Scoop: The new #2 at CDC is a top ivermectin prescriber who ended Louisiana’s vaccine-promotion media campaigns.

The current Surgeon General of Louisiana has made headlines recently, including for allegedly burying a whooping cough outbreak.

We have some breaking news that I believe we are first to report, right here in Inside Medicine. My thanks to the HHS employees who continue to bravely speak out. It is important that we amplify them. Thank you for your help doing that—by reading, sharing, and supporting this work.

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The CDC’s internal email server now lists Louisiana physician Dr. Ralph Lee Abraham as the agency’s Principal Deputy Director. Until now, Dr. Abraham has served as Louisiana’s Surgeon General. The above screenshot was provided to Inside Medicine on the condition of anonymity. While the news has not yet been publicly announced, an HHS spokesperson confirmed the news to me this morning.

“An irresponsible choice.”

One source, a national public health expert who previously served in government and is familiar with Dr. Abraham’s career, said that this would be “an irresponsible choice.” He added that “he’s a dangerous guy because he’s very slick,” referring both to his style and his experience as a US Congressman from 2015-2021.

Here are some recent highlights from Dr. Abraham’s career:

• In February 2025, Dr. Abraham made headlines by announcing that Louisiana would end mass vaccination campaigns. While Abraham may not be a strict anti-vaxxer (he said that childhood immunizations are “important”), the announcement came the same day that Robert F. Kennedy Jr. was confirmed as Secretary of the US Department of Health and Human Services—not exactly a subtle way to audition for a top job within HHS.

• The state of Louisiana, under Dr. Abraham’s leadership, failed to alert physicians about two whooping cough deaths (and the largest outbreak in the state in 35 years) in 2024-2025 for months, despite medical professionals’ attempts to raise the issue. Whooping cough (also known as pertussis) is a vaccine-preventable disease, making outbreaks crucial information for the public.

• A MedPage Today analysis found that out of around 12,000 practicing physicians in 2021, Dr. Abraham was the 7th highest prescriber of ivermectin in the state, a drug that by then had already been found in some high-quality clinical studies to be ineffective in treating Covid-19. Dr. Abraham prescribed the medication 422 times in 2021, which meant that he was personally responsible for 1.1% of the state’s ivermectin prescriptions. In fairness, that pales in comparison to Texas physician Dr. Stella Immanuel (yes, the demon sperm lady), who milled out 31,979 ivermectin prescriptions in 2021, thereby accounting for 1.7% of the entire nation’s prescriptions of the drug that year (which, by the way, does reduce malaria transmission).

• As the opioid crisis became more apparent last decade, Dr. Abraham was found to be among the most active prescribers of the drug class. The Advocate in Baton Rouge, LA, reported that “Abraham was in the top 0.2% in the number of Medicare Part D patients he wrote opioid prescriptions for in 2013, according to data from the U.S. Centers for Medicare and Medicaid Services.”

• While Dr. Abraham is an MD, and presents himself as a “family physician,” it appears that he is not board-certified in Family Medicine, a recognized medical specialty. He is still licensed to practice medicine, however.

One CDC employee I spoke to was philosophical about the news, saying, “I’ll tell you, I heard way worse names floated,” when I shared the name of the apparent pick. That scientist felt that, while Abraham’s views were “probably pretty terrible,” he at least has genuine experience running a major public health system. “Look, I don’t think any of our top leadership is up for the job. Who there has large organization management expertise?” the CDC employee asked. “They also lack subject matter expertise, for that matter, but that’s another story” he added.

Dr. Abraham’s X/Twitter account follows 45 other accounts, including Secretary Kennedy. A notable omission? US Senator Bill Cassidy of Louisiana, a physician who chairs the Senate HELP Committee that confirmed Kennedy. (Cassidy has taken enormous heat for his vote to confirm Kennedy, and has expressed discontent with the Secretary since he assumed the job.) In fact, Senator Cassidy has had choice words for Abraham this year…

How Secretary Kennedy may be leveraging federal law to maintain maximal control at the CDC— for a long, long time.

…And that may be what this is about.

