Former CDC Director Rochelle Walensky shares leadership lessons gleaned from making policy during a two year period dominated by pandemic anxiety, rapidly shifting science, and toxic politics.
Featuring Rochelle Walensky
October 5, 2023
41 minutes and 29 seconds
There are just certain jobs you should probably be wary of taking. And given what we’ve seen over the past four years, being director of the U.S. Centers for Disease Control during a pandemic is probably now high on that list for many people. Dr. Rochelle Walensky, who served as CDC director from 2021 to 2023, calls the job “probably the hardest thing I will ever do.” But she also calls it “the honor of a lifetime.” After stepping down from the post this summer, Walensky is now a senior fellow at the Women and Public Policy Program at Harvard Kennedy School, studying the topic of women’s leadership in the health care field. She is also exploring health care policy issues in concurrent fellowships at both Harvard Law School and Harvard Business School.
Rochelle Walensky’s policy recommendations:
When she was appointed by President Biden as the CDC’s 19th director, she was already used to politicized health care issues, having spent her formative years as a physician working on HIV and AIDS. But COVID thrust her into an unprecedented spotlight, forcing her to lead a demoralized agency through the challenges of implementing policy and informing the public while navigating a highly polarized and often toxic public sphere and rapidly changing scientific data. Walensky says she learned some hard and valuable lessons during her tenure.
Former Director of the Centers for Disease Control (CDC) Dr. Rochelle Walensky is a renowned expert exploring the challenges and what it means for leaders, organizations, and the world to protect public health. Dr. Walensky was the chief of the Division of Infectious Diseases at Massachusetts General Hospital and served as the 19th director of the CDC and the ninth administrator of the Agency for Toxic Substances and Disease Registry. Having received an M.D. from the Johns Hopkins School of Medicine, she also trained in internal medicine and earned an MPH in clinical effectiveness from the Harvard School of Public Health in 2001. In the earliest part of the pandemic, Dr. Walensky served on the front lines, taking care of patients, serving on the Massachusetts General Hospital incident management team, and conducting research on vaccine delivery and strategies to reach underserved communities. Dr. Walensky’s tenure at the CDC began on January 20th, 2021, when she led the nation—and the world—through unprecedented times, facing the largest density of infectious threats likely ever seen in the United States. Dr. Walensky has also worked to improve HIV screening and care in South Africa, led health policy initiatives, and researched clinical trial design and evaluation in a variety of settings. She was chair of the Office of AIDS Research Advisory Council at the National Institutes of Health from 2014 to 2015. She has also been a member of the U.S. Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents and served as co-director of the Medical Practice Evaluation Center at Massachusetts General Hospital since 2011 before assuming the position of CDC director.
Ralph Ranalli of the HKS Office of Communications and Public Affairs is the host, producer, and editor of HKS PolicyCast. A former journalist, public television producer, and entrepreneur, he holds an AB in Political Science from UCLA and an MS in Journalism from Columbia University.
The co-producer of PolicyCast is Susan Hughes. Design and graphics support is provided by Lydia Rosenberg, Delane Meadows, and the OCPA Design Team. Social media promotion and support is provided by Natalie Montaner and the OCPA Digital Team.
This episode is available on Apple Podcasts, Spotify, and wherever you get your podcasts.
Preroll: PolicyCast is a podcast that explores evidence-based policy solutions to the world’s most pressing problems. Our show is a production of the Kennedy School of Government at Harvard University.
Intro (Rochelle Walensky): Among the things that were challenges was this was complicated. The science was evolving every single day. Pre-prints were coming up every single day. Somebody might've read something where somebody else had not. What do you think about this study? I don't know, it was just released an hour ago. And that happened frequently on press conferences. I had been in the studio at the time that the study was released. The other thing, so the virus was changing, the science was evolving at an incredible speed, and it was complicated. It was scientifically complicated. So if we are supposed to communicate to the American people at a fourth grade reading level, which is what people generally say, talking about the difference between authorization of vaccines and approval of vaccines or what does this rate of myocarditis mean? And oh, by the way, what's myocarditis and what is the background rate of myocarditis? And trying to do that, and then you kind of got a 90-second news clip. So if you tried to speak in general, which is what we really wanted to do to speak to the American people, you were missing the nuance. And then people would call you out on the nuance and that became really hard.
