The US taught the world public health. Now it's getting schooled.
CDC, started in the late 1940s as a way to combat malaria in the American south, quickly became the world authority on infectious disease.
- That authority is being put into question as the CDC fumbles its
- Business Insider spoke with several former CDC leaders and staff about the shift, and why it's putting the US woefully behind in its coronavirus readiness.
- Visit Business Insider's homepage for more stories.
When a new and mysterious virus emerged in the middle of China in late 2019, no one from the US Centers for Disease Control and Prevention was stationed there to investigate the outbreak.Since 2017, the CDC had slashed its China staff by more than half, from eight US disease experts down to three. Advertisement
"As soon as we're given the invitation, we are happy to do that," the CDC's Nancy Messonnier would tell reporters in mid-February, when asked whether the CDC was investigating the coronavirus outbreak in Wuhan.
"We haven't been invited yet."As the CDC waited, others around the globe raced to confront this new and troubling disease.
fumbled for two more months dispatching its own coronavirus test, delaying a rollout of flawed test kits to many US state health departments into March. By then, the virus had already been spreading for weeks, untested, across the country from Seattle to New York and Florida. Americans just didn't know it, because they didn't have the tests to show it. Advertisement
For two months now, the CDC has been silent at a time when the country has, arguably, never needed its guidance more. The US
This slow, unusually stifled, and seemingly flawed coronavirus response stands in sharp contrast to the lightning-quick speed the CDC mustered the last time a pandemic virus confronted this nation, and the world.
A quick federal response prevented the H1N1 virus from becoming deadlier than it wasIt was early March of 2009, when dozens of people in Mexico began coming down with a new and troubling viral illness, one with symptoms much like the novel coronavirus: A fever, a cough, and difficulty breathing. Advertisement
By mid-April, the virus had spread across that country, and into the US. Patients were severely ill. Some were dying. Laboratory tests confirmed this was a new strain of influenza that had hopped to people from animals.Advertisement
"I remember very clearly the phone call," Besser said. "The question I was asked was ... 'On a scale of one to 10, how concerned are you that this is a new pandemic?' And I said an eight. And she said, 'Alright, I'm going to notify the White House. And we activated the emergency operation center, and we're off and running.'"
It took the CDC two days to complete gene sequences of the H1N1 swine flu, allowing researchers around the world to study the new viral threat, and another two days to open the federal stockpile of masks, gowns, and antiviral drugs. In less than a week, the agency had developed an FDA-approved H1N1 test, which was shipped nationwide.Advertisement
The 2009 H1N1 virus would go on to kill hundreds of thousands of people around the world that year, but things could've been much worse if it weren't for that speedy federal response, as well as a stroke of good luck — that H1N1 wasn't as deadly as some previous pandemics, like the flu of 1918.The US response to swine flu in 2009 was textbook CDC, and it's what the agency had taught the world how to do well. It's the reason China, Africa, and Europe have each modeled their public health systems on the US CDC. But since 2009, as much of the rest of the world has raced to stay on its toes and prepare for the next unknown viral threat, the CDC has fallen woefully behind.Advertisement
The esteemed US public health workforce that once taught the world its ways has been pushed to the back of the class — a slip that has had fatal consequences for Americans in the coronavirus outbreak.
China, Africa, and Europe modeled their public health systems and pandemic responses on the US CDCThe United States was once at the forefront of teaching the world how to conduct life-saving public health. Advertisement
"There has been a deep scientific collaboration between institutions in the United States and around the world," Mike Ryan, Executive Director of the World Health Organization's Health Emergencies Programme, said during a
The CDC, originally called the "communicable disease center," and started in the summer of 1946, was initially tasked with the sole purpose of stamping out malaria from the southern US after World War II.But what began as an operation of fewer than 400 people equipped with trucks, shovels, and DDT mosquito sprayers in Atlanta, quickly became the top spot for disease research, prevention, communication, and surveillance, not just on the globe, but in the entire galaxy. Advertisement
The CDC helped NASA make sure it wasn't depositing Earth germs in space in the 1960s, and helped rid the world of smallpox for good in the 1970s.
