Avoiding the CDC's systemic blunders and flip flops

Last update: Friday 1/7/22

The Centers for Disease Controly (CDC) has blundered many times throughout the pandemic. It blundered under President Trump and it continues to blunder under President Biden. The wonder is not that it blunders so often; the wonder is that it makes the same kind of blunder again and again and again. Almost two years into a lethal pandemic, why does the CDC still fail to understand that one size does not fit all? What will it take for the CDC to acknowledge that one guidance is not appropriate for all of our fifty states and territories???

The CDC's latest blunder began with its confusing guidance issued that recommended shorter quarantine periods for health care professionals who were infected or exposed to another infected person

• "C.D.C. Shortens Covid Isolation Period for Health Care Workers", Azeen Ghorayshi and Reed Abelson, NY Times, 12/23/21  

The blunder was completed by the CDC's guidance issued a few days later that specified even shorter quarantine periods for the general population.

• "As Omicron Surges, Officials Shorten Isolation Times for Many Americans", Benjamin Mueller and Isabella Grullón Paz, NY Times, 12/27/21 

Health care professionals flooded the media with criticisms of each guidance and of the inconsistency between the two guidances. The discussions of the CDC's omission of any role for rapid tests were polite, but scathing. For example, consider the following critiques:

• "Will Shortened Isolation Periods Spread the Virus?", Benjamin Mueller, NY Times, 12/28/21 
• "The C.D.C. Has New Covid Guidelines. This Is What It Got Wrong.", Aaron E. Carroll, NY Times, 12/28/21

This blog note acknowledges the confusion caused by these guidelines; but it is mostly concerned with the CDC's promotion of the same guidelines for all 50 states and territories. Its unshakeable commitment to the dogma that one size fits all is the primary source of the CDC's systemic blunders. In this instance, its second guideline seems like a "corrective" response to the criticisms it received for the first, i.e., a flip flop, another one of the CDC's signature blunders because flip flops undermine the CDC's credibility. (Note see the  P.S. at the end of this note for some comments about the CDC's confused guidance about testing) 

Doctor, patient, and medication

The CDC acts as though it were a "doctor" prescribing pandemic "medication" for one "patient", i.e., the entire nation. Correction, the CDC acts like it is the only doctor who is qualified to determine appropriate pandemic medication for the nation. 

This could be a workable model if the U.S. were a small, relatively homogeneous country in Europe that had an all powerful central government. But the U.S. is a large federated nation, large in geographical size, and large and diverse in population. For example California has a larger population than 22 of the 27 nations in the European Union. The U.S. central government is not all-powerful; our federal government shares power with the governments of the 50 states and territories. And many states are homes to eminent universities whose faculty include eminent researchers whose pandemic expertise equals or exceeds the expertise of the CDC's personnel.

The large size of the U.S. guarantees that there will be considerable variation in the medical resources available in the 50 states and territories and in the medical challenges facing them. These variations guarantee considerable diversity in the political preferences of the 50 states and territories. One size, one set of CDC guidelines, will therefore be a highly unlikely fit for all of them or be politically acceptable to all of them ... unless ... unless the guidelines can be derived from well established scientific findings.

For the foreseeable future many of the CDC's most important pronouncements will be judgement calls.

It has become increasingly clear that we cannot achieve zero levels of Covid, that our society must learn how to live with the virus. We must therefore make wise decisions that enable lives that are more normal for the many in exchange for higher, but acceptable risks to the few.  Unfortunately,  the virus is now throwing up new variants whose transmissibility and severity change too fast for researchers to achieve traditional levels of scientific certainty as quickly; so we must accept the fact that our unavoidable real-time decisions cannot wait.  

Some of our most important real-time pandemic management decisions about how we should behave in our workplaces, our schools, our recreation sites, and our homes must be now be based on well-considered judgement calls, calls that are informed by whatever scientific knowledge is available, but are not limited by limited scientific knowledge. Judgement calls can never attain the indisputable rigor of replicated scientific findings, so disagreements will arise, some of which may align with the political boundaries of our 50 states and territories.

Where scientific knowledge is limited, the CDC's judgements are no better than the judgments  of governors. Indeed, the judgments of governors can be informed by the opinions of local pandemic experts that are based on their extensive understanding of local conditions. Moreover, governors are better positioned to assess the political acceptability of various pandemic policy options in their states. Accordingly, the judgements of governors should be given greater credence than the confusing one-size-fits-all oracular pronouncements and corrective flip flops that are proclaimed by the CDC from high atop faraway Mount Atlanta. 

Recommendation to the CDC ==> Collaborate to avoid systemic blunders and flip flops

Let's back up a bit before moving forward. The CDC already engages in extensive collaboration with the 50 states and territories:

• The CDC collects massive amounts of data about vaccinations, infections, hospitalizations, and deaths from each state and territory, then it shares this data with all 50 states and territories via its Website
  
  
• The CDC also collects information about innovations developed by the states and territories, then recommends the effective innovations, i.e., the "best practices", to other states and territories via its issue of new guidance.
  
