Like the Jedi, It Is Time for CDC to End
The World’s Public Health Protector Needs a Reboot of Sorts
I posted on social media the other day that it was time for the Centers for Disease Control and Prevention (CDC) to effectively “end.” Man, was I ever in for a controversy. As a doctor of public health working in a local health department during the pandemic, I’ve depended a lot on the science and guidance from the CDC from the very beginning of the pandemic. In fact, going back to before I received my Master of Public Health (MPH) degree, I relied on CDC for all sorts of neat educational and scientific material. It is because of CDC’s Principles of Epidemiology course that I got interested in epidemiology.
I’ve always said that public health is political by its very nature in this country and in countries around the world. After all, public health requires many resources to be carried out effectively, and most of those resources come from countries that can afford big budgets for big projects. So, you end up with a health department (or ministry) being run by a government-appointed official who then appoints someone else to head the acting arm of the public health component of the department. In the United States, this means that the President — who is elected — appoints a Secretary of Health — who is approved by the Senate — who then appoints the Director of the Centers for Disease Control and Prevention and directs the Centers’ day-to-day operations. As a result, CDC’s mission, vision, and even its values can change the minute a new Administration takes over.
Heck, it can change wildly even before that if anyone in that chain of command decides to go a different way. This is what we are seeing with the CDC today. A President who is being criticized for his Administration’s response to the COVID-19 pandemic said he wanted to slow down testing, and CDC then turned around and recommended that asymptomatic contacts of confirmed cases should not be tested. I wasn’t surprised to hear of public health experts rebuking this recommendation.
The reason why South Korea brought the virus under control so quickly is that they extended testing to all corners of their territory. If someone was positive, their contacts got tested and put in quarantine. If any of them tested positive, those contacts got tested and put in quarantine. This went on for many circles until it eliminated the chain of infection. Korea got to have baseball back, and what did we get?
Many states and localities are adopting the contact tracing methodology to the COVID-19 response. They’ve used it before for other diseases, especially tuberculosis, and Sexually Transmitted Infections. It works well when it is implemented well, and many are doing it well… Or at least as well as they can in an environment where some governors and even the President are skeptical of public health interventions. Now, with this new guidance from the CDC, things are changing.
I’ve heard from colleagues that some of their partners (e.g. police departments or managers of large governmental office buildings) don’t want to test contacts of confirmed cases in their agencies because it is no longer recommended. They want to save money that would go to testing and use it for other purposes. When they get pushed back by public health, they retort with something like, “CDC says we don’t need it” and “Do you think you know better than CDC?”
A few months ago, I would have definitely said that, no, I do not know better than CDC. I don’t have the treasure trove of knowledge and wisdom that those buildings in Atlanta have in-house. Today, however, I’m going to go with, yes, I know better. I know better because I’ve seen my colleagues leave CDC one after the other, disgusted over the decisions being made by political appointees or under the supervision of “someone sent by the White House” to make sure their decisions are aligned with the Administration.
“It’s almost like that movie, Hunt for Red October,” one of them said. “We have to get things approved by the Party Officer.” Except that it is not one Party Officer, it’s many, and they are all over the place.
So, What Now?
It would be very difficult to take the politics out of Public Health. I would dare say that it is nearly impossible. After all, the decisions made by Public Health affect us all, and there has to be accountability if any of our money goes into that work. You can’t privatize it like you would trash collection… Or can you?
More on that in a minute.
At this point, I must clarify to you that this is a post that lacks the nuanced discussion that such a seismic shift in how public health is done in the United States needs. But we do need to have it. We need the adults in the Public Health and Public Policy world to have these discussions because something has gone horribly wrong, and we now have the premier public health agency being dragged through the mud because of political considerations.
And now, my two suggestions…
The Academic Model With Politics on the Side
Perhaps a different model would be an academic one. Let’s have CDC become a big institute of Public Health learning where all the professionals in the world can go and learn Public Health from the best, from the people who have been there and done that. Instead of a Director, CDC gets a Dean who reports to a Board, and a Board appointed by the President for a period of time that exceeds the time that presidential administrations are in power. The appointees and the Dean are approved by the Senate and subject to dismissal via only a 2/3 vote in the House. No 3 AM tweets removing someone for doing the right thing and offending the person in power. No 51–49 votes in the Senate.
