Today’s Threats, Tomorrow’s Health: A Discussion with CDC Leaders

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This transcript is from a CSIS event hosted on May 13, 2024. Watch the full video here.

Julie Gerberding: Well, good afternoon, everyone, and welcome to this CSIS discussion. I’m very pleased to honor our guests here today. And I’ll introduce them in a moment. But we are going to be discussing CDC’s global mission and the evolution of a more integrated strategy for global health security that the agency is leading. I’m Julie Gerberding. I am currently the president and CEO of the Foundation for the NIH. But I’m wearing a different hat in the context of this meeting, as the co-chair of the CSIS Bipartisan Alliance on Global Health Security. And on behalf of my co-chairs and I, I really welcome you. And I will make sure we have time for questions at the end of our discussion. So please be prepared for that. And we’ll invite you to the microphone to participate in the conversation. We also welcome our online guests and hope that you enjoy this discussion.

So why are we here? Well, we’re here because we are operating under the basic premise that biosecurity is national security, and that CDC has an absolutely critical role to play in that. The Bipartisan Alliance has really tried to be productive in helping the CDC build its capacity in this regard, and really look at what is necessary for the CDC to, in a sense, recover from some of the issues that emerged during the global pandemic. We had a wonderful working group under the auspices of the Alliance led by Steve Morrison and Tom Inglesby from John Hopkins University that really examined what was going on at CDC, what were the opportunities for improvement, what were the strengths, where were investments needed? Both actions by CDC, but actions on behalf of CDC to really respond to what I think was the soundbite from the working group’s report: The CDC is in peril.

And yet, it is so important to our national security that it was an urgent priority to step forward and try to understand what could be done. So in January of 2023, CSIS published a report, Building the CDC the Country Needs. And there are many stakeholders and experts who participated in this working group report. And one of the things that you’ll hear today, if you saw that report, is that our leaders from the CDC have already taken steps to respond to some of the recommendations in the report, particularly two recommendations that specifically address global health issues. First and foremost, what really was the best way to integrate CDC’s global health work with its domestic biosecurity agenda? And then, second, what were the investments, the budget, the workforce, the practical policy, authorities, et cetera, that CDC really needed to acquire in order to successfully fulfill its global mission?

In the time since that report, there has been significant progress, I just want to take a moment to highlight some of those areas of progress. In particular, the CDC director has been very visible globally, as have some of the CDC leaders who are here today. Regional offices have been opened around the world to try to coordinate CDC’s agenda, particularly its global security agenda. And specific investments have been made. But I think what is probably most exciting for us is really the recognition that this – the whole is greater than the sum of the parts. And by coming together as a whole of CDC, we can really build on the vertical strengths and capabilities of the agency, but move them in a direction where we have a more powerful, a more visible, and, I think, a more successful global agenda.

So let me introduce our panelists. First, I’d like to start by introducing Kayla Laserson, who is the head – or the director of the Global Health Center at CDC. Sitting to her left is Dr. Dan Jernigan, who’s the director of the National Center for Emerging and Zoonotic Infectious Diseases.

And do you pronounce that NCEZID? (Laughter.)

Daniel Jernigan: N-C-E-Z-I-D. Don’t say NCEZID.

Dr. Gerberding: OK. Just checking. (Laughter.)

And then sitting next to Dan, on Dan’s left, is Demetre Daskalakis, who’s the director of the National Center for Immunization and Respiratory Diseases, and a leader across public health but particularly in the HIV arena, and someone who I’ve long held in highest esteem.

And then finally, at the other end of the panel, is Henry Walke, who’s the director of the Office of Readiness and Response, someone who was in the hot seat during COVID but continues to provide a really unique frame of leadership for the CDC.

So what I’d like to do is just maybe give our panelists a chance to say a few words, really focusing not so much on what’s ahead in the context of this strategy but what’s already been accomplished? What actions have you taken since – maybe since January of 2023 when the report came out but in the recent months that really are kind of moving us in a new direction?

So, Kayla, I’ll start with you because I know you have probably the über view of the overall strategy.

Kayla Laserson: Great. Thank you so much. And thanks to everyone for being here and everyone who’s online.

Today we wanted to talk a little bit about sort of a unifying strategy, unifying framework for CDC’s global health work and it really fits into the CDC director’s 2024 priorities of readiness and response, to really look at data infrastructure and modernization, lab quality and safety, and overall risk-based pathogen prioritization. So this global framework really fits into those larger 2024 priorities. And we’ve learned a lot over the last few years, especially from COVID, both domestically and globally, and we wanted to put it all together in our global work. We know that in order to protect the U.S., to protect the work and our lives here, we need to be working globally to do that, and our global work leverages many of the platforms that we work in overseas, much of the work that we do in PEPFAR or the President’s Malaria Initiative or any of the work in influenza. All of that global work we leverage both for those vertical programs but also horizontally, to build systems, to have system strength for our global work. And so when we work overseas we have over 60 country offices and six regional offices, and we really work shoulder to shoulder with ministries and with government and with the community in the countries where we are and we really have a trusted partnership, and we are, for that reason, the first call when something happens. And we’ve seen that repeatedly, and especially since COVID, but that has been going on for decades. And so it’s really important that we frame our work, and so what we’ve done is we’ve put together a global strategic framework which its elements are not new and its – the core capacities and the mission and the vision of CDC globally are not new. But the framework is a new way of framing and it’s a way of ensuring that across the entire agency, across all of our different programs and the centers and our country offices and in our regional offices we’re all working together, kind of in the same – pushing in the same way, pushing in the same lanes to be the most effective, to be the most efficient, and to have the most impact.

