Bio(un)ethical

#17 Rochelle Walensky: How can we fix American public health infrastructure?

• with Leah Pierson and Sophie Gibert • Season 2 • Episode 17

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In this episode, we speak with Dr. Rochelle Walensky, former director of the Centers for Disease Control and Prevention (CDC). We discuss the state of American public health infrastructure, the challenges it faces, and what we can do to improve it.

(00:00) Our introduction
(03:45) Interview begins
(09:32) Core challenges: Maintaining and growing the workforce
(18:41) Core challenges: Standardizing and modernizing data systems
(28:01) Core challenges: Reorganizing laboratory systems
(30:32) The problem of fragmentation
(44:55) Tradeoffs in communication; “following the science”
(52:57) Biggest lessons learned
(1:00:37) Public health infrastructure in the US vs. elsewhere
(1:07:34) Paths forward: public investment
(1:09:42) Paths forward: H5N1 and the scope of CDC’s authority
(1:15:32) Advice for aspiring public health professionals


Used or referenced:

Bio(un)ethical is a bioethics podcast written and edited by Leah Pierson and Sophie Gibert, with production support by Audiolift.co. Our music is written by Nina Khoury and performed by Social Skills. We are supported by a grant from Amplify Creative Grants.

Sophie: Hi, and welcome to Bio(un)ethical, the podcast where we question existing norms in medicine, science and public health. I'm Sophie Gibert, a Bersoff Fellow in the NYU Department of Philosophy, and soon to be an assistant professor at the University of Pennsylvania.

Leah: And I'm Leah Pierson, a final year MD/PhD candidate at Harvard Medical School.

Sophie: Think about the last time you went to the doctor. You probably navigated a familiar system: scheduling an appointment, checking in at the front desk meeting with nurses and physicians, perhaps getting lab work done, or picking up a prescription. This healthcare system, while complex, is tangible and visible to most of us. But there's another health system operating largely behind the scenes, our public health system. And its invisibility might be both its greatest success and its biggest challenge.

Leah: This vast network of people, data, and laboratories works tirelessly to protect our health in ways we rarely notice: preventing disease outbreaks, ensuring our food is safe, and protecting us from environmental hazards. When it succeeds, it's nearly invisible. We don't celebrate the pandemics that never happened or count the breaths of clean air we take each day. 

But the COVID-19 pandemic pulled back the curtain on the system, revealing both its critical importance and its concerning vulnerabilities. We watched in real time as our public health infrastructure grappled with unprecedented challenges, from tracking case numbers and coordinating testing, to managing vaccine distribution and communicating rapidly evolving scientific information. These challenges weren't just bureaucratic inconveniences. They had real consequences for American lives.

Today, we're diving deep into the state of US public health infrastructure: its strengths, its weaknesses, and why it matters for every one of us. We'll explore why our system looks the way it does, what happens when it's stretched to its limits, and most importantly, how we can fix it before the next crisis hits.

Sophie: To help us understand these issues, we're joined by Dr. Rochelle Walensky, who served as the 19th director of the Centers for Disease Control and Prevention (or CDC) from January 2021 through June 2023, during one of the most challenging periods in American public health history. Before leading the CDC, Dr. Walensky served as chief of the division of infectious diseases at Massachusetts General Hospital and as a professor of medicine at Harvard Medical School.

She's currently an executive fellow at Harvard Business School, Hauser Leader at Harvard Kennedy School, and the Bayer Fellow of Health and Biotech at the American Academy of Berlin. Few people have had such a comprehensive view of our public health system's inner workings, especially during a crisis, making her uniquely qualified to help us understand the challenges we face and the solutions we need.

Leah: It's worth noting that we recorded this conversation on December 4th, 2024. And so some of the context and the science—especially around H5N1—have evolved between then, and when we're releasing this, at the end of January 2025. If you want to learn more about these changes, check out the Science paper by Lin et al or the Johns Hopkins link in our episode notes. As always, you can access all other papers we reference there or on our website, biounethical.com. And if you enjoy this episode, please consider subscribing, submitting a rating or review, or sharing it with a friend.

 Dr. Rochelle Walensky, welcome to the podcast.

Rochelle: Thanks so much for having me. Delighted to be here.

Leah: So you ran the CDC for two and a half years during one of the most tumultuous periods for public health in American history. When you left in June 2023, you wrote an op ed in the New York Times in which you wrote, quote: "Decades of underinvestment in public health rendered the United States ill prepared for a global pandemic. Some estimates suggest we are 80,000 public health workers short across the United States to meet basic public health needs. To this day, some of our public health data systems are reliant on old fax machines. National laboratories lack both state of the art equipment and skilled bench scientists to work them." In this conversation, we'll broadly categorize these problems as problems related to public health infrastructure. So, we wanted to start by first asking, how do you conceive of public health infrastructure?

Rochelle: Yeah, thank you for highlighting that. So, there's so much that can be woven into public health infrastructure. I think I find it simplest to think of it in 3 large categories. One is the workforce that you commented on—the deficit in the workforce right now. Second is the data infrastructure in the country. And the third is the laboratory infrastructure in the country. Now, there can be a lot else that is woven in in how we deploy all of the efforts in those 3 buckets. But those are the 3 buckets that I think of when I think about the infrastructure.

Leah: Can you elaborate a little bit on what each of those three components entails?

Rochelle: Yeah, so first is the workforce and as noted, we're about 80,000 public health workers in deficit. And that is not just people at CDC specifically, but people in local and state public health departments across this country who do data analytics and who do genomic epidemiology and who do outbreak investigations at the state and local levels. And so we need to not only upskill our workforce as we think about our data systems, but we actually need to recruit more and more people into the public health workforce. There was just a piece last year that Howard Koh at the Harvard School of Public Health wrote that surveyed the public health workforce even today and demonstrated that most people, many people under the age of 50, who are in the public health workforce today are actually potentially anticipating leaving; over 50 percent are anticipating leaving. So, there's a whole lot of issues related to the compensation in a public health workforce, the short term funding of that workforce, the burnout, and the potential threats associated with that workforce, that make that workforce particularly vulnerable in doing the day to day good job of public health around the country.

So, one is workforce. The second is our data systems. Turns out there is no such standardized way that our data get reported from a local or state public health department to the CDC. Not only does that not get standardized in the mechanism by which is reported, does it come in by fax or Excel or cloud or phone call? But how it gets reported, how the age and demographics get reported, if the age and demographics get reported, what gets reported, is not necessarily standardized. And the highways by which they connect—so that if there is a county A that is next to county B, in a different state, for example and they each have cases of something that's atypical—how would we even know for County A to inform County B, and would County A report, but County B not? Such that, somebody central like CDC would be able to recognize there might be an outbreak that's happening at the state border. And so those kinds of things make it very difficult from a data standpoint to actually really see what is happening across the country.

Now, there are several dozen nationally notifiable diseases. When things happen, like there's a case of syphilis or a case of gonorrhea or a case of Lassa fever or whatever, there's a standardized required, these things absolutely get reported to CDC, but there are a lot of things that are not on that list.

