Maggie Fox to Peter M. Sandman and Jody Lanard, January 18, 2021:
I am writing a story on what CDC needs to do to regain public trust in talking about coronavirus. Would you all like to weigh in?
Peter M. Sandman and Jody Lanard to Maggie Fox, January 19, 2021:
The question you asked us is “what CDC needs to do to regain public trust in talking about coronavirus.”
We are talking here about one significant segment of the U.S. public. According to survey data, a very large segment of the public continues to trust CDC – not as much as their own doctors, but more than any other government agency. And a third segment (fervent antivaxxers, for example, and many people of color) never trusted CDC and will be very, very tough to win over.
But there is a crucial segment of the public that has lost trust in CDC directly as a result of COVID-19 events. This segment is crucial because it is attentive. It has been watching CDC for the past year, and what it has seen has aroused mistrust.
This attentive public is the “public” we’re talking about.
Regaining their trust is too ambitious a goal. We would reframe the task as earning a second chance – ameliorating distrust enough that people are willing to reconsider whether they see reasons to start trusting CDC once more.
To earn that second chance at regaining trust, we believe the CDC must first come clean about how it lost trust.
In particular, it must disavow the self-serving mantra that has insulated it from criticism, from self-criticism, and ultimately from a second chance: the mantra that CDC is a superb agency replete with world-class scientists who were thwarted by the monster in the White House from playing the role they had been preparing to play for decades, leading the battle against America’s worst public health crisis in a century.
There is some truth to that mantra. There are certainly instances where CDC’s world-class scientists were genuinely thwarted by the White House. Interestingly, most such instances are about CDC communications, not CDC science. The clearest example: After weeks of CDC compliant silence, on February 25 Dr. Nancy Messonnier gave an appropriately alarming press conference about the threat posed by COVID-19. President Trump was enraged. Thereafter, Dr. Messonnier and her colleagues spoke seldom and timidly. They were barred from the crucial role of media briefer that CDC typically performs so well in infectious disease outbreaks.
So yes, there is some truth to the mantra.
But most of CDC’s loss of trust has resulted from unforced errors. To earn a second chance, CDC must acknowledge these errors – which for the most part it has never done, at least never done vividly. It must apologize for them. It must diagnose why they occurred and propose a plan to prevent their recurrence. And it must ask the attentive public to look again, to give it a second chance to earn back their trust.
By far the most consequential of CDC’s COVID missteps was also the earliest. For crucial weeks in the spring of 2020, CDC failed to develop a usable test for the virus that causes COVID-19, leaving health departments with no way to track its spread. Worse, CDC had no Plan B to fall back on when its test development efforts failed, even though a very obvious Plan B was available: It could have licensed some other readily available test, such as the German test protocol distributed by the World Health Organization starting in mid-January 2020. And as far as we can determine, CDC never pressured the FDA to relax the rules that kept state and hospital labs from deploying their own tests, as many were begging to do.
CDC’s test was more sophisticated than the other available test protocols early on. Or at least it would have been more sophisticated if it had worked right – but it didn’t work right because of contamination. The simpler tests that much of the world deployed while CDC was still trying to fix its test worked reasonably well, especially compared with virtually no testing. But CDC didn’t want to settle for a simpler test, or anybody else’s test. It wanted its own test, complete with bells and whistles.
There wasn’t a whisper of political interference in all this. It was hubris, pure and simple. Political interference, in fact, was exactly what was needed – a politician to demand a simpler working test now and CDC’s bells and whistles be damned.
Several reporters have told this story, but it is a story CDC has yet to tell – a story CDC must tell over and over, with anguish and sorrow and embarrassment, if it is to earn a second look. Something like this:
Our lab work got sloppy. Our management got bureaucratic and ideological. We let the perfect be the enemy of the good enough. We lost the most fundamental understanding that guides any crisis management effort: In an emergency you can’t afford to dot every i and cross every t, and you succeed or fail based on your ability to decide wisely which corners you should cut and which you dare not cut.
