High hopes but tempered expectations as CDC launches review of agency’s structure and systems

By Elizabeth Cohen and Danielle Herman, CNN

As a sweeping review of the nation’s premier public health agency commences this week, interviews by CNN with more than a dozen people close to the US Centers for Disease Control and Prevention reveal an agency in need of serious changes to make it more nimble and ready to respond to the next pandemic.

The experts — current and former CDC staffers as well as outsiders who’ve worked closely with the agency — told CNN they hope the review could improve deep-seated problems that showed themselves in glaring ways during Covid-19, the worst pandemic in the United States in more than a century.

“At the end of the day, the killer thing here for me is the layers, the bureaucracy, the clearance, the process — it just takes way too much time during a crisis, especially when that crisis is moving at warp speed,” a senior federal official said.

That official and others described an agency in which scientists are smart, dedicated and hardworking but often siloed and hyperfocused on their individual projects rather than the larger public health picture, working within an inflexible budget that’s difficult to change quickly when a new pathogen emerges.

Last week, CDC Director Dr. Rochelle Walensky announced the review of the agency’s “structures, systems, and processes” to be led by Jim Macrae, a longtime employee of the US Department of Health and Human Services, with input from three senior CDC leaders.

“At the conclusion of this collective effort, we will develop new systems and processes to deliver our science and program to the American people, along with a plan for how CDC should be structured to facilitate the public health work we do,” Walensky wrote in an email to CDC staffers last week.

A senior CDC physician said the review would look at how the agency has handled the pandemic.

“How do we take the lessons that we’ve learned over the last two years and make sure that we don’t make any mistakes again, and make sure that we apply them well?” she asked. “It feels like we should codify, formalize, understand lessons learned over the last period of time, things that we did well, things that presented challenges so that we can learn from them.”

In response to a detailed list of questions, a CDC spokesperson sent CNN a statement that says, “Beginning April 11, Jim Macrae began a month-long process to engage with our CDC community — along with key external stakeholders — to help modernize our processes around developing and deploying the agency’s science. During this time, we will also conduct careful review of the agency’s overall structure and operations to ensure we are positioned for the future of public health, with a strong focus on the agency’s core capabilities — data modernization, laboratory capacity, public health workforce, health equity, rapid response to disease outbreaks, and preparedness within the US and around the world.

“The work we do will not only inform what we can do during a pandemic, but also what we do during normal operations to ensure our science reaches the public in a timely and implementable manner. The strength of this agency comes from the people who work at CDC. Since the director’s arrival, she has heard from many employees and external experts that they would like to see CDC build on its rich history and modernize for the world around us — this effort will lean into the hard work of transforming CDC for the better.”

Of the 16 people interviewed for this story, one is a senior federal official, one is a senior CDC official, and two are senior CDC physicians, and CNN granted those four anonymity given longstanding norms about government employees speaking to the media. The others were willing to be named: eight former senior-level CDC officials, including two past directors of the agency, and four outsiders who have worked with the CDC.

The senior CDC official said “data collection” for the review will take a month, and “synthesizing it and determining what the plan is” will take longer.

Whatever the timeline, a CDC review is clearly a complex undertaking, given the agency’s size and the breadth of its mission.

“It’s really hard to slice and dice an organization like the CDC to get everything into alignment,” said Dr. Nancy Cox, who served as chief of the CDC’s influenza team from 1992 to 2014.

Still, she and others hope the review will be a starting point for finding solutions to problems, many of which have plagued the agency long before Covid-19.

1. Get CDC scientists out of their silos

The CDC is huge: 13,000 employees spread across campuses in nine states and Puerto Rico, working in more than 10 centers — one for injury prevention, for example, and another for immunization and respiratory diseases.

“CDC is notoriously siloed in its organization,” said Dr. William Schaffner, a professor at Vanderbilt University Medical Center and a vaccine adviser to the CDC for 40 years. “Everyone is so involved in their own matters that there is very little cross-fertilization and conversation.”

“They care about their little potted plant, if you will, their budget line, and not about the broader public health issue,” said Dr. Tom Frieden, who served as director of the CDC from 2009 to 2017.

Cultivating one’s “potted plant,” as Frieden put it, might work when there’s not an emergency, but he and others say it hinders the agency when it needs to move quickly.

“I think [the CDC] is pretty good in peace time,” said Andy Slavitt, who worked with the agency as temporary senior adviser to the White House’s Covid-19 response team from January to June last year. But he said the agency needs “a less contemplative, more practical approach during wartime.”

