The COVID-19 pandemic marks the greatest public health crisis since the 1918 influenza pandemic, with more than 1,000,000 Americans dead and more than one in three of those previously infected with COVID-19 suffering from long-term ill-effects. Historically, the Centers for Disease Control and Prevention (CDC) has played a pivotal role in planning for, participating in, or leading both domestic and international responses to disease outbreaks. Recent successes include responses to the 2001 Anthrax attack, the 2009 H1N1 influenza strain, and the 2014 Ebola outbreak. Key to historic successes in our country’s public health emergency responses has been a political understanding that public health security is national security.
The scale and scope of the COVID-19 pandemic has overshadowed past success and exposed longstanding challenges in the CDC, which functions as the US’s public health fire department. While the agency succeeded in creating a contact tracing playbook for local and state health officials and industry-specific guidance (such as for the meat and poultry industry), in other areas it has exhibited dual strategic and operational failures in launching a single channel diagnostic testing strategy and an inability to follow its own recommended best practices in crisis communication. These failures have resulted in conflicting messaging regarding non-pharmaceutical interventions, quarantine and isolation guidelines, and challenges with pharmaceutical supply chains.
Policy experts and stakeholders have proposed oversight boards, technology infrastructure, and increased funding. None of these ideas alone will work to effect permanent positive change ensuring that the agency can retake its place as the nation’s and the world’s premiere public health agency. With Democrats and Republicans calling for institutional reform, along with the current CDC director, there is an opportunity to constructively re-focus the CDC on its historical mission. Our nonpartisan group of public health practitioners, policy experts, and clinicians suggest a path forward. We propose a three-pronged strategy for supporting and reforming the CDC: a return to the agency’s founding mission, a tight focus on communicable disease policy and supporting programs, and a readiness-oriented staffing model built around a reinvigorated the US Public Health Service (USPHS).
Back To The Basics: Focusing The Agency’s Vision
Born out of the “Malaria Control in War Areas” program under the USPHS, the CDC got its start as the Communicable Disease Center in 1946. During the Korean War and heightened concerns regarding potential biological warfare, Dr. Langmuir established the Epidemic Intelligence Service (EIS) in 1951. The EIS served as the agency’s training ground for its legendary “disease detectives,” rigorously training clinicians and public health experts in epidemiology, disease investigation, and other tools. These experts still go into communities using “shoe-leather epidemiology” to investigate disease outbreaks.
Over time the CDC’s mission has expanded, with a 1992 rebrand designating the agency as the Centers for Disease Control and Prevention. Today the CDC is a vast organization, with the Office of the Director consisting of 10 direct reports, an additional center director, and four deputy directors, the latter of which represent a total of 16 centers. An unwieldy organizational structure leaves the director, a political appointee, managing 15 direct reports in an agency with a vaguely defined mission and a diffuse strategy. Recent legislative attempts at bipartisan reform highlight gaps in basic organizational performance, such as the need for a statutory requirement to write a strategic plan every four years.
As the CDC’s mission broadened beyond communicable disease detection, investigation, and outbreak control, it also expanded into areas such as non-communicable diseases, injury prevention, climate change, racism, and upstream factors affecting health. The agency was granted or assumed responsibility for all of these domains while also failing to effectively and efficiently fulfill its core mission during the greatest pandemic in a century. The COVID-19 pandemic was marked by a handful of public health successes, with the most notable being a product of the Department of Health and Human Services (HHS) in conjunction with the Department of Defense: Operation Warp Speed and the astonishingly rapid development of COVID-19 diagnostics, therapeutics, and vaccines.
Early in the pandemic, the agency struggled with basic data questions such as case counts, mortality, and demographic data. The Johns Hopkins University Coronavirus Resource Center stepped into the gap, providing critical data on case counts, hospitalizations, and mortality, and subsequent federal efforts centered around the HHS Protect Data Hub. While the CDC eventually reasserted its role in this critical public health response function, its early struggles highlight staffing and technical challenges, despite a decade of $300 million annual investment in federal, state, and local surveillance, and epidemiology and public health informatics on top of a separately funded Advanced Molecular Detection Program. In August 2021, in response to those and other failures, the CDC announced the creation of a disease forecasting center, a core function that spurred the agency’s creation some 75 years earlier.
As an agency that attempts to be “everything to everyone,” the CDC largely fails to fully execute many of its assigned missions. A well-known literature in corporate finance documents the “diversification discount,” which has never been solved in organizational design. The reasons for the discount are many, but chief among these is the loss of accountability, known as the agency problem, stemming from the collision of tactical goals and information asymmetry between the businesses and the corporate head office.
