S1E24 / Is the CDC MIA? / Jim Curran & Mark Rosenberg

Before we start today's show, we want to take a minute to recognize Larry Kramer, who died this week. Larry was one of the leading voices in the fight against HIV. He was a vital voice during the AIDS pandemic, and his passing is a reminder that we need more voices like his today in the fight against COVID. I'm Dr. Celine Gounder.

And I'm Ron Klain.

And this is Epidemic. Today is Friday, May 29th. Back in February, the Centers for Disease Control and Prevention, the CDC, hosted a routine press briefing. The topic was the latest updates from the CDC on the novel coronavirus.

We are joined today by Dr. Nancy Messonnier, Director of CDC's National Center for Immunization and Respiratory Diseases, who will give opening remarks before taking your questions. I will now turn the call over to Dr. Messonnier.

But the reporters who dialed into that press briefing got a blunt assessment from Dr. Nancy Messonnier about the spread of COVID in the United States.

We expect we will see community spread in this country. It's not so much a question of if this will happen anymore, but rather more a question of exactly when this will happen and how how many people in this country will have severe illness. I understand this whole situation may seem overwhelming and that disruption to everyday life may be severe. But these are things that people need to start thinking about now. I had a conversation with my family over breakfast this morning, and I told my children that while I didn't think that they were at risk right now, we as a family need to be preparing for significant disruption of our lives.

Nancy Messonnier was talking about what this epidemic is going to do to our country. And she said that it could really disrupt our daily lives, that its impact could be much more extensive than we had ever imagined.

This is Dr. Marc Rosenberg. He's a retired medical epidemiologist with the CDC and president emeritus of the Task Force for Global Health.

And I think there were people who thought that that was not a good thing to tell people because it could hurt the economy. It could cause stock prices to fall. And it was an example where people did not want to know the truth. And she was punished and sidelined and censored because she had spoken the truth.

The Wall Street Journal reported in April that President Trump was furious with Messonnier after the briefing. Her remarks nearly got got her fired, according to the journal. Now, when we think about official voices of the pandemic, Dr. Tony Fauci from the National Institutes of Health is a household name, but you probably can't name the person in charge of the CDC.

That would be Dr. Robert Redfield, if you're playing along at home.

People are used to hearing from Tony Fauci, and he's done a tremendous job, but Tony heads NIH infectious diseases, He doesn't head the Centers for Disease Control. Tony's institution is a research institution. It's a gem. It's incredibly important, NIH. But its job is not to control epidemics. It's to do the basic research. CDC's job is to control the epidemics. And we're trying to operate with two hands and two legs tied behind our back.

So why is the CDC, the federal government's agency dedicated to responding to health threats and preventing disease, missing in action during this pandemic?

In this episode, we're going to speak with former CDC scientists like Dr. Marc Rosenberg about the agency's complicated history with political leaders, what's happening to CDC's work in the time of COVID and what's at stake when politics take precedence over science.

How do you think research at the CDC, and for that matter, policy out of the CDC, for example, guidelines for reopening the country, how has all of that been suppressed during the COVID pandemic?

So what people have focused on, I think, with the CDC is that their guidelines have been altered or muzzled, that their director's job is being threatened. I mean, clearly the CDC voice and the epidemiologic and prevention voice has not been very evident at the national level.

This is Dr. Jim Curran. Jim led the CDC's HIV/AIDS division before becoming an Assistant Surgeon General, and now he's the Dean of the Rollins School of Public Health at Emory University.

We're hearing that the CDC can't do this, the CDC can't do that, so therefore we're not going to let you hear them anymore. We don't think their voice is important, and therefore people are suspicious when they see things that don't have the CDC imprint on it, or when they see something come out of the CDC, they feel like it's been watered down or muzzled. That's a mistake for a democracy, and it's a mistake for the credibility of what comes out.

This antagonism toward the CDC is nothing new. Part of that has to do with the fact that the CDC's job is to tell people what to do to stay healthy, and that doesn't always go well. Think about how the CDC is seen versus the NIH, the National Institutes of Health. These organizations might sound interchangeable at first, but the NIH and CDC have very distinct missions: basic science research versus public health research and policy. And that distinction has a lot to do with why the CDC seems like it's been sidelined from the federal response to COVID.

Why is there bipartisan support for the NIH but not for the CDC? Why is the work of the CDC perhaps more political in some ways?

I think there are 3 reasons for that. The NIH is a remarkable agency which is the primary funder of biomedical research throughout the United States and to some extent in the world, and it funds virtually every university that does biomedical research in the United States. So it does things which are laudable, necessary, highly technical, and generally not very controversial. The CDC, on the other hand, is improving the health of populations, and improving the health of a population means constantly redefining the unacceptable. The CDC comes out always shaking their fingers at people. Telling them they should socially isolate, telling people they should wear masks, telling people they should get tested if they have HIV, telling people they need to get flu shots, which they may not want to get.

