As her tenure as director of the Centers for Disease Control and Prevention winds down, Mandy Cohen is in persuasion mode — simultaneously trying to convince critics of the CDC in the incoming administration that the agency has re-focused since its pandemic-era missteps, and calm nervous staff about what is to come.
The public health agency, which has long served as a model for peer institutions around the globe, is in the crosshairs of both the Republican-led Congress and the people set to be nominated to key health positions in the second Trump administration.
Congress recently proposed a 22% budget cut for the CDC, saying it’s time for the agency to shed many of its responsibilities — entrusted to it by Congress — and return to its original mandate, a focus on communicable diseases. At the same time, some allies of President-elect Trump, notably those in the “Make America Healthy Movement,” believe the CDC needs to train its resources more squarely on efforts to curb chronic diseases.
Cohen, who had a reputation for being able to work effectively with politicians on both sides of the aisle when she was North Carolina’s secretary for health and human services, was in Washington last week, seeking support for the embattled CDC on Capitol Hill.
Her message: We learned from our Covid-19 mistakes. We’re not the same agency.
“Folks may have an image of what CDC was in April of 2020 during the [first] Trump administration. And I want folks to make sure that they take the time to see the progress that we have made. So that’s what I’m spending my time on,” Cohen told STAT in an interview last week.
She said she had not yet had the chance to make that case to Dave Weldon, Trump’s pick to succeed her, though she hopes to. “We have been put in touch,” Cohen said. “We’re trying to find time to connect.”
The agency employs roughly 13,000 people in its Atlanta headquarters, in public health departments around the country, and in international outposts in places like Thailand and Kenya. Many are on edge for a variety of reasons — not least of all because Weldon has a long track record of challenging the safety of vaccines, seen as vital tools by most experts in the field. One of CDC’s key functions is making recommendations for the appropriate use of vaccines.
Cohen, though, tried to cast that anxiety as typical administration transition jitters. The message she’s giving staff, she said, was that the CDC’s mission has not changed. The work continues. And she said the agency isn’t seeing resignations.
“While people are anxious because it’s a changing time, we’re not seeing those kinds of changes and I hope not to, because we have great career officials here,” Cohen said. “I think folks who work at CDC come for the mission, to protect health and improve lives, to work on things that you can’t work on in other places.”
Another message Cohen is trying to convey is that the wide range of health issues the CDC works on — everything from establishing growth charts for children to how to prevent infections in nursing homes — are inter-related, and that infectious diseases and chronic diseases, in particular, don’t exist in silos.
This is an area that critics have focused on. “CDC is spending a whole bunch of money, distracted in areas not their core mission. They should be focused on fighting infectious and communicable diseases,” Joe Grogan, who led health policy in the White House budget office in the first Trump administration, said at a STAT event in October.
Cohen noted that a revamping of the platform for the health data CDC collects both shows those interconnections and helps staff working on those issues see a fuller picture of U.S. health problems, pointing to the interplay of diabetes and Covid as an example. The former is a risk factor for more severe illness caused by the latter, but the previous methods of data collection didn’t make the connections between infectious and chronic illnesses readily visible in the way the new system does. “And that allows us to be more efficient, more effective with our work,” Cohen said.
The congressional budget zeroed out funding for the CDC’s National Center for Injury Prevention and Control, which works on issues like suicide, drowning, and opioid addiction. These are among the main causes of death of people under age 50, Cohen said, arguing that it is the CDC’s job to study and make policy on health threats that are actually killing Americans. And progress is being made, she said, pointing to recent data showing a decline in drug overdose deaths.
“I’m very concerned about seeing infrastructure that has been built, that is working, go backwards,” she said. “Because what I hear is, ‘Oh, we don’t want that work to stop. Maybe we want it to be in a different place here or there.’ And I’m like: But it’s working. Why would you spend money to break something and then recreate it somewhere else? That’s not efficient.”
In many cases, if the CDC doesn’t do the work, no other federal agency will, she said. “I think that we provide many, many types of data expertise and investment that no one else can bring to bear. And we are pulling it together for a national picture,” Cohen said.
The spread of H5N1 bird flu is one of the topics Cohen would like to brief her successor on, if the two manage to arrange a meeting. “I want to make sure that we don’t lose any ground in a handoff here,” she said. Sixty human infections have been confirmed this year in seven states, most with major outbreaks in dairy cows or poultry farms. On Friday, Louisiana reported detecting a human case in a person who had exposure to sick and dying wild birds. That person, whose infection must still be confirmed by CDC, has been hospitalized.
“Right now, my concern level is low for the general public. We have not seen human-to-human spread. But … we’ve entered a new chapter here with this virus being in dairy cattle,” Cohen said. “We’ve put a lot of pieces in place and I just want them to know where we are [and] the fact that we have to keep up our vigilance, because we’ve learned that these viruses can change.”
Cohen admitted, though, that she’s concerned about the amount of H5N1 virus in the environment, whether it’s in cattle or poultry operations, or in wild birds. “The more virus that is circulating, the more interactions of that virus with humans, the more risk. So we want to cut that down as much as possible.”
She suggested that the CDC is better positioned now to handle an infectious disease crisis than it was in the past because of the work the agency did to learn from the lessons of the Covid pandemic. One change: The agency stood up a national surveillance network that searches wastewater for pathogens that sicken people. “We built it for Covid. We’ve now used it for avian flu. We’ve used it for mpox. And it’s a scalable, nationwide system we didn’t have before,” she said.
Another change: The agency now has access to real-time data that allow it to monitor what is sending people to emergency rooms across the country — a tool that could help the CDC spot a new disease outbreak.
Cohen said in her discussions with politicians she reminds them of the importance of the CDC’s international work, including its field epidemiology training program, which helps public health staff in developing countries learn the skills needed to spot and contain burgeoning disease outbreaks. The program both builds on-the-ground capacity and connections between the CDC and international counterparts.
“I want to make sure the incoming team knows that this is not the time to go backwards on those, particularly at a time where we want to maintain those diplomatic relations around the world,” Cohen said. “We protect our folks in the United States by stopping the outbreaks at their source.”