Updates on the attack on US public health from within (January 23-24, 2025).

The news was mixed today. Here's what happened.

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Interim CDC Director named. Reactions from both sides of the political spectrum.

Politico reported that senior HHS official Dr. Susan Monarez has been asked to serve as interim Director of the CDC. If so, Monarez would lead the agency until Trump nominee Dr. Dave Weldon is confirmed. As a date has not yet been set for the confirmation hearings, Monarez’s tenure could last a while, especially since the CDC Director position had never been Senate-confirmed until now. The change requiring Senate confirmation came in 2023 (after the last director was installed), so, this is new terrain for the Senate.

What we know about Dr. Susan Monarez. Monarez served as deputy director in ARPA-H (The Advanced Research Projects Agency for Health) starting in January 2023 and is considered an expert on AI and other health technology.

The good. I spoke to multiple insiders today who know Monarez to varying degrees, including people on both sides of the political divide. The general consensus is that she’s a smart and qualified individual.

“People who work closely with her really enjoy working with her. She’s a breath of fresh air….She’ll be even-keeled and reasonable,” Dr. Rick Bright, a former senior HHS official told me today. While noting that Monarez likely wouldn’t push back too hard against any Washington influence, he said that is to be expected in any interim role. “Susan brings in-depth expertise in AI to the table. This is not only a primary focus of the new administration, but it would certainly serve the CDC well, as they transition into the modern data era.”

The choice “seems solid,” a former Biden White House official told me.

Another highly knowledgeable expert who supported the choice in Monarez said that given her status as both a health data expert and a true CDC outsider, she might find the CDC’s data systems to be rather antiquated.

The less good. Reporting by others suggests that anyone being considered for a major role in the Trump administration had to either explicitly or implicitly pass some kind of loyalty pledge. If true, anyone filling key positions may lack the independence we’d like to see.

The nitty-gritty. In the past, interim CDC Directors have always come from career officials within the agency. This has made prior transitions boring but smooth. Because Monarez has never worked in the CDC, she will have a steep learning curve. By the time Monarez is up to speed, the permanent Director may well be confirmed. That means that Deputy Directors Dr. Deb Houry and Dr. Nirav Shah will likely be steering the wheel on many important issues for some time.

ICE now permitted to enter hospitals. What do doctors need to know?

This week, President Trump ended a “sensitive locations” policy that technically protected immigration law enforcement officials in places like hospitals (and also churches). Does this mean that ICE (Immigration and Customs Enforcement) could now show up in the ER and ask us questions? Apparently so. Would healthcare providers have to provide demographic information? That’s another story.

First, this is terrible health policy. We don’t want people avoiding life-saving care out of fear of getting rounded up by ICE. It’s just cruel. Also, if ICE is so bad at its job that it has to raid hospitals, it needs some serious improvement.

I expect responses to this policy to differ around the country. But here’s what I’d like—and frankly expect—major hospitals to advise clinicians seeking to help their patients:

1. We should err on the side of minimal demographic documentation. It can be useful to document demographic data for various epidemiological and quality purposes. At this time, it may not be worth it. And, actually, not documenting this information would ironically align with the administration’s stated preference against DEI efforts, many of which rely on careful tracking of exactly this type of demographic information for outcomes and disparities research. In the present environment, we might remember that a patient’s immigration status is not usually an important part of their medical circumstance—and if it is, it can be described neutrally. For example, instead of documenting “40-year-old Mexican patient who in the US without legal documentation needs emergency dialysis” one could write “40-year-old man without access to dialysis due to social determinants of health needs emergency dialysis.” Not only is this accurate, but (as my medical colleagues will know), that’s some good Category III for Medicare and Medicaid documentation right there! (Not that it would matter, in such cases, but whatever.)

2. Advice on what to do if an ICE official asks health providers for information. If it were me being snooped on about some patient under my care, I suppose I’d ask ICE (or some Homeland Security official) for a warrant. But, honestly, that seems a little aggressive and above my pay grade. So, I’d probably just call my supervisor, or legal. That said, as one writer reminded us today, the 4th Amendment requires ICE to provide a search warrant, so remaining silent is a perfectly reasonable option. However, that does not mean we are allowed to obstruct or lie. So, we should be careful.

Public health gag order update: Are key datasets being censored?

The Trump Administration gag order on public health communications continues to be a source of confusion. As someone who does lots of data analysis, the CDC’s weekly data updates contain crucial information. Yesterday, I told you about the CDC’s vaccination dashboard not being updated. Today, we saw an important dataset updated related to Covid-19, RSV, influenza, and other conditions like drug overdoses. That was an encouraging sign.

The reason for this potentially good news may be due to exceptions outlined in an HHS memo obtained and published by independent journalist Ken Klippenstein. In it (item 5, below), officials can ask for exceptions related to “critical health,” including reporting requirements under Federal law. Because hospital reporting on Covid, flu, and RSV is indeed a requirement stemming from a Federal Rule, the data we need might fall under this carve-out. We’ll find out tomorrow when the data we need to run the Inside Medicine data dashboard either does or does not get refreshed, as usual. Still, the notion of needing to ask for permission for transparently providing government data as usual is chilling—and a dangerous precedent.

Meanwhile, the CDC’s Morbidity and Mortality Report indeed was not published Thursday, marking the first time it was absent from circulation in its over 60-year history. Unreal.

On a lighter note…

I worked in the ER from 7 a.m. until around 5 p.m. today. It was stressful, but it felt good to see patients. And something really cute happened today that might cheer you up, as it did me. The secretary in the department (the nicest person you’ll ever meet) asked me a question I’d never heard before:

“It’s the Franklin Zoo on the phone. They want to know if they can proceed with using ultra-high doses of opioids for a surgery they need to do on one of their animals.”

“Huh?” I asked.

She told me that whenever the Zoo needs to use high doses of powerful opioids (as in, “moose tranquilizers” like carfentanil), there’s a policy that they need to inform a hospital. The idea is that if any humans are accidentally exposed (e.g., get squirted in the eye, which has happened—they were fine), we’d know ahead of time what was going on.

I gave my approval on one condition: I wanted to know the kind of animal they were treating. It was a zebra, I told. I’m glad, I said, and not one of these lovely guys below. That way, I could tell you this story. After all, we wouldn’t want any HIPPO violations!!!

(I’ll show myself out).

Goodnight, everyone!

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