Almost two years ago, the leadership of our country’s Centers for Disease Control and Prevention (CDC) announced it would undergo a self-examination. This was comforting, given this federal agency’s questionable handling of the coronavirus outbreak.
The newly appointed head of the CDC Dr. Rochelle Walensky’s first order of business was to restore public trust in the 75-year-old agency. Her first step was to examine what went well, what did not, and why the response may have been suboptimal to an event that ostensibly the CDC, state, and local public health agencies had been planning for decades.
A Review to Revamp the Centers for Disease Control and Prevention
Walensky, an infectious disease doc and outsider with no public health agency experience, created a team of reviewers to look at the agency’s data systems, decision processes, internal and public communication efforts, and workforce effectiveness (about 13,000 employees).
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There was a “litany of sins” in the federal agency’s response to the coronavirus outbreak, including sluggish and uncoordinated illness event reporting; ambiguous and changing risk reduction behavior advice, such as donning masks, social distancing, and what needed to be cleansed; initially faulty testing kits; isolation and quarantine protocol changes; and clunky disputes on treatment options. Fundamentally, the CDC needed to give more accurate, useful, and timely information — backed by science — to state and local public health agencies and to the range of healthcare systems providers in the US.
Once CDC leaders passed the default position of “Trump made me do it,” insiders and outsiders seemed prepared to utter, at some level, a mea culpa.
Low-Hanging Fruit for Organizational Change
Naturally, the tangible and low-hanging fruit for organizational change came in the form of modernizing public health data collection, training a public health workforce for the future, structural changes to units, coordination with partner agencies, and “faster response to scientific changes and easier-understandable guidance” for health workers and the public.
Respect for Federalism is a Best Practice
One close to home shortcoming that did not make their list of sins is respect for authentic federalism. Paradoxically, a major stranded asset of our public health response to the virus was not to trust and to engage soon enough the local public health and healthcare experts “on the ground.” They had a playbook on responding to such outbreaks. Post 9/11, towns, cities, counties, and regions have been setting up emergency response teams and plans, including Point of Dispensing counter medication measures operations. Some federal officials, and even more salient state officials, were “back in the locker rooms drawing Xs and Os,” so to speak, for implementation, when the local workforce had already drafted and practiced responses to such public health outbreaks.
Respect for federalism is a best practice when dealing with public health issues. For example, if you suffer a cardiac event in the home, you call 911. Air Force One does not fly in to respond; rather, it is the local (often volunteer) ambulance corps or police/fire rescue that arrives to assist. The person is taken to the closest hospital — not the Walter Reed National Military Medical Center in D.C.
When the mantra for what many CDC personnel do has become “provide technical assistance,” it’s fair to question the size of the Centers in terms of staffing and resources…
The structure and function of this vertical federalism is no accident. It works when it is respected. Almost everything that takes place during a serious public health response does not come out of 1600 Pennsylvania Avenue. Instead, it comes from the work of committed and talented people in many local agencies. They know how to work with state officials and understand their nuanced health delivery systems.
A philosophical and historical principle of public health policy and practice is that those closest to the people are in the best position to consider and protect the health and safety of the people. In fairness to the public health leaders, high level administrators, such as governors, went “all in” for political circumstances, rather than focusing on the nature and extent of the problem. It may have been “showtime” for political operatives, but local public health and healthcare professionals were ready to work.
A Need for Cultural Change at the CDC
A not so tangible, but important, goal of the CDC’s recent and strategic plan for the future of public health is to change the culture of the agency.
This is a bold move. For example, those outside the agency may not realize that a strategic driving rewards system, and consequently motivation of the CDC workforce, is publications, much like an academic enterprise, versus practice in serving the public. For example, it’s peculiar that many of the CDC workforce, headquartered in Atlanta and with units strategically placed throughout the country, are still working remotely.
It’s no question that CDC publications are important — the highly respected Morbidity, Mortality, Weekly Report, for instance — however, when the mantra for what many CDC personnel do has become “provide technical assistance,” it’s fair to question the size of the Centers in terms of staffing and resources, and what they accomplish, including refocusing any mission creep.
Involvement in the Political Sphere is Distracting
Regarding mission creep, a major cardinal sin not on the soul-searching list of behaviors by CDC employees is their actions in the political sphere. Naturally, public health workers enter the profession to improve the human condition through essential public health services. While public health professionals can play the roles of analyst, advisor, or advocate and be passionate in their work, the political sphere, with all its trappings, is not their place.
Overt and covert advocacy actions among public health professionals have gone well beyond educating and empowering the public. Now, the professionals are part of the political circumstances story. Like the demise of journalists who don’t serve their traditional role of being objective purveyors of the news, public health professionals have become distracted by focusing on political actors and partisanship, rather than leading collectivist efforts to serve and protect communities.
Like the news stories that characterize principals as either good guys or bad guys, public health leaders have taken on this bifurcated lens. Health issues are complex, requiring a web of causation lenses. Responses need to be reasonable and responsible, without placating to ideological or partisan interests.
The slippery slope concerns about “public journalism,” i.e., the journalist playing the role of an advocate instead of a neutral reporter, came true. Consequently, the public has very low regard for the truth in journalism. Public health professionals may have gone too far down this same path.
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In the long run, the public should forgive the mishaps of the leaders fighting the coronavirus pandemic, because their work is a matter of life and death. However, acts driven by partisanship and mucking around in the political sphere may not receive amnesty from the public.
Focusing on the Mission Yields Results
Public health professionals have several major accomplishments to be proud of. For example, the eradication of smallpox and the ongoing assault on polio through mass vaccinations is heroic. The major decline in cigarette smoking in the US via research, education, and advocacy was a protracted fight. People are thankful for improvements in oral health. Decreases in certain cancer deaths, not simply through improved treatment but through public and professional education, contributes immensely to life expectancy in the US.
Aside from these milestones, much of what public health workers do goes unnoticed, given that their work is often mundane — restaurant inspections, for instance — and in the shadow of esoteric activities fighting complex health issues, such as AIDS. However, the coronavirus assault exposed that many public health professionals sit comfortably and confidently in the political sphere of influence. Having an acute understanding of the political circumstances of a health issue is useful, but being captured by politics inhibits the art and science of protecting communities. The worldview of politics is quite different from the worldview of the public health and healthcare professions.
Periodically, leaders and groups in the public health sphere generate documents that chart a course to create conditions in which people can be healthy. The success of this review of the CDC depends on how sincere public health officials are in their pledge to forgo the limelight of politics and focus on protecting the public’s health. Consequently, the public’s trust in their work can be redeemed.
Stephen F. Gambescia is a professor of health services administration at Drexel University.