Former CDC Directors on the Public Health Economy: Infrastructure is Broken

By Christopher Williams
Founder, Public Health Liberation

Former CDC directors gathered in April 2022 to discuss the state of the Centers for Disease Control and Prevention (CDC) - the leading federal public health research and response agency in the US. The Covid pandemic raised the profile and public criticism. They mostly limited their discussion to the traditional public health infrastructure of surveillance, public health research, and emergency preparedness and response. Their critical assessment of the CDC can be extrapolated to support Public Health Liberation (PHL) theory on disorder in the public health economy, which contravenes the public health commitment and capacity to address health inequity. Accelerating health equity particularly by income and race is the mission of Public Health Liberation. The challenges within the CDC are structural, political, and cultural, encumbered by underfunding and a lack of mission-driven strategic focus. By its own admission, “The Centers for Disease Control and Prevention (CDC) faces structural and systemic operational challenges, which were exacerbated during the COVID-19 pandemic…However, since the pandemic, we also acknowledge that CDC is responsible for some large, public mistakes.” [1]

Their discussion highlights the interaction of the political economy with public health aims and provide evidence of the assumptions of public health realism that posits hyper-competition and tensions to explain constraints on the CDC and the public health economy broadly. Rick Berke, Co-Founder and STAT Executive Editor moderated a critical dialogue among Bill Foege (CDC Director, 1977 to 1983), Tom Frieden (CDC Director, 2009 to 2017), Julie Gerberding (CDC Director, 2002 to 2009), Robert Redfield, (CDC Director, 2018 to 2021), and Bill Roper (CDC Director, 1990 to 1993). The purpose of this essay is to ground CDC challenges within PHL theory and practice. Our inaugural manuscript described the CDC’s role in one of the most egregious contemporary examples of environmental racism in Washington, DC. I relied on a transcript of the panel discussion (below).

At the time of the webinar in April 2022, CDC Director Dr. Rochelle Walensky had just publicized plans to restructure the agency after fallout from the CDC’s response during the Covid pandemic. Dr. Walensky recently announced her resignation.

Two Critical Questions:

1) How Does the CDC see its role within vast and, in some instances, growing health inequity outside of the effects of the pandemic? The discussion did not provide a clear answer to this question, although the need for regaining public trust was a major theme to achieve the public health mission of the CDC. Public trust in the CDC is dependent on its ability to account for the public health economy wherein threats to public health are 1) comprehensively assessed, 2) followed by public positions, 3) met with marshalling of resources, and 4) expending of political and social capital. The CDC’s mission remains unclear to many of the panelists, “But one of the most important things to get clarified with regard to CDC is, what is its mission?” However the CDC re-positions, a broadened mission is necessary.

The scope of public health challenges in the US from water policy to strengthened social determinants is vast. “Abandon(ing) its mission of public health in favor of promoting individual health and responsibility,” as one question posed to the panel asserts, reflects a source of mistrust in not just the CDC but public health and government broadly. Americans of all incomes, abilities, and background most want an apolitical defender of public health - a “People’s CDC”. If the CDC is only focused on data gathering and analysis without an intervention and advocacy arm, then it cannot reasonably restore public trust in the agency. Public trust is deeply rooted in interdependent perceptions of fairness and equality generally in society - and their lack. Sentiments of an out-of-touch government that rig policies to benefit the wealthiest Americans, rampant racism and discriminatory treatment, and hyper-partisanship and over-politicalization, are the lens through which perceptions of the CDC will be interpreted.

It appears that the CDC does not seek to weigh in on the public health economy. Dr. Redfield explained, “It is not our relationship with North Korea, Iran, or China, or Russia. It's really the pandemic potential. And the fact is we're not prepared for that pandemic potential…And we really ought to really relook at the threats that we have in this nation and make public health one of the major investments that our nation makes proportional to our Defense Department.” If pandemic-readiness is the core mission of the CDC, albeit a worthy cause, such a position will eschew the public health economy and miss immense opportunities to sow goodwill for improving public trust. Reticence to square with and to affect the conditions in this economy will deepen the CDC’s alienation and reinforce public perceptions of the CDC and government.

The moderator noted, “We published an analysis in STAT last summer that argued that we need to invest another $4.5 billion, which would be $13 per year per US resident to adequately fund public health in this country.” If $4.5 billion is primarily intended for research and data modernization, then the benefits of such an expansion in public funding will be highly beneficial for researchers and salaries but highly limited to the broader public because it would not provide a pathway for accelerating health equity. An assumption that more data in itself will achieve optimal public health is unfounded. Data do not necessarily make a difference. There is plenty of data going around that is not being used and not making any difference in political discourse and policymaking. We witness this in our own communities of practice. Understanding the public health economy can give insight why that is the case. The political determinants of health - partisanship, lack of data-driven policymaking, and politicized health policy for scoring political points - figure prominently as barriers. The CDC’s 500 Cities project from 2016-2019 only produced 50 manuscripts based on a PubMed search on May 6, 2023. This might suggest underutilization of this dataset for public health planning and research since it produced a manuscript for 10% of the represented cities.

2) How does the CDC see itself as breaking through the intractable nature of the public health economy to make public health gains meaningful? The panel acknowledges several features of the public health economy that hinder its mission - 1) Congressional Budgeting (“prevention is scored by our government as an investment that has to be recouped in the same year in which the money is paid.” 2) State Independence (“for the most part, the information that the states give CDC-- and that's the right word-- gives CDC- is up to their goodwill.”) 3) Lack of Independence of Director (“But the FBI director is independent. I just want to see the CDC director be clearly independent in their decisions, whether they're part of HHS or whether they're not.”)

These are important issues, but the discussion vastly underestimates the intractable nature of the public health economy. As we posit in public health realism, the public health economy is an anarchical system defined by competing interests that has the effect of reproducing vast inequity. Agents or classes of agents go to great lengths to maintain the status quo wherein their self-interests are realized. Highly sophisticated tools from false speech and coalition-building are common.

The panel discussion provides neither insight into the effects of agent conduct in the public health economy nor into the nature of public health micro-economies. The realistic gains in health equity varies considerably by region and political economy. What may work in Dallas, Texas to support conditions for improved public health will look different from Boston, Massachusetts. That, as much, should be acknowledged because the practical strategies for political and stateside engagement will need to tailored to be effective. Appealing to health equity as a value might work easily in resource-rich liberal-leaning states and jurisdictions and fail spectacularly elsewhere. Texas lawmakers may be more convinced to address health equity based on costs savings and increased worker productivity. The CDC would benefit from insight and data analysis of public health micro-economies.

