FY 2022 Budget Request for the Centers for Disease Control and Prevention

House Appropriations Subcommittee on Labor, Health and Human Services, Education, and Related Agencies

Witnesses: Rochelle P. Walensky, MD, MPH, Director, and Anne Schuchat, MD, Principal Deputy Director

Chairwoman DeLauro, Ranking Member Cole, and distinguished members of the Committee, it is an honor to appear before you today to discuss how investments in the Centers for Disease Control and Prevention (CDC) are protecting American’s health, now and in the future. I am grateful for this opportunity to address this committee, as well as for your long- standing and consistent leadership on issues of critical importance to the health of Americans, and the world.

It is my privilege to represent CDC at this hearing. CDC is America’s health protection agency. For 75 years, CDC has been trusted to carry out its mission to protect America’s safety, health, and security. Even during the unprecedented circumstances of the past year, CDC’s scientific expertise, determination, selflessness, and innovation has helped the agency continue to advance its mission. We work 24/7 to prevent illness, save lives, and protect America from threats to our health, safety, and security. Addressing infectious diseases and pandemics, like COVID-19, is central to our mission. CDC’s expertise lies in our ability to study emerging pathogens like SARS-CoV-2, to understand how they are transmitted, and to translate that knowledge into timely action to protect the public’s health. CDC identifies and mitigates other causes of morbidity and mortality beyond infectious diseases, such as environmental and workplace hazards and intentional and unintentional injuries (such as those from falls, violence, or overdose). CDC promotes healthy behaviors, such as exercise and nutrition, to prevent chronic diseases such as diabetes and heart disease, and to prevent outcomes such as stroke. We promote healthy communities by increasing access to nutritious food and safe walking and green space.

By deploying experts on the ground to support our state, Tribal, local, territorial and global partners, we translate science into implementing guidance that protects individuals, communities, and populations. In our work with other Federal agencies we ensure the safe and appropriate use of medical countermeasures, including vaccines, and collaborate with the academic and private sector to further our understanding of new diseases and problems that affect health.

The COVID-19 pandemic threw the United States and the world into a health, economic, and humanitarian crisis. As the crisis unfolded, it put a spotlight on pre-existing weaknesses and gaps that threaten the health of Americans. It brought into stark light the great disparities in health outcomes by race and ethnicity. We must acknowledge the long-standing and too often unstated impact that racism has on public health. The pandemic has also highlighted our frail public health infrastructure, and the way that frailty impacted our ability to respond at the necessary scale and speed.

Experts had warned for years that a pandemic of this scale was coming. Today, we know to expect additional novel and currently rare diseases to emerge and gain footing as a result of our changing climate, closer interaction with animals, and globalization. Over the last 12 years, the United States has faced four significant emerging infectious disease threats – the H1N1 influenza pandemic, Ebola, Zika, and COVID-19. These experiences show that public health emergencies and, specifically, infectious disease threats, are here to stay. While urgency demanded rapid and unique responses to each of these threats, none resulted in the sustained improvements needed in our nation’s public health infrastructure. This lack of robust public health infrastructure continues to present significant challenges in our ongoing fight against COVID-19. In fact, emergencies have resulted in the rapid build-up of infrastructure needed to address the emergency, then dissolution of that infrastructure, often leaving no sustainable infrastructure in place to address the next threat. This lack of robust public health infrastructure continues to present significant challenges in our ongoing fight to tackle COVID-19.

World-wide, billions of people do not and will not have immediate access to COVID-19 vaccines. Cases will continue to increase, and variant COVID-19 strains are likely to emerge, persist, and cause outbreaks. As this becomes more common, our public health system at home and abroad must be ready with highly sophisticated detection and sequencing, combined with a rapid response at the source. The unprecedented investments provided to CDC through COVID- 19 supplemental appropriations have helped our efforts to control COVID-19, and will also go a long way toward addressing deficits in the core components of the public health infrastructure that has long been ignored. Our ability to respond to the next public health crisis will depend on whether we invest in a public health system that is highly functional on a day-to-day basis and pivots to meet new threats, rather than continue our partial defense, which ramps up in response to an urgent and often short-term event.

A resilient public health system can be realized with careful planning that builds on the gains made with COVID-19 emergency supplementals and incorporates lessons learned as a result of this crisis, including reliable, flexible funding. The FY 2022 Discretionary Budget Request for CDC and ATSDR includes a total funding request of $8.7 billion, an increase of $1.6 billion over FY 2021 Enacted. This is the largest increase in budget authority for CDC in nearly two decades and defends Americans’ health in four ways: 1) building public health infrastructure, 2) reducing health disparities, 3) using public health approaches to reduce violence, and 4) defeating other diseases and epidemics.