In the case of the CDC, multiple objectives mean that the agency does not have a clear set of consistent performance benchmarks against which it can be held accountable by Congress and the public. In times of relative calm, this problem manifests as a growing bureaucracy demanding increasing taxpayer dollars to stay afloat. During crises such the COVID-19 pandemic, the dangers in the CDC’s atrophied core are exposed, showing the need to return to a focused and nimble organizational structure. We propose that the agency refocus on its core mission: as a public health response agency focused on the detection and management of communicable diseases.
A focus on communicable disease does not discount other operational areas of public health, which lack the same level of urgency and immediacy. Refocusing on communicable diseases allows the CDC to function more as an intelligence agency, gathering data and advising, and to thrive as a disease monitor, data collector and integrator, and first responder. In this role, the CDC partners with and advises local and state first responders, the Federal Emergency Management Agency, and other HHS agencies such as the Assistant Secretary for Preparedness and Response and the Biomedical Advanced Research and Development Authority. Thus, the CDC reasserts its rightful position as the chief public health response and governmental adviser.
Structure And Function: Policy And Programs
The CDC was originally structured as a federal hub of consultants and specialists in communicable disease with field agents stationed in state and local health departments; this dual centralized and diffused structure facilitated the agency functioning as a first responder and early warning system for health crises and a hub for processing information and generating policy guidance. Moving forward, core functions should remain within the agency, including public health informatics focused on communicable diseases and early sentinel awareness. The agency should cultivate and maintain key contracting relationships with technology companies to support functioning as a data integrator of local, state, and federal information supporting early awareness, knowledge dissemination, and policy development.
The CDC should remain a principal public health policy adviser for communicable diseases, a role jointly removed and abdicated during the COVID-19 response. A focused mission would allow the agency to have a more responsive and meaningful voice while providing bandwidth to publicly exercise its statutorily endowed public health regulatory functions through rulemaking with notice and comment, building scientific consensus, and engaging stakeholders in real time. This would allow for a role in key policy decisions—such as public health masking in schools, a scientific question that unfortunately became politicized.
With a renewed focus as a public health first responder, the CDC should reform existing relationships with key local, state, and federal agencies and regularly liaise with key private-sector stakeholders, helping to insulate the agency from politicization. Cultivating a hub-and-spoke web of policy relationships would empower the CDC to target its public health police powers more rapidly and appropriately by receiving continuous feedback and escalating or de-escalating interventions as appropriate. This would help the CDC avoid such missteps as the eviction moratorium, a use of quarantine powers that was later struck down by the US Supreme Court. Given the shifting public opinion on the government’s endowment with and use of public health police powers, preserving the CDC’s regulatory functions through improved feedback mechanisms and integration of economics into public health policy is a necessary step toward regaining credibility with the public.
Other public health response functions require further buttressing. With the agency’s scope expansion, EIS officers have drifted over time away from investigating outbreaks into other functions such as chronic disease management, academic research, and grantmaking. A return to the basics of communicable disease management is required, with EIS core functions of outbreak investigations, advising local and state officials, and support for local and state epidemiology functions remaining critical.
Writing and effectively implementing a new and improved pandemic response playbook will require the partnership of other agencies at HHS, as well as the Department of Defense through the Assistant Secretary for Defense Health Affairs, and the Deputy Assistant Secretary of Defense for Chemical and Biological Defense, the Department of Homeland Security Office of Health Affairs, and the National Center for Medical Intelligence. Formalizing and strengthening these relationships, with the support of the executive branch, while building multilateral stakeholder coordination and data collection through local and state health officials will be critical for early detection and intervention in future communicable disease emergencies.
With large sums of taxpayer funds spread across a broad mission, the CDC has engaged in grantmaking, a function best left to agencies with the appropriate infrastructure and expertise. This endeavor has had questionable results, including a $6 million 2021 award to the American Hospital Association for a vaccine awareness program at a time when the Department of Health and Human Services lacked its own vaccine campaign, a stark contrast with successful polio vaccination program 70 years ago. Over the past decade, the CDC has spent more than $1.1 billion categorizing and combating chronic diseases with little success; the prevalence of diabetes and obesity rose from 9.8 percent to 14.3 percent during that period.
