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April 18, 2023

CDC Reform: Where to Start?

The Centers for Disease Control and Prevention—abbreviated CDC so as to maintain consistency with the original Communicable Disease Center established in 1946—has been on troubled footing recently. It famously released a flawed Covid test in early 2020, and “wound up costing scientists precious weeks in the early days of a pandemic.”

During Covid, as shown in a new paper led by Kelley Kronhart and Vinay Prasad, the CDC has repeatedly released statistics that were wrong or internally contradictory, and that had to be corrected. For example, for seven months (until notified by an outsider), a CDC webpage claimed that children made up 4% of COVID deaths when the actual number was 0.04% — off by a factor of 100! [Here’s the current corrected webpage, and here’s an archived version with the 100-fold error.]

For another example, a CDC meeting featured a presentation claiming that Covid was a top 5 leading cause of death in children, but this number arose from an incorrect comparison between yearly deaths of other causes versus more than 2 years of Covid deaths!  

In response to these and other criticisms, the CDC Director launched a major review and strategic overhaul of the agency in April 2022, the results of which are here. The top recommendations are:

1.       Sharing scientific findings and data faster. This recommendation is borne out of the view that CDC was too slow during Covid.

2.      Translate science into “practical, easy to understand policy.” CDC guidance documents to date have been “long and overly complex,” and didn’t involve “key partners upfront.” Thus, CDC plans to “implement a standardized policy development process” that leads to “plain language, easy to understand implementation guidance documents.”

3.      Prioritize public health communications. During Covid, the CDC lacked “regular communications and consistent channels/methods for sharing information” with the general public.

4.      Develop a workforce prepared for future emergencies. During Covid, the CDC’s lack of trained staff “often resulted in changing priorities, lack of continuity, and a mismatch of needed skills and people.”

5.      Finally, “promoting results-based partnerships.” The CDC notes that some have started to view the agency “as more of an academic institution than a public health, service-oriented organization,” and it wants to build more partnerships “with others in and outside of government.”

This is all fine and well, but in part misses the point.

            First, the focus on whether public health guidance is “fast” or “easy to understand,” or whether the CDC has enough channels to communicate directly with the public, is misguided unless we first know that the information is accurate and trustworthy.

If someone overestimates the Covid risk to children literally a hundred-fold, it would not be progress to spread that misinformation more quickly and in a more easy-to-understand way via more public communication channels!

            Second, the CDC’s guidance (such as its guidance for how schools should operate) might indeed be complicated and hard to understand. But those issues are secondary to a much larger problem: the CDC’s process for coming with such guidance is far from transparent.

Even though these guidance documents can have a substantial impact throughout the country, the CDC does not treat them like traditional agency rules. Traditional rules, after all, are issued only after an official notice to the public, a comment period during which anyone can submit comments, and a final rule that addresses all of the substantive comments (and that usually makes the comments themselves public). These principles have been embodied in the Administrative Procedure Act since 1946.

            The CDC does very little of this. It issues guidance for how schools or workplaces should respond to Covid, or for the use of Covid vaccines and boosters, but there is little public visibility into how the guidance was created, who exactly was involved and in what capacity, which outside stakeholders might have been consulted, or how influential their comments were.

As an example, the Advisory Committee on Immunization Practices (ACIP) at CDC holds regular meetings, and its website mentions the possibility of submitting public comments. But the webpage does not say what upcoming issues are on the Committee’s agenda, and it merely links to At that site, a search turns up the most recent agenda for the Feb. 2023 ACIP meeting, where this is literally the full text about the meeting agenda:

Matters To Be Considered: The agenda will include discussions on mpox vaccines, influenza vaccines, pneumococcal vaccine, rotavirus vaccines, varicella vaccines, meningococcal vaccines, Polio vaccine, respiratory syncytial virus vaccine pediatric/maternal, respiratory syncytial virus vaccine adult, dengue vaccines, Chikungunya vaccine, and COVID–19 vaccines. Recommendation votes on mpox vaccine are scheduled. A Vaccines For Children vote on rotavirus vaccines is scheduled. Agenda items are subject to change as priorities dictate.

Also noteworthy: this notice went out on Jan. 30, 2023, and it said that CDC would receive comments only between Feb. 6 and Feb. 17, 2023.

In other words, it is difficult even to find the meeting agenda, and once you find it, you have next to nothing to go on: the meeting might be about 12 different vaccines, but there is little or no explanation as to what CDC might be considering (as would be the case for any normal agency rule). As a result, if you want to make a comment, you are taking a total stab in the dark as to whether you are responding to any of CDC’s concerns or contentions. Even worse, you’d never know about the possibility of making comments unless you were checking on a weekly basis (if not, you’d probably miss out on the mere 12 days during which commenting was possible). And after the fact, it is difficult at best to check for political bias, evidentiary bias, quality and accuracy of the comments, and more.  [ACIP does make its meeting minutes available, albeit after several months.]

On top of that, the CDC’s guidance often ends up having legal authority, but no one wants to take responsibility for it. Thus, the viral meme on Twitter:

Source: @techjudge

Like it or not, a fair number of the public are wary of extra requirements as to child vaccination, especially given that Covid poses so little risk to children in the first place. The main federal agency that makes recommendations here (even if not legally binding) should bend over backwards to make sure that its guidance is fully transparent and that it addresses a steelman version of the critics’ concerns (no matter how unpersuasive they might seem).

In short, CDC’s number one priority should be to establish a process that is directly aimed at accuracy and full transparency. As well, any CDC entity that sets policy or issues guidance should be firewalled from any team that collects statistics and data. Only when CDC adequately addresses those issues will it be able to make progress at rebuilding trust with the American people.