CDC Director Mandy Cohen on the Future of the CDC

This transcript is from a CSIS event hosted on January 8, 2024. Please cross check quotes against the event recording here.

John J. Hamre: Good afternoon, everybody. My name is John Hamre. I’m the president here at CSIS, and I have a very limited role today because we want to hear the experts. I want to say – I’m really here to say thank you to Dr. Mandy Cohen for her remarkable leadership of the Center(s) for Disease Control, one of the most important institutions we have in the federal government, underappreciated. And we want to be able to hear her thoughts now as we’re entering into a transition.

In my view, CDC has been doing heroic work, not without its challenges. I mean, that’s – it’s very clear that she inherited an institution that needed some reform. She’s been working very hard at that. And we’re very grateful that she’s been willing to share so much of her time with us here at CSIS and especially working with Steve and with Richard Burr, who’s been on this bipartisan commission. This has really been an important work that both of you have been doing, and so we’re very glad for that opportunity.

I would ask that – we have a good audience here in the room, our huge audience out in cyberspace, and I want to say welcome to all of you. This is going to be a dialogue. I think Dr. Morrison is going to kick it off.

But I did want to just say a word of thanks to – especially to you, Dr. Cohen, for being here, for our partners that are going to be participating with you in this conversation, and a special thank you to Sophia Hirshfield who has been pulling all the mechanics together to make this happen today.

Thank you all for joining us. We look forward to this session. Steve, I turn it to you.

Stephen Morrison: Thank you. Thank you very much, Dr. Hamre.

Welcome, everyone. Senator Burr co-chairs the CSIS Bipartisan Alliance with Julie Gerberding, who sends her best greetings to all of us here today.

Senator Burr, I’d like you to open things up, please.

Senator Richard Burr: Steve, thank you and, John, thank you for all the many good deeds that CSIS does and especially this one that relates to global health.

Today is a conversation with not only the CDC director but a good friend of mine, and let me say to our audience here and our audience electronically every four years our country experiences a change in leadership. Some of those changes are more drastic than others and we’ll have to wait to be – to see exactly how drastic this one might be.

But let’s suggest that this is also significant, that it’s a transition from politics to policy, and I think here two weeks out we’re beginning to hit that period where, hopefully, the focus of those who will have the mantle of responsibility, who will look more at policy, and we’ll have an opportunity to learn a little more about the direction that they intend to go.

The degree of change is always determined based upon the baseline when you start. So I hope, Dr. Cohen, that today we’ll have an opportunity to understand a little more about where that baseline is at CDC and your personal feelings about those things that are most important.

It’s my hope that the CDC director today can educate us on the changes that she has initiated the future – for the future and that we will all understand that starting point for the new administration that much better.

So with that, Dr. Cohen, welcome. Mandy Cohen is one of the nation’s top health care leaders with experience leading large and complex organizations. Proven track record protecting Americans’ health and safety.

As CDC director she manages and directs the activities of the agency which includes developing and applying disease prevention and control, environmental health, health promotion, health education activities designed to improve the health of the American people as well as other nations and international aspects. We might ought to start on the definition of CDC at some point.

Dr. Cohen is an internal medicine physician. She ran the North Carolina Department of Health and Human Services. Prior to joining CDC Dr. Cohen served as executive vice president of Aledade and CEO of Aledade Care Solutions, which helps independent primary care physicians, health centers, and clinics deliver better care to their patients and thrive in value-based care. Previously, she served as chief operating officer and chief of staff at the Centers for Medicare and Medicaid Services and served as acting director of the Center for Consumer Information and Insurance Oversight. In February of 2019 – you might have forgotten this – Modern Health Care named Dr. Cohen one of the top 25 women leaders in health care. In September 2020 Dr. Cohen was awarded the leadership and public health practice award from Harvard University.

We clearly have benefited by your service not just at CDC but your service in the public health space. We welcome you today and I turn it over to you for any comments.

Mandy Cohen: Great. Well, thank you so much to CSIS; Dr. Morrison; my home-state senator, Senator Burr; and thank you for our long partnership and your counsel and advice when I was in North Carolina leading health and human services and as I took on this role at CDC.

I wanted to start with three examples during my tenure of how CDC has protected the health of the country, and I’ve been saying a lot when public health is working it’s often invisible. Like, we’re really not good at telling the stories of how we’ve protected health and prevented crisis from happening. So let me give you three examples.

First is from this year. You may remember we had an outbreak of Marburg, which is an Ebola-like viral hemorrhagic fever, not just – in Rwanda, but it was in Rwanda’s capital, in their flagship hospital. So my blood pressure went up. But what I saw was swift action based on decades of trust-building that has happened between the United States and CDC and the Rwandan health ministry, where we were able to, one, get that call, right? So they called us when they said, “We are seeing this.” One, it was identified by a CDC-trained epidemiologist, and they called us to say, “We need help,” and we sprung into action. Within hours we sent our head of our viral pathogen lab to Rwanda to help make sure that we were setting up the lab infrastructure and making sure that they had what they need to identify cases. And within nine days, the United States donated and deployed vaccines that were used. So nine days of turnaround, and to this point we’ve been able to extinguish that outbreak. The best way to protect the United States is to stop it from ever getting here in the first place. So that’s one.