Frieden and others recommended that the CDC send certain staffers to work in state or local health departments for a period of time because those offices are the ones that carry out much of the public health work during a crisis and receive about 70% of the CDC’s domestic funding.

“There are so few people who’ve spent a lot of time in the state and local, especially local and city health departments [and] that’s really quite a major issue,” said Frieden, who was health commissioner for New York City before he became director of the CDC.

Dr. Arthur Reingold, a former assistant chief of the CDC’s Bacterial Special Pathogens Branch, agreed that sending CDC staff to local health departments was crucial.

“I have worked in a local county health department. I have worked in a state health department. I have worked at CDC,” Reingold said. “Many of the people at the CDC, however smart they are, have never worked in a state or local health department. They’ve grown up, if you will, with the best academic training, [and] they’ve ended up at the CDC. They have expectations about state [and] local health department partners, but they have no experience working in those agencies and understanding the challenges and complexities that are there, and I think that perspective is badly needed.”

The senior CDC official said agency officials do go out to work in health departments “but not at the level that I think others would hope” and that structural changes would have to be made to allow it to happen more often.

“You can’t just pluck an MD from here and stick them there,” she said. “We have to create a system to make this happen.”

2. Practice for a pandemic

It was January 2007, and Dr. Stephen Redd, a retired rear admiral with the US Public Health Service, had never felt so grateful for an ice storm.

It was a CDC pandemic practice event, a military-like exercise in which, for 24 hours at the CDC’s headquarters in Atlanta, hundreds of staffers pretended there was a pandemic and played out what needed to be done to stop the dangerous pathogen.

The exercise went so poorly that Redd said he was relieved when an ice storm forced everyone to go home and end the exercise early.

“You could kind of feel the wheels were coming off the car during [the exercise],” he said. “We were not ready.”

When the ice storm hit, “I remember thinking that was good that we were able to stop the exercise because it was about to blow up,” added Redd, who worked at the CDC from 1985 to 2020 and served as the CDC’s deputy director for public health service and implementation science.

There have been many more pandemic exercises since 2007, and the agency’s readiness has improved over the years, Redd said. The senior CDC official said the exercises have continued during the pandemic.

Cox, the former CDC flu chief who spent nearly 40 years at the agency, said the exercises were helpful not just for the practice but also because they allowed managers like her to observe staffers and identify who worked well under pressure.

“You have to have a clear idea of how people are going to behave under a lot of stress, because a pandemic, especially one like Covid, is extremely high-stress,” she said. “Some people simply don’t work well under a lot of stress. You need to have a clear idea of how much of the firehose they can drink from.”

3. Learn to ‘keep it simple, stupid’

Improving the CDC’s communications was high on the list of every one of the 16 experts interviewed for this story. They said the agency must learn how to communicate with real people — not other doctors, not epidemiologists, not people with Ph.D.s in zoology or biostatistics, but real people.

A senior CDC physician said Walensky asked Macrae, the HHS official leading the review, to specifically address communications during the pandemic in his review.

“How did we handle things?” the physician asked.

For the sources interviewed by CNN, the answer was not well.

The senior federal official gave the CDC a grade of “D” for its communication during the pandemic.

“We weren’t nearly as consistent as we needed to be in both the timing and the frequency of providing information that the public needed,” the official said.

Several sources said it’s ironic the CDC had messaging problems during Covid, given that the agency taught the world how to communicate during a pandemic.

Starting in 1996, the agency published what is now called “The CDC Field Epidemiology Manual,” which has a chapter on communicating during an outbreak. There’s also the CDC’s “Crisis and Emergency Risk Communications” manual, which was first publishsed in 2002.

“It’s so odd, because CDC literally wrote the book on how to communicate in a health emergency — literally,” said Frieden, the former CDC director.

“I don’t know what happened,” added Dr. Sonja Rasmussen, co-editor of the field epidemiology manual, who worked at the CDC for 20 years, including as director of the Division of Public Health Information Dissemination.

As an example of poor communication during Covid-19, a different senior CDC physician pointed to “horrible” CDC messaging to immune-compromised people about how many vaccine shots they need.

The doctor treats immune-compromised patients who “didn’t get it” that they needed more shots than other people.

“It was just sh*tty. I have all these immune-compromised patients, and they didn’t understand it because we didn’t do a good job communicating it,” the physician said.

Many pharmacies also didn’t understand the CDC’s directive and turned away immune-compromised people who needed extra shots.

