Report Launch: Building the CDC the Country Needs

 

Katherine E. Bliss: So, if you’ve been following pandemic-related news in the United States over the past few years– and I’m guessing that if you’re here or watching it online most of you have been – you’ll have noticed an intense focus on the U.S. Centers for Disease Control and Prevention, or CDC. And if you’ve looked at the headlines at all, you’ll have seen a great deal of criticism from a range of publication types over the agency’s response to the COVID-19 outbreak.

“Why the CDC Botched its Coronavirus Testing,” from the MIT Technology Review in March of 2020. “CDC’s Slow, Cautious Messaging on COVID-19 Seems Out of Step with the Moment,” from STAT News in May of 2021. “CDC Criticized for Failing to Communicate, Promises to Do Better,” on NPR in January of 2022. CNN in February of that year, “The U.S. Still Isn’t Getting the COVID-19 Data Right.” And in August of last year, even as CDC Director Rochelle Walensky announced some of the findings from the Moving Forward Initiative, “CDC Admission of Disfunction Misses the Big Problems,” from National Review. And then in Roll Call a month ago, “Post-Pandemic CDC Faces Uphill Battle for Backing From New Congress: Agency Plan for Overhaul Comes as Public Trust has Dropped.”

So indeed, over the course of the pandemic, public confidence in public health agencies, including CDC, has dropped significantly, with trust in the CDC’s communications and guidance breaking down along party lines. In December of 2020, 73 percent of people surveyed by the Kaiser Family Foundation Vaccine Monitor said that they had a great deal or at least a fair amount of trust in the CDC to provide reliable information about COVID-19 vaccines. But by April of 2022, that number had dropped to 64 percent, with 89 percent of declared Democrats saying they had confidence in CDC and just 41 percent of Republicans saying they felt the same way.

A Pew Research Center survey released in October of 2022 showed that nearly half of people surveyed said that public health agencies, including the CDC, had done only a fair or poor job in responding to the pandemic. Many respondents said they felt that political pressures got in the way of good policy and decision-making for public health. Now, the agency we know as the Centers for Disease Control and Prevention was launched in 1946 as the Communicable Disease Center. Located in Atlanta, Georgia, it was originally charged with controlling malaria transmission in the United States, mostly in the Southeast. But over the past 80 years, the agency has grown significantly by almost any measure. Its staff, its budget, and its geographic footprint, to name just a few indicators.

Its mission has also expanded from an emphasis on vector-borne disease surveillance and control to encompass work on HIV, tuberculosis, influenza, maternal and child health, noncommunicable diseases, and occupational health, among many other areas. Today, in addition to its domestic work, it also has a significant overseas presence, with staff in country offices assisting ministries of health in responding to disease outbreaks, strengthening laboratories and health systems, and training epidemiologists and health leaders.

So, in this sense, the agency’s mission to prevent, prepare for, and respond to disease outbreaks that do or could affect the United States’ population make it a critical, core asset of U.S. national security. But as the CDC’s pandemic-related challenges have deepened over the past three years, how to rebuild the agency and restore that trust in public health and science have become important questions to consider and are the topic of today’s discussion.

So, welcome to CSIS. I’m Katherine Bliss, a senior fellow with the CSIS Global Health Policy Center. And it’s my pleasure to moderate a discussion today centered around a new report issued by the CSIS Commission on Strengthening America’s Health Security, called “Building the CDC the Country Needs.” Now, this report argues that a significant reset of the CDC is necessary, and possible, if carried out through building actionable recommendations across branches of government and across party lines. No small task. The CSIS commission is a bipartisan group of experts. It’s co-chaired by former CDC director and current CEO of the Foundation for the National Institutes of Health Julie Gerberding and by former congresswoman from Indiana Susan Brooks.

In August, the commission launched a working group on the CDC to consider the following questions: What are the most important near-term steps that will drive a significant reset with CDC, within CDC, as the agency continues through a period of heightened pressure and scrutiny? What concrete measures could CDC and other stakeholders take to improve performance and regain popular trust across political divides? What steps could the agency take to be more flexible, fast acting, accountable, and better equipped to respond to the uncertainties of emerging and evolving infectious disease threats, both at home and overseas? And what kinds of actions will be needed in the organizations that oversee, fund, or partner with the agency?

Now, the commission’s working group was co-chaired by Steve Morrison, director of the Global Health Policy Center at CSIS, and joining me here on stage; and also by Tom Inglesby, director of the Center for Global Health Security at Johns Hopkins. Last week, they released a report endorsed by nearly 40 working group members. And it contains a series of recommendations focused on clarifying the CDC’s core and global missions, enhancing congressional and executive dialogue on the future of CDC, and changing the way CDC carries out its operations to ensure greater timeliness and action orientation.

So, in many ways, this report is really a capstone of the four-year Commission on Strengthening America’s Health Security, which had its last meeting in December of 2022. And as the commission winds down, the report also serves in many ways as a bridge to the work of a new bipartisan alliance on health security, which will be launched later this year. You’ll hear more about the bipartisan alliance in the months ahead, but briefly it will carry on much of the commission’s work while integrating a greater focus on HIV, routine immunizations, antimicrobial resistance, among other topics of importance to America’s health security in the years ahead.

Now, for today, we have a busy agenda. First, we’ll hear from the commission co-chairs, Julie Gerberding and Susan Brooks, who will offer some of their reflections and insights on the report. Next, I’ll turn to Seve Morrison and Tom Inglesby to discuss the report’s main findings and recommendations. And then we’ll have a roundtable discussion, bringing in Gary Edson, who’s also joining me here on stage, president of the COVID Collaborative; Tom Frieden, former director of the CDC and president and CEO of Resolve to Save Lives, joining us virtually from New York; Anne Zink, chief medical officer for the state of Alaska, and president of the Association of State and Territorial Health Officials, joining from Alaska. And that’s our group joining us virtually today. So, we’ll have a hybrid discussion. And towards the end of the event, we’ll have some time for questions and comments from the in-person audience here today.

So, first, Julie Gerberding, let me turn to you. Let me invite you to offer some thoughts on the report’s findings, and what you see as the critical steps on the road ahead. And thank you for joining us from Europe, I believe.

Julie Gerberding: Well, thank you so much. And I thank my co-chair, Susan, and certainly Steve and Tom, for their incredible leadership in pulling this together with such robust input from so many really wise people. I think it really was a wise crowd that came together thoughtfully. And every effort was made to provide a balanced perspective.

I actually really also want to thank the CDC, Dr. Walensky and the team there, who contributed a lot of staff time to go deep in some of the data to help the workgroup understand some of the nuances and the subtleties of what was going on behind the scenes, and in a really honest and candid way laid out an appraisal of what they had learned from their own sort of internal review of what’s going on in the agency. So, we had several conversations with senior leaders at CDC, including Dr. Walensky. And we couldn’t have had a balanced report, I think, if we didn’t have the broad perspective.

You really laid out the – you know, the big picture here is we all see a need for a reset of the agency. Some of the reset has to be structural. Some of it needs to be activity that only Congress can really manage. And that has to do with how the budget is structured, the size and scope of the budget, and the flexibilities or lack thereof. And some of it has to do with, I think, modernization, really looking at how the CDC can take advantage of data science and the opportunities to build better data systems, more interoperable data systems, and really complete the trajectory that they’ve already started with the Data Modernization Act.