Second: things on our shore. Last year for the first time ever we saw cases of malaria. Actually malaria was why the CDC was created. And we hadn’t seen malaria in the United States in 25 years. But last year in Florida – and in Texas, but a larger outbreak in Florida – we saw malaria. And again, this is the great partnership not just at the CDC but at the state and local level – great work at the state and local level in partnership with their health care systems, making sure we were identifying cases, doing the vector control work. And as I’ve been saying in some speeches, you didn’t hear that we had to close Disneyworld, right, because public health worked. We did not – we extinguished that malaria outbreak and you haven’t seen it again. And in fact we did not see it again this season.

Third example: mpox. We know that we have a certain kind of mpox that is here in the United States, but we’ve been watching a new form of mpox – mpox clade II – in East Africa, and we’ve been preparing to be able to detect it here. We saw our first case from a traveler coming back from that part of Africa, and we were able to make sure, again, that we were deploying quickly, using our wastewater data infrastructure partnerships to make sure that we sprung into action and that it didn’t spread further and become endemic here in the United States.

Now, we have to keep up that posture to make sure we’re doing it, but three times that we can see that when you are able to have the necessary ability to detect, necessary ability to respond, we can protect the health of the country. And we know it’s more than health, right? It’s the economy as well. So it’s critical to our national security to be able to do that.

And I think CDC has been on this journey to learn a lot of lessons from the COVID pandemic. Look, we know that there were ways in which CDC did not do all of what it needed to do. We’ve taken accountability for that, particularly in the lab space, in the communication space. And you know, we have very much – and I personally have done a lot of listening and learning, and I think the organization has as well.

And so what I’m hopeful for the team that is coming to HHS, coming to CDC, is to make sure that they know, to your point, the baseline. What is the status of things at CDC right now? And of course there needs more improvement. We should always be an improving, learning organization. But where are we? And I just wrote an op-ed in the Financial Times where the headline was “CDC needs a scalpel, not an axe,” and so what – because I want folks to know the improvements we made.

So how are we different? Because we’ve listened, we learned, and we took action, importantly. And that started with prioritizing – what are the most important priorities for us to take action on? And it started with our response capability, making sure that we had the ability, again, to see and prevent a threat before it became a crisis. So we built a wastewater infrastructure, for example, for COVID, but now we’ve been using it for mpox, for avian, for COVID. So we’ve been able to take that asset and utilize it.

We are now able to see into 95 percent of the emergency rooms in the country in real time. So today I can pull up on the computer if we are seeing a cluster of, say, headaches in southern Louisiana, and then we can say what is that trend over there. Now, it just gives us trends, but then we can ask more questions, right, and we can get early signals.

Third is we have different partnerships with commercial labs, right? So one of the things that we know we had to learn from during COVID was how do we get to high-quality lab and have that be able to be scalable. So we have new partnerships with commercial labs that brings them in in day one – frankly, before day one – to say, how can we work together on scalable diagnostics that we need. So we’re doing it in avian right now, which is where we want to make sure avian testing is available all over the country, not just in public health labs. That’s why Quest, Labcorp, and others, with our partnership, have scaled up H5 testing.

We also – data. Data, data, data. So important, right? You can’t solve problems, you can’t protect health if you don’t see it and you see it early. So getting data faster, more reliably has been such a really important focus, and making sure that we are using data across diseases, right? So we don’t just collect data for COVID or just for malaria; we have to be sharing that data across the different disease states. So we’re getting data faster, more accurately, but that is a baseline. We have more work to do to make sure that we have the data infrastructure that we need and the authorities to make sure we can get that data in real time to protect health.

And the last that I’ll mention is I think we are communicating differently. So, obviously, communication is a priority of mine. I think pragmatic, simple communication that can help people take action for themselves to protect their own health, their community’s health is what is needed. So we all are consuming our own information differently, so that means we as an agency have to be sharing information differently, right? How are we thinking about leveraging social tools and others? And we completely revamped our website. We archived 60 percent of that; again, prioritization. How do we get to what people really need to protect their health, and how do we do it in a pragmatic way? But we also know we need a lot of trusted voices out there. And how do we partner with others to make sure that we are communicating well and fast?

And so I’d also say – I want to just touch on some of our global work before then we go into questions. The Marburg work is emblematic of that global work. What I think I didn’t realize as a state – you know, a federal and state leader coming new to CDC is that CDC is remarkable in the way it supports and builds capacity in our – countries that we partner with. So there are other countries – and we may talk about them – who are good at writing checks, maybe, to build labs. What we do is train the laboratorians, right – train the folks who are either going to do the epidemiology or do the laboratory work. And that takes time. It takes trust. It takes that relationship building. But it’s ultimately what I think protects the United States, because then we are in a place where folks are calling us in the middle of the night when there’s an emergency, because that’s where we want to be.

