Building a stronger CDC

Asaf Bitton
The Big 3: Three questions, three answers

March 2, 2023 – In January, a bipartisan commission working group released a report outlining steps the Centers for Disease Control and Prevention (CDC) can take to improve its capacity to deal with future pandemics. Asaf Bitton, executive director of Ariadne Labs, a joint center for health systems innovation at Brigham and Women’s Hospital and Harvard T.H. Chan School of Public Health, and one of the working group and commission members, discussed some of the report’s recommendations.

Q. Why was the report commissioned and what were its key findings?

A. In the wake of the CDC’s response to the COVID-19 pandemic, public trust in the CDC declined, particularly around the agency’s ability to prevent and respond to infectious disease outbreaks. Without a strong, effective, and accountable national public health agency, the U.S. remains vulnerable to local and global health threats. Rebuilding the CDC’s reputation as an independent, trusted scientific authority is a matter of national security and social cohesion.

In August 2022, the Center for Strategic and International Studies formed a working group to review the CDC’s capacity for epidemic preparedness and response. The group was chaired by J. Stephen Morrison, senior vice president and director of the CSIS Global Health Policy Center, and Tom Inglesby, director of the Johns Hopkins Center for Health Security at the Bloomberg School of Public Health, and included three former heads of the CDC, six members of Congress, and public health experts including myself.

Our report, “Building the CDC the Country Needs,” identified a number of challenges, both internal and external to the agency, that are currently interfering with the CDC’s ability to be an effective and reliable institution. Fundamentally, the CDC’s overall mission, function, and purpose is not as clearly defined as that of other federal agencies, and its global mission is often poorly understood and undervalued by policymakers. The CDC lacks sufficient ability to communicate effectively, independently, and directly with the American people, government leaders, and other public health authorities. Furthermore, its public health coordinating role and messaging have not been integrated well with external champions in the corporate sector, media, academia, and local governments. The CDC’s budget is inadequate in amount and structure for the demanding and expansive role it is expected to play; less than 5% can be easily mobilized and shifted by the director toward urgent emerging health threats in any given time period. The agency has faced difficulty in retaining and recruiting new talent, and promotions are based on an outdated system of hierarchy that is not fit for its current purpose. And, as was clear during the COVID-19 pandemic, there is a need for a faster, more nimble process for developing and disseminating clear public health guidance.

Q. What recommendations did the report make for the CDC to strengthen its performance in preventing and responding to future outbreaks?

A. Our final report outlines nine key recommendations that fall into three categories: an integrated mission, leadership and accountability, and operational capabilities.

First, it is critical to clarify and reaffirm the mission of the CDC to save lives and protect the public from health threats, both at a national level and globally. To create a better leadership and accountability structure, more direct channels of dialogue and decision-making are necessary with entities that include the White House, the Department of Health and Human Services, and Congress to drive forward reforms and set the long-term agenda for the agency. Further, the CDC needs a reformed process for developing rapid guidance during crises based on the best available information, including an efficient, transparent process for gathering input from external stakeholders and sharing it directly and clearly with the public. The agency also needs to have an expanded leadership role in the federal interagency policymaking process around health, and increased engagement with Congress around sustainable support for programs that mitigate threats to the nation’s health.

Operationally, budgets must be flexible enough to be able to respond to an infectious disease or other emerging health crisis within days, not months to years. Clear steps must be taken to improve the speed, standardization, and quality of data collection and reporting, especially during the early phases of a crisis. Partnerships should be strengthened to create greater coherence and predictability of action, and quickly move the CDC closer to the front lines of public health action and delivery. Finally, the agency should revisit its career incentive system to reward operational excellence, experience in the community, and effective health threat response.

Q. For major reforms to happen, the commission said that CDC leaders must work closely across the federal government and across party lines. That’s no easy task; what are your thoughts on how that can be accomplished?

A. Securing our nation’s health is a matter of national security. Understanding our shared vulnerability and fundamental interconnectedness should be a clear lesson from our response to COVID. Pandemics don’t respect geographic boundaries or political ideology. I think that if we can center on these core truths, a way forward emerges.

The reality is that pandemic preparedness is too important to leave to political squabbles or interagency disagreement. In the same way that we have come together to support our military across bipartisan lines, so too should we support our core health security assets. There will always be healthy disagreement on how to do so, and the right policy mechanisms to pursue. But the starting point has to be a recognition that the American people have a right and a need to expect competent, coordinated, proactive, effective responses and planning for the grave health threats that exist in our world today.

One of the inspiring lessons of working on this bipartisan commission is that there are thoughtful, creative, and effective leaders on both sides of the political spectrum and across agency and discipline boundaries who can come together to tackle these massive challenges. These leaders can build the will to harness respectful disagreement into effective consensus around our nation’s health security priorities. It gives me hope that even in these cacophonous times, we can find a way forward to protect and secure everyone’s health.

Brigid Tsai