Rochelle Walensky walked into a hot mess when she took the helm of the U.S. Centers for Disease Control and Prevention (CDC) in January 2021.
Then head of infectious diseases at Massachusetts General Hospital, Walensky was an HIV/AIDS clinician and researcher who specialized in cost-effectiveness studies and oversaw fewer than 80 physicians. She took over an agency with a $15 billion annual budget, nearly 11,000 employees, and a world-renowned reputation that had been battered by its haphazard, inconsistent response to the COVID-19 pandemic. Part of the problem lay at the feet of outgoing former President Donald Trump’s administration, which had restricted CDC’s ability to communicate with the public, altered its scientific reports, and pressured it to go along with advice that sometimes ran counter to scientific evidence.
But the pandemic also revealed cracks in CDC’s structure that had little to do with politics. The agency had difficulty keeping up with the fast-moving crisis. Whereas most scientists had shifted to preprints to publish COVID-19 data, researchers at CDC often published in the agency’s own Morbidity and Mortality Weekly Report (MMWR), which requires several levels of clearance before publication. CDC also botched the development and distribution of COVID-19 tests, sending out a faulty diagnostic to state labs; issued unclear directives about prevention efforts such as social distancing and vaccines; and was at a loss to combat disinformation spread on social media.
In April, Walensky announced two reviews of the agency. One looks back at CDC’s COVID-19 response to analyze its failings; the other assesses the agency’s organizations, systems, processes, and policies. Last week, after seeing preliminary findings from these reviews, Walensky spoke to the entire CDC staff in a video that didn’t mince words. “To be frank, we are responsible for some pretty dramatic, pretty public mistakes, from testing to data to communications,” Walensky said. “This is our watershed moment. We must pivot.”
Science spoke with Walensky about the reviews, neither of which have been finalized, and her vision for reforming CDC. The interview has been edited for brevity and clarity.
Q: In September 2020, former CDC Director William Foege wrote a blistering letter to then-CDC Director Robert Redfield, saying CDC had been “a colossal failure” in its COVID-19 response and lamenting that the agency had gone from “gold to tarnished brass.” He urged Redfield to send a letter to employees laying out the facts to try to rebuild morale.
Are your public statements about the shortcomings identified in the reviews your attempt to help rebuild morale within CDC and own its mistakes?
A: I stepped into that. You’re absolutely right. I’m not sure that the headlines of the last week boosted morale within the agency. I mean, the headlines said, “We botched the response.”
But I wasn’t necessarily motivated by [Foege’s] letter.
I was always a really avid consumer, champion, and cheerleader for CDC before I got here. The people at the CDC are amazing. They have subject matter expertise and have been able to stand up to so many different things. And yet there were so many structures and incentives and alignments and priorities that made it hard for them to do so [during the pandemic]. So my job after a year and a half in this agency was to understand things better from the inside, to say: Let’s comprehensively look at what went well and didn’t go well, with COVID-19 and outside of COVID. And then let’s course-correct.
Q: This is essentially what Foege was recommending: Lay out the facts for your employees, own it, and apologize for mistakes.
A: The issue though is whether the people themselves were responsible or whether many of the things in the structure around them didn’t allow them to operate as swiftly as possible and didn’t allow them to prioritize. I think it’s a little bit of both.
Q: You’re a specialist in prioritizing. That’s what cost-effectiveness studies are all about.
A: That is exactly right.
Q: What are you going to prioritize? You could overnight say: CDC employees, you’re welcome to submit preprints and no longer wait for MMWR. Are you prepared to do that?
A: I don’t know that I can do that at the drop of a hat. But that is something that we are looking at: How is it that we get our data out faster? I published enough papers to know that as painful as the review process is, the papers are generally better after it. So I don’t want to get rid of that necessarily. But there is the case, especially in public health, that we have to make data public if we are pretty confident they are pretty clean, because we need to take that action imminently.
But CDC has been changing. Last week, we put the American Men’s Internet Survey data about monkeypox up on our website, and the paper hasn’t come out yet. The question is, what’s the best way to do it? There are lots of different ways. But the clearance process at CDC for published things is too slow.
Q: The central criticism of CDC is that it’s been hamstrung by its own caution and reticence again and again. Testing was an infamous botch in the early days of COVID-19, and the way CDC has handled monkeypox testing has also been criticized.
A: By virtue of being a leader now I have to own what happened with the COVID testing. And we’ve been doing a lot of work on testing. We now have an infectious disease review board so that any test that comes out of CDC is reviewed. We’ve been doing a lot of work on quality assurance.
What happened with monkeypox is different. We had a test. We had published data on the primers [used in the polymerase chain reaction assay] online as soon as the first monkeypox cases were being reported. Within days of the first couple of cases, we were on the phone with commercial labs, which we felt was the fastest way to scale up as much testing as possible across the country. We got rid of the manual processing and automated it.
There were challenges in access to laboratory resources, I’m not going to deny that. And there was education that needed to happen. We were accused of not testing broadly enough, widely enough: “Why can’t I just walk in the door?” People don’t necessarily recognize you need a rash to be tested.
Q: A problem a lot of people point to is the relationship between CDC and states and local public health offices. Some, for example, defiantly ignored CDC’s masking and COVID-19 vaccine recommendations. How are you addressing that?
A: We have to prioritize our partnerships. I have had regional calls with each of the states. I am on the phone with the Association of State and Territorial Health Officials (ASTHO) frequently. I actually have said to ASTHO, some of you I hear from, some of you I don’t. I wanted to meet them so they feel free to reach out to me if something is not going well.
As you probably know, we need to be invited into states. We can’t just show up and say we want to be here. What we really want to do is say how can we be most helpful to you.
Q: Are there any concrete plans you have based on the drafts of the reviews that you’ve seen? Are you planning to fire or reshuffle staff?
A: For most of its history, CDC has spoken to public health partners and to scientists, not to the American public. Most people did not go to the CDC website to see what the school guidance was before COVID. So we have to become more versatile in how we speak to the American public. We have not historically been challenged by social media and disinformation. How do we do all of those things?
Secondly, we’re going to realign incentives for staff so that we move toward promoting people for taking actions that benefit public health. How do we realign our communications to speak with the American public?
It’s not lost on me that changing boxes around on an organizational chart is not going to do anything in and of itself. We haven’t spent enough of our time, energy, and resources on our public health infrastructure, our core capabilities of personnel, data modernization, and laboratory infrastructure. And that is the investment that I think we really need to make.
Q: How are you going to convince good people, especially young people, to join CDC in the future given what it’s been through in the past few years?
A: It’s such an easy sell. It’s such an incredible organization of people who are up all night, whose names you will never know, because they are benefiting health around the country and truly around the world. I just spoke to somebody yesterday who was retiring. She said, “I can’t believe they pay me to do this job.” And so if you are that inclined toward science, epidemiology, and health missions, I’d be happy to talk to you because I think it’s an incredible place and full of just incredible people.