And with every health minister I met during my tenure, what I said is we want to be your first phone call. If something’s going wrong, if there is a case or Ebola or Marburg or whatever, call us, because we want to solve these problems for you, because we know that protecting the United States means working side by side to protect the people in your country as well. And I think CDC does that exceptionally well, and we need to keep doing that.

And I know, you know, Senator, your leadership was part of making sure that we have the investment around PEPFAR, and how do we make sure that that investment – yes, it was for a particular disease, but it has been leveraged to do so much more. The fact that we’ve had that infrastructure is health security for us here in the United States.

And, look, I can’t end – I just want to end by saying, you know, we also do incredible data work to understand health threats that are here in the United States. And, look, the thing that is killing people under the age of 50 here in the United States, it’s suicide and overdoses. And so I couldn’t do my job and say we were truly making this country healthier, protecting the health of, if we didn’t understand and focus on the things that are killing out adults, young: suicides and overdoses. And the good news is, is we are making progress on overdoses. You may have seen we’ve had a – for the first time in five years had a reduction in overdose deaths, right? You can’t solve problems when you’re not getting that repetitive feedback of data. Are we making progress with – are we spending our money on the right things? Are we doing the right things to prevent overdoses? And our data can tell us that. And I think CDC, while we don’t lead in the space of suicide or overdoses, we provide that infrastructure of data to allow folks to know what’s working and what’s not.

So much more that I could do. As I said, I’m proud of the work. We’re not done. We have more to do. But I think we’ve learned a lot. And I want to make sure, again, the incoming team knows that the team that they remember and the CDC that they interacted with in 2020 is not the same organization that we are now. And there’s always more to do, and I look forward to continuing to support that work even as I pass the baton. So thank you so much.

Sen. Burr: Well, you’ve given us a tremendous amount of items that we can talk about today.

But before we go to that, Steve, I want to allow you to make some comments.

Dr. Morrison: Thank you.

Thank you very much, Dr. Cohen. I want to offer just a few thoughts.

One is just on your leadership. I mean, we did a lot of work here before you had arrived, published an analysis on CDC which we were very proud of, and we worked closely with you as you came in in July of 2023. And I think your leadership’s really been remarkable. I mean, you did your homework, you listened and consulted widely, and you – and you delivered rapidly on these many fronts that we’ve talked about. And it is a different – it is a different agency. It’s a different capability. It’s a different outlook there. And I want to thank you for your leadership on the global – on the global side of that, which is of special interest to us here; the HIV work; the new regional offices like Michelle McConnell in East Asia, I was just talking last week with Chuck Vitek in Tbilisi; remarkable work on AMR reaching into Ukraine and the war, war wounded, but also beyond into all sorts of states. So I want to thank you for that.

But it’s clear that today those changes are very important that we acknowledge, but they’re not going to be enough to carry us forward into this divided environment. We’re going to need to think about – carefully about the debates that are ongoing right outside our door. And what I mean by that is we still have a trust deficit that we are still seeing. It’s something that’s not fixed quickly. It’s something that requires a kind of persistent long-term approach. We know that CDC still remains quite vulnerable. We know that there are debates swirling around what should the – what should the future of CDC be. There are those calling for it to narrow its focus to infectious diseases. There are those arguing it should be turning itself towards the MAHA agenda around NCDs and prevention in primary care. There are those talking about splitting CDC’s work on vaccines into the science and data side, and having the evaluation and guidance put somewhere else. There’s proposals to just shrink the size of it through budgetary matters, through workforce things. And there are court decisions that have been made that are – that are looming out there that could have some consequences.

So I do think we’re at a moment of where we should be – we should be worried about the future and talking about how to move forward in the most constructive way. I don’t think we see a clear consensus among critics of CDC about which pathway of reform. Reform is in the air, but there’s no clear single pathway. There’s a division of opinion. People are pulling in different directions – infectious disease, chronic diseases, or both, or shrinking. Bipartisanship is frayed, but it’s not done with. And one of the things that you did was perhaps triple or more the outreach and engagement up on the Hill on a bipartisan basis, which was a very important element, I think, in getting people to think again around what you do, what CSIS does.

I do think there’s no time to spare in the sense that the threats that are continuing to come at us are not going to cease. And giving those case studies around the way in which you extinguish threats is very important, but I think also we’re not done with H5N1. We are going to see more coming forward at us. We’ve got all sorts of things that are on people’s minds right now, including reports coming out of Asia. And we can’t afford – CDC, it seems to me, can’t afford a sudden loss in its capabilities. It can’t suffer a sudden loss of its workforce out of resignations or rifts or the like, or sudden budget shifts that remove those capabilities.

On a more positive note I think the 17 percent drop in mortality caused by opioid overdoses in those last eight or 12 months is a remarkable fact and a testimony to something going right across an interagency approach by this government.

We had Dr. Rahul Gupta here for a conversation just recently, a broadcast conversation around that topic. That’s an achievement that I think we need to continue to remind people of along with stopping Marburg and stopping these other outbreaks.

Thank you.

Sen. Burr: Great.

