RICK BERKE: Hello, and welcome. I'm Rick Berke, the co-founder
and executive editor of STAT. And I'm glad to be
here to moderate this important conversation. It's the first in a
year-long series of programs at the Harvard Chan
studio entitled, Public Health At the Brink. This could not be a
more timely moment to look at the
turmoil at the Centers for Disease Control
and Prevention. As many of you no doubt
know, late yesterday, CDC Director Rochelle
Walensky announced plans to revamp the agency and
hired an outside group to conduct a month-long review
to look at strategic change in the agency.
The collection of
individuals here to discuss the CDC and
the news yesterday is– I can't imagine a better
group or more qualified group. We have four former
CDC directors here. Let me introduce
them chronologically. Bill Foege led the
agency from 1977 to 1983 under Presidents
Carter and Reagan. Bill Roper was at the
helm from 1990 to 1993 under President
George H. W. Bush. Julie Gerberding was the CDC
director from 2002 to 2009 under George W. Bush. And Robert Redfield ran the
agency from 2018 to 2021 under President Trump.
Tom Frieden, who led the
agency for eight years under President
Obama, had a conflict and was unable to make
this live discussion. But he did send us a couple
of thoughts by video. Let's dive in right
away, initially with the news yesterday
from Director Walensky, who's looking at strategic
change in several major areas at the agency, from the
public health workforce to data modernization, to lab
capacity, to health equity, to pandemic response. Let me go around and just
ask you your initial reaction to this. And is it enough? Is it too much? What's your reaction? Who wants to go first? BILL FOEGE: Rick, I would
say it's very healthy to ask for outside help.
And I don't know if this
is going to be enough. I think there are
a number of things that should be looked at. I've been pushing for the
National Academy of Medicine to actually do something in this
area of asking the question, what are the skills? What's the knowledge we need? What is the technology? What's the science
that CDC needs to stay at the cutting edge? And so this may be a
beginning for that. So I'm all in favor
of looking for help. RICK BERKE: Dr. Gerberding– JULIE GERBERDING:
I can chime in. I really agree with Dr. Foege. I would also say that it's
important to not just have this focus on the CDC per se. Because what really, I think,
the pandemic has revealed to us is that our entire
public health system is in need for
some modernization and some additional support. So we need to really hear
from our local health officials, our state health
officials, territories, and tribes, but also our
schools of public health, which have to be a very important
part of the modernisation of the science and
bringing to bear the most emergent technologies
and sciences that we're going to
need to bring the agency into the next generation.
RICK BERKE: Dr. Roper. BILL ROPER: Yeah,
I was just going to agree with now my two,
soon-to-be three colleagues. There's nothing
to be lost, a lot to be gained with
inviting others to give input to the process of
reexamining the CDC's mission and organization
and work and so on. I think Dr. Walensky would
be the first to say not everything has been perfect. It's important to be striving
for improving things. The one caution I would
pose is this needs to be done as rapidly as
possible because, heavens, you can create a scope
so big and so complicated that we can do a 10-year
study, and it wouldn't really be enough. I think her calling
for a one-month review is a very smart idea. And I encourage this because
it will never be done. CDC needs to be
constantly reviewed, but it needs to get on. RICK BERKE: Dr. Redfield. ROBERT REDFIELD: Yeah,
my only comment, I'd agree with my colleagues.
I think it's really important
that our nation look critically at a proportional investment
in our public health capacity. As Julie said,
it's not just CDC. It's the entire public health
system of the United States. And I do think there's
real opportunity to get a much greater
proportional investment, as Rochelle commented, whether
it's data modernization, whether it's workforce capacity,
whether it's laboratory resilience, or whether
it's our global health pandemic footprint response. So the agency has
evolved over the years. And I would say one of the
most important missions that it has is public
health response. And to do that, there needs
to be a substantial increase in the investment strategy
that our nation has in public health
in this country. RICK BERKE: What you
are all describing is an overwhelming
challenge for the agency and for public health. And it's in intrinsic, systemic
issues across the board.
If you had to pick one
thing, where would you start? Dr. Foege, if you were
talking to Dr. Walensky, there's a laundry list of
things that need to be done. And as Dr. Roper said, it's
not going to happen overnight. It's a constant thing. But where would you start? BILL FOEGE: Well,
Rick, will you let me have two starts instead of one? One start is CDC has never had
national authority over what states do in public health. And yet we haven't
had the problems we're having right now. In the past, if there was even
an outbreak investigation, CDC had to be asked by
the state or a county or a city or a tribe to
do that investigation.
They couldn't just
go out and do it. And yet the system
worked so well that it was never
actually a problem. We didn't need more authority. Now the trust has been lost. And it's trust that holds
a coalition together. And so it's very important
to reestablish that trust. And I think if CDC would have a
series of meetings with health officers from states,
counties, cities, tribes, that they could come up
with, how do we seamlessly approach public health
problems in the future? So that would be one thing. The other one would be what
we've already discussed, that we have to review what we
need in the way of technology and science and information
for CDC to do all of this correctly. RICK BERKE: Dr. Roper. BILL ROPER: Yeah, I would make
a point that we could talk about for the full hour. But one of the most
important things to get clarified with regard
to CDC is, what is its mission? And I'm not so much talking
about the scope of diseases or ailments that are
considered, but rather what is it doing with
regard to science and politics and public health? And one of the things
that is frequently said, and I think meant
well when people say it, is we need to get the
politics out of public health.
