The Good Soldier Takes Over CDC

Last week, Dr. Erica Schwartz took over an agency in crisis.

The CDC is reeling after withering attacks by elected officials, brutal staff firings and resignations, and an extremist shooting. By my count, eight leadership positions are now vacant, and (with one three-week exception) the agency hasn’t had a permanent director for 19 months. Meanwhile, it’s facing rolling waves of measles outbreaks, a food contamination epidemic that has sickened thousands, and the fastest-growing Ebola outbreak in history.

Can Schwartz right the ship?

Who is Dr. Erica Schwarz?

Dr. Schwartz opened her testimony at the Senate confirmation hearing this way: “The most important thing to know about me is that I come from a God-fearing, military family.”

And sure enough, the military is a strong theme in her life story. Her father was in the Navy, and three siblings are in the Navy, Marines, and Army. After finishing an 8-year combined BS/MD program with the help of a Navy scholarship, Schwartz spent seven years in the Navy and thirteen years in the Coast Guard. Her specialty is occupational medicine, that is, keeping sailors and coast guardsmen safe and healthy.

In the hearing, Dr. Schwartz came across as the consummate military officer: intelligent, respectful, well-spoken, and poised. But, for someone jumping into the maelstrom of the Trump administration, she was also shockingly oblivious.

Most people I know are glued to news feeds these days, bracing for Trump’s or Kennedy’s next outrage. But when Schwartz was asked about the elimination of CDC’s Office on Smoking and Health, she said she was “not aware” of the problem.

In the public health world, the elimination of that office, and the parallel firing of the director of the FDA’s Center for Tobacco Products was (and still is) a major news story. It’s hard to fathom how she missed it, especially with her calling smoking cessation a major focus of her work in the Navy.

By now, we’ve become accustomed to Trump appointees lying to Congress. But here I believe Schwartz was telling the truth. That makes me wonder what else about the trashing of the CDC she’s missed.

Granted, Schwartz was trying to pick her way through a minefield. The senators wanted to pin her down on whether she would refuse Kennedy’s or Trump’s orders if she believed they would hurt the public’s health. Her answer, over and over, was that she didn’t believe those bosses would issue harmful orders.

Of course, she was obligated to say that. If she didn’t, Trump would pull her nomination.

Maybe I’m too gullible, but her response struck me as also being honest. It looks like Schwartz truly believes that Trump and Kennedy wouldn’t force her to do things that would damage public health.

And that’s very, very strange. The previous CDC Director Susan Monarez was fired precisely because she resisted Kennedy’s attempt to take vaccines away from children. If Schwartz believes (as she said repeatedly), that as CDC Director she would “never betray the science”, shouldn’t she have asked in her job interview whether Kennedy would overrule her on vaccines or other important health decisions? Is it conceivable that she didn’t ask that? Does she think it’s inappropriate to question an order from her boss?

Her most telling response was to a pointed question from New Hampshire Senator Maggie Hasan. The Senator asked whether Schwartz agreed that the CDC Director was, according to the charter of the Advisory Committee on Immunization Practices (ACIP), at “the top of the chain of command” for vaccine recommendations. Schwartz answered that the CDC Director could accept or reject the ACIP recommendations, but then added, “I understand that – and I can be wrong on this – that the Secretary ultimately has the policy decision regarding that.”

She’s a good soldier. She follows the chain of command.

What would she do at CDC?

Today, CDC needs - for starters - an internal leader who will support the embattled staff, hire the best available experts, earn trust, and develop a clear plan to fight measles, Ebola, foodborne outbreaks, and those chronic diseases that Kennedy claims to care so much about. And an external leader who can translate science-based facts for average Americans.

But there is more to the job than that. CDC is at its best when no one knows what the hell is going on. That is, the agency rises to the challenge when a new pathogen appears (think legionnaires’ disease, AIDS), or an old pathogen takes a strange turn (think monkeypox), or a self-inflicted crisis crops up (think prescription opioids). Responding to those kinds of crises require original thinkers - people who can look at raw data, ask difficult questions, reason for themselves, and challenge conventional wisdom.

From what we know now, is Schwartz up to that?

On the plus side, she’ll likely bring order, structure, and standard processes. She’ll try to fill empty staff positions. She’ll support the troops.

On the minus side, she’ll probably look for Standard Operating Procedures when they don’t exist. She may struggle responding to unknown unknowns.

Most important, I’m afraid that when Kennedy tells her to do something wrong, she’ll follow orders.

Erica Schwartz might have been a fine CDC Director in an earlier era, when HHS secretaries were too preoccupied with our medical care system to pay attention to CDC. But when the HHS Secretary is hell-bent on forcing his unhinged views about health on the nation, a good soldier can be very destructive.

What will this mean for public health?

In Washington today, public health policy is set by crazies and cronies. The most obvious example is the recent Trumpian vaccine policy, issued by an Executive Order that contradicts law, science, and common sense.

To protect us, health experts are refuting or just ignoring what the federal government says. Look at how quickly Trump’s vaccine order was rejected by infectious disease experts, the American Academy of Pediatrics, and state health departments.

So the loss of Americans’ trust in federal public health leadership is now complete. I don’t know what it will take to regain that trust. But this new CDC Director, in this administration, can’t do it.

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