The Perfect Enemy | The CDC can’t be apolitical on COVID. Politics are inherent to public health. - Slate
May 28, 2022

The CDC can’t be apolitical on COVID. Politics are inherent to public health. – Slate

The CDC can’t be apolitical on COVID. Politics are inherent to public health.  Slate

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America’s favorite pandemic punching bag, the Centers for Disease Control and Prevention, is making many people angry once again. Three weeks ago, the agency defined away “high transmission” areas and walked back its recommendation to wear masks in essential indoor spaces like schools or grocery stores. “We want to give people a break,” said the agency’s director, Rochelle Walensky. “The scarlet letter of this pandemic is the mask. … It reminds us that we’re in the middle of a pandemic.”

For some, the CDC’s shift is a welcome acknowledgment of a new reality where many are protected by vaccine- or infection-induced immunity. For others, the CDC is acting prematurely, putting politics over public health, and setting the stage for another surge that will only postpone the normalcy a weary public seeks—and put vulnerable populations in further danger.

In the wake of the recent shift in guidelines, many are lamenting the “politicization” of the CDC. This has been a favorite accusation of pundits, politicians, and public health officials throughout the COVID-19 pandemic. “Re-establishing the firewall between politics and science must begin immediately,” wrote four former CDC directors in an opinion piece last year.

To an extent, these critics have a point. No one is in favor of the big-P Politics of the Trump administration’s ham-handed political interference, or the Biden administration’s subtler but pernicious tendency to suppress evidence that undermines preferred policies. And during the profound and destabilizing crisis of the past two years, many of us have yearned for an impartial authority, a font of scientific wisdom that will offer salvation in trying times. In the popular imagination, the CDC was supposed to be that trusted scientific authority. Now, a sense of disillusionment about the agency has set in.

But the cries of “politicization” miss an important point about what kind of institution the CDC can ever be. No public health decision is purely scientific, so the agency cannot avoid the small-p politics of health policy. No matter what we may yearn for, there is no ethereal scientific plane the CDC can ascend to. “The ‘politicization’ accusation implies that we should just isolate the CDC and let it do its work by itself,” said Gil Eyal, a sociology professor at Columbia University. “But I think that’s wrong. I don’t think we know of an obvious way to organize the relationship between science and politics.” That is, they are always intertwined, especially when it comes to the work of a large government agency.

This realization may seem like cause for deeper disillusionment. And depending on your priors, maybe disillusionment will be the result. But it also holds an opportunity for hope. The goal shouldn’t be to depoliticize the CDC, but to have an honest discussion about what small-p politics it should champion. Thinking about how to politicize the CDC—what values it should hold, and how it should act on them—is exactly how people in power can better equip the agency for the next public health crisis that is almost certain to come. And with this less reductive view, we can better understand the CDC’s foibles and how to apply its guidance to our lives.

The tension between the science and politics of public health is as old as the field itself. As medical historian Daniel Goldberg of the University of Colorado conceptualizes it, there have long been competing “narrow” and “broad” views of public health’s mandate. In the narrow view, public health should focus on the proximate health factors contributing to disease. In the broad view, public health should consider the underlying societal causes of disease, and even advocate to change them. Take a complex problem like malnutrition. In the narrow view, public health might focus on education campaigns urging people to eat better food or spread technological fixes that correct nutritional deficiencies, such as vitamin A supplements. In the broad view, malnutrition is rooted in poverty, so public health should study and act on ways to eliminate poverty.

This debate inevitably takes on political or even moral overtones. In the late 1990s, some academic epidemiologists were lamenting that their field had become obsessed with molecular mechanisms of disease and individual risk factors, with little regard for the social context of health and well-being. “For many epidemiologists the study of social factors is considered too political,” two authors lamented in a 1997 book. “It is necessary for epidemiology to affirm its connection with policy and to reject scientific isolation.” Some epidemiologists even accused their peers of being blinkered by their own privilege. As one expert wrote in the American Journal of Public Health: “Epidemiologists tend to be most interested in risk factors that they can relate to, or may even be exposed to. Epidemiologists are frequently at risk from tobacco smoke, alcohol, diet, viruses, and even some occupational chemical exposures, but they are rarely at risk of being poor.”

