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The CDC’s Mission Impossible

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The CDC’s Mission Impossible

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The Wall Street has a new exclusive story about the incoming head of the CDC, Rochelle Walensky, and her plans to greatly increase vaccination rates and restore faith in the agency.

Dr. Walensky has an impressive background: the recent head of infectious diseases at Mass General, one of the top teaching hospitals in the US, where she was also a member of state advisory panels on Covid policy. Some questioned her elevation due to her lack of public health or CDC experience. Walensky said she was surprised to get the nod and assumed her outsider status was a big reason why.

Dr. Walensky will presumably be implementing the Biden Adminstration’s Covid-19 vaccine plans. Given Dr. Walensky’s not anticipating that she would be offered the leadership of the CDC, one has to assume she was not meaningfully involved in the development of this program.From WebMD’s summary, based on an announcement a few days ago:

Biden outlined five major goals:

  • Work with states to expand eligibility to anyone age 65 or older, and to essential workers, while continuing to vaccinate health care workers.
  • Set up thousands of new federally-supported mass vaccination centers at gyms, stadiums and other locations—with 100 by the end of his first month in office– supported by the Federal Emergency Management Administration. FEMA will mobilize thousands of staff and contractors to work with state and local teams and the National Guard.
  • Deploy mobile vaccination clinics to hard-to-reach underserved urban and rural areas, relying in part on community-based physicians.
  • “Jumpstart” a federal partnership with pharmacies to increase capacity at chains and independent outlets.
  • Use the Defense Production Act to help ensure uninterrupted production and delivery of vaccine and vaccine supplies. The aim is to release most vaccine supply when available, while keeping a small reserve to cover unforeseen shortages or delays.

Other elements were more napkin-doodles. Again from WebMD:

The Biden plan would encourage states to allow additional qualified professionals to give vaccines. Biden said he envisions using military health care professionals, FEMA employees and staff from the U.S. Public Health Service Commissioned Corps to help expand the number of people who can give vaccines. He also said he would seek to allow certain qualified professionals, including retired medical workers who are not licensed to administer vaccines, to do so with appropriate training….

He said that addressing vaccine hesitancy will also be a priority and will be done through a “massive public education campaign to rebuild that trust, to help people understand what science tells us—that vaccines help reduce the risk of COVID infections”.

This is very ambitious, since it involves coordinating across Federal agencies, with state and local governments, hospitals, and major pharmacy chains. And at the same time, Walensky also plans to address the CDC’s damaged reputation. From the Wall Street Journal:

Dr. Walensky vowed to restore public trust in the CDC, which surveys show sagged after the Trump administration interfered in decision making and the agency made its own mistakes, such as botching the rollout of a diagnostic test for detecting Covid-19…

The CDC will hold regular press briefings, release current data, and will announce changes in recommendations, said Dr. Walensky, who is moving on Friday to Atlanta, where the CDC is based. “There will be way more communication, the science will be out there,” she said.

She said she may seek an external review of how the CDC’s Covid-19 diagnostic test was botched, which hampered testing for the virus in the crucial initial weeks it was spreading in the U.S.

Also among her top priorities, she said, are strengthening the nation’s public-health departments, which have suffered from years of funding and staff cuts, and modernizing the CDC’s outdated data systems.

Those steps will require substantial new funds from Congress. “I plan to be there often,” she said.

“We need to build a sustainable public-health infrastructure across the country, because one of the reasons that we’re in this mess is because we didn’t have it,” she said.

While it may seem churlish to express reservations at such an early stage, and it would be better if we were wrong, there are reasons to harbor doubts.

Poor operational competence and capacity in large swathes of the public and private sectors. It is impossible to describe this overarching impediment in strong enough terms, so forgive me for the very short form treatment. We are suffering the consequences of decades of rule by MBAs and lawyers. Fetishizing efficiency over safety has resulted in a reduction in hospital beds. Many hospitals have outsourced their emergency room staffing to private equity, giving rentiers a choke point on a vital public health issue.