Our test catastrophe wasn’t because of Trump. In fact, our biggest problem was just exactly the opposite of what everybody seems to think it was. We were too isolated from political decision-makers, stuck in Atlanta, some 600 miles from the White House. Decades ago somebody thought that sort of insulation would protect us from political interference. Instead, it isolated us. We had too few political appointees doing two-way communication between us and senior administration officials: telling us what the administration was thinking; telling the administration what we were doing, and why.
We were proud of our autonomy, resentful of any effort to boss us around. And it turned out we desperately needed bossing around on some issues. Or if not bossing around, at least dialogue, discussion, jostling out of our hermetic isolation. Yes, there are well-known examples of the administration tampering with our desire to put out certain information. But the worst decisions we have made during this pandemic we made alone.
Here are three more examples of some of those “worst decisions” that CDC needs to acknowledge, apologize for, and move beyond:
Masks.
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Worried about exacerbating the shortage of surgical and N95 masks for healthcare workers, CDC joined in the false claim – which it knew or should have known was false – that masks were useless to ordinary people worried about catching or spreading the disease. And in April 2020, when CDC finally turned on a dime, lurching from “mask-wearing is foolish and antisocial” to “mask-wearing is essential and obligatory,” it pretended that the turnabout was a response to newly available data that the virus could be spread by people who weren’t sick. The “new data” CDC referenced in April merely reconfirmed what was famously reported in February: case clusters in Singapore and Germany launched by asymptomatic or presymptomatic cases.
The politicization of masks has had many causes, but early public health dishonesty was the beginning of this sorry tale. And CDC’s failure to apologize is the continuation of this sorry tale.
As the pandemic matured and the virus spread, the need for detailed real-time data became critical – for policy-makers, healthcare providers, medical reporters, and worried citizens alike. CDC has almost always been the premier source of infectious disease data – fast, reliable, clear, and complete. (Only almost always. CDC was dishonest about the age-specific death rates from swine flu. It overstated the risk (and later the harm) from Zika transmission in the continental United States – first to help the Obama White House get more money out of Congress and later to justify how the money was spent.)
CDC collects COVID-19 data too. But several outside sources have become more prominent and more highly trusted. Where do you look if you want to compare the current or cumulative COVID-19 tallies for ZIP Codes, counties, states, or countries; if you want to know more about case counts, test positivity, hospitalizations, deaths, or vaccinations? You might be looking at the CDC’s COVID data tracker, but you’re probably relying more on the wonderful COVID Tracking Project, the Johns Hopkins Coronavirus Resource Center, Our World in Data, or the fairly new HHS hospital facility-level dataset.
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Though the vaccination rollout isn’t the disaster many people think it is, it is messy and frustrating and slower than ideal. One of the key defects of the rollout is excessively complicated, endlessly changing, and hotly debated prioritization categories. In late November, the CDC’s Advisory Committee on Immunization Practices recommended that the 53 million or so people 65 and up (the group with the highest COVID hospitalization and death rates) should be in the same vaccine priority group as almost 100 million people 18-64 with high-risk medical conditions – all of them in line behind about 87 million essential workers. That didn’t seem to match the goal of quickly trying to reduce deaths and relieve hospital overcrowding. The ACIP’s explicit rationale: Yes, the elderly were likelier to overburden hospitals and die, but essential workers were likelier to be people of color and were therefore especially deserving of protection.
This politically loaded emergency response aroused a lot of outrage. So in late December CDC came up with a compromise, prioritizing frontline essential workers and people 75+ over the remaining essential workers and people 65-74. Many states rejected that one too, and are vaccinating people based mostly on age. It was hard to follow the story of shifting vaccine priorities without reaching the conclusion that CDC and its ACIP were mired in ideological mushiness that interfered with clearheaded reasoning in a public health emergency.
Data collection.
Vaccine priorities.