Intro (Ralph Ranalli): Welcome to the Harvard Kennedy School PolicyCast. I’m your host, Ralph Ranalli. There are just certain jobs you should probably be wary of taking. Like javelin catcher at the Olympics, for example. And given what we’ve seen over the past four years, being director of the U.S. Centers for Disease Control during a pandemic is probably now high on a lot of people’s list. Dr. Rochelle Walensky, who served as CDC director from 2021 to 2023, calls the job “probably the hardest thing I will ever do.” But she also calls it “the honor of a lifetime.” After stepping down from the post this summer, Walensky is now a senior fellow at the Women and Public Policy Program at Harvard Kennedy School, studying the topic of women’s leadership in the health care field. She is also exploring healthcare policy issues in concurrent fellowships at both Harvard Law School and Harvard Business School. When she was appointed by President Biden as the CDC’s 19th director, she was already used to politicized health care issues, having spent her formative years as a physician working on HIV and AIDS. But COVID thrust her into an unprecedented spotlight, forcing her to lead a demoralized agency through the challenges of implementing policy and informing the public while navigating a highly polarized and often toxic public sphere and rapidly changing scientific data. Walensky says she learned some hard and valuable lessons during her tenure, and she’s here to share them with us today.
Ralph Ranalli: Rochelle, welcome to PolicyCast.
Rochelle Walensky: Thank you so much. I'm so delighted to be here.
Ralph Ranalli: So I kind of have the sneaking suspicion that you're about as sick of talking about COVID as some of the rest of us. So while we will get there, I kind of wanted to start with your background because I was very interested to read when I was going through some of your biographical information, that a lot of the formative experiences for you as a physician and in medicine were during the AIDS era, which was another famously politicized public health crisis. Can you walk us through that period of time when you were becoming a physician, and you were formulating your thoughts and your approach about the kind of doctor and public health advocate you wanted to be?
Rochelle Walensky: Yeah, absolutely. So it was 1991 when I was a first year medical student, '91, '92. And I remember walking into the lecture hall and everybody was pouring over the newspaper and it was the news that Magic [Johnson] had announced that he had HIV. And I remember that moment and I remember thinking about HIV in somewhat of a different way after that moment. And then fast forward 1995, I was a medical intern in inner city Baltimore. 1995 was a pretty dark time. Many of the patients that we admitted every single night were dying of AIDS. And the end of 1995 was the FDA approval of Saquinavir, that was the third drug in the cocktail. And all of a sudden, in that single year where we were admitting people and they had no hope, was this period of time where we could actually say, "You might actually live with this disease and this is not a death sentence."
And that was so instrumental in my thinking about what the next phases of my career were going to be. And yet at the same time what was happening was the patients that we were seeing, they were vulnerable, they were sick. We were asking them to do things that, on public health grounds, were the right things to do, but they didn't have access to the things that we were asking them to do. They didn't really have the potential to succeed in some of the ways that we wanted them to succeed medically because of their social vulnerabilities and their lack of access to care. So it really was the intersection of the socio-demographics and the disease that they were afflicted with that really piqued my interest. And at the time, it was a magical time for that disease where we really had hope. And that's where I said, I got to see how this unfolds. This is what I'm going to be doing for my career.
Ralph Ranalli: Yeah, the parallels are interesting because AIDS did affect marginalized populations the most at first, and that did happen also for COVID.
Rochelle Walensky: Yeah, it's true for so many infectious diseases. And in fact, one of the things I have said before about COVID is COVID reached our shores by people who could afford cruise ships, by people who could afford plane rides. And yet, it quickly went, like so many infectious diseases, to places and people who, when you said the word quarantine, never had the capacity to do so. When you said all of the things in public health that we would want people to do, they never had the capacity to do so. And that was true of HIV. It's true of COVID and it's true of so many infectious diseases.
