Former top officials at the US Centers for Disease Control and Prevention (CDC) warn that the rapid dismantling of the US public health system has left the nation less prepared to prevent, identify, and halt infectious disease outbreaks than before the Covid-19 pandemic. A series of health challenges—including hantavirus, screwworm, Ebola, cyclospora, measles, whooping cough, and bird flu—are exposing widening gaps in America's ability to respond.
Staffing and funding cuts cripple CDC capacity
Dan Jernigan, former director of the CDC's National Center for Emerging and Zoonotic Infectious Diseases, said: "Are we ready for the next big pandemic? My answer is no." Debra Houry, former chief medical officer of the CDC, told the Guardian: "Unfortunately, we're really moving in the wrong direction."
Approximately 80% of senior leadership positions at the CDC still have no permanent officials appointed, and between 25% and 30% of the CDC's entire staff are gone. "Those are boots on the ground," Houry said. "When you have Ebola, hantavirus, measles, and throw cyclospora in there—staffers were already spread thin, and now they're spread even more thin."
Loss of parasitic disease expertise
When the Trump administration effectively dismantled the US Agency for International Development (USAID) last year, the CDC lost around $40 million in funding to fight malaria and neglected tropical diseases. This resulted in 35 of 73 employees being laid off from those divisions. The program clawed back $4 million but faces an uncertain future. The laid-off employees were some of the premier experts in the US on all parasites, not just malaria.
"We're not where we would have been with parasitic diseases because of the changes that happened to USAID," Jernigan said. "The laboratory methods you use and the expertise and the microscopy and all of that stuff is the same… So the expertise in parasitic diseases has dropped." The CDC laboratory specializing in cyclospora has fallen from 11 people to three. Similarly, few mpox and Ebola experts remain on staff.
Funding cuts for mRNA vaccines and state-level restrictions
Millions in funding for mRNA vaccines, which would be "significant" for battling the next pandemic, have been cut, Jernigan said. More than half of US states have passed laws limiting public health actions during emergencies. Outbreaks are intensifying; the US just surpassed last year's measles tally.
"There's all these unintended, or intended, consequences that impact health in America and around the world," Houry said.
Ideological approaches create confusion
Jernigan noted that leaders' ideological approaches worsen the confusion. "When confronted with complex situations where decisions need to be made quickly, their gut response might be one driven by ideology rather than by what the data is actually showing. So in that sense, you might then get wildly different answers from different people that are having to make those decisions," he said. "Without that clarity and hierarchy within a big response, you're going to end up with uncoordinated activities and interventions."
For example, during the hantavirus outbreak, officials first said passengers from the MV Hondius could quarantine at home, but then required some to stay in a biocontainment facility. Robert F. Kennedy Jr., secretary of the US Department of Health and Human Services (HHS), overruled a CDC medical officer who said home quarantine was sufficient.
Ebola monitoring and conflicting guidance
Between 100 and 150 people land in the US every day and need to be monitored for Ebola by public health departments. New travel guidance adds confusion: American travelers from the Democratic Republic of Congo must quarantine in a third country for three weeks, but travelers from the region must also monitor for symptoms for three weeks after entering the US. It is unclear if both requirements apply.
"It's difficult for states to implement this guidance that isn't based on science and often not on logic, coupled with the staffing and budget cuts," Houry said, calling this a "precarious" time for public health.
Long-term rebuilding needed
Those who remain at the CDC are working hard, but their ability to manage complex crises has been compromised. "When you've got 30% less workforce, that's 30% less people able to respond, and when you're losing specific experts with backgrounds in some of these rare diseases, there's not the capacity then," Houry said. It will take time to rebuild that expertise even when the CDC is re-funded.
Cuts under the so-called "Department of Government Efficiency" (Doge) ended a program to bring in early-career laboratory and epidemiology staff, but some employees also retired early or left and were not replaced. "We lost a lot of our lab scientists, and some of our specialized experts on things like rabies—those you can't replace overnight," Houry said.
While officials have focused on returning the CDC to its size before Covid, Houry argued the pandemic revealed the need for expansion. "During the Covid pandemic, that's where we saw we didn't have enough staff to go around the nation to respond to outbreaks, and public health was already significantly understaffed in state and local health departments. It was a time to try to get right-sized, not oversized. And unfortunately, reverting back to more of the 2019 size leaves us woefully underprepared to respond to outbreaks, as we're seeing."
Regional alliances fill the gap
In the absence and confusion of federal leadership, other organizations are stepping in. The Association of State and Territorial Health Officers coordinates regular calls for state health officials, and regional organizations like the Northeast Public Health Collaborative and the West Coast Health Alliance—for which Houry is a consultant—have formed to collaborate on vaccination and crisis management.
"Now you're starting to see more regional alliances forming to better track things," Houry said. "Like with measles—we very much see that it doesn't stay within a city or state. So as a result of this moment, we're seeing others step in to fill the gap."
