How has the CDC traditionally communicated with the public during outbreaks or epidemics? How does the current response compare?
There are few if any CDC “dictates” vis-á-vis the public health decisions of states and localities. For better or worse, the federal government has very little power over these decisions. The CDC informs, helps, funds, and advises – but governors and state legislatures, mayors and city health departments make the actual decisions. I see this local control as a feature, not a bug. The fact that different state and local governments respond differently to the same set of facts is the essence of our constitutional republic. Most of the time, state and local governments decide to do what the CDC recommends. The exceptions may turn out well or badly, and everyone gets to see what works.
When U.S. volunteers started returning from the 2013–2016 West African Ebola epidemic, the CDC recommended a fairly lax protocol to watch for symptoms of Ebola. Mostly, volunteers were instructed to “self-monitor,” and to notify the authorities if they started to feel sick. A few states took a more cautious approach. Most famously, New Jersey isolated returning nurse Kaci Hickox in a hospital for several days after a Newark Airport screening initially registered a fever that she insisted was illusory – and that indisputably turned out not to be Ebola. The controversy over whether returning volunteers should be quarantined became highly politicized. Most experts took the view that quarantine was unnecessary, arguing that volunteers could be trusted to recognize and report their symptoms and that they were extremely unlikely to be infectious before those symptoms began. The pro-quarantine position was widely ridiculed as right-wing unscientific demagoguery.
Interestingly, however, many hospitals and medical schools would not let returning volunteers return to patient care until they had been back and symptom-free for 21 days – a very quarantine-like policy. And the CDC’s recommended protocol for returning volunteers went through several revisions, all in the direction of greater caution. The CDC ended up with guidelines closer to New Jersey’s policy than to its own original lax protocol.
In short, local divergence from CDC recommendations is a right, a tradition, and a valuable source of new information.
Within states, the division of authority among state, county, and city varies. But more often than not, local health officials have enormous power – in an emergency, their power often exceeds that of the political leaders whose policy choices they are accustomed to implementing. Local health officials rarely use their power; they are more comfortable advising politicians than overruling them. But it might be worth remembering that they do indeed have power. In 1892 there was a cholera outbreak in New York City. The city health department head at the time (then called the sanitary inspector), Cyrus Edson, famously said that he had the power to seize City Hall and turn it into a hospital if he wanted.
In some ways, the CDC’s absence of power is a source of influence. Nobody has to resent the CDC for telling them what to do, because as a rule it can’t tell them what to do. So they can afford to follow its lead – which they usually do – without worrying about losing authority.
Let me be clear about this. State and local health departments usually do what the CDC recommends, but they don’t have to. They usually take orders from governors and mayors, but quite often they don’t have to do that either. The CDC, on the other hand, has a chain of command it must follow. CDC experts take orders from the CDC director, Dr. Robert Redfield. He takes orders from the Secretary of Health and Human Services (HHS), Alex Azar (an attorney). He takes orders from President Trump.
The bigger the crisis, the more political leadership weighs in. That’s true on every level, local, state, and national. In recent months I have had a couple of opportunities to remind state and city health department heads that they might have the legal power to overrule governors and mayors if they chose to do so. That would be a career-defining or career-ending moment, of course. But if they were convinced that the political leadership was underreacting to COVID-19 in ways that threatened countless lives, and if they failed to persuade the political leadership to act more urgently, they should at least seek legal advice on what their prerogatives were. I lost both clients.
On the national level, the CDC’s prerogatives are negligible. I have advised the CDC on and off since the early days of HIV. President Trump is by no means the first president in my experience to dictate national public health policy. Sometimes, as with Zika, the president was setting (and demanding) a more alarmist policy than most CDC experts considered appropriate. Other times, as with HIV at the beginning and now COVID-19, the president was taking a more reassuring stance than most CDC experts would have advised.
Over-reassurance is a much bigger threat to health, of course, than excessive alarm. The U.S. undoubtedly wasted money on excessive Zika precautions in the continental United States, which saw no cases other than travel-related cases in any state but Florida and Texas. By contrast, presidential nonchalance about HIV and COVID-19 was devastating.
In all of these cases, the CDC followed orders.
The alternative to following orders is to go rogue – and, presumably, get fired. Any CDC officials (or any other government officials) who believed the U.S. government was underreacting to COVID-19 were entitled to work within the system on behalf of a more aggressive policy. They were also entitled to quit the system and advocate publicly for a more aggressive policy. Which one they should have done is certainly debatable. Which one they did is obvious.