But kind of stepping away from the actual contents of the report, which I think we’ll be going into in more detail in a few minutes, I do really want to emphasize that while there is substantial opportunity here for evolution, modernization, and performance improvement at the CDC, it has also done a lot of things well. And we shouldn’t lose sight of the fact that in the midst of a pandemic, there were many other public health activities going on. CDC teams were deployed all over the United States and internationally to assist with local response efforts. The CDC Foundation stepped up and engaged some 3,000 or more people to help the workforce shortages, and so forth.

So, there were a lot of very positive things that happened. And we need to make sure that we don’t throw the baby out with the bathwater here when we’re looking at the really critical things that need to be fixed, but also to appreciate and respect what our public health system has been able to accomplish for the past three years. It’s been a daunting challenge. And I think Tom would agree, while we had our own outbreaks and challenges to deal with, the scope and scale of this pandemic was significantly more complex orders of magnitude.

So, thank you for that. And as I turn this over to Susan, I just really want to thank her as my co-chair for the wonderful experience it has been for me to be able to work with her these past couple of years on this effort.

Dr. Bliss: So, Susan Brooks, I mean, as co-chair of the commission you’ve really brought your perspective, from serving in Congress during the first phases of the pandemic, while that was unfolding, as well as your perspective from serving on, you know, reviews, and really the perspective from Indiana. What do you see as priority actions for the CDC reset, you know, coming out of this report?

Susan Brooks: Well, thank you. And I too want to thank my co-chair, Dr. Julie Gerberding. I have always been amazed not only by the depth of her insight and her knowledge about – whether it was the CDC, the NIH, anything having to do with HHS. She has been a champion for public health. She has been a champion really for all sectors of our health care system. And as a lawyer and then a member of Congress, we rely on people like Julie, people like Dr. Inglesby, Dr. Frieden, and all of those, Anne, in Alaska to really inform us.

And so, my role in this commission has really been to be a reminder to all of the experts that have been a part of putting this incredible report together, to remind everyone of the importance of educating elected officials at all levels of government, from local elected officials to state and to federal. Because all of the incredible experiences you bring is not something that most of us know. Citizens take so much of this for granted, until our country or our communities are presented with these incredible disasters, like this pandemic.

And so, I just finished my service as well on our governor from Indiana had a public health commission to really look at the public health in the state of Indiana. And I must say that the work of this report, and I want to commend Tom and Steve for the really aggressive steps they took to get this report done, and the number of really incredible experts they brought together to this report. Now, the goal is to get this report before members of Congress. New members of Congress in particular. Members of Congress that have been engaged in these issues because, as Julie said, Congress impacts the CDC so greatly.

And it is the year of reauthorization of PAHPA. It’s going to be very important, and with this new Congress, that we do that education. And I think this report is a fabulous tool to help them with actionable steps. To help the CDC tell the story. To help all of those stakeholders around the CDC tell the story, explain the story of what needs to be done in the reset, which is very much needed. Not only at the federal level, but I would say at the state and local levels as well. Public health really needs a reset, as I’ve seen both here at home in Indiana as well as in the country.

And I want to commend CSIS and the leadership of Steve really for bringing this together and getting this report going. So, congratulations and I look forward to hearing from our experts today. It’s been my honor to serve. It’s been one of the most important pieces of work that I will have done while in Congress. And I was proud to support it after I left and will continue to.

Dr. Bliss: Susan Brooks and Julie Gerberding, thank you both for your leadership as co-chairs of the CSIS commission and for supporting the work of this working group. Steve and Tom, I want to turn to you. Congratulations on the release of the report last week, and the arrival of hard copies, for those of you who are in the room, to be able to look at the report in its – in its final form.

You write in one of the first chapters of the report that at present CDC is not equipped to be the highly effective and reliable force within the U.S. government, at home, and abroad that American need and rely upon for rapid disease detection and containment. So, you know, Steve, can I ask you to discuss the origins of the working group, the process of consultations, and how you arrived at this conclusion? And then the main recommendations? And then, Tom, I’ll turn to you to say a little bit more about, you know, where you see the reforms – the proposals moving in the near future.

J. Stephen Morrison: Thank you, Katherine. And thanks for taking on this role here today. And thanks to all of the members of the working group and the commission who are organizing this. Just a quick note of thanks to a few people who really contributed enormously to this effort, and to our – to our activity today. Michaela Simoneau on our staff has really been exemplary in moving this forward at every step of the way and deserves special thanks for that role. Humzah Khan, a research associate with our program, is also very integral to our successes. I want to second the note that Julie made that CDC leadership was very generous and forthcoming with us, and that enriched the quality of all of this – all of the work that we did here.

We are very attuned to what Susan said in terms of trying to reach members of Congress. We have a plan. We’re reaching out to those who have very – within our staff, who are directing our congressional relations effort and others, and we’ll be very aggressively doing that. To Katherine’s question around the origin of this, the commission’s been ongoing since 2018 – spring of 2018. And at different moments in the course of that commission, we visited this issue of what was happening to CDC, from a note of concern and sympathy around such an important institution, and what was happening.

I think when we met back in June, we had a commission meeting June 14th, and we tabled the idea and said: Look, the storm clouds are forming. Criticism is coming from multiple directions. This is not going to get better. It’s important for us to take this on in the right spirit and with the right focus. And I’ll say a bit more very succinctly on how we went about the business. But that is too much at stake. That America cannot afford to have an agency that is not able to perform at the highest level to protect all Americans. And that’s CDC’s public health mission. And that that is at risk.

And so it was in that spirit that we won consent within the commission to proceed in this way. And we launched it at the end of August – it was an intense surge of effort. We had four full meetings. We had two rounds of edits of the report that you have today. This was somewhat record speed for such a complicated enterprise, but we were able to drive it forward in hopes that we would have something as the new year opened that could be a source of serious consideration within the administration, within the Hill, among state and local authorities, and the broader constituencies concerned.

So, we had this surge of activity, with many private consultations – senior ranks of the White House and others, executive branch agencies, with serving governors, former governors, leaders in the Trump, Obama, and Bush administrations. And those enriched this. And many of those folks are acknowledged. We deliberately composed this working group as a highly diverse and broad group. We have several former CDC directors, heads of other public health agencies. We have those who served in senior positions in both Republican and Democratic administrations, state – those who understand and have authority as state and local public health leaders, those from the foundation world, public health world, industry.

Our operating premises are that this is a serious problem. There’s no denying it. The decline in performance and trust and confidence that has – that Katherine has referenced. And that action is needed in order to reverse course and reset. The current situation, we’re arguing, is a matter of national security. This is not something that is a side issue that we can afford to live with. It’s something that’s antithetical to U.S. national interests. And it’s not good news if we wish to protect all Americans reliably in this period. We focused on key areas. We’ll hear about those. Data, communications and guidance, the global mission. Partnerships, including state and local authorities, including the way in which the CDC itself operates within the executive branch and with external allies and partners.

This is not an encyclopedic effort. It’s focused on the pandemic preparedness and response agenda. And it’s really intended to help start a reset. And we proceeded with a view that we had to listen very carefully, focus on what those core problems are, and come up with concrete and actionable solutions that could attract support across the aisle. And they had to be very bipartisan in nature. And that accountability, equity, speed, transparency, and better communications, these are all central themes. But they mean different things to different audiences and different constituencies. And we needed to be sensitive to that reality and listen carefully to what that meant as we thought about what the concrete solutions are.