3) How does the CDC believe to be the role of the community in modernization effort? The word “community” was not spoken once during the panel discussion. The former directors’ view of the CDC’s stakeholders likely reflects a cultural mindset within the CDC, “So we need to really hear from our local health officials, our state health officials, territories, and tribes, but also our schools of public health, which have to be a very important part of the modernization of the science and bringing to bear the most emergent technologies and sciences that we're going to need to bring the agency into the next generation.” Notably, communities are absent in this new vision.

A belief that the CDC can accomplish its mission to combat all manner of diseases - “chronic or acute, curable or preventable, human error or deliberate attack,” - by marginalizing community perspectives and depriving them of a seat at the table is deeply flawed.[4] In our inaugural manuscript, we discussed the ongoing challenge of alienated scholars, “PHL eschews estranged public health, which can occur through alienation of the “objective” researcher from a community of practice rather than engaging non-instrumentally in promotion of an inclusive public health agenda.”

There is a deep undercurrent in public health that quality research can be conducted without community involvement by scientists who spend little time in vulnerable communities outside of research activities. That attitude is based on a flawed assumption that data collection and statistical analysis are sufficient to explain health disparities and to prove what interventions work. Another flaw in this thinking is that researchers believe that their research is devoid of researcher bias. The researcher’s worldview plays a key role in problem conceptualization, program planning, intervention design, and analysis. My dissertation is aimed at precisely this problem, “Standardizing Critical Analysis for Evaluating the Scientific Rigor of Health Disparities Research that Uses Racial Classification.”

Community involvement is essential to sound research. It is well-documented that public health lacks diversity that reflects the nation, but somehow the CDC and key public health stakeholders believe their knowledge and skills to be superior in every way to affected communities. It is that arrogance that is reproductive of health inequity, which wastes public health resources and funding to solve :”problems” at the level of intervention that fits the researcher’s worldview. The focus on individual health behaviors and denial of structural inequality are value statements and potential form of bias in research.

Exact Copy of Transcription from YouTube Closed Captioning

RICK BERKE: Hello, and welcome. I'm Rick Berke, the co-founder and executive editor of STAT.

And I'm glad to be here to moderate this important conversation. It's the first in a year-long series of programs at the Harvard Chan studio entitled, Public Health At the Brink.

This could not be a more timely moment to look at the turmoil at the Centers

for Disease Control and Prevention. As many of you no doubt know, late yesterday,

CDC Director Rochelle Walensky announced plans to revamp the agency and hired an outside group

to conduct a month-long review to look at strategic change

in the agency. The collection of individuals here

to discuss the CDC and the news yesterday is--

I can't imagine a better group or more qualified group.

We have four former CDC directors here. Let me introduce them chronologically.

Bill Foege led the agency from 1977 to 1983

under Presidents Carter and Reagan. Bill Roper was at the helm from 1990 to 1993

under President George H. W. Bush. Julie Gerberding was the CDC director from 2002 to 2009

under George W. Bush. And Robert Redfield ran the agency from 2018 to 2021

under President Trump. Tom Frieden, who led the agency for eight years

under President Obama, had a conflict and was unable to make this live discussion.

But he did send us a couple of thoughts by video. Let's dive in right away, initially

with the news yesterday from Director Walensky,

who's looking at strategic change in several major areas

at the agency, from the public health workforce to data modernization, to lab capacity, to health equity,

to pandemic response. Let me go around and just ask you your initial reaction

to this. And is it enough? Is it too much? What's your reaction? Who wants to go first?

BILL FOEGE: Rick, I would say it's very healthy

to ask for outside help. And I don't know if this is going to be enough.

I think there are a number of things that should be looked at. I've been pushing for the National Academy of Medicine

to actually do something in this area of asking the question, what are the skills?

What's the knowledge we need? What is the technology? What's the science that CDC needs

to stay at the cutting edge? And so this may be a beginning for that. So I'm all in favor of looking for help.

RICK BERKE: Dr. Gerberding-- JULIE GERBERDING: I can chime in. I really agree with Dr. Foege.

I would also say that it's important to not just have this focus on the CDC per se.

Because what really, I think, the pandemic has revealed to us is that our entire public health system

is in need for some modernization and some additional support.

So we need to really hear from our local health officials, our state health officials, territories, and tribes, but also our schools of public health, which

have to be a very important part of the modernisation of the science and bringing to bear the most

emergent technologies and sciences that we're going to need to bring the agency into the next generation.

RICK BERKE: Dr. Roper. BILL ROPER: Yeah, I was just going to agree with now my two, soon-to-be three colleagues.

There's nothing to be lost, a lot to be gained with inviting others

to give input to the process of reexamining the CDC's mission

and organization and work and so on. I think Dr. Walensky would be the first to say not

everything has been perfect. It's important to be striving for improving things.

The one caution I would pose is this needs to be done as rapidly as possible because, heavens,

you can create a scope so big and so complicated that we can do a 10-year study, and it wouldn't really

be enough. I think her calling for a one-month review is a very smart idea.

And I encourage this because it will never be done. CDC needs to be constantly reviewed,

but it needs to get on. RICK BERKE: Dr. Redfield. ROBERT REDFIELD: Yeah, my only comment, I'd

agree with my colleagues. I think it's really important that our nation look critically

at a proportional investment in our public health capacity. As Julie said, it's not just CDC.

It's the entire public health system of the United States. And I do think there's real opportunity

to get a much greater proportional investment, as Rochelle commented, whether it's data modernization,

whether it's workforce capacity, whether it's laboratory resilience, or whether it's our global health

pandemic footprint response. So the agency has evolved over the years.

And I would say one of the most important missions that it has is public health response.

And to do that, there needs to be a substantial increase in the investment strategy that our nation has

in public health in this country. RICK BERKE: What you are all describing is an overwhelming challenge for the agency

and for public health. And it's in intrinsic, systemic issues across the board.

If you had to pick one thing, where would you start? Dr. Foege, if you were talking to Dr. Walensky,

there's a laundry list of things that need to be done. And as Dr. Roper said, it's not going to happen overnight.

It's a constant thing. But where would you start? BILL FOEGE: Well, Rick, will you let me have two starts instead of one?

One start is CDC has never had national authority over what

states do in public health. And yet we haven't had the problems we're having right now.