Ralph Ranalli: How did that experience with AIDS inform you about what approach you wanted to take to trying to get those marginalized populations better served by the public health infrastructure?
Rochelle Walensky: So as I was caring clinically for patients living with HIV, and that is the work that I did throughout my clinical career. My research was all about access. How do we get drugs that, when I started, were $15,000 a year, they're now up to $50,000 a year. How do we get those to people who don't have access to care? That is also true for HIV pre-exposure prophylaxis. And so access was really an important component to me. I'm a quantitative person by design, so I like mathematical methods, and so I use those methods in cost-effectiveness analysis and decision science to look at cost-effective mechanisms of care, cost-effective interventions.
One of the early ones we looked at was routine HIV screening. It costs about $10. The uptake was really poor, so what if we blanketed routine HIV tests across the country and everybody who was admitted to the hospital, anytime people came to medical care, they just got an HIV test. We would diagnose people earlier, they could get on antiretroviral therapy earlier. We could prevent more transmissions. And so that was a lot of my early work to demonstrate the value of routine HIV screening. We did that work here in the United States. We did it in resource-limited settings. We did it in South Africa, and we've done it really in many resource-limited settings.
Ralph Ranalli: I'm curious, what did you see in South Africa that was different than here and that …
Rochelle Walensky: The volume.
Ralph Ranalli: ... opened your eyes?
Rochelle Walensky: The volume. So here in the United States, the medical structures are so different, the access to antiretrovirals was so different. But I had not only done testing on the ground, we had done some clinical trials and routine HIV screening in an emergency department, so I knew we were going to find things if we looked and then we can look at the value of that intervention, the cost effectiveness of that intervention. But I had colleagues on the ground that I was working with, mentees, Ingrid Bassett high among them who went to South Africa and said, "There is a lot of HIV infection here, a lot of undiagnosed HIV infection." And I think her earliest study now, back in the early 2000s, people just walking into urgent care for any given thing, broken, sprained ankle, one in three had HIV infection. And so that was really, it was stunning. It was eye-opening. These were times that when we would try and get our collaborators on the phone for a call, calls were routinely canceled for funerals. It was really a striking time. And I give PEPFAR [U.S. President's Emergency Plan for AIDS Relief] a lot of the credit to be able to scale up the HIV therapy around the world, high in South Africa, as well. And it's been astounding to see how much has changed just in my career.
Ralph Ranalli: So you never left AIDS and HIV behind as something as something you cared about, as evidenced by the fact that finally, and I was reading this just today, we finally moved past these restrictions on gay men donating blood, a lot of which was basically based on-
Rochelle Walensky: Old data, old science.
Ralph Ranalli: Old data, old science, and throw in a spoonful of discrimination and prejudice. Can you tell me about what it was like when that finally happened? Because that's been a long journey.
Rochelle Walensky: It has been a long journey. One of the things that I have done in my research career is look at places where either policies or trials or interventions have not served the people who need them well or have not served the population well and really said, what is the core behind this and is this the right reason and can we make a difference here? So we've done that in access to HIV therapy and access to pre-exposure prophylaxis. In 2015, and I am a pretty regular blood donor, and in 2015, I had a particularly hard day on clinical service with my fellow, Robbie Goldstein, Dr. Goldstein, and I said, "It's been a rough day. I think we should just do something to feel good. Let's go give blood." Robbie is a gay man, and he said, "I will go with you, but I can't give."