And that’s before getting to the widespread adoption of practices in private sector that reduced the discretion and therefore competence of low-level and supervisory staff. This is the level of worker whose motivation and judgement calls are essential in emergency responses. Yet the US has had three decades plus of working to deskill their jobs in order to cut their pay.

Trump wasn’t crazy to talk about using the military to help with the vaccine rollout. They have unmatched skills in logistics. But the armed services made it very clear they weren’t interested in the vaccine tar baby. Trump lacked the credibility and cojones of some earlier Presidents to call them to his office and give them their marching orders.1

Magnitude of CDC role relative to Dr. Walensky’s previous experience.
Walensky has never managed a bureaucracy the size of the CDC, which has 21,000 employees. It’s a little troubling that there is no “infectious diseases” department on the Mass General org chart from June 2019.2 That confirms the concern that she does not have a history of running a large or even a not-so-large operation. Nor has she designed or overseen the implementation of large-scale program. This challenge is even more daunting given the need for rapid execution to accelerate vaccine distribution.

Some people step up successfully to battlefield promotions. A high profile example was when Elizabeth Warren started up the CFPB. There was nothing in her background to suggest that she could execute an administrative task of that magnitude, let alone in six months.3 But this is an even bigger skill jump.

And keep in mind another issue: Dr. Walensky is going from an elite organization to one where she’ll deal with top managers and numerous important outside constituencies who won’t be at the same level, intellectually and likely in terms of professionalism, of her former colleagues. This is another difficult adjustment.

Existing CDC weaknesses. The test fiasco wasn’t the only CDC failure. From STAT in April:

While individual states oversee their public health departments, provision of health care, and actually implement policies and programs, the CDC has always provided the intellectual leadership, technical expertise, the expert guidance that states rely on to do their work. This federal agency coordinates efforts across states so they can learn from one another. And the CDC standardizes data and methods so we can get a true national picture of what is happening….

Want to know how many tuberculosis cases there were in the U.S. last year? Ask the CDC. Want to know about health-care-associated infections? Ask the CDC. It knows.

But ask how many Covid-19 tests have been done, and the CDC’s doesn’t have an answer. Want a daily update on how many people are getting hospitalized for Covid-19? The CDC isn’t tracking it. Want to know if social distancing is making a difference? The CDC doesn’t know.

During this pandemic, when accurate, timely, nationwide information is the lifeblood of our response, the CDC has largely disappeared.

The performance of the world’s leading public health agency has been surprising, and by that I mean surprisingly disappointing….

Beyond its testing failure, the CDC has been slow and its response inadequate in another area where it has always excelled: evidence-based guidance…

The agency was slow to suggest that we should end large gatherings. As masks for health care workers became scarce, it recommended that health care workers wear bandanas and scarves with zero evidence that these would protect workers from the virus. Investigative reporting has uncovered unclear and disorganized communication to state public health agencies. And the CDC’s restrictive early testing guidelines did not necessarily align with what was understood about disease symptoms and risks at the time.

The reason for the lengthy excerpt is to serve as a reminder of what the CDC’s role is: a data/research organization to inform state and local public health initiatives. Dr. Walensky does want to address these shortcomings, but it’s not clear how high these issues are on her to do list.

Massive mission expansion. Disturbingly, the Biden Administration looks to be intent on having the CDC play a significant role in vaccine distribution, when it couldn’t even get something in its wheelhouse, Covid test kits, right. Giving a poorly performing bureaucracy a whole heap of new responsibilities that are way outside its historical scope is a prescription for failure.

Dr. Walensky confirmed that the CDC will attempt to play a much more hands-on role. The Journal article admittedly discusses the broader Biden strategy first without clarify what will fall, say to HHS versus the CDC. However, as I read this, Dr. Walensky seems to be using the CDC “we” as opposed to the Biden Administration “we” with respect to mobile clinicsFrom the Journal:

The incoming administration of President-elect Joe Biden plans to accelerate vaccinations by boosting supplies, matching the number of people who are eligible for vaccines to the number of doses available and hiring retired health-care workers, public health officers and others to administer the shots.

The plan also includes making vaccines easier for people to get, particularly those in underserved communities.