And the framework really has four major goals as to why we’re working overseas. The first goal is to stop health threats at their source, and that’s CDC’s really fundamental goal, stopping outbreaks at their source so they don’t move anywhere or to the U.S.

The second is to prevent or contain disruptive outbreaks. This is the dengue, this is the cholera that may not move but it’s very disruptive to societies, to economies, to the health of nations, and it’s very important to work on that.

The third goal is really around global knowledge and how we can use it both globally and domestically, and that’s something like our influenza strains that we know from around the world that help go into our vaccines, and that global knowledge of disease elsewhere and how we use it domestically is very important. So that’s the third goal.

And the fourth and final goal is really the platforms that we build that really prevent morbidity and mortality. Again, that’s the PEPFAR or the malaria or the flu or the anti-microbial-resistance platforms that reduce morbidity and reduce mortality, but also serve as a platform where we build system strength so that we can then respond to outbreaks, that we are working in clinics and training. And those actually help in all of our work overseas.

And then there are six pillars that get us to those goals: data and surveillance, laboratory, prevention and response, innovation and research, workforce and institutions, and communication policy and diplomacy. So through all those pillars of work, we reach those goals. And so what we want to do today is to share with you some of the ways in which the most recent outbreaks are really showing how we’re using that framework, we’re working within that frame globally, and how it connects to our domestic work and vice versa.

Dr. Gerberding: So, Kayla, what I’m struck by in your conversation here is that none of this has a disease name, right?

Dr. Laserson: That’s right.

Dr. Gerberding: You’re talking about the cross-cutting capacities and capabilities that really distinguish CDC’s expertise that you can apply to whatever the threat is, whether it’s a domestic threat or a global threat. And we certainly have plenty of those in play right now. So I thought maybe I would ask Dan to start by talking a little bit about mpox and how that’s playing out, and how this approach is illustrated in the context of this arguably primarily global outbreak, but certainly with U.S. implications as well.

Dr. Jernigan: Sure. Yeah, mpox is one of the pathogens that sits within the National Center for National Center for Emerging and Zoonotic Infectious Diseases. But to the point, it really requires the all-agency activity force to really be able to respond to it. We did have cases of the Clade 2b, which is the cases that we had previously – 30,000 of them in the United States.

What we have right now is something happening in the Democratic Republic of the Congo called Clade 1 mpox, which has a little bit – it has some higher severity. It may have higher transmissibility. We’re seeing about 4,000 cases from the first part of this year. And Clade 1 mpox really demonstrates the threats that we have with emerging infections, that the world is more connected than it ever was, so you can get from Democratic Republic of Congo to anywhere in the world within the incubation period. The world is more crowded than ever before. And the worlds of animals and humans are really converging like they never have before. And right now mpox is showing that – rodents giving it to kids, kids getting it within the family. It then can go on to have sexual transmission and then get outside DRC.

So we want to be able to have that capability inside the United States to have diagnostic tests, to have the right surveillance in place, and this framework really helps us to say data – what data do we need, both in the United States, what do we need for the teams that are in DRC? What’s that’s coordination between the country team, the experts, and the folks that are being deployed, the laboratories that we have in the United States? We need to think of this across a spectrum from domestic all the way to global so that we’re not thinking of it in one place or the other, but we’re thinking it across that spectrum. And then how do we use the full breadth of all the different capabilities we have across these different centers and across the USG in order for us to have the most optimal response and keep Clade 1 mpox from coming in and causing another set of cases in the U.S.

Dr. Gerberding: Potentially even worse.

Dr. Jernigan: Yeah.

Dr. Gerberding: Yeah. So in thinking about how you actually implement that response, one of our greatest strengths globally is the PEPFAR platform. So I don’t know, Demetre, can you say a little bit about how that vertical gets leveraged in the context of this new strategy?

Demetre Daskalakis: Sure. I’ll say that one of – I think it was remarkable seeing sort of PEPFAR in action for mpox in Cambodia when we went for our visit there – so Kayla, the director, and myself. I thought it was really important to see sort of how that was leveraged globally, and really that was also reflected in how the work happened domestically during the outbreak. And I think sort of thinking about PEPFAR, a very clear equivalent is Ryan White. And so I think we did a very sort of similar – the lessons from the sort of global and the domestic sort of converged in that looking at the sort of HIV platform globally and domestically to really reach communities that needed to be reached, but also addressed some of the gaps that are sort of well-known in HIV treatment and prevention, and how that was, you know, exactly synched to the populations that were having the worst outcomes for mpox. So I think it’s – it is sort of in the – in the image of this framework where we’re, in a disease-agnostic way, stepping back and saying, what can be leveraged and how far can we push it? And I think that that’s, like, some of the great leadership that Kayla has sort of shown, that bringing us all together to sort of work on this framework demonstrates the importance of really saying, like, where can we leverage?

Where do we have sort of infrastructure, like influenza, which is now the center that I work over? Like, how can we leverage that not only for our seasonal flu, but also for our more emergent or urgent pathogens that we’re seeing? And then also, in a more pan-respiratory fashion. So sort of thinking about the lessons, it really is a pathogen agnostic strategy. Where, you know, how can you leverage the platforms? How can you sort of look at the laboratory, the relationships, the diplomacy, you know, the data, and really make it – sort of make those systems work together to achieve a better public health outcome?

Dr. Gerberding: I think we all realized in COVID how important the PEPFAR investments were, as well as the Global Fund investments, and the countries that had an infrastructure for laboratory and surveillance, and the capacity to understand PCR, and we converted into tools for COVID, et cetera. So, you know, that’s kind of an occult knowledge, because not most Americans understand that that was incredibly important in supporting the outbreak response in many countries. And it was a value from that investment that I don’t think we predicted back when George Bush invented PEPFAR. So sometimes that leveraging capability really gets us far more than we bargained for.