And he wanted to, it's just that the policies didn't allow him to. And this was now 2015. I had done a lot of work in HIV testing. I knew the time and place for donation bans back in the eighties when we didn't have good tests, we didn't have good screening. But in 2015, where we had nearly perfect tests, and really, a real capacity to understand this disease way better than we did 30 years prior, it just didn't make sense. And so Dr. Hanna Sacks, Robbie Goldstein and I sort of wrote a piece about how we are way behind in this policy. And this policy actually not only serves to discriminate against men who have sex with men, but also importantly eliminates 5 million to 10 million people from blood donations and we are in real need of blood donations right now. I just got a call yesterday asking, again, for me to donate. I just donated. And so it was really something that once I went into the administration and Dr. Goldstein was my senior advisor at the CDC, we felt like we were in a place that we could really make this happen and make a difference. We were certainly not working alone. We worked closely with the FDA, closely with the Assistant Secretary of Health, Dr. Rachel Levine, and we were able to make it happen. And so I am really happy to say that now, appropriately, it's based on risk. It is non-stigmatizing, and it is based on risk.
Ralph Ranalli: So we could probably spend all our time together just kind of picking through your tenure as CDC Director, but you've already given a number of interviews where you've talked through the many decisions and statements you made during tenure and the reasons behind them and why some were controversial. Just for our listeners, I thought the interview you did with the New York Times was pretty thorough, and so I would recommend that one. I’d like us to focus on what your takeaways are from that experience, the big takeaways of the challenges of implementing healthcare policy under difficult circumstances in the middle of a deadly pandemic. What were some of your big takeaways from those 28 months when you were CDC Director?
Rochelle Walensky: It was probably the biggest honor of a lifetime, and probably the hardest thing I will ever do. I came into an agency that most people, prior to the pandemic, I would say, had never heard of. When public health is working and working well, nobody really knows about it. You don't know about the 60 foodborne outbreaks that happened last year necessarily unless it affected your community. You don't know about diseases that were averted because public health was there. Those are not advertised. What I came into was an agency of about 13,000 people who were working tirelessly, who came in having pretty well been thrown under the bus in the prior administration, where morale was low, where they were too feeling the impact of the pandemic. Each of them had their own challenges at home with kids and with parents, and the same concerns that we all were having during the pandemic. And they were continuing to work tirelessly. And we, as a country, relied on them to work tirelessly even under all of those circumstances.
And so it was really a gift for me to be able to represent them and to actually give voice to the incredible work that they did. We had to admit there were lessons that we learned. I like to remind people that CDC is an agency that is 76-years old, and our last pandemic was a hundred years ago. So it's an agency that has never seen an outbreak and a pandemic, the size, scale, and scope of the one that we were faced with. It is also the federal agency for health departments in over 3000 counties, 50 states, many big cities and jurisdictions. And the infrastructure there is highly important, and we learned it was frail. It was not up to the task because it had been under invested for four decades. And so there is a lot of work that we need to do as an agency and as a country to bolster that infrastructure.
Ralph Ranalli: Were you surprised by the extent that politics affected the pandemic response? I'm talking particularly in the earlier years of the pandemic. Coming from an AIDS background, you-
Rochelle Walensky: I've seen this movie.
Ralph Ranalli: We're in the middle of ... You've seen that movie before. But I think throughout our history, one of our American exceptionalism tropes is that we all come together during a crisis. But instead, it felt like we did the opposite. And that probably ended up with a lot of people dying unnecessarily who could have lived. How much worse, in your estimation, did politics make the pandemic and did that, even given your background, did that surprise you?
Rochelle Walensky: When I rewind the clock to early in the pandemic, I remember really beautiful times where people were cheering as healthcare workers left the hospital. I remember notes of thanks for taking care of loved ones. So I know that we were once there and it was heartening, and it was beautiful, and then something shifted. I am not a deeply political person. They hired an academic when they got me, and that's what they got. And so much of what I really tried to do is put my head down and say, what does the science say? And how are we going to move based on what the science says, recognizing it's continuously evolving.
That said, we all have to recognize that health and science is maybe my top priority, but not everybody else's top priority. And that as part of working within a government, we have to recognize that education has to have an important seat at the table, and the economy has to have an important seat at the table and transportation. And we may have to give up some things so that some other things can have a voice. And so I will say that I was disappointed as politics infused more and more—less the word ‘politics’ and more the sort of active efforts to sabotage efforts that were good for health. And that was just hard and disappointing.