And prevention is also more inherently political because you have to employ measures that some people and their economic or political interests may oppose.

Mark Rosenberg again.

So no one opposes the treatment of patients with cancer with chemotherapy. People don't oppose that. In fact, they benefit from that economically. A huge healthcare industry in this country benefits from what NIH develops. But when you come to imposing limitations on movement restrictions, wearing of masks, being immunized before you can go to school. These always stir up resentment and resistance.

Some people may resent these recommendations, but public health initiatives have a track record of preventing deaths.

In the 1960s, there was an epidemic of young people dying on the highways in car crashes. And the government said, we've got to stop this. And they started doing research on motor vehicle crashes. They appropriated $200 $200 million starting in 1970, and every single year thereafter, they put in $200 million into research on motor vehicle crashes, and they started the National Highway Safety Traffic Administration. That research brought about a minor miracle. Buckle up for safety, buckle up. What they did is they totally redesigned the car. And they made engine blocks that crushed like an accordion to protect you. And steering columns that collapsed. They also designed front airbags, then side airbags, knee airbags, head airbags. They designed seatbelts, rollover protection, side impact protection. But they redesigned the car totally based on research. And what happened was that they brought the death rates way, way down. So that between 1970 and today, this research, this science has saved more than 600,000 lives.

Everybody buckle up!

And we looked around in 1983 and we said, why don't we apply the same type of scientific research to gun violence?

At the time, the federal government was spending next to nothing on gun violence prevention research. Mark and others at the CDC hoped that with some funding, they could achieve similar life-saving results with guns. So the first thing they looked at was the impact of guns in the home.

The research we did showed not only did having a gun in your home not make your family safer, but it markedly increased the risk that someone in your family would die from a gun homicide. That went up 200%. That's a huge increase in risk. And the risk that someone would die from gun Suicide in your home went up 400%, and the NRA did not like this. They thought this would be bad for business. So they developed a strategy that turned out to be very effective for them, but had a terrible toll on the country. They said, look, you can either allow this research to go forward or you can keep your guns. You can't do both. They basically demonized science. And they said science was on the side of taking your guns runs away.

The NRA's battle against the CDC's research reached its peak with something called the Dickey Amendment in 1996. This was named after Representative Jay Dickey, a Republican from Arkansas. The provision said that no federal funds could be used to advocate or promote gun control, and some thought research on gun violence prevention was doing just that.

This was a shot across the bow, and it effectively helped to stop the research. For 20 years after that, there no effective federal funding of gun violence prevention research. And during that time, we lost 600,000 lives to gun violence. I'm not saying that the research would have prevented every death, but it would have made a huge impact on that toll.

How is it that the science wasn't against gun rights? How could you have science on gun violence prevention and yet still maintain the right to own arms?

That's a really good question, Celine. Jay Dickey, the congressman from rural Arkansas who led the fight for the NRA to stop gun violence research, taught me that you need to say at the beginning that we are looking for those interventions that will do two things. They will reduce gun violence and at the same time protect the rights of law-abiding gun owners. We want to find those things that will do both. And I guess the analogy to COVID-19 is that it's not a struggle between public health, saving lives, and saving the economy. It's very much like the argument for gun violence. You can do both. You can find those things that will save lives and support the economy. But you have to use science to find out what works to achieve both objectives. And if we demonize science, if we say that science is the enemy, if we weaken our scientific institutions, we are shooting ourselves not in the foot, probably substantially higher up.

A decade or so before Marc was trying to get CDC's gun violence prevention program off the ground, Dr. Jim Curran was working on another epidemic, the AIDS crisis.

As I always mention to students, public health is always political because it involves change and epidemics and populations, but to the extent possible, it shouldn't be partisan.

You know, I love your statement, Jim, that public health is political but hopefully not partisan because obviously there's no separating public health the public. Talk a little bit about the climate of fear at this time and how the public reacted to the emergence of this disease.

Doctors who had never seen this before would see one case and it would change their lives in the sense that they would say, I've never seen anything like this— a previously healthy person deteriorating so much and becoming so ill. So they were afraid for themselves, but there was not a great deal of fear in the public until cases were diagnosed in infants and until there was strong documentation of heterosexual transmission. There was sort of a knee-jerk public reaction then to, oh my God, everybody's gonna get it, and that resulted in a huge amount of fear. Just like with any epidemic, Denial, discrimination, and scarcity are the main enemies.

Alongside the work of activists and their allies, the CDC played an important role in the early days of the AIDS crisis. Before anyone knew that AIDS was caused by the HIV retrovirus, CDC did an epidemiological study to track the cases.