There are other examples. CDC would do well to list as many as it can think of – and then invite its attentive and disillusioned public to add to the list.
In a nutshell, here’s what we think CDC needs to do:
- Own that it has earned mistrust by mishandling many aspects of the COVID-19 pandemic.
- Assert that its principal mistakes were its own, not forced on it by the President or the administration.
- Tell people what it thinks it did wrong, and invite others to add to the list.
- Say how sorry it is for these defects in its performance, how many deaths it knows it caused.
- Diagnose what elements of its culture led to these many mistakes – with an emphasis on too much hubris and too much isolation/autonomy.
- Prescribe how it thinks it can change to perform better in emergencies to come.
- Resolve to do better.
- Propose accountability mechanisms so others can track its improvement (if it improves), and invite suggestions for additional accountability mechanisms.
- Ask not for renewed trust, but only for a chance to earn back trust – only for a second look, however skeptical it may inevitably be.
The downside of doing this: Millions of people who haven’t been paying much attention and whose trust in CDC is high might overhear portions of our recommended mea culpa. This might lead them to realize for the first time how poorly CDC has performed through the first year of the COVID-19 pandemic.
There is always this collateral damage when an organization attempts to mend fences with a disillusioned public. The process strips some bystanders of their illusions. Earning back the trust of those who have been paying attention, in other words, endangers the unearned trust of those who haven’t been paying attention.
This is a price worth paying. Earned trust is the only kind that’s sustainable. And an organization that has forfeited trust must earn it back. The first steps are acknowledgement and apology – humbly asking disillusioned publics to give you a second chance as they skeptically watch you diagnose, plan, and finally implement your recovery.
Peter M. Sandman to Maggie Fox, February 17, 2021:
The January 19 email to you from Jody and me is still on-target, I think. And I’m still refraining from posting it in the hope that you’ll draw from it first.
But if I were commenting de novo this morning, I’d have something additional to say about CDC’s new back-to-school guidance and Dr. Walensky’s comments. Especially interesting: The six-foot social distancing recommendation, which the new guidance stresses heavily, is actually more a step toward closing schools than toward reopening them. There’s no way to keep students six feet apart without (a) building new classrooms and hiring new teachers or (b) settling for at most halftime in-person and halftime virtual instruction. President Biden stressed yesterday that “back to school” should mean five days a week, not one day a week as Jen Psaki had suggested. But the CDC guidance basically says five days a week won’t be doable in most of the U.S. anytime soon – not even in communities that are already doing it!
Also interesting: Dr. Walensky’s comments emphasized that CDC had developed the guidance after extensive consultations with stakeholders, with the teachers’ unions prominently mentioned. She said these consultations had meaningfully changed the content of the guidance. That doesn’t sound to me like CDC doing “The Science.” It sounds like CDC doing the politics. There are three possible roles for CDC vis-à-vis politics:
- CDC does science; policy follows science; politics doesn’t figure.
- CDC does science; politicians factor in the politics and reach policy decisions grounded in both – which means sometimes overruling CDC.
- CDC does its own merger of science and politics.
The first is a nonstarter, though scientists often claim it’s the goal and politicians often claim they’re doing it, “following The Science.” The second is the way things are supposed to work. The third is how Dr. Walensky’s comments on back-to-school came across to me – a potentially dangerous conflation of science with politics masquerading as science and promulgated as science. That’s no way to resuscitate CDC’s scientific reputation!
Also: When she was at Harvard, Dr. Walensky told Newton school officials that three-foot social distancing ought to be sufficient for primary students. Now she says six feet are essential – which constitutes a major barrier to school reopening. Rightwing media have covered this discrepancy more assiduously than mainstream media. As far as I know, Dr. Walensky hasn’t explained whether she changed her mind (and if so why) or others at CDC changed her mind or the unions changed her mind or what.
Maggie Fox to Peter M. Sandman, February 17, 2021:
I also notice CDC has not restarted regular media briefings. They are doing all briefings from the White House. What do you make of that?