In the past, if there was even an outbreak investigation,

CDC had to be asked by the state or a county or a city or a tribe to do that investigation.

They couldn't just go out and do it. And yet the system worked so well that it was never actually a problem.

We didn't need more authority. Now the trust has been lost. And it's trust that holds a coalition together.

And so it's very important to reestablish that trust. And I think if CDC would have a series of meetings with health

officers from states, counties, cities, tribes, that they could come up with, how do we seamlessly

approach public health problems in the future? So that would be one thing. The other one would be what we've already discussed,

that we have to review what we need in the way of technology and science and information for CDC to do all of this

correctly. RICK BERKE: Dr. Roper. BILL ROPER: Yeah, I would make a point that we could talk about

for the full hour. But one of the most important things to get clarified with regard to CDC is, what is its mission?

And I'm not so much talking about the scope of diseases or ailments that are considered, but rather

what is it doing with regard to science and politics and public health?

And one of the things that is frequently said, and I think meant well when people say it,

is we need to get the politics out of public health. That is never going to happen.

That's, frankly, in my view, a naive notion. We need science, the best of science,

to guide the decisions that are made by political leaders to implement effective public health programs.

So we need a constructive working together of science and the political process.

And by that, I mean the best of the way we make decisions in a democratic society. We need those two things working together for public health

to be successful. One of the things that has been an issue of late with CDC is people have said it's been too political or not

political enough or whatever. And I think the best solution to that is a recognition that CDC

has not a political agency. It is a scientific agency just like the NIH is, but in a different sector of science and medicine.

RICK BERKE: Bill, let me ask you, hasn't that hampered the CDC in some ways?

Based in Atlanta from the very beginning, it's away from Washington, away from-- it's tried to be nonpolitical.

But hasn't that cost it in terms of influence from the various administrations?

BILL ROPER: We're never going to redo what happened in the late 1940s. CDC is in Atlanta, and that's, on the whole, a good thing.

But the issue of how is the scientific advice from the CDC incorporated into the president and his administration,

and then interfaced with the Congress and their guidance and oversight and so on, that's a really important process.

And I think the issue that we face is not so much a scientific question any longer.

If I can be blunt about it, it's our dysfunctional political system. And so the fact that things are off in crazy directions,

if I can be blunt about it, is not CDC's fault. It's the political system.

And so that can't be solved by even the wisest people that Dr. Walensky invites in.

My suggestion, I guess, is to unabashedly say, CDC is a scientific agency, and we

will give the best advice to the public at large, to the political leaders at large,

and then work with them, one hopes, to have effective implementation of those programs.

RICK BERKE: Let me ask, Dr. Gerberding-- first of all, I'll give you a shot at saying the one thing that you would address first.

But before you do that, do you agree with Dr. Roper that the CDC should stay in Atlanta?

If you could wage your map [INAUDIBLE].. JULIE GERBERDING: It's a moot point. It is in Atlanta.

And it, I think, has made a very good demonstration of the value

in that location as well as the challenges. To initiate a conversation about moving the CDC

would be a waste of everyone's time and energy. It's not really where it's located.

It's how does it interact with the Department, with the White House, and with the Congress.

And those are things that, I think, all of us have solved in various ways through the years. There's no question that those relationships are important.

But I'm not sure they're going to be better or worse based on the geographic location of headquarters.

Now, with respect to your question about where would I start, I actually

really agree with my colleagues on this one. If I could add anything to that, I would probably say, again,

really looking at the emergent sciences, and I include in there data science,

because I think that's a real opportunity for the agency. But I also don't want to have our viewers left

with the impression that everything is broken at the CDC. There's incredible science going on there.

There is incredible evidence of ongoing capacities in outbreak investigations, in chronic diseases, environmental health,

birth defects. So we have to be careful that we don't paint the entire agency with a black brush when, in fact, there

are a lot of really good things happening. RICK BERKE: That's a fair point. Dr. Redfield, what's the single thing you would do?

You talked about data modernization. Is that your primary--

ROBERT REDFIELD: I think it's a critical tool for CDC to have real-time data that one can then execute

a public health response. I think it needs to continue to enhance its ability

to be a public health response agency. I know I always felt a little embarrassed every night

when I came home and watched the nightly news. And it's nothing against my father's alma mater

where he went to medical school at Johns Hopkins, but I always thought it was bothersome

that the data the nation used to track the epidemic was from a medical school rather than CDC.

So I do think there's an enormous need for CDC to be

the hub of a public health data modernization, which Julie commented is not just the CDC public health data

modernization. It's the whole nation that has a real-time, public health data

system that can be used for public health response. I do think that's fundamental.

Related to the Atlanta question, one of the things that I do think CDC would benefit from

is to expand its decentralization. We have many people that are CDC employees that

are detailed to different states, local, tribal, territorial health departments. I think that it would be useful to expand that public health

workforce so that we have a public health workforce that's pre-positioned throughout the nation,

and I would argue throughout the world. That can be used for that public health response.

RICK BERKE: What's your response to the question about the CDC is viewed as too political and needs to move away from that?

ROBERT REDFIELD: Well, there's no question. I agree with my colleagues. I agree with Bill. The reality is that public health is always going

to have a political tone to it. But I do think-- this is where I think-- and we will disagree with some people, Tom Friedman in particular.

I think there's an advantage to get the CDC director to be appointed similar to the FBI director,

where it's a seven- to 10-year appointment. I think there's an advantage for that director

not to have a response to the Secretary of Health, but to be independent and to be able to run that job, he

or she, as they feel is in the best interest. So I do think there's some structural opportunities

to help reinforce independence. Because the public health advice that the CDC gives

the nation has to be independent of the politics. The politicians will do what they

want to do with that advice. But the agency, for credibility, for the American public, has to be viewed as politically independent.

RICK BERKE: Dr. Foege, I know you wanted to jump in. BILL FOEGE: Two quick points--

this meeting on Zoom should put to rest the question of where CDC has to be physically.

It just makes no sense to argue that anymore. But I would like-- the second point is to totally agree with Bill Roper.

Don't separate public health from politics. Public health is totally dependent on politicians.

It's one part of the medical system that has a single-payer system.

And why? Because politicians decide on the appropriations. Our question should be, how do we incorporate politicians

into the solutions so that they really see themselves as part of the solutions and not just the place

that gives money? RICK BERKE: Thank you. Let's now talk about something that Dr. Redfield just

brought up about confirming the position. I know senators in both parties are

getting behind the idea of making the CDC director a confirmed position by the Senate.

