An open letter to President Biden regarding the critical need to reorganize the CDC immediately

Last update: Thursday 6/17/21 

Dear President Biden,

On Sunday 3/21/21 you tweeted the following words of high praise for the CDC:  "The CDC represents the best of this nation. Brilliant minds. Deep faith in science. And a strong commitment to public service. On Friday, Vice President Harris and I stopped by to thank them for all the work they do."

Your gracious compliments may be valid for most of the CDC's staff, but certainly not for the CDC as a whole. Most close observers of the CDC's performance in 2020 and thus far in 2021 have expressed profound disappointment. 

EXECUTIVE SUMMARY

The Center for Disease Control and Prevention (CDC) should be a policy-oriented research operation that provides answers to high priority questions facing decision makers -- presidents, governors, mayors, corporate executives -- as to the relative advantages and disadvantages of specific policy options related to the control and prevention of infectious diseases. One must conclude that the CDC's failure to deliver clearly written, timely, consistent recommendations on a wide range of issues throughout the pandemic reflects the failure of its management to mobilize its talented staff into effective policy teams.

The CDC must be reorganized immediately. Its upper level managers and perhaps large segments of its staff should be replaced to reflect the nation's need for a CDC that provides practical advice to decision makers in the public and private sectors, a public agency more akin to McKinsey & Company than to the National Science Foundation (NSF) or to the National Institutes of Health (NIH). Our governors, mayors, and corporate executives need workable options that are informed by science where possible, but also reflect best practices and well considered judgements based on hands-on experience when problems are so complex as to exceed the scope of any of the established sciences. 

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Rather than present a lengthy review of every one of the CDC's important blunders, this discussion focuses on masks because 20-20 hindsight makes it clear that the CDC's mismanagement of masks was a catastrophic fumble that cost hundreds of thousands of lives. This harsh assessment will be explored via three scenarios: ideal, real, and prospective. 

A. Ideal scenario ... N95 respirator masks for everyone

This scenario supposes that the supply of N95 respirators in March 2020 was sufficient to enable everyone who wanted N95 respirators to be able to purchase them at affordable prices whenever they needed them. If this counter-factual had been true, then the following conditions would have been in effect:

• Everyone who wore N95 respirators would be able to engage in face-to-face encounters with other people regardless of whether the others were wearing masks, just like doctors, nurses, and other health care providers.
  
  
• People who refused to wear N95 respirators would be risking their own health, but they would not pose health threats to people who wore masks, especially if the mask wearers maintained a social distance from the non-mask wearers as an extra precaution.
  

For mask wearers the "ideal new normal" would have been very similar to the "old normal". 

• The vast majority of mask wearers would have been able to continue working in their usual offices and other work place environments and the need for lockdowns and other severe disruptions of employment would have been minimized ... perhaps with some social distancing in order to accommodate the presence of non-mask wearers who were critical to an organization's operations
  
  In particular, schools at all levels would have been able to maintain their traditional face-to-face classroom arrangements for students, faculty, and staff who wore masks.
  
  Exception:  restaurants would have had to impose social distancing because their customers would have to remove their masks while they were eating.
  
  
• Mask wearers would have been able to maintain their usual face-to-face social relationships.
  
  In particular, mask wearers would have been be able to visit sick and dying relatives in hospitals and nursing homes.
  
  
• Mask wearers would have minimum concern about significant virus mutations that reduced the effectiveness of the latest vaccines that were available as long as the mutation did not develop significant non-respiratory transmission capabilities.

Unfortunately for the anti-mask minority, the "ideal new normal" would have been the same kind of hyper-stressful "new normal" that actually occurred during the pandemic. Most anti-maskers would have been required to work at home or lose their jobs; to have their children educated via remote learning; to maintain social distancing in their social relationships; and to be denied access to dying relatives in hospitals and nursing homes.

Bottom line: Had the U.S. been able to follow this ideal scenario, the mitigation policies needed to manage the pandemic would have been far less stressful for most of the U.S. population; hospitalization and death counts would have been a fraction of the hospitalizations and deaths that actually occurred; and the recovery funds needed to get the economy back on track would have been measured in billions of dollars, an order of magnitude smaller rather the multi-trillion dollar costs that were actually incurred. After vaccines were developed, if substantial variants of the virus appeared, vaccinated members of society would merely resume their use of N95 masks until they received updated versions of the vaccine that provided protection against the new variants.