And we’ll come back to this whole issue of funding and budget for both verticals as well as horizontals in a sec, but I want to bring Henry into this conversation a little bit. So we have another very worrisome situation emerging in the U.S. And that, of course, is the avian influenza. If you’re a bird, it is a pandemic. (Laughter.) So and certainly even this week we learned that pigeons, which were thought not to be susceptible to H5N1, now at least in, I think, Michigan, have been shown to have been infected. But I want to talk a little bit about dairy cattle, because I know that’s what’s on people’s minds.

You’re the head of, you know, the Preparedness and Response Center at CDC. What’s going on in your center, both domestically and internationally, in this context of this outbreak?

Henry Walke: Right. Well, you know, domestically, we at CDC are trying to coordinate together across multiple centers. Stood up a – and, actually, was in Demetre’s center, where we stood up an incident management system to help coordinate all the activities.

There has been one case in Texas, a human case, so far. Certainly we’re detecting it in multiple herds across the U.S., which requires that collaboration with other sectors – USDA, basically – and the FDA within HHS, to ensure that milk is safe. So this is an interagency collaboration, as not only in HPAI, this particular outbreak, but as it was in Ebola, as it was in Zika, as it was in mpox. It’s not just CDC coordinating within itself, but it’s also CDC coordinating across HHS and coordinating across the interagency.

So domestically, USDA has the lead on the animal side. We obviously have a lead and a leading role on the domestic side. We continue to try to investigate potential cases on farms. But it actually has been quite difficult to get access to some of those farms and understand the epidemiology and where the risk is actually – whether it’s in the milk barns or not. So we are supporting the states, supporting this migrant population that’s actually working on the farms. It's a difficult population to reach.

So we’re working with various partner organizations to try to gain that type of trust, so we actually can do more of those epidemiological investigations. FDA is responsible for the milk – for the quality of the milk. And so we’re working quite closely with FDA. And you’ll see a lot of information coming out from FDA around pasteurization of milk. And, yes, the milk is safe. Pasteurization – raw milk – don’t drink raw milk. It’s not just H5 that you have to be concerned about. (Laughter.)

So I think within CDC, certainly, we have multiple groups engaged, including Demetre’s center. We have our One Health Group, that actually is in Dan’s center. It’s engaged. And we have actually some forecasting and analytics as well engaged to try to predict, if this does take off, what does the future hold? Fortunately, now our vaccines – there are candidate vaccines that will work. Our laboratory testing, we can pick up this particular strain of H5, and our therapeutics as well also work. So it’s very reassuring at the moment. We are – we need to learn more about where the risk is on these farms. And then long term, is there surveillance in these cattle? Is it milk surveillance? Is it herd surveillance? Is it among dairy farm workers? There’s a number of activities that are going on.

Dr. Gerberding: Or wastewater. (Laughter.)

Dr. Walke: And, of course, there’s wastewater. And you’ll see – you’ll see some more results coming out actually fairly soon, I’m looking at Demetre, around wastewater.

Dr. Gerberding: So, Kayla, like, right now, we’re kind of managing this as a U.S.-centric situation, although H5N1 is not just a U.S.-centric problem. But yet, communication has to be relevant globally. And I’m sure there’s a lot of anxiety on the part of the food production industry in terms of trade and the global impact of – concern about the safety of our cattle industry, et cetera. So how are you managing the global communication around this kind of unfolding? This is the hardest part of an outbreak, is the early days when there’s so much uncertainty – how bad is it, how bad will it be, who’s affected, how far will it go? You just don’t know. So how are you handling that?

Dr. Laserson: Yeah. Thank you. So a couple of things we’ve done so far. I mean, obviously, we have all the – you know, everything we have on CDC, you know, websites we’re pushing out to all of our partners, all of our global partners. But also, we just did a webinar with our country and regional, you know, CDC teams to make sure everybody was fully informed, had a chance to ask questions. We just met with State Department and talked about ways in which we can push out, you know, another seminar and webinar to get everybody sort of up to date and aware of what’s happening, and make sure that, you know, questions are answered – keeping that awareness very high. If countries are interested in getting engaged or looking at surveillance, we want to be able to support that.

So right now it is mostly domestic, as you’ve said. But we are ensuring that all of our partners, global offices, everybody is aware and ready and watching. So that in case anything, you know, is needed, we’re right there. But for avian influenza in Cambodia, different Clade, our teams there were right on those cases that just happened recently. In fact, a couple happened right as we were there. And so there our teams are well trained and ready to respond, and did respond quite quickly and with the sort of capacities that they have from the work we’ve been doing there for years, and also in their whole region. So, again, that was sort of a U.S.-global sort of link between all of this.

Dr. Gerberding: Now, one of the strengths of CDC is the international workforce, although it’s not as optimized as I think it could or should be. And that was one of the findings of the CSIS commission report, is that this incredible investment in talent and public health capacity that we have in many – I think, over 100 countries, is still not managed as a global asset. It’s managed as often a therapeutic area or, you know, an assignment on a temporary basis, with no real career development and career planning. Will this strategy be able to help address that opportunity to really strengthen the workforce internationally?

Dr. Laserson: So, you know, one of the strongest parts of CDC workforce overseas is the – is the locally employed staff, right? Almost 2,000 locally employed staff around the world. And we have spent, you know, a lot of energy and a lot of investment to ensure, you know, great training amongst the staff, whether they’re trained in epidemiology, or in laboratory response. And now we’re having more and more opportunities for those staff to move from country to country, to be assets from country to country. And so the development of the locally employed staff is extremely important.