In 1999, the CDC started what's now known as the Strategic National Stockpile of drugs, equipment, and vaccines for emergency health.Advertisement
China's CDC, started in 2002, based its entire public health model on the US system. The US CDC-China relationship dates back more than 30 years, with the US heavily involved in China's efforts to combat HIV/AIDS, promoting immunizations, prioritizing lab safety and quality, and developing a Chinese public health workforce.Africa's CDC officially launched in 2017, as the continent rebounded from a devastating Ebola outbreak. The US CDC had been instrumental in Africa's testing and treatment for Ebola. The Africa CDC now functions, much like the US CDC, as a hub for disease surveillance and preparedness across the African Union, fostering data and knowledge sharing between member states, strengthening public labs, and establishing research goals. Europe's CDC was created in 2005 in response to the global SARS outbreak. Though the US played less of a direct role in the creation of the ECDC, the agency fits the CDC's mold, providing data, advice, training, and field support across that continent. Advertisement
"The CDC way, the CDC model, has proved useful and has helped several other countries," Dr. Chima Ohuabunwo, a former US CDC Epidemiologic Intelligence Service Officer and assistant professor at Morehouse School of Medicine, said. "It's about the world's best."
One of the major early contributions the CDC made to global health was dispatching disease experts, like Ohuabunwo, to assist with outbreaks happening in other countries. Advertisement
"They are called disease detectives," he said. "Just like FBI. What FBI is to crime, that's what CDC EIS officers are to disease."
In addition to his work in the US, Ohuabunwo has tracked outbreaks in a handful of countries around Africa, and in Latvia."Across the world, we speak the same language, we understand diseases," he said. "That's telling you how much CDC has contributed to disease response globally."Advertisement
The US is getting schooled as COVID-19 scales the globe
The CDC has, until now, always been at the global forefront of diagnostic testing for disease outbreaks.It was the CDC that rapidly identified the dangerous pathogen at work in the 2001 US anthrax scare, the CDC that first lab-confirmed the swine flu outbreak in 2009, the CDC that lead Ebola testing in West Africa in 2014, and the CDC that played a key role in linking Zika to the birth defect microcephaly in 2016. Advertisement
"In past responses, it was providing the lab tests, not just for the US, but for the whole world, really, without a glitch," former CDC Director Tom Frieden said.No one suspected the CDC might be capable of messing up its COVID-19 test. But the agency did, by insisting on making its own test, as it always had. In March, CDC director Robert Redfield was still set on defending the "remarkable" rigor of the CDC's labs, when the agency had tested fewer than 2,000 patients. Advertisement
Meanwhile in Africa, the continent's 3-year-old CDC was busy hosting weekly webinars for clinicians on how to diagnose, manage, and treat coronavirus patients. Doctors share their best clinical practices for the novel virus with each other via WhatsApp.
"We knew that COVID-19 was a significant threat to Africa, so we started addressing it very early," John Nkengasong, director of the Africa CDC, said in a recent press release. "Because of the early political engagement there was a continent-wide awareness and alertness."Though it's still too soon to know for sure what the virus' final toll will be in Africa, the continent took a far more aggressive approach to locking down early, closing many national borders in mid-March, just days after the first confirmed cases surfaced in countries including Ghana, Kenya, Namibia and South Africa.Advertisement
It's not clear what, exactly, went wrong with the US tests, but according to the Washington Post there may have been some cross-contamination in the CDC lab — a clear violation of basic scientific diligence. Microbiologist Justin Kinney, who runs a molecular biophysics lab at the Cold Spring Harbor Laboratory in New York, called the CDC's lab woes an "amateur mistake."
"Absolutely, it delayed our ability to recognize that this virus was spreading," Frieden said of the US testing snafu. "In places where you don't have any cases, you need it to know when COVID's there."
Buoyed by its own success, the US has been whittling down its world-class public health systemAdvertisement
Scientists and public health experts have been warning for years that a dangerous virus like the novel coronavirus could be on the horizon."The world needs to prepare for pandemics in the same serious way it prepares for war," Bill Gates said in 2018. In the 11 years since the 2009 H1N1 pandemic flu, the US has done the opposite, whittling away at preparedness at every possible level. At state and local public health departments, roughly 50,000 jobs have disappeared over the past decade. Advertisement
"Basically, we took our public health army and disarmed [it]," Dr. Don Milton, a leading US virologist and environmental health professor at the University of Maryland, said of the trend.
Then, in 2018, the White House got rid of its pandemic preparedness team."So first we laid off the army, and then we decapitated ourselves," Milton said. "We're left totally naked and disarmed, defenseless." Advertisement
Finally, in July 2019, a key CDC epidemiologist working in China who was training public health workers to track, investigate, and contain outbreaks was axed, Reuters reported. She might've been acutely placed to spot the threat of the new coronavirus early on, but her position was set to be defunded in September, just a couple months before the first signs of the new outbreak began in Wuhan."If there's no pandemic, then everybody starts getting a bit relaxed," Michael Leavitt, a former Utah governor who served as secretary of Health and Human Services in the Bush administration recently told NBC News. Advertisement
"When there's not an alert, and people are not standing on the balls of their feet, anything you say about a pandemic in advance just sounds alarmist."