This is not an easy task we have taken on. It’s politically charged, as we all know, but it’s also many different complex issue sets that don’t lend themselves to fast and easy solutions. And as I said, bipartisanship remains fundamental. It’s been fundamental to the existence and prosperity of CDC over the ages, as well as other public health institutions. And it will be essential to the solution as we go ahead. We have – you’ll hear, we have said that much of the solutions lie within CDC’s leadership choice, but much of it, the majority of power around reaching solutions, lies outside of CDC. And we need to focus on that and forging a combination around White House, secretary of HHS, senior figures in leadership in the House, and Senate of both parties.

We make the – we make the reference that when NASA stumbled badly in 1986 when the Challenger exploded, when FEMA stumbled badly in 2005 with the Katrina debacle, there was a rallying across party line and across institutions to devise solutions, to come up with a plan that was a multiyear plan, and to execute. These lessons are relevant to us today as we think about what the path forward would be like.

My last comment is, we could not have gotten where we are today without Tom Inglesby. He just brought a remarkable depth of knowledge, expertise, and a real sensitivity to the nuance and complexities of all of these issues. And I’m just very grateful, Tom, for all that you brought to this and, as I said, I think we would be at a much different point were it not for your agreeing to join us in the way that you have. So, thank you.

Dr. Bliss: So, Tom, you are back at Johns Hopkins, at the Center for Global Health Security. But you recently completed service in the administration at health and human services and within the White House. And so, you know, I wanted to ask you to reflect on the recommendations in the report and, you know, really drawing on your perspective, you know, what are you most optimistic about in terms of where change and reform can be carried out in the short-to-medium term?

Tom Inglesby: Great. Great. Thanks so much, Katherine. First of all, I just want to say thank you to the CSIS team for inviting me into this process. I have great admiration for the work that you all have been doing here, and it’s really an honor and a privilege to have been part of this process.

And I also want to echo what others have already said, which is I start with the greatest admiration for CDC’s mission and its people. I think we all have to acknowledge what that organization has gone through in the last three years, and the pressure it’s been under, and think about what we can do from the outside to help strengthen this critical national institution. And I think, in that spirit, we undertook this study with the hope of being able to help in that reset effort that CDC has initiated this summer, and that we’re hoping to help propel and provide momentum for.

And so, I think just a few words about some of the priorities that came out of this effort and what we recommended in the report. And then we can – and kind of think about the overall context. But I think at the highest level, the recommendations break down into strengthening and clarifying, integrating the mission. Making sure we all are on the same page around the community, around its mission as compared to other missions in the – in the federal government and outside the government. Improving leadership and accountability at a general level, and we’ll talk about that. And then, strengthening operational capabilities within CDC.

And so, if you think about some of the particulars around that, the first area, around mission, even now after the country has gone through this really searing experience, there still is – there still is a lot of misperceptions around what CDC is charged to do, and what its sister agencies are responsible for. So, for example, policy – there’s policymaker and public misunderstanding about what CDC should have been doing around contracting with the private sector, or around moving or distributing products around the country. When we know that other agencies of the federal government had specific responsibilities to do that. So, as we think about strengthening CDC’s mission, it’s important to keep in mind what its extraordinary and unique capabilities are, and what we’re asking it to do.

Along those lines, we also have to think about its critical role internationally. There are other agencies of the federal government that work internationally. They have, in some ways, many more of the processes in place that they should have for that work. And we need to make sure CDC has the staffing, the hiring capabilities, the processes, the cultural training that’s afforded to other U.S. agencies that work overseas, and make sure that that is available to CDC as it does its critical work. When embassies overseas get emergency calls about new outbreaks that are occurring in one country or another, the first call they make is U.S. CDC. And we need to make sure that U.S. CDC has the people in place, the assets, the tools they need to be able to respond to those calls – those urgent calls.

Thinking more about its – kind of moving towards leadership and accountability – I think Steve referenced the importance of this administration, future administrations, and Congress being on the same page. We called for a highest-level dialogue about the future of CDC there. The purpose of that recommendation is to recognize that, as Steve just said, the power for much of the change that’s needed in CDC rests in Congress, rests in HHS leadership, and in the White House. So, if we want CDC to do big things going forward, to think about its mission, to accelerate or strengthen its operational capabilities, they’re going to need help from the power centers in Washington. And so, we have called for that dialogue. CDC, obviously, is a critical participant in that, but it can’t do it alone.

Thinking about the experience of the last few years, one of the things that I think CDC has been criticized for is its guidance development process. And so, one of the things that we talked about in the report is the importance of CDC being able to reach out to the private sector, to state and local agencies, as it’s moving quickly to develop guidance around emergencies. That’s easier said than done because we want CDC to move as quickly as they can. But we’re also asking them to test feasibility and to – and to get input from outside the federal government. So that’s important.

It’s also important for all of us to recognize that some of the things that happened during the pandemic around, for example, issues of the economy or schools, we need to make sure that the inputs around those decisions are also not just CDC’s alone to make. CDC has extraordinary capability, but they can’t be responsible for all of the decisions that have impact across society in a setting like the pandemic. So, as we go forward, it’s not just CDC’s to fix, but the federal governments to fix how we think about guidance development in crisis.

And then, kind of rounding out some of the recommendations, we also called for a strengthening of CDC’s presence in Washington. CDC is in Atlanta, for reasons Katherine described, because of its mission. But it puts it at a substantial disadvantage in terms of easy access to policymakers, interactions with federal agencies. That kind of collaborative work in the federal government is going on all the time every day. And to have CDC two hours away by plane, even with its Washington office, it needs a substantial increase in its footprint in Washington, its ability to interact, its ability to respond to all the congressional inquiries and information requests, and to make sure that Congress is informed at all times with what it needs to know. So, we called for increased Washington presence.

We also called for strengthening CDC’s partnerships outside of the federal government. That means tighter relationships with state and local agencies. I think Anne and Tom, hopefully, will say more about that. But that means embedding CDC experts in local organizations where they can do good, they can learn from each other and learn from the local level and bring that expertise back to CDC and make that much more of a living partnership between federal and state and local entities.

We think CDC needs to make sure it is able to reward operational excellence in the way that it already rewards scientific excellence. CDC needs to recruit the best scientists in the country and to maintain that reputation and substance of scientific excellence around the world.

But it also needs to be able to increase its ability to respond quickly and that requires different kinds of skill sets in addition to the best scientists in the country. We need the best operators in the country to be working at CDC so they can respond immediately and get into the field in crisis.

And, finally, the last two things I’d say, and then we’ll move on to the other parts of this conversation, are that we recommended a real focus on increasing the ability for CDC to gather and to organize data from around the country in crisis. We expect CDC to have moment to moment understanding of what’s happening across the country and to deliver that back to policymakers and to the public.

But we don’t have – CDC does not have the authority to do that and does not have the authority to get data from the rest of the country in that way. So we need to change the authorities around that relationship, and that also comes with contracting authorities that are present in other agencies of government but have not yet been afforded to CDC – other transaction authorities, one specific kind of federal contracting authority that other agencies have and have had for a long time.

CDC doesn’t have that. We need to be able to give them those kinds of tools if we want them to move as quickly as, I think, we all do.

And, finally, back to Steve’s point about budget, CDC’s budget is in 13 different Treasury accounts. It’s a hundred and sixty different specific lines. They do not have the flexibility to move things around in crisis.

So, we have asked in this report for Congress to consider a real change in the way that they provide budget flexibilities to CDC – I think Director Walensky has wisely called for this a number of times in the last year – and that – the final part of that is making sure that CDC has the flexibility it needs at the start of a crisis.

There is – there’s, certainly – there’s a fund that’s been created for that purpose but has not been provided resources for CDC to do that work. So, at the beginning of any crisis, CDC finds itself having to really struggle to get permission to spend money in ways that they need to get out in the field.