And I know in our video conversation with Dr. Frieden,

we asked him about that. So let's start the conversation on that by listening to a clip from him.

He takes a different point of view than Dr. Redfield about the question of a confirmation,

confirming the CDC director. Let's listen to this. [VIDEO PLAYBACK] - Public reforms included in the Bipartisan Prevent Pandemics

Act are moving through Congress. And much of what's in the bill is greatly needed. But there's also language that would require that the CDC

director be Senate confirmed rather than appointed as is done now.

Making this position Senate confirmed would politicize the process of naming a new director,

with contentious partisan debate delaying confirmation potentially in the middle of a health emergency.

There's also a risk that people will be nominated not for their technical expertise or ability

to manage a public health problem, but for their industry or political connections.

Although intended to make the agency more non-partisan, making the CDC director a Senate-confirmed position

would likely do the opposite, and it's a dangerous idea. [END PLAYBACK]

RICK BERKE: Let me hear from the other three-- dangerous idea. Dr. Gerberding, what do you think?

JULIE GERBERDING: I've thought about this a lot, and I see both sides of it. But I have to say, net, net, especially given,

as Dr. Roper put it bluntly, the complications of our political system right now,

I just can't see that this is going to be part of the solution. I think it's going to worsen the situation, not make it better.

RICK BERKE: Dr. Roper. BILL ROPER: Yeah, I tend to favor the notion of having the Senate advise and consent

to the appointment. There are some additional things Dr. Redfield was mentioning earlier that might be done like making a term

appointment as is done with the director of the FBI, for example.

But I think, like it or not, the Senate confirmation process

is a measure of the credibility and importance that the Congressional branch puts to the position.

And I just find it an anomaly that, for reasons that just are historical, we've never caught up with the fact

that the other counterpart agencies within the US Department of Health Human Services-- the FDA

commissioner, the NIH director, the head of the Centers for Medicare and Medicaid Services, et cetera--

are all Senate confirmed. This one should be as well. Now if one wants to say, that's a slow and difficult process,

heavens, I agree. See what just is happening now with Ketanji Brown Jackson.

I'm not a defender of the efficiency of the Senate confirmation process.

But I do think it adds real credibility to the person who is so chosen.

RICK BERKE: Dr. Foege. BILL FOEGE: Well, I served as CDC director

for both President Carter and President Reagan. It is possible to be in this position

and not have it be political. I don't know the answer to Senate confirmation,

but I worry that it could be a real problem in the future.

So I think the Department-- HHS has to totally depend on the director of CDC.

And I can see problems if they don't feel that they can depend on it, and that they have someone that's working against their best interests.

So my bottom line is I don't know. I'm not sure whether this is the right thing or not.

RICK BERKE: Dr. Redfield, let me ask you. The CDC-- obviously, it's been very turbulent, obviously,

with the pandemic under your tenure, in the current tenure.

Did you ever have an opportunity to give Dr. Walensky any advice before she took over about what you experienced?

ROBERT REDFIELD: Yes, I did. I actually called her to congratulate her when her appointment was announced.

Like my colleague Bill Roper, I told her one thing she wasn't going to get from me

was public criticism. I had the opportunity to have a number of CDC

directors aggressively publicly criticize me. I didn't think that was helpful to the agency.

And I told her she wasn't going to get that from me. And I told her to have faith in her instincts.

It's a great organization, enormous number of men and women that are really committed

to the public health of our nation and the world. And she should stick to what she believed

and not get pressured into changing her point of view because somebody was trying to convince her

that there was a political advantage to that change. Just stay true to herself. I have a lot of confidence and faith in her.

And when people ask me to criticize the CDC director, I

step back and tell them, one thing I know for sure, as the colleagues on this call now,

one of the hardest jobs that I have ever had and probably ever will have was being the CDC director.

So great deal of confidence in her. Complicated job, a lot of political pressures

on that job. She needs to stay true to herself and continue. And, hopefully, the CDC directors

that have come in the past will be supportive and non-critical of her. RICK BERKE: Is there anything that any of you

could say given you've all been in the hot seat in that job, anything you wish someone had told you

that had been in that seat before you took over, something you wish you had known?

ROBERT REDFIELD: Maybe I'll start since I was last. I was really, obviously, honored to be given the opportunity

to lead CDC, which I do believe is the greatest public health agency in the world.

I will say that I was shocked to see how under-resourced the agency was.

And I give one example that I've said publicly before. The first briefing I asked for in April

was a briefing on opiate-related deaths. People know that one of my six children

almost died from cocaine that was contaminated with fentanyl. Obviously, it was a big priority for the president

and the secretary. So I asked to be briefed on that. And I had a great briefing by real experts.

We lost 80,000 people from drug-related deaths that year.

And when the briefing was over, I just asked a simple question. What was the data through?

And the briefer looked at me, and he said, well, Director, it was through March 2015.

And I said, but it's April 2018. And they said, yes, but, Director,

you don't understand the complexity of gathering data from the states, making sure it's curated.

I did say-- and this is why my view on data modernization-- I did say when I came here, I thought

I was going to be leading the premier public health agency in the world and that we were

going to use data to make impact on public health. And what you're telling me is I'm a medical historian.

So I do believe very strongly, the importance of modernizing our data system.

So data comes in at a time that it's actionable. And I think that was what I was totally shocked by because I

had idolized CDC for my 30-year medical career, thinking this was the top of the top.

And to find out how under-resourced they are-- this is why I said to you, one of my most important priorities

is that our nation invests proportionately to CDC and public health.

I personally believe that our national security is much more impacted by the capacity of our public health

system in this nation than it is by North Korea, Iran, China,

or Russia. And yet we don't invest proportionately to that,

and we need to start to do that. And, hopefully, Congress will finally look that this is an agency that doesn't

need $5, $8, $10 billion. We need three to five aircraft carriers, and they need to sustain that so that we

can build a public health system in this nation. CDC can clearly lead it. I have no doubt about that.

But they need the resources to do it. RICK BERKE: Dr. Roper, I see your hand. BILL ROPER: I just would say, I totally agree

with Dr. Redfield's points. But I want to link that back to something

Dr. Foege said at the outset. To do the kind of modernization that Dr. Redfield is calling

for of the data systems requires a basic change in the relationship between CDC and state

and local public health departments. For the most part-- there are a few tiny exceptions,

but for the most part, the information that the states give CDC-- and that's the right word-- gives CDC--

is up to their goodwill.