The US government's pandemic response capabilities have become 'fat and lazy'
There is something that threads together many of the countries that were ahead of the US in their COVID-19 response: They have more recent outbreak battle scars, which hotcoiled them into action.Advertisement
During an eight month SARS outbreak in 2002 and 2003, 386 people died in China and Taiwan, 299 perished in Hong Kong, and another 43 were killed in Canada."There's a lot of concern about emerging infections and about coronavirus now, a lot of caution," Ben Cowling, a professor of epidemiology at the University of Hong Kong's School of Public Health, said. In West Africa, Ebola killed more than 11,300 people between 2014 and 2016. Advertisement
Since the early 1900s, the US has, by contrast, been very lucky. The H1N1 outbreak in 2009, deadly as it was, lulled the country into thinking even a pandemic influenza is no tough task for the US CDC, and the SARS outbreak — with only eight laboratory-confirmed US cases — perhaps tricked the agency into thinking that coronaviruses can be easily contained.
"If you have not had any problems, then you're not challenged to think about new ways of dealing with them," former CDC EIS officer Scott McNabb, a professor of public health at Emory University, said. "So I think, in part, the US government — if I can say this crassly — has become fat and lazy."The CDC didn't even develop an Emergency Operations Center for health threats — whether they arrive by terrorism, influenza, or natural disaster — until after 9/11, when the agency realized it needed better systems in place to communicate during unprecedented events.Advertisement
"One of the most critical things is trust, and gaining trust of the public," Besser said.
"You do that by leading with
It's hard to be dynamic in an 80-year-old institution, especially after a decade of cutsAdvertisement
The CDC is getting old and rusty.
"The issue with the US is that we have a legacy system," McNabb said.The system is organized into silos: coronavirus experts work on coronaviruses, while flu experts toil in separate labs, largely walling off what they've learned from the past influenza outbreaks, like 2009's H1N1. They expected their tests would continue to be the best, no matter what kind of disease came their way next.Advertisement
"We just don't have our stuff together," former CDC EIS officer Dr. Rishi Desai, who's now the chief medical officer at Osmosis, said. "As a country, we have a remote history of doing it right, it's just right now we're doing it wrong."Some have also questioned the credentials of the CDC's chief, Robert Redfield, a Trump appointee who in the early 1990s created a wholly ineffective HIV vaccine. "He was just not a very good scientist," Peter Lurie, executive director of the Center for Science in the Public Interest, said.Advertisement
Though CDC staffers are typically not permitted to speak to the press, one 2018 poll of CDCers by the Union of Concerned Scientists found that 48% thought political interests were hurting the agency's ability to make science-based decisions.
The agency can't function when things get too politicalAdvertisement
The CDC is certainly not the only place to lay blame for a lax coronavirus response.
"In the early days of any emerging infection, what you don't know just far surpasses and dwarfs what you do know," Besser said. "It's a setting of uncertainty when everyone wants certainty."US intelligence officers had been tracking the threat of the novel coronavirus since November 2019, as ABC News recently reported.
But, despite being briefed earlier than most, Trump continued to downplay the seriousness of the coronavirus threat in the US into March.
The pandemic is now so political it is hard for the US to right its wrongsAdvertisement
Now is the time in a global public health crisis where the CDC would typically be front and center in the pandemic response, but the agency has not held a press briefing since March 9, and the White House Coronavirus Task Force that had largely taken its place has now also been silenced and pushed aside."If you can engender trust, that you're being transparent, you're being direct, you're not sugarcoating, but you're also not overhyping, you can get people to follow your lead, and do the things that will reduce the impact on themselves, on their families and their communities," Besser said. Instead, the advice Americans are getting from their government is erratic, highly political, ambiguous, and dangerous.Advertisement
"So it raises the question, whenever there's something brought forward, well, is this being done for public health reasons, or for political reasons?" Besser said. "And you shouldn't have people asking that."
McNabb says it's time to foster a more transparent, nimble outbreak response on every level of US government."I want CDC to do their very best and to maintain a sense of purity, scientific rigor, and selflessness," he said. "It's time to become lean and mean, self-critical, really try to make things better in the future."Advertisement
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