The United States is facing a public health crisis – not some new measles epidemic or another new or resurgent infectious disease. A more fundamental crisis is unfolding because of declining trust in our public health system and our public health leadership. If the nation is unable to address this problem it will never have the social cohesion necessary to confront a truly devastating public health event.
The primary responsibility for the public health of Americans rests with the states and localities. But the federal government's lead public health agency, the Centers for Disease Control and Prevention – popularly known as the “CDC” – also plays a very important role. Responsible for protecting people from international and interstate health threats, the CDC also collects public health data; does research; and provides coordination, technical support, and guidance to state and local governments. Because the federal agency does so many vital things, it must be trusted as a rigorous, nonpartisan resource by state and local officials as well as the American public. But, unfortunately, over the past year, the agency’s at times uncoordinated response to the entry of frightening Ebola infections into the United States contributed to a sharp decline in public trust.
Eroding Public Trust in Public Health Authorities
During the fall of 2014, officials at the CDC were slow and inconsistent in responding when Ebola-infected travelers arrived in the United States. In Texas, the infection spread – and fears were stoked everywhere. Some 21 states rejected the federal guidance on Ebola procedures and instead implemented more restrictive policies, including three-week mandatory quarantines of health care workers returning from West Africa. Such drastic steps were criticized by many public health experts as being unnecessary and counterproductive.
Inconsistent federal and state policies, accompanied by shifting and inadequate public pronouncements about Ebola procedures, in turn contributed to an erosion of public confidence in both the CDC and state public health agencies. According to a CBS News poll in October 2014, 37% of respondents rated the CDC as excellent/good, while 60% rated it fair/poor. This reflected a sharp decline from a May 2013 Gallup poll in which 60% of the American public rated the CDC as excellent/good. Of course, even a 60% positive rating is worrisomely low for such an important agency.
Trust in U.S. public health authorities was already in decline, as other episodes show.
- In 2009, U.S. public health officials were concerned about a possible epidemic caused by the “H1N1” influenza virus, and vaccine production was greatly increased. Some 80 to 90 million Americans received the vaccine, but 70 million doses went unused and had to be destroyed. The political party affiliations of Americans were shown to be closely associated with trust in the government's public health pronouncements and the likelihood of taking the H1N1 vaccine.
- The recent measles outbreak in parts of the United States demonstrates the dire public health consequences flowing from the growing refusal of some parents in recent years to vaccinate their children, thereby creating serious risks to other, vulnerable members of their communities. It would be unfair to fault the CDC for this deep-seated distrust in government and skepticism about the advice scientific experts give about the importance of vaccination. Nevertheless, on this and other matters, the agency’s declining credibility undermines its ability to serve as a trusted source of public health guidance for public officials, health professionals, and the public.
How Can Trust be Restored?
Is it possible to restore trust in the Centers for Disease Control and Prevention, so the agency will be better able to safeguard the American public’s health? Surely the answer cannot be simply to blame personalities and unfolding political disputes, and merely hope for the arrival of a better political climate. A modest proposal would be to change the term of the CDC Director to a fixed span of ten years, instead of having agency heads serve at the pleasure of whatever president happens to be in office. Since the position was established in 1942, the average tenure of a Director has been only about four years. The current head, Dr. Thomas Frieden, is one of the longest serving, but even he has served only since 2009.
As suggested by the example of the Governors of the U.S. Federal Reserve Board, one advantage of long, clearly defined terms lies in the possibility of reducing the role of partisanship in appointments of vital public posts. If the term at the CDC were ten years, the agency’s head would necessarily serve during two or three presidential administrations and possibly enjoy greater bipartisan credibility. In addition, by having the same official in office for a substantial time as the face of the nation's public health system, Americans could become more familiar with that individual. There would be greater opportunities to build public trust.
In the U.S. federal system, the nation’s chief public health officer cannot just order other levels of government around. Trust becomes a vital national resource because, unlike other high-ranking health officials such as the Director of the National Institutes of Health or the Commissioner of the Food and Drug Administration, the CDC Director is front and center in any national health emergency. He or she plays a vital role in mobilizing Americans to act in the face of a dire threat – or reassuring the public when a perceived threat is not serious. The availability of a trusted head of the CDC to take up such crisis responsibilities is especially important at a time when the position of U.S. Surgeon General has become less prominent.
In a era when health perils can spread very rapidly, public wellbeing can depend on the willingness of all U.S. citizens and residents to set aside individual interests and act for the common good – whether that means getting vaccinated, respecting quarantine procedures, or following other vital guidelines. Because people’s willingness to respond depends on faith in federal public health officials, it is vital that we explore ways now to restore full trust in the nation’s top public health agency, the Centers for Disease Control and Prevention.