B. Real scenario .. N95 respirators, but not for everyone

Question: why wasn't the ideal scenario feasible? Answer: lack of supply. 

• Shortage and confusion
  In early March 2020, the anticipated demand for N95 respirator masks by doctors, nurses, and other COVID-19 health care professionals greatly exceeded the supply from existing N95 providers. The CDC and its health care associates on President Trump's Task Force were so concerned that non-medical customers would buy the scarce N95 respirators that they initially discouraged the public from buying any kind of masks at all.
  
  In their television presentations the CDC Director and the other members of the Task force asserted again and again that the only masks that provided effective protection against COVID-19 were the scarce N95 respirators. Moreover, wearing ineffective masks might provide wearers with a false sense of protection that might make them less likely to maintain social distancing, wash theirs hand frequently, and other effective coronavirus prevention practices. 
  
  However, a few weeks later the CDC and its Task Force associates suddenly reversed their position. Now they proclaimed that non-N95 masks were good things that would significantly reduce the spread of the virus. The public was confused by this reversal, but most people began to wear masks anyway. While non-N95 masks did not offer substantial protection for their wearers, the CDC argued that their widespread use within communities would substantially reduce the spread of the virus within those communities.
  
  Subsequent studies confirmed that communities wherein most people wore masks experienced rates of infection that were much lower than communities wherein masks were not prevalent.  Please take a look at two comprehensive reviews: "Face masks: what the data say", Lynne Peeples, Nature, 10/6/20 ... and the more recent "An evidence review of face masks against COVID-19", Jeremy Howard et al., PNAS, 1/28/21
  
  It is important to note that these two comprehensive reviews could not cite any studies about masks and the coronavirus that were published before June 2020 when the first paper providing direct evidence about masks impeding the coronavirus appeared. Indeed, the October 2020 review in Nature admitted as much:
  
  "At the beginning of the pandemic, medical experts lacked good evidence on how SARS-CoV-2 spreads, and they didn’t know enough to make strong public-health recommendations about masks." [bold added by editor]
  
  The CDC's initial recommendation in early March 2020 that strongly opposed the wearing of non-N95 masks was a bad judgement call; however the CDC's flip-flop a few weeks later to recommending non-N95 masks was a good judgement call because it subsequently received substantial support from the many other scientific studies cited by the Nature and PNAS reviews.
  
  The point here is that the CDC should not confine its recommendations to those that are based on science. It must also make judgement calls informed by science, but ultimately based on experience.
  


• Double masking
  Careful observers of our efforts to manage the pandemic were noting as early as June 2020 that the CDC's haphazard approach to masks was not sufficient. For instance, see the following article:  

  "We Need Better Masks", Ranu S. Dhillon, Abraar Karan, David Beier, and Devabhaktuni Srikrishna, Harvard Business Review, 6/18/20. 

  This article's second paragraph reads as follows: "Testing remains an order of magnitude short of what is needed, and a vaccine won’t be available until at least early next year [2021]. But we could potentially achieve control and confidence now if better masks were available for the general public that are more protective than the cloth ones worn now and closer in caliber to the N95 and high-filtration surgical masks used by health workers."

  The most obvious improvement that would have required no time or effort to develop and market would have been two masks, e.g., wearing a cloth mask over a surgical mask. If the CDC suspected that a single mask might reduce the number of infections, hospitalizations, and deaths, why didn't it consider potential further reductions from double masking? Alas, the CDC did not see fit to recommend double masking until February 2021. (See "Masks should fit better, or be doubled up to protect against coronavirus variants, CDC says", Lena H. Sun and Fenit Nirappil, Washington Post, 2/10/21.)
  
  
• N95 respirators, but only for health care personnel
  The scarcity of N95 respirator masks at the start of the pandemic in early 2020 -- i.e., lack of stockpiles and lack of U.S. providers ready to ramp up production -- reflected years of underfunding of the CDC and its state-level public health affiliates. However their continued scarcity throughout the pandemic reflected bad judgments by President Trump and by the leadership of the CDC and their associates on Trump's Task Force.
  
  President Trump had been briefed in January 2020 that the coronavirus posed a clear and present danger to the U.S., a threat that he took very seriously. His response to this threat was Operation Warp Speed, a multi-billion dollar high speed initiative to develop effective vaccines by the end of 2020, vaccines that would enable the U.S. population to achieve herd immunity. 
  
