Rochelle Walensky served as the 19th Director of the Centers for Disease Control and Prevention under President Joe Biden from 2021 to 2023, where she played a central role in shaping the U.S. response to COVID-19. Prior to joining the CDC, Dr. Walensky was Chief of Infectious Diseases at Massachusetts General Hospital. The Harvard Political Review sat down with Dr. Walensky to discuss the structural demands of the U.S. healthcare system, the evolution of public trust, and the international soft power of global health diplomacy.
This interview has been edited for length and clarity.
Harvard Political Review: Several public health recommendations changed multiple times during the pandemic. Do you think those shifts reflected evolving science, communication challenges, or external pressure? How did you balance scientific uncertainty with the need for clear public guidance and maintaining the CDC’s credibility?
Rochelle Walensky: Certainly, the science evolved dramatically during those two years. I mean, thousands of papers were written during those two years, and as we were learning, we had to work in real time. I think it was my responsibility to pivot when we learned more, different, or new.
The other challenge is that the virus also changed dramatically. We initially had the ancestral strain from about March until December of 2020, but by January of 2021, we had the Alpha strain. By the summer of 2021, we had the Delta strain, and by the winter of 2021, we had the Omicron strain. Each of those strains worked differently and responded differently to our medical countermeasures. In that context, with evolving science and evolving viruses, I think it would be irresponsible for us to not change when we learned more and the virus evolved.
What you then have to do when you are in that position with that responsibility is bring the public along and make sure that as your policy and recommendations are changing, they understand why. We had forces working against us that very much wanted to frame it as “you’re flip-flopping,” “you’re pivoting,” “you were wrong before,” so there was a lot of that resistance.
I can appreciate a public that very much wants stability and control. And so not only was there a communication resistance, but people wanted things to not change because they really wanted to understand, and that was very hard at that moment. So I don’t deny that there were dramatic communications challenges, but I would say that when we had to alter course, it was generally in the context of either more science or a different virus.
HPR: What kept you up at night during the height of the pandemic? Looking back, how do you evaluate whether the pandemic response ultimately succeeded or failed?
RW: It really depended on the period of time. My first year of the pandemic was spent at a hospital in Boston, helping to manage patients and a full faculty of infectious disease experts, while working with the incident management team and the state. It’s hard to recap what things worry you when you walk to work and there’s a morgue truck outside. It was heavy. It was awful.
I had never thought I would read a document of crisis standards of care as it was relevant to my own hospital decisions about who will get a ventilator, about how patients get triaged. I had a set of heavy decisions. I used to say, and continue to say, that when you were in a position like mine and you were asked to make a decision, it was because nobody below you could make that decision. And if nobody below you can make that decision, it was because there were going to be losers with every decision you made. So you had to rapidly pivot to get a sense of where you could do the greatest good for the greatest number of people, but that necessarily meant that somebody wasn’t going to get something, which was heavy.
HPR: The pandemic exposed weaknesses in public health structures across the U.S. Were we aware of these deficiencies previously, and if so, why had they not been addressed and what has been done since then to address them?
RW: We who work in public health and healthcare knew very much about the infrastructure challenges in our public health system in this country, and I will name three big ones. One is workforce: Before the pandemic, it has been estimated that the public health workforce in the country was about 80,000 persons in deficit before just to do the day-to-day work of public health.
We also had a laboratory challenge. If there was a case of Ebola that landed in Texas and then they took an internal flight to Montana, is there a laboratory anywhere near where that person lands that can actually do an Ebola test? And if there is, are the laboratorians there? Do they have the technology that does those tests? Do they have laboratory workers who can actually perform that test with the precision and accuracy that it merits? So there’s a laboratory infrastructure challenge that we have in this country.
