What Is the CDC?

The Centers for Disease Control and Prevention has not covered itself in glory of late. On this, many agree.

But how has the CDC failed? By offering unreliable information? Failing to suppress the virus in its earliest days? Being unable to get political leaders to follow the science?

Perhaps the reason our fights about the agency have become so interminable is that we assume we’re all arguing about the same thing, when really we’re each arguing about something different. We lack a shared sense of what the agency is for. We lack a shared sense of what the agency even is — and this at just the moment when it plays a vastly larger role in our lives than ever before.

In search of that shared sense, here are just a few of the rival answers we might give about what the CDC is:

The CDC is the chief authority on what the latest science tells us about preventable diseases. It takes the welter of studies with their arcane terminology and often conflicting conclusions and condenses it all down, stating frankly where medical researchers have achieved full consensus, where they are halfway confident, and where they are still totally in the dark.

It is important to have some authority that provides just the facts, ma’am, about disease. It is important to have a public authority, one charged with this task by the American public and accountable to us for the same. Unlike presidents and pundits, business owners and principals, union heads and pharma CEOs, the CDC stands outside of politics. This is exactly why all these figures can trust the agency’s conclusions, and why they must.

Perhaps this view of what the agency is supposed to be is why its performance has seemed so lacking: As a rule, throughout the pandemic the CDC has actually been the last to board the scientific train. For example, there has been ample evidence since the early months of the pandemic that Covid transmits through air — possibly its main route — but the agency still grants this account little more than a footnote in its public messaging.

The CDC doesn’t exist to neutrally interpret science; it exists to worry. Germophobia is an important perspective, risk aversion merits a voice. Most of us won’t follow this view entirely, but we need someone to give us a sense of how we would act if we did. That’s what a public health agency is for, that’s why it’s useful. What else should we expect of it?

Long before Covid, for example, the agency warned people not to eat eggs that aren’t fully cooked or pasteurized, to avoid the risk of salmonella. Federal moratoria on eggs benedict could come down at any moment.

The agency thus exists to churn out recommendations with roughly the gravity of a tag warning that your mattress may contain chemicals known to the State of California to cause cancer. Life hummed along just fine for years with Americans roundly ignoring this advice, or really not even being aware of it. No surprise, then, that the agency continues to offer the same perspective now on the latest threat. That the influence of this perspective seems to have grown by a factor of approximately one million is not all to the good, but it is not because the CDC has become anything other than what we always asked it to be.

Restaurant owners, office landlords, public transit agencies, church leaders, even individuals just trying to be considerate of others: All need to be able to say “I have followed the infection control guidelines outlined by ___.” Places of business need these guidelines to be simple enough that they can be represented with icons on Google Maps popups in order to show that customers are protected, widely believed by enough of the public to serve this function, cheap enough not to be crippling, and authoritative enough to defend against lawsuits. Everyone needs these blanks filled so that enough agreement can be reached for society to go about its business (sort of). Someone needs to fill this blank. The CDC does.

The CDC’s role is hardly just to provide information. It has the power to set national norms of practice, both through the enormous deference it commands and its powers to regulate. It effectively makes medical decisions for many individuals and institutions. It is something like the head of a national medical association plus a hospital chief for the whole country.

It has the de facto power to make decisions about vaccination for a large number of Americans in schools, universities, offices, and places of business whose policies simply defer to CDC guidelines, often without permitting exemptions to be made by an individual’s doctor.

It has the power to decide who should be tested for emerging diseases, as it did for Covid until March 4, 2020. Together with the FDA’s restrictions forbidding doctors from using any tests other than the one developed by the CDC, the two national public health agencies, hoping to establish a consistent system across the country operated by the CDC, shut out universities and private labs who were developing their own tests. (The agency’s test turned out to be worthless, and these moves critically hobbled the American response in the first two months of the pandemic.)

As of this writing in late August, headlines widely report that the “Biden administration” will soon approve and recommend vaccine booster shots. Up to this point, decisions about vaccine approval have generally been described as coming from the FDA, not the administration. In April, the decision to pause the Johnson & Johnson vaccine was made jointly by the CDC and the FDA, chiefly under the advisement of the CDC’s Advisory Committee on Immunization Practices. Many headlines have simply described the individual views of Anthony Fauci. Is there a difference between these descriptions? Does the Biden administration just follow the CDC, which just follows the science — or is any action of the CDC by definition an action of the Biden administration? Who sets an agenda for whom?

Is it appropriate for a political leader to make decisions about your medical care? Is it legitimate for bureaucrats who are not elected to make decisions that will chart the course of American life for the coming months and years?

