Central Problems of CDC Reform
Also, Public Domain Day and Danish Life
One of the things that this pandemic has made clear is how dysfunctional the United States’ public health system is. Making changes to this is starting to be called CDC reform, but policymakers need to look beyond the Centers for Disease Control and Prevention to all sorts of agencies if they want to grasp the scope of the problem. I don’t have a solution, but I have a list of problems that policymakers should think about when crafting reform proposals.
The US’s public health system is spread across three cabinet-level agencies and one independent agency. Most of it lives in the Department of Health and Human Services (HHS). The health functions of the HHS theoretically live in the Public Health Service (PHS) but actually are under the Assistant Secretary for Health. These are the CDC, the Food and Drug Administration (FDA), the National Institutes of Health (NIH), the Indian Health Service, and some smaller agencies. The PHS also includes the Surgeon General and the Public Health Service Commissioned Corps which seems to mostly exist to stroke the egos of political appointees and staff the Indian Health Service.1
Outside of HHS, there are several other agencies. Some environmental health functions are out of the Environmental Protention Agency. The Department of Defence conducts public health-related research through its labs and hospitals. A number of global health programs are run out of the State Department and the United States Agency for International Development. There are also two interagency public health groups: the President's Malaria Initiative and the President's Emergency Plan for AIDS Relief.2
With this many agencies and groups with overlapping missions, it leads to a lot of turf wars. One of the things that any plan to reform the US public health system needs to do is to force the various agencies to play nicely with each other. Much of this probably needs to happen by clearly splitting responsibilities between each agency.
The turf wars are not just domestic. The CDC and the World Health Organization (WHO) have a rocky relationship. Instead of using the COVID-19 testing regime that the WHO created, the CDC, in a blatant example of a culture of “not invented here”, trudged forward to make their own test. It did not work very well, but that didn’t matter, it was the CDC test.
The CDC’s desire for people to send samples to Atlanta that Scott Alexander picked up on but nobody else did is a real problem. My personal opinion is that the CDC sees themselves as the only competent people in the world. The agency’s dream would be for them and them alone to do testing because they know it will be done right. This also leads them to be, in my experience, something of an information black hole.
This is not unique to the COVID-19 pandemic. And the Band Played On: Politics, People, and the AIDS Epidemic by Randy Shilts shows that similar things happed a the beginning of AIDS research. The CDC and the NIH could not put their egos aside over who got credit for discoveries to work together to save lives. The US-based public health agencies had a hard time working with the France-based Pasteur Institute
The various public health agencies are subject to regulatory and political capture. At-home COVID testing is cheap and plentiful here in Denmark. A test costs 35 DKK ($5.25) and they are sold at every grocery and corner store. In the United States, there were only a few manufacturers that were allowed to make at-home tests until November 2021. Interestingly, two of the very few companies with approved tests previously employed the head of the office that approves tests. Who would have known!
Testing is not the only case of capture over the past two years. When the CEO of Delta asked for the length of isolation for COVID-positive people to be reduced from 10 days to 5 days the CDC did just that a few days later. In the first portion of the pandemic, the Trump administration interfered with CDC’s tracking and research into COVID-19 for political reasons. There is mounting evidence that the COVID-19 vaccine was pushed until after the presidential election in November 2020.
Research-first bureaucratic quagmire
While we think of the CDC as a public health agency, it is better to think of it, like the NIH, as a collection of academic research groups under federal patronage that also puts out public health advice. Joanna Masel had a good thread last week about working with the CDC.
Any public health reform proposal has its work cut out due to the wide array of issues. I am clear-headed about this. I don’t think any real reform is possible.
Much like the attempts to create The Department of Homeland Security and the Director of National Intelligence after 9/11, any reforms will be the equivalent of rearranging deck chairs on the Titanic. Each agency has its champions in Congress who will fight to make sure nothing changes; nobody wants to lose jobs in their district or state even if it would save lives. The plan was to create an American version of the British Home Office and head of the Intelligence Community. What we actually got was a new cabinet member and some minor reforms to agencies. We might see HHS split into two cabinet-level departments, but the bones of the system will remain unchanged.