“This was a good example where we needed a spokesperson who could be all over the media and be on webinars with pharmacy organizations and Walgreens and CVS and explain all of this over and over,” the physician said.

When the CDC did communicate with immune-compromised people, it was often in technical and confusing language. In January, a CDC website for immune-compromised people stated, in part, “After completing the primary series, some moderately or severely immunocompromised people should get an additional primary shot. Everyone 12 years and older, including immunocompromised people, should get a booster shot. If you are eligible for an additional primary shot, you should get this dose first before you get a booster shot.”

Although that exact language is no longer on the CDC’s website, it still contains references to technical terms and includes no fewer than six footnotes.

“There’s this misunderstanding among CDC scientists sometimes that if ‘I write a document and post it to the web, it will happen.’ That’s called hubris,” the doctor said.

The doctor added that CDC scientists are sometimes disdainful of simple messaging, even when it’s effective.

“The media is excellent at communicating messages to the public, but some of the scientists say those are dumbed down too much, and I say to them, follow the principles of KISS: Keep It Simple, Stupid,” the physician said.

The senior CDC official said messaging on fourth shots “is a very good example” of agency communication that wasn’t as good as it should have been.

“That’s exactly what I’m talking about, which is, how do you translate science to practice? And I think that’s an area where we’re going to need some feedback and some recommendations of how we can do that better,” she said.

4. The CDC needs to regain its voice

The federal official said the reason they gave the agency a D grade on communications is in large part because the White House, under both Biden and Trump, had a “stranglehold” on the CDC, making it difficult for the agency to communicate effectively.

Several sources said a glaring example of this stranglehold happened August 18, when President Biden announced that “we’ll be ready to start” booster shots the week of September 20, even though there had been no review — or at least no publicly available review – of the science to see whether boosters even worked.

Biden did preface the comment by saying that boosters would be made available “pending approval from the Food and Drug Administration and the CDC’s committee of outside experts,” but sources for this story said it seemed clear the President was prejudging what the scientific data would show on the boosters. Less than two weeks later, two high-level FDA officials announced their retirement amid reports that agency scientists were angry about Biden’s announcement.

The sources interviewed by CNN said they were concerned that incidents like this engendered mistrust among Americans who didn’t like Biden to begin with — and that this was exactly the group that was hesitant to get vaccinated.

They said Americans who don’t trust the President would be more likely to listen to CDC scientists rather than to Dr. Anthony Fauci, Biden’s chief medical adviser, or to Dr. Vivek Murthy, the surgeon general, who might be suspected as being too political.

“Some messages are best heard not coming from the White House because a lot of the country isn’t going to believe anything this White House says,” Frieden said.

“As much as I admire both Tony and Vivek, they ought to sit down and be quiet,” added Schaffner, the Vanderbilt infectious disease expert who has served on the CDC’s Advisory Committee on Immunization Practices since 1982.

Although Walensky appears frequently in public, it’s often on short television segments, where there isn’t enough time to explain the scientific reasoning behind public health decisions, or at White House briefings, which have the appearance of being political and might not engender trust.

The public has rarely heard about Covid-19 from CDC scientists besides Walensky, which is in stark contrast to other outbreaks and undercuts the agency’s authority with the public, the sources said.

Dr. William Foege said that while he was CDC director from 1977 to 1983, his policy was to let scientists working under him speak directly with journalists.

“I told them they can talk to journalists; they don’t have to go through the front office,” Foege said.

Traditionally during outbreaks, CDC directors and agency scientists have held regular media briefings that explained in detail the science and the agency’s public health measures.

“You do need very clear, frequent communications: Be first, be right, be credible, express empathy, promote action, show respect,” Frieden said.

During the SARS outbreak of 2003, which resulted in zero US deaths, the CDC held 17 media briefings on the outbreak, according to CDC records. During the Ebola outbreak of 2014, which resulted in two US deaths, the CDC held 20 telebriefings on the virus. During the Zika outbreak, two years later, which resulted in two US deaths, the agency held 16 telebriefings.

But under the Biden administration, the CDC has held just nine media briefings on Covid-19. During that 16-month period, more than half a million people have died from the virus in the US.

Even at arguably its most contentious moment during the Biden presidency, the agency did not hold a briefing to explain its science. In December, Walensky announced new CDC guidelines to shorten the quarantine time for Covid-19, earning the agency severe — and extremely rare — rebukes from the American Medical Association and others.

It’s unclear why there have been relatively few briefings under the Biden administration — whether it’s been the CDC’s choice or if it was done at the direction of the White House.

