CDC, under fire, lays out plan to become more nimble and accountable

The Washington Post / Lena H. Sun, Dan Diamond

14:05 JST, August 18, 2022

The nation’s top public health official acknowledged Wednesday that the Centers for Disease Control and Prevention had failed to respond effectively to the coronavirus pandemic and announced plans for extensive changes, including faster release of scientific findings and easier-to-understand guidance.

CDC Director Rochelle Walensky told senior leaders she was committed to a long-sought revamp of CDC culture based on an internal review that called for a more nimble and better-trained workforce and incentives that would reward actions over publication – moves that allies said were necessary and critics said could not come quickly enough.

“For 75 years, CDC and public health have been preparing for COVID-19, and in our big moment, our performance did not reliably meet expectations,” Walensky said in a statement. “My goal is a new, public health action-oriented culture at CDC that emphasizes accountability, collaboration, communication, and timeliness.”

Walensky appointed Mary Wakefield, a deputy health secretary in the Obama administration, to lead the effort, which she cautioned “will take time and engagement at all levels of the organization.” The director shared the recommendations on Wednesday morning, first to senior staff and then across the Atlanta-based agency, which employs about 13,000 people, according to a senior CDC official who provided details but was not authorized to speak on the record.

Since the coronavirus pandemic began two and a half years ago, the once-storied agency has been under fire over its response, criticized for initial delays developing a coronavirus test, eligibility limits for testing and missteps often attributed to Trump administration meddling. Even under President Joe Biden, who appointed Walensky to lead the agency, its guidance and decision-making on masking, isolation and quarantine, and booster doses has been repeatedly faulted as slow, opaque and confusing. A consistent criticism has been a lack of agility from the agency, especially with the analysis and release of real-time data.

White House officials have also grown frustrated with the CDC and other health agencies over their response to monkeypox, with patients, physicians and even some administration officials asking why it was so hard to expedite testing and treatment.

Rich Besser, president and CEO of the Robert Wood Johnson Foundation, a health philanthropy, said he was interviewed for the CDC’s internal review and agreed with Walensky’s ambitions. But he also cautioned that the plan requires cooperation from Congress, more transparency from the CDC itself and a realistic assessment of the challenges when overhauling a federal workforce that has been scattered during the pandemic.

“I worry about the ability to affect culture change when the agency is still largely remote,” said Besser, who served as acting CDC director during the Obama administration. “I would want to be standing in front of the agency and laying out a vision and inspiring people towards that change. And then I would want to be walking the halls … but my understanding is that the buildings are still pretty much empty.”

The senior CDC official acknowledged the many groups that would have to sign off on parts of the plan but described Wakefield “as a force of nature” and said that some changes were already underway. “Work on essentially everything else is launching today,” the official said.

Walensky also briefed officials at the White House and the Department of Health and Human Services last week about the plans to modernize the agency. “They are supportive,” the official said.

Other outside experts on Wednesday offered endorsements of Walensky’s proposal.

The CDC director “did a very good job diagnosing the problems,” said Scott Gottlieb, who led the Food and Drug Administration under President Donald Trump and criticized the CDC’s bureaucracy in a book he wrote about the U.S. coronavirus response, called “Uncontrolled Spread.”

“CDC is a very academic organization – and I think Dr. Walensky recognized that when she says that they need to change the reward structure, so people aren’t rewarded for publications but for operational execution,” Gottlieb said.

He also praised Walensky for vowing a new communications approach, adding that simplifying the CDC’s language and publishing data more quickly would better reach people confused by the agency’s guidance. “They have to learn how to put out bottom-line information,” Gottlieb said.

Caitlin Rivers, a senior scholar at the Johns Hopkins Center for Health Security who helped launch the CDC’s new forecasting initiative, said she supported the plan and called on the agency to go even further. “The Center for Preparedness and Response is a wonderful resource within CDC,” Rivers said. “I think they could stand to be brought in earlier in [an outbreak], because they have so much expertise to share.”

The recommendations for change come from an internal review of the CDC’s structure, systems and processes that Walensky ordered in April. It was led by Jim Macrae, a senior official at the Health Resources and Services Administration, part of HHS. Macrae interviewed 120 people inside and outside the agency from mid-April to early June, the senior CDC official said.

Wakefield will create an executive council of agency staff that will track progress and report directly to Walensky.

A background briefing document shared with The Washington Post spells out some of the CDC’s most pressing problems and proposed solutions.

Some measures, such as new authority to mandate state data reporting, hire people faster and offer competitive salaries to recruit and retain top people, will require action from Congress. Others are internal changes that Walensky can make, such as having science and laboratory sciences offices, two key divisions that would be out front on a public health crisis, report directly to her. And some will require negotiations with unions.

The document laid out several issues, including the CDC’s lack of nimbleness during public health emergencies. “It takes too long for CDC to publish its data and science for decision-making,” it said.

Agency officials acknowledge that problem and blame it on the CDC’s incentive structure for promotions, which puts a premium on publication in agency reports and scientific journals, something that delays the release of public health findings, especially during emergencies.

“This whole idea where people say ‘We don’t want to scoop ourselves and put that information out before we can do an MMWR’ should be shamed,” said one official who requested anonymity to speak frankly about the practice of holding data back until it is published in the agency’s Morbidity and Mortality Weekly Report. “It’s not right. And part of that has to do with the incentive structure within CDC to get promoted.”

One solution under consideration, the briefing document said, is creating an online mechanism for “pre-publication delivery” for faster public health responses.

Another is simply sharing actionable material faster. For example, agency officials do not plan to wait to release a survey the CDC is conducting among gay men to determine whether they have changed their behaviors because of the spread of monkeypox, the senior CDC official said.

Wakefield will be in charge of changing CDC culture “by prioritizing and incentivizing public health action and impact over the number of scientific publications,” the briefing document says. “Produce data for action (not data for publication).”

The senior official acknowledged that such a culture change might prompt some at the CDC to leave, adding, “There will be some people … who would prefer to work at more of an academic institution and are going to feel like this is not the right fit.”

The changes also include efforts to introduce clarity to the CDC’s guidance documents, which “are confusing and overwhelming,” the document states, underscoring one of the most frequent complaints from consumers.

Recommendations include communicating in plain language, reducing the number and length of guidance documents, including scientific rationales and using FAQs that can be updated in real time.

To strengthen training and avoid burnout, Walensky is considering requiring a minimum rotation of six months for officials leading an emergency response. During the pandemic, some senior staffers were exhausted by deployments that lasted longer than six months. It has also been challenging to persuade officials to step away from regular duties to take a tour of duty leading the coronavirus or monkeypox responses.

“Leaving your position, where you’re publishing papers, to lead [an outbreak response], that’s not rewarded right now,” the senior CDC official said.

The agency also plans to create a one-stop shop to help outside groups “navigate the agency and receive timely information,” the document says.

In addition, it will set up a new equity office that will work across the agency, including in recruitment and retention of employees of diverse backgrounds.