And then on top of that, we have the field epidemiology training programs, and we have the emergency management training, we have laboratory training. So we are building the workforce overseas through all these different methods, bringing people to Atlanta for training, for sort of rotations throughout CDC, or throughout Washington sometimes. So we’re really trying to build up that workforce, and also have that cross communication across the workforce overseas.

Dr. Gerberding: So, Dan, prior to your current role as the – I’m not going to try to say it – (laughter) – emerging zoonotic diseases – (laughter) – you had responsibility for data modernization efforts – or were very much in that effort. Tell us where that plays into this global strategy.

Dr. Jernigan: Yeah. I think Kayla mentioned the different pillars that are listed in this framework, the first being data and surveillance. And so, really, we see that as having an interoperability desire, interoperability component. We want the data to be able to be shared, so if you are collecting information through a DHIS or one of those systems that are used in country it’s able to be shared with other countries, but also shared with the U.S. and other partners as well. We want that information to be used for making decisions, too. And so having that data available so that you can get the right policies developed from that quickly, that’s an important part of that data and surveillance part as well.

I think other things that we want are the ability to have that data available to inform people as well. So right now we’ve got an emerging problem with Dengue in the United States – excuse me, in Puerto Rico, which is part of the United States – as well as in Central and South America, where lots of Dengue cases are likely to occur. We want to be able to have that data from El Salvador, from Honduras, or from wherever be able to be presented so people around there can see, oh, it is increasing; we need to take care to make sure that we’re looking out for those cases, get them in the hospital, et cetera – and that we can monitor that in the United States to see what’s happening and likely may happen in Puerto Rico, which we think is the case as well.

So interoperability, data for decision-making, and data so that it can be seen and lead people to do the right thing.

Dr. Gerberding: So, you know, when you look at the strategy and the six pillars, who could argue with the importance of the six pillars? But they cost money. And we’re dealing with a very difficult budget situation across the board in the U.S. government, but particularly as it pertains to the CDC and some of our other agencies. So, you know, when you think about the PEPFAR reauthorization challenge and the fact that PEPFAR was only reauthorized for one year, that was – it felt ominous to me. What is that saying about the perspective of our government on our global health investments and the long-term value that we’ve been able to deliver that – not only in terms of human health and the incredible impact on lives saved, but also on health diplomacy and the respect and trust that the United States has earned internationally in many countries as a result of those investments?

So here we are now, we’ve got bold ideas about how to do a better job with our global biosecurity, and yet I don’t think you have a big budget line for this particular effort. So how are you going to get the story out there? How are you approaching the importance? And maybe I’ll ask all four of you to answer that because you’re probably all playing a role in that. But what can be done to make sure that people understand the value and the importance, but also the opportunity that this strategy really presents for the U.S. government and our national security? I’ll start with you. Yeah.

Dr. Daskalakis: Great. I think I’ll probably use influenza as a great example, which is, you know, I think the seasonal preparedness that we do every year ends up being what we leverage into preparedness for pandemic and preparedness for sort of unexpected events like bovine transmission of H5N1. So I think – I think that that is part of the storytelling; that, you know, I think we can tell the story of Cambodia and sort of the work that happens in Cambodia, and really, you know, I think, remarkably, I think these visits end up being really important because I think then our director can speak about it in very clear terms and we can speak about it in clear terms. Like, that visit to Cambodia, you actually saw the CDC infrastructure in action and how that actually mattered months later, when we have sort of the outbreak of H5 in cows. So I think, you know, seeing the – what happens to sort of find the village where we have the case; and how that moves into the clinical arena that is supported by the TA that’s so important from CDC; and that that supported the care of individuals diagnosed with HPAI in Cambodia; and then moved into the laboratory where, after identification of that case, you had sequence that then told you exactly what you were dealing with lets you assess what the risk is, think about antivirals, think about mammalian adaptation, and also think about the vaccine candidates that we have. So I think sort of thinking that that’s far away, but we did the same thing in Texas, and sort of making the point that that trained the system that allow us – that global work not only was creating, like, the security and understanding of what’s circulating in the world for flu so we can build better vaccines next season and also have better vaccines in the bank in case we have some surprises, but I think the other piece was that it exactly trained the system which we were able to go from, there’s a human with conjunctivitis in Texas to 24 to 36 hours later having a risk assessment about the sequence up and available for all the world to see, really creating, you know, both appropriate concern and adequate reassurance of where we were that day. So I think part of it is really just making sure that we tell the story –

Dr. Gerberding: Connect the dots.

Dr. Daskalakis: Exactly, and that we connect the global into the domestic and the domestic into the global since – though I think that we partitioned it; in some ways that’s because of the way things are funded. Ultimately, the way that we’re acting at CDC is for that to flow from domestic to global and global to domestic in a sort of seamless way with an osmotic barrier that is hard to perceive. (Laughter.)

Dr. Walke: Maybe if I could jump in with a couple of examples. What comes to mind is the work that was done with mpox the last two decades, for example, with the JYNNEOS vaccine, with health care workers, actually NDRC. Translation of that work led to the use of JYNNEOS vaccine actually in the U.S., but that story is not told and so telling that story of the work that we’re doing internationally and other countries, where the actual disease is endemic – Clade I mpox, for example – are telling that story and translating it for the American people and for Congress.

I can think of the work on Ebola, for example, in Uganda. Lot of work done in Uganda. This is Ebola Sudan. We’ve been working with Uganda public health lab for years and they had the capability that government stood up, contained the outbreak, based on some of the work we’d done actually in the lab in Uganda a decade prior. The work that was done in Marburg, actually in Equatorial Guinea. That was a nice collaboration with USAID and Department of State and with CDC, getting people on the ground in a very difficult environment to contain that outbreak. But that’s – part of the issue here is that we invest in laboratories, we invest in people, we invest in surveillance systems, early detection and containment. It’s hard to describe prevention. It’s hard to show the success of what we prevented. But talking more about it – talking about the counterfactual, for example, of what would have happened, actually, if we didn’t have the training, didn’t have the laboratory testing, hadn’t done the workforce training – I think that’s an important piece of it as well.