That is never going to happen. That's, frankly, in my
view, a naive notion. We need science,
the best of science, to guide the decisions that
are made by political leaders to implement effective
public health programs. So we need a constructive
working together of science and the political process. And by that, I mean the best
of the way we make decisions in a democratic society. We need those two things working
together for public health to be successful. One of the things that has
been an issue of late with CDC is people have said it's
been too political or not political enough or whatever. And I think the best solution to
that is a recognition that CDC has not a political agency.
It is a scientific
agency just like the NIH is, but in a different sector
of science and medicine. RICK BERKE: Bill,
let me ask you, hasn't that hampered
the CDC in some ways? Based in Atlanta from
the very beginning, it's away from Washington,
away from– it's tried to be nonpolitical. But hasn't that cost it
in terms of influence from the various
administrations? BILL ROPER: We're never
going to redo what happened in the late 1940s.
CDC is in Atlanta, and that's,
on the whole, a good thing. But the issue of how is the
scientific advice from the CDC incorporated into the president
and his administration, and then interfaced with the
Congress and their guidance and oversight and so on, that's
a really important process. And I think the
issue that we face is not so much a scientific
question any longer. If I can be blunt about it,
it's our dysfunctional political system. And so the fact that things
are off in crazy directions, if I can be blunt about
it, is not CDC's fault. It's the political system. And so that can't be solved
by even the wisest people that Dr. Walensky invites in. My suggestion, I guess,
is to unabashedly say, CDC is a scientific
agency, and we will give the best
advice to the public at large, to the political
leaders at large, and then work with
them, one hopes, to have effective implementation
of those programs.
RICK BERKE: Let me
ask, Dr. Gerberding– first of all, I'll
give you a shot at saying the one thing that
you would address first. But before you do that, do
you agree with Dr. Roper that the CDC should
stay in Atlanta? If you could wage
your map [INAUDIBLE].. JULIE GERBERDING:
It's a moot point. It is in Atlanta. And it, I think, has made a very
good demonstration of the value in that location as
well as the challenges. To initiate a conversation
about moving the CDC would be a waste of
everyone's time and energy. It's not really
where it's located. It's how does it interact
with the Department, with the White House,
and with the Congress. And those are things
that, I think, all of us have solved in various
ways through the years. There's no question that those
relationships are important. But I'm not sure they're going
to be better or worse based on the geographic
location of headquarters. Now, with respect
to your question about where would
I start, I actually really agree with my
colleagues on this one. If I could add anything to that,
I would probably say, again, really looking at the
emergent sciences, and I include in
there data science, because I think that's a real
opportunity for the agency.
But I also don't want
to have our viewers left with the impression
that everything is broken at the CDC. There's incredible
science going on there. There is incredible evidence of
ongoing capacities in outbreak investigations, in chronic
diseases, environmental health, birth defects. So we have to be careful that
we don't paint the entire agency with a black brush
when, in fact, there are a lot of really
good things happening. RICK BERKE: That's a fair point. Dr. Redfield, what's the
single thing you would do? You talked about
data modernization.
Is that your primary– ROBERT REDFIELD: I think
it's a critical tool for CDC to have real-time data
that one can then execute a public health response. I think it needs to continue
to enhance its ability to be a public health
response agency. I know I always felt a little
embarrassed every night when I came home and
watched the nightly news. And it's nothing against
my father's alma mater where he went to medical
school at Johns Hopkins, but I always thought
it was bothersome that the data the nation
used to track the epidemic was from a medical
school rather than CDC. So I do think there's an
enormous need for CDC to be the hub of a public health
data modernization, which Julie commented is not just
the CDC public health data modernization. It's the whole nation that has
a real-time, public health data system that can be used
for public health response. I do think that's fundamental. Related to the Atlanta
question, one of the things that I do think CDC
would benefit from is to expand its
decentralization.
We have many people that
are CDC employees that are detailed to
different states, local, tribal, territorial
health departments. I think that it would be useful
to expand that public health workforce so that we have a
public health workforce that's pre-positioned
throughout the nation, and I would argue
throughout the world. That can be used for that
public health response. RICK BERKE: What's your response
to the question about the CDC is viewed as too political and
needs to move away from that? ROBERT REDFIELD: Well,
there's no question.
I agree with my colleagues. I agree with Bill. The reality is that public
health is always going to have a political tone to it. But I do think– this is where I
think– and we will disagree with some people,
Tom Friedman in particular. I think there's an advantage
to get the CDC director to be appointed similar
to the FBI director, where it's a seven- to
10-year appointment. I think there's an
advantage for that director not to have a response to
the Secretary of Health, but to be independent and to
be able to run that job, he or she, as they feel is
in the best interest. So I do think there's some
structural opportunities to help reinforce independence. Because the public health
advice that the CDC gives the nation has to be
independent of the politics. The politicians
will do what they want to do with that advice. But the agency, for credibility,
for the American public, has to be viewed as
politically independent. RICK BERKE: Dr. Foege, I
know you wanted to jump in. BILL FOEGE: Two quick points– this meeting on Zoom should put
to rest the question of where CDC has to be physically.
It just makes no sense
to argue that anymore. But I would like– the second point is to
totally agree with Bill Roper. Don't separate public
health from politics. Public health is totally
dependent on politicians. It's one part of
the medical system that has a single-payer system. And why? Because politicians decide
on the appropriations. Our question should be, how
do we incorporate politicians into the solutions so that
they really see themselves as part of the solutions
and not just the place that gives money? RICK BERKE: Thank you. Let's now talk about something
that Dr. Redfield just brought up about
confirming the position. I know senators in
both parties are getting behind
the idea of making the CDC director a confirmed
position by the Senate.