The main communication task of the CDC, in short, is to recommend what everybody should do – state and local health departments, hospitals, doctors, and the public. In ordinary times on ordinary issues, it has considerable autonomy over what to recommend. But on hot-button issues (and what could be more hot-button than a worldwide health crisis?), it must take its cues, and sometimes direct orders, from the chain of command – from HHS and the White House.
The CDC does its recommending through publications, especially its highly influential Morbidity and Mortality Weekly Report. It does it through its website. It does it through endless emails to lists of interested recipients. It does it through call centers on specific hot topics. It does it through webinars, conference calls, and other venues to keep clinicians up to speed. And it does it through press events, mostly via telephone.
All of the above except the last have been active throughout the COVID-19 crisis. The CDC has not gone quiet, in other words, except vis-á-vis outreach to the public via the media.
Has the CDC gone quiet internally? Opinions differ on whether the CDC exercises as much influence as it should when top federal officials are mulling COVID-19 policy. CDC Director Redfield says it does. Most others seem to think it doesn’t.
It is indisputable that the CDC shut down its COVID-19 media outreach. A list of CDC “Media Telebriefings” shows seven such events devoted to COVID-19 between January 17 and January 31; eight more in February; and three in March. The last one was March 10 – nearly a month ago … and what a month!
These 18 COVID-19 pressers were presented by Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases. Dr. Messonnier is the CDC’s top expert in respiratory diseases. Nobody who outranks her, either at the CDC or elsewhere in the federal government, can match her expertise.
I don’t have time and you don’t have space for a blow-by-blow account of Dr. Messonnier’s COVID-19 pressers. But three are worth memorializing.
For weeks, health experts at the CDC and throughout the federal government were getting more and more alarmed about COVID-19, and more and more at odds with President Trump, who was steadfast in his insistence that everything was under control. According to reporting in The New York Times and elsewhere, there was an emerging consensus that it was crucial to convince the president to be more candid – and thus more alarming – in communications to the American people, or at least to permit the CDC to do so. The decision was apparently to push the issue with him as soon as he got back from his February trip to India.
But Nancy Messonnier apparently jumped the gun. On February 25, just as the president was boarding Air Force One in New Delhi, she held the fourteenth CDC COVID-19 presser. Of all the CDC’s COVID-19 pressers, this one was the most alarming, the most human, and the most compatible with crisis communication best practices. Some excerpts:
The U.S. has been implementing an aggressive containment strategy that requires detecting, tracking, and isolating all cases…. But as more and more countries experience community spread, successful containment at our borders becomes harder and harder. Ultimately, we expect we will see community spread in this country. It’s not so much a question of if this will happen anymore but rather more a question of exactly when this will happen and how many people in this country will have severe illness….
I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe. But these are things that people need to start thinking about now. I had a conversation with my family over breakfast this morning and I told my children that while I didn’t think that they were at risk right now, we as a family need to be preparing for significant disruption of our lives.
In the wake of Messonnier’s appropriately alarming briefing, the stock market plummeted – or what passed for plummeting in those halcyon days. The president was angered, and the opportunity to convince him to take a harder line had been lost.
The next Messonnier presser I want to talk about was February 28, just three days later. Jody Lanard and I wrote a website column critiquing this one. Our title says it all: “Absence of evidence” portrayed as “Evidence of Absence.” We wrote:
Messonnier explicitly talked about the very few U.S. communities with positive test results as if they were the only U.S. communities with local transmission. She spoke as if “absence of evidence” of local transmission is “evidence of absence” of local transmission. There is absolutely no reason to believe this is true. Days before the first identified community case, we were getting emails from public health officials around the U.S. decrying the test eligibility and availability scandal, and saying they were virtually certain that community transmission was occurring in their locations. Dr. Messonnier claimed repeatedly that the risk of current, ongoing COVID-19 transmission is low in any community that has no positive test results. There is no way that she could know this. And it seems unlikely that she believes it.
The pretense that “absence of evidence is evidence of absence” is profoundly misleading and disingenuous since most communities’ COVID-19 test status is zero for zero. Zero positive tests, zero negative tests, zero total tests. For nearly all U.S. cities and towns, “no positive results” is the only possible outcome because there have been no tests.… You might as well say that the Lakers have scored no baskets so far, when the game isn’t until tomorrow….
Public health policy in the United States is set mostly by state and local officials. But state and local officials almost always follow the advice of CDC. Usually that is good advice. Today it is questionable advice: Continue business as usual until you get your very own positive test result.
It seemed like a chastened Nancy Messonnier had learned her lesson and was now hewing to the administration line. But in her final presser so far, on March 10, she was again sounding the alarm:
This virus is capable of spreading easily and sustainably from person to person based on the available data…. Based on this, it’s fair to say that as the trajectory of the outbreak continues, many people in the United States will at some point in time either this year or next be exposed to this virus and there’s a good chance many will become sick…. The highest risk of serious illness and death is in people older than 80 years. People with serious underlying health conditions also are more likely to develop serious outcomes including death.
