COVID-19 Was Always Going To Be A Struggle For The CDC

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The newspapers had been filled with bleak photo essays for months, but Dr. Sonja Rasmussen was still struggling to take the plunge and tell the world that the Zika virus was causing birth defects. It was 2016, and as the director of the Centers for Disease Control and Prevention’s division of public health information dissemination, she had to decide when there was enough evidence to prove that Zika was harming babies. She knew there was no turning back once she decided there was.

Like everyone else, Rasmussen had seen the heartrending pictures of babies with microcephaly, a condition in which the brain stops growing early, resulting in a smaller-than-normal head. She knew that thousands of babies had been born with this condition in Brazil, the epicenter of the Zika outbreak, compared with only 150 a year before. And she knew that Americans, particularly pregnant women, were scared — canceling travel plans as cases of the virus were identified in Latin America and the Caribbean.

To a layperson, it was easy to look at those media reports from the winter of 2015 and 2016 and assume that Zika was the cause of this and other permanent disabilities in children — and that everyone knew it. But Rasmussen, the expert, wasn’t as certain as the media narrative, even as the evidence mounted. She knew how science always contained nuance and how a risk of something bad happening was almost never 100 percent. And she knew that new evidence could easily turn a past warning into a false alarm. For the sake of the public’s understanding — and for the sake of the CDC’s reputation — she didn’t want to be too certain. “It was my job to waffle,” said Rasmussen, now a professor in the departments of pediatrics and epidemiology at the University of Florida College of Medicine and College of Public Health and Health Professions. “Saying something was definitely causing birth defects, I felt like I was truly jumping off the high dive headfirst.”

She jumped anyway. When she did, some scientists and journalists thought there wasn’t enough evidence yet and criticized the CDC’s hastiness. Others asked why it hadn’t gone public sooner.

That time, the CDC was right, and things generally worked out OK — Zika, by luck mostly, never gained a major foothold in the continental U.S., after all. But the CDC’s struggles with uncertainty, risk communication, public critique and public trust didn’t vanish when fears of Zika did. The past 18 months have made that very clear.

Public statements about health risks are themselves a risk — both for the agency making them and for the public that desperately needs information it can trust. It’s terrifying to think that the people who are in charge can feel disoriented and uncertain about the choices they have to make and the information they have to communicate. But it also makes what happened during the COVID-19 pandemic a lot clearer. We all watched the CDC waffle in real time on numerous occasions over the past year and a half. And more often than not, when the agency jumped, it crashed to the ground.

Why that happened, though, is complicated. The CDC itself didn’t respond to interview requests. Talking to people who have worked for the CDC and know it well, however, suggests that the agency’s problems weren’t some totally unpredictable anomaly — or purely the work of bad actors in the administration of then-President Donald Trump. Instead, we watched what happens when an organizational culture of caution meets truly toxic politics during an emergency. And the people I talked to said the same issues that have haunted the CDC in the past are still looming over its future.

Early in the pandemic, the CDC emphasized good hygiene over mask-wearing because the science hadn’t confirmed that masks were highly effective at stopping the spread of COVID-19. PAUL HENNESSY / NURPHOTO VIA GETTY IMAGES

THE MASK MUDDLE

The classic example of the CDC’s confused approach during the COVID-19 pandemic is the one that’s literally right in front of our faces: masks.

Questions like whether to wear them, what kind to wear, and when they matter have been a major source of conflict and contradictory information since the earliest days of the pandemic. In February 2020, the U.S. surgeon general famously pleaded with Americans to stop buying masks. The next month, the CDC issued guidelines for COVID-19 protections that made no mention of masks at all. Meanwhile, other countries’ public health officials were distributing masks or actively making them mandatory, and the Pan American Health Organization/World Health Organization recommended masks only for people experiencing symptoms of illness and their caregivers.

Even when the CDC did begin to recommend mask-wearing for everyone in early April 2020, a National Academies of Sciences, Engineering, and Medicine report came out less than a week later that found little evidence to support cloth mask-wearing as an effective way to prevent the spread of disease.

If it seemed as though no one knew what they were doing, that’s because no one really did, said Dr. Richard Besser, a former acting director of the CDC who sat on a subcommittee that prepared the National Academies’ mask report. Public health recommendations are built on scientific evidence, and at the time, there just wasn’t much research on the effects of community-wide mask usage or cloth masks at all, he told me. What evidence did exist wasn’t very promising — but that didn’t mean you could rule out masks’ usefulness. The Great Mask Debacle wasn’t an issue of who was telling the truth. It was an issue of there just not being much truth to tell.