Dr. Gerberding: So we’re in an environment right now where trust is not high. Trust in any institution is not high but trust in the CDC is probably still on the low side, from everything that I’ve read. There are some partisan dimensions to that, of course.

So, Dan, you know, you’ve been at the CDC for a long time; you were there when trust was very high and you were there when trust was very low. When you’re thinking about how to get the word out about the value of CDC, who are you going to talk to and what do you think is the most important thing for a budget decision maker to understand?

Dr. Jernigan: It’s a great question and I think several angles to that, but just in terms of us speaking more. We need to communicate more clearly. We need to communicate more often. We need to be transparent in what we’re saying. We also need to be able to listen as well, and I think we really learned that over the last several years, especially the last year, for me, just that there are things that we say that individuals out there just – they don’t hear it the way that I think I’m saying it. And so it really is on us to be able to understand where people are coming from, listen to them, and then adapt that message to get the highest amount of people being able to do the right thing to protect their own health. So that kind of communication is absolutely needed if we’re going to build that trust back.

Dr. Gerberding: So if you were going to pick one story that you would like to tell, what would be the story?

Dr. Jernigan: (Laughs.) From a global standpoint here? Yeah, I think – sure. I mean, one that really comes to mind is with antimicrobial resistance, and so this is an issue that, you know, you think of it as a hospital thing or a long-term care facility thing, but it’s really emerging across the globe in the community as well as in health care facilities, to the point where we just won’t have any antibiotics to treat people. And so in the United States we actually, to your point about having networks and laboratory capability and epidemiologic capability, we were able to pick up a case of infection in the eyes of some long-term care facility residents where they were actually getting puss in their eyes. Their eyes were completely opaque and having a really bad infection that led to them sending that off to a laboratory that got to a public health laboratory where, because of antimicrobial resistance support and genomic sequencing support, they were able to actually see that that was a pseudomonas, which is a kind of soil bacteria – it’s a nasty one –

Dr. Gerberding: (Laughs.)

Dr. Jernigan: – that was resistant to 12 different antibiotics. And so that’s a really bad bug. We also found that there were several other cases in the United States. And it turned out that those individuals had all been using artificial tears, which you use to wet your eyes, if you have a problem with your eyes. But we found out that, in fact, that artificial tears was from India and it was a kind of bacteria that we had not seen in the United States. And so that particular pattern of that resistance had only been seen in India and we were able to know that it was coming from there, but we were able to find that, stop it at the source so that it doesn’t come in, which is at the top of the global health goals, and didn’t prevent that transmission from happening in the United States. But we still had that bacteria that’s periodically showing up in some places, so it just shows you that domestic, global are highly connected; there’s lot of ways that it can get there, the world being more connected, crowded, converging. (Laughs.) All of those things are happening now and we have to work together in order for us to be able to address those problems and stop things like those eyedrop problems.

Dr. Gerberding: So, Kayla, I know you served in India for many, many years and had a very pivotal role there in terms of building the partnerships and the alliances with public health in India and the CDC perspectives. That kind of diplomacy is really critical for health but it’s also critical for broader national security, global security issues. You talk a little bit about how this strategy reinforces that?

Dr. Laserson: Yeah, I mean, I think if you look even at that – the last pillar, which has diplomacy in its name, communication policy and diplomacy. I mean, our – really the fundamental backbone of everything we do is diplomacy, and health is diplomacy, and so working in government, working, you know, next to somebody – often our offices are actually in the ministry of health or working really closely with the ministry of health. That creates those partnerships. It creates the trust that you are asking about – and it means that we can bring in our scientific expertise, we can support, we work together, and when something happens and we’re not there or we’re, you know, not in that place at that time, we are the first call. And so when something like, you know, this could happen or any of the avian flu, any of it, we get that call first and we can either have people in country or go there and we are trusted to go there, we’re trusted to be able to support and to help, and that diplomacy is really the backbone of all of the global health work that we do. And really, PEPFAR – just going back to your question about PEPFAR. PEPFAR built that over decades, that kind of relationship, that kind of trusted partnership. And all of the examples that we just heard about, all those different outbreaks, all built on PEPFAR, on the platform of PEPFAR and of all that laboratory surveillance data. Those sorts of platforms are what allow those outbreaks to get identified and then responded to. So it’s both diplomacy and it’s also the system strengthening that gives us that kind of relationship in country and our ability to respond.

Dr. Gerberding: Well, and we also have to sort of think, if we’re not there doing this, who will be there, and will they have the same relationship with the U.S. government that we would like to have with our allies? So, you know, there’s a global competition for allies at the moment, as we all know, and that’s another dimension of this that doesn’t really seem, at face value, like a public health issue, but when you step away from it, it is.

In just a couple minutes I’m going to open this to questions from the audience, so be thinking about your question. I think the microphone is over here in this corner, so we’ll ask you to step to the microphone and please, just maybe line up so that we can go quickly through the questions. We’ll probably ask a few questions and then give the panel a chance to respond.

But before we move there, I just want to, you know, remember that a strategy is a grand thing. It has to be budgeted. It has to be socialized, and that’s what we’re doing today is getting input and feedback as you begin to roll this out. But it also has to have measures of success. So just, you know, in one short kind of sound bite, how will you know you’re successful? And what are you most interested – say, in three years. What do you want to make sure has gotten accomplished?

I’ll start with you, Henry.