I’ d like to go through our recommendations for people at highest risk. Make sure you have supplies on hand like routine medications for blood pressure and diabetes. And over-the-counter medicines and medical supplies to treat fever and other symptoms. Have enough household items and groceries so that you will be prepared to stay home for a period of time. Take everyday precautions like avoiding close contact with people who are sick, cleaning your hands often, and to the extent possible, avoid touching high touch surfaces in public places. Avoid crowds especially in poorly ventilated spaces….
These are the kind of recommendations that I have made to my parents and I’m taking the appropriate steps recommended for family members of vulnerable people. Other staff at CDC are doing the same.
That wasn’t just Dr. Messonnier’s last COVID-19 presser. It was the CDC’s last COVID-19 presser.
How much of a loss is that?
A CDC that disagreed openly with the president might have been useful. It might have given state and local health departments the cover they needed to push governors and mayors harder … or conceivably even to overrule them and mandate social distancing on their own. But that’s not how the system works. Arguably Nancy Messonnier did all she could along those lines. Arguably she did more than she could, which is presumably why there have been no more CDC COVID-19 pressers. (Tony Fauci of the National Institutes of Health is more skilled at walking this particular tightrope, and hasn’t fallen off yet.)
A CDC that convinced the president to get more worried sooner would surely have been useful. We have to think it tried, and presumably failed, for weeks.
Now that the president is more or less onboard with the idea that the COVID-19 pandemic is a serious threat to public health, the economy, and damn near everything else we hold dear, would it be useful to resume CDC pressers? Maybe. But the president is clearly enjoying his own televised daily briefings, and is not about to authorize any competition. In fairness, he gives a fair amount of time to Fauci and Deborah Birx, and sometimes others, to explain the various technicalities – mathematical models and all. Given the huge audience they’re getting day after day, it’s hard for me to think a couple of CDC telebriefings each week would add much. I wouldn’t object to them. But I’m not pining for them either.
And it’s worth noting that the CDC has lost a lot of credibility over the testing debacle. Its original mishandling of the test rollout was a fiasco – but any organization can have a fiasco. I see four aspects as unforgivable:
- Having no Plan B ready to go, as if CDC leaders never imagined that they might have problems with their test, or that they might need additional testing capacity even if theirs had turned out fine.
- Stubbornly refusing to seek out alternatives such as Germany’s test, which the World Health Organization had adopted, for crucial weeks, for no reason I can detect except organizational ego.
- Failing to blow the whistle on the Food and Drug Administration when it became clear that the FDA’s stubborn insistence on niggling regulations was keeping other labs, public and private, from rolling out their own tests.
- Never once to this day acknowledging and apologizing for the fiasco.
The first two are standard crisis management basics; the second two are standard crisis communication basics. The CDC went 0 for 4.
Add to this the CDC’s patent dishonesty about masks. First it falsely claimed that the public had no need for masks. It bolstered the claim by pretending that personal protection was the only possible reason “you” might want a mask, and not because “you” might be infected and might view the mask as a way to protect others. The CDC should have grounded its objections to public medical mask usage exclusively in the ghastly supply shortage, sadly and apologetically asserting that healthcare providers had an even greater need. Instead, it implied that people were idiots for wanting masks. And it explicitly worried that masks would give them a false sense of security (a point never made about handwashing) and that they would be unable to learn how to use masks correctly. Then after belatedly conceding that homemade masks made sense for potential source control, the CDC pretended that it had just uncovered new data about presymptomatic transmission that changed the science underlying its original contention that public mask-wearing was useless.
Given this record, I’m finding it hard to feel much conviction that putting the CDC back in the COVID-19 public communication spotlight will add a whole lot of value.
In the absence of much public communication from the CDC, it seems like there’s a lot of competing voices from states and other federal authorities. What are the consequences of this situation?
The conventional wisdom in crisis communication is that sources should work hard to centralize their messaging. The term of art is “speak with one voice.”
In 2006, I wrote a website column entitled “Speak with One Voice” – Why I Disagree. One of my reasons for disagreeing is this: When an organization forces a fraudulent public consensus on its staff, those who are required to hide their disagreement are likely to leak, leading to justified skepticism about the credibility of the majority.
Perhaps even more importantly, an organization that respectfully lets diverse opinions show teaches the public that the matter is debatable, and that the organization has welcomed robust debate before the leadership made the necessary decisions. Virtually everyone trusts an organization that has debated the tough issues more than an organization that has suppressed all disagreement – in spite of which, many leaders imagine the opposite: that visible disagreement undermines trust and enforced compliance builds trust.