  For example, the CDC recently monitored the efforts of a few states to implement "test and stay programs" that would be far less disruptive to children's education than sending all of the children exposed to infections home for quarantine. It then issued guidance that endorsed this innovation 
  
  -- "C.D.C. Says Unvaccinated Students Exposed to Virus Can ‘Test and Stay’", Noah Weiland and Emily Anthes, NY Times, 12/17/21 

So what is being proposed here is that the CDC greatly expand the scope and depth of its efforts to identify best practices via collaboration with the 50 states and territories. This proposal is an application of a powerful concept popularized by U.S. Supreme Court Justice Louis Brandeis ==> States are the laboratories of our democracy. Here's an excerpt from Wikipedia's succinct discussion:

"This concept explains how within the federal framework, there exists a system of state autonomy where state and local governments act as social laboratories, where laws and policies are created and tested at the state level of the  democratic system, in a manner similar (in theory, at least) to the scientific method."

In short, pandemic policy innovations developed by one or more states could, if proven to be effective, be adopted by other states. Ideally most of the CDC's future guidances should begin as trials in a few states. Indeed, some policy innovations might be developed by the CDC itself and suggested to a few states for trials. If the innovations were successful, the guidelines suggested by the policy innovations could be recommended by the CDC to other states that faced similar challenges. 

We should not assume that all 50 states would adopt any innovation, just the states whose situations on the ground were similar to the situations encountered by the innovators because one size may fit some or fit many, but is unlikely to fit all ... unless the innovative policy was confirmed by rigorous scientific findings, an exceptional achievement as long as the virus keeps mutating quickly.

Finally, the spirit of collaboration would require that the CDC never surprise the nation's governors. Any proposed new guidance, no matter how it is developed, should be shared with the nation's governors a few weeks before the CDC makes any formal announcements. The CDC should request that the governors provide detailed comments on the proposed new guidance, modify the guidance if possible to reflect their comments, and include their comments in an appendix to the guidance when it is officially announced.

P.S. ... testing ... testing ... testing ...

Of course the worst kind of blunder is not a flip flop, but a  bone-headed bad call that is widely contested by other public health officials. In this case the CDC quickly resisted nudges from Dr. Fauci and others to include testing as a condition for exiting from isolation, thereby undermining its own credibility yet again. Indeed, lack of testing was one of the main reasons why the teachers union in Chicago recently refused to return to in-class teaching. The CDC's guidance has also been denounced by the American Medical Association.

• '"CDC could add a negative test to its new isolation guidelines, Fauci says", Jpe Hernandez, NPR, 1/3/22
• "The CDC says a test to get out of COVID isolation is not needed, resisting pushback", Jonathan Franklin, Jane Greenhalgh, Pien Huang, NPR, 1/4/22
• "‘An Untenable Situation’: Chicagoans in Limbo After Schools Abruptly Close",  Mitch Smith and Robert Chiarito, NY Times, 1/5/22
• "AMA: CDC quarantine and isolation guidance is confusing, counterproductive", Gerald E. Harmon, M.D., American Medical Association, 1/5/22
• "The C.D.C. Is Hoping You’ll Figure Covid Out on Your Own", Zeynep Tufekci, NY Times, 1/5/22

Some other criticisms directed at the CDC recently have also addressed fundamental sources of its errors, most notably: 

• "Former Biden Advisers Urge a Pandemic Strategy for the ‘New Normal’", Sheryl Gay Stolberg, NY Times, 1/6/22  
  

The views offered by these former advisers to President Biden address significant shortfalls, especially the overriding delusion that we can defeat the virus rather than learn to live with it. But these advisers share the CDC's fatal "One size fits all" national policy bias, rather than allowing for the possibility that different states and territories might prefer different levels of risk to the few in exchange for normal living for the many. This point can be underscored by a slight modification of Benjamin Franklin's famous dictum:  We have a [federal] republic if we can keep it"

The CDC posted another guidance, i.e.., another flip-flop, on Friday 1/7/22, its first coherent response to the tidal wave of criticism it received for the confusing guidance it published last week.

• "Test for Current Infection", Centers for Disease Control, 1/7/22
  
• The CDC's brief overview contains a link to an interactive quiz that asks useful questions and provides concise recommendations based on your answers to its questions ==> Get Started

The discussion makes no mention of routine weekly or bi-weekly self tests nor does the quiz suggest this practice. Neither the discussion nor the quiz considers meetings, visits, or indoor public spaces wherein one might have no idea who was or was not infected. Nevertheless this flip-flop is a giant step away from the confusing illogic in the CDC's original guidance.

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Links to related notes on this blog:

• "Omicron Defense", Last update: 1/26/22