Dr. Walke: I think we’d have to go back – first of all, let me say that we do need to measure our accomplishments and we are working on performance metrics as part of the strategy and trying to dig deep into those six pillars and across the four goals. I think one of the ways, for me at least, is stopping outbreaks at their source. And so I think that’s a fundamental piece of this, helping countries where they see an event, an emerging threat. How are we – CDC or the U.S. government – able to contain that either within the country or within the region very quickly? I think that’s going to be one of our successes.

Dr. Gerberding: Great. Thank you.


Dr. Laserson: I would – I would say, just to build on that, measuring those pillars, those are the things that will get us to those goals. So where are we in each of those areas and how do we identify gaps? And then how do we intervene and measure our progress? So those pillar metrics are extremely important to build the system.

Dr. Gerberding: Do you have a favorite pillar? (Laughter.)

Dr. Laserson: Yes.

Dr. Gerberding: Data and surveillance.

Dr. Laserson: I knew it. (Laughter.)

Dr. Gerberding: Dan.

Dr. Jernigan: Yeah. For me, I think if we have in place in strategic locations capable laboratories that can do genomic sequencing quickly, that will be a success that we can identify emerging pathogens and unique aspects of pathogens, or anti-microbial-resistance pathogens quicker there. They get that information quickly; they can act on it. We’ll have that information, and we can act on it quickly as well.

Dr. Gerberding: Yeah, it’s foundational, absolutely.


Dr. Daskalakis: I’m going to just ditto, actually, what Dan said, which is really about, you know, how the laboratory interacts with surveillance to accelerate what happens on the ground. So that, for me, would be – is, like, probably the strongest metric, which I think, you know, frankly, blends some of the pillars into that surveillance piece and the lab piece and the efficiency that you go from there’s someone who’s sick to, like, we have a problem, to we have a response.

Dr. Gerberding: So the FELTP – the field epidemiology laboratory training programs –

Dr. Laserson: Training.

Dr. Jernigan: Exactly.

Dr. Gerberding: – really build that capacity locally, because it’s one thing to set up a lab; it’s another thing to be able to operate it and to maintain it. So that give us hope. Those are concrete things and budgetable things. (Laughter.)

So let’s move to the microphone and our Q&A.

Q: Yes. Hi. My name’s Jerry Martin. I’m currently adjunct faculty at the Cummings School of Veterinary Medicine at Tufts, but prior to that I ran a series of avian influenza control programs funded by USAID called Stop AI, community-based avian influenza control in Indonesia, and other programs including directing the preparedness and response program.

So the purpose for that context is you talked about how we can learn from our global work and bring it back to the United States. H5N1 here in the United States, obviously, is a serious issue right now. There’s a lot of lessons that were learned through that – the funding of AID programs, and one of the big ones was the establishment of national One Health platforms. And I know there’s a One Health office within CDC – it was mentioned earlier – but I understand at least in the United States right now there is no national One Health platform that includes USDA, includes FDA, includes CDC. I’d like your opinion about the feasibility of establishing that type of entity so that you wouldn’t have this issue where we can’t necessarily get to test farmworkers because there’s all this extra coordination and state rules and regulations that you have to deal with.

Dr. Gerberding: You’re asking a question that I asked Dan about 25 minutes ago, so. (Laughter.)

Q: Yes, but I’m asking specifically about whether establishing a national One Health platform is a mechanism that is needed beyond what you already have at CDC.

Dr. Jernigan: Yeah. So the One Health office in our National Center for Emerging and Zoonotic Infectious Diseases – NCEZID – (laughter) – that group has been tasked by the federal government to run the One Health consortium. And so that is a group of USDA, FDA, EPA, and others that are within the United States government in order for us to have a(n) ongoing dialogue, rules of interacting with each other on outbreaks, et cetera. So it really is intended to get to that.

Is that a platform that is specifically stood up for that? It could be over time. This is something that was in authorizing language last year, and we’ve now instantiated it with our – I don’t know if we had our first meeting or not, but they’re certainly working on that. But that is a – that is something that the government wants. We’ve been tasked with helping to bring it together. But it’s really something that has to work across all the different partners.

Globally, we also work with a number of the international parties as well. We do the One Health zoonotic prioritization activities where we’ve gone to multiple different countries, have them pick what are the most important zoonotic pathogens in their country, and then help them bring together agriculture folks, the animal husbandry folks, as well as the health-care – human health-care folks so that they have each other’s cellphones, they know each other’s phone numbers, they know how to work with each other, there’s some standard operating procedures. That same thing that we’re helping countries to do we’re trying to do here within the United States as well, and the H5 event really brings that to the forefront –

Dr. Gerberding: Brings it to live yeah.

Dr. Jernigan: – and helps us to really move that forward.

Dr. Gerberding: Thank you for your question.

Q: Thank you.

Q: Thanks very much. And, sorry, I have to move this down since nobody else in the panel is – in the – in the line is over six-foot. My name is Andrew Mack. I’m here representing BioSAFE Engineering, which is an Indianapolis-based company that deals with biomedical waste and the treatment of it.

And you talked an awful lot about trying to knock down an epidemic before it gets out of hand not just in the United States, but in other countries. One of the things that was really interesting to me, we’ve got a lot of best-of-breed technology coming out of the United States; one of the biggest challenges is getting it into the hands of people around the world so that we don’t – number one, so that we can track the data for sure; number two, so that we can prevent the spread – hospital waste, biomedical waste. When things start to go bad, you don’t want it to wipe out all of the herd in Botswana – one of our friends, right – or in Tanzania, or in any one of a number of countries where we have interests, both national security, biosecurity, and just friends of ours, right?