Well, Dr. Cohen, now we get to discuss a lot of these things and I hope you’ll give us as thorough a(n) answer as you possibly can, I think we can all expect, based upon the calls for greater efficiency, less duplication, smaller workforce, and likely an executive order that’s a return to work for all federal employees.

How, in your mind, do you think CDC will react to that? Are they capable of looking and understanding to look at duplication, to look at greater efficiency? Because that involves a degree of technology incorporation that I’ve found not necessarily to be welcomed at CDC in the past. Not reflective of the time that you’ve been there. Tell us about that and how you think it will be received.

Dr. Cohen: You know, CDC has been on a change journey for a number of years and was started before I got there with a moving forward initiative that reorganized the agency to be more response ready, to make sure that we were organized in a way that we were doing our work as one team. But there’s a reorg and then there’s, you know, putting that into practice and what we’ve been doing over the last couple of years is really focusing and prioritizing.

Now, is there more to do? Absolutely, and that’s why, you know, I think having a smart conversation about it. But what I’m hearing or, frankly, what I can react to is I just look at a proposed House budget. That looked like an ax, not a scalpel, meaning that there was a 22 percent cut for CDC.

We cannot protect the health of the country, be proactive, have the data infrastructure, do the genomic sequencing, have the diagnostic tests that I think we need to protect folks if we just lop off, you know, 22 percent. 

We have to be thoughtful about doing it. But I am all – as you know, you’ve known me a long time. I am for effective, efficient work and I’d say we’re on that journey. So what are the things, again, that we need to continue, and I would say our data infrastructure for sure are the things that we absolutely must prioritize and continue – their wastewater infrastructure, the genetic sequencing, the diagnostic tests, these core capability that we need to be able to respond to any health threat. 

Whether that’s overdoses or avian flu those are the things we need to prioritize. I’ll say one thing on, you know, as we think about talent this work needs talent. It needs expertise, and I want to make sure that we are a welcoming environment to folks who are talented that want to do this work.

And so as we think about what are the right structures to bring people and keep and retain your workforce I want to make sure we’re thinking about it, again, not with broad brushes but to be specific.

So we are very lucky to have some incredible data scientists or folks who are working on our data. They may reside in California to do that work because that is – they have done great things in their first parts of their career and then they come to CDC to give back, to do public service but they’re not willing to move their family.

I want that talent. I want that talent at CDC. We should want it to protect. So just we need to think about as we think about making sure we can retain the talented workforce that we need. Not everything can be painted with one broad brush. 

And I will say, though, it’s hard to – you don’t do lab work from home. Our team has been in doing the work in person for a very long time and that that hasn’t changed.

Sen. Burr: Well, you’ve opened the door just for a follow-up before I turn to Steve because I believe data is an important aspect and it seems that data matched with artificial intelligence is like the supercomputer. So how much have you begun to integrate AI into the process at CDC and will that be able to fill some of the talent gaps on that data analytics side, going forward?

Dr. Cohen: So a couple things. So, one, I want to remind folks that when we made – we made tens of multiple hundreds of millions of dollars of investment in data infrastructure in the health delivery space, right. When you all did the HITECH Act and we said we need to digitize what we’re doing there, public health was not part of that.

So actually the COVID dollars that came from Congress have allowed us basically to catch up with that investment that was made on the health delivery side. But I would say you can’t put any of these what I think are very exciting tools in the AI space unless you have the foundation right and we are still building some of that foundation.

So I want to do all of the very interesting and exciting, and we are, on some large language models, again, to pick up trends when you start to see things happening on social media. Why are people Googling, again, headaches in southern Louisiana? We can start to pick up some of those trends and we are – we are using it for Legionella disease – so to look at different patterns.

So we are using it but I want to make sure that those models are only as good as the data it is powered by, right, and so getting that infrastructure right, making sure that the data has standard ways of it being liquid and interoperable, are so critical to power what I think can be that data future.

Sen. Burr: Steve?

Dr. Morrison: The bigger – the bigger picture, I think, that we’re looking at is that this is a very fragile moment where we’re trying to preserve the gains and move them forward and continue to rebuild trust and confidence, preserve a bipartisan consensus and come up with a very legitimate, constructive reform agenda and drift away from a kind of vengeful, angry, and destructive sort of debate.

Are we getting anywhere in that? I mean, when you paint – when you describe the gains in the last few weeks in many different settings you described how you were able without new money, without new authorities, to connect up 11,000 medical facilities electronically.

On a volunteer basis you were able to get compliance, and when I read that I thought, well, maybe the temperature is coming down. Maybe we’re getting past the most acute phase of COVID sensitivities and anger.

Are we? Are we at a moment where a legitimate conversation around reform is possible? Are we still at a high risk?

Dr. Cohen: I think it could go in two directions. When I have private conversations there is a lot of consensus about needing to protect health and to need to have the data infrastructure and the ways to monitor genetic, but – and that no one wants to leave us vulnerable. And I think – I don’t know who said it but I do think there is a difference between campaigning and governing and I think this is – there’s an opportunity here as we turn to folks who are going to take the baton of governing to help turn that chapter.

