The Centers for Disease Control and Prevention may be about to undergo a paradigm shift with the anticipated appointment of former North Carolina health secretary Mandy Cohen as the agency’s next director.
The Atlanta-based CDC has always prided itself at being at a remove from Washington, and the politics that engulf it. With 634 miles separating the U.S. Capitol building from the CDC’s main campus in northeast Atlanta, the agency and its staff have preferred to focus on science. For decades, its directors have almost always been infectious disease experts with CDC experience; some were even graduates of the CDC’s renowned disease detective school, the Epidemic Intelligence Service.
The narrow focus on science hasn’t always stood the agency in good stead. And increasingly, some long-time CDC watchers have come to conclude the agency needs someone with political clout — and someone who knows how government functions — to lead it as it attempts to course correct after the reputation-bruising Covid-19 pandemic.
“CDC has always been defiantly about the science. … And I think increasingly it’s been impossible to be just about the science,” said Ed Hunter, who was director of the agency’s Washington office for years. “CDC needs to be more engaged, more politically sophisticated, know how to play hardball a little bit more.”
In recent years, the CDC has fumbled the ball far too often, critics say. The agency was faulted for failing to move quickly enough to prepare the country for the threat Covid-19 posed, issuing confusing guidance for the public on how to avoid infection, and caving to pressure from political operatives in the Trump administration to loosen Covid crowd restrictions on churches, among other things.
The Biden administration, seemingly having come to the conclusion it is time for a different approach in its selection of the CDC director, has chosen Cohen, a Yale-trained internal medicine physician with a masters in public health from Harvard who has held high-level health administration jobs at both the federal and state level.
Cohen’s fans suggest she has the political chops needed to lead the agency. And even people who don’t know her well believe she brings to the job assets previous directors have lacked.
While historically most CDC directors were named from within the agency’s ranks, the three most recent — Brenda Fitzgerald, Robert Redfield, and Rochelle Walensky — did not work at the CDC before taking on the post. CDC experience and time spent in the public health trenches have been valued both by the political masters filling this position and most especially by the 10,000 or so people the agency employs.
Cohen has some public health experience, having led North Carolina’s response to the Covid pandemic. She was the health secretary there for nearly five years, stepping down at the beginning of 2022.
Her leadership through the pandemic was widely lauded, with her communications skills, in particular, earning high praise.
“Dr. Cohen held roughly 150 press briefings during the Covid-19 pandemic, a number which helped ensure North Carolinians knew where we stood in terms of the disease and the state’s response to the disease,” said Brian Southwell, lead scientist for public understanding of science at RTI International, an independent non-profit institute that seeks science-based solutions to societal problems.
Southwell and others said Cohen’s messaging stressed the evolving nature of Covid science. “She was consistently clear about what state public health officials knew and what they did not know,” he said.
Leah Devlin, a former state health director for North Carolina and just-retired professor at the University of North Carolina’s Gillings School of Global Public Health, said Cohen was adept at building bridges with key communities during the pandemic, working to bring business leaders, university administrators, and faith communities representatives into the response.
But Cohen’s biggest asset, observers say, is her experience in running big government operations.
“She has this ops experience at the federal level, really running something in health care finance that has a broad impact in the states,” said Devlin, who is also a member of the board of directors of the CDC Foundation, which generates private sector support for the agency’s work.
“She’s got the leadership skills, the communication skill. She’s an operational person and she values public-private partnerships. And at the end of the day that’s what this is about — those four things right there,” she said.
Cohen also has serious White House connections. She is close to Biden’s current chief of staff, Jeff Zients, having volunteered to help him when the 2013 rollout of the Affordable Care Act’s enrollment failed spectacularly and Zients was drafted to fix the problem. She was working at the time as a senior adviser to the administrator of the Centers for Medicare and Medicaid Services.
From 2015 to 2017, when Andy Slavitt was acting administrator of CMS, Cohen was his chief of staff and CMS’ chief operating officer.
One of his key insights about Cohen, Slavitt said, is that she is not afraid to tackle tough tasks.
“A lot of people kind of shy away from the difficult challenges that we all know we need to solve. She doesn’t. She calls out the thing that most needs to be fixed, whatever it is,” said Slavitt, who was also involved in the effort to fix the faulty healthcare.gov website.
One of those tough things was North Carolina’s application for a Medicaid waiver, a version of which was in the approvals pipeline when Cohen became health secretary. She filed a more ambitious waiver application, one that gives qualifying Medicaid recipients access to free groceries, or the damage deposit on an apartment and other such programs. Despite having been appointed by a Democratic governor in a state where both the House and the Senate are under Republican control, Cohen’s approach was supported.
Hunter finds the fact she pushed for more robust benefits heartening — especially given the times. “A typical model for living in a divided political situation like that is to be small and careful and stay the course and try to defend what you have and try to do things that are on the margins,” he said. “I’m hoping that she will bring that same willingness to be bold to CDC.”
While he was director of the CDC’s Washington office, Hunter worked with many previous CDC directors as they tried to forge connections with D.C. power players. Cohen needs no such assistance.