When CNN asked the senior CDC official about the small number of briefings, she said that “we’ve heard this feedback loud and clear.”

If the CDC had fewer briefings because of pressure from Washington, all the reviews in the world won’t help, said Glen Nowak, a former communications specialist at CDC who co-authored the communications chapter of the CDC field manual.

“You can change the structure all you want, but if at the end of the day CDC is always going to be overridden by HHS or the White House, I don’t know that the organizational structure is going to matter much,” said Nowak, who spent 14 years at the CDC, including six as the agency’s director of media relations.

If the CDC has been under pressure from Washington, what could help is joining forces with medical organizations and other partners, said Dr. Walter Orenstein, who worked at the CDC for 26 years.

Orenstein was director of the CDC’s National Immunization Program from 1988 to 2004, and he said when HHS tried to “direct CDC” to make certain decisions, he found it helpful to get groups like the American Academy of Pediatrics and the Children’s Defense Fund on his side.

“No one wants to tick off the Children’s Defense Fund,” Orenstein said.

5. The CDC needs a more modern data system

Dr. Robert Redfield has been relatively quiet since leaving his position as CDC director under Trump, but last week, he said one sentence that resonated with the sources interviewed for this story.

“I always thought it was bothersome that the data the nation used to track the epidemic was from a medical school rather than CDC,” Redfield said at an event at the Harvard T.H. Chan School of Public Health.

Redfield was referring to data from Johns Hopkins University tracking Covid-19 cases and deaths, which the media and others have often relied on instead of CDC data.

A senior CDC physician said Hopkins data was “faster” than CDC data because the university can “webscrape” — take data from state, county and local websites — but the CDC isn’t allowed to do that.

“We can’t webscrape. We report [data] from the states, and the states gave it to us slowly,” she said.

Beyond webscraping, there are concerns that the CDC’s data infrastructure is in serious need of modernizing.

The senior CDC official said the agency is making efforts “to move data collection to the cloud” so that it could be more “interoperable.”

Tempering expectations for the review

During the measles outbreak of 2018, when anti-vaxxers were spreading lies to the Orthodox Jewish community, the CDC turned to Shoshana Bernstein, a pro-vaccine activist in the religious community in Monsey, New York.

The CDC staffers flew from Atlanta and met with Bernstein, who shared ideas about educational videos and publications that could help turn the tide.

“The impression I got was that everyone was committed and dedicated to public health,” she said. “I can’t stress this enough: They were wonderful people and kind and caring. They were public servants. They were not just there to collect a paycheck.”

Bernstein said the CDC staffers were enthusiastic and followed up with emails. But then, to her surprise, it became clear there wasn’t CDC funding readily available to make the videos or the publications she’d suggested, even though measles was raging in her community and the projects were small and relatively inexpensive.

“It was such a disconnect. They were so dedicated and committed and compassionate about public health, but there was so much red tape and processes that there didn’t seem to be a structure for pivoting from ‘that’s a great idea’ to actually making it happen,” Bernstein said.

Bernstein said to her great surprise, the CDC asked her if she had any ideas for where to get money to fund the pro-vaccine educational projects.

“I was like, ‘wait, aren’t you the CDC? Aren’t you this giant agency with a huge budget, and you’re asking me for help finding money?’ ” Bernstein said.

Bernstein ran into what former CDC director Frieden calls “inflexible funding,” where the director cannot easily move funds around when a new public health threat emerges.

“When Ebola hit, it happened to be at the end of a fiscal year, and we literally didn’t have enough money to buy plane tickets for staff. We had to borrow $3 million from another agency,” Frieden said. “When I was New York City health commissioner, I had 20 times more flexible funds than I had as CDC director.”

Despite efforts by the CDC, that hasn’t changed since Frieden left the agency five years ago.

“That’s an unfortunate part of the CDC budget,” the current CDC senior official said. “In the 150-plus individual disease and risk factor specific lines, [it] leaves minimal to no flexibility throughout the year to respond to public health emergencies.”

Because of this inflexibility, Frieden and others tempered expectations about what a review of the CDC’s internal processes and structures could accomplish.

“I think it’s important that there not be the impression that structural changes alone are going to make a big difference in some of the big problems, because they won’t be sufficient,” he said.

One of the CDC senior physicians said she wanted to “set the stage for managing expectations” about what the review will accomplish.

Anyone who thinks the review is “going to fix all the problems the CDC had and public health had, I think, is not sort of seeing the forest for the trees,” she said.

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