in 21st century America. The scientists wanting to get attention from their peers will have more success focusing on, say, obesity rather than pathogenic outbreaks, which happen only rarely but are supposed to be the agency’s core mission.
Except a pandemic did happen, and when it did, the CDC was not ready. This became most obvious when it repeatedly insisted on developing the tests for COVID-19 even though its first effort led to a flawed test that didn’t do the job. Nevertheless, the CDC kept insisting that it should develop the test and worked with the FDA to make sure that other entities—both in the private sector and nonprofits—were not creating alternative tests. The resulting lack of testing put America back on its heels with respect to dealing with the coronavirus outbreak, since so much of our pandemic response plan is based on our ability to test, track, trace and isolate.
COVID-19 revealed that the CDC is not really a pandemic response center, so much as a series of quasi-academic centers that study diseases or health conditions after they emerge. These types of centers are not really equipped to identify an emergent disease, develop a test at scale, and bring back real time information about how cases are emerging in America.
In fact, one of the biggest frustrations with the CDC’s performance during the pandemic was that its COVID case numbers were not actual numbers of cases so much as estimates of what the caseload might look like based on modeling. In the 21st century, with email and websites readily available, there was no reason to rely on statistical modeling for guesstimating the number of cases. Hospitals can quite easily report actual case numbers to a centralized database, allowing the CDC to provide real time information policymakers need.
For these reasons, it’s clear that the CDC needs to be reformed. Going forward, a helpful improvement would be the separation of the CDC into two agencies: one that focuses on pandemic preparedness, and another with a different director focusing on behavioral health. Congress will then be able to more clearly focus on how much is needed for the all-important pandemic preparedness mission, while the behavioral health folks will have to make their own case for funding for their trendier but mission adjacent agenda separately.
In addition, the CDC needs to improve its relationships with the private sector. The agency’s unwillingness to accept private sector tests and its insistence on developing the test alone set America back in the early days of the pandemic. Explicitly making clear that the private sector should be the first option when it comes to the development, manufacturing and the large-scale production of pandemic countermeasures will help in this regard.
A refocused look at pandemic preparedness, greater reliance on private sector capabilities, and improved data collection would go a long way toward making sure that the CDC is better prepared to handle the next pandemic, whenever it may arrive. These three things will not solve every problem at the CDC, but if the one-month review leads the agency to take on just those three things, it will have been a month very well spent.
Reforming this important institution will help demonstrate that the hard work of identifying internal problems and fixing them is a model that can be applied to other key American institutions as well.