And I know in our video
conversation with Dr. Frieden, we asked him about that. So let's start the
conversation on that by listening to a clip from him. He takes a different
point of view than Dr. Redfield about the
question of a confirmation, confirming the CDC director. Let's listen to this. [VIDEO PLAYBACK] – Public reforms included in
the Bipartisan Prevent Pandemics Act are moving through Congress. And much of what's in the
bill is greatly needed. But there's also language that
would require that the CDC director be Senate confirmed
rather than appointed as is done now. Making this position
Senate confirmed would politicize the process
of naming a new director, with contentious partisan
debate delaying confirmation potentially in the middle
of a health emergency. There's also a risk
that people will be nominated not for their
technical expertise or ability to manage a public
health problem, but for their industry
or political connections.
Although intended to make
the agency more non-partisan, making the CDC director a
Senate-confirmed position would likely do the opposite,
and it's a dangerous idea. [END PLAYBACK] RICK BERKE: Let me hear
from the other three– dangerous idea. Dr. Gerberding,
what do you think? JULIE GERBERDING: I've
thought about this a lot, and I see both sides of it. But I have to say, net,
net, especially given, as Dr. Roper put it
bluntly, the complications of our political
system right now, I just can't see
that this is going to be part of the solution. I think it's going to worsen the
situation, not make it better. RICK BERKE: Dr. Roper. BILL ROPER: Yeah,
I tend to favor the notion of having the
Senate advise and consent to the appointment. There are some additional things
Dr. Redfield was mentioning earlier that might be
done like making a term appointment as is done with
the director of the FBI, for example.
But I think, like it or not,
the Senate confirmation process is a measure of the
credibility and importance that the Congressional
branch puts to the position. And I just find it an
anomaly that, for reasons that just are historical, we've
never caught up with the fact that the other counterpart
agencies within the US Department of Health
Human Services– the FDA commissioner, the NIH director,
the head of the Centers for Medicare and Medicaid
Services, et cetera– are all Senate confirmed. This one should be as well. Now if one wants to say, that's
a slow and difficult process, heavens, I agree. See what just is happening now
with Ketanji Brown Jackson. I'm not a defender of the
efficiency of the Senate confirmation process. But I do think it adds real
credibility to the person who is so chosen. RICK BERKE: Dr. Foege. BILL FOEGE: Well, I
served as CDC director for both President Carter
and President Reagan. It is possible to
be in this position and not have it be political.
I don't know the answer
to Senate confirmation, but I worry that it could be
a real problem in the future. So I think the Department– HHS has to totally depend
on the director of CDC. And I can see
problems if they don't feel that they can depend
on it, and that they have someone that's working
against their best interests. So my bottom line
is I don't know. I'm not sure whether this
is the right thing or not. RICK BERKE: Dr.
Redfield, let me ask you. The CDC– obviously, it's been
very turbulent, obviously, with the pandemic under your
tenure, in the current tenure. Did you ever have an
opportunity to give Dr. Walensky any advice before she took over
about what you experienced? ROBERT REDFIELD: Yes, I did.
I actually called her
to congratulate her when her appointment was announced. Like my colleague
Bill Roper, I told her one thing she wasn't
going to get from me was public criticism. I had the opportunity
to have a number of CDC directors aggressively
publicly criticize me. I didn't think that was
helpful to the agency. And I told her she wasn't
going to get that from me. And I told her to have
faith in her instincts. It's a great organization,
enormous number of men and women that
are really committed to the public health of
our nation and the world. And she should stick
to what she believed and not get pressured into
changing her point of view because somebody was
trying to convince her that there was a political
advantage to that change.
Just stay true to herself. I have a lot of confidence
and faith in her. And when people ask me to
criticize the CDC director, I step back and tell
them, one thing I know for sure, as the
colleagues on this call now, one of the hardest jobs that
I have ever had and probably ever will have was
being the CDC director. So great deal of
confidence in her. Complicated job, a lot
of political pressures on that job. She needs to stay true
to herself and continue.
And, hopefully,
the CDC directors that have come in the
past will be supportive and non-critical of her. RICK BERKE: Is there
anything that any of you could say given you've
all been in the hot seat in that job, anything you
wish someone had told you that had been in that
seat before you took over, something you wish
you had known? ROBERT REDFIELD: Maybe I'll
start since I was last.
I was really, obviously, honored
to be given the opportunity to lead CDC, which I do believe
is the greatest public health agency in the world. I will say that I was
shocked to see how under-resourced the agency was. And I give one example that
I've said publicly before. The first briefing
I asked for in April was a briefing on
opiate-related deaths. People know that one
of my six children almost died from cocaine that
was contaminated with fentanyl. Obviously, it was a big
priority for the president and the secretary. So I asked to be
briefed on that. And I had a great
briefing by real experts. We lost 80,000 people from
drug-related deaths that year. And when the briefing was over,
I just asked a simple question. What was the data through? And the briefer looked at me,
and he said, well, Director, it was through March 2015. And I said, but it's April 2018. And they said,
yes, but, Director, you don't understand the
complexity of gathering data from the states, making
sure it's curated. I did say– and this is why my
view on data modernization– I did say when I
came here, I thought I was going to be leading
the premier public health agency in the world
and that we were going to use data to make
impact on public health.
And what you're telling me
is I'm a medical historian. So I do believe very
strongly, the importance of modernizing our data system. So data comes in at a
time that it's actionable. And I think that was what I was
totally shocked by because I had idolized CDC for my
30-year medical career, thinking this was
the top of the top. And to find out
how under-resourced they are– this is
why I said to you, one of my most
important priorities is that our nation
invests proportionately to CDC and public health.
