Saturday, March 19, 2022

Strategic implications of some basic facts about the CDC

Last update: Saturday 3/19/22 
This note is an attempt by the editor of this blog to answer some of the questions that most health conscious residents of the U.S. have had about the CDC, but didn't have the time to go searching around the CDC's Website to find the answers ever since the pandemic began in early 2020. As readers will discover, there's a lot more to the CDC than they might have suspected, but a lot less than what they might think is really needed for it to be the lead agency in our efforts to manage the coronavirus pandemic.


A. Profile ... Sources = Links in bold/italic 

B. Organization and Chart ... Sources = Links in bold/italic 
As can be seen from the following organization chart, five public service departments report to the Office of the Director
  • NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH
    Mission = "To develop new knowledge in the field of occupational safety and health and to transfer that knowledge into practice."
    Number     of "centers" = 8
    Effective date of mission= N/A

  • PUBLIC HEALTH SERVICE AND IMPLEMENTATION SCIENCE
    Mission = "The mission of the Deputy Director for Public Health Service and Implementation Science and staff is to lead, promote, and facilitate science, programs and policies to identify and respond to public health threats, both domestically and internationally."
    Number of "branches" = 28
    Effective date of mission = 9/25/2018

  • PUBLIC HEALTH SCIENCE AND SURVEILLANCE
    Mission = "The mission of the Deputy Director for Public Health Science and Surveillance and staff is to lead, promote, and facilitate science, surveillance, standards and policies to reduce the burden of diseases in the United States and globally. 
    Number of "centers" = 4
    Effective date of mission =     9/25/2018

  • NON-INFECTIOUS DISEASES
    Mission = "The mission of the Deputy Director for Non-Infectious Diseases and staff is to reduce the burden of noninfectious diseases, injuries, birth defects, disabilities and environmental health hazards."
    Number of "centers" = 4
    Effective date of mission = 9/25/2018

  • INFECTIOUS DISEASES
    Mission = "The mission of the Deputy Director for Infectious Diseases and staff is to lead, promote, and facilitate science, programs, and policies to reduce the burden of infectious disease in the United States and globally"
    Number of "centers" = 3
    Effective date of mission =     9/25/2018

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C. Employees
According to FederalPay.org the number of CDC employees in recent fiscal years was as follows:
  • FY 2020 = 10,013 -- Trump
  • FY 2019 = 10,377 -- Trump
  • FY 2018 = 11,574 -- Trump
  • FY 2017 = 10,899 -- Obama
  • FY 2016 = 10,798 -- Obama
A copy of a table created by FederalPay.org that displays the distribution of the occupational categories of the CDC's employees in FY 20 appears in the following scrollable frame
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Note: This frame can be scrolled left to right, also up and down; its image can be made larger or smaller by clicking any position in the frame, then clicking the plus or minus icons that appear at the bottom of the frame.
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Appendix -- What's missing?
Part C. (above) marks the end of the blog note. What follows in this appendix is commentary. 

The note is much shorter than its editor intended because the CDC does not include useful information about itself in readily accessible locations on its Website. It took the editor more than an hour of searching to find the limited data that appears in Parts A, B, and C. He has no doubt that some, perhaps all of the other information that he sought is readily accessible to the CDC's employees on the Websites of its private intranet that is not accessible to the public. But there are some kinds of data that public agencies should make extra efforts to share with the public. The diversity of the CDC's employment is an obvious example.

1. Diversity and inclusion
Full disclosure requires that the editor acknowledge that he is a Black, 80 year old male, personal characteristics that might make him overly sensitive to an important agency's diversity and inclusion with regards to race/ethnicity, gender, and age.

When the editor used a search box on a CDC Webpage to find information related to "diversity", the search engine returned a link to a page, a copy of which is shown in the following frame, as one of its first results. This page affirms the CDC's allegiance to diversity and inclusion, but provides no data about total employment nor breakdowns by age, gender, or racial/ethnic categories. As for inclusion, there is no data that demonstrates the diversity of the CDC's middle and upper management levels. 

The location of the CDC's headquarters in Atlanta -- home to a nationally renowned cluster of HBCUs as well as Georgia Tech, a top ranked public university with diverse enrollment -- should make it relatively easy for the CDC to recruit a highly diverse, highly qualified staff. The CDC's failure to document this important achievement is a great disappointment. However, the page does contain a picture of a diverse looking group of employees. Is this supposed to be proof by diverse photo? Or a presumptive demand for unearned trust, the same presumptive demand that suffused too many of the CDC's guidance proclamations throughout the pandemic.
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Note: This frame can be scrolled left to right, also up and down; its image can be made larger or smaller by clicking any position in the frame, then clicking the plus or minus icons that appear at the bottom of the frame.
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2. Meeting the new challenges of pandemic management 
Whereas concern about the CDC's diversity would have been appropriate at any time, the issues addressed in the following paragraphs are only of concern in the context of Covid-19, the world's first pandemic in over one hundred years. 

Most U.S. residents understood that no living public health professionals had hands-on experience in managing a pandemic. But given the CDC's extensive experience with epidemics and endemics, most were inclined to give the CDC the benefit of the doubt, meaning: they were inclined to trust that the CDC staff would become fast learners by modifying their old tools and quickly developing more appropriate new tools. 