And CDC's perhaps major important role was one of surveillance. Surveillance became the conscience of the AIDS epidemic and drove people to say, this disease is more important than our prejudices, more important than not doing anything about it.

You know, I think one thing that's interesting here is when diseases are politicized, whether it's Ebola or more recently COVID, there's very often this conversation about whether the disease is real. We had this discussion about, is Ebola a hoax or is it real? Even in South Africa, with HIV, there were questions of, does HIV actually cause AIDS? In the US, was that the conversation? You know, did the politics, the fear about AIDS lead to that kind of discussion, or was it more of a situation of neglect?

Well, I think that in the US, it was a combination of things. I would use Thabo Mbeki in South Africa, by the way, as the worst example of a politicized leader in AIDS. There were some competitions for that, but Thabo Mbeki's role resulted in the death of millions of South Africans during a time when highly active antiretroviral therapy was becoming available. He courted many of the AIDS deniers.

So, Jim, I want to ask you about the point you were just on and the parallel and differences to today with COVID What's interesting now is that with COVID we have a relatively simple way to reduce the transmission of the disease, wearing masks when we're around other people. And you have the public running around, many members of the public, many complying and happy to do so, but others running around saying, "It's my right not to wear a mask. I'm an American." And the politics seems to be against restrictions or requirements that would slow the transmission of COVID Why do you think there's this real almost 180-degree difference in kind of where the political thrust was then versus where the political thrust is now.

So why don't people do all the things that need to be done? Well, we know the lack of testing and contact tracing was related to access and availability to begin with, but also confusing messages. Initially, we were told, well, people didn't need to be tested unless they were really sick. That's never been true. The hallmark of prevention of infectious disease is to identify and isolate infectious people. We just didn't have enough tests. But the messages are very unclear. Initially, we were told you didn't need to wear masks, and now we're being told you need to wear masks. The president and the vice president don't wear a mask. Well, if they don't wear a mask, why should anyone else wear a mask? And so the thing is, leadership is really important.. But also consistency in messaging is really important.

I want to follow up though on one thing you said. It is a fact that the disease is most lethal among the elderly and a fact that in many of our cities the principal victims have been disproportionately people of color. Is there some of the public reaction to this similar to the reaction that AIDS was a gay disease, quote unquote, and now 'Maybe COVID is an old person's problem. Maybe it's a problem for people of color. It's not my problem.' Do you think there's some parallel there?

Yes, I think there are two parts to it. One is the issue of denial, which is that not only won't I die from it, but I also, I won't be affected by it, and I don't want to think about being affected by it. And the other one is the question of social responsibility for others. We really don't want to not be able to go back to work. We don't want to not be able to go to the beach. We don't want to not be able to have vacations and go to bars. And so we are able to deny the implications to ourselves. The severe illness rate and fatality rate in young people is, is not negligible. It's much lower than it is in the elderly, but there's been a lot of young people who've been very ill and who have died. So I think, again, the leadership issue is an important one for the social responsibility part, but a lot of people behave based on their own feeling of risk.

Jim, let's talk a little bit more about denial, but among politicians. So if you go back 20 years with South African President Thabo Mbeki, for example, or look at COVID in the United States and other countries today, why is denial such a common response among politicians to and infectious disease outbreaks like this?

Infectious disease outbreaks are at least inconvenient and at most very disruptive to a broader agenda. You know, whether this is something as simple as getting reelected or something as simple as having a legacy, no one wants to think that an infection is going to come along and become the public health crisis of the century., and something which is going to be in all of our memories kind of the equivalent of World War II. And presiding over a community, whether you're a mayor or governor or president, during a time when the course is uncertain and watching, you know, the ship go down, if you will, is a very frightening thing. That's not why you went into politics. This is occurring in an election year. It's accompanied by the biggest election bugaboo, which is the decline in the economy. There's all sorts of reasons for these political issues to become partisan issues. The important thing is that the facts don't change, or that they aren't suppressed. And so it's important to have agreement and accuracy of things like, for example, mortality rates. Or infection rates. And then you can argue about how you deal with those facts in terms of reopening the economy.

Marks says politics, like the 2020 presidential election and the urgency to reopen the economy, are pressuring the CDC in unprecedented ways.

I think there are some people who are afraid that the truth will hurt the economy. That if we let CDC speak the truth, that will hurt stock prices, that will hurt people's jobs in the manufacturing sector. But even when the truth may hurt, even when it's painful, we've got to know the truth. And right now people are taking steps to keep CDC from speaking the truth. What I have heard from colleagues and friends inside CDC is that their work is censored now to a degree that they have never before seen.

Take, for example, clearance. CDC researchers normally request clearance to pursue their work, but Marc says that these approvals are now coming from Washington in the form of something called pre-clearance.

