Is the CDC Leading on COVID or Leading From Behind?

Kathleen Doheny

May 14, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Minutes after the Centers for Disease Control and Prevention (CDC) issued its new guidance Thursday that those fully vaccinated against COVID-19 can now (mostly) ditch their masks both indoors and out, Twitter and other social media lit up with reaction.

Some people posted closeups of their first unmasked smile, others posed with T-shirts reading "Fully Vaccinated (not an anti-masker)." Still others vowed to keep wearing their masks, and many wondered how many people would be maskless liars.

Meanwhile, many public health experts commented, too. Some see the new guidance as a sudden and unwise pivot in direction, while others welcomed what they see as progress.

The agency has taken its lumps during the pandemic. Problems early on with distribution of tests in March 2020 led to nearly the entire nation locking down. In July, the Trump administration stripped the CDC of its ability to track hospitalization data. In August, other federal officials posted testing guidance on the CDC website that contradicted what its own scientists were saying.

While those incidents all took place under then-President Donald Trump, the CDC under President Joe Biden has not been without its issues. In April, the agency released guidance for gathering outdoors that many found frustratingly confusing and woefully late compared with how people were actually behaving.

Now comes the new indoor mask guidance that is a sharp turn away from recommendations the CDC has long offered. It all leads many to wonder if the CDC is leading, following, or out of touch.

So it may not be a surprise, then, that a recent poll from the Robert Wood Johnson Foundation and the Harvard TH Chan School of Public Health found that only 52% of Americans say they have a great deal of trust in the CDC.

Medscape Medical News asked them to weigh in on how the ''new" CDC under director Rochelle Walensky, MD, MPH, is doing compared with the CDC under the previous administration and for their best advice for how the agency can move forward to manage the pandemic.

Differing Expert Opinions

"We have more people not vaccinated than vaccinated, and we are declaring victory," said Cheryl Healton, DrPH, dean of the New York University School of Global Public Health. With variants incubating, and hundreds still dying every day of COVID, ''that's still a lot of infection and it's still a lot of deaths."

She will continue to wear a mask, she said. "I am doing it to be a role model at this point. Because I am very concerned that many people who are not vaccinated will not wear their masks in multiple places. Who is put at risk? Other unvaccinated people."

While Healton bemoans the unwillingness of the unvaccinated to accept science, she asked: "Should they die because of that? I don't think so."

"What's happening with the CDC is, it is kind of lurching from overcaution to abandoning caution," said Lawrence Gostin, professor of global health law at Georgetown University and director of the World Health Organization Collaborating Center on National and Global Health Law. The abrupt change in CDC guidelines, he said, "speaks on its face to the idea that they are succumbing to public and political pressure."

However, other experts applauded the updated advice. "The new guidance is something many of us were waiting for," said Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore, Maryland.

Past and Present

"I would say the Biden CDC, the Walensky CDC, has been characterized by being very cautious, [taking] baby steps, but baby steps in the correct direction," Adalja said. "But they are still baby steps. I think a lot of us [public health experts] would like to see the CDC be more aggressive about the value of the vaccines, and show more confidence in the vaccines."

He would welcome the CDC ''being much more bold and proactive about what vaccinated people can do."

Healton said that ''The CDC is greatly improved under this administration, because it is first and foremost less politicized. It is also sticking to the science of transmission very closely. This latest policy is an example of a policy change that was wedded to new data with respect to transmission.

"Specifically, [it looked at] how likely someone [vaccinated] is to become infected and how likely they are to infect someone else [if infected]. The answers to those questions is low and low."

So while the guidance change is based on science, Healton said, ''what I think is wrong with it is, it didn't sufficiently make obvious to me or in a public statement the impact of saying the vaccinated don't have to wear a mask." There is no way to determine if those without masks are vaccinated, she said.

The CDC is the gold standard for public health science, and ''I think we still are," Gostin said. "But I think the public trust in the CDC is plummeting, frankly. I think it certainly was caused mostly by the censorship imposed by the Trump administration."

But it's still occurring, he said. He noted the mixed reactions among experts to the new advice. In the past, he said, when the CDC would issue new guidelines, the entire scientific community would be in lockstep. "That isn't happening now."

Navigating the Path Forward

"You want the CDC to be ahead of the people, to be aggressive, so they are one step ahead of what people are doing, so the guidance is actually operational," Adalja said. By the time the recent guidance about travel came out, he said, many vaccinated people were already not wearing a mask outdoors, or were already traveling.

Adalja also takes issue with what he calls the ''abstinence" approach with COVID-19 guidance that he said the CDC took early on in the pandemic.  

He compared it with the early days of HIV, where abstinence was first preached, until the CDC went to what he sees as a more realistic and productive approach — harm reduction. "With COVID 19, it was basically abstinence only [previously]. Only in recent weeks are you starting to see some softening of that."

Better than the abstinence approach, Adalja  said, is the harm-reduction approach. Harm reduction means meeting people where they are, dealing with reality. "This is something that would have been helpful early on," he said. "A lot of the acrimony [over advice given] was driven by this abstinence only [approach]. Instead of saying 'don't do this [activity] ever,' the CDC should be saying, 'This is how you do something more safely.' "  

As a result of the previous abstinence approach, ''you had one group of people who thought it was Mardi Gras every day and another group of people who wouldn't leave the house," he said.

If you have strip bars and casinos open, surely you can have schools open.

Adalja views the new mask guidance ''as a big step." Next, he said, the CDC should reopen schools. "They need to come out forcefully about in-person learning in schools. If you have strip bars and casinos open, surely you can have schools open. I think many people are short sighted, looking only at COVID and not looking at the global picture of what is happening psychosocially with these children out of schools."

The CDC falls short on communicating health messages, the experts agreed. "What I would like the CDC to do is try to invest in health communication," Gostin said. "Don't just hire scientists, hire health communicators, teachers, community leaders, anthropologists. In other words, they have to make their messages sharp, clear and understandable to the public so the public has confidence in them.

"Right now they are looking more like an academic science think tank. They do the science and the communication is an afterthought. That has to change. That is part of the reason we have such huge vaccine hesitancy.''

"To me, it's very sad to see this steady erosion of trust and confidence in the CDC," Gostin said. "They are just world class scientists who work hard and have great compassion."

Healton agreed that a strong public health message is crucial. "What has not gone out the door yet is a national public education campaign promoting vaccination." She cited Truth Initiative, the campaign that helped bring teen cigarette use down from 23% in 2000 to 5% in 2020. She was the president and CEO of the initiative (now known as Legacy) for 14 years.

The message that would also help, Adalja said, is for the CDC to communicate that we are not getting to the point of zero COVID.

Instead, he said, the CDC should communicate to the public messages such as "This is what COVID will look like two years from now."

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