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The new director of the Centers for Disease Control and Prevention had spent days on television and social media urging Americans to get the updated coronavirus vaccine. The new shot is the most effective protection for the looming virus season, she said. And it’s free.
But by the afternoon of Sept. 21, it was becoming clear to Mandy Cohen that the nine-day-old vaccine rollout was stumbling, with many Americans unable to promptly get shots at pharmacies, insurers making erroneous claims about who would have to pay, and little explanation from the government.
Cohen ducked into a small basement conference room at the embattled agency’s headquarters for an update. Across the table, Nirav Shah, the CDC’s principal deputy director, laid out several insurance and supply chain issues. The federal government was no longer overseeing the manufacturing and distribution of vaccines now that the covid public health emergency has ended, so the CDC had much less control over the rollout, he explained.
Cohen frowned. She wanted to publicly address the delays right away. “If we don’t say something, it makes it seem like we’re not paying attention,” she told Shah. “I don’t want to say ‘supply chain.’ I want to say real words.”
The next day, Cohen recorded a short video acknowledging the problems. “It’s important to know that there is vaccine available. You will be able to get one and it should be free for you. Whether or not you have insurance,” she said in the message, posted on Twitter. “If you’ve had a problem finding the vaccine, stick with it.”
The exchange illustrates Cohen’s approach to leading the once-vaunted public health agency as it tries to recapture public trust battered by its missteps during the coronavirus pandemic. While the rollout for the updated vaccine has improved in recent weeks, uptake remains slow, and some Americans are still having difficulty finding shots — dimming a moment Cohen and her colleagues had hoped would showcase her ability to rebuild confidence in the agency.
The Washington Post attended public and private meetings over three days with Cohen in Atlanta and Washington, D.C., in September and spoke with three dozen agency officials, Biden administration leaders and public health experts to discuss her early tenure. The snapshot that emerged captures someone who acts quickly and decisively, sometimes at odds with long-standing CDC tradition and engendering frustration among staffers who say her expediency has at times led to confusion and redundant work.
Shortly after arriving as an outsider to lead the agency, she sent senior officials a “Mandy Cohen User Guide,” a two-page document of bullet points detailing “the most productive user experience using me.”
Cohen, a physician and the former North Carolina health secretary, does not like surprises or “meandering meetings,” the guide warns. She wants to be kept in the loop with “frequent, SHORT updates by email.” Otherwise, the guide says, “I (often wrongly) assume nothing is happening.”
Several senior officials said they appreciated her candor and readily responded when Cohen asked them to fill out a similar document. But their forms included an assessment of their weaknesses, a category they noted Cohen’s “user guide” omitted.
Installed at the CDC by the White House in July, Cohen is tasked with restoring staff morale and public credibility at a time of extreme political divisions and fading trust in government — and in science. The 12,000-person Atlanta-based agency has become a target in Congress and on the campaign trail: Republican presidential candidates such as Florida Gov. Ron DeSantis and Vivek Ramaswamy have vowed to gut the CDC if elected next year, insisting that the agency’s COVID-19 guidance was too cautious and led to unreasonably long school shutdowns, rising mental health woes and other social problems.
“We are at this post-COVID moment, where the imperative is rebuilding trust,” said J. Stephen Morrison, a senior vice president at the Center for Strategic and International Studies, who co-authored a January report on much-needed changes at the CDC.
He noted that Cohen faces extra demands heading into fall and winter, when respiratory illnesses like flu, COVID and respiratory syncytial virus (RSV) tend to spike: “Americans are wondering‚ ‘How should I behave? Where do I turn to try to minimize risk or severe illness or worse?’”
The CDC, Morrison said, must be ready to provide answers.
Prioritizing covid, flu and RSV
When she took over in the summer, Cohen told senior leaders her foremost priority for the agency is to prepare for the respiratory virus season. Officials said they assumed that meant following well-established protocol of surveillance since there was no crisis with any of the now-familiar illnesses: flu, RSV and coronavirus.