Unfortunately, the CDC failed to perceive the conditional nature of this unearned trust, committing unforced blunders again and again, thereby losing credibility month after month, beginning with its confusing flip-flop about cloth masks in March 2020. Detailed descriptions of some of these blunders are presented in other notes on this blog -- see "Related notes" at the bottom of this page -- so they won't be discussed here. 

The CDC staff needed to quickly grasp the devastating impact that Covid-19 would have on all segments of our society until effective vaccines were developed. More specifically, using existing mitigation tools to cope with this virus would (1) often require more data to justify the use of these mitigations than was currently available if the justifications had to meet the usual scientific standards of proof, (2) require profound changes in everyone's most deeply ingrained daily behavior, and (3) require painful trade-offs,
1. Whenever the speed of pandemic events exceeded the speed of normal science guidance that would ideally be based on science would have to give way to judgement calls that were informed by science but not limited to rigorously documented scientific findings. 
2. Wrenching changes in individual behavior can be dictated in autocratic societies like China, but not in a federal democratic republic like ours. In the USA the behavior of the public cannot be controlled, but it can be managed by elected officials and other community leaders. However, public persuasion campaigns that work in some states might not succeed in others. One size might not fit all. 
3. The pervasive nature of these changes would quickly pose painful trade-offs, for example: the strongest mitigations -- e.g., lockdowns and remote schooling -- might save the lives of elderly residents who might otherwise have been expected to only live a few more years. But they would impose substantial losses on the quality of life available to younger residents and their children that would persist for decades thereafter. 
The resolution of these kinds of value conflicts in a federal republic is an inherently political process that involves public discussion and compromise, preferably at the state and local levels. Guidance compromises accepted by leaders in some states might be rejected by the leadership in others. Again, one size might not fit all.others
Question: How did the CDC modify its structure, staffing, and work flow to cope with these strategic challenges?

Answer: Without access to the information on the CDC's private intranet, it's not possible to produce definitive assessments. However the data cited in Parts A, B, and C provide circumstantial evidence that the CDC did not make substantial modifications to its structure, staffing, and workflow that were commensurate with the seismic, once in a century surges in its workload that were generated by this once in a century pandemic. 

1. Timely judgment calls vs. untimely science    
The mission statements for its public service departments listed in Part A were completed in 2018, two years before the pandemic began, nor do there seem to be any modifications to these statements in 2020.
As per the employment stats in Part C, the CDC had a larger total staff in 2018, the year of the mission statements, than in 2020, the first year of the pandemic. Let's assume that the CDC cut all departments by more or less the same percentage. This would suggest that the units responsible for managing the pandemic were short-staffed during the first year of the pandemic. i.e., they were doing more work = old work plus massive amounts of new pandemic work with less staff
The mission statements make repeated reference to "science" but do not mention results that were "timely" or "judgements", so the CDC would tend hold out until it had enough data to produce statistically significant levels at a .05 or .01 level rather than make timely judgment calls based on the data at hand. 
Being short-staffed, the units managing the pandemic would be even less likely to complete studies that met the rigorous statistical levels required by science in a timely manner.   
2. Managing difficult behavioral change 
Throughout most of the the pandemic, the CDC engaged in "Covid shaming" as its primary tool for getting people to wear masks or become vaccinated. "Do this, damn it. Masks work. Vaccines work. Here's what happens when you don't wear masks, when you don't get vaccinated. Are you too stupid to understand this?" Of course, Covid shaming is no more effective than fat shaming. 
Question: Why didn't the CDC understand this simple fact of behavior modification?  
Answer: Take a quick look at the bar chart in Part C that shows the distribution of CDC positions by occupation categories. The chart shows no categories for behavioral or social sciences, so no psychology, social psychology, sociology, anthropology ... not to mention commercialized categories like marketing and advertising whose practitioners are paid to persuade people to do things, buy things, that they wouldn't do or buy otherwise.
 
3. Politics as the peaceful resolution of value conflicts
By the start of the U.S. component of the world-wide coronavirus pandemic in early 2020, the nation was three generations deep in formalized policy analysis, the most familiar types being cost-benefit analyses and environmental impact statements. So the editor of this blog was repeatedly surprised to see guidance issued by the CDC that was not buttressed by policy papers that attempted to weigh the public health benefits to be gained against economic, child development, and other costs that might be incurred. 

Referring again to the bar chart in Part 3 (above), one can therefore assume  that the 500 positions noted in the category "Management and Program Analysis" are not counts of CDC employees who assess the impact of the CDC's proposals from perspectives other than healthcare. Indeed, the CDC loudly proclaims its fundamental values in the mantra that appears at the bottom of the banner that appears at the top of every one of its Webpages: "CDC 24/7, Saving Lives, Protecting People."

Whenever the CDC's one value guidance collided with the interests of people who valued other concerns, e.g., the early education and social development of their children, the parents had no choice but to complain to their political leaders; at which point the CDC and its media allies cried "politics!" or "anti-science" ... which was nonsense. In our society we resolve conflicts in values via political processes, e.g., discussions, compromises, and votes. That's what we elect our community leaders to do.

Responsible agencies minimize potential conflicts by conducting cost-benefit analyses of policies before they announce them to the public. These internal analyses not only let the proposing agency anticipate possible objections; it also gives them the opportunity to modify their proposals so as to greatly reduce, maybe eliminate political conflicts. For example, invoking a different mix of mitigations might achieve comparable healthcare benefits while greatly reducing the economic and educational costs.

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