So, I think that’s kind of a very quick wrap up of the different categories of recommendations that we made in the report and, hopefully, we can go into it in more detail.

Dr. Bliss: Thank you.

So, this is a big agenda for our roundtable discussion. There’s budget, communications, data, state-CDC relationships, the health workforce. There are a lot of different topics we can get into and, fortunately, we have a wonderful panel of roundtable experts to help us get into these.

I want to start with a question about data and the CDC-state relationships. Now, a lot of the recommendations, Tom, as you pointed out, center around ensuring the CDC has access to the most up-to-date accurate data in order to guide decision making, guidance, and forecasting.

The recent omnibus bill authorizes the CDC director to continue activities related to the development of capabilities for the forecasting of public health emergencies and infectious disease outbreaks and it refers to improved collaboration among federal departments and it even directs the secretary of HHS to help the states, localities, territories, and tribes better leverage public health data and improve data use arrangements between federal agencies and other public entities.

But it really stops short, as Steve said, of mandating states and localities provide data to CDC and we’ve seen a great deal of tension and variation in practice between states and the federal government when it comes to sharing that data.

So, I want to start, Tom Frieden, with you if I could. You are a former director of CDC. You’re now in New York and have been in New York in the past. So, bring that perspective both from the agency and from the regional perspective.

Does CDC need to reach out to states directly, to governors and others, to really initiate a better and improved relationship or dialogue about the use of data?

You know, the report recommends a series of congressional executive dialogues and, you know, could this be – what could this accomplish? Could this be a way forward?

Tom Frieden: I think this is a really important issue. It’s not a straightforward one.

When it comes to legal authorities, you’re going to have controversy and some misconceptions and maybe some politicization of the issue. You’ve seen that already with vaccine status, for example. And so that’s going to have to be very delicately addressed in this kind of hyper partisan time that we’re living through where very sensible measures to share risks that may be multistate may be difficult to establish.

I would hope for more progress in this area, and Dr. Gerberding and I and other ex-CDC directors have editorialized on that. But, realistically speaking, it’s hard to imagine that getting through Congress anytime soon.

So, barring that, the broader issue way beyond data, including data, but is the public health enterprise, the connection of federal, state, city, and local health departments, and all too often it’s not well aligned, and I think this is something which in my nearly eight years as CDC director I tried hard to address. I think we did make some progress in this area but much more progress has to be made.

And as I think about it, if you kind of look at the broad scope of history, it used to be until around 20 years ago that almost everyone in leadership positions in CDC, especially in the administrative side, had spent a few years, often five or 10 years but at least two years, working in a state or local or city health department.

For various reasons that was discontinued and you now have most people at CDC not having actually worked at the front – on the frontlines for a prolonged time, and that’s important because the result of that is sometimes a lack of the kind of speed and practicality that’s needed, not because people aren’t hard working, working fast, smart, dedicated, but because they don’t have that multi-year experience of dealing with things at the local level.

As you mentioned, I was health commissioner in New York City for nearly eight years before becoming CDC director and that gave me a unique vantage point. But that’s the case for, really, the range of public health programs.

So one of the most important things I think CDC could do is to increase its hiring of people who have spent a few years on the frontlines at the state and local level and one way of doing that is to greatly expand training programs that the CDC has like the Public Health Associate Program, which could easily double, triple in size or even more and over years then more and more of the leadership of CDC will have spent that time at state and local level.

There will be that kind of shared vision, and from my perspective, having thought about it a lot, I think that’s extremely important. That and the budget issues are probably the two most important issues to try to strengthen CDC’s functioning in this country.

Thanks.

Dr. Bliss: Thank you.

Anne Zink, let me turn to you from – you know, you’re in Alaska. You’ve been also working with the Association of State and Tribal – or Territorial Health Officials. When you think about this state and CDC relationship, you know, Tom has proposed, you know, increasing that connectivity between the state and local experience and work with the agency.

Would embedding more either early career CDC officers at the state level and arguing for greater financing for the health workforce help create a more positive state-CDC relationship, particularly around the data issues and are there – what are some of the other areas of tension that you see, from your perspective, that could be resolved?

Anne Zink: Yeah. No, thank you so much for the question and thank you for the opportunity to be here, and also thank you for including states, local government, and territories in the CSIS process. We are really the United States of America, and we have a federation of states that come together to make our system.

I appreciated how the report started off by saying the power to make changes lies outside of the CDC itself. And that’s not just the federal agencies, but that’s in its relationship to the states that, obviously, have a lot of the power on data sharing, and those are limited as well as enabled by local government and the local decisions that are made. And so, I really appreciate that kind of early recognition and being able to provide a state perspective on this space.

I’ve been honored to serve in this position throughout the pandemic, and that relationship between state and federal has been both a success and a challenge throughout that time.

You know, I kind of push back a little bit on the question on the relationship. I think most local, and state public health officials have really good relationships with the CDC people and people to people. We want to do the same thing and we really want to work well together and, in general, have good relationships.

I see four major limitations, and these got called out in different places. One is just state laws. Many times, our state laws prohibit us from sharing data.

The second big thing was data use agreements, and this got highlighted in the report. But I would take it even further and not just data use agreements but data governance, and so the way that data is then used by CDC or other federal agencies and placed back towards states really needs to reflect on the ground what that looks like on a state to make sure that people see themselves within the data.

I love this quote about that – everyone wants to see the “me” within the “we” of data, and we have such a big and diverse state and country that what may look really good in New York is not going to look really good in Alaska and may not be very useful. So, making sure that we have fenestrated and malleable tools that allow us to take the data that is there.

Just like the weather forecast in New York isn’t going to be super helpful in Alaska today, what is happening in different areas there are similarities but there are also limitations, given how large our country is, and I think we need to take that into account.

The third thing is just the physical limitations of the data entry, and this gets called out multiple times in the report. You know, we hired the National Guard to enter one positive COVID lab into three different data systems. And so oftentimes our ability to share data wasn’t because of lack of will or interest or even data use agreements. It was, like, physically people to enter them into different systems because the systems don’t talk to each other and connect.

And this goes back to the budgetary things that have already been highlighted before, and if we have very limited and controlled budgetary line items for CDC, they create their own individual databases and then we, as states, have to enter it into all these different databases.

But I might have someone who, you know, is HIV positive as well as COVID positive, and I’m working through – you know, they’re one person but we’re entering in multiple different data sources in different systems.

And the fourth thing I’d just highlight is that both politics and public health are based on people and that relationship, and I think, you know, Susan really called this out early at the beginning of the comments about the way that we make sure that we are accountable and that we communicate and that we partner with local, state, and federal authority, and I think that that will then help to change state laws and help to increase the compatibility.

Moving forward with data, you know, just really making sure that we’re doing all that we can to standardize, this mentioned previously, you know, by you, Tom, about the amount of funding to really create that infrastructure. We just – I’m a practicing emergency medicine physician as well as a public health provider and I tell my colleagues if they think EMRs in hospitals are bad they should try state government. It’s a whole new level of dysfunction in trying to get systems to work together, and we need to really think of our health care partners as partners in that space, so what ways can we learn from our health care colleagues and partner with public health.

And then building workforce, and I do think specifically to your question would it be helpful to have more CDC people in states, a hundred percent. It really helps us to understand what the CDC’s thoughts are on and ask or question and vice versa, and it is a world of a difference when you are working with someone at CDC who has been in your shoes and understands the challenges and limitations that you’re going through.

