The Reason the US Needs A CDC Focused On Emergency Risks, Not Process

The US has been fighting a war against Covid for two years, but the government agency tasked with leading that fight is a cautious, politically deferential bureaucracy more comfortable managing long term research protocols than a fast spreading virus that has killed @850,000 Americans, the most in the entire world. So far. 

The CDC was not designed for this, though it was equipped to see a pandemic coming. The question now is not at whom to point fingers, but on how to fix the agency so this doesn't happen again. JL

Josh Marshall reports in Talking Points Memo:

During the pandemic we’ve seen many instances where a deliberative, methodological approach is used when a more proactive and risk-balancing approach is warranted. These aren’t individual failures. They’re structural – institutions designed for normal times operating in crisis and stumbling repeatedly. Nor are they just over-reliance on expertise. Politicians defer to experts to avoid hard decisions. Excessive deference is a decision. It’s clear the institutional and organizational framework that works in ordinary times simply isn’t a fit for what is more analogous to a wartime footing.

I’ve spent the last couple days writing posts I’ve then set aside about what we’ve learned in two years about the CDC and FDA and whether they are, institutionally, up to the challenge of managing the crisis of pandemic response. To paraphrase Sonny Corleone, during a pandemic we need a wartime CDC. And it’s clear we don’t have one. The institutional apparatus designed for managing ‘ordinary’ infectious diseases, researching and improving care for chronic maladies simply isn’t designed for what we’ve confronted in the last two years.

One issue I’ve mentioned a few times over recent months was the slow-rolling of the decision to recommend or allow booster shots which carried on from late summer until the days just before the arrival of the Omicron variant only a few weeks ago. That illustrated two important issues. One was using standards of scientific proof appropriate for ‘ordinary’ times which didn’t match the moment. There was very little potential medical downside to boosting and huge potential upside. Waiting for certainty about increased immunity was a mistake. A second was more subtle: having vaccinologists make decisions about public psychology, politics and civic behavior. The cult of expertise – a great cult to be part of! – led us to defer to experts operating well outside their domain of knowledge.

Will supporting boosters make people doubt the efficacy of vaccines? Will pushing boosters come at the expense of public campaigns targeting the vaccine resistant? I doubt it. But an immunologist doesn’t have any more insight on that question than I do. Quite possibly less – inasmuch as they are questions tied to public opinion, state action and the role of political belief and polarization. In any case, in a broader perspective this shortcoming speaks to a key issue of bureaucratic drift tied to the over-reliance on expertise. In a democratic polity we elect people and hold them accountable to the people for making critical decisions about the public good. We want them to give great deference to professional expertise within the domain of that expertise. But the decisions themselves almost always involve questions that go beyond that technical knowledge and involve a range of equities that are fundamentally public and political.

During the pandemic we’ve seen many instances where a deliberative, methodological approach is used when a more proactive and risk-balancing approach is warranted. In other cases, we’ve seen big decisions made with deference to experts in which the expert decision-making involves guess-work the experts in question have no real purchase on. These aren’t individual failures. They’re structural – we see institutions designed for normal times operating in crisis context and stumbling repeatedly. Nor are they just over-reliance on expertise. Often it’s politicians deferring to experts as a matter of avoiding hard decisions. In the case I noted above about booster policy, I think the expert panels the CDC and FDA relied on made the wrong call. But these agencies work for the political appointees the President appoints to run these agencies. These decisions aren’t out of the White House’s control. Excessive deference is a decision.

The final point – perhaps one of the biggest – is that if you immerse yourself in the expert commentary on 24 hour cable and social media, you realize one thing pretty quickly: a lot of the obvious and good policies we should definitely be enacting are put forward with a limited knowledge of and often an almost complete indifference to the range of complexities inherent in the national policy-making process: the political constraints, the complicated mix of legal and constitutional constraints, the sheer breadth of the country and mix of federal, state and local responsibilities, the balance of public health versus civic and economic vitality. If we simply stand up ideals and contextless hypotheticals against the reality of the world as it is we aren’t so much analyzing or advocating as preening. Proactiveness and recklessness can bleed into each other or become hard to distinguish in a climate of crisis. (Remember: Sonny gets ambushed and killed and almost brings down the whole family.) We need some roadmap or beginnings of a plan to get from A to B. We need some way to distinguish between things that can and should be done better and those that are just a hard slog without obvious or easy paths to improvement. As an outsider to most of these questions that’s the part that I’ve had the hardest time making sense of.

One more example: this week the CDC changed its public guidance from 10 days isolation after testing positive to 5 days. That shift has been greeted with a wave of criticism. Many states, municipalities and organizations are rejecting the guidance. One major criticism is that it was done not for public health reasons but to keep the economy open amidst the Omicron surge – a criticism CDC Director Rochelle Walensky appeared to partially validate. The CDC itself wasn’t ‘following the science.’

But this wasn’t the entirety of the story. Especially in recent weeks there’s been an emerging scientific consensus that 10 days of isolation is much longer than it needs to be – especially weighed against the massive dislocations caused by people being forced out of work or school or other activities for ten days, even when they have no symptomatic illness. That growing consensus has pointed to five days as a much better benchmark for when people are actually contagious. In other words, the shift in policy was following the emerging science. Indeed, the community of epidemiology, vaccinology and public health ‘influencers’ on social media had been increasingly clamoring for it. The catch was that these proposals were usually matched with a need to test out after 5 days. So after 5 days if you get a negative result on a rapid antigen test, or perhaps two negative results, you’re good to go. No need to wait for ten days.

So why wasn’t this testing out part included in the guidance? I don’t know. But it seems like that part of the decision was driven by two factors. One is the fact that rapid antigen tests are currently in such short supply. The other is that the CDC and FDA have yet to sign off on the accuracy of rapid antigen tests as used in this precise context. Few instances better capture the mix of science following, competing equities (spread versus economic breakdown), logistical breakdowns (lack of tests) and bureaucratic sluggishness and box checking (test accuracy sign off). Guidance on testing is meaningless or even harmful if the test aren’t available. It also shows the compounding nature of the problems. How to provide concrete and helpful guidance in response to evolving science about duration of contagiousness in the face of test scarcity – a ship that for the next several weeks at least has already sailed?

What does seem clear is that the United States doesn’t have an agency or political apparatus designed for public health crises like the one we’re living through. In a way that’s almost inevitable. The last crisis of the same magnitude was a century ago, before most of modern medicine even existed. (AIDS had a comparable human toll but its impact on daily life – non-pharmaceutical interventions, work stoppages, restrictions on movement and socialization, vaccinations – not to mention risk of infection was concentrated on a vastly smaller subset of the population.) The CDC itself grew out of a malaria eradication program targeting the American South in the 1940s. It slowly grew its remit, adding sexual transmitted diseases, oversight of vaccination policy and finally the whole raft of chronic diseases and public health endeavors it now manages. I don’t know enough about this domain of study and action to say just what it is we need. But it’s clear the institutional and organizational framework that works in ordinary times simply isn’t a fit for what is more analogous to a wartime footing.