A lack of guidance on mask-wearing from the CDC contributed to the novel coronavirus spreading unchecked in the early days of the pandemic. TAYFUN COSKUN / ANADOLU AGENCY VIA GETTY IMAGES

In a public health emergency, especially one involving a completely new virus, scientific evidence is going to be limited and what it tells us will change. The problem, experts said, wasn’t so much that there was uncertainty about mask usage — that kind of initial lack of data is par for the course in a crisis that involves a completely new virus. The problem was in how the CDC and other groups communicated about that uncertainty.

“It’s that, ‘Hey, we’re going to level with you that we don’t know,’ that’s really important,” Besser said. Foreshadowing the reality that information will change is something he himself remembered doing in press conferences during the 2009 H1N1 influenza pandemic. This time, though, he watched as the CDC first didn’t really talk about its own uncertainty and then slowly disappeared from press conferences altogether. “Then, when new guidance would come forward, it seemed like it was dropped from the sky. Because we hadn’t been brought along on that journey,” he said.

Besser was relieved that he was merely summarizing the smattering of mask data rather than trying to make decisions about what to do with it. The people on his subcommittee worried that a masking recommendation would send Americans out in public, perhaps inadequately prepared, at a time when they needed to just avoid other humans entirely. But the lack of a recommendation from the CDC early on, when other countries were already masking — or a clear explanation of why guidelines differed — helped set a tone, contributing to a larger zeitgeist of Americans being unsure whether the CDC knew what to do, or if it did, whether it would tell them.

That’s an effect we can see playing out in polling data. Morning Consult, for example, has tracked Americans’ net approval — that is, positive approval ratings minus negative approval ratings — of several government roles and agencies since the start of the COVID-19 pandemic, and while the CDC has remained the group with the highest net approval for its handling of COVID-19, the agency still lost trust during this pandemic. The tracking poll began on March 1, 2020, with a +63 percentage-point net approval and ended on June 20, 2021, at +37.

It’s an enormous drop, especially compared with public health agencies in other countries, such as Taiwan, Vietnam and South Korea, which gained trust during the COVID-19 pandemic, said Gil Eyal, a professor of sociology at Columbia University who studies the history and sociology of public health.

This finding is particularly significant because those countries’ public health agencies are based on the CDC. The way those other organizations are structured, the work they do, how they communicate with the public — everything about them right down to the name in many cases — were patterned on our CDC, according to Jennifer Nuzzo, a professor at the Johns Hopkins Bloomberg School of Public Health. For the CDC to lose trust as badly as it did when other countries were using the tools the CDC had left them to build trust in their nations suggests something must have really gone wrong.

President Trump’s administration pushed public health officials to the side throughout the pandemic. Outside experts say that a lack of visibility hurt the CDC when it needed to issue new guidance. JABIN BOTSFORD / THE WASHINGTON POST VIA GETTY IMAGES

POLITICS AND THE PEANUT GALLERY

Should schools be open? Should they be closed? In summer 2020, everyone had an opinion, and the CDC appeared to be caught in the middle. The American Academy of Pediatrics and the Trump administration pushed for reopening schools. Teachers unions pushed to keep them closed. There really wasn’t much evidence to prove what was safe until later in the fall, and in the meantime, public health experts, education experts and scientists debated on Twitter and in the nation’s op-ed pages. At first, the CDC’s guidance on what schools could do to reopen safely was influenced by and edited to conform to Trump administration priorities, resulting mostly in the same nonspecific advice it offered all public buildings plus a few administration-inserted reminders that reopening schools was important for kids. Later, when the agency included a safety checklist, the administration publicly criticized it as extreme.

How much of that school problem, and others like it, was attributable to Trump administration interference and pressure on the CDC is something experts don’t agree on. Some, such as Patrick McConnon, who headed up the agency’s Emerging and Reemerging Infectious Disease Program from 1994 to 2002, thought Trump was the main problem.

And, to be sure, the Trump administration did things that not only were well outside established norms but also undermined the CDC and the entire field of public health. For example, on April 3, 2020, while announcing the agency’s recommendation to wear masks, the president repeatedly emphasized that no one had to wear masks and explicitly said that he personally wasn’t going to wear one.