The world of medicine is split between researchers and practitioners, between academic medicine and frontline doctors. Like the FDA, the CDC falls squarely in the first camp. It is academic medicine’s voice on disease. It is preoccupied less with getting things done than with ensuring the highest standards of scientific certainty.

It is thus neurotic about the threat not of disease but of action without evidence. This means that it is actually foolishly incautious toward rapidly unfolding health crises. Its function during Covid has been to throw up hurdles to innovators, and to doctors tasked with actually treating patients. It acts, as economist Alex Tabarrok has argued, as if the pandemic were a grand classroom exercise rather than a real emergency. It is the Grumman rep in Apollo 13 who just wants to warn that this has never been tried before, a gutless turf-protector intoning about what the science doesn’t show who has forgotten what science is for.

Perhaps the most common complaint about the CDC’s pandemic handling is that it has had “confusing messaging.” This is the criticism many observers have offered about the agency’s seemingly endlessly shifting guidelines on masks and vaccines, and its equivocations about transmission modes.

The agency must offer clear takeaways, an official statement of position about the country’s view on the pandemic. Moreover, the agency’s job is to offer not just a clear message but easily followable advice. The six-foot rule, for example, is probably useless, but it has at least been clear and simple to follow.

More still: the messaging needs to offer a positive incentive structure. The brief interlude when the CDC said that people who get fully vaccinated can stop masking did this. Little else has.

On the other hand, psychological considerations appear to have led the CDC to downplay the risk of an Ebola outbreak in 2014. And they seem to explain why director Rochelle Walensky remarkably told a CNN interviewer that against the Delta variant of Covid, what vaccines “can’t do anymore is prevent transmission.” (Most available studies show that, while vaccines were around 90 percent effective at preventing transmission before, they are still 60 to 70 percent effective against Delta.) One falsehood aimed to prevent panic, the other to prevent slackening adherence to masking and the like; both were communications strategies.

Can the agency responsible for presenting the full complexity, nuance, and uncertainty of scientific research also offer coherent messaging about a rapidly unfolding crisis?

America is beset with “epistemic trespassers” — journalists, skeptics, and right-wing kooks who think they have the right to decide what science says. The paramount task is to keep these barbarians outside the gates. The CDC is charged with running the patrols. Much of its power is delegated to our de facto national information enforcer, Facebook.

Playing up health threats at some points, playing them down at others: More than a supposed fight between epistemic boldness versus caution, hypochondriacs versus risk-takers, frank talk versus doublespeak, this view makes the best sense of why the CDC has often not just agonizingly procrastinated in accepting the truth, but seemed more comfortable with half-truth and falsehood. What is most fundamentally at stake is not achieving reality but ensuring that the right people decide it and the wrong people don’t. In a war for the very notion of truth, what do a few lies matter?

The fundamental job of the CDC is not weighing in on what is true so much as figuring out what works. It is not the host of Jeopardy!; it is a fixer, a place that gets things done. Scientific research is an exceptionally powerful tool toward this end, although not always a nimble one.

A skilled engineer is bound by physical reality, but he must also at times draw on intuition, common sense, and trial and error to solve a problem. He understands science’s limits. Yet he is also demanding of science: He does not passively wait for it to answer the questions it chooses, but pressures it to answer the questions holding him back, and soon. He does all this while working within his client’s budget, even as he makes the case for more spending when he thinks it’s needed. Like with a car mechanic or a home handyman, there is a constant push-and-pull between the expert, who has skill, and the client, who suffers the costs.

A pandemic agency preoccupied with what is true is like Snopes, its focus driven by which questions public discourse makes salient. It is about masks, lockdowns, and vaccines, and little else.

A pandemic agency preoccupied with what works is more like NASA at its best: focused on a clear goal, ready to improvise, willing to drop frustrated hypotheses, clever and creative. It has skin in the game; it knows what failure looks like, and careers and reputations and consciences will be ruined if it does fail.

Thus it is eager to vet whatever looks promising. It takes a yes-and attitude, while turning its attention away from questionable or burdensome approaches. It recommends masking without letting that issue become an all-consuming battle. It makes ventilation an integral part of the American Covid plan. It is a clearinghouse of advice for practical decision-making. It looks at what worked in Slovakia, striving to make rapid, free, widespread, frequent at-home testing a reality, allowing the national strategy to shift from assuming everyone might be infected to only isolating people we know are infected, letting everyone else resume normal life.

Okay, so this is obviously not what the CDC is, though it seems to be what many expected it to be.