And so until we have the ability to do the kind of modernization

you just heard about, we need to face the question, do we want-- and I sure hope we do-- do we want

a standardized, nationwide public health data system? If that's the case, then we can get the smart people together

and design it and implement it across the 50 states plus the District and the territories and so on.

But until we get that, in the current situation, every governor can basically say,

no, I don't think we're going to do that. And that just blows the whole thing apart. We have to face this issue of who

is running the system, which Dr. Foege started with.

RICK BERKE: Before I move on, does anyone-- does Dr. Foege or Dr. Gerberding want to answer the question about what

you wish someone had told you? JULIE GERBERDING: I wish I had understood the resourcing

of the CDC as well. And you look at the number on paper. It looks, wow, that's a great budget. We ought to be able to do a lot with this.

But, first of all, there's very little discretionary funding. So the line item process preallocates the resources

that are coming to very specific programs, which often are championed by people who need that investment,

but also by congressionals who care about those issues. I think the other structural issue, other

than the amount of money, is the fact that when an emergency occurs like we're experiencing right

now, our Congress has been incredibly helpful in appropriating emergency funds.

Those are one-time dollars. And you can't hire people on them or really build and expand the capacity of the system

over time. Those monies go away as soon as the crisis is over. And so we are left back at the zero starting point

again, where we really don't have any capacity to continuously improve both our bio preparedness,

which I completely agree with Dr. Redfield is a matter of national security. But we also don't really make the sustained investments

in health equity and health impact that we need for the chronic diseases and the other problems that people have.

So we're basically operating a CDC in a public health system right now that's funded on a per capita basis

less than it was in the 1950s in real dollars. And that just doesn't make any sense in this day and age.

RICK BERKE: Dr. Foege. BILL FOEGE: Two quick points. Number one, advice that I got that was very valuable.

My predecessor, Dr. David Sencer, let me know that every place in the world

is both local and global. Therefore, anyone working on public health anyplace

is working on global health. And the objective is global health equity.

And if you have that in mind, it gives you a mission statement that you can proceed with. Number two, I support exactly what

the others are saying, that the resources are always so inadequate except when we have an emergency.

And then you think-- but it doesn't come true-- you think it's going to change.

Now we're going to get enough resources to actually get an infrastructure. But we're always beggars.

And we know that poor people think differently than rich people.

And there's plenty of evidence that we were thinking always like poor people.

We were begging for money. We didn't have a chance to say, here's the problem, and this is what it would cost, and this is the infrastructure

we have to go forward with. And people have made the comparison

that if you go 20 years at an airport without an emergency, no one tries to reduce the budget for the emergency

services at the airport. So why do they do that in public health? Because we don't have the same mentality.

RICK BERKE: Let me say, Dr. Frieden also has some interesting comments on the budget

or the lack thereof. And I want I want to run that clip in one second. And then right after that, we've gotten lots of questions

from viewers. And I want to get to as many of them as I can in our second half.

And also you can type any additional questions into the live chat on YouTube.

And, again, I'll get to as many as I can. But let's go right to the Frieden clip,

talking about his approach to funding.

[VIDEO PLAYBACK] - We have to approach our nation's health defense with the same urgency we approach our military defense.

In peacetime, we don't cut military and intelligence gathering capabilities so that we're at risk.

Why then are we starving our health defenses when those threats are no longer in the headlines?

We spend literally 300 to 500 times less on our health defense than we do on our military defense.

And yet no war in American history has killed a million people as COVID

has in the past two years. If we had invested sufficiently in our health defense,

most of these deaths could have been prevented. The HDO designation would ensure that critical public health

defense functions have sustainable and sufficient funding, finally breaking that deadly cycle of panic

and neglect. [END PLAYBACK] RICK BERKE: One thing I want to talk about on funding

is I want to ask Dr. Gerberding, during your tenure, you did try to tackle the budget system to get both the CDC

and state agencies more flexible on spending, but it didn't succeed.

Can you tell us what happened and how you would advise the current leadership to tackle the issue?

JULIE GERBERDING: Yeah, it was an experiment in a sense. After meeting with many mayors and their health leaders

as well as governors and their health leaders, it became clear that the way the CDC budget arrives

at the state in several different line items creates an administrative inefficiency.

But it also means that decisions about what gets prioritized are really coming from the federal government to the states rather than maybe

the other way around, or at least some negotiation on what individual states and cities feel are the priorities.

So we tried to create a more flexible system where a state could establish its health priorities.

And then the CDC dollars could be used to support those priorities in a way that was still

transparent and accountable. That was a great idea on paper, and it received a fair amount

of support from the state health officials as you can imagine. But it set off some alarms for the people who

had worked really hard to make sure that we had line item budgets for certain disease categories.

And so there was a tension between what the states felt were important and what stakeholder groups felt

were important. And I think if we go forward with this kind of notion, we're going to have to do a lot more groundwork for so

that there isn't an either/or situation, but rather we come together and agree

on what the priorities are, and then find more transparent and flexible ways and accountable ways to make sure

that the right things get funded from the state and local perspective. RICK BERKE: Let me throw in a question

from a viewer named Nathaniel, who asks, if the CDC gets more

authority over states, can or should the American public have greater oversight over the CDC?

How can we ensure more transparency? Anyone want to tackle that?

BILL ROPER: Well, CDC is a federal agency. And the oversight of federal agencies happens in a variety of ways, including

the media coverage, et cetera. But the official way it gets done is the Congressional oversight process.

And, again, I would just point out there's some problems with the way oversight

is undertaken these days and the partisanship with which it is wrought. But I think there's ample avenues

for that kind of transparent oversight if we just use them right. RICK BERKE: Speaking of partisanship,

we published an analysis in STAT last summer that argued that we need to invest another $4.5 billion,

which would be $13 per year per US resident

to adequately fund public health in this country. If we think that that's a reasonable investment,

how could we break through the partisan divide in Congress to make the case for this?

JULIE GERBERDING: Can I just add one point of view on this just for completion? I think we're talking about public health as a cost.

And how much do we need to invest to accomplish modernization improvement in our public health system?

But we have to also think of it as an investment in health, in health protection, and in many cases in cost savings

somewhere else in our federal or state or local budget because of the tremendous value that prevention, preparedness,

and health protection really creates for people. One of the challenges that we have is that prevention is scored by our government

as an investment that has to be recouped in the same year in which the money is paid.