Ralph Ranalli: That’s a good point, because I think we do paper over what were actually active efforts to sabotage public health by describing them as political differences. When I read the news about certain people sometimes it feels like there’s some sort of permanent asterisk attached to their names denoting that this person, through their actions, was responsible for this many people dying unnecessarily. There are a lot of situations in politics where people who are political actors do things for reasons other than the right ones, yet it doesn't yield such immediate and lethal human consequences. But in this case, it really did.
Rochelle Walensky: There are studies out there that are poorly done and the data is biased and they will get, if not published, either a white paper, they can find an audience somewhere. And how do you say, this paper in the New England Journal shows this? It went through extensive high-level peer review of the highest caliber while there's another paper out there too. And so it becomes very hard to say, this is truth in science where this is not.
Ralph Ranalli: So I think that kind of touches on messaging. What struck me about the CDC Director's role during a pandemic public health crisis, is that you sort of immediately become to public health what the chairman of the Fed is to the economy, right? Every word you say is hung on and parsed and dissected and scrutinized. And you said you're not a political person. What did you know about messaging at the end of your CDC tenure that you didn't know going in?
Rochelle Walensky: Well, maybe I'll just speak about some of the things that we did and some of the things that we learned, and some of the things that I personally learned. I think I was a couple days in and we started at every other day press conferences. So I think I did nearly a hundred press conferences on COVID during-
Ralph Ranalli: How many press conferences?
Rochelle Walensky: Nearly a hundred.
Ralph Ranalli: How many press conferences had you done in your life before that?
Rochelle Walensky: Yeah, I could count them on maybe one hand. And so we were thrown into it, I was thrown into it, and all of us were. And the importance of having unified messaging, I think, was really clear. One of the things I did when we were here, when I was here for the first year of the pandemic as an infectious disease chief is we had worked together as a number of the infectious disease chiefs across the city to have several op-eds in The Globe to say, this is the unified message of expertise in your city. And so I really recognized the importance of a unified single message. So nobody was trying to dice and split, that we were all singing from the same page, and we were really uniformly speaking from the same page. That was really important.
Among the things that were challenges was this was complicated. The science was evolving every single day. Pre-prints were coming up every single day. Somebody might've read something where somebody else had not. What do you think about this study? I don't know, it was just released an hour ago. And that happened frequently on press conferences. I had been in the studio at the time that the study was released.
The other thing, so the virus was changing, the science was evolving at an incredible speed, and it was complicated. It was scientifically complicated. So if we are supposed to communicate to the American people at a fourth grade reading level, which is what people generally say, talking about the difference between authorization of vaccines and approval of vaccines or what does this rate of myocarditis mean? And oh, by the way, what's myocarditis and what is the background rate of myocarditis? And trying to do that, and then you kind of got a 90-second news clip. So if you tried to speak in the generals, which is what we really wanted to do to speak to the American people, you were missing the nuance. And then people would call you out on the nuance and that became really hard.
Ralph Ranalli: Yeah. So you're here at the Kennedy School on a fellowship with the Women in Public Policy Program. You're also at the law school and the business school, which is quite impressive. One of the things you're studying is women in leadership and the challenges of leadership during difficult times, particularly for women. Did you learn things about yourself during this whole experience?
Rochelle Walensky: Yeah, absolutely. First, let me say, I am not a scholar in women in leadership, and in fact, I'm just a practitioner, if you will. And so part of why I wanted to be here was to learn some of the things that I might've done well and some of the things that I might've done better and what the science is behind it and the people who do this all the time. So it's really a gift for me to be here. While I was a woman in the room, and probably a deep minority woman in the room, I was oftentimes the only woman in some of the Zoom rooms. And I recognize that, and the dynamics were probably different for me than they were for others. It was actually an interesting time because I was so ingrained in the content and the science, what we were doing was so important that that component of it was secondary to me.
