Ever since the start of the Covid-19 pandemic, the performance of the Centers for Disease Control and Prevention has come under withering criticism. The backlash began during the tenure of Donald Trump’s CDC chief, Dr. Robert Redfield (who had no business being in that job), and has continued under the occupancy of its current director, Dr. Rochelle Walensky, a well-respected clinician and researcher on infectious diseases.
In January, Walensky began instituting a major shakeup at the CDC following a lengthy review of the agency last year. While Walensky has only announced changes in leadership and agency structure so far, the overarching strategic goal of the reorganization is to overhaul virtually everything about the way that the CDC works, from its internal bureaucracy to its research priorities. Among other things, this would mean reforming the agency’s much-maligned communications apparatus and honing its ability to capably respond to public health emergencies in a way that it has singularly failed to do during the Covid pandemic. If enacted, this would represent the kind of top-to-bottom revamp that rarely, if ever, happens at most federal agencies.
I’ve disagreed strongly with Walensky on various issues, from the utility of the agency’s community-level metrics for assessing a population’s Covid risk to problems with the short, five-day isolation period recommended for those with the disease. She has also faced substantial criticism in many corners for other aspects of her tenure, though there isn’t space to get into those details here.
I have no quarrel with anyone seeking to hold Walensky’s feet to the fire. In over 30 years as an activist, I’ve screamed at, protested, and criticized many federal officials. I know that it’s often the only way to force change through. But those decades in the trenches have also taught me that there are moments when leaders push forward and support the right things against overwhelming odds. These moments need to be seized by critics on the outside whether or not the battle at hand is ultimately won. Walensky’s attempt to reform the CDC is one such moment.
I have worked with former (and potentially future) adversaries many times during my years as an activist with ACT UP and a member of the Treatment Action Group in order to make progress on vital public health issues. At the height of the AIDS crisis, we joined forces with Anthony Fauci to bring activists into the meetings in which AIDS research priorities were being set. He succeeded with our pressure from the outside and together we were able to shift the trajectory of AIDS research in America. When former FDA commissioner David Kessler realized that a new piece of legislation was endangering the ability of the agency to ensure drugs are safe and effective for patients, he worked with us to push back (unsuccessfully) against the bill. More recently, Trump’s former surgeon general Jerome Adams has come out in support of needle exchanges and we’ve worked together to support communities fighting to keep these life-saving programs in place.
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Walensky’s reform agenda is another important mission that we all need to get behind. I urge people to read the CDC’s “”Moving Forward Summary Report.” It’s short and outlines what she is trying to accomplish, which is nothing short of bringing an agency formed shortly after World War II into the 21st century. The CDC has grown by accretion over the decades, buffeted this way and that by a series of public health crises, as well as by the whims of its directors and their political masters. It hasn’t had a scientific, programmatic, and structural overhaul like this before. After the worst pandemic in over a century, where the US response fell short again and again, it’s time for a change.
However, the calls for reform need to be examined in the context of the real threats to the CDC and American public health right now. Unleashing the current House of Representatives on any legislative fixes that might be necessary is like handing a match to someone holding a Molotov cocktail. Moreover, the “reasonable right,” including those commentators and institutions—like Scott Gottlieb and the American Enterprise Institute—which see deregulation and a smaller CDC as the primary policy goal of their work, are not to be trusted either. Furthermore, the judiciary, from the Supreme Court on down, has been itching to limit the CDC’s legal and regulatory authority for several years now, which makes this a particularly perilous moment.
Rather than rely on groups with more ideological aims and less direct experience in actual public health, we would do better to look to the CDC’s own articulated agenda, along with proposals in reports from the Center for Strategic and International Studies and others. Over the years, there have been numerous analyses by independent, scientific bodies like the National Academies of Science, Engineering, and Medicine and nonpartisan groups like Trust for American’s Health of aspects of the CDC’s work, which can provide more specific recommendations for the agency.
That’s not enough, however. The CDC’s plans for restructuring do not reflect the breadth of experience and expertise held by those at the state and local levels, where public health policies play out the closest. And Beltway think-tank reports are no substitute for the perspective of frontline workers. So it’s critical to bring people from the grassroots into the discussion. Rounding out CDC reform proposals with this local knowledge means elevating the voices of local public health officials and organizations from diverse communities unmediated by the lobbyists in D.C.
We’ve done this when responding to the AIDS pandemic, and Walensky has the skills and knowledge from her experiences fighting HIV to make this happen. Moreover, she knows that the loud and critical voices of activists often mask common-sense recommendations. Indeed, she has worked with many such advocates during her long career in HIV/AIDS. Bringing good-faith critics to the table, particularly those from within public health and from communities hit hardest by this pandemic, is going to be essential too.
The CDC also needs two key things in the years ahead that are not internal to its functioning.
First, whatever mistakes and errors one might lay at the feet of the agency, the CDC is beholden in its major decisions to the political needs and inclinations of the White House. This is not to wave away the CDC’s many failings, but simply to say that it is not clear how much latitude the agency has had to set its own priorities in the midst of the worst pandemic in over 100 years.
There has to be some way to insulate the CDC from the political whims of the president of the day. Some form of greater independence is necessary that still also allows for accountability from the agency to the American public. While President Biden said he’d follow the science, it’s become clear that, like presidents before him—of both parties—following the path of political expediency often comes first.
Second, no matter what administrative or legislative reforms get enacted, the CDC is grotesquely underfunded, as is the state and local public health infrastructure across the country (as I’ve mentioned before, for every dollar we spend on health overall in America we likely spend between 1.5 and 2.5 cents on public health). Unless we boost public health spending in the United States, we are going to remain vulnerable to pandemics and continue to see life expectancies here fall further behind other nations (according to one report, we’ll be 64th in world rankings in this regard by 2040). And this funding has to be sustainable. This is why my colleagues and I, along with others like Harold Pollack at the University of Chicago have called for public health to be financed “through a state-federal partnership similar to what we now do with Medicaid.” Otherwise, annual appropriations for the CDC and public health will be at the mercy of appropriators, the cycle of panic and neglect, and even the raiding of funds for other projects.
The past three years have shown us what a lack of investment in public health, a refusal to make public health a priority in this country, offers. It has been a national tragedy of our own collective making. There is a chance to reboot and change the future. CDC reforms, regulatory and legislative changes, with real independence, accountability, and stable, long-term funding for the agency, are needed to make a difference. Without this, we’re rearranging deck chairs on the Titanic and we’re all going down with the ship sooner or later. If we want to stay afloat, we have to make sure that, on this issue, Dr. Walensky gets our support. Then we can make sure she does what she’s promised to do.