Experts hope the review will be a starting point for finding solutions to problems, many of which have plagued the agency long before Covid-19.
CNN  — 

As a sweeping review of the nation’s premier public health agency commences this week, interviews by CNN with more than a dozen people close to the US Centers for Disease Control and Prevention reveal an agency in need of serious changes to make it more nimble and ready to respond to the next pandemic.

The experts – current and former CDC staffers as well as outsiders who’ve worked closely with the agency – told CNN they hope the review could improve deep-seated problems that showed themselves in glaring ways during Covid-19, the worst pandemic in the United States in more than a century.

“At the end of the day, the killer thing here for me is the layers, the bureaucracy, the clearance, the process – it just takes way too much time during a crisis, especially when that crisis is moving at warp speed,” a senior federal official said.

That official and others described an agency in which scientists are smart, dedicated and hardworking but often siloed and hyperfocused on their individual projects rather than the larger public health picture, working within an inflexible budget that’s difficult to change quickly when a new pathogen emerges.

Last week, CDC Director Dr. Rochelle Walensky announced the review of the agency’s “structures, systems, and processes” to be led by Jim Macrae, a longtime employee of the US Department of Health and Human Services, with input from three senior CDC leaders.

“At the conclusion of this collective effort, we will develop new systems and processes to deliver our science and program to the American people, along with a plan for how CDC should be structured to facilitate the public health work we do,” Walensky wrote in an email to CDC staffers last week.

A senior CDC physician said the review would look at how the agency has handled the pandemic.

“How do we take the lessons that we’ve learned over the last two years and make sure that we don’t make any mistakes again, and make sure that we apply them well?” she asked. “It feels like we should codify, formalize, understand lessons learned over the last period of time, things that we did well, things that presented challenges so that we can learn from them.”

In response to a detailed list of questions, a CDC spokesperson sent CNN a statement that says, “Beginning April 11, Jim Macrae began a month-long process to engage with our CDC community – along with key external stakeholders – to help modernize our processes around developing and deploying the agency’s science. During this time, we will also conduct careful review of the agency’s overall structure and operations to ensure we are positioned for the future of public health, with a strong focus on the agency’s core capabilities – data modernization, laboratory capacity, public health workforce, health equity, rapid response to disease outbreaks, and preparedness within the US and around the world.

“The work we do will not only inform what we can do during a pandemic, but also what we do during normal operations to ensure our science reaches the public in a timely and implementable manner. The strength of this agency comes from the people who work at CDC. Since the director’s arrival, she has heard from many employees and external experts that they would like to see CDC build on its rich history and modernize for the world around us – this effort will lean into the hard work of transforming CDC for the better.”

Of the 16 people interviewed for this story, one is a senior federal official, one is a senior CDC official, and two are senior CDC physicians, and CNN granted those four anonymity given longstanding norms about government employees speaking to the media. The others were willing to be named: eight former senior-level CDC officials, including two past directors of the agency, and four outsiders who have worked with the CDC.

The senior CDC official said “data collection” for the review will take a month, and “synthesizing it and determining what the plan is” will take longer.

Whatever the timeline, a CDC review is clearly a complex undertaking, given the agency’s size and the breadth of its mission.

“It’s really hard to slice and dice an organization like the CDC to get everything into alignment,” said Dr. Nancy Cox, who served as chief of the CDC’s influenza team from 1992 to 2014.

Still, she and others hope the review will be a starting point for finding solutions to problems, many of which have plagued the agency long before Covid-19.

1. Get CDC scientists out of their silos

The CDC is huge: 13,000 employees spread across campuses in nine states and Puerto Rico, working in more than 10 centers – one for injury prevention, for example, and another for immunization and respiratory diseases.

“CDC is notoriously siloed in its organization,” said Dr. William Schaffner, a professor at Vanderbilt University Medical Center and a vaccine adviser to the CDC for 40 years. “Everyone is so involved in their own matters that there is very little cross-fertilization and conversation.”

“They care about their little potted plant, if you will, their budget line, and not about the broader public health issue,” said Dr. Tom Frieden, who served as director of the CDC from 2009 to 2017.

Cultivating one’s “potted plant,” as Frieden put it, might work when there’s not an emergency, but he and others say it hinders the agency when it needs to move quickly.

“I think [the CDC] is pretty good in peace time,” said Andy Slavitt, who worked with the agency as temporary senior adviser to the White House’s Covid-19 response team from January to June last year. But he said the agency needs “a less contemplative, more practical approach during wartime.”

Frieden and others recommended that the CDC send certain staffers to work in state or local health departments for a period of time because those offices are the ones that carry out much of the public health work during a crisis and receive about 70% of the CDC’s domestic funding.

“There are so few people who’ve spent a lot of time in the state and local, especially local and city health departments [and] that’s really quite a major issue,” said Frieden, who was health commissioner for New York City before he became director of the CDC.