I personally believe that
our national security is much more impacted by the
capacity of our public health system in this nation than it
is by North Korea, Iran, China, or Russia. And yet we don't invest
proportionately to that, and we need to start to do that. And, hopefully,
Congress will finally look that this is an
agency that doesn't need $5, $8, $10 billion. We need three to five
aircraft carriers, and they need to
sustain that so that we can build a public health
system in this nation. CDC can clearly lead it. I have no doubt about that. But they need the
resources to do it. RICK BERKE: Dr. Roper,
I see your hand. BILL ROPER: I just would
say, I totally agree with Dr. Redfield's points. But I want to link
that back to something Dr. Foege said at the outset. To do the kind of modernization
that Dr. Redfield is calling for of the data systems
requires a basic change in the relationship
between CDC and state and local public
health departments.
For the most part– there
are a few tiny exceptions, but for the most part, the
information that the states give CDC– and that's the right
word– gives CDC– is up to their goodwill. And so until we have the ability
to do the kind of modernization you just heard about, we need to
face the question, do we want– and I sure hope
we do– do we want a standardized, nationwide
public health data system? If that's the case, then we can
get the smart people together and design it and
implement it across the 50 states plus the District and
the territories and so on. But until we get that,
in the current situation, every governor
can basically say, no, I don't think
we're going to do that. And that just blows
the whole thing apart.
We have to face
this issue of who is running the system, which
Dr. Foege started with. RICK BERKE: Before I
move on, does anyone– does Dr. Foege or
Dr. Gerberding want to answer the
question about what you wish someone had told you? JULIE GERBERDING: I wish I
had understood the resourcing of the CDC as well. And you look at the
number on paper. It looks, wow, that's
a great budget. We ought to be able
to do a lot with this. But, first of all, there's very
little discretionary funding. So the line item process
preallocates the resources that are coming to very
specific programs, which often are championed by people
who need that investment, but also by congressionals
who care about those issues.
I think the other
structural issue, other than the amount of
money, is the fact that when an emergency occurs
like we're experiencing right now, our Congress
has been incredibly helpful in appropriating
emergency funds. Those are one-time dollars. And you can't hire
people on them or really build and expand
the capacity of the system over time. Those monies go away as
soon as the crisis is over. And so we are left back
at the zero starting point again, where we really
don't have any capacity to continuously improve
both our bio preparedness, which I completely agree
with Dr. Redfield is a matter of national security. But we also don't really make
the sustained investments in health equity
and health impact that we need for the chronic
diseases and the other problems that people have. So we're basically operating a
CDC in a public health system right now that's funded
on a per capita basis less than it was in the
1950s in real dollars. And that just doesn't make
any sense in this day and age. RICK BERKE: Dr. Foege. BILL FOEGE: Two quick points. Number one, advice that I
got that was very valuable.
My predecessor,
Dr. David Sencer, let me know that every
place in the world is both local and global. Therefore, anyone working
on public health anyplace is working on global health. And the objective is
global health equity. And if you have that in mind,
it gives you a mission statement that you can proceed with. Number two, I
support exactly what the others are saying, that
the resources are always so inadequate except when
we have an emergency. And then you think– but it doesn't come true– you think it's going to change. Now we're going to get enough
resources to actually get an infrastructure.
But we're always beggars. And we know that poor
people think differently than rich people. And there's plenty of evidence
that we were thinking always like poor people. We were begging for money. We didn't have a chance to
say, here's the problem, and this is what it would cost,
and this is the infrastructure we have to go forward with. And people have
made the comparison that if you go 20 years at an
airport without an emergency, no one tries to reduce the
budget for the emergency services at the airport.
So why do they do
that in public health? Because we don't have
the same mentality. RICK BERKE: Let me
say, Dr. Frieden also has some interesting
comments on the budget or the lack thereof. And I want I want to run
that clip in one second. And then right after that,
we've gotten lots of questions from viewers. And I want to get
to as many of them as I can in our second half. And also you can type
any additional questions into the live chat on YouTube. And, again, I'll get
to as many as I can. But let's go right
to the Frieden clip, talking about his
approach to funding. [VIDEO PLAYBACK] – We have to approach our
nation's health defense with the same urgency we
approach our military defense. In peacetime, we don't cut
military and intelligence gathering capabilities
so that we're at risk. Why then are we starving
our health defenses when those threats are no
longer in the headlines? We spend literally
300 to 500 times less on our health defense than we
do on our military defense.
And yet no war in
American history has killed a million
people as COVID has in the past two years. If we had invested sufficiently
in our health defense, most of these deaths
could have been prevented. The HDO designation would ensure
that critical public health defense functions have
sustainable and sufficient funding, finally breaking
that deadly cycle of panic and neglect. [END PLAYBACK] RICK BERKE: One thing I want
to talk about on funding is I want to ask Dr.
Gerberding, during your tenure, you did try to tackle the budget
system to get both the CDC and state agencies more
flexible on spending, but it didn't succeed. Can you tell us what
happened and how you would advise the current
leadership to tackle the issue? JULIE GERBERDING: Yeah, it
was an experiment in a sense. After meeting with many mayors
and their health leaders as well as governors and
their health leaders, it became clear that the
way the CDC budget arrives at the state in several
different line items creates an administrative
inefficiency.