First, building the public health infrastructure. CDC’s FY 2022 request prioritizes foundational funding to rebuild the public health infrastructure needed to safeguard the Nation’s health and economic security. Drawing on lessons learned, as well as the latest information and technologies, CDC will begin to address long-standing vulnerabilities in the U.S. public health network by training a larger cadre of experts who can deploy and support public health efforts, and building capacity to detect and respond to emerging global biological threats.

Public health action is driven by data. Earlier improvements in our systems for collecting information after other public health emergencies, including Ebola and EVALI, facilitated exchange of health information, linking local, state, and federal public health systems with healthcare systems and the public. With investments in public health data modernization in the FYs 2020 and 2021 appropriations and the COVID-19 supplementals, CDC increased the scale and speed of these systems during the COVID-19 response to protect people who are at risk for severe illness (such as older Americans), those with chronic medical conditions, and those from racial and ethnic minorities. These advancements must be applied across the public health system and at all levels of government. The funds requested in FY 2022 will be used to continue building a modern disease surveillance system at CDC, which will catalyze a multi-sectoral, comprehensive, and cohesive approach to documenting evidence, using state-of-the-art technology and analytical tools. CDC will continue working diligently to ensure its research and data are of the highest quality and are disseminated nationally to inform decision-making throughout the public health system, while supporting advances in data systems at all levels.

The COVID-19 pandemic made clear the role that CDC labs and public health labs across the nation play in conducting critical surveillance and responding to outbreaks and emerging threats. CDC and state laboratories were required to flex and surge during peak periods of illness, far beyond routine clinical testing. In FY 2019, CDC was only able to meet 50% of state and local health departments’ stated needs for epidemiology and laboratory capacity funding, with personnel support being the biggest unfunded need, followed by equipment and supplies.

The FY 2022 request will foster innovation, collaboration with the clinical system, and a commitment to quality. Improving technologies at the state and local levels would enable public health labs to quickly utilize and scale up essential laboratory analyses. In a post-COVID-19 world, investments to maintain and improve laboratories will help prevent the failures we experienced while trying to address COVID-19.

The U.S. needs a workforce of qualified public health professionals who will prepare for, respond to, and prevent public health crises. Physicians working for states often earn less than $150,000 per year. This is after having taken on medical school debt of $200,000 on average. The FY 2022 request includes an increase to build a diverse and culturally competent workforce who can rapidly develop innovative approaches in surveillance and detection, risk communications, laboratory science, data systems, and disease containment. With this funding, CDC will support critical training programs for public health professionals that develop strategic and systems thinking, data science, communication, and policy evaluation. Existing cooperative agreement mechanisms will be leveraged to support public health jobs that meet current needs and attract new personnel to work in underserved and rural areas.

Addressing gaps in capacity across levels of government to detect and respond to outbreaks while maintaining and surging in other problem areas requires investments to be disease-agnostic and flexible. With FY 2022 funding, CDC will provide support to health departments to meet national quality standards, conduct performance improvement activities, increase communication and collaboration across the public health system, and reshape health departments to meet changing conditions and needs. Funding will help health departments strengthen their abilities to effectively respond to a range of public health threats, such as COVID-19, and build capacities that do not currently exist.

COVID-19 is a sobering reminder that a disease threat anywhere is a disease threat everywhere. Or as stated by WHO: no one is safe unless everyone is safe. We cannot adequately protect American lives and the U.S. economy without addressing global disease threats wherever they may arise. CDC’s strategic investments in global health security are critical to U.S. health security by building sustainable global capacity to prevent, detect, and respond to emerging infectious disease threats. CDC works in more than 60 countries on more than 150 projects and is a key implementing agency for the U.S. Government’s leadership role in the Global Health Security Agenda. With additional resources requested in FY 2022, CDC will build on existing partnerships with Ministries of Health, public health agencies, infectious disease research institutions, and international organizations to strengthen global laboratory capacity for early disease detection, enhance disease surveillance for accurate data to drive decision making, and foster effective regional and global coordination.

Next, I’d like to talk about reducing health disparities. The disparities seen over the past year among communities of color were not a result of COVID-19. In fact, the pandemic illuminated inequities that have existed for generations and revealed a known, unaddressed, and serious public health threat: racism. The well-being of our entire nation will be compromised as long as we fail to address this.

Racism is not just discrimination against one group based on the color of their skin or their race or ethnicity, but the structural barriers that impact racial and ethnic groups differently to influence where a person lives, where they work, where their children play, and where they worship and gather in community. The social determinants of health (SDOH)—such as high- quality education, stable and fulfilling employment opportunities, safe and affordable housing, access to healthful foods, commercial tobacco-free policies, and safe green spaces for physical activity—are critical drivers of health inequities in this country, and impact individuals living in urban, rural, and suburban areas. CDC is building the evidence-base for collaborative approaches to SDOH through community accelerator planning and expanding a network of community health workers to develop a sustainable infrastructure to improve health equity. CDC’s FY 2022 budget request includes an increase of $150 million to use a social determinants of health approach to improve health equity and health disparities in racial and ethnic minority communities and other disproportionately affected communities around the country.