But I think it’s going to take them just assessing, again, the baseline of where we are as opposed to coming in and saying I remember something from 2020 so I’m going to slash and burn. I’m going to cut 22 percent.

If they come with the mindset of I know this is important for our national security, some good work has been done here, let’s think about how we can rebuild trust together, how we maintain this, I absolutely see that going in a positive direction.

And so, you know, I think it’s to be seen. That is the moment. I think there is a lot at stake here but I’m an optimist and, like I said, I am having good conversations with, you know, members on the Hill about this and their understanding why this needs to go forward and I think it does need, you know, continued leadership.

But it could easily go the other way if folks aren’t thoughtful about how to approach change. I’m for change and for efficiency. Just do it in a thoughtful way to understand what is the – how do we maintain that expertise, how do we maintain the progress that is made, and then go forward.

Dr. Morrison: May I just ask one other question on that?

I mean, I agree with you that when the House Appropriations passed that bill on July 10th that was a thunderclap – 22 percent cuts, 1.8 billion (dollars), 23 programs. Those cuts, if enacted, would affect public health officials all across the country in states and localities, in municipalities. Why didn’t we see a – or maybe we did, but my sense is that that threat was not just to CDC in Atlanta; it was to all of these programs and experts that protect Americans in their communities and in their states. That’s been historically a bit of a weak constituency in terms of its voice and its power. Not that they don’t matter tremendously; they do. But when I saw that thunderclap moment, I didn’t see an eruption of reaction against it. I didn’t see governors standing up and saying, “This is crazy; our state shouldn’t be treated this way.

Dr. Cohen: Well, one, I think that then that is a failure of communication of having governors understand how four out of every five dollars that comes to CDC goes to states and localities. And I think it’s a misunderstanding of when budget cuts come to CDC, they very much impact what’s happening at the state level, and that that again, I think there is a lot of consensus about needing to do the work of public health. And so that just means pressure at the local and state level, in terms of their budgets.

But I think if we can have a national conversation about what are we prioritizing, how are we using those funds – I will say one of the reasons I don’t think we saw the outcry is that not too much later we saw a Senate – a unified Senate budget that looked very different. I still think that there are things that could change in that budget as well, but it didn’t have that. So I think that tempered the reaction.

Dr. Morrison: Shock, yeah.

Dr. Cohen: But that – but it tells us what the threat could be. And so when you’re saying, what could be in the future, I think that could be our future. The House budget could be a future when you’re looking for the kinds of budget reductions that I’ve heard – again, are we campaigning or are we governing? And so I hope as folks take up the governing mantle they’ll recognize, wow, these are such important issues, we cannot cut X, Y, and Z things; otherwise our national security – right? They’re not going to walk back from our commitments on the defense side – on the military defense side; we should not be walking back our defense on the biologic side, right, on the public health side. So I think that’s the message, and we’re at that moment in this is why this is such an important conversation.

Dr. Morrison: I just want to add, some of the work that we’ve done over the last year in partnership with the Brown University Pandemic Center and with the COVID Collaborative in the United States looking at what happened during COVID has brought forward just how central the governors are, of all stripes politically, in innovating and empowering. And I know you’ve had this same experience with Governor Cooper, and you, sir –

Dr. Cohen: Of course.

Dr. Morrison: ― that they oftentimes exercise enormous authority and ability to innovate and cross the political lines and connect with people and empower. And I hope that fact doesn’t get lost in this debate, where it can become a Washington-centered debate, but it shouldn’t be.

Over to you, Senator.

Sen. Burr: Mandy, I’m still – I’m going to stay stuck on technology for a second because it’s unique that it really wouldn’t matter which agency were sitting in your chair right now; I think the number one issue is how do you deal with technology and what’s the policy. And I could say prior to your leadership there was a reluctance on the part of CDC to have any partnership with the private sector, regardless of whether it was technology or data or anything. So what specifically have you set up at CDC that would make a private sector potential partner want to come in the door and engage with CDC to be a full-fledged partner?

Dr. Cohen: Yeah, this is one of the things I’m really proud of, that we have mechanisms for the first time that allow for that private-public partnership. The lab space is really important. So, look, these are businesses. They’re there to make money, but they also have incredible talent and scale. And so we needed to figure out, how do we bring them in? And so we have this new partnership that’s not just in name, but there is a structure and a contract for how we can interact that allows us to share more, right, and allows us to buy some warm lab capacity. So if we needed to scale up lab capacity, we already have some waiting in the wings, right? And so I’m really excited about that. And I think it was that we needed to find the right construct so that the team could see how that private-public partnership was possible.

And now that we’ve done it in the lab space, we can do it in others. We’re partnering, you know, with the team at Palantir to build the backbone of our enterprise infrastructure – again, a private sector company, but one that works very often in the government space, so they know how to handle privacy, they know how to be in the security space. And they are helping us, again, de-silo our data, make sure that we are being effective and efficient.

So again, we’ve put some of these pieces in place, and I think it not only shows tactically that we can do it, but then it role-models, okay, like, how do we think about that for other types of work that we might want to do in the future?