But it also means that
decisions about what gets prioritized
are really coming from the federal government to
the states rather than maybe the other way around, or
at least some negotiation on what individual states and
cities feel are the priorities. So we tried to create
a more flexible system where a state could establish
its health priorities. And then the CDC
dollars could be used to support those priorities
in a way that was still transparent and accountable. That was a great idea on paper,
and it received a fair amount of support from the state health
officials as you can imagine. But it set off some
alarms for the people who had worked really
hard to make sure that we had line item budgets
for certain disease categories. And so there was a tension
between what the states felt were important and what
stakeholder groups felt were important. And I think if we go forward
with this kind of notion, we're going to have to do a
lot more groundwork for so that there isn't an
either/or situation, but rather we come
together and agree on what the priorities
are, and then find more transparent
and flexible ways and accountable
ways to make sure that the right things
get funded from the state and local perspective.
RICK BERKE: Let me
throw in a question from a viewer named Nathaniel,
who asks, if the CDC gets more authority over states, can
or should the American public have greater oversight
over the CDC? How can we ensure
more transparency? Anyone want to tackle that? BILL ROPER: Well, CDC
is a federal agency. And the oversight
of federal agencies happens in a variety
of ways, including the media coverage, et cetera. But the official
way it gets done is the Congressional
oversight process. And, again, I would
just point out there's some problems
with the way oversight is undertaken these days and
the partisanship with which it is wrought. But I think there's
ample avenues for that kind of
transparent oversight if we just use them right. RICK BERKE: Speaking
of partisanship, we published an analysis
in STAT last summer that argued that we need to
invest another $4.5 billion, which would be $13 per
year per US resident to adequately fund public
health in this country.
If we think that that's
a reasonable investment, how could we break through the
partisan divide in Congress to make the case for this? JULIE GERBERDING: Can I
just add one point of view on this just for completion? I think we're talking about
public health as a cost. And how much do
we need to invest to accomplish
modernization improvement in our public health system? But we have to also think of
it as an investment in health, in health protection, and in
many cases in cost savings somewhere else in our federal
or state or local budget because of the tremendous value that
prevention, preparedness, and health protection
really creates for people.
One of the challenges
that we have is that prevention is
scored by our government as an investment that
has to be recouped in the same year in
which the money is paid. I don't want to get
into the complexities of the Congressional
Budget Office accounting. But we are not able to say,
if we invest x in, say, vaccination this year
down, the road we're going to save y in diseases
averted or cancers prevented, et cetera. The outyear benefits
don't really help in offsetting
the investments that are coming through the
appropriations process. So when Dr. Frieden was
talking about modernizing the way we invest in our
health protection system, he's really talking
about changing the rules so that that kind
of annual accounting could be more flexible and allow
for more sustained, regularized support. BILL FOEGE: Julie is
absolutely right in that this has to be seen as an
investment, not a cost. And one of the examples
of this is the US made an investment in
smallpox eradication at a time when we didn't
even have smallpox. But we were spending a lot
of money vaccinating people and treating their adverse
reactions from vaccination and so forth.
Our investment after
smallpox eradication has been recouped every
three months, which means that since
smallpox disappeared, our investment has come back
160 times what we put in. So if everyone understood
that was an investment, they would say, yes, that
was a great investment. And the same thing
with immunization, that for every dollar we
put into immunization, we get at least $10 back unless
we use this short-sighted way of saying the benefits
have to come back the year that you give the vaccination. RICK BERKE: Let me ask you– Dr. Foege, let me ask
you about smallpox because you did play a big
role in that eradication. And the pandemic
certainly showed us that disease does
not respect borders. Yet we still see many Americans
hesitant about spending tax dollars overseas. How does the CDC
balance the priorities between global and
domestic imperatives? BILL FOEGE: We have to see
ourselves as global health equity being our objective no
matter where we're working, and then balance it that way.
We should have been giving
much more vaccine globally at an earlier date with
coronavirus than what we did. Because it comes
back to benefit us if we don't have
new variants that are coming from Africa
and other places because there's so
much transmission. So we have to from the beginning
see we are involved in global health and that we cannot
walk away from that, that this is part
of protecting us. Now, Dave Sencer
at one point asked the question, how could
we improve global health from CDC's point of view? And the answer was, we
don't have a lot of money, but we have a lot
of good managers. And so we were willing at CDC
to put some of our best managers into places where global health
decisions were being made. So DA Henderson was at WHO,
heading up the smallpox program for 11 years. Most people don't know he was a
CDC employee that entire time. Rafe Henderson was head of the
childhood immunization program. He was a CDC employee.
Mike Merson was head of
the diarrheal disease program, a CDC employee. Jonathan Mann was working
on HIV, a CDC employee. This is the way we
contributed to public health and we protected the US. RICK BERKE: Let me ask
Dr. Gerberding a question from Selena at NPR,
which is, Dr. Gerberding, you led a restructuring
of the agency when you were director, which
was criticized by agency staff and reportedly negatively
affected morale. Do you have lessons
learned from that process to share with the
current director? JULIE GERBERDING:
Well, first of all, I think there's a lot
of emphasis placed on restructuring as a solution. And I'm not at all sure
that restructuring solves any problem in an organization. If you have the right people
and the right strategy, probably the structure isn't
the most important issue. For me, the restructuring
was primarily a consequence of the fact
that when I came into the job, I had way too many
direct reports. And I had to think of a
way to bring folks together in scientific units
that made sense. So the people involved
in chronic diseases were in a cluster.
The people in
infectious diseases were in a cluster, et cetera. And I think that the lack
of creating a burning platform, if you will,
for making those changes was a rookie mistake on my part. Because in order for
people to really not be fearful of a restructuring
and to move in that direction, they have to see
what's in it for me.
