The U.S. Centers for Disease Control and Prevention (CDC) is the federal agency mandated with protecting the health of Americans. Among the world’s preeminent health agencies, it plays a crucial role in fighting disease globally, conducting cutting-edge research and acting as a first responder in crises such as outbreaks of the Zika virus in South America and Ebola in West Africa.
However, the agency has faced sharp criticism at times, particularly over its response to crises and ethical lapses. In 2020, it was thrust into the spotlight again amid the pandemic of a new coronavirus disease, COVID-19, and missteps during the U.S. outbreak have prompted some calls for reform.
What does the CDC do?
The CDC has a broad mandate to address health, safety, and security threats both at home and abroad. Its roles include:
- detecting and responding to new and emerging health threats, such as the spread of COVID-19 and other epidemics;
- tackling the leading causes of death and disability for Americans, including heart disease and cancer;
- promoting healthy communities and best health practices; and
- developing the public health workforce.
To accomplish this, the CDC carries out scientific research on new and ongoing threats, with more than two hundred specialized laboratories across the United States. It is also often the primary U.S. agency communicating critical health information to the public.
What are its origins?
The Communicable Disease Center was founded in 1946 as the successor to a program focused on controlling the spread of malaria during World War II. The fight against the mosquito-borne disease, which at the time was believed to be widespread in the American South, led to the agency being based in Atlanta, Georgia. It eventually took on research and response efforts for other health issues, including sexually transmitted diseases, tuberculosis, and immunizations. Over time, its mandate expanded further to include threats such as gun violence, chronic diseases, environmental contaminants, and bioterrorism.
The CDC went through several more name changes before taking on its current title: for several years in the 1960s, it was the National Communicable Disease Center; it was the Center for Disease Control through the 1970s; and it was renamed the Centers for Disease Control in 1980. In 1992, it became the Centers for Disease Control and Prevention.
How is it organized?
The CDC is an agency within the Department of Health and Human Services (HHS). Headquartered in Atlanta, it has a workforce of more than twenty thousand people around the globe. As of 2016, it had over 300 full-time staff and 1,300 locally employed workers outside the United States, across more than sixty countries. The directorship of the CDC is typically a political appointment by the president that does not require the Senate’s approval. Directors are always health-care professionals; Robert Redfield, a medical doctor and virologist, has headed the agency since March 2018. The CDC is divided into institutes, offices, and centers—there are twelve major units and more than two dozen in all—each with their own focus, such as the National Center for Injury Prevention and Control and the Office of Minority Health and Health Equity.
In fiscal year 2020, the agency’s budget was about $12 billion. Close to $5 billion of the CDC budget goes toward Vaccines for Children, an entitlement program that provides free vaccinations to children whose families are uninsured, underinsured, on Medicaid, or are members of an indigenous group—about half of all children in the United States. Roughly 60 percent of the budget, excluding Vaccines for Children and Global Health funding, supports state and local health departments.
How does it fit in with other U.S. health agencies?
There are several other agencies within HHS doing work related to that of the CDC. These include the National Institutes of Health (NIH), the Biomedical Advanced Research and Development Authority (BARDA), and the Food and Drug Administration (FDA). Within the NIH is the National Institute of Allergy and Infectious Diseases (NIAID), which is a research rather than public health practice entity. The NIAID, currently led by Anthony Fauci, has been at the forefront of the COVID-19 response alongside the CDC.
Additionally, the CDC supports state and local health departments, not only financially but also by providing technical guidance. The agency deploys hundreds of employees to these departments to help run more localized health programs. However, the CDC’s ability to influence local health policy is limited. “With the states and localities, it doesn’t have any regulatory authority. It only has funding and moral authority,” says CFR’s Tom Frieden, who headed the CDC from 2009 to 2017.
What is its global role?
For many health professionals, the CDC is the gold standard for national health agencies. It has regularly worked in tandem with the World Health Organization to respond to international health concerns and has built a high reputation in many parts of the world, maintaining staff in dozens of countries.
“Quietly and effectively, the CDC projected American competence and leadership,” writes Sudip Parikh, chief executive officer of the American Association for the Advancement of Science. “Around the world, public health agencies across Asia, Africa, and Europe are called ‘CDC,’ despite the fact that the acronym may be meaningless in the home language.”
A principal aspect of the CDC’s global reach is its field epidemiology program, through which it trains what it calls “disease detectives” in the United States and abroad. With more than ten thousand graduates, the program has produced many of the world’s leading epidemiologists. The CDC has also played important roles in implementing several high-profile global initiatives, such as the President’s Malaria Initiative and the President’s Emergency Plan for AIDS Relief, both launched under President George W. Bush. Experts say it has contributed to a slew of major public health achievements, such as the eradication of smallpox in 1980 and the near elimination of polio worldwide.