“On Day 1, it’s not like: Gee, can we [meet] with important people in the secretary’s office? She’s probably worked with them before when she was at CMS,” said Hunter. “One of the people who was her deputy in North Carolina is now a deputy in the Domestic Policy Council. She’s worked with these people. She has standing with these people. She brings on Day 1 things that it took a long time for prior CDC directors to build.”
Those connections should help Cohen — and the CDC — play a pivotal role in D.C.-led policy discussions. Redfield, an HIV clinician and researcher who headed the agency when the Covid pandemic began, lived in Washington, and was “in the room where it happened” during the early days of the pandemic, Hunter said. But the former director of the National Institute of Allergy and Infectious Diseases, Anthony Fauci, and Deborah Birx, the former U.S. global AIDS coordinator who was named the White House’s coronavirus response coordinator, played more prominent roles in the Trump administration’s response.
“Simply physically being somewhere is not the same as having the skills and the orientation and the interest in being effective in those roles,” said Hunter, who now works as a public health consultant.
“I think we’re well past the days when you could have just a really, really good doc or a bench scientist” as a CDC director, Hunter said. “You really need the person to be out front, you need the person to have influence in the administration, on the Hill, need to speak with authority to the states.”
Another of the assets Cohen brings: She has experience working with both sides of the political aisle. It was expected that she would face stiff opposition from majority Republicans during her North Carolina Senate confirmation hearing. Instead she was unanimously recommended for confirmation. (She doesn’t need Senate confirmation to become CDC director. While Congress recently made the job a Senate-confirmable one, the provision doesn’t go into effect until the start of the next administration.)
Anne Zink, Alaska’s chief medical officer and the current president of the Association of State and Territorial Health Officers, said people in her field have been following Cohen’s work with interest.
“I think that many of us who have kind of bridged the space between public health and health care have known Mandy for some time in her work at CMS. And then when she was able to take that information and knowledge and when she moved over to North Carolina, they really initiated this idea of a health-related social needs [waiver] … to pay for time-limited, targeted health-related social needs that would improve patients’ health,” Zink said, calling it an “inspiring mechanism to connect the way that we pay for health care and the way that we pay for public health to improve the overall health of the patients we serve.”
Still, Zink and others don’t expect everything to be smooth sailing for Cohen. “I think it’s a very challenging and nearly impossible job that she’s stepping into,” she said, pointing to Cohen’s lack of CDC experience as something that could affect the staff’s view of her.
Morale at the agency has been battered in recent years and the connection between agency staff and their director has perhaps been weakened by a more rapid turnover than was seen in the past. Tom Frieden, for instance, served as CDC director for most of President Barack Obama’s two terms. A few previous directors were actually appointed by a president of one party and went on to serve in an administration of the other. But those days seem well and truly over.
Brenda Fitzgerald, Trump’s first CDC director, served merely six months before resigning when it was revealed she had purchased tobacco stocks after taking the job. Redfield served out the rest of Trump’s term, and led the agency when its efforts to develop a Covid-19 test stumbled, hamstringing the country’s early response to the pandemic and deeply wounding the CDC’s credibility.
Walensky, who had been hailed as a skillful communicator because of TV appearances where she explained the changing science surrounding the new virus, proved to be not as adept when she was trying to explain the CDC’s changing policies around Covid. The administration ended up spending more than $25,000 on media training and executive coaching for Walensky.
With only about 19 months to go before the next presidential swearing in, in January 2025, Cohen won’t have a lot of time to make a mark.
She may take flak for the amount of time she will be spending outside of Atlanta. Devlin believes Cohen’s family’s base will remain in North Carolina, where her young daughters are going to school, though she will get a place to live in Atlanta and will be on site at the CDC when she’s not in Washington. One of the knocks against Walensky among some of the CDC staff was that she didn’t move — with her family — to Atlanta.
Hunter, who was in the agency’s top management echelon and never moved to Atlanta, isn’t so sure that’s going to be a problem. What he sees as an issue is the fact that much of the CDC staff continues to work remotely.
“Going to Atlanta may be overrated,” he said. “I think the importance of being in a specific location is diminished because of the opportunity to be in places in a hurry, virtually. And I think if she can master the skill of being present with the CDC workforce and being engaged wherever they are — in their homes, in their offices, and their labs — I think that to focus on that is possibly more important than physically living in Atlanta.”
Other challenges include the fact that Walensky relatively recently launched a reorganization of the agency — one that she will not be around to see to completion. Cohen will have to decide how much of the renewal effort she wants to pursue, Hunter said.
Finally, the agency is about to find itself teetering on the edge of a cash cliff, as Covid money dries up.
“CDC’s never had this much money, and has never had this much money that came as a surprise. And so it’s really an unprecedented thing to figure out: How do we tail off things as opposed to trying to grow things?” Hunter noted.
“All the things that CDC is trying to do — to change the culture, to modernize data, to modernize state and local health departments — have real sustainability issues.”
Correction: A previous version of this article misspelled the name of UNC’s Gillings School of Global Public Health