Opinion | C.D.C. Director Mandy Cohen on Avian Flu and Public Mistrust

The editorial board and our colleagues in Times Opinion met on Monday with Dr. Mandy Cohen, who became the director for the Centers for Disease Control and Prevention last year. Dr. Cohen was the top public health official in North Carolina during the Covid pandemic, winning praise for working with Gov. Roy Cooper to steer the state’s response without allowing it to become politicized.

She wants the C.D.C. to be prepared for the next big public health challenge “in a disease-agnostic way,” rather than focusing on a specific threat, like avian flu, dengue or an as yet unknown pathogen. We also talked to her about how to address Americans’ persistent mistrust of big institutions and how the 2024 presidential election might affect her future and that of the roughly 13,000 employees she leads.

Following is an edited transcript of the conversation.

Mandy Cohen: I thought I would start by just doing a quick “What do we focus on for 2024 at C.D.C.?” The first is to be ready to respond no matter the health threat — that might be something like avian flu or it might be something like drowning.

So we’re spending a lot of time making sure that we are having the core capabilities, the data infrastructure and laboratory capability, the talented work force, and the response capability to actually respond. And that is different from what the agency has done in the past. We are really planning as one team in a disease-agnostic way.

The two other areas of focus are where we’re just seeing a lot of challenges. One is making sure we’re improving mental health. We lost over 100,000 people to overdose and more than 50,000 to suicide just last year. And so we’re wanting to make sure we’re bringing our data and expertise and our investments to bear on that issue.

And the last place of focus is supporting young families. C.D.C.’s known for responding to things like viruses, but the C.D.C. has a really big focus on protecting health and improving lives globally. And that means thinking about starting as early as we can to make sure that folks are setting their lifelong health patterns.

So just to back up, because I don’t know how much everyone’s following avian flu, but the top line is that the overall risk to the public for avian flu continues to be low. We’ve built our laboratory capacity, we’ve built our data capacity. So we’re utilizing all that now, and then the good news is, you know, we’ve only seen one human case of avian flu. It was mild; that person recovered well.

And we haven’t seen any human-to-human spread of avian flu in the United States, but we have been following avian flu globally for quite some time.

Zeynep Tufekci: I’ve written about the bird flu outbreak since last year and I’ve been speaking to lots of people on the ground, including the veterinarian who helped figure out that this sickness was H5N1. She just told me that there were a lot of farm workers with conjunctivitis [the key symptom in the only known human avian flu case] at the time; they were not getting tested. What do you see as a way forward rather than “We’re doing our best”?

Cohen: What I want to make sure is that you don’t think that we’re not ready. To contrast with what happened during Covid, right now, we have H5N1-specific tests in every public health lab in the country. We have treatment, right? We have millions and millions and millions of courses of treatment that folks could get right now.

Tufekci: So the question isn’t “If it happens, what are we going to do?” The question is, given how catastrophic it would be even to have a micro-outbreak, what are we doing to stop it from happening rather than saying, “We have vaccines if that terrible thing does happen”?

Cohen: So we’re not waiting for a signal; we want folks to be protecting themselves now.

Tufekci: But there’s no plan to make anything mandatory from what I’m hearing.

Cohen: I don’t think we’re in a place of an emergency. And I think those would be the times when we would escalate to those places.

Neel Patel: My question is a follow-up to what Zeynep was just asking. Why have things not been made mandatory here when it comes to testing? What’s the reason we’re still sort of in a hold-and-wait pattern?

Cohen: We’ve never seen a human-to-human case with the virus, right? The one case [of avian flu in a human] that we have seen was very mild. And so you want to make sure that we are getting as much visibility as we can, that we are building bridges, we’re building trust. You know, look, I led through the Covid pandemic in North Carolina. I will tell you that trust is very important here.

So just telling people and saying it’s mandatory does not get you everywhere you want to be.

Patrick Healy: How do you see the nature of the mistrust some Americans feel? You mentioned trust several times. Is it a mistrust of science? Is it anti-establishment? Is it specific to Covid decision-making?

Cohen: I think it’s all of the above. I think trust was a central component to how I thought about leading through Covid, particularly in a purple state and trying to keep us all united and moving in the same direction.

Particularly with this population, farm workers, we know that immigration status and their interaction with the government has not been always positive. And so I think there are layers of mistrust and fear. I think from the farmer perspective, they kind of run their business and there’s fear there financially for them and for their family’s business.

So I think we’re trying to work through that. We’re saying, “Don’t be afraid here. This is not information we’re going to keep and give to the immigration officials.” It’s important to do that because this is not going to be something that’s going to be gone in a couple of days. We have to think about building up that trust so that we can keep that work going.

Healy: To build trust, it’s important to really identify where things went off track. Can you be as specific as possible about what you yourself saw as the point where things really got off track in America over trust in science or the C.D.C.?