At the same time, the CDC is often a leader in the rapid response to international crises. The outbreak of the Ebola virus in West Africa in late 2014 triggered the CDC’s Emergency Operations Center (EOC), which coordinates the delivery of medical supplies, deploys scientific experts to the crisis area, and trains local health workers on strategies such as contact tracing. A year later, the EOC similarly responded to an outbreak of the Zika virus across the Americas. In all, the EOC has responded to more than sixty health emergencies. The CDC also assists in disaster relief; for example, the agency partnered with Haiti’s public health ministry to combat cholera in the wake of the country’s 2010 earthquake.
How has it responded to the coronavirus pandemic?
Widely expected to be the leading U.S. agency responding to the pandemic, the CDC appears to have been largely sidelined, though it is part of the coronavirus task force created by President Donald J. Trump. It clashed early on with the Trump administration after warning the public of the potential for severe disruptions to public life beginning in January. Since then, the agency has faced harsh criticism as it has struggled to develop a diagnostic test, issue guidance to states and localities, and share best practices with the public. More recently, it has been working alongside the NIAID and others to develop a COVID-19 vaccine.
In February, the CDC came under fire for developing a diagnostic test for the virus that sometimes produced inconclusive results in state laboratories. It took three weeks, a critical period as the U.S. outbreak unfolded, before states were able to use the test effectively. Many experts have said other missteps, including very narrow criteria for who should be tested, also contributed to the virus’s spread throughout the United States. In response, CDC Director Redfield has said that the blame should not fall solely on the CDC—that it was the responsibility of the FDA and the private sector to quickly get enough tests out to Americans. Some have also questioned why the United States did not use tests already developed in other countries, but Frieden says distributing those tests across the country likely would have taken just as long as fixing the CDC’s test. Other critics have pointed to poor communication by the CDC to local health officials and the public, including its reversal on whether to wear face masks.
Throughout the pandemic, the agency has appeared at odds with the Trump administration, issuing guidelines that the president himself has flouted, such as the recommendation to wear a face mask. In a departure from past emergencies, CDC officials have largely been absent from White House coronavirus press briefings and have not spoken regularly to the public since March, which is believed to be the result of the administration rejecting CDC requests to hold briefings. Analysts say the change has led to mixed messaging for Americans. Redfield also sought to distance his agency from Trump over the president’s criticisms of the WHO.
Despite the debate over blunders in the COVID-19 response, the U.S. public continues to trust the CDC. In a March 2020 survey by the Kaiser Family Foundation, 85 percent of Americans polled said they trust the agency for reliable information on the coronavirus.
What are other major criticisms of the CDC?
The CDC has faced its share of criticism in its seventy-five years. It has been at the center of several controversies, and has been faulted for being out of touch with what’s happening on the ground.
The agency oversaw the infamous Tuskegee syphilis study, in which Black male patients were tested without their informed consent and were not offered treatment for up to forty years until its end in 1972. Following a massive CDC effort in 1976 to vaccinate against a flu strain, several hundred immunized people developed the rare Guillain-Barre syndrome; the debacle was seen as a major setback for public trust in vaccines. And amid the anthrax attacks that took place shortly after 9/11, the agency was seen as disorganized and ill-prepared to handle the bioterrorism threat. Though the CDC also took blame for a slow public health response to the HIV/AIDS epidemic, many experts say the agency was hamstrung due to White House resistance to funding research and prevention efforts.
There have also been concerns about CDC laboratory safety, something Frieden says he pushed to improve during his tenure. In a high-profile accident in 2014, a harmless flu sample was mistakenly contaminated with the deadly H5N1 virus, also known as avian flu.
Nor has it escaped political controversy. It was reported in 2017 that the Trump administration forbade the CDC from using certain words in its publications, including “transgender” and “fetus,” prompting worries about its independence.
The coronavirus pandemic has revived calls to reform the agency. The Cato Institute’s Chris Edwards writes that the CDC’s mandate has expanded too much over the decades, resulting in an agency that is being pulled in too many directions at once. Defenders argue that limiting the agency to infectious disease threats would leave Americans even more vulnerable. Saad B. Omer of the Yale Institute for Global Health echoes this sentiment, and also suggests modernizing the CDC’s surveillance systems, boosting funding for the agency, and reducing Congress’s influence over CDC priorities. Frieden has testified before lawmakers in favor of a new funding structure so core health programs aren’t pitted against other programs at the CDC, throughout HHS, and across the federal government.