And I wasn't very good
at articulating that. I did find it somewhat
amusing that when it was all said and done,
and Dr. Frieden came in, he pretty much
ended up with a very similar organizational
structure, which just tells you that it isn't how people are
organized as much as it is having the right people
and, more importantly, making sure that everyone
understands what work needs to get done. So these are lessons
learned, I would say. RICK BERKE: Yeah, in
those lessons learned, is there a cautionary tale
for Director Walensky? Because she's talking
about restructuring. It's the same thing
that you've all tried. Is it futile? Is it– anyone? JULIE GERBERDING: Well, I really
wouldn't want to second guess what Rochelle is
looking at right now. A lot has changed at CDC
since I've been there. And I know from
conversations I've had with her that she's
very focused on the science and getting the science right.
So I suspect if she's
moving in any direction, it's really an effort
to try to understand how to accelerate progress
in the emergent sciences. And at the same
time, we're still in the middle of a pandemic. We can't forget that the CDC is
still in very operational mode. So it may very well
be an appropriate time to think about, are we
really organized in a way to continue what has
become a marathon? RICK BERKE: Right. Dr. Redfield, you were
looking to jump in. Did you have something? ROBERT REDFIELD:
Well, I was just talking about the importance
of investment in public health. I was going to add, when I was
able to be the CDC director, one of the things
that was clear to me was that we had
40,000 people a year, each year getting HIV infection.
But we had all the
tools to prevent that with
antiretroviral therapy, with diagnosis, with
treatment for prevention. And to try to begin to
work with OMB to let them understand that when you looked
at the 40,000 cases per year, over 10 years, $500,000,
$600,000, $700,000, $800,000 a person, it got
into enormous amount of money, a quarter to a half
a trillion dollars. It made a lot more sense
to invest in public health, whether that investment was
$100 billion or $200 billion, and try to help bring an end
to new infections with HIV. So I think it's so important,
as Julie pointed out, it's not about the cost.
It's about the savings. I would argue that, in general,
investments in public health have substantial savings,
not to mention the impact it has on the human condition. And, unfortunately, the
system, the way they do that, we were able to
get it through OMB when I made the arguments,
but it's complicated because they want to look at
everything on an annual basis. And I think there's many
ways that public health can generate substantial health
savings and should be invested. I think the biggest issue
that I will continue to say is that our proportional
investment in public health is just highly inadequate. And we need to think
about it like Tom said. I spent over 20 years in
the Defense Department. We need to think about it
proportional to our investment in the Defense Department. This is probably the greatest
threat to the United States in terms of our way of life. It is not our relationship with
North Korea, Iran, or China, or Russia. It's really the
pandemic potential. And the fact is
we're not prepared for that pandemic potential. Even if we can get
the science right, we don't have the
manufacturing capability to be able to develop
the countermeasures.
And we really ought to
really relook at the threats that we have in this nation
and make public health one of the major investments
that our nation makes proportional to our
Defense Department. RICK BERKE: Let me jump in
with a question for all of you about trust. Because it's something we're
hearing from a lot of– obviously, it's out there. We're hearing from
a lot of viewers about this on this question. And let me read one question
from a viewer named Tara, who says, as a journalist who
has covered public health, including the CDC for
well over a decade, I admit that I myself have lost
all faith in the organization and feel a bit like
I've lost my religion.
What do you think the CDC
can do and might actually do to regain the trust of those
who know the organization far better than average people and
yet feel completely betrayed by how the institution
has abandoned its mission of public
health in favor of promoting individual
health and responsibility? Pretty strong words, but
you hear them everywhere. Anyone want to weigh
in on that, respond? BILL ROPER: I just would
say a couple of things. But I wasn't sure what
that last sentence meant.
So that's why I looked
a little quizzical when you read it about
individual responsibility. RICK BERKE: Why don't we
drop the last sentence, but sort of the larger– BILL ROPER: Yeah. So trust is a big issue. Americans–
worldwide, people have lost faith in institutions. CDC is, unfortunately,
a part of that. Without criticizing–
and my colleagues have done this disclaimer. I'll do it myself. I'm not criticizing any
decisions recently made or done or whatever. But I think it's
important that each time CDC or any other health
official makes a pronouncement to say with humility, to use the
fancy word, epistemic humility, that we say, this is
what we know today. And this is our best advice
given what we know today. We may know tomorrow. And if it is different
from what we know today, we will change our
advice tomorrow.
But I think people are so
anxious for a pronouncement from on high that is
permanent and forever more. And that's just not
the scientific process. Now I'm trying to call up my
memory bank of famous quotes. But somebody, I
think in politics, once said, when the facts
change, I change my opinion. What do you do, sir? I think it was a
British statesman. But anyhow, that's
the process we use. And people should not
say, that's crazy, or CDC made a mistake, or
we can't trust them anymore. They should value
the humility that's demonstrated when CDC directors
and all the rest of us say, we're doing the best we can. When we learn more, it probably
will change our advice, but that's what we know today. RICK BERKE: So if someone
else could jump in and say, what needs to be done
to rebuild trust? What's the fastest–
is it doable? How do you do it specifically? ROBERT REDFIELD: One
comment I would make, I really do believe it's
so important to create the structure of independence.
