Public health experts worry CDC is being stifled on COVID-19

Agency has been unusually quiet about coronavirus guidance, compared with previous outbreaks

Robert Redfield, director of the Centers for Disease Control and Prevention, arrives to testify before a House committee on June 23. (Tom Williams/CQ Roll Call file photo)
Robert Redfield, director of the Centers for Disease Control and Prevention, arrives to testify before a House committee on June 23. (Tom Williams/CQ Roll Call file photo)
Posted July 6, 2020 at 9:50am

Gregory A. Poland, an internist at the Mayo Clinic and spokesperson for the Infectious Diseases Society of America, said he was walking with his wife on a Florida beach three weekends ago when they were confronted because of the masks they were wearing.

“Somebody about 50 yards away started yelling obscenities at us. ‘Don’t you know masks don't help? The virus can't be caught that way.’ And I thought, ‘This is interesting,” Poland said.

Poland did not reply. But he said the interaction points to a troubling skepticism about science among many U.S. residents. An ABC News/Ipsos poll published June 26 found that 89 percent of people said they had worn masks in public the week before, as cases climbed. But photos on social media from all corners of the country suggest mask wearing and social distancing can be sporadic.

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Public health experts say that before the discovery of a vaccine or effective drugs, mask wearing — a so-called “non-pharmaceutical intervention” — is one of the most important tools in fighting the virus.

The Centers for Disease Control and Prevention stresses that people should wear cloth masks in public.

But the CDC, which has experts in public health communication as well as its own television studio, has not emphasized interventions such as wearing masks through an advertising campaign or regular press conferences.

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The CDC has had two telephone press briefings since March. That’s far less publicity than during earlier, less devastating epidemics.

During the 2009 H1N1 pandemic, the CDC held press conferences every day, including weekends, for about eight weeks, according to University of Georgia Center for Health and Risk Communication Director Glen Nowak, who led CDC communications then.

That practice was typical of other outbreaks, too. Nowak, who worked in CDC communications for 14 years, said the CDC regularly held press conferences every three to four weeks during seasonal influenza season and regular press conferences on foodborne illnesses.

“The CDC has been unusually quiet during this pandemic,” said Howard Markel, University of Michigan School of Public Health professor of the history of medicine, an expert on the impact of nonpharmaceutical interventions during the 1918 flu pandemic.

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“I don’t know if it’s because of the president’s dislike of [CDC Director Robert] Redfield or [CDC National Center for Immunization and Respiratory Diseases Director] Nancy Messonnier for saying in February how serious this was going to be. I don’t know. I will tell you the greatest fighting force in the history of public health is not right there upfront,” Markel said. “In order to get people to change their behavior for health reasons, you have to do constant and effective communication.”

“In 2014 during the Ebola outbreak, thankfully there were very few cases, but [then-CDC Director] Tom Frieden was all over the place as a trusted health official,” Markel said.

Tension with White House

A February briefing in which Messonnier starkly warned that disruption to daily life "may be severe" caused the stock market to dip, reportedly angering President Donald Trump.

Epidemiologists expressed concerns that the White House is muzzling the CDC.

“The CDC and other public health experts need to be on the front line talking to the country every day and talking science about what we know and what we don’t, the way they did in 2009,” said Marc Lipsitch, professor of epidemiology and director of the Center for Communicable Disease Dynamics at Harvard T.H. Chan School of Public Health, on a call with reporters Wednesday. “That needs to be unmuzzled.”

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The White House overruled the CDC on critical decisions about its guidance on how to relax stay-at-home orders, relaxing restrictions on businesses and churches, press reports show. Some of the president’s aides initially opposed the CDC’s guidance encouraging people to wear masks, according to The Washington Post.

States reopening without the precautions recommended by experts led to the current spike, experts say.

That’s an outcome the CDC foresaw: a 2007 CDC pandemic flu plan said one of the lessons of the 1918 pandemic was that erratic lockdowns and reopenings inconsistent with the best science could ultimately inflict social and economic harm while failing to contain the disease.