Sen. Burr: Yeah. Let me just say, my skepticism to some degree is that the same career folks that blocked this for decades are still there. And it makes me somewhat suspect as to whether it is maintained when there’s a leadership change or whether they revert back to a world that’s very protective, because I think your example of the focus of labs was the direct result of CDC trying to maintain custody of lab creation and COVID, and it was their failure that opened up the door for the enterprise to look at the private sector as a partner.

Dr. Cohen: Yeah. Look, we’ve – we learned.

Sen. Burr Yeah.

Dr. Cohen: And I think the team has been in a learning posture, and I want to give them credit for that. And we are also on the other side of them seeing how important these partnerships have been. So, because we have these lab partnerships, we also get in real time de-identified lab data from the 200 most common infections disease tests that are out there. And so now we’re getting in data, so now there is, like, super value-add in the moment for many, many of our teams. And that – right, you start to get to the other side and they’re like, whoa, this is – this is great.

And so it not just does something tactically; it changes the culture. So I do believe that we are in a different place, and I’d like – you know, I think folks have learned and have taken action on that.

Sen. Burr: I don’t think that any of the three of us believe that CDC is going to get an increase in funding in the next budget cycle – 

Dr. Cohen: Yeah. Yeah.

Sen. Burr: – nor in potentially the new administration. So let me ask this: How much confidence do you have that the Congress can understand where the gaps are that the decrease will cause? And is CDC positioned to work with Congress to provide suggestions as to how those gaps are filled? 

Dr. Cohen: I think we have very detailed conversations, particularly at the staff level. I think they – there are folks who know our agency well – though I will say there are a lot of new folks on the Hill, on the staff side as well – so again, making sure they are educated about our programs. You’ve seen this, right? That kind of turnover is – you know, means we have our work cut out for us to make sure folks understand.

What I’m trying to lay out are the core priorities that have to get done – lab, data, workforce response capability – and then to make sure that we are – that we are helping folks understand the through-line of, like, how does that look to our budget. You look at the CDC budget as many little line-items, not core investments. I think there’s an opportunity there to rethink about how do we want to fund CDC to be the response agency that we need it to be to protect health. So there’s some opportunity there that – and I think there are some things in there that particular members cared a lot about who are no longer in Congress, so there may be an opportunity – (laughs) – to rethink about whether that’s the top priority.

Sen. Burr: I will not – I will not take that personally. (Laughter.)

Dr. Cohen: And so I think there’s opportunity – and that’s what I was – the headline was “scalpel,” right? I get it. Budget times are tight. I get it. “Scalpel, not an axe,” is the – is the topline there. Be thoughtful. There are ways to get, you know, some efficiencies, but make sure it’s not at the expense of making us less safe.

Dr. Morrison: I’d like to talk a little bit more about vaccines. One statement you made struck me, which is you were worried about misinformation from places of influence or power. Can you describe a bit more about what that means?

Dr. Cohen: Look, we take our job very seriously at putting out solid information, but part of what we have to do is also move faster and share information, but we need to do it in a way, like, this is what I know today. That may be different. We’re trying – I hope folks are seeing us communicate differently about avian flu – like, this is what we know today, which is there’s no human-to-human spread, that we have vaccine candidates ready, that we have – right – that we are, you know, ready and prepared. However, we’ve all learned that these viruses change, and so I want folks to also hear the statement that things could change in the future. And that’s not making public health wrong now, right? That doesn’t mean we made some mistake now. It just means things change, and then you have to react to those changes and make different – you know.

But what I was probably reacting to there is making sure that we stay grounded in the evidence that drives those decisions. There is – there are policy decisions that are embedded in our work. There are. Should we – should we fund this? Should we –

Dr. Morrison: Yeah.

Dr. Cohen: Right. But the evidence is what the evidence is. And I think wanting to make sure that we stay true to that evidence as we move into the next administration is important.

And I do want to push back a little on the premise that – on the trust premise, because actually we see people poll quarter over quarter on trust in CDC, and I’m really proud that actually over the last 18 months we’ve seen that trust in CDC go back up. And I think it’s because we’re communicating differently, we’re focused on priorities that matter for people in their everyday lives. And so I think we’re on that journey of rebuild trust.

And, look, when – on the topic of vaccines, more than 90 percent of folks have gotten those routine vaccines. We’re in the 90 percent. That’s a lot of trust in those vaccines. So I don’t want to overblow what is untrusted in the moment, because actually I do think that routine childhood vaccines for the vast, vast, vast majority of the United States is very well trusted, and folks understand that that is science that has been revolutionary in this – in this – you know, the last hundred years.

Dr. Morrison: Yeah. Now, we know the incoming Trump administration is going to press for greater study and transparency of vaccine safety and mandates, and they’re going to tie that to rebuilding trust. There also is the possibility that they’re going to take another look at the composition of the ACIP, the committee housed at CDC that reviews vaccines. How can this be managed effectively without going off in the wrong direction and causing damage to – further damage to public confidence or to the processes themselves which are essential to keeping that confidence up?

Dr. Cohen: Yeah. Well, first, it starts with knowing that we care very much about vaccine safety and transparency, and want to make sure that the public understands that and sees that on an ongoing basis.