Peter M. Sandman to Maggie Fox, February 17, 2021:
Before Biden’s inauguration, a lot of public health professionals said it would be a good idea for CDC to resume its accustomed central role as the key source for media information about infectious disease outbreaks. They predicted – in fact, they virtually demanded – that Anne Schuchat and maybe also Nancy Messonnier be reinstated as top COVID-19 sources.
That didn’t happen. It looked for a week or two like it might be happening. But for the most part it didn’t happen. And I don’t recall seeing many complaints about it (any, in fact) from public health professionals.
Once Biden was in office and had appointed several White House pandemic officials, it became clear that the White House, not CDC, would be the principal locus of media information about the federal COVID-19 response. CDC Director Rochelle Walensky has been fairly visible. The CDC’s experts in infectious diseases, pandemic management, and vaccination under her, not so much.
I don’t especially object to the White House being the dominant source of media information about federal COVID-19 policy – questions like how much stress to put on reopening schools, or what goal to set for daily vaccination totals. Policy questions should be addressed by policy-makers – and that’s the White House, not CDC.
But I would have expected to see a lot more CDC briefings on COVID-19 science – on what precautions are most effective in reducing in-school transmission, for example. And I’d have expected to see more CDC briefings on the sorts of response management coordination issues that CDC has traditionally headed up – what logjams are inhibiting COVID-19 vaccine administration, for example, and what measures might best relieve the logjams.
Maybe President Biden and the White House team figure that CDC’s reputational damage can best be repaired by a period of relative silence, lest it get enmeshed in pandemic-related controversies that it now lacks the stature to settle – and that trying to settle might actually worsen its stature. When I reflect on Dr. Walensky’s efforts to explain and justify the recent CDC back-to-school guidance, I have to admit I see some merit in that argument. The same goes for CDC’s earlier efforts to explain, justify, and walk back the preliminary decision of its Advisory Committee on Immunization Practices that vaccination priorities should rank antiracism ahead of saving the most lives.
Or maybe it’s the other way around, and simpler. Maybe the White House figures the COVID-19 news is good right now (vaccinations up, cases and deaths down) – and wants the benefit of sourcing good news to accrue to the President and his senior advisors, not to CDC.
Maggie Fox to Peter M. Sandman, March 16, 2021:
They promised to restore the CDC briefings but are these tightly choreographed White House things anywhere close to being a substitute?
Peter M. Sandman to Maggie Fox, March 16, 2021:
Under Trump, the White House COVID-19 briefings were far too undisciplined. Under Biden, they feel too disciplined – too structured, too predictable. The Biden team doesn’t make false claims as often or as spectacularly as Trump did. (It’s hard to refer to a “Trump team.”) That’s surely an improvement. What’s unchanged from Trump to Biden: The briefings seem dictated more by the White House political agenda than by new data.
What the CDC failed to do under Trump it is still failing to do under Biden: Give reporters easy, understandable, interactive access to new data and new recommendations based on the data.
A separate matter: The CDC is embarked on a concerted effort to clean up its reputation by repudiating some of what it said and did under Trump. CDC Director Walensky asked her top deputy Anne Schuchat to spearhead a “guidance review” of things it got wrong that it could credibly blame on political interference – that is, on the former president.
In an accompanying statement, Dr. Walensky said, “This agency and its critical health information cannot be vulnerable to undue influence, and this report helps outline our path to rebuilding confidence.”
I don’t believe the CDC can rebuild confidence by shifting blame. Many of the key things the CDC got wrong in the past year had nothing to do with Trump: the testing debacle, the mask debacle, the asymptomatic transmission debacle, the school reopening debacle, the data collection debacle, the vaccine prioritization debacle, and on and on. For people who were paying attention to these missteps, the process of earning back confidence begins with acknowledging responsibility.
Copyright © 2021 by Peter M. Sandman and Jody Lanard