“America remains at the center of a global pandemic and needs well-established, credible scientists — not political appointees — informing public health decisions,” Infectious Disease Society of America President Thomas M. File warned in a June 23 statement. “As the number of COVID-19 infections, hospitalizations and deaths surge, CDC leadership is urgently needed to set national guidance for preventing further transmission.”

A CDC spokesperson disputed the idea that the agency has not been out in front promoting mask wearing. A spokesman pointed to its posts on social media and its YouTube videos.

One CDC video featuring Surgeon General Jerome Adams instructing people on how to make a mask using a piece of fabric and two rubber bands has been viewed more than 4 million times. Other videos on face coverings have a few thousand views.

Nowak said the mask-wearing recommendations on the CDC’s website are “not as prominent as one would expect.”

The CDC revamped its website late last month to make its guidances easier to find, Principal Deputy Director of the Centers for Disease Control and Prevention Anne Schuchat told the Journal of the American Medical Association June 29.

The relative quiet from the CDC comes as more evidence supports the widespread use of masks.

“People are most infectious in the two days before they show symptoms and in the first couple of days in which they begin to show symptoms,” Schuchat said. "So that face covering before you have any idea you have this virus is really important."

Schuchat, an expert in respiratory diseases and emergency response and a regular public presence during the H1N1 epidemic, is not a regular member of White House pandemic briefings.

Nowak said “the big breakthrough” would come if the president was vocal about wearing masks. Trump and Vice President Mike Pence “have the credibility with the people who are choosing not to.”

Trump downplayed the importance of masks, contradicting the administration’s scientists. The president and Pence have often declined to wear them in public.

“The problem with CDC doing it on their own is that persuading people to change their behavior is hard to do, but it’s impossible to do if the people you’re trying to convince are people who don’t see you as a credible source and are taking direction from somebody else,” Nowak said.

On Wednesday, Trump publicly encouraged people to wear masks for the first time since the new surge in cases began.

"I'm all for masks,” Trump said in a Fox Business interview.

Century-old patchwork approach

In the absence of White House messaging, people are left with a jumble of state and municipal rules. That is somewhat similar to the patchwork that existed during the 1918 influenza, before the CDC or National Institutes of Health existed.

COVID-19 has killed 128,104 Americans, according to the Johns Hopkins University School of Medicine. The 1918 flu pandemic killed about 675,000 Americans, according to CDC.

Markel’s analysis found that in cities affected by the 1918 pandemic non-pharmaceutical interventions like wearing masks reduced deaths. But masks worn during the 1918 flu were typically made of gauze, a readily available material because of World War I, and less effective, said Markel.

Inconsistent messaging also played a role in decreasing the masks’ efficacy a century ago. In San Francisco, where masks were mandatory, the mayor and health commissioner were photographed at a boxing match with masks “dangling down their faces.”

"It’s damaging for our leaders not to be setting an example,” Markel said.

Public health experts worry people may feel betrayed by the administration’s reversal on mask use. Officials first stated only health care workers should wear masks.

That decision was in part motivated by an effort to conserve scarce surgical masks and N95 respirators for health care workers, according to National Institute of Allergy and Infectious Diseases Director Anthony Fauci.

The Trump administration should practice “radical transparency” about why recommendations change, said Poland.

“When recommendations change, there is not enough appreciation for why they change, and not enough effort is made to let people know why they change. The primary reason is they have learned more information and new studies help inform those changes in direction. That should be well communicated,” said Nowak.

Frontline workers have criticized the CDC for being too deferential to the White House.

Kim Cordova, president of United Food and Commercial Workers Local 7 representing grocery store workers in Colorado, said that her union pushed for the CDC to recommend that employers provide masks sooner, given science showed as early as January that asymptomatic people could drive up cases.

Cordova said she worries that existing CDC guidance suggesting critical infrastructure workers can return to work after exposure to the novel coronavirus is misguided and will likely lead to more deaths.

Schuchat said recently the current moment resembles the 1918 crisis.

“What we’re experiencing as a global community is really bad, and it’s similar to that 1918 transformational experience,” she said.