Second, you know, we have for a very long time made so much progress to protect the health of folks using vaccines, right? It is why we don’t see cases of polio. We are starting to see more cases of measles, right, as such a – you know, it’s so contagious, it is always the canary in the coalmine. So we – I think that we need to make sure that we are being clear about the folks who are on those advisory committees, what their role is in terms of looking at the data and the science. And they are from very different walks of life with different perspectives on it, so I do think that we have diversity of thought. And they have good discussions at every meeting about are we looking at the data to make sure we’re evaluating it. And so I hope to see that continue and to make sure that folks are using those processes the way they were designed, to look at the data and the evidence but also to recognize when settled science is settled science.

Dr. Morrison: Thank you.

Richard?

Sen. Burr: I want to stay on transparency, if I can. And I want you to understand I’m not trying to beat up on you; I’m really sharing with you what we hear publicly, that you’ve made progress but you’re not there, and that there’s still a concern about why CDC won’t really inform the American people.

So I go back at where we started. During COVID, there was such a tight cap on information that it was John(s) Hopkins that created a daily COVID infection sheet and it became the gold standard for America. It wasn’t the Centers for Disease Control, which should have been. But for some reason, CDC didn’t at that time believe that that was important information.

We’re in a society today where everything is transmitted in real time by social media. And in the absence of you doing it, somebody’s going to do it. How do you recapture not only the primary role, but as you do that convince the American people that they’re getting the full monty with everything that CDC’s sharing?

Dr. Cohen: Well, one, I don’t think that CDC didn’t think it was important; they just didn’t have the capability, the authority, the infrastructure to be able to do the work. And we’re in a very different place now. So, again, we don’t have everything that I would wish we could have in terms of data infrastructure, right? Data takes a long – like, these are long-term projects that we’re bringing pieces over over time. And, like, frankly, budget drives a lot of it. The more budget – the more money we have, the faster we can go. If you don’t have as much budget, you have to, you know, space things out over a number of years. And so that’s that journey that we’re on.

But I think – we’ve always prioritized it – is do we have the budget to execute on it? And I think the investment that was made with the COVID dollars puts us in a very different place to be able to have those capabilities now. But any retraction puts us – puts that at stake – at risk, right? So we have to keep making progress forward.

So I don’t think anyone isn’t interested in transparency. I think everyone is interested. It’s do they have the capability to execute on that, because it is hard to put all those pieces together and want to be the authority in the data, right? There is – there’s also a lot of we are getting better at CDC at putting out data quickly and saying this is provisional data, right, and so this is what we know today. We may get some data tomorrow that we may then need to come back to this. And it’s not – doesn’t mean we’re wrong today; this mean(s) this is the best I have today and I want to share it with you as fast as possible, but it does mean that tomorrow I may need to come back and say, hey, that’s science, it evolves and it changes. And so I think we also have to be in a realistic place to understand that transparency needs to be facilitated by capability – by a capability that allows you to be transparent.

Sen. Burr: We’ve talked a little bit about CDC’s international footprint. You’ve made at least three trips abroad –

Dr. Cohen: More, yeah.

Sen. Burr: – and I think have a pretty good understanding of the importance of that international work that CDC does, the partnerships that we have. Some places are stronger; some places they’re nonexistent. That’s typically because of politics in a geopolitical landscape versus a willingness. Share with us, if you will, your impression of CDC’s global programming, its connections to work on programs like PEPFAR, and the impact that global programs have on CDC’s core domestic mission to protect the health of the American people. 

Dr. Cohen: Yeah. You can’t separate out our ability to protect people at home without doing the work globally because the most cost-effective way to protect us here is to actually extinguish something before it gets to our shores. Marburg, that we talked about earlier, is a – is a perfect example of that, right? We are working hard to make sure mpox clade I doesn’t come to the United States. That’s why we’re working so hard in East Africa to do vaccinations and do the work there, to keep it there and hopefully contain it.

And I would say but you can’t just show up at the moment of crisis. No one’s going to call you to tell you about the crisis unless you are doing the work to build relationships, to build the infrastructure alongside them, to say how do we help you build your laboratory capacity to even identify an Ebola case, right? If you don’t have a lab test that tells you it’s Ebola, what do – how are we able to even respond to it? So we have to do the work: the relationship building, the training, the infrastructure. And PEPFAR is a great example of how that infrastructure is both meeting countries where they are, where they saw a devastating virus that was impacting, you know, a generation if we look at Africa, and then we said let us come stand side by side with you to work on this, to get people antiretrovirals, to get them tested. And that trust building, that relationship that we did in the HIV space has been so critical for our ability to say let us help you on viral hemorrhagic fever, on mpox, on the next threat that is coming. And so these are all interlinked. You can’t separate one from the other. So I hope as, you know, Congress comes back and folks talk about PEPFAR, it is really about that foundational investment that allows us to build those relationships.

And frankly, we – I think CDC does it in a truly cost-effective way because it is really about sharing of expertise. So we’re not – we’re not building big labs in other places; we’re training the people to be experts in doing the laboratory work. And that is more time consuming, but I think most cost efficient as well, and builds tighter and better relationships ultimately.