So one of the things that I didn’t hear was – we talked a lot about the challenges of finding budget. Obviously, it is cheaper so solve the problem at the source early by pre-positioning goods that will allow us to treat the problem, but I haven’t heard anybody talk at all about jobs and trade, and the fact that the United States is one of the countries that produces the best solutions for a lot of these problems. Perhaps we should also be looking to try to wrap in other parts of USG who are in the trade-promotion business together with what you’re doing and talk about that, because outside of the oozing-eye thing most of this I think really would have gone over the heads of a typical person who doesn’t have a lot of time or a lot of background in the field, and we want to engage the public. And a future risk is hard to engage them about, but current and future jobs are really easy.

Dr. Gerberding: Thank you. We’ll come back to respond to these, but let’s just hear the questions so that I can make sure we get them all out on the table.

Q: Hi. It’s Lena Sun with The Washington Post. I have two questions. One is very specific and one is more general.

The specific one I direct to Demetre and Dan, since you guys are supposed to be overseeing H5. Finally, there are some incentives put in place to encourage more testing of animals and workers, because, as we know, what we don’t know is how much of this virus is transmitting asymptomatically. How long do you think you would give it to see whether any workers take up your offer, Demetre, of $75? And why is it only now being allowed for farms with infected herds? Wouldn’t you want to know in some of these other states whether workers are – maybe also have antibodies? That’s the first question.

The second question. Thinking about November and thinking about a particular scenario, what kind of measures can you put in place now foundationally to protect CDC from some of the things that happened last time around? You recall that under the Trump administration, you know, there was all this funding cut for cooperation with WHO. I think it’s fine to have all these pillars and metrics, but it’s not going to mean anything if you’re not allowed to do that – do that work. So is there anything that’s being put in place now, if you can share in public with some specifics, other than collaborating with each other? Thank you.

Dr. Gerberding: Thank you.

Q: Thank you guys. Peter Kyriacopoulos, chief policy officer, Association of Public Health Laboratories.

Obviously, learning about the role and the importance of laboratories and data is just music to my ears. As we think about how we’re going to continue to tell these stories and connect dots, let’s remember that there are state and local public health laboratories that are very involved not just domestically, but globally. APHL has 50 staff in 10 countries that are helping to build lab systems through twinnings and global lab leadership. So, again, a fuller, more robust accounting of the role of partners, I think, is also going to be critical in telling this important story to preserve the funding and maybe, in future years, increase it. Thank you.

Dr. Gerberding: Thank you.

Q: Good afternoon. Nadine Gracia, president and CEO of Trust for America’s Health. Great to see all of you.

Henry, you noted in one of your responses – you spoke about the JYNNEOS vaccine and what was learned specifically in in the continent of Africa, what could then be applied in the United States, and making that connection between global and domestic preparedness and response. And yet you said that the story, though, is not being told. Could you share with us the approaches of how can we tell that story more? And is that part of the communications policy and diplomacy pillar? And perhaps elaborate on how that will be elevated to really speak about the stories that truly aren’t being told as much as they should be?

Dr. Gerberding: Thank you. So we have a good and robust set of questions. I think we can start with the first comment about the export of – you want to take that one, Demetre?

Dr. Daskalakis: So the export of the deferred – yeah. So I think that, again, part of the diplomacy and the relationship building is really about making sure that sort of we assess, as Kayla says, sort of what the gaps are, and then thinking sort of creatively about what our partnerships are. And so I think one of the really sort of exciting things about CDC is really the willingness to engage more deeply with sort of private entities. We’ve seen that a lot in vaccine. We’ve seen it a lot in other areas. So I think that as we sort of understand that sort of global situation and identify those gaps, like, those relationships that end up being important to leverage into those other spaces. So I think that the most important piece of that is, like, we hear you, and agree. Like, that that component of, like, our partnerships is critical, not only in our borders but beyond.

Dr. Gerberding: So you’re developing an intra-agency strategy to bring the CDC together in an integrated way. You’re working interagency across the USG to build those partnerships. But then there’s the intersectoral aspects of this, with private sector and a broader state and local public sector engagement. And then, of course, the international. So as is typical in public health, it’s a ripple of interrelated relationships. But clearly, the nongovernment sectors are going to be particularly critical here. And I would say, in an environment where some are non-supportive, shall we say, of spending taxpayer dollars in some of these areas, the ability to leverage private sector investments and private sector partnerships is going to be particularly strategic. So that makes sense to me.

So, Dan, questions about – from The Washington Post. You want to tackle those?

Dr. Jernigan: Yeah. I can try and address that. Just in terms of what might happen in November, really can’t speculate on what would happen at that time. But, you know, what I can say is that we really do need to focus on the core public health activity. I think that’s really what we’re trying to get at here, is what is it that we have to do? What is the important thing that protects Americans from these emerging threats? So focusing on those fundamentals, I think, is going to be key for whatever happens in November.

Dr. Gerberding: And do you want to comment on the personal protective equipment?

Dr. Laserson: The incentives.

Dr. Jernigan: That one’s –

Dr. Daskalakis: I can do that. So I think – so, first, thanks for question. So I think that –

Q: The question was not about PPE.

Dr. Daskalakis: Yeah. It’s about the 75 – the incentives –

Q: How much time would you need before you realized that it’s not going to work. If you think it’ll be spreading asymptomatically everywhere, by then it’s too late.

Dr. Daskalakis: Great. I think the most important sort of answer is that we’re not putting all of our eggs in one basket, which is, I think, what’s most critical, which is thinking not only about sort of the how can public health get there, but really also partnering with academic partners to see where we can get, if there are other strategies to sort of get to the same question. I think one of the sort of, I think, conversations up here has been that CDC is really excited to sort of have, like, lab support, even if we’re not the ones who are principally doing the labs. And so I think that we’re really sort of chipping at different sort of aspects of the problem.