But Cohen wanted more. One month into the job, she overhauled the leadership of the center in charge of the agency’s response to COVID-19 and other respiratory illnesses, a move she felt would help the CDC better stay atop the upcoming virus season. And she’s prompted the agency to activate its second-highest level of emergency status to address current cases of flu, RSV and COVID-19 — just one level down from the agency-wide mobilization at the height of the pandemic — according to three senior officials who spoke on the condition of anonymity to share internal conversations.
Longtime CDC officials are confused why the agency has taken such an aggressive posture — with some staff tasked with focusing intensively on flu, RSV and COVID-19 on top of their day jobs — given that none of the viruses has risen to the level of an emergency, said one official, adding that “working around-the-clock ... scientifically may not make sense.”
Cohen’s prioritization of respiratory viruses has already led to resentment among some agency officials, who say they are concerned that overextended staff will burn out by the time a true emergency hits.
Cohen’s decision to assign one of her deputies to work on COVID messaging also was seen by staff as duplicative and dismissive of their expertise, since another CDC team had already begun that work.
“I am asking the CDC to be different and the teams to be different. ... I think that is necessary,” Cohen told The Post in response to the criticism. “Part of being a leader is making sure you have the right people on the bus with you.”
Cohen, 45, said government leaders should be biased toward action. She acknowledged some “growing pains” in her efforts to deliver “one harmonized response” to the three circulating respiratory viruses.
Her urgency is driven by a growing public health problem: Many Americans tuned out the CDC during the pandemic. The agency was criticized for the botched rollout of coronavirus tests as the pandemic first menaced Americans in early 2020; was repeatedly mocked for slow and conflicting guidance on when to wear masks, isolate when sick and seek out booster shots; and it remains deeply distrusted by many parents, who blame the CDC for learning loss stemming from school shutdowns.
Axios/Ipsos polling shows 86 percent of Americans in March 2020 said they trusted the CDC to provide them with accurate information about COVID-19. By February 2022, that had fallen to 61 percent.
Cohen has tried to regain public confidence by traveling to health clinics, pharmacies and senior centers around the country urging people to get vaccinated against COVID, RSV and flu. This is the first time the nation has the tools to prevent severe illness from all three viruses, she says over and over again. She repeatedly cites the importance of vaccinating her young daughters and elderly parents with the latest shots targeting the constantly mutating coronavirus.
Despite her efforts, uptake of the updated coronavirus vaccine has been low: Just 10 percent of adults and 4 percent of children had received the shot as of Nov. 8, according to CDC data.
Navigating political pressures
Since starting at the CDC, Cohen has been in perpetual motion — ping-ponging between her family’s home in Raleigh on the weekends, her apartment in Atlanta on weekdays and regular trips to Washington, D.C., to meet with Biden officials and members of Congress — in her bid to build relationships with her worn-down staff as well as with fellow government officials who have long viewed the agency as aloof and disconnected.
The CDC chief is especially conscious that she must win over the lawmakers and officials who can determine the agency’s fate, after her predecessor Rochelle Walensky struggled to make inroads in Washington and ultimately lost the confidence of the White House.
But unlike Walensky, a Harvard-trained infectious-disease expert with limited political experience, Cohen arrived at the CDC as a known figure to many in the Biden administration. As a senior Obama administration health official, she helped oversee Medicare, Medicaid and the Affordable Care Act. Her longtime allies include Surgeon General Vivek H. Murthy and White House senior health official Christen Linke Young. And her most important champion is White House Chief of Staff Jeff Zients, who played a central role in selecting her to run the CDC.
But Cohen’s limited prior experience with the agency — and reports that the White House previously considered her to run the Department of Health and Human Services, a Cabinet-level role — has contributed to speculation that the new director is using her role as a steppingstone for higher ambitions.
Cohen says she is “100 percent focused on CDC work” and making sure the agency benefits from her previous experience leading crises in federal and state government.
Cohen has also been trying to build bridges with congressional Republicans, who are pursuing multiple probes into the CDC over its response to the pandemic and other matters. Her allies insist Cohen is well-prepared for that challenge, saying she’s battle-tested after navigating a GOP-led legislature in North Carolina for four years as the state’s top health official, steering the state through the COVID-19 pandemic.
