We’re Expecting the Wrong Things from the CDC: If you want the CDC to be apolitical, you’re missing the point of public health

Excerpt – 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. [..]

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. [..]

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. [..]

“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? [..]

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.

[..] 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.” [..]

“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.”

Full article, T Requarth, Slate 2022.3.21.