Medice, cura te ipsum. Physician, heal thyself. That is just what the CDC is beginning to do based on a recently published in-house structural review. Leave aside the shame and blame game of amnesty. What does the CDC believe it did wrong and could do better?
The review, summarized in the CDC Moving Forward Summary Report, is just the beginning of their institutional soul-searching. As an article from the Lancet reports, the major findings included the need to:
- Share science and data faster
- Translate science into practical policy
- Prioritize public health communications with a focus on the American public
- Develop a CDC workforce ready to respond to future threats
- Promote partnerships
Rearranging the deck chairs
“CDC’s academic approach has sometimes slowed critical agency action.”
While acknowledging the need for “a deep understanding of the science to develop and implement public health action,” the CDC feels that its workforce incentives to publish is too great a focus and that public health action must be more heavily rewarded. I am not sure that incentives are the solution for “paralysis by analysis.”
“CDC’s silos have impeded critical, cross-cutting support functions. CDC must improve its internal coordination and work with external partners.”
For those unfamiliar with the MBA organizational talk, silos are self-contained units on the “org chart.” While connected on the chart, in reality, they rarely speak with one another. This becomes a critical issue when these silos need to interact.
Bell Laboratories, a much older name for what is now AT&T, was a powerhouse of innovation in the day, giving us, among other gifts, the transistor, laser, satellite technology, and the first computer to play music. The “laboratory” building featured an innovative design where different specialties were housed together and ate in a common cafeteria to promote the serendipitous exchange of information. Of course, that has been hard to replicate in the modern cubicle office, and it requires on-site workers, an unintended, possibly harmful casualty of remote work.
CDC’s internal operating model often fails to support the public health core …[and] must implement new governance with an emphasis on the core capabilities and accountability at all levels. … CDC would benefit from being nimbler and more flexible.
There is no doubt that the CDC must speed up its responses, although there will be a trade-off between speed and certainty. Perhaps this is the critical line in the report,
“CDC needs to be fast-paced and response-oriented and needs to move agency culture towards integrating preparedness and response into every activity….”
The problem with all these words is that they just rearrange the org chart. The key is “to move agency culture,” described in these statements, but how it is accomplished remains unknown. It will require a concerted effort over a much more extended period than the news or election cycles will tolerate. It will mean that the older leadership must give way to the younger ones; while simultaneously maintaining or transferring the acquired wisdom of the elders.
“Guidance documents were also often long and overly complex with a large number of caveats and footnotes. As a result, the central message of the implementation guidance became obscured or misinterpreted by the public, media, or other stakeholders.”
The messaging of the CDC was poor for two reasons. The unstated reason is that the messaging relied on eminence and expertise and failed to explain the underlying thinking behind the recommendations. The messages were delivered akin to Moses bringing down the Ten Commandments. When the virus changed its behavior and the guidance needed to be adjusted, no one used the phrase “we were wrong” or “conditions have changed.” Until the CDC owns this failure, the culture will not change.
The stated reason was that it failed to consider its audience, which is also true. Unfortunately, the public is not well equipped to understand scientific information, especially when delivered by individuals who rarely interact with the public. According to a 2016 NASA study, only 28% of the American public is scientifically literate. If you doubt that, go back over the tweets and Facebook entries of 2021 and 2020.
Producing “plain language, easy to understand implementation guidance documents” is difficult. I try to do it every day. Mark Twain is believed to have stated the problem best, “I didn't have time to write you a short letter, so I wrote you a long one.”
Issues outside of the CDC’s control
The Lancet article mentions issues impacting the CDC's public health policy responses that they cannot control. First, the CDC budget involves 150 different “spending categories,” and only Congress can authorize transfers within those categories. In an emergency, perhaps letting the leadership of the CDC shift funds will focus command and control more locally.
There are over 3000 local public health agencies that need to coordinate with the CDC in a public health crisis. They need to be able to feed information to the CDC about their local conditions, and the CDC needs to provide scientific support and guidance. There are no established protocols for data sharing, and layers of bureaucracy impede the flow of information in both directions. As they noted concerning monkeypox,
“it took 2 months to complete data use agreements with 61 jurisdictions “so that we could finally see the data on who was getting vaccinated. For 2 months, we were making decisions about how we were distributing and allocating vaccine without any information necessarily on how that vaccine was being used.”
Until the CDC makes the personnel moves to change the culture, all we will be seeing are changes on an org chart. Those personnel changes have more to do with reigniting a desire to serve the public interest than to protect one’s fiefdom and wait for that government pension. The CDC must also recognize that guidance must be tailored not only for the audience but for the circumstances; to paraphrase House Speaker Tip O’Neil, “All healthcare is local.”
Source: CDC Moving Forward Summary Report
US CDC begins agency-wide changes after pandemic failures Lancet DOI: 10.1016/S0140-6736(22)02354-6