CDC system misses the point, where should we go after the epidemic is over?
Originally Posted by DXY DINGXIANGYUAN
Throughout this new crown pneumonia outbreak, the Chinese Center for Disease Control and Prevention (CDC) has played a pivotal role. This institution, which is directly under the National Health and Wellness Commission, has been put on the front burner of public opinion precisely because of its performance in this epidemic.
From the CDC experts' conclusion early in the outbreak that "no significant human-to-human transmission was found" and "limited human-to-human transmission cannot be ruled out" for the new coronavirus, to the failure of the nationwide direct reporting system of the infectious disease network, various issues have sparked heated debates.
So, in this major public health event, is the capacity of the CDC related to the efficiency of outbreak prevention and control? How do we view the 30-year history of CDC reform? Where should it go after the epidemic is over?
Professor Chen Zhuo is invited to answer our questions. Chen Zhuo was a senior economist at the CDC and has unique insights into the structure, functions and other knowledge areas of the CDC in China and the US.
The following is the main content of the conversation.
Clove: At a press conference on February 27, Zhong NanGong said that the epidemic spread because "the status of CDC in China is too low, it is only a technical department under the leadership of the Health and Welfare Commission. In the U.S., the CDC can go straight to the central government and does not need to make declarations at any level, and can even make direct announcements to the community in special cases. Do you agree with this view, and is there a direct relationship between the CDC's capacity and the efficiency of outbreak prevention and control?
Chen Zhuo: I strongly agree with Zhong's viewpoint.
We can assess the capacity of CDC in four dimensions: function, budget, personnel and structure.
First, in China CDC is a career agency, a social service organization, and a department that implements government CDC services. It often gives the impression of having a weak bottom line when it comes to performing government functions such as isolation and coordinating infectious disease control.
In the United States, the federal CDC, as a federal government agency, has the authority by law to enforce inbound quarantine and isolation, and also has statutory investigative authority for outbreaks of infectious diseases that cross state lines. For example, after the outbreak of novel coronavirus pneumonia, the CDC sent employees to enforce entry quarantine at major airports.
We can also make a comparison in terms of budget and staff. The U.S. CDC's budget for 2019 is $6.6 billion, plus $4.8 billion for the Low Income Program immunization program. I couldn't find the CDC budget for the same period, but the 2019 budget for the CDC, its agencies, institutions, and hospitals is only 22 billion RMB, or less than $3.2 billion. This comparison surprised even me, a health policy person, when I looked at it.
In terms of staff, the CDC has 11,195 permanent staff plus 3,000 to 5,000 contract workers, while the CDC has only 2,120 (2016 data). Some would argue that there is only one U.S. CDC, while China has many CDCs at the provincial, city, and county levels, totaling about 193,000 people.
This view lacks sufficient understanding of the U.S. public health system.
State health departments and county and city health departments in the United States also have agencies that do CDC-related work, but they generally do not use the name CDC. The only exception is probably the Maine CDC.
When I worked for the CDC, I was involved in the U.S. public health workforce statistics. At the state level, the American Association of State and Territorial Health Officials (ASTHO) gave a 2011 count of 103,267, and the National Association of County and City Health Officials (NACCHO) gave a count of about 184,000 public health workers at the county and city level.
In addition, there is a broader definition of public health practitioners at the federal level that includes approximately 216,056 public health-related practitioners in CDC, NIH, Veterans Health Services, and other units. Consider also that our national CDC serves 1.4 billion people, more than four times that of the United States!
In terms of organizational structure, I think there is room for improvement in the organizational structure of our national CDC. For example, the NCDC only has operational guidance authority over local CDCs, while other aspects are under the control of local health committees, which creates difficulties in coordination during an epidemic, such as inconsistent policy steps.
In this regard, we can also compare with the US CDC.
In the U.S., state funds (for public health) are allocated to local health bureaus through the U.S. federal CDC in the form of programs, and the federal CDC contracts with the local health bureaus and then transfers the funds to them.
In this process, local health departments must meet certain conditions of the federal CDC. Thus, the federal CDC can reflect their ideas, philosophies, and policy priorities in the program, guiding the local health department to do something specific. For example, if some localities lack some resources in public health, then the federal CDC will require the local health department to use those funds to focus on public health capacity building. In this way, the CDC can maintain coordination between their work and that of the local health department.
Also, I think that health communication is part of public health. The WHO and the U.S. have a concept of "Healthin All Policies," and we can have health reflected in all policies. I think China has the potential to do this even better than other countries.
CDC staff in the lab
Photo credit: Station Cool Helo
DINGXIAN: Do you think China CDC should have greater power?
Chen Zhuo: Yes.
Public health events tend to move the whole body, and local epidemics can quickly evolve into national or even global relevance in this era of greatly increased human mobility. The country is fortunate to have a strong CDC system to coordinate and respond.
Some examples from the U.S. CDC and the Department of Health can be considered. At the institutional level, the U.S. CDC Office of Emergency Response currently has a staff of 485 and plays a key role in major public events. When necessary, such as in the current COVID-19 emergency, the CDC can pull personnel from centers and offices to participate in emergency dispatch and front-line work.
For particularly critical public health events, the U.S. Department of Health can mobilize an unarmed Public Health Service Commissioned Corps (PSC) under its umbrella.
