The Washington PostDemocracy Dies in Darkness

Opinion How to fix the CDC: First, make it smaller

The Atlanta offices of the Centers for Disease Control and Prevention in April 2022. (Ron Harris/AP)
5 min

Scott Gottlieb is a fellow at the American Enterprise Institute and the author of “Uncontrolled Spread: Why Covid-19 Crushed Us and How We Can Defeat the Next Pandemic.” He was the 23rd commissioner of the Food and Drug Administration and serves on the board of Pfizer.

Three years after the coronavirus started to spread in the United States, the nation’s institutions remain poorly equipped to respond to routine outbreaks, let alone combat a future pandemic.

Many of the shortcomings stem from the Centers for Disease Control and Prevention.

The agency lacks both the culture and capacity to deal with fast-moving outbreaks that require rapid response and information-sharing. The problems became obvious from its failures during the pandemic, but its shortcomings are systemic, long-standing and deep-rooted.

For the agency to be better prepared to move quickly and effectively in the future, first it needs to be made much smaller.

Congress should direct the CDC to focus on its original mission: controlling communicable diseases. The CDC has a dozen different centers devoted to separate areas of interest. Only six of them deal directly with infectious diseases and response. Much of the CDC’s research activity relating to other priorities should be passed to agencies that have the regulatory tools to act based on the findings. The CDC’s related initiatives in training and education could be absorbed by agencies with more operational responsibility over these same areas.

As the CDC’s centers are transferred in part, or whole, to agencies with overlapping obligations, the goal should be getting CDC’s analytical work closer to agencies with large programs already aimed at achieving the same public health objectives.

Much of the $505 million that the CDC will spend this year on opioid overdose prevention and surveillance can be allocated to the Substance Abuse and Mental Health Services Administration. This would align CDC’s research activities with federal programs that directly address the crisis of addiction.

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The CDC’s Office on Smoking and Health spends about $240 million on programs to prevent people from using tobacco products — programs that could be handled by the Food and Drug Administration (an agency I formerly headed). The FDA already has a broad regulatory scheme focused on an identical effort.

Some of the work done by the CDC’s Center for State, Tribal, Local and Territorial Support, providing grants and conducting research, could be entrusted to the Indian Health Service, which has 4,500 front-line providers, and is often closer to the actual provision of health care.

These are just some of the dozens of places where the CDC’s mission could be more focused and determined through better alignment of federal initiatives.

Once the CDC is streamlined, more resources could be invested into efforts more closely aligned with its core infectious-disease mission, such as the Center for Forecasting and Outbreak Analytics, launched in August 2021 and funded in 2023 with $50 million.

That’s a much more appropriate area for the CDC’s energies than, say, trying to develop lab tests. The agency botched the job of making a coronavirus test early in the pandemic; it shouldn’t be in the business of making lab tests. The work is better realized by contracting directly with private manufacturers.

Another blot on the agency’s pandemic record: The CDC for too long lacked dependable data on covid-19 hospitalizations because it over-relied on its own bespoke data streams rather than collaboration with the Centers for Medicare and Medicaid Services and other agencies. Many of the CDC’s systems for collecting and analyzing data depend on proprietary feeds it gets from public health departments. The CDC must be directed to make this process an open architecture that uses the best sources of data available.

In whittling down the CDC, Congress should also reform a culture that rewards academic achievement over operational execution, shown by the agency’s penchant for withholding actionable data until it can publish its findings in academic journals. The CDC’s current director, Rochelle Walensky, released findings last summer zeroing in on many of these cultural challenges. Her examination was unflinching and would be a good place for Congress to start.

When I served as FDA commissioner from 2017 to 2019, the CDC’s proclivity for prioritizing publication over policymaking and public health intervention meant that we were sometimes forced to take regulatory steps without the benefit of its evidence. This was true when the FDA warned the public of a particularly bad flu season in 2018; a move that the CDC had objected to because it said it wasn’t yet finished analyzing its own data. Or when the FDA acted to address a shocking spike in youth vaping. The CDC initially wouldn’t share with the FDA the bottom-line data it had on the rise, even though the FDA had commissioned — and paid for — the study.

These same cultural flaws were manifest in the nation’s troubled pandemic response, when the CDC was slow to release data that could inform medical and public health decision-making, or when the CDC struggled to issue practical, timely guidance to help people manage risk.

Shrinking the CDC’s functions would allow more funding to flow to core activities. In 2022, the CDC’s entire budget for global health security was $253 million — about the same amount it spent on stopping smoking.

In 1951, when the CDC created its Epidemic Intelligence Service to investigate global outbreaks, using the word “intelligence” was deliberate. The agency’s founders wanted the CDC to be viewed as a vital part of U.S. national security. It’s time to return the CDC to these roots. Focus it on moving quickly to mitigate dangers from known pathogens and prevent future ones.