And so, when there is an outbreak of an e-cigarette associated lung injury, for example, that was not initially reported because people didn't know to report those things. So, the data highways and the standardization of those data highways and building up those data highways, making them electronic, making sure they're easy to get to a central place has been a long term under investment.

And then thirdly is our laboratory infrastructure. CDC has the responsibility of developing in collaboration with the FDA a new test for novel pathogens for special pathogens and whatnot. How we take that new test and deploy it to labs across the country such that they have not only the equipment to execute that test, but the personnel who are equipped to conduct that test in a technically savvy way, such that when there is a new outbreak of say Mpox across the country. Are there laboratory tests across the country that can detect Mpox that are run by laboratorians who know how to do that test reliably? And what does that look like? And you know, if you go to some of your state and local public health departments and go to their laboratories, they do not look like, in many cases, the most sophisticated laboratories of our academic institutions and they are not run, in all cases, by laboratorians with all the skill sets that we might want. Now, some of them are extraordinary, don't get me wrong, but that infrastructure needs support.

Sophie: Okay, great. So, why don't we get a little bit more into the details of each of those buckets, and we'll start with workforce. So, with respect to workforce, you write that the U.S. needs to increase its public health workforce by 80 percent in order to meet basic public health needs. Could you talk a little bit more about why we have this workforce shortage and the problems that it creates?

Rochelle: Well, if we go back to how public health is funded, essentially what happens is that, CDC will put forward a budget and say, this is sort of what we need in public health across the country. Much of what comes to CDC will then get deployed to state and local public health departments. Those state and local public health departments will also use statewide resources to fund their efforts that happen locally. So what happens at state and local public health is some mix of federal resources coming in and local and state public health resources coming in. Now, as you can imagine, how much comes into state and local public health departments very much depends on elected officials' opinions about how that should be funded, which means that people do not have job security for 5 years necessarily, or potentially even for 2 years. It is dependent on a stream of funding that is at the whim of elected officials. And so it is very hard to take somebody who is really well trained, who has the potential, the opportunity cost, of either working in an academic institution and/or working in industry and tell them to come work in public health where they may or may not have job security over time. And so I think that is one fundamental challenge.

I think we saw many people during the pandemic who were interested in working in public health. Think of all the volunteers who were willing to do contact tracing, who were willing to do health care navigation. Who we upskilled, and yet those resources then vanished. And so we had a potential group of people who were actually more skilled than when we started, and yet we were not able to retain them in doing the good work of local public health. So I think there's that issue. I think there is the issue that many epidemiologists, PhDs, MDs can be compensated much higher in other places. Burnout is high. We saw that during the pandemic. Public health works 24/7, the CDC business card says 24/7 and I promise you, you get those calls 24/7. And so you do need people who have the stamina and willingness to be able to do this. It is not lost on many people in public health that they've been the targets of threats.

They have been the targets of protests. Many people through public health over the last several years have felt this. So you put all of those things together, and then, education is expensive, loan repayment issues and things like that.

The other thing I will say is as we start to modernize our data systems, for example, we have to upskill the people who are there. We have realized that we need more in public health and different in public health in today's era than we might have needed 10 or 20 years ago. Where is our communications workforce in public health? Where is our workforce to help address missing disinformation in health? Where is our workforce in environmental health and, water safety, water security, heat safety, those kinds of things? And we have a pretty robust workforce in data entry, but less so in data analysis. So, when I went to the state and local public health departments across the country, one of the things that I really heard is we need mechanisms by which we take people who have data skills, but don't have data analytics skills for what you are doing as you're modernizing your data systems. So I think that there are many, many different issues around workforce, but that's kind of a handful of them.

Sophie: Got it. And it sounds like that workforce shortage might be concentrated in the area of highly skilled workers, like data scientists and things like that. Is that correct? Or where does most of that shortage come from?

Rochelle: Yeah, it's a great question. I think it is true that we have highly skilled people who are in deficit, but I would not underestimate the folks who can do really great on the ground work in executing public health at the local level: our navigators, getting people in to be vaccinated, for example, or recognizing when buildings have heat challenges. Like those kinds of on the ground navigation, that really great prevention work—contact tracing for sexually transmitted infections. I mean, we had people doing those things, right? But many of those contracts disappeared and we did, and we're not able to retain the talent that we had.

Leah: Yeah, so we wanted to follow up on this issue related to workforce shortages versus misallocation because in medicine, a lot of attention has been paid to doctor shortages, but in many ways the problem is more accurately characterized as doctor misallocation. It's not hard to find a gastroenterologist in Boston, but it is hard to find a primary care doctor in rural Mississippi. We're wondering if the public health workforce shortage has the same shape, because as you pointed out in one of your articles, the number of people earning Masters of Public Health or MPHs has actually increased in recent years. So, to what extent would you say the workforce challenges are challenges related to workforce misallocation rather than shortages?

Rochelle: I've spent some time over the last year thinking about the healthcare workforce as well, so I would say it's both. It might not be hard to find a gastroenterologist in Boston, but it's hard to find a primary care doc in Boston, and Massachusetts has probably the highest density per capita of physicians than anywhere in the country. And if you look at the map, across the country, and you look at diseases, such as diabetes or stroke or HIV, you can see kind of where they're concentrated and they're concentrated in places that happen to have fewer health care providers and also, potentially, less investment in health and public health and prevention. And that is actually true at the extreme of life expectancy. And so they're all actually concentrated in the same places. But some of this is under investment in public health. Some of this is a coincident of policies that make it harder to deliver health or more stigmatizing to deliver health. And so we could potentially look at correlation, but not necessarily causation. And there are a lot of correlates to examine.

Leah: Part of what I'm wondering is like, where are the MPHs is going? Are they getting jobs in the private sector? Do they not have the skills that we need them to have to work in public health departments locally? Like, in theory, we're training people, but where do they go?

Rochelle: Right. And so a couple things. First is, while, there have been more applicants to schools of public health, and potentially more graduates of schools in public health, we're not nearly training them at the rate that we are in deficit. So we continue to run a deficit, and if you go to many of the highest tiered schools of public health reported across the country, they're training academicians. And, in fact, in many places, and I've visited many of them, I have said, how many have you have ever done an internship in a state or local public health department and most have not. In fact, most don't have the capacity. And this is a limited sample, don't get me wrong. And it's different across the country. But is there a mechanism by which trainees at schools of public health have a streamline inroad into working in a health department? I don't know that those are facile across the country. And so there are a lot of skillsets that you have after you've completed a master's or a PhD in public health and those skill sets are very much needed state and local public health departments, but they're also needed in other places that are more lucrative, that have better job security, that have easier hours, and less burnout and all the things that we just talked about.

Leah: Mm hmm. Yeah, one more follow up on this because I know you've thought about the doctor workforce shortages also, and I'm curious, do you see the solutions to the public health workforce shortage and the doctor workforce shortage as similar kinds of solutions? Like, maybe in both cases, we need financial incentives to encourage people to move to areas they might not otherwise move to or pursue specialties they might not otherwise pursue? Or would you say that these actually are likely to have pretty different solutions?