As policy makers seek to determine the best organizational structure and function for the nation’s largest public health agency, the CDC should undergo a holistic, external review by a congressionally mandated commission of civil service, private-sector, and public policy experts—akin to the VA Commission on Care or 9/11 Commission. The Commission should examine the efficacy of longstanding investments and whether the associated financial and human capital could be more effectively deployed elsewhere. Some CDC offices would be better situated for success located under the umbrella of other federal agencies. For example, the National Institute for Occupational Safety and Health could be paired with its regulatory partner, the Occupational Safety and Health Administration in the Department of Labor.
Versatile Staffing: Capitalizing On Existing Enthusiasm For Public Health
The COVID-19 pandemic has generated renewed interest in public health, with rising enrollment at public health schools across the country. At the same time, the CDC is experiencing a critical staffing and infrastructure misalignment, with a desperate need for technical staff and program managers, as evidenced by the agency’s use of fax machines for COVID-19 reporting despite more than $2 billion in public health informatics investment since 2014.
With estimates of the total long term domestic cost of the pandemic debated and as high as $16 trillion in economic activity, more than one million deaths, and more than 1.6 million Medicare hospitalizations, as of December 2021, readiness is no longer an abstract concept. Long recognized as an appropriate and necessary cost in the military health system, investing in public health readiness represents an important down payment to secure America’s future. The CDC will need to undergo a staffing transition to better facilitate the agency’s activation as a rapid response force in times of need. Currently, the agency is jointly staffed through the USPHS Commissioned Corps (5 percent), the federal civil service (56 percent), and a separate group of contractors (39 percent), with nearly 90 percent of staff working directly at CDC offices. Agency leadership is faced with two hiring models: a uniformed service bureaucracy and a civil service bureaucracy. While in times of calm, the latter is more cost-effective for many roles, the former is a theoretically more adaptive and responsive organizational model, which has unfortunately been allowed to atrophy. Currently, USPHS and civil service staff undertake similar roles and responsibilities, in contrast to the Department of Defense, where civilians serve to support the uniformed services in their military mission. We propose that the CDC transition to a similar model, wherein civil service staff would support an expanded USPHS.
A uniformed service with a storied history, the USPHS recently has been a target of cuts. The COVID-19 pandemic offers an opportunity to reassess and reinvigorate the USPHS to promote readiness, bolster the CDC’s public health emergency response functions, and grow the EIS. This would necessitate a holistic review of the USPHS, creation of new occupational categories, and expansion of the service—including providing existing CDC civil servants with the opportunity to join. An expanded uniformed service would provide agency leadership with the flexibility to rapidly train domestic and international investigators, reinforce the agency’s mission, and clarify the role of the civilian workforce.
A core component of the expansion of the USPHS and revitalization of the CDC includes the recruitment, training, and retention of a robust information technology workforce to serve as program managers, ready for rapid deployment to local and state health offices in a public health emergency. The now famous EIS model offers a framework to build such a program for recruiting recent computer science, informatics and engineering graduates for the USPHS, and placing them into roles to develop and manage a future public health informatics infrastructure through a combination of internally ideated and managed, externally executed information technology infrastructure projects.
Recommendations For Policy Makers
While the CDC’s failings during the COVID 19 pandemic are notable, this should not lead to defeatism. By refocusing the agency as a public health response agency, a reinvigorated CDC can again return to the forefront of public health policy and as a leader in public health emergencies. Policy makers will need to embrace the CDC’s role as a regulatory agency that follows standard administrative process and integrates input from a diverse group of stakeholders as it decisively and iteratively shapes public health policy.
As the US has suffered the consequences of insufficient public health readiness, readiness should be central to a retooled staffing model of the USPHS and the CDC. Using the uniformed service as a model will be critical; civil service staff should support the uniformed service mission, necessitating a combination of expansion, repurposing, and readiness of the corps.
Finally, supporting and reforming the CDC will require more than a month-long review by a small team of federal civil servants. A congressionally chartered independent and external multistakeholder review of the agency and the USPHS including input from diverse voices such as local, regional, and national public health experts, clinicians, business leaders, economists, and public policy experts will help guide the CDC and identify best practices. The CDC serves a critical public health need and has a bright future if we work together. The past two years should serve as a platform for building a better future to ensure that we are ready for the next public health emergency, as public health security is national security.
This article represents the views of all of the authors alone and does not necessarily reflect those of their institutions, employers, or affiliations. Dr. Miller reports receiving grant support from Arnold Ventures, the Mercatus Center, and the Charles Koch Foundation.