CDC Is Not To Blame For Ebola Cases

The recent Ebola cases and fatality have triggered a collective process of finger pointing as we struggle to understand events and hold someone accountable.

In the desire to pin the blame somewhere, notably the Centers for Disease Control and Prevention (CDC), we overlook the essential fact that in the United States public health responsibilities are fragmented among federal agencies, and decentralized throughout state and local government. 

Let’s look at one of the most basic public health functions – disease surveillance and reporting. Reporting is the first step in preventing and controlling the spread of disease. We need to know about cases before we can take actions. One would think it would be mandatory. Not so. The US National Notifiable Diseases Surveillance System or NNDSS) is VOLUNTARY.

The CDC role in this system is not voluntary, but is limited to receiving reports from states and publishing the data in an annual report.

Are states required to report notifiable diseases to the CDC? It is actually entirely voluntary. THAT means that the state and local governments decide and mandate the data that are to be collected, not the CDC. The CDC works within this voluntary network to assemble and publish the best data it can.

The CDC is fundamentally an information organization. It conducts scientific investigations, analyzes laboratory samples, designs systems for collecting data, prepares and distributes information, publishes reports, and makes recommendations. It has relatively few powers. Authority to close down a restaurant? Local health departments. Authority to close a poultry plant? The U.S. Department of Agriculture. Authority to recall a food item from the supermarket shelves? FDA, and, if it is a meat product, Agriculture. 

What about the authorities to mandate that hospitals train their staff in safe procedures for treating Ebola? While the CDC can recommend a certain level of preparedness, it does not have the powers to conduct audits or enforce recommendations. The level of preparedness at hospitals throughout the nation depends largely on decisions taken by hospital administrators to implement CDC recommendations, but there is no process in place to evaluate implementation or to correct inadequate implementation. Our only method of identifying non-adherence to recommendations is the occurrence of a major failure such as the one we have seen at the hospital in Dallas.

THE CDC works effectively with states that value its input. In a foodborne outbreak, for example, states have the option of inviting the CDC to help it manage the outbreak – or not. When an outbreak is contained within state lines, the state health department is not required to call on the CDC, and not even required to report the outbreak – and some states don’t. As a result, the US has a calico pattern of statistics regarding foodborne outbreaks. States with strong food safety programs take a proactive approach to tracking down and identifying outbreaks, request CDC assistance with investigations, and report the outbreaks to the CDC; other states do just the opposite.

So, States with strong food safety programs have high rates of reported outbreaks! States with weak programs or no interest in reporting show few reported outbreaks.The pattern of fragmentation and decentralization is not limited to data reporting, but is repeated over and over throughout our healthcare system and public health infrastructure.

The rewards in public health are the rewards of doing interesting and important work. Every CDC employee (or ex-employee) that I have ever known works with amazing dedication and takes their responsibilities with the utmost seriousness. All see themselves as public servants, and I have never heard any of them complain about the lack of resources or any other aspect of their work. Blaming the CDC for our unpreparedness in the face of Ebola is probably the least productive thing we can do right now. Instead, we need to strengthen all the pieces of our decentralized public health network so that every American is protected in times of public health emergencies. Expecting an agency with relatively limited powers, such as the CDC, to be held accountable for failures in a decentralized network won’t get us where we want to be.

Tamar Lasky is an epidemiology and public health consultant. A version of this article originally appeared on The Health Care Blog.