Rochelle: I think there are some that are gonna be similar; the production cost, for example, of creating a physician is huge. We probably have less production cost of creating a contact tracer. Right? So, I think that there are some that are similar. There are some that are going to be different, like: How do we create investments in our state and local public health departments that are longitudinal, that make job security, you know, reasonable, that will compensate. So I think some of them are similar, and some of them are going to be different.

Sophie: So we want to jump into the data bucket now. So with respect to data, the CDC receives data, as you said, from thousands of local jurisdictions, which in turn received data from numerous hospitals, labs and doctors offices. This makes it difficult to standardize and streamline the collection and use of public health data. Could you talk a bit more about what problems this creates and what steps are being taken to address it?

Rochelle: Yeah, so the two buckets I really want to talk about are the data highways and the data authorities. So, let's first start with the data highways. We come from a very fragmented data system, as you noted. And while public health departments get some data from hospitals, they actually house some data themselves. So, one of the big challenges that we had during the COVID pandemic was vaccination data lives in public health departments; hospitalization data lives in the hospitals. They don't connect or talk to one another. And certainly they don't with identifiable information. So, if you asked a public health department, we want to know who's vaccinated, but ended up in the hospital. Those systems don't connect, which is why we had to create platforms for that to be possible and research settings for that to be possible so that we could connect those data. Now, that dates back to, like, the 1910 Flexner report where public health, unlike many other countries, public health and health systems actually got disentangled and that has served a problem from a data system. Now, there are things that are happening at the federal government level that are trying to connect our health care data.

For example, if you go to a hospital that has, an Epic electronic health care record, you can now see your electronic health care record in other hospitals that use Epic. However, if you go to a hospital that uses Cerner, a different health care record, you can't see those records. Only Cerner hospitals can see other Cerner hospitals. Now that is actively being worked on such that there is going to be a trusted framework. They call it TEFCA, the trusted exchange framework for a common agreement where these electronic health systems will one day be able to talk to one another, in a privacy protected way so that all of those data connect. However, they don't yet connect to public health. And the big picture vision would be that in a privacy protected way, the health systems data connects to the public health. Now, you need to make sure that the platform in Boise, Idaho connects to the platform in, you know, Paducah, Kentucky, and that those platforms have to talk to one another.

And all of these states and local health departments have different investments in their data systems across the country. So, if I want a Cadillac and you want a bike, how do we make sure we're driving on the same road? Right? And that is not trivial either, as it turns out. So there has been about a billion dollar investment in modernizing our data systems over the last five years that has been given to CDC through Congress. And that sounds like a huge amount of money. But what I will tell you is the hospital system that I used to work in just eight years ago, upgraded to Epic. And it cost the system 1.2 billion. One hospital system. And there are single counties that need a billion dollars to upgrade their data systems. So there has been investment and there's been huge progress made with that investment, but that investment is probably less than 10 percent of what we need to really modernize our data systems across the country. And you can see the progress that has happened with that investment, but it's not nearly enough. So that's kind of the modernization of the data systems.

The second is the authorities and what does CDC have the authority to say? This is required to come to us. I'll give you an example that I thought was really sort of salient for me. And that is states don't necessarily have a requirement to share data with each other. They don't have a requirement to share data with CDC. As I mentioned, it's not always standardized as to how it comes in. And because of that, we have actually tribes that cross state lines that can't actually see their own data because we have part of the tribe in one state, part of a tribe in another state, and they can't even see the full comprehensive data of their tribe. You now take that to a federal—we have 574 tribes in this country, we have, 3000 counties and 50 states—and you start to realize the complexity of what might get reported and what might not get reported and it relies on really astute people on the ground, scratching their heads and saying, huh. That's weird. Maybe I should let the CDC know about that. So you're relying on that system. and then CDC becomes responsible for outbreak investigation. So it doesn't necessarily have the authority to require the data come to it, but it is responsible for the investigation.

Once there is an outbreak. You can imagine the challenges.

Sophie: One follow up on highways first. So, it sounds like the original source of the difficulty here is maybe mostly historical, but that right now the barrier to creating these data highways is: A) privacy concerns and B) money. And I guess I was wondering, does that seem right? And then also, do you think the privacy concerns or the money are holding us back more?

Rochelle: I would say privacy concerns, money, and an upskilled workforce.

Sophie: Okay.

Rochelle: Yeah, so I think, you can't create an epidemiologist; like, even during COVID, as we were getting resources coming in, there were not enough skilled people to do the work that we needed done with the skills that we necessarily had locally. You know, if we distill down to it, if you had political will, you would then have both the motivation to address the privacy issues and the motivation to finance it. The bottom line is that when public health is working, you don't know about it. Public health works all the time. Most people had never heard of the CDC until COVID. It turns out when you have an outbreak that affects 300,000,000 people at the same time, that overwhelms, particularly frail under invested public health system. But during my first year of tenure, I believe we had over 60 food borne outbreaks, most of which you never heard about. We had during my tenure an Ebola outbreak in Uganda and two Marburg outbreaks and things that we were tackling and made it to some news, but not really mainstream news that many people heard about. And that's because public health is working and it is hard to think about how you would invest in something that is working.

Leah: Yeah, I can imagine that this could lead a lack of political will because public health isn't salient to people when things are going how they should be.

Rochelle: Exactly.

Leah: So, I was wondering if you could kind of speak more to that and what challenges this creates around funding.

Rochelle: Yeah, I mean, maybe I'll give an example that I think is really interesting. In August of 2021, the government brought 70,000 Afghan evacuees to the United States in the project called Operations Allies Welcome. And my phone rang as that was being planned and organized for concern, both about COVID, but the fact that 70,000 people from Afghanistan were about to come to the United States without medical clearance. Now, you generally need a medical clearance to come to the United States from an international country to immigrate. What was happening in Afghanistan at the time was a measles outbreak. They had 24,000 measles cases and the vaccination rate for measles was under 80%. And the other challenge in Afghanistan at the time was, and continues, is that they still do have endemic wild type polio. And the vaccination rate for polio was also low, lower than we'd like it to be. So we are about to embark on bringing 70,000 people to the United States. And during that period, we had to vaccinate many of them. We had to do a lot of work on the medical clearance side. Within three or four days, we had an active measles case. Within a week, I think we had 10 active measles cases. And none of those cases got into the community, which is kind of extraordinary, actually. In the evacuees we had active measles, mumps, TB, varicella, COVID and flu, hepatitis A, and we did an extraordinary job, I would say, of treating the community, making sure that they got what they needed, diagnosing their infectious diseases, and making sure that they didn't extend into the broader community. I consider that a huge public health success and no one knew about it.

Leah: So to get to the last piece of the infrastructure that you mentioned, the laboratory systems. So, as you noted, the CDC has the responsibility to develop and deploy tests for novel pathogens and before you took over the CDC, early in the pandemic, there was a lot of criticism, I think, about how the CDC approached its development and deployment of COVID tests. To what extent were those challenges anticipatable and have we taken steps since to make that go better the next time?

