Although the newspapers were filled with dark photo essays for many months, Dr. Sonja Rasmussen struggled to make the big leap and declare that Zika virus was causing birth defects. As the director of the Centers for Disease Control and Preventions division for public health information dissemination she had to make a decision about when enough evidence was available to prove Zika was causing birth defects. Once she made that decision, there was no turning back.Rasmussen, like everyone else, had seen heartbreaking pictures of microcephaly babies. This is a condition where the brain stops growing at an early stage, leading to a smaller head. In Brazil, where the Zika epidemic was at its peak, thousands of children were born with the condition. This is a far greater number than the 150 babies who were born in the same year. She also knew that pregnant women in America were afraid to cancel travel plans because of the possibility of contracting the virus in Latin America or the Caribbean.It was simple for a layperson to see the media reports from 2015 and 2016 and conclude that Zika caused this and other permanent disabilities in children. Although the evidence grew, Rasmussen, an expert, was not as sure as the media narrative. She understood science was always nuanced and that there was almost never a 100 percent chance of something bad happening. She also knew that any new evidence could make an old warning false alarm. She didn't want to make too many assumptions for the sake the the public and the CDCs reputation. Rasmussen said that it was her job to waffl. She is now a professor in pediatrics and epidemiology at University of Florida College of Medicine and College of Public Health and Health Professions. It was like I was jumping headfirst off the high diving platform when I said something was causing birth defects.But she jumped anyway. Some scientists and journalists felt there wasn't enough evidence and criticized the CDC for their hastiness when she did. Others wondered why it wasn't made public sooner.The CDC proved right that time and things turned out OK Zika. It didn't gain a significant foothold in the U.S. continental. The CDC's problems with uncertainty, risk communication and public criticism didn't disappear when Zika fears hit. This has been evident for 18 months.Public statements on health risks pose a risk to the agency that made them as well as the public who desperately needs reliable information. It is frightening to imagine that people in authority can feel confused and uncertain about the decisions they make and the information they need to share. It also makes the COVID-19 outbreak a lot more clear. Over the past year and a quarter, we all witnessed the CDC waffling in real-time on many occasions. The agency almost always crashed to the ground when it jumped.It is not clear why this happened. Interview requests were not answered by the CDC. People who worked at the CDC know the agency well and it's not an unpredicted anomaly. It could also be a result of bad actors within the Trump administration. Instead, we saw what happens when an organization culture of caution meets toxic politics in an emergency. The same problems that plagued the CDC in the past still haunt the CDC today, according to the people I spoke with.The CDC stressed hygiene more than mask-wearing early in the pandemic. Science hadn't yet proven that masks could stop the spread of COVID-19. PAUL HENNESSY/ NURPHOTO VIAGETTY IMAGESTHE MASK MUDDLEThe most famous example of the CDC's misguided approach during the COVID-19 pandemic was the one right in front our faces: masks.Since the beginning of the pandemic, questions like when to wear them, how to choose, and what to wear have been a source of conflicting information and confusion. The U.S. surgeon General famously asked Americans to stop buying masks in February 2020. The CDC published guidelines for COVID-19 protections in February 2020 that did not mention masks. Other countries' public health officials distributed masks or made them mandatory. The Pan American Health Organization/World Health Organization recommended that masks be used only by people with symptoms of illness or their caregivers.Even though the CDC recommended mask-wearing for everyone starting in April 2020, a National Academies of Sciences, Engineering, and Medicine (NASEM) report was released less than a week later. It found very little evidence supporting cloth mask-wearing to be an effective way of preventing the spread of diseases.It may seem as though everyone knows what they are doing, but that is because nobody does, according to Dr. Richard Besser. He was the former acting director at the CDC and sat on a subcommittee responsible for the National Academies mask report. He explained that public health recommendations are based on scientific evidence. At the time there was not much research on the effects on community-wide mask use or cloth masks. Although the evidence was not very convincing, it didn't mean that you couldn't use masks for their usefulness. The Great Mask Debacle was not about who was telling truth. It was a matter of not knowing enough truth.The lack of guidance from the CDC on mask-wearing contributed to the spread of the coronavirus in the early days after the pandemic. TAYFUN COSKUN / ANADOLU AGENCY VIA GETTY IMAGESScientific evidence will be limited in a public health emergency that involves a new virus. Experts said that the problem was not that mask use was uncertain. This is normal in a crisis involving a new virus. It was the way that the CDC and other organizations communicated this uncertainty.Besser stated, "Hello, we are going to share with you that what we don't know is really important." He was able to foreshadow the fact that information will change, something he recalled doing during the 2009 H1N1 flu pandemic. He watched, however, as the CDC began to talk less about itself and then gradually disappeared from all press conferences. It seemed as if new guidance was just a drop from the sky when it came forward. He said that we had not been taken along on the journey.Besser felt relieved that he was only summarizing the scattered mask data and not trying to make any decisions about how to use it. His subcommittee was concerned that a masking recommendation could send Americans out in the open, possibly inadequately prepared, at times when they should just avoid all other people. The lack of a CDC recommendation early in the process, when other countries were already doing so, or a clear explanation as to why the guidelines differed, helped to set a tone. This contributed to