HHS investigation into Covid test failure at CDC
December 8, 2021 12:42 PM   Subscribe

Secret Investigation Documents Reveal How The CDC’s First COVID Test Failed In the Pandemic’s Early Days. "Federal investigation records obtained by BuzzFeed News show how one of the most pivotal mistakes of the pandemic fell on an overburdened CDC lab with only three full-time employees." By Dan Vergano.

Some key problems, besides the small size of the Respiratory Virus Diagnostic lab:
  • Cross-contamination in the CDC manufacturing process. (It's unclear where exactly the contamination occurred; the article discusses two scenarios.)
  • A time-consuming FDA approval process.
  • Unwillingness to use an existing test.
posted by russilwvong (8 comments total) 8 users marked this as a favorite
Neither Lu nor Lindstrom would speak to BuzzFeed News on the record about the events described in this article or about their interviews with investigators.

The US Food and Drug Administration and HHS — the FDA and CDC’s parent organization — declined to comment on the record.

HHS and the CDC did not comment on the email or the allegation that the contamination may have involved the core lab.

[T]he core lab’s branch chief, Jan Pohl... did not respond to BuzzFeed News’ offer to him to review the interview notes...

Stenzel declined a request to speak on the record.

In a phone call, Hughes told BuzzFeed News she had been told not to speak to reporters by the CDC’s press office.

Messonnier, who now works at the Skoll Foundation, did not respond to a request to review and comment on the interview notes.

posted by doctornemo at 2:05 PM on December 8, 2021 [7 favorites]

Key conclusions / contributing factors:
This investigation, based on the documents and interviews with health officials knowledgeable about the test’s development, reveals:

Government dysfunction. Congress, CDC leadership, and past presidential administrations have neglected labs at the world’s most highly regarded public health agency for decades. The small, underfunded Respiratory Virus Diagnostic (RVD) Lab was overburdened as COVID-19 blazed across the country.

Questionable blame. The initial investigation summary criticized the RVD lab for the catastrophic failure of the nation’s first COVID test. But further documents and interviews call its conclusions into question, indicating a larger lab may have been the actual culprit — something HHS investigators failed to find.

Cut corners. In the CDC’s rush to develop a lab test, officials chose to assemble two of its critical parts in the same facility, leading to cross-contamination that compromised the kits sent to state and city health agencies nationwide. This type of contamination happened before, during the 2012 MERS outbreak.

Overconfidence. The CDC did not initially rely on tests already in use in other countries, because officials thought they could build a better one. Agency leaders did not coordinate with outside manufacturers for support, and they never performed any validations of previously developed tests that could have been used as backup.

Systemic failures. The documents also reveal something even more damning: that the failures extended far beyond any one lab. The test’s problems, the documents show, are a symptom of much bigger mistakes — still unexamined — starting with the Trump administration's lack of a pandemic plan, lack of leadership and coordination at federal public health agencies, and widespread medical misjudgment in the early days of the pandemic that left the CDC holding the bag for everyone else’s failures.
posted by darkstar at 5:03 PM on December 8, 2021 [7 favorites]

We talk a lot in the abstract about the superficial inefficiency of government work, vs. its ability to serve actual people (as opposed to just lucrative demographics). It's inefficient because it has to work for everyone, and it's great because it has to work for everyone.

But beyond those abstractions are actual government workers, and we don't talk about their productivity under a Trump administration the same way we talk about employees being inspired/intimidated to greatness by Steve Jobs or discouraged/intimidated towards self-sabotage by Steve Ballmer.

We've relied for so long on government workers being willing to work for far lower wages than the private sector in exchange for some combination of (1) job security and benefits, (2) experience and networking for more lucrative opportunities (and, yes, the occasional mostly-tolerable level of skimming off the top), and (3) Doing Good in the World.

The Trump administration marked a clear end to, or at least poisoning of, each of those incentives:
  1. He was performatively antagonistic to federal employee compensation and job security... his Secretary of Energy was the guy who couldn't remember that it was one of the top three departments he wanted to abolish.
  2. Experience isn't helpful to an administration that won't accept bad news, networking only becomes useful if you're helping to cover for your superiors' mistakes or malfeasance (and it sure helps with the skimming).
  3. And here's the kicker. Trump didn't want the government to Do Good in the World. Even if you ignore the griftiness, just assuming he's a post-Reagan Republican means at best "government is not the solution to our problem, government is the problem."
So yeah, we can look back and recognize that labs were underfunded and understaffed. They were, that's been the trend for decades. But why did they fail here, now?

Because when you're holding things together with duct tape, you still need someone who's incentivized to apply the duct tape.
posted by Riki tiki at 7:31 PM on December 8, 2021 [26 favorites]

There was a netflix documentary that covered parts of this, albeit focused mostly on the last part (Trump admin incompetency). IIRC in the documentary they point out that the head of the CDC was a Trump admin apointee and almost comically incompetent, but that even after the initial failure of the test, they still could have salvaged the results by approving for the tests to be used in a modified way (only use 2 of the 3 results the test looked for, because the 3rd part was compromised but not strictly necessary for detecting COVID).

For that to happen, they needed the Trump admin to fast-track the paperwork as an emergency case. This is what did not happen, because the admin wanted to slow down the testing so the numbers would look better for them.
posted by subdee at 10:45 AM on December 9, 2021 [5 favorites]

It kind of shows that if all parts of government work as they're supposed to, it doesn't matter so much who's ultimately in charge. But if there's an issue that requires a decision from leadership, who's in charge suddenly becomes extremely important.
posted by subdee at 10:47 AM on December 9, 2021 [2 favorites]

After reading about this in the NYT story in Jan 2021; I have felt that any historical postmortem, 20 years from now or so; is going to place a majority of the blame for the initial dysfunction on the HHS/FDA/CDC cockup of the initial testing protocol.

It is more disheartening, because the folks in Washington State, where the first cases were discovered, knew the CDC was fucking up and tried their best to get on top of it early. The hubris of CDC had nothing to do with the Trump Administration, underfunding, lack of incentive for doing their best etc.
posted by indianbadger1 at 10:47 AM on December 9, 2021

How much did this actually affect the course of things given what we know now about how this disease spreads and superspreaders?
posted by interogative mood at 12:09 PM on December 9, 2021

How much did this actually affect the course of things given what we know now about how this disease spreads and superspreaders?

My then-7 daughter's then-7 friend's mother is an X-ray tech in Boston, who spent that interval diagnosing Covid with chest-rays while wearing the n95 masks I found in my house.
This shitshow damn near turned my kid's playmate into an orphan.
posted by ocschwar at 12:15 PM on December 9, 2021 [9 favorites]

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