Rochelle: Several things. First, I inherited that. That did not happen on my watch. I was not there at the time. I can't speak to what went down while I wasn't there. What I can say is, as an agency, we had, I felt, under my watch the responsibility and accountability to say, this is what went down, we have reviewed it. I had a special committee on my advisory committee of the director who could review the laboratory infrastructure of what was happening within the CDC understand where the challenges were and what were needed such that that would never happen again.

Now, among the things in that were that the laboratory space within the agency was kind of buried down within several layers of bureaucracy, which I wanted to make sure that the folks that did laboratory work reported directly to the director him or herself. I actually felt strongly that all of the basic infrastructure pieces of public health—laboratory, workforce, and data—all reported to the director.

I thought that that was really critically important. So, we did some reorganization of the agency that alone, of course, does not address the problem. It helps to address the problem, but that alone was not going to address it. We had to make sure that tests that were developed at CDC were validated in another piece of CDC.

You can't have the development side be doing the validation side. It's gotta be validated by independent scientists, at least in my mind, that was work that needed to be done. And then you have all the hard work of what happens within the agency, but the effector arm is local and state public health departments. And so are there mechanisms are there laboratorians that can do that? And this is going beyond the COVID question, but that can do that. So there was a lot of sort of 360 work that happened within the agency, both by people who are there and who were external advisors to me so that we could address that issue. And that the public would know from an accountability standpoint that we were looking at that carefully.

Leah: Yeah, I mean, one general problem that seems to undermine the efficacy of the public health infrastructure, like all of these challenges is that our system is very fragmented. And to some extent it seems like this fragmentation is inherent to public health, right? Like we need to rely on individual doctors who see patients with rare infectious diseases to report those cases. On the other hand, it does sound like to some extent this fragmentation could be a byproduct of how decentralized the US government is generally, how our public health systems were built, and so on, and so I'm wondering like to what extent is this fragmentation problem U.S. specific or is this something that around the world every country is grappling with a similar set of issues?

Rochelle: I think the structural fragmentation problem is pretty specific to the U.S. Like when I did my calls with other countries, their public health system and their health care system are integrated in ways in Israel and the U.K., for example, had all of their data in one space.

Why did we get our vaccination outcome effectiveness data earliest from Israel is because they had the most integrated data system, which allowed us to see it. Now, we were able to be not far behind them, but they had data systems that were easiest to be able to see those data. So, that is most definitely part of the challenge.

I do want to sort of speak to one of the issues that you came up with, which is the reliance of somebody on the ground who scratches his or her head and said, this doesn't feel right. There was a lot of press early on in the Mpox investigation. (So, I use the term Mpox. It was originally called monkey pox. So people know what I'm talking about.)

But in that original Mpox investigations about not having enough tests. Now, it turns out CDC has had for years, a pretty tiny budget working on Mpox. We had experts on Mpox. We had a test for Mpox in the state and local health departments. Our resource labs had tests for Mpox and we scaled up that testing to 80,000 a week—and we never reached that need for capacity—within a couple of weeks. So, yes, it was the case that many people said it was hard to get an Mpox test. But in my mind, one of the biggest challenges was no clinician had ever seen a case of Mpox. And so people would go to an emergency department, an STI clinic, an urgent care center and say, I've got a bad, painful rash and no clinician had ever seen it. And didn't know what it was and didn't know how to diagnose it. And in fact, we would get calls like, I want to swab my nose for Mpox.

And that's like, not how you make the diagnosis of Mpox. And it reminded me that we don't have what I call the amber alert for a new disease. Right? How do you know that somebody has a new disease if you've never seen it, never heard of it? Among the things that we did early on in that Mpox outbreak was figure out how do we get to every clinician that bills for any procedure in any site so that they know that this is out there and that they should look for it?

And oh, by the way, open this email, right? This one is important because you might be seeing it. That's really hard to do at a national level it turns out. We can do it at state and local health departments. We can do it through billing. And we worked with our partners at CMS. We worked with our partners at the double AMC. We worked with our partners in, academia. It was not so easy to do. And that is true for any new or novel pathogen that we might see that it's estimated that 75 percent of new pathogens will come from a human animal interface, which may very well mean that we have clinicians who've never seen or heard of some of the diseases that we are about to embark on. But that's a real challenge.

Leah: Yeah, one follow up on this is it seemed, at least as an outsider, that the media was doing a lot of work here and that social media was doing a lot of work here as well—for better and for worse, right? There was a lot of like misinformation being propagated about how you get Mpox, who's liable to get it, and so on. So I take it that you kind of need the media and social media, but also that that's sort of a double edged sword. I was wondering if you could talk a bit about how you can partner with those folks to sort of get the information into the hands of people who need it, but in ways that are actually accurate and informative.

Rochelle: Yeah. I mean, I think, you're absolutely right. This is a double edged sword. If we were able to work with reliable social media platforms legally—and I think some of these legal judgments are still out there—to say, when somebody Googles "blistering rash," make sure they get this information. Right? That would be super helpful. Is that legal to do? Well, folks who want to propagate mis and disinformation be unhappy by that? We worked a lot with our societies, to make sure that the information got blasted out by our infectious disease societies. There are other societies that work in the fields STIs and work on those sorts of things.

But, yeah, I think that that is going to be an ongoing challenge and it was the case that crowd sourcing allowed folks, especially in the highest risk and sometimes stigmatized communities to get information that they potentially needed. But in the earliest days, you would hear cases of "I went to 3 different people and nobody knew what it was." And those were particularly frustrating because you knew that they were delaying access to something that they really needed.

Leah: Mm hmm.

Sophie: To what extent could issues around fragmentation be addressed by centralizing government public health efforts to a greater degree? And do you think it would be a bad idea to try to do this?

Rochelle: I think particularly with some of the authorities, it would be really helpful to have. And I spent some time on Capitol Hill, letting folks recognize, like, you realize that this makes public health difficult, and it doesn't make public health difficult necessarily is a CDC director job. It makes public health difficult in your state in your counties. So, for example, authorities like our budget authorities. Like, do we have the capacity to hire folks in a surge the way FEMA does, to be able to move money around? So one of the challenges that happened actually during Mpox is this was increasingly becoming clear that we were seeing patients in STI-like spots that we needed to do some contact tracing, and that folks in public health knew how to address similar kinds of outbreaks. Yet there was no budget for Mpox, right? We had a STI budget, but Mpox hadn't been declared an STI and it took weeks to be able to do that kind of thing. But these budgets are so clearly defined. I think CDC has over 150 line-item budgets for different diseases. And can you use your gonorrhea/syphilis budget for an Mpox outbreak?

No, that's not allowed until certain things happen. So these budget authorities make it very difficult to move money in disease-agnostic ways to hire people in surge situations. So we talked about the data authorities and not necessarily the authority to be able to see. Budget authorities are another one.