Can we partner with academics, who potentially have better access? Can we work deeper in the One Health space with veterinarians, who potentially could ease access? And, yes, if necessary, how are we able to sort of provide some incentives? So I think, you know, we’re really looking to understand this, not only with, like, what’s happening today on a farm, but, you know, what’s happening sort of globally, sort of in that situation. And, again, it’s really about, like, what are the multiple mechanisms that we can use to get there.

And I think that in terms of how long? As long as it takes to be able to make sure that we actually get the data that we need and actually access for folks to be able to better understand what exposures are like. Because our goal is not only to sort of understand how this virus is moving, but also that we can give, like, appropriate guidance around how people can protect themselves. And we need that information to be able to sort of fill that out from the perspective of PPE, going back to that question, and other strategies. So, again, lots of different angles.

Dr. Gerberding: I would just also go back to the CSIS report, because there are some authorities that CDC does not have in turn terms of gathering state health data in the context of a public health event. In the public – a true, bona fide public health emergency, it gets a little bit easier, but not entirely. So we still have not accomplished those authorities that are on the docket and need to be addressed.

Henry, maybe you’d just like to comment on the importance of the APHL of engagement, not just U.S. but internationally, as part of our frontline of preparedness and –

Dr. Walke: For APHL?

Dr. Gerberding: Yeah.

Dr. Walke: Yeah, absolutely. When you said labs or music to my ears, I wrote that down. (Laughter.) So, you know, we appreciate the engagement among a number of different partners who are supporting our laboratory work overseas. Kayla and I actually were recently in the Middle East and actually met one of your – one of your staff there and learned about the work that was actually going on there as well.

But I wanted to also answer the question related to telling stories. And we need help, because we come at it from a public health standpoint. Of course, don’t you see, yeah, this is – this is wonderful. And we stopped the outbreak at its source. But converting that into a conversation, into a story, we can utilize the partners in this – in this room to help us. Also, potentially, there’s an opportunity to think more about that as a national security threat. You know, when we looked at COVID, for example, it wasn’t just about public health. It was about the impact upon our economies, for example, and impact upon, you know, our school children.

And so it’s framing this in – potentially in a in a larger context around the national security threat. And I think we’ve done some work in this space. We need to do more thinking about different types of communication, different types of audiences, and certainly across both aisles. But we could use help.

Please, Kayla.

Dr. Laserson: No, I was just going to add to that, and what Julie mentioned to us earlier in the earlier session. Just to build on that is we talk a lot at the level of the Hill and those sorts of stories. And we need those stories. But we also need to talk to the community, and make sure that our stories are actually reaching all ears and hit all the right tones for all the different audiences that we have. So we need that help, because sometimes it’s too technical, or sometimes it’s just not being heard. As Dan said, you think you’re saying what you think you’re saying, but you’re not being heard that way. So, again, telling our story to everyone is really important. And these outbreaks that we’re finding and stopping, it’s really important to everyone. But we have to tell the story better.

Dr. Jernigan: It’s also important to communicate the innovations that we’re having too. I mean, you and I were just in El Salvador where we were looking at Wolbachia, which is just kind of bacteria that you can infect mosquitoes and prevent dengue. That’s something that can be probably used in multiple places around the globe. But those are things that we’re doing that people probably just don’t know about, from that domestic to global sort of spectrum. Also looking at travelers genomic sequencing, where we’re taking wastewater from planes that are coming in from particular areas around the globe and seeing what’s in that wastewater to see if there’s something that we need to know about and see if it is coming into the United States. So with wastewater, travelers genomic sequencing, these innovations with – (inaudible) – there’s a lot happening that I think we can be communicating a little bit –

Ms. Laserson: Even that travelers genomic – you learned about COVID variants three, four weeks ahead of them being noticed actually in clinic settings, which is really a huge advance warning.

Dr. Gerberding: So we really need an inside story of CDC. (Laughter.) I’m serious. I mean, we really – in our public health system. Because this is a CDC issue, but it’s also a state and local public health issue as well. We just don’t have insight and visibility. When something goes wrong, it’s visible. But when something goes right or why something didn’t go wrong is really part of the story that never gets told. And yet, those of us who’ve been insiders know every single day something happens or doesn’t, because of the CDC work. So I think you’ve done a fantastic job of sort of presenting the framework for the strategy.

I’ll just go back to the CSIS statement. When we looked at the CDC and how we can help strengthen the CDC. And that really was, yes, the CDC is in peril. And there are things that the CDC must do. And those things are started and well underway. And it’s really encouraging to see the commitment and the effort, particularly in the global space. But I know there are other things going on, particularly in the data science space, et cetera. But there are also things that need to be done on behalf of CDC. And those of us who are here trying to be advocates for science-based policy and security-based policy, we really understand that not everything that needs to happen at the agency is within the agency’s control. And you need allies and advocates and people who can speak up and speak out about what a vital resource you are – not just a national treasure, but in my view a global treasure. And we all need to stand strong on your behalf.

So thank you for spending time with us –

Dr. Laserson: Thank you.

Dr. Gerberding: – and for sharing this next step. Appreciate it.

Before we close, I would really like to thank some people. First and foremost, Steve Morrison, who is the genius behind the CSIS Bipartisan Alliance for Global Health Security and has been a(n) incredible advocate for all things biosecurity, and particularly CDC. But I also want to thank Sophia Hirshfield, Maclane Speer, and Michaela Simoneau, who have been the people who have pulled this all together and guided us and put all my talking points together. (Laughter.)

So thank you so much for being here. I thank our audience and our advocates. And you know, stand strong for public health. Thank you.

Dr. Laserson: Thank you. (Applause.)