This is why I have the view
that congressional approval of the CDC director is
a positive thing, not a negative thing. But I understand
the controversy. I do believe that the CDC
director being appointed for seven to 10 years
like the FBI director– the FBI director is not– his decision or
her decision is not dependent on what the
attorney general says. I think the structure
right now is complicated, where the CDC
director is reporting to the Secretary of
Health, who's deciding to weigh in on what happens. And then that's weighed
in on the White House. And there may be
a special advisor to the president on health
like we have right now. I think there has to be
a structural independence of the agency. RICK BERKE: It should
be moved out of HHS and be an independent– ROBERT REDFIELD: I
just think there needs to be structural independence. The FBI is in
Justice, but there's structural independence. And I do think
that we're seeing– I know I felt it in my term. I'm not sure my
colleagues, what they felt.
But I'm sure Rochelle
feels it in her term. There needs to be structural
independence for public health advice to the American public. RICK BERKE: So you
would stop short, or would you stop
short of making it an independent agency? ROBERT REDFIELD: To me, as I
said, the FBI is in Justice. And they report to–
they're in the organization under the attorney general.
But the FBI director
is independent. I just want to see the CDC
director be clearly independent in their decisions,
whether they're part of HHS or whether they're not. I think that's less important. What's important is that
they're independent. They're not having to
discuss their recommendations with the secretary and
have the secretary then modify what they want. They're not having to
discuss those recommendations with the White House and
have the White House. No, it needs to be an
independent agency. And the individual
is going to be in that job for
seven to 10 years. And they give the best
public health advice that they give to America.
I think it's the lack of
perception of independence that has undercut trust. RICK BERKE: Dr. Gerberding,
is that the biggest issue with trust, the
lack of independence? Or are there other issues? JULIE GERBERDING: I think
it's been an issue, especially in recent years. But I also think that goes back
to what Dr. Roper said earlier, that CDC needs to be presented
as the scientific resource in response to our public
health requirements. And I think it's helpful to
have that perspective emanating from Atlanta, not from
other political components of our government. I think it's helpful to have
that perspective articulated with the best
scientists in the world standing beside the CDC
director and offering their scientific
opinion and perspective. And I think it's helpful
to include the state and local public health
officials, who are also part of the recommendations
of the policy and the advice so that we are a public
health system responding to the science. Probably one of the
things that I'm secretly– I wouldn't say proud
of because that implies a lack of humility.
But one of the
inventions that occurred when I was the CDC director
was the frequent use of the word interim– interim guidance
for x, y, and z. And when we were
able to use the word interim in the MMWR guidance,
it implied that this is what we know today. This is what we are recommending
based on what we know today. But guess what–
these recommendations are subject to revision when
we know more and the science has evolved. And I'm happy to
see that continuing. But I think that's the
flavor of the message that we're all talking
about, that people can handle uncertainty
or ambiguity if they're told with humility
that that's what's going on. And they can
appreciate and respect that you're working as hard
as you can to get answers, but you don't have
all the answers yet.
So stay tuned. We'll update you tomorrow. RICK BERKE: Let
me ask Dr. Foege. You warned early in the
pandemic that the CDC was losing its credibility
with its reputation sinking from quote, "gold
to tarnished brass." Among the things
that frustrated you was that you felt
the agency had ceded its role as the authority for
credible, timely public health information to
pundits and academics. Do you still feel that way? How can the CDC
regain its authority? BILL FOEGE: Well, this is what
Dr. Redfield was talking about, having independence. And he was not allowed the
independence he needed. And he was being told by a
White House how to do things. And we've had 225 years
of modern public health since Edward Jenner
did that first smallpox vaccination in 1796.
And we've learned a lot of
things about how science works and the need for having truth
and the need for coalitions. And the avoidance of
certainty, as Bill Roper was saying, that we simply have
to avoid the idea of certainty. Because Richard Feynman,
the physicist was right. That is the Achilles' heel of
science, but also of politics and religion and
everything else. And we've learned over
the years that you have to do evaluation and keep
changing what you're doing, that you need to
respect the culture, that you have to combine,
as Julie was saying, the science and the
management in public health. You have to be working
with politicians. You have to have
a global response. And my feeling was that the
White House, the Trump White House, was violating every
one of those lessons learned. And so I came to,
well, there's got to be another lesson here,
which is lessons are useless if they're not regarded. RICK BERKE: Let me give Dr.
Redfield a chance to respond. Do you agree that the
Trump White House violated all those instances,
all those examples Dr.
Foege is mentioning? ROBERT REDFIELD: No, I don't. I was actually very disappointed
in Bill and his decision to publicly criticize
me fairly aggressively. But that's water
under the bridge. I can say I always fought
for the independence of public health. I'm not saying that people
politically didn't try to influence those decisions. I say, the one thing I've gained
by being CDC director for three years and the Trump
administration is every time that I go
through a airport now, I trigger the metal detector
because of all the shrapnel that's in my back,
even though I spent 20 years plus in the military
and never got any shrapnel, including Pakistan, Afghanistan. But I would say that
those of us at CDC strove to try to maintain
the public health message despite substantial pressure. That's why I feel firmly
about what I said here, that the agency would
benefit, future directors would benefit from
making the structure so it's very clear that it's
independent with a seven- to 10-year appointment.
It's not in any command
chain with the Secretary. So I did the best I could, as
did my agency when I was there to promote what we believe to be
the sound public health message and to promote that
despite others that may have other point of views
about what they wanted to see. It was disappointing that some
of my CDC director colleagues felt the necessity to publicly
criticize me in the news. This is why, with Rochelle,
the first call I made, I said she's never going
to get that from me. I'm 100% in her camp. I know it's a tough job. If she wants my
advice, give me a call. I'll give it. But I'm praying
for her every day to be able to lead
what I consider to be the premier public
health agency in the world.