The reason we partnered with FEMA—who are wonderful partners—as we did COVID vaccine mass vaccination sites across the country is because CDC did not have the capacity to move money in a way that will allow those sites to be created. So, budget authorities, hiring authorities, and data authorities. And to the extent, that Congress recognizes some of those challenges, that would depoliticize health and public health and I think make things a lot easier, to be able to pivot in crisis times.

Sophie: Mm hmm. Just to follow up on the insufficient flexibility with respect to budgeting. Could you speak to whether you think the bigger problem is that there isn't enough funding or whether the bigger problem is that there's not enough flexibility with respect to how funding can be used?

Rochelle: I don't know that I could call one bigger than the other. I think they're both real challenges. There is not, I talked a lot about it while I was at the agency, disease agnostic resources. So, the classic example is the request: "Can I use my sickle cell fax machine to fax you COVID data?" Now, there's like a whole host of things wrong with that question. Like, why are we using fax machines? But the fact that there are two fax machines, one that was purchased on sickle cell dollars, and another that was purchased potentially with COVID dollars, so that kind of gets you down into the weeds, but it also gives you a sense of like, if I've hired a contact tracer in COVID, can I use that contact tracer in Mpox? Well, in an ideal world, we would have a disease-agnostic contact tracer, right? Who is skilled and whenever it is that we need a contact trace for whatever disease, we have somebody who knows how to do that. But that is not how it generally works.

Leah: This all feels very intuitive, like it does feel like it should be disease agnostic. Why, why isn't it like that?

Rochelle: The ways the laws get written, like even transferring money, like the CDC does not have transfer authorities such that or and even like state and local health departments in many cases don't have transfer authorities such that, you know, somebody wanted this disease studied at CDC, something got passed through Congress, there is now a budget for this disease and this line item, and that needs to stick because that was really important to some host of members who created that.

But what that has created is 150 line items of the budget, and an incapacity of the CDC to transfer monies without permission. And that permission, even in, outbreak investigations, even in public health emergencies, takes time to move forward. But I think that there's real concern and desire for oversight in: can you exactly tell me what that workforce person is doing and on what disease and are they focused on the disease that I care about or are they specifically focused on a disease that I don't want you to address?

Sophie: So we want to move now to talking about how some of the infrastructure challenges we've discussed made it harder for public health agencies to respond to outbreaks in the past, and how these challenges might make it more difficult for agencies to respond to future public health challenges. So, our first question is, how might past outbreaks have gone differently in the US if public health infrastructure had functioned optimally?

Rochelle: So, one of my colleagues at Mass General diagnosed the first case of Mpox in this country. She called me that afternoon and so unlike what usually happens in public health, the CDC director knew of the case immediately, which is kind of an amusing sequence. So, on May 17th, 2022, I got a phone call that we had our first case of Mpox in the country by the person who diagnosed it. Now, that generally happens directly at the state level. And we, of course, wait for the state to make a comment because the CDC cannot comment before the state. So that was May 17th. It was very clear we were starting to get more and more cases throughout the end of May, early June in several different cities across the country. And we had the ASPR, the Assistant Secretary of Preparedness and Response, had a limited stockpile of the JYNNEOS vaccine, the vaccine that we were going to be using and the questions of how it was going to be used, whether it was going to be pre exposure prophylaxis or post exposure prophylaxis, all of those questions remained, and we had a very limited supply. So, Mpox was not a reportable disease at the time. Turns out that we didn't have enough cases to have it ever be reportable. And so most jurisdictions were actually pretty good at telling us about cases of Mpox, but not necessarily reporting on gender distribution, on risk factors, on demographics. At all. So we were getting most of the case data, but not the demographic data. We had our peak number of cases of Mpox in this country, if you look at the national history curve, on August 1st. There were, I think, over 600 cases that day. The public health emergency was declared on August 4th, in retrospect, three days after our peak number of cases. And during that period of time, the government is distributing one of the most resource scarce things we had to respond, which was the Janius vaccine. During this period of time, we had no capacity to see who had actually been vaccinated. All we knew is that we were giving out vaccine to jurisdictions, but we did not know that the people who were getting that vaccine were the ones who are at risk of getting disease. We had no way of getting that information. So we continue to distribute vaccine without knowing whether it was going to the people at highest risk.

That's a huge problem. By August 4th with the public health emergency, CDC and the federal government had the capacity to enter what we call data use agreements with each of the jurisdictions. So that we could comment and make a decision as to what data were going to be collected, how it was going to be standardized, and what was going to come to CDC. That took a whole host of lawyers with every state health department. And by September 1st, we had data use agreements so that we could get the case data and the vaccination data. But that's three months after our first case on May 17th. And if you look at the epidemiologic curve, cases are already coming way down by the time we have the capacity to see the data. But in that critical period of time, that peak number of cases, those outbreak investigations where CDC is and should be doing its best work, there were a lot of times where we wanted to see data that we had no capacity to see, and that could have better informed really hard decisions. And that, I think, is the crux of the challenge.

Sophie: One issue that we haven't touched on directly yet has to do with communication. We're interested in how the CDC's communication strategy in recent years has often emphasized following the science. The strategy seems to face two challenges. One is that public health recommendations aren't value neutral. And second, science and our understanding of it change and, change throughout pandemics and outbreaks. Given these challenges, do you think that orienting public health communication around following the science is the right approach?

Rochelle: I think we have a responsibility to let folks know that our recommendations are going to be science and data driven. I do wish in the follow the science that America and the public had recognized, not only did the virus change during COVID, but the science changed and that there is a responsibility of the people who are following the science to update recommendations when the science gives us new information that requires those recommendations to be updated. I think that is true. It is also the case—and we talked a little bit about this early on—that our public health system is under resourced in communications in general. We started our White House, press conferences with me and Dr Fauci and the White House COVID team, 7 days after I started in the administration and we, did thrice weekly press conferences, for probably over a year. I know I did nearly 100 of them. And, I was doing that without a communications director. I had an acting communications director. The communications director job at the CDC had been empty for four years when I started. So, I worked with some incredible people in the communication side, but CDC has always had a communications bench that deals with foodborne outbreaks or new science, right? Not necessarily three times a week press conferences.

So I worked with extraordinary people, but just to give you a sense of the bench of public health communications has always been pretty thin, just like much of the frailty of the public health infrastructure in general. So that is one issue. The second is, I do think we have a responsibility to the public to let them know that the people who are making recommendations are doing so with the best evidence that is available at the time those recommendations are made. And then the third thing I think is the piece that health is not the most important thing to everyone, and that that is a values judgment. And while people call it politics, I would say we all have to respect other values. People in health were very critical on the news a lot about decisions that were made without recognizing if you make a decision in health, how that impacts something very far away. And I think one of the gifts that I got in the federal government is to be able to see that line of sight. I'll give you an example from when I was here in the state. I was working with the state and there were discussions about opening schools, another very charged topic. And there was a discussion about the after school sports decisions as to what was going to get opened. And this was in the era before adult vaccines and before kids vaccines. And I remember a conversation I was part of where they were talking about letting kids wrestle and, they said, you know, what we're going to do is we're going to let the kids wrestle.

