The pandemic exposed many of CDC's flaws. Writing in the Washington Post, Scott Gottlieb, a former FDA Commissioner, argues that CDC should be downsized to allow it to focus more fully on combating infectious diseases. However, former CDC Director Tom Frieden argues that Gottlieb's recommendations will only "endanger the health of people."

How to fix CDC, according to Gottlieb

According to Gottlieb, CDC currently lacks "both the culture and capacity to deal with fast-moving outbreaks that require rapid response and information-sharing," which significantly hindered its response to the pandemic.

To address these issues, Gottlieb argues that CDC first "needs to be made much smaller." Instead of devoting its resources to a broad range of topics, the agency should narrow its focus to its original mission of controlling infectious diseases.

"Much of the CDC's research activity relating to other priorities should be passed to agencies that have the regulatory tools to act based on the findings," Gottlieb writes. "The CDC's related initiatives in training and education could be absorbed by agencies with more operational responsibility over these same areas."

For example, CDC's funding for opioid overdose prevention and surveillance could be allocated to the Substance Abuse and Mental Health Services Administration instead. Programs on tobacco prevention run by CDC's Office on Smoking and Health could instead be handled by FDA, which has a broad regulatory scheme with the same purpose.

Shifting these health programs to other agencies would allow CDC to invest more funding and resources into its core infectious disease mission, including for its Center for Forecasting and Outbreak Analytics, which initially launched in August 2021.

Gottlieb also criticized CDC's data collection methods, saying that the agency lacked reliable data during the pandemic because it heavily relied on "its own bespoke data streams rather than collaboration with [CMS] and other agencies."

Going forward, CDC "must be directed to make this process [of collecting and analyzing data] an open architecture that uses the best sources of data available," Gottlieb writes.

As CDC is downsized, Gottlieb also recommends that Congress change the agency's culture of prioritizing "academic achievement over operational execution" since it tends to withhold "actionable data until it can publish its findings in academic journals."

"These same cultural flaws were manifest in the nation's troubled pandemic response, when the CDC was slow to release data that could inform medical and public health decision-making, or when the CDC struggled to issue practical, timely guidance to help people manage risk," Gottlieb writes.

Overall, Gottlieb said CDC should return to its roots and focus on "moving quickly to mitigate dangers from known pathogens and prevent future ones."

Frieden pushes back on Gottlieb's recommendations

In response to the article, Tom Frieden, former CDC Director under President Barack Obama, published a rebuttal on Twitter, arguing that Gottlieb's recommendations would "endanger the health of people throughout the country." 

According to Frieden, Gottlieb misunderstands CDC's role, which is to "protect people from ALL health threats," not just infectious diseases like the flu and COVID-19. In fact, Frieden notes that both communicable and non-communicable diseases can have "profound impacts" on each other.

For example, several conditions, such as hypertension, obesity, and cancer, can increase the risk of severe symptoms from infections. Infectious diseases, such as the Zika virus or COVID-19, can also lead to long-term health conditions.

"Having experts who have deep subject matter expertise during an infectious disease response and non-communicable disease response ensure both have a seat at the table to craft guidance and strategies to protect those at highest risk," Frieden writes.

Frieden also argues that Gottlieb is confusing public health and public health regulation. "Despite the exceptional experience of the Covid pandemic, CDC has only limited regulatory authority," he writes. "Most public health regulation is done by state, tribal, and local governments."

In addition, Frieden notes that public health includes more than just regulation. Although FDA has regulatory authority over tobacco, CDC leads the work that supports state and local action on tracking tobacco use trends, investigating e-cigarette harms, training clinicians, and more.

Although Gottlieb recommended that CDC transfer some of its programs and functions to other agencies, Frieden argues that this idea misunderstands the roles different agencies play. For example, FDA determines whether drugs and vaccines are safe and effective, but CDC is the one to provide recommendations to clinicians on how these treatments should be used.

"People in the US—and around the world—depend on CDC to protect them, even if they don't know it," Frieden writes. "Let's focus on meaningful prescriptions for reform rather than quack cures that only serve to enrich industry, undermine public health agencies, and endanger Americans' health."

"CDC can rebuild trust by being more practical and timely in its guidance, and work is underway as part of the plan CDC Director Dr. Rochelle Walensky released last year," he added. (Gottlieb, Washington Post, 1/19; Frieden Twitter thread, 1/22)