“We want to do mobile clinics, because not everybody is going to be able to get to a stadium,” Dr. Walensky said. “We want to bring those clinics to the people, to the communities where they otherwise wouldn’t have had adequate outreach.”

Mobile clinics sound easy. How hard is it to send around little vans? But this scheme alone illustrates how significant operational issues are. Remember that nursing homes are having difficulty with vaccinations despite having a captive population. It isn’t just the complications with getting informed consent when a meaningful proportion of the residents are cognitively impaired. It’s that with the Pfizer and Moderna vaccines, the techs need to thaw and transport enough vaccine for that visit’s shots and no more. That means the nursing home needs to give an accurate count of how many are to be vaccinated that day. That apparently gets messed up frequently.

Let’s start with:

How do you identify which neighborhoods to visit and at what hours? And how many visits will it take to do the job?

How do you let the residents know when you will be there? Fliers in stores? TV and radio ads? Mailers?

How do your confirm eligibility if distribution is restricted?

Will patients sign up for a time slot? What happens if they are late?

Will the mobility restricted be able to get help getting to and from the truck?

How will the mobile clinics allow for anaphylaxis risk? The current practice appears to be to have patients wait 15 minutes after a shot to see if they are OK, and a half hour if they have a history of allergic reactions. Will the clinics provide chairs? What happens if it is cold or rainy and therefore not comfortable to wait?

What about second shots? Will patients get reminder calls, e-mails, and/or texts? Will the vans come back?

And Dr. Walensky plans to do serious empire-building. Again from the Journal:

Also among her top priorities, she said, are strengthening the nation’s public-health departments, which have suffered from years of funding and staff cuts, and modernizing the CDC’s outdated data systems.

Those steps will require substantial new funds from Congress. “I plan to be there often,” she said.

“We need to build a sustainable public-health infrastructure across the country, because one of the reasons that we’re in this mess is because we didn’t have it,” she said.

Huh? Is this ignorance or delusion? Public health is a state responsibility. From the NIH website, a lengthy appendix, Summary of the Public Health System in the United States, from the book The Future of Public Health:

States are the principal governmental entity responsible for protecting the public’s health in the United States. They conduct a wide range of activities in health. State health agencies collect and analyze information; conduct inspections; plan; set policies and standards; carry out national and state mandates; manage and oversee environmental, educational, and personal health services; and assure access to health care for underserved residents; they are involved in resources development; and they respond to health hazards and crises. (Hanlon and Pickett, 1984; Public Health Foundation, 1986b) States carry out most of their responsibilities through their police power, the power “to enact and enforce laws to protect and promote the health, safety, morals, order, peace, comfort, and general welfare of the people.” (Grad, 1981) In the tenth amendment of the U.S. Constitution, states and the people are designated as the repository of all government powers not specifically designated to the federal government. States, as sovereign governments, derive plenary and inherent power to govern from their people.

The appendix also describes the some of the various ways states organize their public health agencies.

The states are already unhappy at the way the Federal government has handled vaccine distribution. Even though many had made their problems worse by changing priorities on the fly, a big source of consternation is that Congress approved $9 billion of funding for vaccination programs in late December. The states would have needed to get the money in the spring or at worst the summer so as to staff up, procure supplies, and devise procedures to be ready now.

It’s one thing if Dr. Walensky were proposing block grants or Federal funds for specified public health improvements. Instead, she’s pumping for an unconstitutional land-grab. This is a prescription for generating hostility and range wars at a time when all officials, Federal, state and local need to be pulling together.

Fighting yesterday’s war. If you read the full article, what Dr. Walensky proposes would have been well and good as of say last October. Despite talking up the importance of vaccinations, she doesn’t acknowledge the acute stresses hospitals and medical professionals are under now, and her plans seem totally inadequate to the expected sharp rise in new infections thanks to more contagious Covid mutations.

Treating better PR as the solution to way too many problems. We pointed out during the Obama Administration that the Democrats saw better propaganda as the solution for every problem. Since PR won’t cure Covid, the Biden has had to moderate its expectations a tad. But they still place great faith in marketing. The Journal reports Dr. Walensky explaining that “Stopping the pandemic will require convincing people to wear masks and follow other measures to slow the virus.” Notice she does not suggest distributing free masks, which is deeply disturbing.