And then as just mentioned previously, both braiding data as well as funding sources to create a whole picture because no one data system or source is going to be able to provide the whole picture, and it was great to see the report call out much of that.

So I just really want to thank the report for diving broadly into these issues and coming out with some really concrete recommendations.

Dr. Bliss: Thank you.

So you know, really, you’ve highlighted the importance of data, I guess, modernization and standardization, but also some of the challenges that exist at the state level around, you know, just legislative differences.

So it’s not just a budget issue or a matter of political will but also that there are legal differences among the states and the federal government that may need to be overcome.

Gary Edson, I want to turn to you. You’re with the COVID Collaborative, an organization that was started during the pandemic to really, you know, address and improve outreach and advocacy around the pandemic response.

You know, the report really points to the reform or overhaul of federal agencies like NASA and FEMA – NASA after the Challenger in ‘86, as Tom pointed out, and then FEMA after the Hurricane Katrina response in 2005 – you know, as really evidence that a reset or a rebuild of a federal agency is possible.

Now, as the report acknowledges, those cases require recognition and acknowledgement of the problems, their relevance for national interests and, you know, really require meaningful interagency coordination, close communication with Congress and the public, and multi-year commitments and budgets to really kind of move those kinds of agendas forward.

So what do you think it would take to launch an initiative of that scale for CDC and what would be the optimal timing for, you know, really moving that kind of rebuilding agenda forward?

Gary Edson: In terms of the timing, there’s no time like the present. Let’s be clear, the issues are urgent, and it is an issue of national security. I’m not sure those are the best examples. I don’t know whether NASA is an example of successful culture change or the poster child for how difficult culture change is.

We had the Apollo I disaster in 1967. Less than 20 years later you had Challenger. Less than 20 years later after that we lost Columbia. So I think that’s an object lesson that this is hard work and is going to take an enormous amount of commitment on the part of the CDC.

But getting to where we need to go is a two-way street. As the report points out and as folks have already mentioned, the great majority of the power to strengthen the CDC lies with Congress in terms of the new authorities the CDC needs – the authority to collect data so that we can mount a successful defense and target inequities, budget flexibility so that we can surge resources to where they’re needed most, hiring flexibility so that CDC can attract the talent it needs – going forward.

But frankly, I don’t think Congress, and especially Republicans, are going to be eager to put new wine in what’s perceived to be an old and broken bottle. I think now it’s up to the CDC to step up and it needs to, first, own the failures of its own making, everything from the about face on masking to the debacle over testing to the inability to produce swift and clear guidance to the sometimes breathtaking lack of humility and transparency in the face of scientific uncertainty and a pernicious virus, and it needs to step up and then address those with fundamental reforms. And what we’ve learned from NASA and FEMA is that culture reform involves new priorities, people, incentives, and the systems to support those.

Now, thus far what Director Walensky has said is she’s offered a public mea culpa and initiated this internally-led as opposed to at NASA it was an externally-led investigation – an internally-led effort to change the culture and reform the agency.

That’s great, but if that results in nothing more than moving some boxes around on an organization chart or tinkering at the margins it’s going to be dead on arrival. By the same token, if congressional investigations are nothing more than a witch hunt that’s not going to make Americans any safer either.

We need to fix the problem, not to blame, and I think that’s the tone of this report, and the report calls on, as pointed out, a high-level dialogue between the executive branch and Congress and I think that that’s the path forward and I think the report can lay the foundation for that.

Dr. Bliss: So, you’ve pointed to the potential for executive congressional dialogue but also the importance of operational change or operational reform.

So, Julie Gerberding and Tom Frieden, I want to go back to you, if I could, because you have direct experience in this relationship with Washington. You know, the report really points to the challenges that CDC, which is located in Atlanta, has for undertaking these kinds of dialogues and making the case for its efforts and its work.

Now, certainly, as the report recommends, CDC can deploy more policy-related staff to Washington to represent its capacities, its achievements, and interests within the interagency and Congress. But, I mean, should it relocate to Washington in order to better make the case or, you know, have a new building or something like that?

And then, you know, how can – Susan Brooks, I’d want to bring you into this, too – I mean, what more can CDC do in this relationship with Congress to demonstrate that it is up to the task of improving its performance and delivering results in a timely manner?

So, Tom Frieden, let me start with you and then go to Julie Gerberding, and then, Susan, if you could weigh in as well.

Dr. Frieden: Yeah. I think the likelihood of actually relocating an agency with thousands of employees and billions of dollars of buildings is zero. But the necessity of strengthening its presence in Washington is definitely there.

As CDC director, I’ve calculated that I made over 250 trips to D.C. from Atlanta, basically, to answer questions, to testify, and to ask for more resources.

The National Center for Health Statistics is in Maryland in the D.C. area and there is a Washington office, but I think the report gets it right. It needs to be much stronger. It’s a structural weakness that CDC is not there to, frankly, make its case to HHS, to OMB, to Congress, to advocacy groups, in the kind of force needed, and there are a few ways to do that but the bottom line is you have to show up and you have to be there, and even hundreds of trips don’t replace having high-level staff there getting to know people.

NIOSH is also in the Washington area. When the NIOSH director mentioned to me that in the past quarter, he had had lunch with every single congressional staff member on one of the committees that either authorized or funded NIOSH and I thought, well, that’s great. That’s one center. But I haven’t done that. No one at CDC has done that for the agency as a whole. And that’s the kind of thing – just one small example – that’s needed.

Dr. Gerberding: I think you can think about this in multiple levels. When I started as the CDC director the Washington office was in the Humphrey Building and a decision was made without consultation that, perhaps, the CDC, a Washington office, should be moved someplace else.

So, it was moved, actually, to co-locate with the NIOSH headquarters, which is a few blocks away, but a few blocks away from the Humphrey Building you might as well be in a remote island.

So, fortunately, for a period of time we were able to maintain a physical office in the Humphrey Building that I could put my name on the door, and so I was able to rub elbows with the secretary and the other HHS leaders.

That was critical. Like, I’d have lunch with them, we could interact and, you know, at an HHS level really engage with my colleagues that helped with a number of collaborative issues so that when we were then in a response mode with whatever public health emergency was occurring at the time I could operate just as easily in that emergency operation center as I could in Atlanta and I was specifically there.

But Tom is absolutely right, the broader presence in Washington. We need a really strong leader – a deputy, if you will, of the CDC – to manage the Washington presence in a strategic manner to really develop the relationships with the whole of government, including the White House, but also with the Congress, of course, and it’s just not possible to do that by flying people up occasionally from Atlanta.

I think the broader issue is that Washington is more than government and there are a number of surround sound opportunities that I’m sure – the pandemic is part of this but I’m sure Dr. Walensky has really struggled to interact with the broader policy environment in D.C. and to really understand and interact with a number of the broader stakeholders and constituents who, certainly, have helped the CDC in a lot of ways in the past.

So, if you want to play you got to be in the game and the game is not played in Washington, at least – I mean, the game is not played in Atlanta unless, you know, you’re a fan of the baseball team there.

So, I think the structural issue of the Washington presence is important and I also think it’s a good opportunity to make the point that what we need in our government is a whole of government response.

When I think back to the incredible and intensive effort that CDC made to exercise and prepare for the influenza pandemic a big part of that preparation and effort was coordinated by the White House. Every Cabinet participated. CDC had very clear understanding of what its mission and role was in the context of the operating plan at that point in time.

Somehow through the years there’s been a dissipation of that clarity, and the mindset about what it would take in order to manage the pandemic from more than just a public health perspective was, I think, diffused over the years so that while even if CDC performance had been optimized there was still a great deal of lagging in other areas what to do about economic support for people, what to do with schools, and so on and so forth.

