The widening path of SARS-COV-2 is destroying lives, families, communities, companies and whole swaths of society. One of the most startling and dangerous casualties of the pandemic, however, may be the sterling reputation of the world’s foremost public health agency, the CDC. Once seen as a can-do, results-oriented vanguard, designed to protect people from the very kind of biological threat we’re facing, the CDC has been reduced to a bumbling, inept, kowtowing agency that has become increasingly irrelevant to and discredited by the pandemic. When this is all behind us and we try to understand how the United States became the world’s COVID-19 epicenter, the CDC’s lassitude and missteps will be investigated, fingers will be pointed, partisan shots taken, and blame laid all around. What we need more than blame, however, is an evaluation of the systemic underpinnings of this failure and a total redesign of the CDC and the broader American public health apparatus in order to protect our society in the future.
This is a systemic failure because every time pandemic events have occurred or have been simulated through table-top exercises such as Crimson Contagion, the same fatal missteps keep happening. They repeatedly show the need for widespread protective measures like masks and PPE, deployment of testing on a large-scale basis, surge capacity in hospitals and honest and direct guidance to the public on what they should and should not do. The same mistakes are made because the culture, methods and tools of our public health apparatus haven’t changed in 50 years. We need fundamental change on a scale equivalent to the restructuring the nation’s intelligence and homeland defense agencies after 9/11.
As the first national coordinator for health information technology charged with developing the nation’s strategy for moving health care into the digital era, I dealt with the very same challenges – short-term thinking politicians, lack of authority, conflicting mandates, jigsaw puzzle budgets and confused public messaging – that are crippling our pandemic response today. Based on the lessons I learned in building a unified and proactive government strategy, here are the five things I would do to reform the CDC for the future.
Independent governance. We cannot allow ourselves to be in a situation in the future where the masters of the CDC are learning what an R-naught is for the first time. The CDC should not be buried as a subcabinet agency that is subject to political pressure, intimidation and manipulation. It should be an independent agency, similar to the Federal Reserve or the FTC. It should be governed by a board comprised of state government appointees, Congressional appointees and leaders from the private sector. Its leaders should be appointed for multiyear terms and serve without political considerations. The CDC should have an unqualified mandate to protect the health of the public. These changes will allow the CDC to be accountable to the public, to speak honestly about science and to act without regard for political fallout.
Standing funding. The depletion of the national stockpile and the lack of preparedness for an inevitable threat shows that short-term budgetary mechanisms are not suited to fight long-term threats. The CDC should have permanent funding, tied to health care expenditures, so that it is always fully funded and ready. This could be achieved, for example, through an incremental payroll tax on top of Medicare – and since Medicare raises $800 billion this way and CDC needs only $10 to $20 billion, it would be an infinitesimally small increment. Funding the CDC this way is equivalent to buying an insurance policy. Without standing funding, a future Administration or Congress could reduce CDC funding and divert the dollars to some other priority, and we would be left empty-handed in the future like we are today.
Break the glass authority. In normal times, the CDC doesn’t need special authorities to play the role of coordinator of aligned interests and shared goals across federal and state health agencies. However, when a public health emergency is declared, it is too late to debate who should have what authority and who should do what. A single agency – the CDC – should have enhanced authority to oversee and manage the national response. This would include managing deployment of testing capacity, enforcing lock down and quarantine rules, overseeing travel restrictions around and into the country, setting national social distancing and hygiene rules, managing regional surge capacity and sharing of equipment and personnel. Centralized authority in times of pandemic prevents unnecessary deaths and economic damage.
Permanent readiness. There should be a single agency, the CDC, that owns and manages the national stockpile and the supply of field hospitals to ensure that they are always ready. Testing capacity – on which the CDC failed miserably – needs to be always ready to operate at scale. Likewise, a modern information architecture that allows easy access into electronic health records, social media data and geolocation data for constant monitoring of health status, and that connects the CDC to state and local public health departments needs to be built and maintained. No different than our military, that is always on alert and prepared for the enemy, our public health apparatus needs to be equally and permanently vigilant.
One voice. The CDC needs to speak with an independent voice on health matters, just like the NTSB speaks about travel safety in an unfettered manner. And the CDC needs to speak honestly and with authority. The CDC’s conflicting messages about the availability of tests confused the public. Its back and forth guidance on wearing face masks further alienated the public. We need one voice in times of a public health emergency, a voice that is scientific, clear and singular. It should be a voice that, even if unpopular or at odds with political orthodoxy, is shielded from political gamesmanship. That voice should be the CDC.
We know that it is a matter of time until we face the next lethal pandemic – and it could be much worse than COVID-19. To be prepared then, we need to make changes now. We need to lock in and preserve these changes to ensure they survive through decades of forgetfulness. We need to act now so some future generation is protected not only from the pandemic, but from the generations between us who don’t know what we know and can’t understand why we are worrying so much.