And I don’t see how you get through to mask refusniks. One friend rants about them and wears flimsy scarves over her mouth to feign compliance. Masks are now required indoors in Jefferson County, which includes my gym (which also strictly limits how many can come in at once, so it is always sparsely populated). I saw a young man wearing a mouth cover that was a joke, visibly open mesh over his face. I decided to take issue with his practice. I got a litany of excuses: he has asthma (sorry, friends with severe asthma mask up). He’d had Covid. Blah blah blah. A store employee at CVS always has her mask below her nose, despite CVS supposedly having a zero tolerance policy for employees and my having complained numerous times when I get a satisfaction survey, as well as a couple of times to store management.

And Dr. Walensky, and by extension, the Biden Administration, is in complete denial about anti-vaxxers. The Journal points out that a recent survey showed that 27% of the respondents aren’t planning to get the shots. From the article:

It is important for the CDC to reach out to people now who say they don’t want the vaccine, whether that is due to convenience or concerns about the science or of missing work, Dr. Walensky said.

“Right now is the time to do that outreach, to do that education, to understand why it is they may not want it and what it is that they need to understand in order to want it,” she said.

Help me. The assumption is the so-called vaccine hesitant are badly informed and if they are properly schooled, they’ll of course fall in line. Some of these individuals are anti-vaxxers and no amount of information will change their views. But Dr. Walensky does not seem to get that for plenty of others, doctors and Big Pharma are not seen as particularly trustworthy. Many patients see their primary care physician for only six or ten minutes, hardly enough to feel cared for. Doctors are doing squat to oppose the patient-rape known as balance billing. Big Pharma has brought us Vioxx, the opioid crisis, and Zantac, among other highly profitable patient catastrophes. Many doctors won’t prescribe new medications until they’ve been in use for six months or even a year. Treating individuals who are cautious as in need of indoctrination will only harden their views.3

On top of the 27% vaccine-reluctant, Kaiser found that 39% were in “wait and see” mode, holding back until they could ascertain how it worked for others.

If we just limit ourselves to the 27% and assume that at least that many won’t get vaccinated in 2021, the US won’t beat back Covid. The new variants with their higher R0s means a much higher proportion of the population would need to be vaccinated, say over 85%, for it to die out. In the meantime, we hear crickets from the CDC and the FDA about prophylactics and treatments.

Dr. Walensky is articulate and telegenic, so perhaps her main role is to rebrand the CDC while some deputies come in to do the heavy lifting of turning around the agency. If not, I’m not optimistic that the CDC will get back on track.

___

1 One of my favorite examples of how things ought to work, cribbed from Jonathan Glover’s carefully researched book, Humanity. And notice President Kennedy didn’t have to stoop to pulling the choke chain himself:

After the US blockaded Cuba, Khrushchev sent ships on course to Cuba, presumably to break the cordon. Secretary of State Dean Rusk asked the Admiral in charge of the operation what the Navy would do when the Russian ships approached. He was told they’d first make a shot across the bow. Rusk said asked what would happen next if the Russians were not deterred. The Admiral got testy and told Rusk that the Navy had been running blockades since 1812 and it was basically none of his business.

I can’t locate the book readily to give the exact wording but this is the spirit of Rusk’s dressing down:

This is not about your pettifogging naval traditions. The stakes are much higher than that. This operation is a means for the President to communicate with Khrushchev. You will remain in constant contact. You will not take a single action unless it has been explicitly authorized by the President. Have I made myself clear?

2 The only org chart box with that is even in the ballpark is “Center for Infection Control and Process Management” which reports to the SVP of Quality & Patient Safety. So I would hazard Dr. Walensky’s role was primarily research and teaching, and not much related to direct patient care.

3 We argued that the Obama Administration had given Warren this task on the assumption she’d flounder around, discredit herself, and then she’d be less of a problem to them.

3 A growing body of research has found that presenting people with information that contradicts their prior beliefs leads them to double down.

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