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June 4, 2020

'I would have expected better': Inside CDC's shaky response to Covid-19

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    CDC has long been considered a world leader in public health, but a series of early missteps, compounded by outdated technology and a culture of caution, "undermined America's response" to the new coronavirus epidemic, Eric Lipton and colleagues report for the New York Times.

    10 takeaways: What America can learn from the world's coronavirus response

    CDC has come under fire for its response to the new coronavirus epidemic. Among other things, critics say the agency stumbled to quickly supply U.S. providers and labs with adequate tests, failed to provide timely and accurate reports of Covid-19 cases and deaths, and has been slow to release guidance that at times contained confusing messages, Lipton and colleagues report. 

    To better understand the agency's response and its impact on the U.S. response to the new coronavirus epidemic, Lipton and colleagues reviewed "thousands of emails" and interviewed more than 100 CDC employees, public health experts, state and federal officials, and medical workers. In the article, Lipton and colleagues highlight some of the key challenges the agency faced in meeting its public health mission during a time of global crisis.

    A culture of working 'at the speed of science'

    Since its establishment in the 1940s, CDC has worked as a "risk-averse, perfectionist" organization, current and former CDC employees told the Times, making the agency ill-prepared to quickly respond to a public health crisis.

    CDC works "at the speed of science—you take time doing it," Georges Benjamin, executive director of the American Public Health Association, said.

    "It's not our culture to intervene," George Schmid, who worked at CDC for nearly 40 years, said. Schmid described the agency as bureaucratic and hampered by "indescribable, burdensome hierarchy."

    This culture, the Times reports, contributed in part to one of CDC's earliest missteps in its response to the new coronavirus: its delay in providing state laboratories accurate diagnostic test kits. CDC in January developed its own diagnostic test for Covid-19, but use issues and manufacturing problems that contaminated the earliest batch of kits sent to states meant access to testing was limited for several months, the Times reports.

    Furthermore, critics say the agency was slow to broaden its testing recommendations or expand travel restrictions to prevent visitors from countries where the virus was spreading rapidly from entering the United States.

    "If we were able to test early, we would have recognized earlier" the scale of the outbreak, Jeffrey Duchin, chief health officer in King County, Washington, said. "We would have been able to put prevention measures in place earlier and had fewer cases."

    Outdated technology

    In addition to the testing delays, CDC also struggled to track the virus' spread in the United States because of the agency's "antiquated data systems, many of which rely on information assembled by or shared with local health officials through phone calls, faxes, and thousands of spreadsheets attached to emails," the Times reports.

    Both federal and state governments for years have underfunded the nation's public health system, forcing officials to rely on outdated technologies that contributed to CDC's slow response, the Times reports. 

    The Times investigation shows the technology problems started early on. In early February, CDC urged state officials to track all travelers from China for potential infections of the new coronavirus. CDC used a computer network called Epi-X to send emails to officials, one at a time, so they could download a targeted passenger list for each flight, the Times reports.

    However, in some cases CDC's data had incorrect dates, was sent to the wrong state, or came more than a week after the plane had landed. CDC eventually temporarily shut down the Epi-X system to "improve data quality," officials said.

    "We got crappy data," Fran Phillips, deputy health secretary of Maryland, said. "We would call them up and people would say, 'Well, I was in China, but that was three years ago.'"

    As the number of U.S. Covid-19 cases began rising in March, CDC attempted to gather hospital data—such as information on the resources hospitals had available to treat Covid-19 patients—using one of its own data systems. However, the data had noticeable gaps, the Times reports.

    Ultimately, HHS contracted with TeleTracking Technologies to help, but hospitals had difficulties logging onto the system. This left many hospitals to coordinate amongst themselves to find and allocate needed equipment and in some cases find additional beds, the Times reports.

    CDC also has struggled to accurately—and quickly—record the number of suspected Covid-19 cases in the United States and related deaths.  As a result, many officials—including those at the White House—have looked to Johns Hopkins University as the primary source for new coronavirus case counts.

    Strained relationship with the White House and a lack of clear leadership

    All of this was compounded by the agency's strained relationship with the White House and the White House coronavirus task force over various guidelines and messaging around the epidemic, the Times reports.

    For instance, the Times reports that CDC on March 15 published guidance on its website that discouraged public gatherings of more than 50 people, despite the fact that several agency officials knew the White House's coronavirus task force was finalizing its own guidance limiting such gatherings to 10 people. According to the Times, the public discrepancy "underscored the strained relationship between the health agency and the White House."

    The agency also has been publicly criticized by President Trump. In a tweet, Trump wrote, "For decades the [CDC] looked at, and studied, its testing system, but did nothing about it."

    Lawrence Gostin, a former CDC official who is now the director of a legal center at the World Health Organization, said, "I would expect the CDC to coordinate with the White House." He added, "But this is not teamwork. This is not coordination. This is confrontation."

    CDC Director Robert Redfield also has been criticized for keeping a "low profile" during the epidemic—even amongst his staff. According to the Times, Redfield has not recently been to Atlanta, where CDC is headquartered, and instead has largely remained in the Baltimore-Washington D.C. area.

    Providers frustrated by a lack of guidance, but others defend CDC's actions

    Health care providers and state public health officials also have raised concerns about CDC's ability to issue clear and timely guidance, Times reports.

    For example, coronavirus patients at Margaret Mary Community Hospital showed up in March with symptoms that included headaches, fatigue, and nausea. But at the time, CDC said masks were only necessary when treating patients with a fever or respiratory symptoms.

    According to the Times, during past outbreaks, such as the Ebola and Zika crises, CDC held press conferences on a nearly daily basis to explain its guidance and any data behind changes. But CDC's leadership has not held regular briefings since March 9, leaving health care workers and the public left to read and understand the vast amounts of information CDC posted on its website.

    In a January email to colleagues, Jim Collins, the Director of Michigan's Communicable Diseases Division wrote, "It would be awesome if CDC could actually announce significant changes rather than bury it on their website and assume it is done."

    And many officials are now beginning to turn to other sources as they prepare for states to reopen. Dan Gelber, mayor of Miami Beach, said, "It's almost as if they just said, 'Open up and figure out whether it's a good idea or not afterward.'" He added, "We don't have a net here."

    A CDC spokesperson told the Times that the agency has published more than 110 advisory documents it, saying the agency has "issued countless guidance and recommendations based on the best available science and data."

    In addition, some providers and public health officials have come to CDC's defense.

    Amy Ray, an infectious disease specialist in Cleveland, said the agency did not "get enough credit" for its response. "They are learning at the same time the world is learning, by watching how this disease manifests," Ray said.

    James Town, medical director of the intensive care unit at Harborview Medical Center, said CDC did the best it could fighting a previously unknown virus. "When they do release something, it does what CDC ought to do—retain the voice of credibility," he said. "Even if it's coming at a slower pace, which can be frustrating, I think they're pretty thoughtful and trying to make even-keeled investigations" (Lipton et al., New York Times, 6/3).

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