Dr. Jay K. Varma is a special contributor to Healthbeat. Public health, explained: Sign up to receive Healthbeat’s free national newsletter here.
The resignations and public statements of multiple senior leaders from the Centers for Disease Control and Prevention last week signaled what I feared was inevitable under the new presidential administration: The nation’s premier public health agency is now guided by ideology, rather than science.
The recently confirmed director and three top officials are leaving, saying the Trump administration directed them to approve vaccine policy changes that defy scientific evidence and threaten the health of all Americans. Forced to choose between professional integrity and political obedience, they walked away.
These dramatic events raise two questions: Why do we need a CDC? What happens if we do not have one we can trust?
Why national public health agencies matter
Since the 1950s, governments around the world have learned that strong national (and multi-national) public health agencies are critical to population health. They serve five roles that no local system can perform on its own:
- Monitor health conditions and potential threats to health that involve more than one state.
- Provide a repository of expertise about these conditions, including highly specialized reference laboratory services.
- Synthesize the best available evidence about these conditions and threats, then translate them into norms and standards for improving the health of communities.
- Coordinate responses to all hazards, both acute and chronic, providing staff, supplies, and funding from the federal government to promote health and prevent disease.
- Train the next generation of public health professionals, including epidemiologists, microbiologists, disease intervention specialists, and informaticians.
Over the past several decades, governments and multi-national organizations around the world have looked to the CDC as the premier model of a public health agency, choosing to create agencies that mirror the CDC for their populations. I had the privilege of helping in these efforts in Asia and Africa.
Amid the 2002-03 SARS epidemic, the Chinese government identified critical weaknesses in its ability to detect and respond to outbreaks. In response, it combined formerly disparate programs into a new public health agency called “China CDC,” named its subsidiary units after the U.S. CDC’s, and asked the U.S. CDC to help strengthen its programs. In 2008, I was invited to help China CDC improve detection and response to emerging infectious diseases. The Chinese government wanted to establish disease surveillance, laboratory systems, and applied epidemiology training programs similar to the United States. One of the programs I helped them build — surveillance for “severe acute respiratory infections” — led to the detection of Covid in late 2019.
I had a similar experience in Africa. The West Africa Ebola epidemic from 2014 to 2016 revealed that no single country in Africa could respond effectively to cross-border threats. In the midst of that outbreak, U.S. President Barack Obama negotiated an agreement with the African Union, the inter-governmental organization that oversees the 55 countries on the African continent, to establish a continent-wide public health agency.
As part of that agreement, I was seconded from the CDC to the African Union to help establish the Africa CDC. Africa CDC’s mission was to “safeguard Africa’s health” by providing technical expertise, cross-jurisdictional coordination, and human resources training. Soon after its establishment, Africa CDC built systems that detected and stopped outbreaks in fragile states, such as Ebola in the Democratic Republic of Congo. During Covid, Africa CDC developed a continent-wide response plan that was endorsed by 55 member states Feb. 22, 2020 – before the United States declared a national emergency on March 13. (The United States had declared a “public health emergency” on Jan. 31, 2020.)
My experiences working in Africa and Asia taught me how important these centralized public health agencies are. Without them, local and state health officials are often left to improvise, resulting in policies that conflict and substantial gaps in data, expertise, and resources.
How the U.S. CDC became compromised
According to public statements of departing officials, the crisis at CDC today arises from a deliberate campaign to subvert these functions. The agency is being directed to endorse policies that have already been decided for political reasons. It is expected to find data that support fringe beliefs, reject input from established professional societies and experts, and enlist advisers who have financial conflicts and limited expertise. Its leaders are constrained in what they can say publicly and what actions they can endorse.
The new acting director for CDC has no training in science, medicine, or public health. He is an expert in politics, and, instead of relying on CDC experts to develop guidance based on scientific consensus, he’s being appointed with a clear directive to implement policies based on ideology. The disclosures by the departing CDC director suggest the CDC is now expected to create policy-based evidence, rather than evidence-based policy.
For much of my career, I have focused on detecting and responding to new external threats, such as pathogens arising from nature, laboratory accidents, or deliberate release. The assumption was that institutions like the CDC would always retain the capacity to respond, even under strain. That assumption no longer holds. The greater danger now is vulnerability created by weakened institutions. Instead of stopping the bullets that are flying through the air, we’re now taking off our bulletproof vests.
Can public health survive without a strong CDC?
If the U.S. CDC is compromised, can public health improve without a national public health agency? I do not know of any models in which an economically advanced country with a well-established public health system suddenly dismantled it. The nearest example might be the newly independent states after the collapse of the U.S.S.R. Those states dealt with highly lethal outbreaks of infectious diseases for more than a decade before they were able to rebuild their systems.
One colleague of mine put it bluntly: “No one is coming to save us.” In his view, throughout recorded history, communities have organized their own systems of care when the government could not meet their needs. The future of public health may need to look like the past with community-owned and operated systems, such as worker-run clinics, community health councils, and locally controlled infrastructure. While these systems would look modest compared to the professionalized infrastructure that we are used to, they could be more resilient. They are rooted in communities and cannot be dismantled by the results of a single election or the preferences of specialized interests.
When I was based in Thailand, I saw how programs initiated by concerned citizens and run by community leaders were uniquely effective at saving lives and reducing suffering during the 2004 tsunami. In the United States, Covid offered a glimpse of this possibility. Mutual aid networks arose across the country, delivering food, masks, and reliable information when official channels faltered.
Building the future of public health in the U.S.
While the lesson of the CDC for over 75 years is that strong central public health agencies matter profoundly, the lesson for the future may be that systems must be built and strengthened at the local level first.
In the United States, public health will succeed only if communities, professionals, and civic leaders across all 50 states organize now to preserve evidence, protect science, and create systems that endure beyond political cycles. The challenge now is whether they can be made durable, with the essential physical infrastructure, legal frameworks, and financing needed to endure.
Dr. Jay K. Varma is a physician and epidemiologist. An expert in the prevention and control of infectious diseases, he has led epidemic responses, developed global and national policies, and implemented large-scale programs that saved hundreds of thousands of lives in Asia, Africa, and the United States.