  -- "Woodward book: Trump says he knew coronavirus was ‘deadly’ and worse than the flu while intentionally misleading Americans", Robert Costa and Philip Rucker, Washington Post, 9/9/20
  
  -- Trump’s ‘Operation Warp Speed’ Aims to Rush Coronavirus Vaccine", Jennifer Jacobs and Drew Armstrong, Bloomberg, 4/29/20
  
  Meanwhile, he needed to carry out two holding actions: (a) provide sufficient N95 respirators and other personal protective equipment to health care personnel, and (b) use social mitigation to keep the levels of infections and hospitalizations from overwhelming the U.S. healthcare system. Unfortunately, both holding actions failed.
  
  President Trump invoked the the Defense Production Act of 1950 to expand the domestic production of N95 respirators for health care providers just once, a timid action that commanded one company, 3M, to increase its output; but the contracts did not go into effect until May 2021 ... but they were too little, too late. This left the health care providers, governors, mayors, and others to continue competing against one another for still scarce respirators from the usual suppliers in a wasteful bidding war. 
  
  -- "The Defense Production Act Won’t Fix America’s Mask Shortage", Wired, 4/8/20
  -- "3M Awarded Department of Defense Contracts to Further Expand U.S. Production of N95 Respirators", 3M, 5/7/20
  
  Social mitigation also failed to block the expansion of the virus. The CDC and its Task Force associates must have convinced President Trump that a nation-wide lockdown, the ultimate mitigation, lasting no more than three or four weeks starting in March2020 would reduce the future spread of the virus to manageable levels; but it didn't.
  
  Correction: the partial lockdown that actually resulted from voluntary compliance with the Task Force recommendations was sufficient to wreck the U.S. economy, but not sufficient to block the continued spread of the virus. It is difficult to understand how the CDC could have anticipated success at a time when there were fewer than 20,000 known cases of COVID in less than 10 states, nor would the virus reach many other states until weeks or months thereafter. (Note: 20,000 cases in a  U.S. population of 330,000,000 represents an infection of rate 0.006 percent)
  
  "A Striking Disconnect on the Virus: Economic Pain With Little Illness", Michael H. Keller, Steve Eder and Karl Russell, NY Times, 6/6/20
  
  Seeing no cases, substantial segments of the people in the other 40 states thought the pandemic was greatly exaggerated or a hoax; so they didn't maintain social distancing nor wear masks. Beyond this, the CDC was requesting a high degree of cohesive action at a time in which the country was more divided than at any time since the decades immediately preceding the Civil War. Indeed, less than half of the population expressed approval of the president, which undermined their trust in his appointed leaders of the CDC and their associates on his Task Force. 
  
  President Trump's angry disappointment at the end of April six weeks later led to his confusing efforts to pull all states come out of lockdown, regardless of the status of the virus in each state.

The CDC's initial error about masks and the confusion caused by its sudden flip-flop were far less consequential than the fact that the CDC (and President Trump) made no significant efforts to provide everyone with N95 quality masks. Protective masks for everyone, not just health care providers, would have saved hundreds of thousands of lives, especially among Blacks, Hispanics, and other minorities who bore a disproportionate share of the coronavirus illness and death.

• "Hispanic Americans are most vulnerable to covid-19", The Economist, 6/5/21

A pandemic "Big Lie"
Despite repeated references to "the science" by the CDC, the Task Force, and liberal/progressive pundits as the basis for the CDC's recommendations for managing the pandemic: there is no such thing as a science of pandemic management.

To be sure, there are relevant biological sciences -- e.g., epidemiology, virology, and genomics -- that might be referenced together as "the science". But there is no body of reliable, data-driven scientific theories about how to change the lifelong habits of a super majority of our citizens so as to win a total war against a virus whose infections have massive impact on the families, educational institutions, local economies, personal relationships, and the individual psychologies of large segments of our population. Why? Because we have only had one other pandemic in the last hundred years, so there has not been sufficient opportunity for researchers to conduct the extensive, multidisciplinary studies required to develop a reliable science of pandemic management.