We're going to shorten the matches from 3 minutes to 2 minutes because generally we say 3 minutes of exposure. We're not going to wrestle and masks. And then we're going to then separate and sit on opposite sides of the bench and not share, water bottles and do really COVID specific things. And everybody was kind of like, really? Are we really going to do this? This doesn't feel like a good idea. And by your chuckles, I can see how you are kind of feeling the same way, right? That just didn't seem like a good idea in the summer of 2020. and a parent then raised her virtual hand and said: if my healthy kid does not wrestle next semester, he will not go to college.

And all of a sudden you're like, your kid would probably do fine with COVID because your kid's healthy. Your family, if they're otherwise healthy, will also probably do fine with COVID. And over the long term, your kid might actually do better if he wrestles than if he doesn't. And it just opens your eyes to how something that would make us chuckle early on would then really say very much rationalize why a values judgment would say, no, this is really important to me and my family and to the welfare of my child, actually.

And I could give you example after example from my tenure of those kinds of things where it's so much so that it would make me ask the questions. What can't I see? What don't I know? What kind of challenges will this impose? Even though it looks like we're making health decisions. There was another decision related to, duration of, quarantine and isolation after Omicron and while we were doing things in health care and why we were shortening them.

And one of the questions I like to ask is FedEx considered health care and people generally say, no, FedEx is not considered health care. But a lot of the incoming I was getting at the time is hospitals couldn't get blood culture bottles. Dialysis centers couldn't get dialysate. Outpatient pharmacies couldn't get drugs because FedEx wasn't working. And so you just realize that while you think you're making decisions about health, it has this incredible domino effect across the entire infrastructure of our country that people who are not necessarily in it can't see. And even when you are in it, you really do have to ask the questions: what am I not seeing here?

Leah: Hmm. Just to follow up on the communication piece a little bit—tell me if I have this wrong—but one thing that comes to mind when you're talking about communication is it seems like there could potentially be a trade off between clarity and transparency where it's easy to give a clear recommendation; I mean, you can give a clear recommendation in one sentence, but that's not going to convey all of the values implicit in that recommendation, all of the scientific understanding of why that recommendation needs to exist and what the uncertainties still are and what we might learn that would change the recommendation and so on. And so you could go for a more transparent recommendation, but then the recommendation may be much less clear. And so I'm wondering is that a correct understanding of a fundamental part of this issue? And do you think that in general, public health agencies are striking the right balance with respect to this clarity/transparency trade off?

Rochelle: I think that is one layer of the trade off. I think well, first of all, I do want to just sort of say out loud that how, public health is communicated is not entirely up to public health, right? So how many times did I have a recommendation that was more complicated than a 30 second soundbite would allow?

But that's all I got. Right. And so I don't get to unpack the rationale behind it. I don't get to unpack the details. I get, you know, America wants to know if the vaccine is safe and effective. And they want to know whether I should go get vaccinated. And that seems like a relatively simple issue, until you have a booster recommendation in the fall of 2021 that has issues related to limited amounts of data that are presented and Pfizer came forward, but Pfizer had put their data forward earlier than Moderna. So we were limited in that we had to make a recommendation for only people who had gotten Pfizer. And why is it that people over the age of 65 are getting the recommendation, but not people over the ages of 18. So, much of America wanted "just tell me what to do" and then many providers were like, "wait a minute, how can you make such a blanket statement when there were all of these nuances that you're not speaking to" and then you layer on the fact that you're at the whim of some news outlet to decide the duration of what you get to say.

Leah: Mm hmm. Okay, so more broadly, what are some of the biggest lessons that we learned from the last pandemic, and how do you think these lessons might affect our ability to respond to the next one?

Rochelle: Well, I certainly learned about the frailty of our public health infrastructure. And I knew it was frail when I came to CDC. It was frailer than I anticipated it would be. And I had really hoped that when over a million people succumb to a disease that there is finally a recognition that, there needs to be investment in this infrastructure.

And very sadly, that is not actually what has been realized from that pandemic. Much of the discussion is not about what do we need to do to be ready for the next one? It is, how it's going to be, pulled apart because it was not successful. And so I would challenge that as the answer.

I will also say that if you go back and you look at the history of the 1918 pandemic, the flu pandemic 100 years ago, much of what was learned is that the political will around the right things to do was not there and that it became more divisive and there was more concern about protecting myself than protecting my neighbor and that many of the lessons that we are learning the hard way here in the aftermath of the COVID pandemic, were actually learned in the aftermath of the flu pandemic.

In the big picture, certainly the frailty of our public health infrastructure, and the investments that are required, and the long term investments. And I say, long term investments, because, as fortunate as we were to receive resources to be able to deploy a lot of different efforts during the COVID pandemic, you can't create a genomic epidemiologist, with a huge lump sum of money, immediately. The expertise that we need in developing that workforce, retaining that workforce, upskilling that workforce is not one that comes with a one-time lump sum of money. One quote that I remember reading during the pandemic was, you can't throw a treasure chest on a sinking ship. Right? That's not what is needed in this moment. So it is the long term, investments. And to be clear, a demonstration that those investments are going to the right places and that they've been successful. I don't expect a blank check. I want to make sure that they, are invested in the right places for the right things in the right reasons. And those investments, I think, are really necessary.

Now, among the things that we did at the agency, while I was there was an effort, towards the end of my tenure, which we called CDC Moving Forward. And a lot of that was, the agency, had been around for about 76 years while I was there. And that means, if you just do the math, that, it was not around for the pandemic flu. Which means that the agency had never tackled a pandemic like COVID during its entire existence. So, among the things that we did is we said, well, what are some of the things that we would want to have known and done better? We did a lot that was incredible: 700 million vaccines went into arms during my tenure is kind of extraordinary, right? A massive public health effort that has never been to that degree. And our job was not to pat ourselves on the back. Our job was to say why did a million people die and what could be done so that that isn't the case the next time?

And where could we have done better? The agency over time had become, and remains, a very academic place. We do a lot of really new and novel science, which is terrific. And the agency needs to be able to produce data in a way that is non academic that is not sort of the ink is dry on the 3rd draft of the manuscript, but rather we know the answer. We see the data, we've corroborated the data in other places. We can't give you the 3rd decimal point, but we can tell you that this is how things are trending and we owe the public that information today. And I can't tell you how many times I would hear "this is coming out in 3 weeks" and external and I would say, "or I'm going to say it at the press conference tomorrow," right? Which is what I would do. Because America needed to know. And we were making decisions based on those data and I had the responsibility to tell America how and why those decisions were being made. So moving data forward. The other, place that we were really moving was to make sure that jurisdictions had options that like there wasn't a blanket.

"You should do this, but not this." That that which might be viable in rural Alaska might not be viable in Chicago, and that, you know, if you spend enough time in the shoes of the director, you realize you are making policy for rural Alaska and Chicago and Hawaii and Indian country. And these are really diverse places and how they make those policies and why they make those policies.