Cohen: Well, let me tell you about the three things that I focus on related to trust and turning that into a tactical plan, and I think inherent in that sort of tells you where I think we may have gotten off track. One is clear, transparent communication and I think that means explaining to folks, “This is what we know now.”

Second is about relationships. In North Carolina that was incredibly important as we were doing our work.

And then the third is on operational excellence. We have to be prepared and be ready to execute.

Those are the three ways. In the past, I think we didn’t do as good of a job on all of those as we needed to.

Kathleen Kingsbury: How do you as an agency think about Covid now? Should we consider it something to be akin to the annual flu?

Cohen: I think it’s very similar now to the way folks should approach flu. I was just speaking to a large bunch of employers and said, “Look, if you had flu-shot clinics before, then you should be offering Covid vaccines at those.” So we’ve already said out loud that this virus changes faster than the flu virus. Unfortunately, it’s still changing, so it hasn’t gotten to a place where it’s settled, which means that we’re likely going to be in this pattern of updating Covid shots. I’m not sure if it’ll be annually, at least right now, and so you should anticipate a new Covid vaccine in the fall.

Kingsbury: I want to ask you a slightly different question, which is, we’ve all read a variation on the story of how the C.D.C. used to communicate with China. Obviously, trust with China has actually eroded even more since Covid. What are your kind of channels of communication right now?

Cohen: The C.D.C. does have an office in China, embedded in a Beijing version of their C.D.C., in order to try to share scientific information on a day-to-day basis. What are they seeing? What are we seeing? How are we thinking about that? What can we learn together? [The U.S. agency maintains an office in the American Embassy in Beijing. The office is not embedded in China’s equivalent of the C.D.C.]

So we do as best we can. We need to trust each other, because a threat anywhere in this world can be a threat to everyone in the world. We are very transparent here in the United States. We post all of the genetic sequences, we post our information, so folks will have a very transparent version of what we’re doing. We hope to see this not just in China but the rest of the world.

Jeremy Ashkenas: Staying on overdoses for a second: You’ve mentioned, a couple of times now, the 100,000 figure. So what exactly is the C.D.C. trying to do to bring that number down?

Cohen: What we bring to the table for those kinds of issues are certainly great data. So the other thing we do is evaluate, well, what should we spend our money on, what does really work?

So I think that’s C.D.C.’s role. I think our responsibility is to help folks think about those dollars and put them to the best use.

Healy: I just want to circle back to trust in the context of the election. You have a vantage point that a lot of Americans don’t have on Covid. And you’ve seen how leaders, whether they’re governors or presidents, can affect transparency and operational excellence in public health. What do you think is important for Americans to know and remember about how Donald Trump led through Covid?

Cohen: Let me say that I put it in terms of how we thought about it in North Carolina, when things started and I worked for Roy Cooper. And he was the one who in February 2020, when we didn’t have any cases of Covid, said our ability to navigate through whatever this will become will be won or lost on trust, and if we can maintain trust with the public. And we took that and made that into a tactical plan.

But in the time of an emergency, you really have to come together as one team. And we’re seeing it. I’m on the phone every day with the U.S.D.A. team working together toward this [on the avian flu outbreak].

Healy: We’re dealing also with trust and questions of that in terms of whether voters can trust President Biden or Donald Trump. You’re in a position to know, on Covid. Can you give us some assessment?

Cohen: I don’t think anyone did it perfectly. We didn’t do it perfectly in North Carolina either. So I don’t want to say that we did all the right things, but I think our approach showed in the results. So I would say contrast what we did there with what you saw at the federal level, where I don’t think there was as much transparency, there wasn’t cohesion in communication there. On the C.D.C. side, I wasn’t there, but C.D.C. had operational execution problems with the test right out of the gate. That should not happen.

Now, trust is not perfection, right? And I reinforce this to my team a lot. Building trust doesn’t mean you have to be perfect in everything because you’re not going be perfect at every single crisis.

Healy: Do you trust Trump?

Cohen: I’m going to defer — I’m trying to turn a new chapter here. And what I’m trying to do is move beyond personalities.

Healy: Would you be comfortable remaining as director of the C.D.C. if he were president?

Cohen: I don’t believe I can remain director of the C.D.C. The job is both a presidential appointment, and now a Senate confirmation. That has changed by law.

Kingsbury: If he asked you to remain as head at the C.D.C., would you?

Cohen: Well, that would be an interesting dilemma that I would think about if he asked.

Thottam: So, what do you think is the responsibility of the C.D.C. director if a president is telling the public just wrong or dangerous information?

Cohen: I think it is our job no matter who it is to make sure we’re clearing up misinformation. I do feel strongly that I don’t repeat misinformation.