A handful of former directors of the U.S. Centers for Disease Control and Prevention say they support a sweeping review of the agency that's been ordered up by CDC head Dr. Rochelle Walensky.
Earlier this week, Walensky announced that she has asked outside experts to conduct a month-long review of the agency's inner workings, as a means of improving the CDC's ability to track and respond to public health threats. The agency has come under heavy fire for its handling of the COVID-19 pandemic.
The five former CDC heads who spoke at a Harvard T.H. Chan School of Public Health forum on Tuesday all agreed it's a wise move for the embattled agency.
"I would say it's very healthy to ask for outside help," said Dr. Bill Foege, who served as CDC director from 1977 to 1983 under Presidents Jimmy Carter and Ronald Reagan.
The rapid pace set for the review also is smart, added Dr. Bill Roper, CDC director from 1990 to 1993 under President George H.W. Bush.
"This needs to be done as rapidly as possible because, heavens, you can create a scope so big and so complicated that we could do a 10-year study and it wouldn't really be enough," Roper said. "I think her calling for a one-month review is a very smart idea."
Walensky announced the review in an e-mail sent to agency employees, and followed the announcement with brief public remarks that appeared to acknowledge criticism of the way the CDC has handled the pandemic.
"Never in its 75-year history has [the] CDC had to make decisions so quickly, based on often limited, real-time and evolving science," Walensky said in the statement. "� As we've challenged our state and local partners, we know that now is the time for CDC to integrate the lessons learned into a strategy for the future."
However, the former CDC directors differed when it came to other ways to improve the CDC's stature and regain trust that's been lost during the pandemic.
For example, they split dramatically over a bill before Congress that would grant the agency more independence but require Senate confirmation of future appointees to the agency's top job.
Dr. Robert Redfield, CDC director under President Donald Trump, said, "There's an advantage to get the CDC director to be appointed similar to the FBI director, where it's a 7- to 10-year appointment. I think there's an advantage for the director not to respond to the Secretary of Health, but to be independent and to be able to run that job as they feel is in the best interest."
Should CDC head need Senate approval?
Roper agreed, noting that other prominent health-related positions are Senate-confirmed, including the Secretary of Health, Food and Drug Administration commissioner, National Institutes of Health director, and the head of the Centers for Medicare and Medicaid Services.
"Like it or not, the Senate confirmation process is a measure of the credibility and importance that the Congressional branch puts to the position," Roper said.
Other former directors disagreed, citing the polarized nature of Washington politics and warning that the move could make the job more, rather than less, political.
"To put it bluntly, with the complications of our political system right now, I just can't see that this is going to be part of the solution," said Dr. Julie Gerberding, CDC director under President George W. Bush. "It's going to worsen the situation, not make it better."
"Making this position Senate-confirmed would politicize the process of naming a new director, with contentious partisan debate delaying confirmation potentially in the middle of a health emergency," said Dr. Tom Frieden, CDC director under President Barack Obama.
"There's also a risk that people will be nominated not for their technical expertise or their ability to manage a public health problem, but for their industry or political connections," Frieden continued. "Although intended to make the agency more nonpartisan, making the CDC director a Senate-confirmed position would likely do the opposite. It's a dangerous idea."
The directors also discussed other means of improving the CDC, including some ideas that have been discussed for years and others that are not mentioned often.
Roper and Foege argued for greater cooperation and coordination between the CDC and the county, city and state public health officials who are on the front lines.
"CDC has never had national authority over what states do in public health," Foege said. "In the past, if there was even an outbreak investigation, the CDC had to be asked by the state or county or city to do that investigation. They couldn't just go out and do it."
That fractured system hampers not just the CDC's ability to respond to a public health crisis, but even to understand the nature of an emergency as it's unfolding, Roper explained.
"The information that the states give CDC is up to their goodwill," Roper said. "We need to face the question, do we want a standardized nationwide public health data system? If that's the case, then we can get the smart people together and design and implement it."
An agency with no formal national authority
"But until we get that, in the current situation every governor can basically say, 'No, I don't think we're going to do that,' and that just blows the whole thing apart," Roper continued.
Redfield agreed that public health data collection needs to be modernized, noting a briefing he received in April 2018 regarding the opioid epidemic, which was claiming thousands of lives every year.
Shocked by the numbers, Redfield asked how fresh the data was on opioid-related deaths, and found out it was three years old.
"When I came here, I thought I was going to be leading the premier public health agency in the world, and that we were going to use data to make an impact on public health," Redfield said. "And what you're telling me is I'm a medical historian."
Redfield was also disturbed that the best tracking data for the pandemic has come not from the CDC, but from Johns Hopkins University and Medicine.
"I do think there's an enormous need for [the] CDC to be the hub of public health data modernization," Redfield said.
At the same time, Redfield added that the CDC could benefit from its decentralized nature, with agency employees detailed to many different states across the nation.
"I think it would be useful to expand that, so we have a public health workforce that's prepositioned throughout the nation and, I would argue, throughout the world that can be used for public health response," Redfield said.
Several former directors also decried the boom-and-bust pattern of funding the CDC experiences, where money floods into the agency during a public health emergency and then evaporates once the crisis has passed.
"We have to approach our nation's health defense with the same urgency we approach our military defense," Frieden said. "In peace time, we don't cut military and intelligence-gathering capabilities so that we're at risk. Why, then, are we starving our health defenses when those threats are no longer in the headlines?
"We spend literally three to five hundred times less on our health defense than we do on our military defense, and yet no war in American history has killed a million people, as COVID has in the past two years," Frieden continued. "If we had invested sufficiently in our health defense, most of these deaths could have been prevented."
Congress has more on the PREVENT Pandemics Act, which would restructure the CDC.