Dr. Arthur Reingold, a former assistant chief of the CDC’s Bacterial Special Pathogens Branch, agreed that sending CDC staff to local health departments was crucial.

“I have worked in a local county health department. I have worked in a state health department. I have worked at CDC,” Reingold said. “Many of the people at the CDC, however smart they are, have never worked in a state or local health department. They’ve grown up, if you will, with the best academic training, [and] they’ve ended up at the CDC. They have expectations about state [and] local health department partners, but they have no experience working in those agencies and understanding the challenges and complexities that are there, and I think that perspective is badly needed.”

The senior CDC official said agency officials do go out to work in health departments “but not at the level that I think others would hope” and that structural changes would have to be made to allow it to happen more often.

“You can’t just pluck an MD from here and stick them there,” she said. “We have to create a system to make this happen.”

2. Practice for a pandemic

It was January 2007, and Dr. Stephen Redd, a retired rear admiral with the US Public Health Service, had never felt so grateful for an ice storm.

It was a CDC pandemic practice event, a military-like exercise in which, for 24 hours at the CDC’s headquarters in Atlanta, hundreds of staffers pretended there was a pandemic and played out what needed to be done to stop the dangerous pathogen.

The exercise went so poorly that Redd said he was relieved when an ice storm forced everyone to go home and end the exercise early.

“You could kind of feel the wheels were coming off the car during [the exercise],” he said. “We were not ready.”

When the ice storm hit, “I remember thinking that was good that we were able to stop the exercise because it was about to blow up,” added Redd, who worked at the CDC from 1985 to 2020 and served as the CDC’s deputy director for public health service and implementation science.

There have been many more pandemic exercises since 2007, and the agency’s readiness has improved over the years, Redd said. The senior CDC official said the exercises have continued during the pandemic.

Cox, the former CDC flu chief who spent nearly 40 years at the agency, said the exercises were helpful not just for the practice but also because they allowed managers like her to observe staffers and identify who worked well under pressure.

“You have to have a clear idea of how people are going to behave under a lot of stress, because a pandemic, especially one like Covid, is extremely high-stress,” she said. “Some people simply don’t work well under a lot of stress. You need to have a clear idea of how much of the firehose they can drink from.”

3. Learn to ‘keep it simple, stupid’

Improving the CDC’s communications was high on the list of every one of the 16 experts interviewed for this story. They said the agency must learn how to communicate with real people – not other doctors, not epidemiologists, not people with Ph.D.s in zoology or biostatistics, but real people.

A senior CDC physician said Walensky asked Macrae, the HHS official leading the review, to specifically address communications during the pandemic in his review.

“How did we handle things?” the physician asked.

For the sources interviewed by CNN, the answer was not well.

The senior federal official gave the CDC a grade of “D” for its communication during the pandemic.

“We weren’t nearly as consistent as we needed to be in both the timing and the frequency of providing information that the public needed,” the official said.

Several sources said it’s ironic the CDC had messaging problems during Covid, given that the agency taught the world how to communicate during a pandemic.

Starting in 1996, the agency published what is now called “The CDC Field Epidemiology Manual,” which has a chapter on communicating during an outbreak. There’s also the CDC’s “Crisis and Emergency Risk Communications” manual, which was first publishsed in 2002.

“It’s so odd, because CDC literally wrote the book on how to communicate in a health emergency – literally,” said Frieden, the former CDC director.

“I don’t know what happened,” added Dr. Sonja Rasmussen, co-editor of the field epidemiology manual, who worked at the CDC for 20 years, including as director of the Division of Public Health Information Dissemination.

As an example of poor communication during Covid-19, a different senior CDC physician pointed to “horrible” CDC messaging to immune-compromised people about how many vaccine shots they need.

The doctor treats immune-compromised patients who “didn’t get it” that they needed more shots than other people.

“It was just sh*tty. I have all these immune-compromised patients, and they didn’t understand it because we didn’t do a good job communicating it,” the physician said.

Many pharmacies also didn’t understand the CDC’s directive and turned away immune-compromised people who needed extra shots.

“This was a good example where we needed a spokesperson who could be all over the media and be on webinars with pharmacy organizations and Walgreens and CVS and explain all of this over and over,” the physician said.

When the CDC did communicate with immune-compromised people, it was often in technical and confusing language. In January, a CDC website for immune-compromised people stated, in part, “After completing the primary series, some moderately or severely immunocompromised people should get an additional primary shot. Everyone 12 years and older, including immunocompromised people, should get a booster shot. If you are eligible for an additional primary shot, you should get this dose first before you get a booster shot.”

Although that exact language is no longer on the CDC’s website, it still contains references to technical terms and includes no fewer than six footnotes.

“There’s this misunderstanding among CDC scientists sometimes that if ‘I write a document and po