I don't want to get into the complexities of the Congressional Budget Office accounting. But we are not able to say, if we invest x in, say,

vaccination this year down, the road we're going to save y in diseases averted or cancers prevented,

et cetera. The outyear benefits don't really help in offsetting the investments that

are coming through the appropriations process. So when Dr. Frieden was talking about modernizing

the way we invest in our health protection system, he's really talking about changing the rules

so that that kind of annual accounting could be more flexible and allow for more sustained, regularized

support. BILL FOEGE: Julie is absolutely right in that this

has to be seen as an investment, not a cost. And one of the examples of this is the US

made an investment in smallpox eradication at a time when we didn't even have smallpox.

But we were spending a lot of money vaccinating people and treating their adverse reactions from vaccination

and so forth. Our investment after smallpox eradication has been recouped every three months, which

means that since smallpox disappeared, our investment has come back 160 times what we put in.

So if everyone understood that was an investment, they would say, yes, that was a great investment. And the same thing with immunization,

that for every dollar we put into immunization, we get at least $10 back unless we use this short-sighted way

of saying the benefits have to come back the year that you give the vaccination.

RICK BERKE: Let me ask you-- Dr. Foege, let me ask you about smallpox because you did play a big role in that eradication.

And the pandemic certainly showed us that disease does not respect borders.

Yet we still see many Americans hesitant about spending tax dollars overseas.

How does the CDC balance the priorities between global and domestic imperatives?

BILL FOEGE: We have to see ourselves as global health equity being our objective no matter where we're working,

and then balance it that way. We should have been giving much more vaccine globally

at an earlier date with coronavirus than what we did. Because it comes back to benefit us

if we don't have new variants that are coming from Africa and other places because there's so much transmission.

So we have to from the beginning see we are involved in global

health and that we cannot walk away from that, that this is part of protecting us.

Now, Dave Sencer at one point asked the question, how could we improve global health

from CDC's point of view? And the answer was, we don't have a lot of money,

but we have a lot of good managers. And so we were willing at CDC to put some of our best managers

into places where global health decisions were being made. So DA Henderson was at WHO, heading up the smallpox program

for 11 years. Most people don't know he was a CDC employee that entire time.

Rafe Henderson was head of the childhood immunization program. He was a CDC employee.

Mike Merson was head of the diarrheal disease program, a CDC employee. Jonathan Mann was working on HIV, a CDC employee.

This is the way we contributed to public health and we protected the US.

RICK BERKE: Let me ask Dr. Gerberding a question

from Selena at NPR, which is, Dr. Gerberding,

you led a restructuring of the agency when you were director, which was criticized by agency staff

and reportedly negatively affected morale. Do you have lessons learned from that process

to share with the current director? JULIE GERBERDING: Well, first of all, I think there's a lot of emphasis placed

on restructuring as a solution. And I'm not at all sure that restructuring solves

any problem in an organization. If you have the right people and the right strategy,

probably the structure isn't the most important issue. For me, the restructuring was primarily

a consequence of the fact that when I came into the job, I had way too many direct reports.

And I had to think of a way to bring folks together in scientific units that made sense.

So the people involved in chronic diseases were in a cluster. The people in infectious diseases

were in a cluster, et cetera. And I think that the lack of creating a burning

platform, if you will, for making those changes was a rookie mistake on my part.

Because in order for people to really not be fearful of a restructuring and to move in that direction, they have to see what's in it for me.

And I wasn't very good at articulating that. I did find it somewhat amusing that when it was all said and done, and Dr. Frieden came in,

he pretty much ended up with a very similar organizational structure, which just tells you that it isn't how people are organized as much as it is

having the right people and, more importantly, making sure that everyone understands what work

needs to get done. So these are lessons learned, I would say. RICK BERKE: Yeah, in those lessons learned,

is there a cautionary tale for Director Walensky? Because she's talking about restructuring.

It's the same thing that you've all tried. Is it futile? Is it-- anyone?

JULIE GERBERDING: Well, I really wouldn't want to second guess what Rochelle is looking at right now. A lot has changed at CDC since I've been there.

And I know from conversations I've had with her that she's very focused on the science

and getting the science right. So I suspect if she's moving in any direction, it's really an effort to try to understand

how to accelerate progress in the emergent sciences. And at the same time, we're still

in the middle of a pandemic. We can't forget that the CDC is still in very operational mode.

So it may very well be an appropriate time to think about, are we really organized in a way

to continue what has become a marathon? RICK BERKE: Right. Dr. Redfield, you were looking to jump in.

Did you have something? ROBERT REDFIELD: Well, I was just talking about the importance of investment in public health.

I was going to add, when I was able to be the CDC director, one of the things that was clear to me

was that we had 40,000 people a year, each year getting HIV infection.

But we had all the tools to prevent that with antiretroviral therapy,

with diagnosis, with treatment for prevention. And to try to begin to work with OMB to let them

understand that when you looked at the 40,000 cases per year,

over 10 years, $500,000, $600,000, $700,000, $800,000 a person, it got into enormous amount of money,

a quarter to a half a trillion dollars. It made a lot more sense to invest in public health,

whether that investment was $100 billion or $200 billion, and try to help bring an end to new infections with HIV.

So I think it's so important, as Julie pointed out,

it's not about the cost. It's about the savings. I would argue that, in general, investments in public health

have substantial savings, not to mention the impact it has on the human condition.

And, unfortunately, the system, the way they do that, we were able to get it through OMB when

I made the arguments, but it's complicated because they want to look at everything on an annual basis.

And I think there's many ways that public health can generate substantial health savings and should be invested.

I think the biggest issue that I will continue to say is that our proportional investment in public health

is just highly inadequate. And we need to think about it like Tom said. I spent over 20 years in the Defense Department.

We need to think about it proportional to our investment in the Defense Department. This is probably the greatest threat to the United States

in terms of our way of life. It is not our relationship with North Korea, Iran, or China,

or Russia. It's really the pandemic potential. And the fact is we're not prepared for that pandemic potential.

Even if we can get the science right, we don't have the manufacturing capability to be able to develop the countermeasures.

And we really ought to really relook at the threats that we have in this nation and make public health

one of the major investments that our nation makes proportional to our Defense Department.

RICK BERKE: Let me jump in with a question for all of you about trust. Because it's something we're hearing from a lot of--

obviously, it's out there. We're hearing from a lot of viewers about this on this question. And let me read one question from a viewer named Tara,

who says, as a journalist who has covered public health, including the CDC for well over a decade,

I admit that I myself have lost all faith in the organization and feel a bit like I've lost my religion.