So having a whole of government with CDC included in that conversation, I think, is one of the frameworks for how we should think about how to define the Washington presence for the public health system, at least in the context of a public health emergency.

At another time we can talk about why that would also be important for a number of other public health issues that also have a center of gravity in Washington, D.C., as well.

So, it shouldn’t be hard to accomplish this but it will take a realignment of the center of gravity and then a lot of work on the part of the build out of the Washington office so that it really can be more than just a very small handful of people.

Dr. Bliss: Thank you.

So, Susan Brooks, let me let me turn to you. You know, you mentioned earlier the importance of educating Congress about the public health and health security issues. You know, we’ve heard about the – you know, the potential for increasing the Washington presence of CDC in order to better engage with some of those congressional offices. Gary emphasized the importance of really bolstering an executive congressional dialogue on CDC.

What do you see as the potential for really moving dialogues, you know, around CDC and its Washington presence forward? What will it take to really enable the agency to make its case to members of Congress, particularly people who are new who are learning for the first time?

Ms. Brooks: Well, first of all, I want to completely agree with everything that everyone has said.

As a fairly recent former member of Congress, the only reason I went to CDC one time was because I was a speaker at another conference in Georgia, in Atlanta, that Representative Rogers had on the opioid crisis, and I realized when I was going there that here I was working on CDC-related issues around pandemic preparedness. I had never been invited. I really didn’t know much about the CDC operation in – you know, in Atlanta and I was overwhelmed when I took the tour.

I had had similar tours of other agencies of the NIH, of ASPR and BARDA. So, I don’t think you can understate the importance of actual site visits and of understanding the magnitude of what government officials are trying to do in these agencies and having those types of visits are very important.

But I think we also can never understate the importance of educating our staffs, and so what Tom just talked about relative to an agency that did a great job educating the staffs, the staff – our staff, members of House and Senate both – are the ones that truly dig deep and have the time and are the ones that you need to find who are most interested in these issues because they are the ones that really tee up often the agendas for us and help us with the details of what we’re working on, and so developing those relationships with our staffs are critically important.

I will say, and I completely agree, there needs to be a much stronger presence in Washington, D.C., by the CDC rather than just the hearings that they appear before.

And, yes, there are going to be hearings. I, certainly, hope they are not viewed as witch hunts. They’re viewed – they’re going to be asked a lot of very difficult questions about what we just went through with respect to the pandemic, and I think that it was explained so well all of the different positions that were taken and why they were taken and why there appeared to be so much uncertainty and lack of readiness when it came to the testing and the masks and the guidance. It was very difficult.

But those are issues that, I think, the American people want to know the answers to, they want to understand better, and members of Congress, both sides of the aisle, want to understand them better.

I think it is very important that when meetings happen that they are bipartisan at the time, that members are identified who are really interested in these issues and help educate them at the same time, Democrats and Republicans together. Those were often the most effective site visits.

But it’s also very incumbent on the administration to promote the importance of what the role of the CDC should be, and so what Julie was saying about CDC being in the mix of just even HHS there is a lot of jockeying not – within HHS, which then finds ways – it finds its ways to Congress.

And I, certainly, saw that, that you might have champions of different agencies or different agencies within the HHS and those things often make their way as we’re really grinding out those difficult pieces of legislation and, most importantly, those difficult items with respect to their budgets.

So, find – and I would often, quite frankly, and while I said I’m a lawyer, medical professionals within Congress, and they are growing, I think they are the – and those of us who are not medical professionals and don’t have that background often look to the medical professionals to give us that advice. And so, certainly, starting with anyone who’s been in public health, who’s been in the medical profession, I think those are the members of Congress – House and Senate – to start with.

We have a very robust docs caucus on the Republican side. There are a number of medical professionals on the Democrat side in the House. And then as well I think those members of the Georgia delegation, that I’ve always said they have a vested interest in trying to make sure CDC is strong and continues to have that presence because you’re not going to move thousands of folks from Atlanta – I completely agree with Tom. And so that Georgia delegation is critically important.

So those are my thoughts about how we can take this report and these – a lot of great solutions and ideas and put them before those members of Congress in a bipartisan way to really put some of these recommendations into motion.

Dr. Bliss: Thank you.

So, you know, Susan Brooks has really emphasized not only the importance of education and the potential for an enhanced dialogue between Congress and the executive branch but also, you know, really raise the issue of communications and so I want to turn to the issue of communications for a moment.

You know, the last three years, you know, building on previous years have really seen an explosion of disinformation and misinformation about COVID, about the pandemic, about CDC, about any number of different issues.

This has been amplified across social media and really has served to undermine faith and trust in scientific methods and evidence-based guidance. But effectively addressing rumors and conspiracy theories is, you know, as I think we’ve seen, not always just a matter of providing additional scientific evidence and a scientific paper. It, in many ways, has to be kind of accessible to – and appealing and in the same way that the conspiracies and rumors might be.

So, I want to turn to our panelists.

Anne Zink, let me start with you, if I could, and just ask for your reflections, you know, in terms of the capacities that are required not just by CDC but also by state and local health authorities to address, you know, some of these issues around misinformation and disinformation and to really ensure that guidance is made available to people, you know, in a way that they can appreciate it.

Dr. Zink: Yeah, and I appreciate that in so many ways. I can’t think of a topic that’s more important because, at the end of the day, we can come up with amazing science, and we saw this with the vaccine.

But if someone doesn’t trust it, doesn’t want to take it, it’s not effective. And so, if you aren’t willing to take that vaccine, if you’re not willing – you don’t trust that science, if you don’t trust that data, you’re not going to move forward.

A couple of things I’d breakdown in communication. You know, communication is built on trust and trust is really accountability as well as clear communication. This has been a huge challenge from a state perspective and, I think, local jurisdictions as well and from the CDC.

Two-way dialogue, I think, needs to continue to happen and finding ways to provide timely, resource-rich information that also makes sense for the public, as well as being able to have a two-way dialogue, you know, at a state level, at a local level, so that we can have two-way dialogue with the CDC and say, why did you make this decision – we don’t understand this. And then that allows us to be able to go back to our constituents and say, this is why this decision was made and this is what you need to know about it and this is how you can do it.

But when it’s just a, you know, doctrine on high that comes down and says this is the way it shall be it becomes really hard to communicate that. And so that’s why that kind of really robust two-way communication needs to happen and then allows us on the state and local level to have that two-way communication with our governors, with our legislators but, most importantly, you know, the people that we directly serve.

Secondly, we’ve got to find a better way to braid health care again with public health, and I know I had mentioned this beforehand. But if you look at the data and science between health care providers it can take years to get change in practice – you know, what ways you control insulin, how do you treat a heart attack – and when you’ve got something like a pandemic moving really quickly we just don’t have really good systems both to learn from what’s happening within the health care sector, to understand, you know, what vaccine-resistant strains are we seeing, how many people are being hospitalized because of X, Y, or Z, because we just don’t have that unified system within our health care and it’s not integrated into public health.

We also just don’t have great ways to communicate with our health care providers and there’s not a lot of education that happens to health care providers to understand what public health is and what it does and how we are all able to be connected. And that individual person-to-person relationship with your health care provider is fundamental to being able to understand an individual person’s health and their choice and the decisions that they need to make on an individual level.