And so we needed to make recommendations that were based on the science that we saw, but that were implementable at the local level, regardless of the kind of local level you were working in. And that generally meant options. And in the HIV world where I've spent a lot of my career, we talk about harm reduction. If you can't do this, do that. And if you can't do that, then do X. So that people, you know, had options. This was not going to be viable in this space. So do this instead. But people expected it to be cut and dry and it wasn't going to be. And then, as we've discussed already, taking those options and communicating them to the American public. Having a workforce that's better to respond was another piece of our moving forward.

And then the final piece really was being a good partner. When you get that phone call, that says something strange is going on to say, "tell me more" rather than "that doesn't sound right." Or how is it that you can work with industry? I remember being in Seattle and seeing incredible work that was being done for vaccine distribution, where the Starbucks was helping with logistics and Microsoft was helping with data. And you're like, yes, that seems like a great, great opportunity for public health to partner with industry. Right? So like, all of those kinds of things, we could be doing more and better.

Sophie: So we are curious about how prepared the U.S. is for another pandemic, and we're wondering are there objective metrics that suggest that we're more or less prepared than we were in 2020?

Rochelle: I think there are objective measures that suggest both. So with the investment in data modernization, there has been huge strides that have been made in electronic case reporting, for example. So when the pandemic started, I think only about 87 health care facilities were reporting data electronically.

That's now up to, I believe, over 30,000 and still far less than half. So we've made huge strides, and I know that work has continued in my absence at the agency. That has been a real focus. We're not where we need to be, but it's way better than it was. That having been said, I think, if you just need to look at the news, or some of the challenges that public health is having right now, to recognize we are not in a situation where all of America agrees on how much public health should have a say, should have reach, and all of those areas, and that's particularly fractured at this point. And that will not serve us well in another infectious outbreak.

Sophie: Mm hmm. So looking beyond COVID specifically, we'd like to understand the cumulative impact of infrastructure challenges on public health in the U.S. The U.S. performs worse on most health outcomes as compared to similar wealthy countries, despite spending vastly more on health care. The reasons for this are, of course, multifaceted, but we're wondering how much of the life expectancy gap between the U.S. and other high-income countries could be closed if public health infrastructure functioned more optimally?

Rochelle: That is not an easy question. First of all, I think, cost and access are real issues here, and, healthcare access, but also preventative services access. So how do you lump preventative services? Do you lump that in healthcare or do you lump that in public health? So I think, there is some fraction that could be closed. But what I might invite you to do is look at the map of life expectancy across the country. And if you look at that map, you realize we have states that have 10 years different life expectancy from other states. And if you realize that, then you realize, well, actually, we might be able to close some of that gap just by delivering better health access prevention regionally.

We have zip codes where life expectancies are very different from one zip code to another zip code in cities. And so, some of that I think is going to be policy related. Some of those policies related to stigma to people coming forward for health care access. Some of it is going to be related to rural urban divides.

Some of it's going to be related to broadband. Some of it's going to be related to food security. And so, even if you said, you know, we're going to address public health issues, is food security, a public health issue? Like, where is the continuum of where that all lives? And I think we're going to have to address all of those things to help address the delta in life expectancy.

Leah: I want to follow up on that point you just made because I take it that like one of the problems is that So many different things contribute to public health. So many different agencies, so many different budgets, and a lot of those agencies and budgets don't see their mandate as promoting public health necessarily, right?

Like education is a key part of public health, but the Department of Education isn't out here being like, how can we best promote public health? So I'm wondering if, you know, given we need this sort of team effort to facilitate public health, do you think there are things that we could be doing better, with partnering across different parts of the government or across industries to get buy in from everybody to promote public health?

Rochelle: Absolutely, and I think this gets back a little bit to the wrestling example that I had before, which is, you know, one of the gifts I had during my time at the agency was to really understand. I worked very closely with Secretary Cardona, with regard to schools, the Department of Education. What I think people sort of don't realize is how health touches everything— agriculture, and food security, and housing. I work closely with Secretary Fudge in Housing and Urban Development. So, I was hospital based for twenty five years; we who work in a hospital sort of think in our little silo of health care. And then you recognize that health just touches almost everything that we do. Childhood health, child education, parents and capacity for childcare, all of the housing security, all of these things, mental health, right? All of these things are really integrated into healthcare outcomes and life expectancy outcomes, and I think breaking down some of those silos to recognize, like, when you invest in this in education, you're not calling it health, but I see that as a health care benefit. I had the gift of going to a school in Manhattan, and they had a clinic in their school, and at lunch, kids could get a pap smear.

Sophie: Wow.

Leah: That's cool.

Rochelle: It was like, kind of incredible, right? So you see that they're really, really creative ways that people could get resources or STI screening right? Or family planning information, and there are really creative ways where things could be integrated. And I think the more integration would be really beneficial.

Leah: Mm hmm. Yeah. So this is sort of an inverse to the other question we asked. But in recent years, there have been some major public health success stories in the U.S. as well. First, opioid deaths in the U.S. are falling, and second, rates of obesity are starting to fall as well. To what extent do you think that the public health community can take credit for these successes versus, say, the medical community or the pharmaceutical industry, recognizing that it's hard to draw clear lines between these different entities? And are there any generalizable takeaways from these success stories about how we should approach other public health challenges going forward?

Rochelle: I think the first question, first of all, some of these really are public health successes or health care successes. I think some of the ones that you mentioned we're still early in the game. If you talked about obesity, for example, I think that that is probably uniquely contributed to an effect of the GLP drugs, and while that is a public health success, don't get me wrong, at 1000 a month, that is going to only potentially further result in health care disparities across the country. Potentially. And so that is something that we really need to—if on average, our life expectancy goes up, but our disparities get worse—is that perceived as a health care success or a health care failure?

And so I think we need to unpack some of these that seem kind of relatively easy and simple. They're not necessarily, you know, as easy and simple as they might seem. The other really interesting one, and I've dug into this a little bit, is to really try and understand why opiate deaths are falling. And this is, I believe, the first year that we've seen that. So that's, this is early, early data. Is it because of our distribution of Narcan? Is it because of our education? Is it because of access, which I know is still a huge challenge. But, you know, among the challenges and among the potential hypotheses is that it's due to survivorship, which is, all of those who might have had such severe addictions have actually already died. That would be very sad commentary on the reason that deaths are falling. But I do think we have more that we need to understand about why that is the case and very much to hope and continue that those trends will continue. But also if we understand why, then we can continue investments into those places.

Sophie: Okay, so we want to move to the last section of the interview, which is about paths forward and how prepared we are for future public health challenges that might come our way. Presumably, there is a feedback loop between the efficacy of public health institutions on the one hand and, on the other hand, public officials and the public's willingness to support them.

In other words, the less well these institutions function, the less eager elected officials will be to invest in them. But do you see any ways in which we can intercede on this feedback loop?

Rochelle: Yeah. I mean, I think that the perception of a feedback loop is among the challenges, right? If one really needs public health, and public health is under invested and you recognize these are all the ways public health did really great stuff over the last 10 years, the one that was in the news it turns out was the one where 330M people all needed public health at the same time. We don't necessarily have an infrastructure that can manage that. Now we can manage a lot and we have managed a lot, but we need to bolster up and we can give you examples of what we were able to do. We need to bolster up the infrastructure, not dismantle the infrastructure because it wasn't able to handle 330M people at risk at the same time.