What do you think the CDC can do and might actually do to regain the trust of those who know the organization far

better than average people and yet feel completely betrayed by how the institution has abandoned

its mission of public health in favor of promoting individual health and responsibility?

Pretty strong words, but you hear them everywhere. Anyone want to weigh in on that, respond?

BILL ROPER: I just would say a couple of things. But I wasn't sure what that last sentence meant.

So that's why I looked a little quizzical when you read it about individual responsibility.

RICK BERKE: Why don't we drop the last sentence, but sort of the larger-- BILL ROPER: Yeah. So trust is a big issue.

Americans-- worldwide, people have lost faith in institutions.

CDC is, unfortunately, a part of that.

Without criticizing-- and my colleagues have done this disclaimer.

I'll do it myself. I'm not criticizing any decisions recently made or done or whatever.

But I think it's important that each time CDC or any other health official makes a pronouncement

to say with humility, to use the fancy word, epistemic humility,

that we say, this is what we know today. And this is our best advice given what we know today.

We may know tomorrow. And if it is different from what we know today,

we will change our advice tomorrow. But I think people are so anxious for a pronouncement

from on high that is permanent and forever more. And that's just not the scientific process.

Now I'm trying to call up my memory bank of famous quotes.

But somebody, I think in politics, once said, when the facts change, I change my opinion.

What do you do, sir? I think it was a British statesman. But anyhow, that's the process we use.

And people should not say, that's crazy, or CDC made a mistake, or we can't trust them anymore.

They should value the humility that's demonstrated when CDC directors and all the rest of us say,

we're doing the best we can. When we learn more, it probably will change our advice,

but that's what we know today. RICK BERKE: So if someone else could jump in and say, what needs to be done to rebuild trust?

What's the fastest-- is it doable? How do you do it specifically?

ROBERT REDFIELD: One comment I would make, I really do believe it's so important to create

the structure of independence. This is why I have the view that congressional approval

of the CDC director is a positive thing, not a negative thing. But I understand the controversy.

I do believe that the CDC director being appointed for seven to 10 years like the FBI director--

the FBI director is not-- his decision or her decision is not dependent on what the attorney general says.

I think the structure right now is complicated, where the CDC director is reporting

to the Secretary of Health, who's deciding to weigh in on what happens. And then that's weighed in on the White House.

And there may be a special advisor to the president on health like we have right now.

I think there has to be a structural independence of the agency. RICK BERKE: It should be moved out of HHS

and be an independent-- ROBERT REDFIELD: I just think there needs to be structural independence. The FBI is in Justice, but there's

structural independence. And I do think that we're seeing-- I know I felt it in my term.

I'm not sure my colleagues, what they felt. But I'm sure Rochelle feels it in her term. There needs to be structural independence for public health

advice to the American public. RICK BERKE: So you would stop short, or would you stop short of making

it an independent agency? ROBERT REDFIELD: To me, as I said, the FBI is in Justice.

And they report to-- they're in the organization under the attorney general. But the FBI director is independent.

I just want to see the CDC director be clearly independent in their decisions, whether they're part of HHS

or whether they're not. I think that's less important. What's important is that they're independent.

They're not having to discuss their recommendations with the secretary and have the secretary then

modify what they want. They're not having to discuss those recommendations with the White House and have the White House.

No, it needs to be an independent agency. And the individual is going to be in that job for seven to 10 years.

And they give the best public health advice that they give to America. I think it's the lack of perception of independence

that has undercut trust. RICK BERKE: Dr. Gerberding, is that the biggest issue with trust, the lack of independence?

Or are there other issues? JULIE GERBERDING: I think it's been an issue, especially in recent years.

But I also think that goes back to what Dr. Roper said earlier,

that CDC needs to be presented as the scientific resource

in response to our public health requirements. And I think it's helpful to have that perspective emanating

from Atlanta, not from other political components of our government.

I think it's helpful to have that perspective articulated with the best scientists in the world

standing beside the CDC director and offering their scientific opinion and perspective.

And I think it's helpful to include the state and local public health officials, who are also

part of the recommendations of the policy and the advice so that we are a public health system responding

to the science. Probably one of the things that I'm secretly--

I wouldn't say proud of because that implies a lack of humility. But one of the inventions that occurred

when I was the CDC director was the frequent use of the word interim-- interim guidance for x, y, and z.

And when we were able to use the word interim in the MMWR guidance, it implied that this

is what we know today. This is what we are recommending based on what we know today. But guess what-- these recommendations

are subject to revision when we know more and the science has evolved. And I'm happy to see that continuing.

But I think that's the flavor of the message that we're all talking about, that people

can handle uncertainty or ambiguity if they're told with humility that that's what's going on.

And they can appreciate and respect that you're working as hard as you can to get answers, but you don't have all the answers yet.

So stay tuned. We'll update you tomorrow. RICK BERKE: Let me ask Dr. Foege. You warned early in the pandemic that the CDC

was losing its credibility with its reputation sinking from quote, "gold to tarnished brass."

Among the things that frustrated you was that you felt the agency had ceded its role as the authority for credible, timely public health

information to pundits and academics. Do you still feel that way? How can the CDC regain its authority?

BILL FOEGE: Well, this is what Dr. Redfield was talking about, having independence.

And he was not allowed the independence he needed. And he was being told by a White House how to do things.

And we've had 225 years of modern public health since Edward Jenner did that first smallpox

vaccination in 1796. And we've learned a lot of things about how science works

and the need for having truth and the need for coalitions. And the avoidance of certainty, as Bill Roper

was saying, that we simply have to avoid the idea of certainty. Because Richard Feynman, the physicist was right.

That is the Achilles' heel of science, but also of politics and religion and everything else.

And we've learned over the years that you have to do evaluation and keep changing what you're doing,

that you need to respect the culture, that you have to combine, as Julie was saying, the science and the management in public health.

You have to be working with politicians. You have to have a global response.

And my feeling was that the White House, the Trump White House, was violating every one of those lessons learned.

And so I came to, well, there's got to be another lesson here, which is lessons are useless

if they're not regarded. RICK BERKE: Let me give Dr. Redfield a chance to respond.

Do you agree that the Trump White House violated all those instances, all those examples

Dr. Foege is mentioning? ROBERT REDFIELD: No, I don't. I was actually very disappointed in Bill and his decision

to publicly criticize me fairly aggressively. But that's water under the bridge.