Others shot back at this sweeping view of public health. “Epidemiologists cannot be expected to solve every problem, especially not those beyond our expertise,” a trio of epidemiologists argued in the Lancet. “Epidemiologists are not social engineers.” Because major social issues like poverty will not end anytime soon, they argued that epidemiologists should focus on—or at least not be discouraged from—studying practical solutions to problems like malnutrition, such as deploying vitamin A supplements to impoverished children.

Too much open politicking, some argue, will even undermine the field. “Public health gains credibility from its adherence to science, and if the field strays too far into political advocacy, it may lose the appearance of objectivity,” Georgetown University law professor Lawrence Gostin has written. Gostin phrased the central tension of public health this way: “If it conceives of itself too narrowly, it will be accused of lacking vision. … If it conceives of itself too expansively, it will be accused of overreaching.”

We saw this tension play out in public during the anti-racism protests in the summer of 2020. At that time, large gatherings were discouraged by the CDC to prevent the spread of COVID. But individual public health experts, including the agency’s former director Tom Frieden, essentially gave the go-ahead to the anti-racism protests (an apparent hypocrisy that baffled some—experts had previously condemned anti-lockdown protests). Writing in the Atlantic, two experts explained their reasoning that the June protests were “a grassroots uprising against systemic racism, a pervasive and long-standing public-health crisis that leads to more than 80,000 excess deaths among black Americans every year.” To protest racial injustice, in this view, is to further the goals of public health. In the broad view of public health, it makes perfect sense, but for advocates of the narrow view of public health, this endorsement feels like a stretch.

The CDC has often pretended to be above politics—a bastion of scientific objectivity in a political and social maelstrom. In earlier stages of the pandemic, the agency confidently asserted, for example, that people do not need to wear masks, and denied that the coronavirus mostly spreads through the air. The agency later reversed both assertions, saying the science had evolved. To a point, that is true, but the agency was also coy about other nonscientific factors at play (a mask shortage for health care workers, the pain of expensive ventilation upgrades). When the CDC recently reduced the recommended isolation period from 10 to five days, the agency emphasized the shift was “motivated by science” suggesting that most people weren’t likely to be very contagious at five days (recent studies show that up to half of people are likely to be infectious at that time). Later, Director Rochelle Walensky admitted the agency didn’t “take science in a vacuum,” but considered the economic effects of asking workers to hole up for a longer stretch. The CDC was also making a bet of sorts: By declaring that five days of isolation was enough, perhaps more people would isolate in the first place. Clearly, the CDC was evaluating the economic trade-offs and behavioral realities, settling on five days as the proper balance. That’s a balance worth debating—but to pretend this was a purely scientific decision was misleading. (The CDC’s press office did not respond to multiple requests for comment.)

And this is where the CDC’s apolitical posturing rings false to some researchers. “Health policy decisions are always about values even if we don’t always articulate them,” said Cecília Tomori, director of global public health and community health at the Johns Hopkins School of Nursing. “The values might be unstated versus explicit, but they are still there.” In the case of the five-day isolation policy, the CDC implicitly valued the short-term effects on the economy and the social well-being of the healthy. It implicitly devalued the long-term effects on the immunocompromised—or at least placed their well-being in their own hands. You can imagine things going another direction, though. Instead of pitting the economy against the most vulnerable, why not use the agency’s influence to pressure institutions and communities to make long-lasting social changes that benefit both? Instead of suggesting that high-risk people don high-quality masks while everyone else doffs theirs, why not improve ventilation for all indoor spaces? Instead of tinkering with an isolation policy, why not ensure all employees, including hourly ones, have paid sick leave? Instead of letting pandemic-battered businesses blow in the wind, why not subsidize short-term closures with federal funds?

There’s only one small hitch: The CDC can’t really make anyone do anything. For an agency of its size and profile, the CDC has surprisingly little formal power. Forget deploying federal funds to businesses or upgrading the nation’s HVAC infrastructure—the CDC can’t even make states submit health data to them. And even if the agency wanted to sponsor ventilation overhauls and sick day vouchers, it has no coffers with which to finance those things. The CDC’s recommendations may be influential, but legally they are toothless. Apart from a few limited emergency powers, “it’s almost like they have nothing other than the bully pulpit,” said David Michaels, a professor at George Washington University who served as director of the Occupational Safety and Health Administration for most of the Obama administration and sat on President Joe Biden’s Transition COVID-19 Advisory Board.