Another "Big Lie"

A second "Big Lie" that the liberal/progressive media pounded into the public's consciousness was that Trump was the "bad guy"; whereas the CDC and its allies on Trump's Task Force were the "good guys" who strove mightily to invoke "the science" in support of good policies that would counter Trump's evil deeds. "The Bad Guy vs. the Good Guys" meme boosted media ratings; but a more accurate meme would have been "The Bad Guy AND the Good Intentioned, but Ineffective Fumblers"

Indeed, the CDC has continued to fumble throughout the first four months after President Trump left office. Case in point: the CDC's recent surprise recommendation that masks need not be worn by vaccinated citizens except in a handful of exceptional situations:

• "Vaccinated Americans May Go Without Masks in Most Places, Federal Officials Say", Roni Caryn Rabin, Apoorva Mandavilli and Noah Weiland, NY Times, 5/13/21
• "Federal Mask Retreat Sets Off Confusing Scramble for States and Cities", Edgar Sandoval, Kate Taylor and Mitch Smith, NY Times, 5/14/21
• "723 Epidemiologists on When and How the U.S. Can Fully Return to Normal", Claire Cain Miller, Kevin Quealy and Margot Sanger-Katz, NY Times, 5/15/21
• "For Many Workers, Change in Mask Policy Is a Nightmare", Noam Scheiber, NY Times, 6/2/21

The CDC's surprise announcement was all the more head spinning because just a few weeks earlier, the director of the CDC had declared that she was scared that our country was facing "impending doom"

• "CDC director warns of 'impending doom' as Covid-19 cases spike in most states", Christina Maxouris and Holly Yan, CNN, 3/29/21

The CDC fumbled the mask issue from the first days of the pandemic, so it is not surprising that the CDC should end the pandemic with another fumble. Throughout the pandemic the CDC's public presentations emphasized national statistics about infections, hospitalizations, deaths, and more recently, vaccinations as appropriate measures for determining social mitigation policies. The CDC never grasped the unavoidable political interactions between the fundamental characteristics of the virus and our federal system:  

• COVID-19 is a local disease that spreads across very short distances primarily by riding the slow moving exhalations of infected persons, then hopping onto the slow moving inhalations of uninfected persons. Hence the COVID statistics that matter most are not national statistics, but the local statistics about vaccinations, infections, hospitalizations, and deaths at state, county, and urban levels. Decisions as to when people should stop wearing masks should be made by local authorities after considering their local statistics.
  
  Governors have this authority. The CDC, after reviewing national statistics, might have strongly recommended that the nation's governors consider dropping mask requirements if their local statistics met a set of criteria suggested by the CDC. Then governors should have be praised or damned according to how well or poorly their decisions fit the specific conditions of their local communities.
  

President Trump mismanaged the pandemic by shirking the tactical and strategic responsibilities of his office in ways whose adverse consequences dwarfed the negative impacts of his foolish comments about masks and his blatant disdain for any kind of science.

Trump's tactical irresponsibility

As the nation's CEO, President Trump was not supposed to manage the pandemic himself; he was supposed to manage the Director of the CDC, a top level federal administrator, and the CDC's top managers. The CDC's failure to develop a reliable COVID test kit in February 2020; its flip-flopping on masks in March/April; and the fact that the national lockdown in March which the CDC and the Task Force had assured the president would only last 3 or 4 weeks was still failing to control the contagion by the end of April, six weeks later -- all of this should have informed President Trump that his CDC Director was not up to the challenge of managing the CDC's operations.

At that point President Trump should have replaced the CDC's director as well as most of its top managers plus key members of its technical staff with a new team who understood that the CDC's primary function was not to conduct scientific research, but to provide the president, the nation's governors, and other top decision makers in the public and private sectors with timely, cogent, and consistent advice about to how to manage the pandemic. That's what he should have done; but he didn't.

Trump's strategic irresponsibility

As the nation's commander-in-chief President Trump should have directed the nation's total war against the coronavirus. Wars are won by generalists, not specialists. This is true for all wars, but it is especially true for total wars wherein all aspects of a society and a high percentage of its population are at risk if the war goes badly. Of course no commander can be an expert in all aspects of a complex military campaign, so generals are usually surrounded by a phalanx of aides whose collective expertise covers all of the relevant specializations. 