I can say I always fought for the independence of public health. I'm not saying that people politically didn't try

to influence those decisions. I say, the one thing I've gained by being CDC director for three

years and the Trump administration is every time that I go through a airport now,

I trigger the metal detector because of all the shrapnel that's in my back, even though I spent

20 years plus in the military and never got any shrapnel, including Pakistan, Afghanistan.

But I would say that those of us at CDC strove to try to maintain the public health message

despite substantial pressure. That's why I feel firmly about what I said here,

that the agency would benefit, future directors would benefit from making the structure

so it's very clear that it's independent with a seven- to 10-year appointment. It's not in any command chain with the Secretary.

So I did the best I could, as did my agency when I was there

to promote what we believe to be the sound public health message and to promote that despite others that

may have other point of views about what they wanted to see. It was disappointing that some of my CDC director colleagues

felt the necessity to publicly criticize me in the news.

This is why, with Rochelle, the first call I made, I said she's never going to get that from me.

I'm 100% in her camp. I know it's a tough job. If she wants my advice, give me a call.

I'll give it. But I'm praying for her every day to be able to lead what I consider to be the premier public health agency in the world.

I just would like to give it the tools to do its job. And that tool most importantly is the proportional investment

that's required for that agency to do its job. RICK BERKE: We just have a couple minutes left.

Let me ask you a couple very quick questions. One is I'm wondering if this mistrust goes both ways.

There have been points during the pandemic when we've heard that the CDC has held back

from releasing data or guidance because it didn't trust the public to understand and respond appropriately.

Is that a problem? Anyone want to jump in on that? BILL FOEGE: Rick, let me just respond to Dr. Redfield.

I never did that publicly. It was a private letter with no one else involved.

I never even consulted with anyone else. And it was leaked from his office.

So it was an attempt to give him my private recommendation.

RICK BERKE: OK, on the question of mistrust going both ways, does anyone fault the CDC for holding back?

No one? No comment. JULIE GERBERDING: I don't think-- I can't comment on that because I have no information that CDC held back anything.

I do think that it's always a natural instinct to think, oh, boy, how are people going to react to this?

We better make sure we think through how this is presented. But it would really surprise me that information was held back

because the public might not respond in the way we hope they would. That's part of good emergency risk communication

is to know how to present bad news in a way where you help people find their way to do the right thing.

RICK BERKE: Final question that, I think, looks to the future that goes to this very question

of independence or not and politicization of the CDC. We've seen the Biden White House take a much more active role

in public health issues that are typically reserved for the CDC because of the pandemic.

When do you all think it will be time for the White House task force to wind down and have those roles go back

to the CDC control? And related to that, has the White House's involvement

been a help or a hindrance? Let's start with Dr. Roper.

BILL ROPER: So rather than answer your question, I'm going to dodge it this way. I think, in general, we have way too many White House advisors

on everything. Not just health and public health and whatever, but there's a czar for this and the czar for that.

What that does is give the president, him or her, the ability to turn to their right or left

and have somebody tell them what the latest is. But it also has the effect of disempowering

the cabinet Secretary, who's in charge of Health and Human Services, and the CDC director, who's the scientific agency

director, et cetera. So having worked in two white houses, Reagan and Bush,

as the health advisor to each of those presidents, I'm strongly in favor of having many fewer White House

staff doing these kinds of supposed coordinating things. Because unless you're very careful,

the White House staff ends up doing what they did in the Vietnam War. And that is selecting the bombing targets

and telling the generals where to drop the bombs. That's just not a good way to run a railroad.

RICK BERKE: Dr. Foege, specifically, should the White House send some of these roles back to the CDC?

BILL FOEGE: Absolutely. I agree with Bill Roper on this, that it becomes confusing

because you get two different messages. And if CDC has to be checking the White House

message every time, that just inhibits good science. RICK BERKE: Dr. Redfield, do you agree with that?

ROBERT REDFIELD: I agree with Bill. I think that the CDC director ought to be driving the train.

Very complicated during my term with, obviously, the coronavirus task force.

And then, obviously, very complicated for Rochelle with now a senior medical advisor in the White House.

I have a lot of respect for Tony Fauci. But my own view is that should be the CDC director.

So I just think that we ought to let the CDC director be the CDC

director and lead this nation's public health response. RICK BERKE: Dr. Gerberding, what do you think?

JULIE GERBERDING: Well, I feel strongly that we do need a national strategy for our health

defense. And I believe that strategic function is best compiled across many cabinets at the White House

level. But the CDC is an operating division. And it's the responsibility of the operating divisions

to operate. And so I completely agree that the management of the execution of the public health

functions for this pandemic or for other health threats really should be left to the agencies.

And we don't need all of these complex coordinating bodies checkered throughout our government.

RICK BERKE: We're supposed to end here, but I'm going to take a minute and a half more, moderator's preference here.

If you all can answer this question in 10 seconds or less,

and I'm going to go around a lightning round. And if you can't do it in 10 seconds, then we'll skip you. And that is, what's the one thing

you would do to restore public trust in the CDC? Dr. Foege.

BILL FOEGE: I would try to come up with more transparency so people see what is happening.

RICK BERKE: Dr. Redfield. BILL FOEGE: And get people information fast, and that we avoid certainty. RICK BERKE: Dr. Redfield.

ROBERT REDFIELD: I would just say, structurally reinforce their political independence. RICK BERKE: Dr. Roper.

BILL ROPER: Be more outgoing and thoughtful and frequent with the communication from the CDC

so that people understand the agency. RICK BERKE: And final word, Dr. Gerberding.

BILL ROPER: Communicate, communicate, communicate. RICK BERKE: You guys are great. You all did it in less than the time allotted.

So that's wonderful. BILL ROPER: We've had media training. RICK BERKE: [LAUGHS] Right. Well, you have.

Clearly, you've all done this before. Anyway, I really think this was a really thoughtful

conversation. I hope Dr. Walensky watches this because she could pick up a thing or two, I'm sure.

And what's interesting to me is not only your thoughtfulness, but your passion for the agency and how most of you

agree more than disagree on most of these points.

It's really helpful for the public discourse to have this conversation. And I thank you for participating.

I thank all the viewers for taking the time out of your afternoon to listen to this

and to offer your questions. I'm sorry I couldn't get to them all. If you missed any of this event, you

can watch it on demand at the Harvard Chan School's YouTube Channel.

And you can also check out other events in the Public Health On the Brink series at HSPH.Harvard.edu/Brink.

Thanks very much. Have a great rest of the day, everyone.