Leah: Yeah, I will also say that it does feel like there's that feedback loop, but then there's also this other piece that we mentioned earlier, which is that it's when these crises happen, that people are willing to invest money. And so to a certain extent, public health infrastructure being broken could perversely lead to more investments if that does tend to lead to more outbreaks.

Rochelle: It is sadly. I mean, I think sadly what happens if it tends to lead to more outbreaks is that more people are at risk and succumb. Right? You know, we're missing 1.2M people from this conversation. and that is the people who died from COVID. Right? The people who survived, maybe some of the ones who say it wasn't so bad, but there are 1.2 million voices who are not going to be heard.

Leah: So, one place where infrastructural challenges appear to be affecting our current public health response is with respect to surveillance for bird flu, also known as H5N1, which has been inconsistent and patchy. Why hasn't there been widespread testing of H5N1 among farm workers at high risk, and how worried are you about H5N1 becoming a pandemic?

Rochelle: I love this question because, I think it really outlines what America perceives versus what's viable. So, CDC is actually not allowed to show up at a farm and test noses. We can't just show up and swab a nose. One needs to be invited in. So to say, why are we not testing more is because, we don't have that capacity or that authority. If you look at the case from the New England Journal that was written up of one of the first cases, from dairy worker with bird flu, that patient, declined serology testing. Why did that patient decline serology testing? I don't know if that patient was working legally or illegally. I don't know whether that patient would continue to have a job. I don't know whether that farm would have to, sacrifice its cattle, but there are a whole host of disincentives, to not do public health well in those situations,

Sophie: Mm hmm.

Rochelle: at the level of the farm worker, at the level of the cattle owners, there are a whole host of reasons why one might not want to, do all the surveillance that would be required.

Leah: Hmm. And, do states also not have this authority?

Rochelle: The states, I believe, do have the authority. And in fact, Massachusetts, was, I think the 1st state to our commissioners and, to the agriculture credit of the state has screened every, cow farm across the state for H5N1, setting the example, I think. But, as you can imagine, there are probably political leanings of folks who are on these farms and how big they are and how much of a vote they have. And there are all sorts of rationale that, may or may not move a state to do those kinds of things.

Leah: Mm hmm. Got it.

Rochelle: So it is not that the agency would not want to know how much H5N1 is out there. And it is reportable. But it is the case that it does not have the authority to go in and ask, the questions and do the testing that you are suggesting. And many public health folks across Twitter and social media, wanted to do.

Leah: Yeah, yeah, yeah.

Sophie: Just to clarify, sorry, what do you mean by is reportable?

Rochelle: It's one of the, nationally notifiable diseases. So we talked about like whole list of, nationally notifiable diseases, syphilis, gonorrhea, Lassa fever, those kinds of things and bird flu is one of them.

Sophie: Okay.

Leah: Okay. So just to summarize, there's farms all over the place. Ideally, we would be testing farm workers who are at high risk, such as dairy workers.

Rochelle: It would be great to have surveillance, some surveillance.

Leah: Yeah, and it sounds like in some places that is being done in states where there's maybe both the authority and the resources to conduct this kind of surveillance, but that this sort of depends state to state and that oftentimes maybe the farms themselves are not motivated to pursue this or the states are not motivated to pursue this because of their relationship with the farm lobbies and so on.

Rochelle: Yeah, but I would also say, I don't believe there was surveillance of humans in Massachusetts. We would have to confirm that it was surveillance of cattle.

Leah: Okay, got it.

Rochelle: Now, just to be clear, everybody recognizes that if there is a dairy worker that has symptoms of H5N1, the CDC is highly, and the state is highly encouraging them to get tested. So it is not for lack of trying. It is just that there is no authority to say, so and so came in with a runny nose today, we're going to stick a swab up.

Leah: That makes sense. And, how worried are you about H5N1 becoming a pandemic?

Rochelle: Well, we have flu season coming. And, just to be clear, like I, it is not because of flu season. It's because there will be more flu circulating and more potential vectors for, flu to mix to result in a novel flu that we haven't seen before. I think, we need to do a lot to get both farm workers and the American public vaccinated for influenza.

Our vaccination rates for influenza are pretty low this season. And, as you probably heard me say, whether it is H5N1 and this outbreak, we have seen more cases of H5N1, in the last several months in humans than we have I think ever seen in this country. And we are mutations away, plural mutations.

So we're not there yet. And influenza is one of those outbreaks that has been known to cause pandemics. But it's also the case that, you know, we have so much human animal interface right now. So much international travel, so many more outbreaks over the last 5 years, even then we have had in many years prior. We have lower, you know, vaccination rates in this country than we've had over time of many vaccine preventable diseases. So, I am worried sort of, and I will also say that while many people anticipated, pandemic flu, 100 years after its last pandemic flu, just because we got a COVID pandemic does not mean we're not at risk of a pandemic flu. So, all of those things together tell me that we need to do a lot of work in bolstering our public health infrastructure so that we are ready and primed and in good shape and caring for one another, when and if this should occur.

Leah: That makes sense. Some of our listeners may be interested in pursuing careers in public health. So we're wondering, do you have any advice for aspiring public health professionals?

Rochelle: It's an awesome career. And I'm not just saying that because we need you, but we do need you. But I will say that there's so many different spaces and places where you can actively make a difference in public health. Obviously, there are places in research, but you do work on the ground. And if you have the gift of spending some time at the CDC, where I did, you really get to see that there's this incredible diversity of areas of expertise; veterinarians and dentists and nurses and epidemiologists and water safety and miner's health and so whatever areas and spaces that you want to be in. There's a place for you in public health and that you can really see that the work that you are doing is impacting other people. So much of what I did at the agency was so very hard. But at the end of the day, when you lift up your head and you say, like, I made a difference in someone's life. I might have been quiet and you might have not known about it.

And they might not ever be able to go back and say, thank you. You really do realize that there's so much, across the gamut that can be done. And that can be extraordinarily fulfilling in the work that you do.

Sophie: We like to close our podcast by asking what is one rule or norm broadly related to what we've been talking about today that you would change if you could and why?

Rochelle: You know, I thought that this was going to be a hard question and it is, but, given the discussion that we had and the places that, I've been talking to Congress about previously. It is the data authorities challenge. The CDC right now has a responsibility to address outbreaks as soon as they happen, but they don't have the authority to see when they're happening necessarily.

And so you start behind. And so obviously we need resources so that those data systems come together and we can see if there's an outbreak in County A and one in County B and put it together and say, wait a minute, we need to act on this. But the authority to be able to go in there and act in privacy protected ways, in ways that don't overstep reach, to just be very clear, but in ways that can nip things at the bud before they expand. And it becomes much harder to do.

Sophie: This brings us to the end of our time. Thank you so much for coming on the podcast. We really enjoyed this conversation.

Rochelle: Thanks so much for having me.