This keeps politics in place, yes. But it also allows for some checks and balances in that Board members and the Dean/Director are subject to a referendum of sorts every two years when a new Congress is formed. If Public Health is not going well, as is the case right now — August 2020 — with the pandemic, then the House convenes, they get the board members and the Dean up to Washington to explain themselves, and then vote on whether to dissolve them and replace them. The People would then speak as to where they want this to go via the President’s appointment and the Senate’s confirmation.
Yes, in the political climate that we live in, this could be an enormous mess, with the House removing the officials and then the President and Senate approving a new set (or the same old set) only to have them removed again. Hopefully, that whole two-thirds vote thing would prevent that since you’d have to convince a sizeable proportion of the minority to come along with the plan. Or, if the filibuster is still a thing, that could hold up the appointment of a new Board and Dean.
However, while all of that is going on, the different Centers within CDC would be allowed to carry on their work, uninterrupted, with plenty of peer review and oversight to keep them honest. Public Health recommendations would be peer-reviewed before being published, so there would be less disagreement by experts after the fact before the guidance can affect us negatively.
There are, of course, other issues and benefits to this, but this is just one of my big ideas. The other one is an anathema to the Left and yet juicy enough to the Right to get their attention…
When I was growing up in Mexico, the trash collectors decided to strike one day because they were not being paid enough, and they were being mistreated by the political bosses. In only a matter of days, the trash piled up so high that the people started demonstrating and protesting on the side of the trash collectors. (Yes, there were some who protested against the trash collectors, telling them to get back to work and stop whining.) The issue got resolved, and everyone moved on.
However, one thing that came from all that was a company that started offering its services of trash collection. They guaranteed to collect the trash from their clients on time every time, and, if the client didn’t like it, they could go back to using the city services. They were cheap, too, but the number of clients they signed up during the crisis made them a lot of money. They were also smart enough to share the money with their employees fairly to guarantee uninterrupted services. Afterward, the city decided to dissolve the trash collection service and stop taxing people for it so they could pay for the private service. Companies popped up, competition drove the prices down, and we were off to the races with lawsuits over competitive practices, etcetera.
If we follow this model with Public Health, we would be opening up to the very real possibility that business interests would be just as deleterious to the operations of a central public health agency as politics are. Not only that, but public health agencies handle a large amount of protected health information. If that falls into the wrong hands — not that it couldn’t right now — there would be grave consequences.
However, something needs to happen that is like the trash collection example above. If CDC is not containing this pandemic, then we need to find someone who will. They need to do it effectively, efficiently, and with accountability to us, their customer. Right now, all we can do if a vaccine is not effective is to shrug and pay pharmaceutical companies the money in the contract for the vaccine. Wouldn’t it be better to demand a product that works and not pay a penny if it doesn’t?
If CDC starts selling what amounts to snake oil when giving politically influenced recommendations instead of those based on science and reason, wouldn’t it be nice if that “product” were subjected to the same scrutiny that we have for other things that don’t work but are branded as such? Would a rating system based on stars and customer feedback be too much?
I Never Said I Had All The Answers
Look, I never said I had all the answers. I do know that there is something going on all over the world regarding politics influencing science in general and Public Health in particular. The pandemic has revealed this to many people who didn’t see it. Sadly, it was not a surprise to me. I’ve worked in Public Health long enough to know that political considerations need to be considered in every move you make. If those who appoint you to your position ask you to jump, you better ask how high or risk being out of a job.
Again, we need to have this discussion sooner rather than later, and we need to not hope for this or that outcome in the elections in November. All political parties and all political people influence the CDC, and that is not a good thing. It needs to be more independent, and it needs to give recommendations based on the best available science, data, and evidence. How we get there will vary, but we need to get there before more people get hurt.
Thank you for your time.
René F. Najera, MPH, DrPH, is a doctor of public health, an epidemiologist, amateur photographer, running/cycling/swimming enthusiast, father, and “all-around great guy.” You can find him working as an epidemiologist a local health department in Virginia, grabbing tacos at your local taquería, or on the campus of the best school of public health in the world where he is an associate in the Epidemiology department. All the opinions in this blog post are those of Dr. Najera and do not necessarily represent those of his employers, friends, family, or acquaintances.