Dr. Morrison: Thank you.

Two points. One, I do hope we continue to push for restoration of a very strong relationship because CDC U.S. and CDC China. That’s never disappeared, but it’s eroded significantly. And we know that we’ve got to restore some kind of dialogue at a senior level and technical level to be guarding ourselves, our own national interests, against future threats. And we’re kind of running blind at the moment in many ways.

The second point is around H5N1. We’ve been struggling with this for a while now. Our electoral season complicated things. There were interagency difficulties. We had resistance from USDA, from the farmers, the industry, and the like. Things have changed recently: the declaration state of emergency in California; the case in Louisiana, passing of that gentleman; the woman in British Columbia. And we’ve had some good news: the release of the new $306 million, some of which – bulk of which is going to CDC. That’s all good, but as we look ahead into 2025 this is not going away. This is still with us. And we’re – people are still sitting – many of the experts are sitting on the edge of their seats, thinking this is really is – this really could change very rapidly into a very ugly situation and a very dangerous one. And yet, we’re going through a political transition right now and it’s not entirely clear how well the handoff is going to be effected in this period.

So just I’m worried, and I’d like to get your thoughts about how can we minimize the risk in this period and get to the best place in what is a somewhat perilous moment.

Dr. Cohen: Well, first, you know, it is high priority for our team to make sure that we are communicating to the incoming team about the baseline: Where are we? What is the status? What is – everything that we’re doing.

I want to make sure that it – that comes from a place of it is a fundamentally different situation than we were with COVID, meaning that we have for 20 years – thank you, Senator, for your leadership – we have been working on this issue for a long time, meaning that we have very different infrastructure around avian flu than we have almost on any other – any other pandemic potential pathogen. You know, we have wastewater infrastructure. We have the ability to see into our emergency rooms. We have – we have laboratory tests that are not just in public health, but are in the commercial labs already. We have Tamiflu, you know, a treatment that maps to the pathogen. We have vaccine candidates – and not just candidates; we also have 5 million doses, you know, already in our stockpile, that going up to 10 million.

But that all said, right, those are a lot of great things – like, we are ready – but we have to stay ahead of the virus, right? We were saying things can change, and it doesn’t mean we didn’t do all the right things right now to be prepared. It just means the virus can change, which means then we have to make sure that our therapies and our vaccines still map to those changes in the virus.

So we do not – so the things that I look at and want to be evaluating in terms of do we need to step up and do something:

Is there human-to-human transmission? No. We haven’t seen that yet. But if we were to see that, that is a – that is a change.

Are we seeing severity of disease? Now, we’ve had this one cases where it was – we know it was from a wild – from a bird flock and an older gentleman did pass. That was our first death. But all of the other cases have been very mild, like not even hospitalized, right? Some pinkeye. So we look at severity of disease. And we look at the genetics. Are the genetics changing? And do we know if they map?

All of that – that’s hard – like, to be able to do that assessment work over and over, we do it literally daily. (Laughs.) Like, are we – we’re looking at it over and over and over. So we cannot, to your point, have a ball drop because we need to continually assess.

And so if there was a change in any one of those things, then we would want to think about stepping up our work. And I – you know, and then we, you know, need to make sure that the incoming team knows that there is that potential, right? Of the things that I worry about what could create the next pandemic, avian flu, of course, is at the top of the list; it’s why we’ve been focused on it – (laughs) – for 20 years. We’ve been watching it for a long time. And now we have more of that circulating in our animal population than we have seen before, which means more exposure for humans, which is more opportunity.

And so, again, we’re – a low-probability event, but could have outsized impact. So you need to highly manage some of these big-impact, even low-probability events. Got to be ready. You got to keep that funding there to do this important, important work.

Dr. Morrison: Thank you.

Sen. Burr: Well, unfortunately, we have quickly come to the end of today’s discussion. And I am grateful to Director Mandy Cohen for her time today – 

Dr. Cohen: Thank you.

Sen. Burr: – but more importantly for your lifetime commitment to public health in many different capacities.

Steve, I want to thank you.

And I want to thank the staff from CSIS, who in many cases worked tirelessly to lay the facts on the table so that we can have discussions like this and, more importantly, stimulate a rather larger discussion both domestically and globally.

I want to thank my co-chair, Julie Gerberding, who couldn’t be with us today but certainly has served in your seat, Mandy, before at CDC, and she is a valuable friend and asset to the country.

And last but not least, I want to thank the donors of CSIS, because without their generous contributions programs like this would not be in existence and we wouldn’t have the opportunity to explore so many different things, and to have a debate and discussion like we’ve had today.

With that, Mandy, we wish you godspeed as you enter that next chapter in your life.

Dr. Cohen: Thank you.

Sen. Burr: And we will all look forward to a couple weeks from now when we get our marching orders as to what the next four years looks like.

Dr. Cohen: That’s right.

Sen. Burr: Thank you very much.

Dr. Cohen: Thank you.

Dr. Morrison: Thank you. (Applause.) 

 (END.)