There were several meetings that I came out of where somebody said to me, "Did you kind of pick up what just went down and how the dynamics were in that meeting?" And maybe if I had thought about it, I would have, but the content was so very important that that piece of it was secondary. So I almost wish I had a tape of some of those meetings. I do not, just to be very clear. But there are probably some interesting case studies in how some of those meetings went that I don't remember, because what we were doing was so important.
Ralph Ranalli: So you had 28 months at the helm of one of our most important government agencies. At least, we know it is now.
Rochelle Walensky: Yes.
Ralph Ranalli: What insight about the CDC did you gain from that vantage point? And are there things that the CDC does that the public doesn't know about, but should?
Rochelle Walensky: The answer to the last question is most absolutely yes. So I would say over the last three years, CDC is known for its work in COVID, maybe known for its work in Monkeypox and Pox, and maybe also known for its work in infectious diseases and foodborne outbreaks. During my tenure there, we also had an outbreak of Sudan Ebola virus that occurred in Uganda. We had two outbreaks of Marburg virus, a cousin of Ebola at the same time, one in Equatorial Guinea and one in Tanzania. We had a new case of paralytic polio in this country, which we haven't had in years. We had more measles cases than we have had in a very long time. So people do know what we do, what CDC does on an infectious disease front, maybe not even all of that. But there was so much other work that was done, and I think that people don't appreciate what CDC does.
Our work in the opioid epidemic, our work in mental health, our work in maternal mortality, our work in firearm violence prevention, where I do want to bring both sides of, really would welcome the opportunity to bring both sides of the aisle on together, because nobody wants to die at the hands of a firearm. And I think the other hidden gem about what CDC does is its global portfolio. The biosecurity and biosafety of this nation is in some part, and maybe even in large part, to the work that we do at CDC, we have offices in 60 different countries. I had the great honor of visiting at least four of them where people are working constantly to avert bio threats in those countries and then it coming to the United States. We had an office in Kyiv that, during the conflict, helped to continue people on TB meds, on their antiretroviral therapy for HIV, even in the middle of the conflict, relocated to Georgia.
We have an office in Haiti, during the conflict in Haiti, and real challenges there. We have an office in the Congo where there's a lot of work happening in Ebola prevention there, and really, all over the world. And so when we think about what we call disease detectives here in the United States, not only do we have them all over the world, but those are the people who are actually training the disease detectives in country. And when we look at how COVID rolled out, for example, in Uganda, and I had the great gift of being there, they will tell me it was the HIV infrastructure, the testing infrastructure that they quickly pivoted to COVID testing. So they had rapid scale-up of COVID testing. It was the disease detectives that we had helped train that were able to do that work on COVID. And it was because of our longstanding collaboration and commitment in those countries and training in those countries that they were able to really scale-up and succeed. So it's a gift to work alongside those countries and to be there in partnership, in deep partnership where they're in the lead, but it's really among the greatest things that I think CDC does.
Ralph Ranalli: So what are the things that need to be done to apply the lessons that we've just learned and to make the CDC into what it needs to be for all of us for the future?
Rochelle Walensky: Right. So in April of '22, just after we had endured the Omicron surge, one of the things that I did is say, we need to really look at this internally. We need to put a mirror up and say, what did we do well? What do we need to learn from? And we put out a report in August of that year and had spent, we called it CDC Moving Forward, and spent the rest of my tenure really enacting that report. There were many lessons learned. One is that CDC had become, and is, we rely on CDC science, but it became more of an academic place and really needed to be more of a science-driven but rapid moving science. So we needed to get our science and data out faster. It was less about the publication and more about getting it out faster. It had to be corroborated. It couldn't be capricious, but we had to get it out to the public faster.
We needed to translate the science that we were saying into a policy, into implementable policies. And I like to say that those policies had to work in Manhattan, and they had to work in Boston and they had to work in Guam and they have to work in Indian country Alaska, and they have to work in rural Idaho. And having singular policies may not work in all of those places. So we needed policies that could potentially work in any of those places or scalable policies. We needed to communicate to the public. CDC had historically been communicating to our partners. Those were our audiences. The public never came to our website. All of a sudden, the public was coming to the CDC website, reading our school guidance. And so that was something that was, really, needed. And if you look at our school guidance and how it evolved over time, it was much more accessible to the American public to what became our user.