This budget directly responds to health disparities recorded in our public health data. For example, about 700 women die each year in the U.S. as a result of pregnancy or delivery complications, and American Indian, Alaska Native, and Black women are two to three times more likely to die than White women. Data show that about 2/3 of these deaths may be preventable. Children from lower-income and racial and ethnic minority households experience a disparate, increased risk for lead exposure.

Achieving health equity is central to addressing the HIV epidemic. The U.S. government spends $20 billion per year in direct health expenditures for HIV care and treatment. An estimated 1.2 million persons have HIV and approximately 15% are unaware they have it. With recent advancements in antiretroviral therapy and biomedical advancements in HIV prevention, such as pre-exposure prophylaxis (PrEP), along with effective care and treatment, we have the tools to end the HIV epidemic. An increased investment requested in FY 2022 for the Ending the HIV Epidemic (EHE) initiative will enable CDC to advance the four key strategies needed to end the epidemic in the 57 EHE focus jurisdictions. In addition, CDC will address health equity in the entire HIV prevention portfolio, test innovation in service delivery models to increase access to prevention services, use syndemic approaches to broaden reach to key populations and create efficiencies, and strengthen engagement of grassroots community-based organizations in implementing EHE initiative.

Third, the budget request also addresses the public health epidemic of violence. We know too well how this epidemic permanently alters the lives of its victims and their families and puts enormous strain on our communities and local economies. Increases in CDC’s FY 2022 budget request will help address violence through public health approaches, which include improving reporting systems that provide the data needed to understand and address violent deaths and injuries in the United States.

And fourth, we must defeat other diseases and epidemics. Just as racism underlies a number of public health issues, climate issues underlie a number of infectious diseases and have significant health impacts. Climate changes are associated with changes in the geographical range of mosquitos, ticks, and other disease vectors. Climate-related events impact a wide range of health outcomes. Some of the most significant climate-related events—such as heat waves, floods, droughts, and extreme storms—affect everyone. These climate events compromise our access to clean air, clean water, and a reliable food supply. In addition, climate events can impact the presence of allergens and vectors, like ticks and mosquitoes, and the subsequent health outcomes that can result from these changes in exposures. We know that a changing climate can intensify existing public health threats, and that new health threats will emerge: unequally distributed risks (age, economic resources, location), increased respiratory and cardiovascular disease, injuries and premature deaths related to extreme weather events, changing prevalence and geography of foodborne and waterborne illnesses and other infectious diseases, and threats to mental health as people feel less safe.

CDC works with states, cities, and tribes to apply the best climate science available, predicting health impacts, and preparing public health programs to protect their communities. To do this, CDC developed the Building Resilience Against Climate Effects (BRACE) framework to help communities prepare for the health effects of climate change by anticipating climate impacts, assessing vulnerabilities, projecting disease burden, assessing public health interventions, developing adaptation plans, and evaluating the impact and quality of activities.

With the requested increase in FY 2022, we can further expand the Climate and Health Program by providing a larger number of health departments with technical assistance and funding and finding innovative ways to protect health via climate adaptations. As with every other public health threat, we will inform our effort by building and examining systems that collect data on conditions related to climate, including asthma and vector-borne diseases, and coordinate programs and communication that improve health outcomes.

The opioid epidemic has shattered families, claimed lives, and ravaged communities across the Nation—and the COVID-19 pandemic has only deepened this crisis. Addressing the current overdose epidemic remains a priority for CDC. The Administration’s strategy brings together surveillance, prevention, treatment, recovery, law enforcement, interdiction, and source- country efforts to address the continuum of challenges facing this country due to drug use. CDC’s role is to prevent drug-related harms and overdose deaths.

The additional funding requested in FY 2022 to address the opioid epidemic will enable CDC to provide more funding to all States, Territories, and select cities/counties. CDC will prioritize support to collect and report real-time, robust overdose mortality data and to move from data to action, building upon the work of the Overdose Data to Action (OD2A) program. To do so, CDC will partner with funded jurisdictions to implement surveillance strategies that include contextual information alongside data, as well as increase surveillance capabilities for polysubstance use and emerging substance threats such as stimulants. The additional resources requested will enable CDC to support investments in prevention efforts for people put at highest risk, for example, supporting risk reduction and access to medications for opioid use disorder for people transitioning from alternate residence (jail/prison, treatment facility, homeless shelter). CDC will also address infectious disease consequences, such as viral hepatitis, of the opioid epidemic.

I look forward to working together to address both the immediate challenges ahead in our fight against COVID-19, as well as the weaknesses in the public health infrastructure that left our country vulnerable to this pandemic. We at CDC are grateful for your support. We will continue to work tirelessly to ensure the health of this nation and the world. Together, we can build a sustainable and resilient public health system that can respond effectively to emerging threats and also to ongoing public health needs of every American.