A way forward would be better integration with other agencies in the federal government that already have those tools and knowledge. It would also have helped for economic relief efforts to be more tightly linked to public health measures. “One of the things that I thought was a major failure in the pandemic response was the inability to focus resources to the intersection of public health and the economy,” said Joshua Sharfstein, a health policy professor at Johns Hopkins and former principal deputy commissioner of the Food and Drug Administration. “We should have been able to compensate the owners and employees of bars that had to close during surges, for example.”

In the absence of tighter coordination, the CDC can expand the expertise it relies on. I spoke to Ed Hunter, who worked at the CDC for 40 years and headed up its Washington office. At the CDC, skills in economics or sociology, he said, “are definitely in the minority. The real decisions are being made by the stock-in-trade of public health—people trained in epidemiology and lab science and medicine.” Leaning more heavily on experts outside traditional biomedical circles could help the agency make choices that thoughtfully account for values—and reality.

Most crucially, what the agency can do is show its work. Mical Raz, a professor of history and health policy at the University of Rochester and a practicing physician, said, “Imagine if the CDC said, ‘It’s ideal that you test at the end of isolation, but we can’t officially recommend it because we don’t have enough tests.’ That would be transparent. Instead, they’re saying, ‘Oh, we’re not recommending testing—hand-wave gesture mumbo jumbo science. … Oh, but you can test if you want to.’ ” She added, “It’s an attempt to hide the massive failures of our public health care system.” That is, not only is the CDC unable to provide practical, material fixes to social ills, but it’s been sweeping the mess under science-y recommendations. We’ve noticed. Raz says, “This lack of transparency is one of the things that’s really reducing trust.”

And what a reduction in trust it’s been. In October 2019, before the first case of COVID-19 was detected in China, the CDC was one of the most trusted institutions in the nation, with more than 80 percent of Americans across the political spectrum holding favorable views of the agency. Today, only 44 percent trust the CDC, at least when it comes to COVID—a remarkable plummet for an agency whose past heroic exploits have been fictionalized in print and on screen. “I think there was a lot of expectation that again, once the Trump administration was out, it was like, ‘Oh, welcome back science, thank you.’ And then a lot of real disappointment that it’s not that simple,” Raz said. “Many opportunities to regain trust were squandered, perhaps in this attempt to appease too many people and ultimately appeasing none. The CDC is doing a stunningly bad job at leveling with the public.”

Despite the rabid calls to return to normal, the virus isn’t done with us yet. And as painful as it may be to think about now, another pandemic sweeping the globe isn’t a matter of if but when. Now would be an opportune moment for the CDC—and the public health field more broadly—to get its political cards in order.

Some believe the CDC could help usher in a new era of public health, one that revives the field as a principled force for social reform. “Health is always political,” said Tomori. “The inequities that we see today are direct consequences of political and historical processes.” She and her team of scholars have criticized the CDC’s approach under the Biden administration, lamenting the focus on individual personal responsibility for health (“your health is in your hands”) at the expense of guidance and policies to protect society’s most vulnerable. “We were reluctant to call out the CDC because the goal isn’t at all to undermine them,” Tomori said. “We want them to reorient towards those core public health principles of protection and equity.”

She sees the tilt toward an individualistic response to the pandemic, even as the CDC’s director pays lip service to health equity, as a reflection of the agency’s muddled values. “I understand that the values of public health seem idealistic. But that is the whole point, the entire point of having human rights, the entire point of having principles around equity,” she said. “I don’t actually see much of that at the CDC. I think that’s part of what I’m disturbed by.”

For the rest of us, it means letting go of the idea that the CDC can ever be the god of pure science we might want it to be—but also letting go of the idea that the CDC is a fallen angel. Rather, it may be time to start metabolizing the agency’s recommendations a bit differently, as suggestions made by people with a viewpoint. Yes, the CDC is staffed by thousands of scientists toiling away in obscurity to produce some of the best science on the pandemic. But as that science gets processed into recommendations, hard questions about politics and values can’t be dodged. And while no one alone can shift the politics of public health, squarely facing the reality that public health is political is the only way forward.