a greater zeitgeist in which Americans were unsure if the CDC knew what they should do or if it would.This effect can be seen in polling data. Morning Consult has, for instance, tracked Americans' net approval. This is the sum of positive approval ratings minus the negative approval ratings for several government roles or agencies. While the CDC has remained the most trusted agency for handling COVID-19, it has lost trust in the face of this pandemic. The tracking poll started on March 1, 2020 with a +63 percentage point net approval and ended June 20, 2021 at +37.It is a huge drop, especially when compared to public health agencies in other nations, such as South Korea, Taiwan, and Vietnam, which gained trust during COVID-19, stated Gil Eyal, a Columbia University professor of sociology who studies history and sociology public health.This is especially significant as these countries have their own public health agencies that are based on CDC. Jennifer Nuzzo, a professor in the Johns Hopkins Bloomberg School of Public Health, said that the CDC influenced the structure and work of these other organizations, as well as how they communicate with the public. It is hard to believe that the CDC lost trust so badly when other countries used the tools provided by the CDC to build trust in their own nations.The Trump administration made public health officials sidelined throughout the pandemic. Experts outside the CDC claim that there was insufficient visibility to allow it to issue new guidance. JABIN BOTSFORD / THE WASHINGTON POINT VIA GETTY IMAGGESPOLITICS AND PEANUT GALLERYAre schools allowed to remain open? Do they need to be closed? Everyone had a different opinion in summer 2020. The CDC seemed to be stuck in the middle. Trump's administration and the American Academy of Pediatrics pushed for schools to be reopened. Teachers unions wanted to keep them closed. There wasn't enough evidence to show that schools were safe until the fall. During this time, scientists, educators, and public health experts debated the issue on Twitter and in national op-ed pages. The CDC's guidance for schools on how to reopen safely was initially influenced and modified by Trump administration priorities. It largely consisted of the same general advice that was offered to all public buildings, plus a few reminders from the administration that reopening schools is important for children. The administration later criticized the safety checklist that the agency had included.Experts aren't sure if Trump's interference and pressure on CDC was responsible for the school problems and other similar ones. Patrick McConnon, the former director of the Emerging and Reemerging Infectious Disease Program at the CDC, believed Trump was the problem.To be clear, Trump's actions were not only out of line with established norms, but also undermined both the CDC as well as the entire public health field. The president, for example, repeatedly stressed that masks were not required and stated that he would not wear them.Also, the administration demanded edits to the CDCs Morbidity and Mortality Weekly Reports. These reports were long the main means of communicating scientific data to researchers and the wider medical community. These edits were politically motivated and sought to minimize the increasing number of COVID-19-related deaths as well as the support decisions that the administration had made regarding issues such school reopenings. Emails showed that Trump Administration members were accusing CDC of trying make the administration look bad by releasing data that revealed the severity of the pandemic.These actions by a presidential government were unheard of. They also contributed to a loss in morale within the CDC and a feeling that everyone needed to stay calm and not make waves. The political issues were not about what the administration did, but also about what it didn't do.The CDC was absent from all press briefings regarding the COVID-19 pandemic by March 2020. Trump never explicitly stated that the agency would not be speaking to the public. It was quietly true that this is exactly what happened. The disappearance of CDC was visible by the Union of Concerned Scientists in May 2020. This was a totally different situation than what happened in previous pandemics when presidents allowed the CDC to take the lead.Moreover, Trump's administration didn't seem to encourage communication between CDC and experts. This is something that scientists who spoke with me said was the norm in past administrations when faced with a public crisis.Nuzzo stated that during the 2009 H1N1 pandemic the CDC held regular press conferences. These included briefing documents created with outside experts. The CDC also had a team of outside experts called Team B to help with weighing the pros and cons before releasing any guidelines or decisions. None of these things were done during the COVID-19 epidemic.This had serious consequences, according to Dr. James Lawler of the University of Nebraska Medical Centers Global Center for Health Security. The CDC is fundamentally an academic research institution, and not a place for people who have expertise in healthcare delivery or administration. He said that the rollout for monoclonal antibodies to treat COVID-19 was hampered by the lack of a formalized system for outside input. The CDC and Food and Drug Administration distributed the medications in ways that made them difficult to reach the right people at the right times.Lawler said that the process of identifying a patient who might need the therapeutic and giving it to them as an IV infusion in an emergency setting is not typical of the usual workflow in health care. It was extremely difficult for patients to receive lifesaving medication due to the lack of federal expertise.Social media commentary became a greater source of scientific criticism of CDC's decisions. Consider the September 2020 statement by the CDC that the novel coronavirus was an airborne virus. It was then taken down from its website three days later. These posts were praised or criticised by a variety of experts on social media. This way of discussing science was detrimental to everyone.SCOTT EISEN / GETTY IMAGESTwitter and other social media platforms made scientific conversations public and more contentious, and more advocacy-influenced. There are many ways that disagreements can turn into heated arguments. Dr. Vinayprasad, a professor of biostatistics and epidemiology at the University of California San Francisco, stated that scientists have taken off their research hats to become hashtag activists. Prasad studied