Sen. Bill Cassidy (R-La.), the top Republican on the Senate health committee that oversees the agency, credited Cohen with being “more forthcoming and quicker to respond” than prior CDC directors.
“She seems to understand what the problems are,” said Cassidy, a physician who has repeatedly criticized the CDC over its lack of transparency and slow, research-oriented culture.
Walensky had begun a dramatic overhaul of the agency last year, seeking faster release of scientific findings and easier-to-understand guidance, a more nimble and better-trained emergency response workforce, and incentives that would reward actions over publication of research papers.
Cohen has embraced those core elements, which she reinforces with her staff every chance she gets.
During a recent virtual meeting to tailor coronavirus vaccination messaging to physicians, Cohen pointed out staff presentations contained too much information. Messages must be “short, concise, clear, factual,” she told participants. For cardiologists, focus on heart-related complications from COVID, she directed. For pediatricians, “let them know the ICU numbers” for children hospitalized with covid-19 but who have no underlying medical conditions, she said.
“I want to make sure that’s beaming off the page,” Cohen said, her voice rising for emphasis, from her 12th-floor office overlooking the sprawling campus in suburban Atlanta. “I worry with so much information that we’re not going to break through with a couple of key points.”
Trying to win allies — even with a song
Everything, it seems for Cohen, rests on forging connections — whether it is convincing more people to get vaccinated or rustling data from hospitals so the CDC can better track disease threats.
When she recently met virtually with David J. Skorton, president of the Association of American Medical Colleges, for the first time, Cohen delighted him by readily agreeing to sing the alma mater of Cornell University, where Skorton had served as president and Cohen received her bachelor’s degree.
“I was in the chorus,” Cohen explained with a smile.
Then she got down to business. “We need to, for our country, have visibility in a way that allows us to know what’s happening and how to respond well,” Cohen told him. That means knowing “how many folks are in the hospital, what their vaccine status is, what their race and ethnicity is, so we can have eyes on emerging patterns,” she said.
Skorton promised to encourage his association’s 157 medical schools and 400 teaching hospitals and health systems to work with the CDC in its quest for comprehensive data.
The previous day, Cohen had underscored the importance of collaboration in what she referred to as the “team sport” of public health at a conference in Atlanta’s Georgia Aquarium. As beluga whales flipped back and forth in a massive tank along the wall, she stressed the need to communicate often, in simple terms, then urged the crowd of largely young health professionals to “follow me on Insta.”
Her CDC social media accounts feature Cohen visiting nursing homes to emphasize the importance of high-risk Americans getting vaccinated ahead of the holidays. Talking about vaccinations on Capitol Hill with Senate Majority Leader Charles E. Schumer (D-N.Y.). Answering questions in the video “Check-Ins with Dr. Cohen”: When is the best time to get a flu shot? (Before the end of October). Can you get COVID and flu shots at the same time? (Yes.)
In addition to focusing on the respiratory virus season, Cohen has selected two other public health priorities intended to be noncontroversial and relatable to average Americans — and her GOP critics: opioid use and maternal and infant health.
If she repeats herself enough times, using clear, concise language, she hopes more Americans will embrace her message.
In a cavernous basement video studio, Cohen read from a teleprompter, urging pregnant people to get the new maternal vaccine to protect newborns against RSV.
The words didn’t sound right to her. The script referred to “RSV season,” but the average person doesn’t know what that means, Cohen told aides. “Should we just say . . . fall and winter?” She also wanted a different adjective instead of saying “extensive” clinical trial data. The CDC uses “extensive” too often, she said.
“Strong?” one aide suggested. “Significant?” another offered.
A third assistant piped up. “I just watched this episode on ‘Veep,’ and I hate to say this, but what about ‘robust?’”
“I’m okay with ‘robust,’ but I’m going to laugh,” said Cohen, catching the reference to HBO’s political satire in which the word was repeated multiple times.
The head of CDC communications stepped in: No adjective was needed. “Say this was based on data and clinical trials,” he advised.
“Okay, no adjective,” Cohen agreed. The staff made additional tweaks. A cameraman combed her hair and reshot the take.
Diamond reported from Washington.