An additional advantage of letting opinion diversity show: If you never pretended your original decision was a no-brainer, it’s a lot easier to change your mind if you turn out wrong.
One final rationale for my disagreement is that in a crisis people triangulate. Especially when uncertainty is high (as it obviously is right now), we gather information from a wide range of sources – official sources, web sources, friends and neighbors – and we look for commonalities. If several sources are saying exactly the same thing, obviously they’re working together, and we count them or even discount them as a single source. If several sources are saying roughly but not exactly the same thing, we begin to suspect that might be the truth.
So my advice to clients has always been to brief everybody – even outsiders, even dedicated opponents – so they all have access to the facts as you understand them. Then leave them free to interpret those facts however they choose. Some people will diverge too far and you’ ll wish they would shut up. They’re your proof that you really do tolerate robust debate. Most people will diverge on some points but converge on many. They’re your most convincing evidence that you’re probably right on those points of convergence.
This is what is happening, I think, with nongovernment experts – the epidemiologists, virologists, mathematical modelers, and so forth who are all doing their best to figure out how to transition from lockdown to some kind of New Normal. They disagree on many important points. But they seem to be approaching consensus on a few: Once the virus is spreading slowly enough that hospitals can cope, we will need to do a lot of testing; we will need to trace the close contacts of people who test positive and quarantine them; we will need to ask young and healthy people to return to work while continuing to wash their hands, stay six feet apart, etc.; we will need to keep the elderly and sick sequestered for longer, maybe for much, much longer until an effective vaccine materializes or we achieve herd immunity; and we will need to remain alert to the possibility of new waves forcing new lockdowns.
Insofar as there is real disagreement, moreover, it is better to let the public see that disagreement – and even participate in it – than to paper it over. A couple of months ago, the disagreement was containment versus mitigation. Then it was suppression versus mitigation. Now it’s how (and when) to ease our way back from suppression to some combination of containment and mitigation.
And throughout these past several months, the core disagreement has been saving lives versus saving the economy. This is a false dichotomy in some ways. (Deaths do economic damage too.) But it is a genuine dilemma nonetheless.
Moreover, it is not fundamentally a scientific question. It needs to be guided by science, obviously. But all that scientists can tell us – albeit with high uncertainty – is which pandemic policies are likeliest to save the most lives. That’s surely relevant, but not necessarily dispositive. People have always taken risks to achieve other goals. If this were an individual decision rather than a collective decision, what increased probability of disease and death would each of us accept in order to keep our job, our savings, or our home; or for our children and grandchildren to keep their educations, jobs, savings, homes, and prospects? What policy-makers have to decide, guided not just by scientists but also by the public, is what the tradeoffs are between saving the most lives and saving the most of our way of life. If anything, this hugely important question hasn’t been debated enough. I certainly wouldn’t want to see it debated less.
Would U.S. pandemic management have been better if the CDC’s voice had somehow become the dominant voice? Maybe. Nancy Messonnier on a good day would have been preferable in my judgment to President Trump on any day. But Nancy Messonnier on a day when she was hewing to the Trump line? Or her replacement on a day after she was relieved of duty for diverging too far from the Trump line? I’ d rather the country were listening to a cacophony of governors and mayors, health officials and academic experts, ferreting out the points of consensus.
That might be less true with a different president, but it would still be true.
For about six weeks in February and March, the U.S. government underreacted to the threat of COVID-19. So did most state and local governments. So did the CDC. More debate – not less – might have helped.
Are there examples of harm that could have been avoided or reduced with more clear communication from CDC (or more harmony among CDC and other authorities)?
The CDC should have warned that COVID-19 looked bad. When it did issue such warnings, it should have made them more dramatic. And it should have urged people to start preparing, both logistically and emotionally.
The CDC should have owned the testing debacle. It should have had a Plan B. It should have bought others’ tests. It should have pushed the FDA to relax the regulations that were inhibiting the development of alternative tests. Instead, it overpromised again and again, pretending a testing capacity it knew it couldn’t achieve. Did President Trump force the CDC to mislead the public? Was President Trump the audience the CDC felt it needed to mislead? I don’t know – but the testing debacle was a catastrophic, unnecessary crisis management and crisis communication mistake.
The CDC should never have attempted the “noble lie” that ordinary people have no use for face coverings. And when it finally abandoned that lie, it should have apologized, not pretended it was responding to new data.
None of these is an example of the CDC failing to communicate clearly. They’re all examples of the CDC miscommunicating all too clearly.
Copyright © 2020 by Peter M. Sandman