Soon after Secretary Kennedy broke promises he had made to secure Senator Cassidy’s decisive confirmation vote, President Trump’s initial nominee for CDC Director, Dr. Dave Weldon, was hastily withdrawn. While it’s never been corroborated, I’ve always felt that Cassidy’s early regrets over his vote for Kennedy were what killed Weldon’s nomination, as Weldon also had an uncomfortable track record on vaccine skepticism. Cassidy, who truly is pro-vaccine, did not want to repeat his mistake on his Kennedy vote with Weldon, or anyone else. As I wrote last summer, I believe Dr. Susan Monarez’s confirmation as CDC Director was slow-walked by HHS because, by then, RFK Jr. had sorted out that Monarez (the replacement nominee to run the CDC after Weldon’s bid fell apart) was, in fact, also pro-vaccine. Drawing out Monarez’s confirmation process left Kennedy with more power—power that was lost when she was finally confirmed, but which he reclaimed once Monarez was forced out of the job just weeks later.

This set up a potential stalemate. President Trump needs a new CDC Director. Secretary Kennedy does not want that person to be pro-vaccine. But Senator Cassidy, having learned his lesson on the issue precisely one vote too late, probably views pro-vaccine stances as a necessary condition for any future confirmation vote on the next CDC Director. (Within the CDC, the Director has the exclusive authority to sign off on national vaccine policy recommendations, recommendations that, by law, compel insurance companies to cover vaccines in their policies. That renders the CDC Director position, acting or permanent, an essential key to RFK Jr.’s campaign to end the US vaccine program as we know it.)

So, given the barrier Cassidy now seems to represent, what is Secretary Kennedy to do? Easy. Game the system by stalling.

To understand how long Secretary Kennedy can effectively control the CDC Director position without another pesky confirmation—in which I believe Senator Cassidy would, this time, do the right thing by holding the line for vaccines—I spoke to Stanford Law Professor Anne Joseph O’Connell. Here’s how it could work out:

Since Kennedy fired Susan Monarez, the CDC’s Acting Director has been Jim O’Neill, a biotech executive installed to do what she would not—that is, Secretary Kennedy’s bidding on vaccine policy. (Whatever else one might think, the CDC’s own regard for O’Neill is such that it could not even be bothered to spell his name correctly on its leadership page.)

It's spelled with two l’s, people.

But under the Federal Vacancies Reform Act, Acting Directors can only serve for 210 days. That means that the Trump administration can lean on O’Neill only until late March. After that, a new Acting Director cannot be named unless a permanent Director has been officially nominated. (The 210-day limit applies to the position, not the person, Professor O’Connell told me.)

Absent a permanent nominee, this means that 210 days after Monarez’s firing, the job of Acting CDC Director would be broken up in two ways. Most duties would fall to the next person in line at the CDC—in this case, the apparent new Principal Deputy Director, Dr. Ralph Lee Abraham. But by federal law, there are some duties that may not be devolved to a lower position in the agency, but rather, only upwards—that is, to the HHS Secretary. For example, it was for that reason that only Secretary Kennedy could sign off on recommendations from the CDC’s Advisory Committee on Immunization Practices earlier this year.

However, the Principal Deputy Director can serve indefinitely, and is not a Senate-confirmed position. So, it’s possible that with Dr. Abraham in place in the #2 role, Secretary Kennedy and President Trump could run the clock on this for a long, long time. That’s because the moment Trump nominates a permanent CDC Director, the 210-day clock extends. So, that means that, say, in late March, there could finally be a new nominee. At that point Kennedy could simply swap in some other lieutenant (the delicious etymology of that word comes from the French, lieu-tenant, or “place holder”) as Acting Director for the entire period during which the nominee is under Senate consideration, plus another 210 days. On top of that, this cycle can repeat twice (O’Neill is the first, because Monarez’s confirmation last summer reset the game).

All of this means that Secretary Kennedy may be able to fully leverage the power he seeks at the CDC by having Dr. Abraham serve as Principal Deputy Director in name only, giving him the tacit power to provide marching orders to his boss, whether it is Jim O’Neill (now through the end of March) or someone else (the second permitted Acting Director placeholder installed after a new permanent nominee is named, which, again, could be anytime between now and late March). So, it could be 2027 before President Trump once again faces the specter of a CDC without an Acting Director. But, even then, why would he care, if Kennedy and Abraham can assume all of the duties?

So, once again, Secretary Kennedy may have found a way to exert the most influence that he possibly can. He may not know much about science, medicine, or health, but he seems to know at least some of our nation’s federal laws. Unfortunately.

If you have information about any of the unfolding stories we are following, please email me or find me on Signal at InsideMedicine.88.