TThe US Centers for Disease Control and Prevention (CDC) was unprepared for COVID-19. After more than two years, it still isn’t. The CDC’s response to COVID-19 has been widely criticized as slow, confusing and mostly ineffective.
Now the agency is taking a long hard look at itself. On Aug. 17, CDC Director Dr. Rochelle Walensky proposed sweeping changes to how the agency communicates with Americans and publishes data — two of its most critical roles as the nation’s lead public health agency.
“I don’t think moving boxes around on an org chart is going to solve the problem,” she tells TIME of the changes she’s already started implementing. “What we’re talking about is a culture change. We talk about timeliness of data, reporting of data and policy guidance. Reorganization is hard, but I think this is even harder than that.”
The remodeling was months in the making. In April, a little more than a year after taking the reins, Walensky called for an agency-wide review of the CDC. While previous directors have ordered such reviews to evaluate CDC operations, this particular review was especially urgent because of the pandemic and low trust in the CDC after the Trump administration sidelined the agency, ignored its advice and at times contradicted its guidance. Walensky solicited honest feedback from nearly 200 staff, academics and other outside experts.
Walenski says the review, which has not yet been published, was sobering but not surprising. “To be frank, we’ve been responsible for some pretty dramatic and pretty public mistakes, from testing to data to communications,” she said in a video message to CDC officials that TIME saw.
Here’s what Walenski says went wrong — and how she plans to improve the CDC.
Need for more agile data
CDC “was built on an infrastructure of academia,” Walenski says. Until COVID-19 forced the agency into the spotlight, CDC’s target audience was primarily other public health experts and academics, and its primary mode of communication was through the periodic publication of scientific papers. “In these times of a pandemic, we’ve found that we need to speak to a wider audience,” says Walenski. “We didn’t have to convince the scientific public — we had to convince the American people.”
Americans wanted timely and accurate information about how to deal with the new virus. But since the beginning of the pandemic, the CDC’s advice has seemed confusing and often contradictory — especially about how the virus spreads, who must wear masks, and what types of face coverings are most effective. The agency has also been slow to provide critical information about how contagious SARS-CoV-2 is. “We all didn’t like the headlines, especially when we knew all the good work that was being done,” Walenski says of the media coverage of the CDC’s missteps. “So how do we deal with the challenge of what people say about us?”
Walensky says he’s now pushing for the CDC to collect and analyze data in a more streamlined way to turn that information more quickly into actionable advice. During COVID-19, researchers began to rely more on preprint servers, which published scientific research on COVID-19 before the results were reviewed and verified by experts (the gold standard for results validation). “The peer review process usually makes the papers better,” she says, “but it’s also the case that if you’re trying to take public health action with actionable data, then you don’t need the fine-tuning of peer review before you do [the results] publicly.”
She and her team are discussing ways to publish data that would be relevant to the public sooner — not to replace the peer review process, but to supplement it so that both the public and health experts can see the evidence on which the agency bases its recommendations. They are considering, for example, uploading the data to a preprint server or publishing separate technical reports to distinguish the early data from the final peer-reviewed product.
Currently, the agency’s advisory is not official until it is published in the CDC publication, MMWR, which requires a relatively long and involved peer review process. During a public health emergency, such data should be made available more quickly, Walensky says. “I called the editors of the journal and said, ‘I know we have an article under review, but the public needs to know, and I’m going to break this embargo,'” she says.
This happened last July, when data from an indoor gathering in Barnstable, Massachusetts, showed that vaccinated people became infected after mask-wearing rules were relaxed; as a result of the findings, the CDC reinstated the recommendation to wear masks in large public settings prior to the study published in MMWR. In another case, CDC scientists had data on the effectiveness of vaccines being tested MMWRbut disclosed the information before publication at a public meeting of vaccine experts convened by the US Food and Drug Administration.
“We can’t be free with the data,” she says. “But there has to be something between putting each point I and intersecting each T.”
Better, clearer messages
The key to making such data more accessible is using clear, jargon-free language to convey it. In her video address to staff, she emphasized that producing “plain language, easy-to-understand materials for the American people” will become a priority, along with ensuring that scientists develop talking points and frequently asked questions.
They have already begun to put this into practice, she says, pointing to the CDC revised isolation recommendations from August 11. Compared to previous guidelines, the new version is written more for the public and addresses people’s practical concerns, such as when to start counting days in isolation and what precautions to take at home, she says.
From her perspective, the cultural change Walenksy hopes to implement comes down to one question she urges all CDC employees to consider: whether the data they analyze or the research they conduct or the advice they generate will address a public health need? “We really need to talk about public health action, not just public health publications,” she says.
It won’t happen overnight, she admits. But now when other viral diseases – including monkeypox and even polio— have joined COVID-19, the stakes are high for the CDC to catch up quickly. The agency continues to I receive criticism by public health experts, doctors and the general public for repeating some of the same mistakes made by COVID-19 in dealing with the monkeypox outbreak. Data on monkeypox cases is still too slow. “To date, we have data on race and ethnicity for less than 50% of monkeypox cases,” she says. “We are still working on getting the case report forms completed and we are still working on getting the immunization data.” Testing for monkeypox also wasn’t widely available for months — delays reminiscent of the early days of COVID-19 — because the agency’s testing protocols were too lengthy and ineffective to fight the fast-spreading virus. But, Walenski says, “within a week of the first case, we contacted commercial labs to rapidly expand testing capacity.”
The changes she’s implementing won’t be immediately apparent to the public, but she’s confident they’ll eventually lead to clearer communication and faster data on emerging outbreaks. “People aren’t going to wake up after Labor Day and think everything is different,” she says. “We have a lot of work to do to get there.”
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