This unit is unarmed, mostly with health backgrounds, and usually works in various agencies on a day-to-day basis, but the personnel system partially follows that of the Navy, with a unique ranking and promotion system and the ability to retire or rehire after 20 years of service. The Public Health Service can be mobilized to participate directly in emergency response activities during emergencies, such as the Hurricane Katrina season, when more than 2,000 U.S. Public Health Service troops were deployed.
Clove: After 2003, the direct reporting system built by China's CDC at a cost of hundreds of millions of dollars did not work for nearly a month in the early days. How do you see the interface between CDC and hospitals?
Chen Zhuo: The reason for this is actually explained very clearly by the CDC: COVID-19 is a new disease and is not in the system. The direct reporting system started to work after the country defined it as a Class B infectious disease and Class A disposal.
Also could have used the pathway of unexplained pneumonia, but unexplained pneumonia is usually a lot, clinicians if each time to report too many false alarms, the system on the doctors themselves consume too much energy, and over time we have laxity, in favor of this time to miss the real situation. It is also important to find ways to improve the sensitivity and accuracy of the system, which involves not only the hardware, but also the software and personnel training.
In the future, on the one hand, the people using the system should be trained to perform the reporting work in a solid and uncompromising manner; on the other hand, a reward and punishment mechanism for the reporting of public health information can be established, with awards for timely and accurate reporting units and individuals, and corresponding penalties for those who do not report. I think there should be regulations on this, but the focus is on how to put it into practice, which needs to be further promoted by the state.
CDC can also be linked to hospital infection control and prevention, and it would be better if it could be promoted together with hospitals. This is not just an epidemic, but also a problem in the future.
China CDC main entrance
Image source: CDC official website
Clove: In the early 1990s, epidemic prevention was gradually pushed to the market; after the SARS epidemic in 2003, the CDC was clearly a state-funded unit; in 2009, the new health care reform, the CDC system did not seize the opportunity to serve grassroots public health. How do you see the transformation of China's CDC over the past 30 years?
Chen Zhuo: Whether basic public health services should be undertaken by the CDC system is a question worth thinking about. What are the pros and cons of having the CDC take over basic public services?
The pros are that it could be a turning point in the development of the CDC system, transforming the CDC organization into a national implementation agency and giving the whole system a new look. And, the CDC system has an advantage in epidemiological investigations. However, how the CDC system is going to take on basic public health services is a considerable problem, with considerable demands, and will be a daunting challenge for CDC.
The CDC was only formally established in 2002 and is a relatively new institution. It faces the problem of integrating the Academy of Preventive Medicine and the epidemic prevention station system after its establishment, a process that also takes time.
Clove: Some experts believe that some of the current work of the CDC can be divided and put on the market for the government to purchase services, do you agree with this view?
Chen Zhuo: I think some work can indeed be done this way, but not all work can be put on the market. For example, some of the computer systems of the CDC can be outsourced to technology companies, which are more professional; however, the work related to the core functions of the CDC needs to be reserved.
Clove: Some scholars have proposed three principles for CDC reform in response to the structural problems in the current functional settings of CDC - professional decision-making (let those who know have the right authority to do the right thing), transactional centralization and global participation, do you think this view has practicality?
Chen Zhuo: I agree with what he said about professional decision-making.
In the U.S., there are also many professional committees, such as organizations like the National Advisory Committee on Vaccination Professionals (ACIP) and the U.S. Community Prevention Guidance Group (USCommunity Guide). They are independent, nongovernmental committees that are organized and run by US CDC staff, but most of its members are not government people, but professionals from around the country. These professionals provide guidance on public health issues, and then CDC staff analyze these opinions, and the committee members vote to make decisions based on the results of their analysis.
Screenshot from the CDC website
For example, the CDC for Africa is a collaborative effort between the U.S. and Chinese CDCs to support the establishment of a global capacity for the prevention and detection of emerging infectious diseases in areas of global health vulnerability. However, the scholar said that it might be idealistic to involve other countries and WHO in the reform of the CDC in China, because it is unlikely that a sovereign country would allow other countries and institutions to vote and intervene in these matters.
Clove: Where do you think China's health care reform is headed after the epidemic is over?
Chen Zhuo: China's health care reform, like that of any large country of similar size, will be a complex and long process. I can only pick the areas I am familiar with to give my thoughts.
First, graded care should continue to advance. I suspect that some of the infections and deaths in Wuhan are due to panic and the crowding of medical resources. In a panic situation flu patients and other patients with similar symptoms flocked to the hospital, providing an opportunity for cross-infection. If graded care is used, problems may be identified at some points, and a run on medical resources is less likely to occur.
Second, hospital management can be further improved, especially the protection and reduction of nosocomial infections. Cooperation between health insurance and medical management is needed to motivate the hospital system to reduce the rate of hospital-acquired infections.
Third, education on prevention should reach the general public, and influenza vaccination should be further promoted. Again, multi-sectoral collaboration is equally important.
Fourth, and last but not least, there should be more sustained investment in public health and disease control. Public health and CDC are doing prevention, and often the better they do, the less they see their importance. We call for more young people doing health policy and health economics to invest in public health to measure and evaluate the effectiveness of public health and CDC.
Author: Chenjin Shi
Title image credit: Station Cool Helo