Scott Gottlieb, former head of the FDA, argues for reforming the CDC along something like these lines, suggesting that we need a “JSOC” — the Joint Special Operations Command, which recommends and executes special military operations, particularly against terrorism — “for public health response.” He elaborates: “CDC isn’t a prospectively-minded agency. They don’t do horizon scanning, make predictions and tie to policy recommendations, coordinate heavy lift capabilities like vaccination campaigns, engage in risk estimates, or collect intelligence on foreign areas of concern. We need such a capability. An action-oriented agency able to engage in assessing and mobilizing preparations against future risks.”

For the record, here is the CDC’s own current mission statement:

CDC works 24/7 to protect America from health, safety and security threats, both foreign and in the U.S. Whether diseases start at home or abroad, are chronic or acute, curable or preventable, human error or deliberate attack, CDC fights disease and supports communities and citizens to do the same.

CDC increases the health security of our nation. As the nation’s health protection agency, CDC saves lives and protects people from health threats. To accomplish our mission, CDC conducts critical science and provides health information that protects our nation against expensive and dangerous health threats, and responds when these arise.

And here is its description of its history: “On July 1, 1946 the Communicable Disease Center (CDC) opened its doors and occupied one floor of a small building in Atlanta. Its primary mission was simple yet highly challenging: prevent malaria from spreading across the nation.” It adds: “Today, CDC is one of the major operating components of the Department of Health and Human Services and is recognized as the nation’s premiere health promotion, prevention, and preparedness agency.”

On September 4, 2020, the CDC issued an order banning residential evictions across the entire country.

As evidence for its authority, the order cites two parts of federal law. One outlines the quarantine powers of the U.S. Secretary of Health and Human Services, the department of which the CDC is a part. The law does not mention evictions.

The second part regulates the CDC’s power to impose restrictions on interstate movement, chiefly quarantine and inspection of goods, to prevent infectious diseases from spreading between states. A brief section permits the CDC director to override local authority, imposing these same measures within states, when the director believes local restrictions are inadequate to prevent interstate spread. In this case, the director may impose “such measures to prevent such spread of the diseases as he/she deems reasonably necessary, including inspection, fumigation, disinfection” and so on.

Eviction moratoria are not on this list. So why are they within the director’s power? The order offers lengthy arguments for why an eviction moratorium would be “in the interest of the public health.” Here is the order’s entire argument for why the eviction moratorium would prevent the interstate spread of Covid-19, the rationale required by the statute: “Over 35 million Americans, representing approximately 10% of the U.S. population, move each year. Approximately 15% of moves are interstate.”

(Were you aware of the eviction moratorium? How long after September 4, 2020 did you find out about it? Were you surprised?

Donald Trump is your friend or he is your enemy. You have thoughts about him. Do you remember the sound of the voice of Robert Redfield, President Trump’s CDC director, who ordered the eviction ban?)

Restricting commerce and social life to combat a public health crisis is one of the oldest known powers of sovereignty. George Washington aggressively imposed quarantine on his soldiers during the Revolutionary War to combat smallpox outbreaks. Countries across Europe exiled lepers to lazar houses during the medieval era. The practice is found in Leviticus.

What is a public health problem? Human beings are wholes of mind and body. Little that alters the shape of one does not alter the shape of the other. Eviction? That’s a public health problem. So are violence, climate change, and homophobia, according to the CDC. Racism, fake news, police brutality, and social media are a few more answers offered by the expert community of late. The governments of Utah and Tennessee recently passed resolutions declaring pornography a “public health crisis.” People who never marry live about two years less than those who do. Are you responsible to your country for getting hitched, or is your country responsible to you?

The Covid-19 virus is a menace made of pure physical reality. It operates under a logic of its own. It cannot be wished away, it is outside our politics. Public health science is what reveals this reality to us; thus it too, we are told, has no politics. Somehow it is because public health is outside politics that it can claim as its territory all human affairs.

Is the head of the Centers for Disease Control your sovereign? Of the FDA, HHS, or NIAID? Some say that they are even more than this, that they are tyrants. This idea seems at once deranged and timid. Anthony Fauci and Rochelle Walensky are not Kim Jong-un and do not have any aspiration to be. But that the person in charge of North Korea is Kim we would not dispute. And that the regulation of fishing limits on Atlantic salmon, the question of the nature of justice, and policies for late library book fines in Terre Haute, Indiana lie firmly outside Kim’s domain we would not dispute either. We would not even think to argue about them.

Our public health agencies are everywhere and nowhere, alpha without omega, beginning without end. No one can be told what the Matrix is. You have to see it for yourself.