And then the third, which I want to focus on the most, is the data infrastructure challenges. When I arrived at the CDC, we were receiving COVID data from across the country by fax, by Excel, by email, by phone call. The data highways in this country are really frail and underdeveloped in ways such that if Coca-Cola was trying to send data those ways, they’d never succeed in the industry or as a company. We really tried to work in our data modernization, recognizing that the reason we needed data from Israel and the UK on how vaccines were working is because their data systems connected, and ours did not. I would call hospitals and say, can you tell me who is vaccinated? And they’d say, “Well, the vaccine data are in the public health departments, and our hospitalization data are in the hospitals.” They don’t talk to each other, so it’s hard to answer those questions.
So we spent a lot of time working to modernize our data systems, and one of the real challenges is the political will to actually get the resources in all three of those domains to make that possible. During my tenure at CDC, we had received about a billion dollars to modernize our data systems across the country. And while that sounds like a lot of money, I had single counties that needed a billion dollars to modernize the data system.
Why do counties need so much? When major health systems like the one here in Boston, MGB, transferred to the electronic health record Epic, it cost them $1.2 billion. So we were putting this incredible effort to try and modernize our data systems, and that work was ongoing, and it was starting to take off. It had a long way to go, and it certainly was massively underfunded. Estimates are that we needed $12-15 billion to do it. And of course, now there is no political will to invest in this. So much of the headway that we’ve made has either stalled or regressed because of that.
HPR: What do you think is currently the biggest challenge or threat to public health in the United States?
RW: All of that I just talked about: the data infrastructure, the laboratory infrastructure, the workforce infrastructure. I said that as I was working for the CDC in 2023 and now we’re in a whole different place. All of those things remain true, and we’ve regressed. We’ve lost people, we’ve lost an incredible amount of institutional knowledge. We’ve lost massive expertise in many different places, both through the firing of public health officials, the retreat from the profession, and people leaving with really specific areas of expertise.
When the monkeypox outbreak started, most people had never seen a case of monkeypox. I had never seen a case of monkeypox. But we had people in the agency who’d spent their entire career working on monkeypox, so when we needed to ramp up our monkeypox response, we had the expertise in no time, because we had people who had spent their career working in Nigeria and the Congo on these outbreaks. They understood how the labs work, understood the medical countermeasures we need, and understood transmission, because that’s what they had done, and that’s sort of the magic of the CDC that I had the honor to direct. But a lot of that has left.
The brand has been hijacked for political purposes when there’s massive amounts of civil servants who still have the expertise but have lost the brand name for what CDC expertise does around the world. Right now, it does feel like there are two CDCs. There are the thousands of civil servants who’ve been working there and still continue to offer extraordinary advice and recommendations and scientific subject matter expertise across the country and across the world. Their voice has been silenced and there’s now the other CDC that is, I think, being utilized for political purposes.
HPR: Countries increasingly use health assistance and vaccine distribution as tools of international influence. What role should U.S. global health initiatives play in maintaining American soft power, especially as other powers expand their own health diplomacy?
RW: I think health diplomacy is just a remarkable way to contribute. And we had such an incredible stature globally. I had the great gift of traveling the world to watch it. When I entered certain rooms and certain embassies around the world, people would say “it was the CDC team that we listened to,” “we were so grateful to have the CDC people here.”
Just the fund of knowledge that we were able to offer — knowledge is the power to control things — like in Uganda was impactful. They said that the work that we had done in ramping up HIV testing for PEPFAR [President’s Emergency Plan for AIDS Relief] gave them the capacity through the HIV test to ramp up COVID tests extraordinarily quickly. So it didn’t just manifest in the work that we were doing in any given disease, but they could then pivot that work and use it in another disease at a time they needed it the most.
We certainly here in the United States, and certainly people who don’t work in a health space, probably do underestimate the value of that soft power. Tragically, I think that we are losing and have lost that credibility. You get to be in these communities on the ground and earn that trust. Once you withdraw it or betray it, once you have people who are on HIV meds and you are withdrawing their lifeline, that trust goes away very quickly, and I think it’s going to be very difficult to replace or return.
Publisher