And then we really needed to rely on partnerships. And we needed to bolster those partnerships not only with public health, but with community-based organizations, faith-based organizations, the messengers for everybody who may not be coming to CDC itself, but who are our effector arms of the work that we're trying to do. And then finally, we really needed a workforce, a response ready workforce. We needed to be the FEMA of public health, if you will. When there was a disaster, we needed to be able to activate. And we have always been able to do that, sending a dozen people here or two dozen people there, but we had 2,500 people in a response at a given time. And that's a heavy lift for the agency the size that CDC is.
Maybe one final thing I will say, and that is, we did a lot of work thinking about how we needed to make the agency stronger. And among the things we also recognized is that CDC alone can't do it. That there are many things that we need congressional help, CDC needs congressional help with. And that includes some of the authorities that we don't have, that CDC doesn't have. So for example, data comes into CDC from 3000 counties, 574 tribes voluntarily. If that data does not come in voluntarily, we cannot see it. CDC can't see it. And so we need some authorities to be able to say what gets reported when and how. Similarly for human resource authorities, how we're able to activate human resources to deploy in case of an emergency.
Ralph Ranalli: So you mentioned Haiti, and Paul Farmer famously said that public health and social justice go hand in hand. And a lot of the places you mentioned where public health needs to work and you need to have a response. Some of those very rich places, some of those are very much less so. And there was a lot of, I think, critical news that came out during the pandemic about the rollout of vaccines going to places where the wealthier people lived and not where people who were underserved by the public health systems did. What needs to change in terms of addressing those inequities in order for us to have a public health system that really works?
Rochelle Walensky: First, you can't mention Paul Farmer without my just commenting on what a massive loss and what a huge giant he has been for all of us, and North Star, he has been for all of us and how we all work to follow his lead.
Ralph Ranalli: He was an extraordinary man.
Rochelle Walensky: Extraordinary. When I came in on January 20th, 2021, there was no plan for a vaccine rollout. And in fact, I will say that is in the context of an infrastructure where we in this country do not have what I will call a vaccines for adults program, which has been on the presidential budget for the last two years. There is no mechanism to vaccinate adults in this country. And so that is something that actually, I think, would be really critically important. There are 23 million uninsured adults in this country. There is no mechanism to vaccinate them. It is why we needed bridge programs and other programs during COVID is because there is no capacity. So at the get-go, we need something that will actually allow us to do this the next time because that has not been fixed. So as vaccines were rolling out, one of the things that we really did was we said, and you recall the big vaccine tents, the mass vaccination sites, we actually strategically planted them in places that had high social vulnerability indices.
So CDC has a social vulnerability index, and we could plant them in places where we knew that people had a harder time getting access. We also put vaccine in our federal retail pharmacy program. So early on when there was a resource constraint on the vaccine itself, it was very hard. As soon as we had more vaccine, we were able to actually really strategically place it. The federal pharmacy program allowed, I think, almost all Americans to live within five miles of a vaccine site. So that was really critically important. And we enrolled pharmacy partners to make that possible. Now, five miles still is too far for some people, and we recognized that. And so then we went to other community-based organizations, but there was real intentionality in a whole of government response to get vaccine to the places that people were not getting it.
I was in Dalton, Georgia, Northwest Georgia, and I remember hearing about access issues, and I believe it was there where we were hearing from the Hispanic community and they said, well, the Hispanic elderly were relying on their teenagers to both translate for them and also convey to them that this was important. They had the technology, they had it on their phones, and they had the language. They could address the language issues. So if we wanted to get an elderly Hispanic population vaccinated, we needed to do TikTok for our Hispanic teenagers.
Ralph Ranalli: That is so counterintuitive.