So too, President Trump as commander-in-chief of our total war against the virus should have engaged a multidisciplinary CDC whose recommendations would have been based on science, but not just biomedical sciences; its recommendations should also have been informed by a broad range of other disciplines, e.g. psychology, economics and other social sciences, plus appropriate branches of engineering, and crisis management. Multidisciplinary advisers would have ensured that the potential impact of all important decisions on all segments of our society would have been considered. Particular efforts should have been made to ensure that our war efforts did not exacerbate the already dangerously high levels of inequality in our society wherein the negative consequences of our policies are disproportionately inflicted on disadvantaged minorities. That's what President Trump should have done; but he didn't.

Note: In our total war against the coronavirus more more Americans have died (about 600,000 so far) , than were killed in World War I (200,000), and almost as many as were killed in World War II (607,000).

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C. Prospective scenarios

At this point you might ask, "Why reorganize now? The end of the pandemic is in sight, so why not wait until it's over? Why not ask a bipartisan Congressional committee to conduct a thorough review of how and why the U.S. managed the pandemic so badly? If this committee's review identifies shortfalls in the CDC's performance, we can restructure and restaff the CDC so as to address their comprehensive findings."

Yes, an extensive bipartisan Congressional investigation is mandatory .... but ... in the current divisive political environment, such an investigation would probably take months to organize, followed by more months of investigation, followed by more months of debate about the findings ... months and months and months during which the current CDC would continue to fumble. 

• "As Pandemic Recedes in U.S., Calls Are Growing for an Investigative Commission", Sheryl Gay Stolberg, NY Times, 6/16/21

There can be no doubt that we have now entered the final phase of the pandemic; but it won't be the tidy ending that our experts promised throughout 2020, an ending wherein all infection, hospitalization, and death curves would be "flattened" by our achievement of herd immunity via extensive vaccinations. Sad to say, a recent consensus has emerged among our experts that the U.S. is unlikely to achieve herd immunity: 

• "Reaching ‘Herd Immunity’ Is Unlikely in the U.S., Experts Now Believe", Apoorva Mandavilli, NY Times, 5/3/21 ...  or listen to a podcast of Mandovilli discussing her article and why she wrote it, The Daily, 5/7/21)

Our experts' pessimism stems from two sources: (1) the likelihood that a substantial percentage of the U.S. population will not be vaccinated (20 to 30 percent) by the end of 2021, and (2) the billions of people in other countries who will not be vaccinated by the end of 2022 or even 2023. These large pools of unvaccinated persons will provide extensive opportunities for the virus to evolve variants that will be highly resistant, possibly totally resistant to our current vaccines.

• Given that the percentage of unvaccinated persons varies from state to state, some states will enjoy a return to normal before others; but Black, Hispanic, and other minorities are disproportionately unvaccinated in most states. Accordingly, some states may continue to experience substantial surges in infections, hospitalizations, and deaths, but at substantially lower rates than in 2020. Nevertheless, the death rates from COVID may be twice as high as the death rates in bad flu seasons. (See "A rough estimate of future COVID deaths now that herd immunity is unlikely", on this blog, last update: 5/10/21)
  
  
• The emergence of resistant variants will require updates to current vaccines from time to time, a need that will also vary from state to state; but we should again anticipate that minorities will be disproportionately non-updated in most states.
  

The confusion generated by these uneven developments will be greatly exacerbated by the current CDC's tendency to issue unclear, inconsistent, and ill-timed recommendations based on national, rather than on more appropriate state or lower level statistics, while the negative consequences of the CDC's shortfalls will continue to fall disproportionately on Blacks and other minorities.

Dear President Biden,

The worst possible prospective pandemic scenario that you might face while in office will be one in which a totally new virus appears against which all current vaccines are ineffective ... or a more likely equivalent: a coronavirus variant appears that renders all current vaccines and readily produced updates ineffective.

Will you confront this awful possibility with a fumbling CDC, thereby imposing an unbearable repetition of the 2020 pandemic nightmare on our nation again? Hopefully you will reorganize the CDC immediately and also take steps to use your authority under the Defense Production Act to quickly build a reliable domestic N95 supply chain plus stockpiles that will provide protective masks for everyone, not just health care professionals, as soon as a nightmare variant appears.

Respectfully,

Roy L. Beasley, PhD

Editor, Neoskeptics blog

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Related notes on this blog:

• "Ending the coronavirus pandemic when it becomes a 'flu'", Last update 3/5/21
• "N95 masks for everyone!!! ... Groundhog Day mutations", Last update  1/29/21
• "Trump supporters who reject masks and other mitigations are not stupid and/or crazy", Last update 11/18/20