The administration also pushed for edits to the CDC’s Morbidity and Mortality Weekly Reports, long the primary means for communicating scientific data to other researchers and the broader medical community. These edits were political, designed to downplay the growing number of COVID-19 deaths and support decisions the administration had already made about issues like school reopenings. Emails revealed that members of the Trump administration were accusing the CDC of trying to make the administration look bad by releasing data disclosing the dire nature of the pandemic.

Those kinds of actions by a presidential administration were unprecedented. And they contributed to a loss of morale and a sense within the CDC that everyone just needed to keep their heads down and not make waves. But the political issues weren’t just about what the administration did — they were also about what it didn’t do.

By early March 2020, the CDC had all but disappeared from press briefings on the COVID-19 pandemic. No one in the Trump administration ever explicitly said that the agency wouldn’t be speaking to the public. But, quietly, that’s exactly what happened. By May 2020, the Union of Concerned Scientists could graph the disappearance of the CDC. And this was a completely different situation from what had happened in past pandemics, when presidents let the CDC take the lead.

At the same time, the Trump administration did not seem to facilitate communication between the CDC and outside experts — something the scientists I spoke to said had been the norm for past administrations faced with a public health crisis.

During the 2009 H1N1 pandemic, for example, the CDC had regular press conferences that involved briefing documents developed with outside experts, Nuzzo said. There was also a Team B — outside experts brought into the CDC to hash out the pros and cons of possible guidelines and decisions before they were announced. None of those things happened during the COVID-19 pandemic.

That had real consequences, said Dr. James Lawler, a director of the University of Nebraska Medical Center’s Global Center for Health Security, because the CDC is fundamentally an institution of academic researchers, not people with expertise in health care delivery and administration. Since there were no formalized systems for outside input, the rollout of monoclonal antibody treatments for COVID-19 was bungled, he said, as the CDC and Food and Drug Administration distributed those medications in ways that made it harder to get them to the right people at the right time.

“What people didn’t realize is the way you identify a potential person who would need the therapeutic, and give it [as] an IV infusion in an outpatient setting, is completely outside of how the normal workflow of health care operates,” said Lawler. This lack of expertise within the federal government made it extremely difficult to get lifesaving medications to patients who needed them.

The absence of press conferences and outside consultation left a vacuum that was filled by social media commentary, and that became a more important source of scientific criticism of the CDC’s choices. Take the debate over the CDC’s September 2020 statement that the novel coronavirus was airborne — information it then removed from its web page three days later. Social media was full of posts from different experts with different perspectives either critiquing or praising these moves. That way of debating science was to everybody’s detriment.

SCOTT EISEN / GETTY IMAGES

Twitter and other social media platforms brought conversations that had been done in scientific spaces into a very public, very contentious and very advocacy-influenced world. In that environment, disagreements could turn into virulent arguments, and some scientists took off their research hats and put on the mantle of hashtag activism, said Dr. Vinay Prasad, a professor of epidemiology and biostatistics at the University of California San Francisco. Prasad has studied the difficulty of changing medical advice to match new evidence, and he told me that social media battles and the way that medium hardened lines made it difficult for scientists to communicate about nuanced issues with one another and with the public. The evidence around a new virus is always going to change, and if people have come to the conclusion that they have to hold a hard line as being pro-mask in a world where the only other option is anti-mask, there’s no space left to talk about (or fund research on) whether masks are more useful in some situations than in others.

Public health has always been fundamentally political. But in this case, politics and social media helped fuel a real politicization of both the CDC and the information it produced. By fall 2020, views on the CDC and its leadership were splitting along party lines. In May 2021, there were visible partisan splits in both vaccination rates and understanding the CDC’s updated mask guidance.

So far, those splits aren’t huge or hardened, but we’ve seen regulatory science agencies — and the fields they study — quickly go from trusted bipartisan sources of information to symbols of political affiliation. The Environmental Protection Agency, for example, became politicized in the span of only a few years, beginning around 1990. That shift precipitated others. Over the past few decades, we’ve watched as the U.S. has gone from a reliable cosigner of international environmental treaties, ratifying protection measures easily, to a holdout country where environmental stewardship is seen as politically suspicious.

Suspicion of the CDC has made some Americans question how involved the U.S. should be in global public health. That distrust doesn’t go away with Trump out of office. Enough has happened that the era of the CDC being a trusted government agency even for people who don’t trust the government in general may be over.

