Last week, Dr. Rochelle Walensky, CDC director announced “major changes” at the agency, admitting that the storied institution has failed in its response to COVID-19 and monkeypox. She announced the changes to the CDC in a video to its 11 000 staff, most of whom are still working remotely, after commissioning a review of its pandemic response in April. This is Part 2 of 2 in our Blog Series covering these changes.

Dr. Walensky said the C.D.C.’s future depended on whether it could absorb the lessons of the last few years, during which much of the public lost trust in the agency’s ability to handle a pandemic that has killed more than 1 million Americans. “This is our watershed moment. We must pivot,” she said.

So what specifically will they do?  Dr. Walensky (who interestingly comes from an academic medical background rather than one of public health) noted that “we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications.”

Data

To address her second point first, Dr. Walensky outlined a framework in which the CDC would place less emphasis on employees’ records of published scientific papers and more emphasis on quicker responses to public health issues, such as preprints. Walensky called it “data for action” rather than “data for publication.” This is an interesting pivot for an academician and one that is not without pitfalls. The process of preparing a manuscript for publication demands rigorous internal review and then is subject to external validation, accessibility of raw data and sometimes independent re-analysis. All of this strengthens the final conclusions. While this review process is time consuming, the public is left with something that has greater reliability than a preprint or a press statement. There were many times during the pandemic that the rush to get something out in the press led to wildly invalid conclusions – notably Stanford studies by Dr. Jay Bhattacharya  (link: https://pubmed.ncbi.nlm.nih.gov/33615345/) which had fundamental methodologic issues from study recruitment (done over social media), to funding source (JetBlue) and antibody test accuracy (see the following for a full accounting: https://www.the-scientist.com/news-opinion/how-not-to-do-an-antibody-survey-for-sars-cov-2-67488). While ultimately published over one year later in May of 2021 – the preprint and press releases in April of 2020 had already done their damage – suggesting that COVID-19 infection was not as bad as originally feared and had a less than 1% mortality rate.

The CDC also has a well established flagship publication, The Morbidity and Mortality Weekly Report (MMWR) which publishes public health information and recommendations that have been received by the CDC from state health departments. So Dr. Walensky’s approach to Data seems to be a bit at odds with what would actually be helpful from the CDC.

Communications

This is one area that the CDC can significantly improve and plan to do so by revamping its public guidance statements and making “information clear and concise and to use plain English, so that information will be easier to understand and can be issued more quickly.” This will be a clear benefit moving forward, although I think it is important to note that the CDC was essentially hamstrung by the Trump Administration during the most critical period of the pandemic. Had it not been for Dr. Nancy Messionier who communicated in clear and stark terms the gravity of the upcoming pandemic, we would have been even less prepared than we were as a country. She needed to make this statement while President Trump was on a trip to India so as to not get crossways with the Administration. She was thereafter silenced (link: https://www.businessinsider.com/cdc-official-warned-us-coronavirus-was-silenced-documentary-2020-10) and ultimately left the CDC.

But the CDC would undoubtedly benefit from improved communication – on multiple fronts from the general public, to health professionals and to local health departments. If you think the CDC website is confusing and difficult to navigate, check out that of the LA County Health Department. The CDC should require some standardization of messaging, content and structure for state and municipal health departments to coordinate information sharing. Point in fact, the CDC and LA County Health Department were so disorganized and unable to come to a consensus that I followed COVID-19 management guidelines from South Korea for the bulk of the pandemic.

Testing

COVID testing was (and continues to be) an absolute debacle. To address such, Dr. Walenksy has proposed that CDC’s science and laboratory sciences divisions report directly to her. While this does elevate the division within the CDC, it does little to address the critical missteps that the CDC made during the development of COVID-19 PCR testing kits. Additionally, they did not include academic or private laboratories in the development process, significantly delaying test availability. Lastly, shortages of rapid antigen tests occurred in January 2022 during the Omicron surge – to the point that our clinic was down to 10 tests at one point. None of these issues will be solved by a direct report, but perhaps such will underscore the importance of these development efforts.

Interestingly, this already seems to be different for monkeypox as there already is a commercially available test through LabCorp (which is our primary laboratory service provider and is contracted with Medicare and most commercial health insurance). Prior to such, any testing would need to be coordinated through the Los Angeles County Health Department which – from my experience with Zika and measles testing – is woefully under equipped for significant volumes of test material.

Equity

In addition to the above, the CDC will also create an equity office to make sure that its workforce is representative of the US population and better communicates public health information to all groups. This will be of great benefit as COVID-19 risks vary greatly by socioeconomic status, access to care, ethnicity, gender and age. As our preferred ways of communication change across social media and traditional media platforms, so should the CDC respond to such – meeting the public where they seek information

Further, the CDC will create an office of intergovernmental affairs to help other federal agencies and state health departments work with the agency. While I think this is helpful, I actually believe that breaking up large municipal health departments (like LA County Health which oversees a population of 10 million) into smaller, more responsive public health ‘units’ will make a bigger difference. This is one difficulty that the CDC faces having only the perspective at the top of the pyramid – they only know what information is fed to them from reporting agencies. Which needs me to my next point…

Shoe Leather Epidemiology

At the end of the day, the CDC needs to return to its most basic function when it comes to pandemic management – which is shoe leather epidemiology. All 3 terms are critical as investigations initiated in response to urgent public health problems must involve substantial work in the field (i.e., outside the office or laboratory). It is clear that the CDC no longer prioritizes this core function of public health.  How do we know this?  See Part 1 of this series – the vast majority of the CDC is still working remotely. None have even set foot in the office, much less at a community center, a testing center, or a mass vaccine distribution site. They need to get into the field – test and trace and, when needed, isolate. By doing so, they will have a better fundamental understanding of the numbers coming across their computer screens – what makes sense, what doesn’t fit because they have seen the pandemic – in real time.

s the New York Times points out (link: https://www.nytimes.com/2022/08/17/us/politics/cdc-rochelle-walensky-covid.html) :

“The agency’s massive complex outside Atlanta sits mostly empty, while employees, including Dr. Walensky, work remotely.

“The actions that are being taken all strike me as actions that make sense and would make C.D.C. a more effective public health agency,” said Dr. Besser, the former C.D.C. acting director.

But he said it was hard to see how Dr. Walensky could execute wholesale changes when she only sees most of her staff at a distance. “I don’t know how you motivate and inspire culture change when people aren’t together,” he said.”