the difficulties of changing medical advice in order to match new evidence. He told me that social media battles, as well as the fact that medium hardened lines make it difficult for scientists and the public to discuss nuanced issues. There is always new evidence, so if people decide that they must be pro-mask in order to continue funding research, then there is no room to discuss (or fund) the question of whether masks are more effective in certain situations than others.Public health has been fundamentally political since its inception. In this instance, however, social media and politics helped to fuel a real politicization both of the CDC's information and its leadership. In fall 2020, opinions on the CDC's leadership and management were split along party lines. There were clearly visible partisan divisions in May 2021 regarding both vaccination rates as well as understanding the updated mask guidance of the CDC.These splits have not been particularly severe or significant. However, we've seen regulatory science agencies, and the areas they study, quickly become symbols of political affiliation. In the space of a few years, the Environmental Protection Agency became politicized, starting around 1990. This shift triggered others. Over the last few decades, we have watched the U.S. shift from being a reliable signer of international environmental agreements, ratifying protection measures quickly, to being a holdout nation where environmental stewardship has been deemed suspicious.Some Americans are questioning the U.S.'s role in global public health after being misled by the CDC. Trump's election doesn't erase this distrust. It is now clear that the era when the CDC was a trusted agency of government even for those who don't trust the government as a whole may have ended.Businesses and governments struggled to create new rules after the CDC released new masking guidelines with little warning. MICHAEL SILUK / UCG/UNIVERSAL IMAGES GROUP VIAGETTY IMAGESMOVING LOWLY TO A SUDDEN DECISIONThe CDC quickly changed its mask guidelines in spring 2021. Evidence had shown that mask usage could prevent the transmission of COVID-19. The CDC recently reaffirmed its recommendations that all people, vaccinated and not, should wear masks in public places. That changed on May 13. The CDC stated that masks were not necessary for fully vaccinated individuals. This switch was not obvious. Even the Biden administration seemed to be caught unawares. Multiple states also dropped their public mask mandates quickly. The public and the CDC's public image suffered.It was yet another moment of chaos during a long year, and a sign that no matter what your views about Trump's administration, its demise did not magically fix the floundering CDC.Experts pointed out that this abrupt shift was, ironically, a sign of how the agency's inability to be cautious and slow was hurting public trust. The reason was that, although the decision was made quickly, there wasn't any new evidence to support it. For months, we knew that people who had been vaccinated were protected from spreading COVID-19. You could easily criticize the decision to implement masks or describe Zika as a reason for birth defects, just as you can with describing Zika's cause.Prasad stated that if it takes six months for someone to say, Vaccines so good, you don’t need to mask anymore then you might start to wonder why. Did there exist any new evidence? Was it just a reluctance?The CDC's risk aversion had again complicated its messaging. Experts I spoke with believed that the root of some of the CDC's problems during the pandemic years was in the agency's desire to fix things and not deem science final too soon. Besser stated that the CDC is a highly academic institution. In situations where science is not complete, or where there aren't enough studies, it can be difficult for the agency to provide useful guidance. It can be difficult to give people the information they need. "What is enough evidence? What if the data doesn't arrive? Many researchers said that there hasn't been enough data to determine which non-pharmaceutical treatments mask, distancing, and so forth. aimed to decrease the spread of COVID-19 and determine what conditions were necessary. Texas was the first state to eliminate COVID-19 masking requirements. Only 11 percent of Texas' 16-year-old population were fully vaccinated as of March 10. Recent research has revealed that this decision did not improve the state's economy as politicians predicted, nor increase COVID-19 cases rates as scientists feared. No one knows why. Experts said that this is the type of question they didn't have the data to answer. Ohne this, the public health community won't be better equipped to manage uncertainty during the next pandemic.Prasad stated that we did more than a hundred thousand things to fight the virus. We will never be able to see the final result for most of it. We won't know if we should have shut down that Vermont mall. This is science failure to me.This is not a CDC issue. In general, evidence-based medicine can be prone to delay decisions and wait until more evidence is available. It is believed that trust can be maintained by being conservative. Experts are not surprised to see this idea backfire. It just shows that scientists struggle to understand risk analysis. Scientists are people, after all. Research shows that people don't like ambiguity. Public health, including the CDC should tell people exactly what they can do and not do. This is impossible, according to Saskia Popescu, a professor of public and community health at the University of Arizona.The CDC must communicate better and foresee the changes that will accompany any crisis in order to avoid repeating the mistakes of the past. It requires better systems to receive advice and have conversations with experts from outside. It needs systems that can gather epidemiological data and answer questions. This will help reduce the ambiguity. Nuzzo suggested that a fund be set aside for sociological research and epidemiological research. This money could be approved in advance of a natural disaster and launched when it is most needed.We had to deal with uncertainty during the COVID-19 epidemic and, in many ways, we lost. As the crisis ends, the CDC, public health, and other organizations will have to address that and adjust their course. Prasad stated that he didn't think we were better prepared for the next crisis.Mary Radcliffe did additional research. Emily Scherer, art direction. Charts by Jasmine Mithani. Jennifer Mason did copy editing. Story editing by Chadwick Mattlin
