Courage and consequences at the CDC

In a recent presentation to preventive medicine residents at Johns Hopkins, I reflected on the painful circumstances that led to my resignation from the Agency for Healthcare Research and Quality (AHRQ) in November 2010. In short, political decision-makers well above my pay grade attempted to protect Democratic congressional majorities from blowback from an anticipated recommendation against prostate cancer screening by forcing the U.S. Preventive Services Task Force to cancel a scheduled meeting. Until this year, when Health and Human Services Secretary Robert F. Kennedy, Jr. cancelled the USPSTF's July meeting and expressed his intent to replace the entire panel, it was arguably the worst example in the Task Force's history of politics trumping science. (This time is worse - a LOT worse.)

Last week, the HHS Secretary fired recently confirmed Centers for Disease Control and Prevention (CDC) Director Susan Monarez over her unwillingness to “to rubber stamp [vaccine] recommendations that flew in the face of science.” In protest, three senior CDC officials simultaneously resigned. On his Inside Medicine Substack, Dr. Jeremy Faust posted the full text of the e-mails that Dr. Deb Houry, Dr. Demetre Daskalakis, and Dr. Daniel Jernigan sent to their colleagues announcing their respective resignations. Without question, these three doctors were far more critical to the day-to-day work of the CDC and HHS than I ever was or might have been at AHRQ. But their collective departure, like mine nearly 15 years ago, raises an important question: when a public servant who is also a health care professional witnesses the federal government taking immoral or profoundly troubling actions, is it more courageous to step down (and draw attention to how these actions endanger health) or to remain in place and continue to resist from the inside, hoping that eventually new leadership will restore the primacy of science and evidence-based medicine?

My red line was that the delay - which ended up being 17 months long - in ratifying the USPSTF's "D" recommendation against PSA-based prostate cancer screening would ultimately injure hundreds of thousands of patients who accepted screening without being aware of the Task Force's determination that it was more likely to cause them harm than good. My primary professional identity was and remains that of a family physician, and inherent in this identity is an obligation to provide patients with the best understanding of the science to help them make health decisions. Being told that I had to set this obligation aside because it might damage the electoral prospects of a Presidential administration and his political party was, in my view, unconscionable.

On the other hand, I admire my colleagues at AHRQ who chose to stay and sustain the USPSTF from the inside. A few still work there; others, unfortunately, were given pink slips by Elon Musk's Office of Government Efficiency when his group of twenty-something contractors couldn't figure out what the agency did that was important enough to warrant employing a few hundred scientists. No doubt the Task Force would have been much worse off if every member of its support staff had walked out with me on my last day and switched to careers in academic medicine. Leaving an impossible situation can be courageous, but staying on is, too. I salute Dr. Monarez and her departed senior leaders at CDC for their principled public resistance, but I also support the many staff who have remained despite RFK Jr.'s horrific interference with the agency's mission to protect the public's health.