So I think there’s a lot that we need to do to build that relationship between health care as well as public health. We see some work along this with the pharmacists and pharmacy lines but so much more work to do along those lines, and then making sure that communication is two-way both with the public, our policymakers, our legislators, our governors, and with our large institutions and agencies via at CDC, ASPR, and others so that we can understand the why and we can also explain the limitations and weaknesses of a particular decision so that those of us on the ground trying to action said decisions can really have it be meaningful and make it make sense. So, I appreciate the focus on that.

Dr. Bliss: Thank you.

Tom Inglesby, let me turn to you. You were working very closely on the COVID testing and treatment, you know, issues earlier – well, last year, I guess, in 2022 – and I know have thought a great deal about, you know, the challenges of communicating about, you know, some of the changing kinds of guidance and the capacities needed to move that forward.

In terms of thinking about what CDC needs to better communicate with the public, what – you know, where do you see some of the best opportunities for improving the agency’s ability to carry that out?

Dr. Inglesby: Yeah. I think even in the course of the pandemic that within CDC there was a recognition that a lot of the communication efforts that go on within CDC were aimed at speaking to professionals, to health care providers, to public health agencies, and that a comparatively underdeveloped portion of the communication effort at CDC was aimed directly at the public and, CDC, I think, has begun to really kind of reassess the way it does large-scale communication.

But that’s, again, dependent, to some extent, on the power outside of CDC. If you look at the team and the infrastructure that CDC has to do that work, we expected to be able to communicate to the public, to all of the technical community, to Congress, to policymakers, to the private sector.

It’s a huge set of responsibilities, and then throw in that critical area of challenge – misinformation, disinformation – that’s happening all the time, not just here but around the world.

That’s a very substantial set of challenges and I do think CDC, to the extent that it has the assets and the contracting authorities, could really use private sector partnership there. We have lots of communication technologies and approaches that are blossoming around the U.S. and around the world that CDC could take advantage of.

I think there were examples in – within the government about successes. For example, in the testing world there was the example of the program that provided testing for the public through the U.S. Postal Service.

That was the very – the driver of that program was: this needs to be directed at the public as simple as possible, as precise as possible, and I think it was – you know, it was commented on by Wired magazine, the cool kids are back in government.

So, it is possible for the government to be a very sophisticated communicator, but we have to make sure that they have the right partners, the right people, the right technicians, within the government to do that work.

Dr. Bliss: So, it’s not just communicating with professionals but reaching the American public in their place.

Dr. Inglesby: Exactly. That has – that’s core, but yes. But public communication is a different strategy. It’s an additional one.

Dr. Bliss: Thank you. So, data, congressional dialogues, communications, addressing disinformation and misinformation, reforming operations, building staff in Washington, this all requires budget, right. It requires a greater budget.

Tom, you mentioned that the CDC budget is highly fragmented across multiple different Treasury accounts and really very little for – very little wiggle room for responding and pivoting in the moment of crisis.

Gary, let me turn to you for a second. You know, the report really underscores the many challenges CDC has faced already in securing aspects of funding for the domestic response and the pivoting challenges that Tom outlined earlier.

In the current context, you know, how difficult do you think it will be to gain budgetary support for this proposed kind of reset agenda that we’ve been talking about that the agency itself is beginning to undertake and do you see – are there any kind of aspects of the reforms that you see as kind of low-hanging fruit in terms of really kind of being able to secure a bipartisan consensus and secure funding in the near term?

Mr. Edson: My guess is that it’s going to be easier to get the budget flexibility than it is to get more money. I think the argument for budget flexibility is strong. I think that there are cases within the federal government of agencies that have secured those same flexibilities.

The straitjacket that the CDC budget is in just constrains so much of what was needed for an adequate both peacetime and wartime response when we’re faced with a threat that I think that that’s an area to push on.

I also think that the data piece needs to continually be pushed on and one of the angles there that you don’t hear enough about is the equity issue. You know, COVID laid bare so many problems in this country and one is the persistent inequities, and there’s no way to address those inequities without adequate data about where the – which communities are being most affected, which individuals are most vulnerable, and then we can target our resources and our response towards them. You need disaggregated data to do that.

So I think this is a confidence – what we need are confidence-building measures between the CDC, the administration, and the Congress, and those confidence-building measures can start with things like budget flexibility.

They can start with things like pushing on the data needs because I think if there is bipartisan support for addressing inequities, I think there’s going to be bipartisan support for being able to surge resources in a timely way to where they’re needed most.

That’s what – that’s the kind of process that I would engage in. I think getting more money – dramatically more money overall goes back to what I said earlier. I think it’s going to be dependent upon congressional perception that the CDC has gotten its own house in order and is deserving of more money and can spend that more money effectively.

Dr. Bliss: Great. Thank you.

So, Steve, I want to turn to you first, you know, on this question. You know, the report really focuses, largely, on pandemic preparedness and response but CDC, of course, has many other areas of work that are of great concern to the American public – long-term chronic diseases, environmental health, mental health, maternal and child health.

But it also has a very significant global health presence that we haven’t really talked about yet. So I want to talk about that global work and footprint for a moment. You know, CDC has country offices and staff around the world. They play a critical role in the PEPFAR programs, overseeing the field epidemiology training programs. There are CDC staff serving as secondees to the World Health Organization and its regional entities.

But, you know, there’s not necessarily a straightforward career path within CDC. We talked a little bit about, you know, some of the training around international relations and cultural competencies and others that other agencies have but, you know, that may not be relevant for CDC or haven’t been so far.

But, you know, I wanted to ask you to reflect on, you know, this process of the reset that’s been proposed here. What steps can be taken to better integrate and strengthen CDC’s global and domestic health security agendas and what will it take to, I guess, in budget – from a budgetary perspective but also from an operational perspective to really ensure and protect that global health action that CDC undertakes that is, you know, really so respected around the world?

Dr. Morrison: Thank you, Katherine.

And there’s lots of knowledge among our other speakers on this. I would just say that CDC has performed very, very well in its overseas missions over many years and that work, as you point out, has been predominantly driven by the HIV program – by PEPFAR.

When you add in those funding – that funding and staffing we’re talking about fully a quarter of CDC’s budget and, roughly, 2,000 employees when you count all categories of employees. It has become in many, many missions around the world, in the U.S. embassy – that CDC presence has become a very important element of our foreign policy and the promotion of U.S. foreign policy.

It’s been a proving ground, a training ground, for a generation of diplomatic leaders coming out of a CDC background. We’ve seen that in some of the sterling folks, Mitch Wolfe and others, who came through that, through the regional hubs. There’s now a new emphasis on building up regional presence. We know that CDC is playing an integral role in the Ukraine response at the moment, and the like.

But it’s been treated at a macro level as a bit of an afterthought or an add on. It’s not been seen as integral element of mission and the systems have been missing, which we enumerate in the report in terms of recruitment, staffing, promotion, career development, integration back in, the domestic and international integrated in terms of funding and the like.

And right now, yes, the PEPFAR program is foundational. But there are many other global health security functions that need to be provided in many countries where HIV is not a top priority and where that capacity needs to be enlarged in this next period, and that’s part of the challenge. And I do believe that bringing across the value and the achievements and the performance to Congress and to the American people and to others will go a long way in trying to build up that.

But there’s not a very good appreciation of that and I think we can do much better. Some of that may involve what was referenced earlier by Susan and others in terms of understanding by visiting. Some of the transformative changes that happened around PEPFAR – Gary can speak to this – involved bipartisan missions going out to some of the key countries and seeing this at work and having quite a dramatic transformative impact on attitudes and opinions, and we may be in a period where some – a repeat cycle with a global health security emphasis would make a lot of sense.

Thank you.