Rochelle Walensky: Right, exactly. So those were the things that we learned by being on the ground and talking to the community. And they worked once we started, but that's really hard work and it is community by community. And what might work in Dalton, Georgia may not work somewhere else.
Ralph Ranalli: I wanted to go back to what you said about what you described as the frailty of the public health system. Can you talk a little bit about that? How do those frailties manifest themselves? Where are they and what's their potential risk?
Rochelle Walensky: I like to, and do recognize that public health will only be as good as the infrastructure upon which it's built. I divide those frailties into three components. One is the workforce. There was a de Beaumont Foundation estimate that the public health workforce now is about 80,000 persons in deficit, to just do basic public health across this country, 80,000.
Ralph Ranalli: Wow.
Rochelle Walensky: So we need incentives for people to go into public health. And if you look at the last three years, people were not incentivized necessarily. They were traumatized, and in fact, many people resigned from public health. Now, some public health school applications are up, but across the skillsets, we need people who are really invested in public health. We need loan repayment for public health. We need incentives for people to be out in public health deserts, if you will, to really incentivize people to go into public health.
The second is our data infrastructure. And that was eye-opening for me. Data flow in from so many different places into the agency and the highways don't connect. We would sometimes get data by fax. We would get them by, and I wish I were kidding, we've still got data. The CDC, to this day, gets data by fax for some of its information. So whether you get it by fax or by Excel or by email, you wouldn't order a Starbucks coffee that way. So we need data highways that connect, and we made huge progress for connecting those data highways, but it was behind and we're not where we need to be for the infrastructure. So the data highway is a really important one.
And then finally, the laboratory infrastructure. And I think all of the public saw the frailty of the laboratory infrastructure. CDC, obviously, had some challenges early in the pandemic prior to my being there, prior to this administration with the rollout of the test. CDC is not an agency whose role it is to provide America with a million tests a day for COVID. And so how do we think about an infrastructure, a laboratory infrastructure in this country that works? People are very interested in wastewater, they're very interested in genomic sequencing. Do we have the investments in our laboratory infrastructure to be able to do all those things, not just in Boston, not just in New York, and perhaps in Boise, Idaho, but perhaps in more rural areas? Do we have all that infrastructure that's necessary? And the upskilled people to actually do genomic sequencing?
Ralph Ranalli: So we've identified a lot of issues, and this is the point in the podcast where we put the policy in PolicyCast. I want to ask you, do you have a couple of specific concrete policy recommendations that our listeners can get behind and support and however they might be able to in a way that would help make the public health system better and address some of the vulnerabilities that we've talked about?
Rochelle Walensky: Yeah, I will list three, and I've already named them, but I'll sort of be more concrete. I do think we need a ‘vaccines for adults’ program. Among the last things I did as CDC Director was write a piece in the New England Journal with our vaccine experts at CDC and say, we in this country don't have the capacity to vaccinate the most vulnerable, those who are uninsured. Vaccines generally work for infectious threats. Infectious threats don't generally respect social vulnerabilities, so we are all at risk if we don't have the capacity to vaccinate that population, and it's the right thing to do. So a ‘vaccine for adults program’, I think, would be really critically important.
The other two are related to authorities at CDC, the human resource authorities. We talked a little bit about that, there are people, public health civil servants who are working at CDC, who are then deployed to Mubende, Uganda to work on an Ebola outbreak and don't get hazard pay, might not get overtime pay. All of those things are not tenable to, or don't get loan repayment for their many loans when they could be earning higher salaries, much higher salaries in other places, is not going to recruit the kinds of people that we need to continue this work in public health.
And then finally, the data authorities. And please understand, I am all for privacy protection. I want to do this in a protected way, but if the data does not come into the agency, the agency will start behind. And so we have to be able to see data coming in. I can tell you numerous examples where I knew the data existed and a better decision could have been made if I had the data, but it didn't have the data to make it.
Ralph Ranalli: Well, Rochelle Walensky, thank you very much for being here. This was a really interesting conversation and I appreciate your time.
Rochelle Walensky: Thank you so much for having me.
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