Having conceded that the Centers for Disease Control and Prevention (CDC) made mistakes and errors in the pandemic response — then launched an ambitious effort to reinvent the agency — Director Rochelle Walensky, MD, has announced she will resign at the end of June 2023.
Appointed by the Biden Administration in January 2021, Walensky took the reins of an agency battered by early mistakes, facing a politicized, sharply divided public.
She is credited with bringing a sense of normalcy and a boost for ebbing morale at the CDC, but both the circumstances and the road ahead of her were difficult.
“To be frank, we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications,” Walensky said in a video to CDC staff last year. (See Hospital Infection Control & Prevention, October 2022.)
However, Walensky began an ongoing revamping of the agency — dubbed Moving Forward — with key goals that included:
• sharing scientific findings and data faster;
• translating science into practical, easy-to-understand policy;
• prioritizing public health communications;
• promoting results-based partnerships;
• developing a workforce prepared for future emergencies.
“The end of the COVID-19 public health emergency marks a tremendous transition for our country, for public health, and in my tenure as CDC director,” Walensky said in a recent resignation statement to President Biden. “I took on this role, at your request, with the goal of leaving behind the dark days of the pandemic and moving CDC — and public health — forward into a much better and more trusted place.”
Could Anyone Have Done Better?
Given the mutability of SARS-CoV-2 — and large swathes of the population who refused to social distance, wear masks, or be vaccinated — one could make the argument that no prior CDC director could have done much better. If there was a weak link for Walensky, it probably was communication and handling of an aggressive press, which published the federal costs of her media training as she tried to get up to speed.
Past CDC directors Julie Gerberding, MD, (2002-2009) and Tom Frieden, MD, (2009-2017) are highly skilled communicators, although they made a few mistakes of their own.
For example, during the November 2001 anthrax mail attacks, the CDC made some assumptions that proved to be fatally false: postal workers who processed mail using high-speed sorting machines were at risk of cutaneous exposure, but anthrax spores would not be re-aerosolized and become an airborne threat. Gerberding already was at the CDC revamping the old hospital infections program and soon was to be promoted to agency director.
This anthrax dogma was “wrong,” she said at an open-forum analysis of the bioterrorism response in 2002 that was covered by HIC. “That was brought home when the postal workers at Brentwood [post office] died of inhalational anthrax and other cases in the Washington, DC, area were identified,” Gerberding said.
For his part, Frieden’s tenure was marked by the first cases of Ebola virus in the United States, with both U.S. caregivers and infected travelers coming in from a record outbreak in West Africa in 2014. CDC guidelines for infection control ran into some perception problems, and perception can become as reality when dealing with the outsized fear of Ebola.
The CDC first emphasized a combination of contact, droplet, and airborne precautions for aerosols, essentially saying that any U.S. hospital should be able to admit and isolate an Ebola patient.
These recommendations were skeptically questioned when the first cases of American care workers infected in Africa returned under heavy barrier precautions and were treated in virtually failsafe biocontainment units.
After two nurses were infected at a Dallas hospital in 2014, Frieden dropped the “any hospital can handle Ebola” message and pledged to bring in CDC rapid response teams if alerted to a case. (See Hospital Infection Control & Prevention, December 2014.)
A Fateful Decision
There is scarcely a federal agency or organization involved in the pandemic response that can claim anything close to a mistake-free record. Walensky was dealing with a changing pathogen, as SARS CoV-2 kept evolving into more transmissible variants.
Although it came relatively early in her tenure, if there was a bridge-too-far moment for Walensky, it began on May 13, 2021.
The CDC told the vaccinated public they could shed their masks and not socially distance in many indoor situations. In wanting to convey a message of progress and optimism while rewarding and encouraging vaccination, the CDC ran headlong into the emerging Delta variant of COVID-19.
On and about the July 4, 2021, holiday, the Delta variant caused a huge outbreak in Provincetown, MA. It not only caused breakthrough infections in those fully vaccinated — particularly if they were unmasked and indoors — but was transmitted from immunized people.
This was a disastrous turn for the agency, hurting its credibility for future recommendations, the first of which was to return to masking indoors. Of course, some never did. (See Hospital Infection & Control, September 2021.)
In retrospect, the masking fiasco seems to be the result of a calculated risk and, possibly, some political pressure for a return to normalcy. The CDC apparently was convinced that this highly transmissible Delta variant would not cause breakthrough infections in any big way, although some level of infections in the immunized always was expected because the vaccines were imperfect.
The Delta variant already had caused large outbreaks in India in 2020 and was spreading globally. Indeed, it was the predominant variant in CDC genomic sequencing in the United States by late June 2021 — about six weeks after the indoor mask removal recommendation.
Looking at these data, the CDC had a narrow window to rethink the masking policy and warn about Delta before the Provincetown outbreak. It may have been fruitless at that point, but it is no overstatement to say that the indoor mask and distancing policy was a spectacular failure. In the outbreak of 469 cases, about 74% were fully vaccinated.
Of course, it will take more than a new director to restore the credibility of what once was considered the finest public health agency in the world. Some have suggested measures beyond the proposed improvements, including granting the CDC enough regulatory power to demand data from states, establish a branch of its leadership in Washington, DC, and finally give the agency the budget to get ahead of the curve while investing in public health in general.
“Since the AIDS (acquired immunodeficiency syndrome) pandemic, our country has lurched from one crisis to another and consistently failed to truly invest in long-term progressive infectious diseases preparedness,” Gerberding said.1 “Once the crisis resolves, we relax back into our baseline complacency. I see that happening right now. I don’t know what it will take for us to embrace the truth that health security is a critical pillar of our national security.”
REFERENCE
- Inglesby T, Morrison JS. How to overhaul the C.D.C. The New York Times. Published May 7, 2023. https://www.nytimes.com/2023/05/07/opinion/cdc-overhaul.html
After conceding that the Centers for Disease Control and Prevention made mistakes and errors in the pandemic response — then launched an ambitious effort to reinvent the agency — Director Rochelle Walensky, MD, has announced she will resign at the end of June 2023.
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