A few months ago, I was one of several candidates under consideration for Director of the Centers for Disease Control and Prevention (CDC). While I did not make the final cut, I was honored to be considered for such an important position. The administration has nominated a highly qualified team to lead the CDC and I wish them well. The experience gave me the opportunity to reflect on what reforms I would like to see at the CDC as it faces a pivot point in the history of medicine and public health. Here are six themes that I see as most important and urgent.
- Develop a new ethical framework for public health practice. Too often during the pandemic, policies were justified by the intended effects with little attention paid to the means used to reach those ends. The Hippocratic Oath and its modern derivatives have served as that ethical framework for medical practice for over 2,000 years and they have made the health professions (until recently) one of the most trusted institutions in our society. Public health practice needs its own version and should adopt many of its principles, including:
- Respect for individual rights: The US just celebrated the 250th Anniversary of the adoption of the Declaration of Independence. America is the “Land of the Free and Home of the Brave.” Public health practice in the US must be consistent with our legal framework, traditions, and Constitution, including the Bill of Rights.
- Subsidiarity: Problems are solved best by those closest to the problem. This idea has already been espoused by the CDC in its new priorities statement. The US is a vast and diverse country with over 50 state and territorial jurisdictions, each with its own constitution and separate police powers. A “one-size-fits-all” public health policy dictated by Washington or Atlanta will rarely be successful. While some public health leaders lamented lack of uniformity in the Covid pandemic response, federalism served us well and allowed states with less restrictive pandemic policies to lead the country away from the worst of other states’ policies. The current US measles outbreaks have also demonstrated that local public health officials with local knowledge are better able to gain the trust of communities affected by outbreaks to bring them under control.
- Non-maleficence: Avoiding harm is a basic Hippocratic principle in medicine which was largely ignored during the pandemic. Former NIH Director Francis Collins has belatedly acknowledged that US pandemic leaders paid little or no attention to the massive collateral damage caused by policies focused exclusively on preventing every possible Covid infection. “First, do no harm” is a dictum which should apply to public health practice as well as medicine.
- Consideration of expertise of others: Public health is also public policy, not just science. A public health program must include expertise in economics, childhood development, psychology, and other fields which are not part of formal public health training. Dr. Fauci famously disclaimed responsibility for understanding the economic and social consequences of pandemic policies as being outside his field of concern. This attitude is not acceptable in medicine or surgery, where practitioners are expected to fully understand the consequences of the treatments that they recommend. It should not be acceptable in public health practice.
- Use of least restrictive means to accomplish public health goals. This is already an acknowledged principle of public health policy, but it was ignored during the pandemic in favor of a misguided “precautionary principle” and “swiss cheese-layered protection” approach that promoted maximalist policies in almost all circumstances. Restraint needs to be reapplied.
- Rejecting fear-based messaging. We recognize that manipulating patients through fear is unethical in the practice of medicine. It should be also in the practice of public health. Fear brings out the worst in human nature. While a public in the grip of fear may be more easily controlled and compliant with public health guidance, fear in the long run erodes social cohesion and trust in leadership. Good leadership inspires courage and fortitude. During the pandemic, some surveys showed that members of the public overestimated their own risk of serious illness and death from Covid by a factor of 100 or more, yet there was little effort to combat this misunderstanding. The CDC should lead with courage and confidence and never with fear.
- Acknowledging uncertainty. Science is not a set of immutable facts. Rather, it is a continuous and iterative process of hypothesis generation and testing to uncover truths about the natural world. All biomedical research studies in human subjects have flaws and limitations, and good scientists are careful not to draw overly broad or definitive conclusions, especially from studies of weaker design. When faced with uncertainty, public health leaders should always take the opportunity to say, “I don’t know, but here is what I think and why.”
- Renounce and combat censorship. For the public to trust statements of public health officials, they must believe that contrary viewpoints can be publicly expressed and debated in the marketplace of ideas. Suppression of those viewpoints by government actors may feed public mistrust and may suggest that they are receiving an illusory consensus and propaganda rather than the best available information. A previous administration embraced the dubious idea that “misinformation” was a “public health threat” and a “leading cause of death.” The new public health framework must treat contrary viewpoints with respect and encourage open dialogue.
- Free, voluntary, and fully informed consent for any medical or preventive treatment. This is a bedrock principle of medical ethics It must be reaffirmed in public health practice.