Dr. Bliss: Thank you.

So, I want to give our speakers an opportunity to offer some final reflections. If there are one or two questions from the floor, I would invite you to share those, and I can ask our speakers to take those into account as they offer final reflections.

But I think, if not, then I want to ask – first, I want to thank our speakers for joining us from near and far today and to ask each of you to, you know, really just kind of reflect on, you know, one or, I guess, possibly two of the steps that you see as most promising in kind of the next six to 12 months that, you know, you see can really kind of make a difference in restoring and rebuilding trust in CDC as, really, a core asset of U.S. national security interests.

So let me start with our panelists and then we’ll go to Tom and Steve, the report authors, and then finally back to our co-chairs.

Well, while we’re waiting for the system to be – to reset, let me invite Gary first here in the audience. 

Mr. Edson: I have the first and maybe last reflection.

You know, I’m going to start on a pessimistic note but end on an optimistic one. You know, there is a view that we heard in some of our working groups from some in the public health community that everything would have been OK if the response had not been, quote/unquote, “politicized,” and while there’s some truth in that, I think it misses the mark. It, obviously, ignores the CDC’s own unforced errors, which undermined confidence in the agency as much as political interference did.

But, more importantly, it ignores the fact that pandemic response and mitigation are inherently political. They involve major societal tradeoffs between health and the economy, between in-person and remote learning, between individual freedom and collective responsibility, and instead of pretending as if the answer is to do the impossible, namely, insulate the CDC from political pressures, what we need to do is come together and better manage the inevitable political nature of the response, to balance transparently the science with the social, educational, and economic impacts.

And my optimism comes from the fact that we heard in our working group and some of us have experienced as Susan did in Indiana, Anne in Alaska, Tom with Maryland, we saw states coming together during the acute phase of the pandemic with ad hoc collaborations, fusion cells, bringing together scientists, public health officials, and elected officeholders to manage the response together.

I think what we need is to translate that now onto the federal stage, and I think that’s what the report is talking about in terms of this intensified engagement with Congress and this more robust executive/congressional dialogue.

So, I have hope for the future and I think we ought to look at some of those state models and lift them up because they succeeded with a bipartisan approach, and I think we’ve got to try and drive the same thing at the federal level.

Dr. Bliss: So, we really need to embrace the political – or the political dimension of the pandemic and really move that that kind of dialogue forward.

Do we have our online folks back?

Dr. Frieden: We’re back.

Dr. Bliss: All right. Let’s see.

Tom Frieden, let me turn to you. One or two reflections – what are you, kind of, most optimistic can be achieved in the next six to 12 months?

Dr. Frieden: Well, first, I wanted to mention the report highlighting the health defense operations approach. This is not going to happen in the next six to 12 months. But over time, this kind of approach that takes what can be accepted by both parties – both houses of Congress – as core issues for our health defense and insulates them from the budget dance, this is a good idea that’s now been included in legislation that was introduced.

You know, good ideas sometimes take a few years to mature. I think this is essential. I think the ability of Congress to be able to give resources to CDC – I think I may be not there anymore – but to give resources to the CDC without taking them from other entities that would enable us to greatly strengthen our health defense on which we currently spend about 1/500 what we spend on our military defense.

Dr. Bliss: So legislative processes at work.

Let me – we just lost Anne Zink, so if she comes back, I’ll turn to her. Are you still there?

Dr. Zink: Yeah, I’m here.

Dr. Bliss: Oh, you are. Oh, OK. I thought we – I thought we lost you. Sorry. Let me turn to you, please. Your thoughts?

Dr. Zink: Yeah. No, I really appreciate the report’s very specific call outs. But one other thing I would just mention about budget is I would, again, think about health care and public health.

You know, I don’t go into a shift and say, I can only take care of so many heart attacks tonight because that is all the funding that I have to take care of heart attacks. But I go to my, you know, day job work in state government and we only have so much funding to take care of so many TB patients. There’s only so much contact tracing that I can do, and those two go really closely together.

So, I think that we need to think about the payment structures for health care and incentivize public health as a part of health care as well as funding for the academic and understanding component.

I think we did this as a nation with EMTALA back in the 1980s to say it’s not OK to show up in an emergency department without stabilizing and treating, and I think we need to do the same thing with public health. It’s not OK to not have the very basic data, information, and public health response because our economy, our schools, our security, are all key dependents of that and it has to be built into the way that we address health care as public health at the same time.

Thanks.

Dr. Bliss: All right. Thank you.

Susan Brooks, let me turn to you.

Ms. Brooks: OK. Thank you.

I think in the next six to 12 months just reminding members of Congress in particular that the public health issues, so much of what we’re talking about, is national security, and trying to make sure that they understand, particularly the newer members – trying to make sure they understand the intersection between national security, our military preparedness, our – you know, which includes our National Guard men and women in our own neighborhoods that – you know, that are – they’re going and serving our country as well. Just making sure that they understand that it is all – it’s all connected and that the bio threats are really significant, and we have to make sure that public health have the resources that they need to detect and to test and to be far better prepared than we were during this pandemic.

I think that is something that brings both parties together, and if we can just continue to educate on what is needed in a humbling way, in many ways, because so many things did go wrong. But so many things, as Julie reminded us, did go right, and so many things that public health has done right in the past we need to remind people what those are, and that with the right resources and with the right mission and the clarity in the types of things we’re talking about we can really get back to that.

But we have to be ready for tomorrow and what tomorrow brings, and we don’t know what that next disease is and what – how it might impact our neighbors and our communities.

Dr. Bliss: Thank you.

Julie Gerberding?

Dr. Gerberding: Thank you.

First of all, I agree with everything that’s been said. I do hate to say it but, you know, it’s not over yet. So, you know, while we all want to put this in the rearview mirror and think about how to learn from it and go forward, we do need to have the humility to recognize that there’s still a certain uncertainty about what’s ahead of us.

But I also vehemently agree with that the CDC needs to fix the things that are within its control to fix and work with the state and locals to really make sure that there’s clear understanding of what those priorities are, not just from the inside of CDC but really reflecting from a systems perspective what can we do right now to execute what has already been defined by Dr. Walensky and the CDC but also to extend that into some of these other areas, in particular, the opportunity to begin the process of expanding the deployed workforce because that will serve us well no matter where we are, to build a strategy for the D.C. presence of CDC.

Even if they don’t have the resources to execute it entirely, they can get a start on it and begin to move forward so that when we have good news about the improvements that are made in the agency, we’ll have a way to communicate them and to really engage with the new Congress.

And with that in mind, I think the PAHPRA reauthorization is a critical opportunity. It almost sets a deadline that we need to have the house in order as we go into the conversations about the importance of PAHPRA what that needs to mean to the agency so that we can assure that the opportunity to shape that reauthorization and to have it, perhaps, solve some of the problems that we’re talking about really is an opportunity that doesn’t get lost due to the timeline.

But I want to end with a very positive note because I – there’s a lot of incredible talent, passion, and capability at the CDC and, you know, I’ve seen them do miracles.

Dr. Bliss: Well, our time has come to a close.

I want to thank the CSIS streaming and broadcast team and the Global Health Policy Center staff for their efforts today, particularly Michaela Simoneau and Humzah Khan, who really manage the commission secretariat and keep it going.

I thank you, the audience, for joining us today and I ask all of you, both online and here in person, to please join me in thanking our panelists for joining us from as near as Baltimore and New York to as far away as Indiana, Alaska, and Europe and, of course, right here in Washington.

So, thank you very much. (Applause.) We are adjourned. Thank you.

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