I just would like to give
it the tools to do its job. And that tool most importantly
is the proportional investment that's required for that
agency to do its job. RICK BERKE: We just have
a couple minutes left. Let me ask you a couple
very quick questions. One is I'm wondering if this
mistrust goes both ways. There have been points
during the pandemic when we've heard that
the CDC has held back from releasing data
or guidance because it didn't trust the public
to understand and respond appropriately. Is that a problem? Anyone want to jump in on that? BILL FOEGE: Rick, let me
just respond to Dr. Redfield. I never did that publicly. It was a private letter
with no one else involved. I never even consulted
with anyone else. And it was leaked
from his office. So it was an attempt to give
him my private recommendation. RICK BERKE: OK, on the question
of mistrust going both ways, does anyone fault the
CDC for holding back? No one? No comment.
JULIE GERBERDING:
I don't think– I can't comment on that because
I have no information that CDC held back anything. I do think that it's
always a natural instinct to think, oh, boy, how are
people going to react to this? We better make sure we think
through how this is presented. But it would really surprise me
that information was held back because the public
might not respond in the way we hope they would. That's part of good
emergency risk communication is to know how to
present bad news in a way where you help people find
their way to do the right thing.
RICK BERKE: Final
question that, I think, looks to the future that
goes to this very question of independence or not and
politicization of the CDC. We've seen the Biden White House
take a much more active role in public health issues
that are typically reserved for the CDC
because of the pandemic. When do you all think it will
be time for the White House task force to wind down and
have those roles go back to the CDC control? And related to that, has the
White House's involvement been a help or a hindrance? Let's start with Dr. Roper. BILL ROPER: So rather
than answer your question, I'm going to dodge it this way. I think, in general, we have way
too many White House advisors on everything. Not just health and public
health and whatever, but there's a czar for
this and the czar for that.
What that does is
give the president, him or her, the ability to
turn to their right or left and have somebody tell
them what the latest is. But it also has the
effect of disempowering the cabinet Secretary, who's
in charge of Health and Human Services, and the CDC director,
who's the scientific agency director, et cetera. So having worked in two white
houses, Reagan and Bush, as the health advisor to
each of those presidents, I'm strongly in favor of
having many fewer White House staff doing these kinds of
supposed coordinating things. Because unless
you're very careful, the White House staff
ends up doing what they did in the Vietnam War. And that is selecting
the bombing targets and telling the generals
where to drop the bombs. That's just not a good
way to run a railroad. RICK BERKE: Dr.
Foege, specifically, should the White House send some
of these roles back to the CDC? BILL FOEGE: Absolutely.
I agree with Bill Roper on
this, that it becomes confusing because you get two
different messages. And if CDC has to be
checking the White House message every time, that
just inhibits good science. RICK BERKE: Dr. Redfield,
do you agree with that? ROBERT REDFIELD:
I agree with Bill. I think that the CDC director
ought to be driving the train. Very complicated during
my term with, obviously, the coronavirus task force. And then, obviously, very
complicated for Rochelle with now a senior medical
advisor in the White House.
I have a lot of
respect for Tony Fauci. But my own view is that
should be the CDC director. So I just think that we ought to
let the CDC director be the CDC director and lead this nation's
public health response. RICK BERKE: Dr. Gerberding,
what do you think? JULIE GERBERDING:
Well, I feel strongly that we do need a national
strategy for our health defense. And I believe that
strategic function is best compiled across many
cabinets at the White House level.
But the CDC is an
operating division. And it's the responsibility
of the operating divisions to operate. And so I completely
agree that the management of the execution of
the public health functions for this pandemic
or for other health threats really should be
left to the agencies. And we don't need all of
these complex coordinating bodies checkered
throughout our government. RICK BERKE: We're
supposed to end here, but I'm going to take a
minute and a half more, moderator's preference here. If you all can answer this
question in 10 seconds or less, and I'm going to go
around a lightning round. And if you can't do it in 10
seconds, then we'll skip you. And that is, what's
the one thing you would do to restore
public trust in the CDC? Dr. Foege. BILL FOEGE: I would try to
come up with more transparency so people see what is happening.
RICK BERKE: Dr. Redfield. BILL FOEGE: And get
people information fast, and that we avoid certainty. RICK BERKE: Dr. Redfield. ROBERT REDFIELD: I would just
say, structurally reinforce their political independence. RICK BERKE: Dr. Roper. BILL ROPER: Be more outgoing
and thoughtful and frequent with the communication
from the CDC so that people
understand the agency. RICK BERKE: And final
word, Dr. Gerberding. BILL ROPER: Communicate,
communicate, communicate. RICK BERKE: You guys are great. You all did it in less
than the time allotted. So that's wonderful. BILL ROPER: We've
had media training.
RICK BERKE: [LAUGHS] Right. Well, you have. Clearly, you've all
done this before. Anyway, I really think this
was a really thoughtful conversation. I hope Dr. Walensky watches
this because she could pick up a thing or two, I'm sure. And what's interesting to me is
not only your thoughtfulness, but your passion for the
agency and how most of you agree more than disagree
on most of these points. It's really helpful for
the public discourse to have this conversation. And I thank you
for participating. I thank all the viewers
for taking the time out of your afternoon
to listen to this and to offer your questions. I'm sorry I couldn't
get to them all. If you missed any
of this event, you can watch it on demand at the
Harvard Chan School's YouTube Channel. And you can also check out other
events in the Public Health On the Brink series at
HSPH.Harvard.edu/Brink. Thanks very much. Have a great rest of
the day, everyone..