Accepting this new ethical public health framework should lead the CDC to renounce mass quarantine/lockdown as a tool of public health. While quarantine has long been accepted as a tool applied to specific individuals exposed to an infectious disease for a specific and limited period of time using the least restrictive means possible, it has never before been applied to an entire nation for an indefinite period of time. It is far too destructive, especially to the poorest among us, and it has proven to be ineffective as practiced in Western countries. It undermines public support for other necessary public health actions. Finally, even if it were theoretically effective, it is unethical under the new framework. In medicine, we do not perform unethical experiments on human subjects, even if they might “save lives.”
- Learn the mistakes of the Covid pandemic response. When practicing medicine, it is not considered acceptable to ignore mistakes and failures. We analyze and learn from them. In surgical and procedural specialties, we use morbidity and mortality conferences, in which we do an extensive review of each case that went poorly or for which an error was identified. When a series of similar complications emerge or there is a poor showing on a quality metric, we do a root cause analysis. The CDC can lead this process of reexamination of the Covid response through grand rounds and seminars. There is too little of this happening on university campuses. The CDC could set the example for how to undertake this kind of reexamination, opening the door for more open discussion and debate in universities and other scholarly venues.
- Embrace diversity in political viewpoints. A Washington Examiner column just before the pandemic showed that >99% of political donations from CDC employees went to one political party. That is a major problem. A CDC which is too biased toward one political philosophy or set of viewpoints will not be able sustain long-term public support. While 50% + 1 may serve as a successful formula for electoral politics, it is a prescription for failure in public health policy, which necessarily blends science with public policy. A public health approach which does not account for a range of political viewpoints will not be able to garner the broad public health necessary for successful implementation, particularly in times of crisis. CDC leadership must examine how certain political viewpoints have been systematically excluded from the CDC and the field of public health and work to broaden the base of political perspectives within the field.
- Improve the rigor of science and data quality. The CDC has a long and storied history and tradition of public health science, but this reputation was badly damaged by Covid pandemic guidance based on weak studies, speculation, and politics. This included arbitrary 6-foot distancing rules, cloth face coverings for small children, overly restrictive school reopening plans, unscientific eviction moratoriums, and advice on the conduct of elections. The CDC needs to rediscover the best of its scientific heritage and steer clear of policies based in politics and not science.
The CDC should take a leading role in overhauling the quality of evidence base for public health practice by calling out limitations of existing methods which appear designed to reach specific conclusions. Retrospective vaccine studies which do not sufficiently account for healthy vaccinee bias, fail to report clinically important outcomes, and lack sufficient negative controls may lead to erroneous conclusions that diminish public trust in vaccine recommendations. Randomized controlled trials of new modRNA vaccines have been marred by selective reporting of results, exaggeration of treatment effects, understatement of risks, and failure to include meaningful clinical endpoints such as total mortality, hospitalization, and net clinical benefit in total influenza-like illness. The CDC could take an important role in examining study design methods used to make important public health decisions, leading us to a more robust evidence base.
- Embrace nuance in public health guidance. The use of a graded class of recommendation and level of evidence is a standard practice for guidelines in cardiovascular medicine and many other medical fields. Recommendations are graded on their strength ranging from I – strongest, to IIb – equivocal. Recommendations are also graded on level of evidence ranging from A where there are multiple high-quality RCTs to C-EO which are based only on expert opinion. During the Covid pandemic, CDC guidance was overly dogmatic and prescriptive; one-size-fits-all. An action was either recommended or not, with no level of evidence given. While there is some value in simple clear messaging to the public, simplicity cannot come at the expense of truth. I have found in my own medical practice that patients can handle nuance and can be trusted to make prudent decisions, even when given conflicting information.
- Put infectious disease in context and embrace MAHA. In most years, infectious disease barely makes the top 10 causes of death in the US but plays an outsized role in public health policy and practice. The Make America Healthy Again (MAHA) movement has questioned a medical and public health establishment that has focused obsessively on the prevention of a few rare infectious diseases while largely ignoring environmental root causes of declining population health. Reconciliation can come through embrace of the key elements of the MAHA movement and incorporation into public health practice and CDC policy. Building a healthier population is an important component of pandemic prevention and mitigation. The CDC has an underutilized National Center for Chronic Disease Prevention and Health Promotion. The Center could be repurposed, reinvigorated, and redirected to facilitate this new preventive health agenda.
These are a few key themes for public health leaders at the CDC, schools of public health, and elsewhere to consider as we collectively strive to build reconciliation and recovery from the disastrous events of the past. Better policy must acknowledge past mistakes while striving to be forward-thinking and optimistic. I will be rooting for the new CDC leadership to succeed in this daunting and historic challenge.
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