After the CDC issued new masking guidance with seemingly no warning, businesses and governments scrambled to establish new rules. MICHAEL SILUK / UCG / UNIVERSAL IMAGES GROUP VIA GETTY IMAGES

MOVING SLOWLY TOWARD A SUDDEN DECISION

When the CDC changed its mask guidance again in spring 2021, the move came quickly. By then, evidence showed that mask usage prevented the transmission of COVID-19, and the CDC had recently reaffirmed its guidelines that everyone, vaccinated or not, should be wearing masks in most public settings. Then, on May 13, that changed. Fully vaccinated people didn’t need masks anywhere, the CDC said. There was little warning of this switch. Even the Biden administration appeared to be caught off guard. Multiple states dropped public mask mandates just as quickly, and the public — and the CDC’s public image — reeled.

It was another moment of chaos in a long year and a sign that whatever your beliefs about the Trump administration, its demise didn’t magically right the floundering CDC.

In fact, several experts pointed to this sudden shift as, ironically, an example of how the agency’s tendency to be slow and cautious was hurting its public trust. That’s because, while the decision came quickly, there wasn’t much new evidence to prompt it. We had known for months that vaccinated people were well-protected from contracting or spreading COVID-19. As with implementing masks — or describing Zika as a cause of birth defects — you could easily criticize the choice as both too fast and too slow.

“If it takes six months for somebody to say, ‘Vaccines are so good, you don’t need to mask anymore,’ you may start to wonder why they took that time,” Prasad said. “Was there any substantive new evidence? Or was it just sort of a reluctance to say what may have been initially unpopular but might have been right all along?”

The CDC’s risk aversion had complicated its messaging yet again. Most of the experts I spoke to also thought the roots of some of the CDC’s problems during the pandemic year lay in the way the agency wants to get things right and not deem science definitive too soon. “CDC is an extremely academic institution,” Besser said. “And in settings where science is incomplete, where we just don’t have the studies, the agency frequently finds it very hard to make guidance that is useful. Because if you don’t have the science, it can be hard to tell people what they want to know, which is ‘Well, how risky is this?'”

But what counts as enough proof? And what if the data never comes? Several researchers told me there hasn’t been the data collection necessary to understand which non-pharmaceutical interventions — masks, distancing, etc. — worked to reduce the spread of COVID-19, and under what conditions. Effective March 10, Texas became the first state in 2021 to abolish its masking requirements and other COVID-19 restrictions — at that time, only 11 percent of the state’s population age 16 and older was fully vaccinated. Recent preliminary research has shown that this decision neither improved the state’s economy (as politicians there predicted) nor increased COVID-19 case rates (as scientific experts feared). And no one knows why. This is the kind of question that experts said the data hadn’t been collected to answer. Without that, the public health community will be no better equipped to reduce uncertainty during the next pandemic.

“We did a hundred thousand different things to combat the virus,” Prasad said. “At the end of it, for [most everything], we will never have any more clarity. We will never know if, you know, we should have closed that mall in Vermont. And, to me, that is a type of science failure.”

This isn’t just a CDC problem. Evidence-based medicine in general can have a tendency to delay decisions and wait for more evidence despite no clear point at which the new evidence will be sufficient. There’s an idea that staying conservative is what preserves trust. But it’s not surprising to experts to see that idea backfire — it just shows that risk analysis is a thing that even scientists have a hard time coming to grips with. Scientists are, after all, people. And research shows that all people are uncomfortable with ambiguity. “People want public health, including the CDC, to tell them exactly what they can and cannot do, and that’s not possible,” said Saskia Popescu, professor of public health at the University of Arizona.

To not make the same mistakes in the future, the CDC needs better communication with more foreshadowing of the change that accompanies any crisis. It needs better mechanisms taking in advice and having conversations with outside experts. And it needs systems that can collect epidemiological data and start answering questions that will reduce ambiguity in the first place. Nuzzo suggested having a pot of money set aside for sociological and epidemiological research that could go through approval processes in advance of a disaster and be launched immediately when the conditions those researchers want to study happen.

We grappled with uncertainty during the COVID-19 pandemic — and in important ways, we lost. Now, as the crisis winds down, the CDC and the public health community will need to deal with that and change course. Otherwise, Prasad said, “I don’t think we’re any better-positioned for the next crisis, whatever that may be.”

Additional research by Mary Radcliffe. Art direction by Emily Scherer. Charts by Jasmine Mithani. Copy editing by Jennifer Mason. Story editing by Chadwick Matlin.

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