What is pre-clearance? It means that before you even write a paper. Before you even think about putting your scientific results together, you've got to get permission to start writing and start talking and start thinking about what you're going to say. When you think about what that implies, it's really scary. So let's say you're a vaccine researcher and you're trying to think about this ahead of time. So So you would request pre-clearance on this. You'd ask for permission. Can I start to look at this now, this question of how best to distribute the vaccine? But what if some of the people who have to give pre-clearance said, no, this is a potentially very inflammatory subject. We don't want you drawing attention to the fact that we don't yet have the vaccine. So no, we don't want you to start this work. So if that work is silenced, if it's not started, if you don't get approval to start that and bring people together to talk about it, that could really damage our efforts when we have the vaccine. And it could be done because political ideas were thought to be more important than finding out the truth. And so if we damp down, if we stop, if we don't start the science, we'll be caught flat-footed. We won't know what to do when the time comes. We won't save time. We won't distribute it most efficiently and economically. So that's just one example of how censoring the science, keeping it from investigating certain questions, could be damaging.

Marc and Jim both say that CDC's most important job is providing accurate information so that policymakers can make the best decisions.

It's hard to know how well the CDC is doing in a variety of areas because they've been silenced, and there's so much that's still unknown. That needs to be investigated that we should be learning about that when we hear from the task force instead of just learning about how many test kits we have or, you know, or things like this. I mean, for example, what is the role of infection and transmission in children? What do we know about which antibodies are indicators of immunity and which aren't? And how do we think that the vaccine people are working with the epidemiology people to understand these things?

Without a full, accurate, evidence-based picture, our mayors, our governors, our senators and congresspeople, and our president won't know what to do. But that picture can be forthcoming from CDC. This is what they do really, really well. And I think even though some people were tempted to sideline CDC, in the beginning, it's time to get CDC back at the table.

Besides providing information like the number of cases, infection rates, or other epidemiological data, there's a more fundamental role for the CDC to play in this next phase of the pandemic.

We need to establish trust. Without that trust, people won't know what to do. We can open states up, But if the people don't trust that they'll be safe, if they don't believe that they'll be safe, they won't go back to buying things. They won't go back to working at their job sites. They won't go back into public if they don't know that it's safe. That message has to be a true message. It has to be based on science. And that's the message that should be coming out of CDC. They have the capability to do that now, and we've got to get them back into doing it.

This need for science-driven, trustworthy voices is especially true for what will likely be our most important tool for ending the pandemic: a vaccine for COVID.

One of the areas where we're going to need Nancy Messonnier and Anne Schuchat is looking at how we recommend to people that they get the vaccine once it's developed. People won't get vaccinated if there's not a credible authority and credible scientific voice telling them, yes, this vaccine is safe. Yes, you should get it. We've had a lot of experience with anti-vaccine folks who have contested vaccines that have been proven safe and effective for their own reasons. They have put out big campaigns against vaccination. People are already gearing up a huge campaign against the COVID vaccine once we have it. And if we don't have a credible voice, a credible authority based on science and evidence saying this vaccine is safe for you and it's safe for your family, it's safe for your children, if they don't have that credible voice, they're not going to go get the vaccine. And that credible voice has got to be CDC. CDC doesn't just help red states. Science doesn't just help blue states. But CDC and science will help all of us. We need it desperately. Our lives depend on it.

In our next episode, we're going to look into the science of vaccines in our series of episodes on the immune system. We'll look at how they work, how they're made, and what they'll mean for reopening our society. That's next time on Epidemic. Epidemic is brought to you by Just Human Productions. We're funded in part by listeners like you. We're powered and distributed by Simplecast. Today's episode was produced by Zack Dyer and me. Our music is by The Blue Dot Sessions. Our interns are Sonia Baradwa, Annabel Chen, Isabel Ricci, Claire Halverson, and Julie Levy. Special thanks to Dr. Bruce Weninger for his help reporting this episode. If you enjoy the show, please tell a friend about it today. And if you haven't already done so, leave us a review on Apple Podcasts. It helps more people find out about the show. You can learn more about this podcast, how to engage with us on social media, and how to support the podcast at epidemic.fm. That's epidemic.fm. Just Human Productions Epidemic Productions is a 501(c)(3) nonprofit organization, so your donations to support our podcasts are tax deductible. Go to epidemic.fm to make a donation. We release Epidemic twice a week on Tuesdays and Fridays, but producing a podcast costs money. We've got to pay Zach, so please make a donation to help us keep this going. And check out our sister podcast, American Diagnosis. You can find it wherever wherever you listen to podcasts or at americandiagnosis.fm. On American Diagnosis, we cover some of the biggest public health challenges affecting the nation today. In Season 1, we covered youth and mental health. In Season 2, the opioid overdose crisis. And in Season 3, gun violence in America. I'm Dr. Celine Gounder. And I'm Ron Klain. Thanks for listening to Epidemic.