WASHINGTON The Centers for Disease Control and Prevention, the countrys top public health agency, is being kicked around by the White House. And it doesnt have much power to kick back.

As President Trump spars with nearly all of the federal agencies that have a hand in his administrations much-maligned response to the coronavirus pandemic, hes been particularly successful at sidelining the CDC.

Theres good reason. The CDC, far more than other agencies, struggles with a slew of structural and cultural issues that have left the agency ill-equipped to fend off political attacks, or even to build up the political capital that could have helped it navigate the stark spotlight it finds itself in now.

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With nearly all of its staff including its director based in Atlanta, the agency relies on a tiny D.C. office, currently leaderless, to navigate interactions with the White House or Capitol Hill. Even when the rest of its staff are taken into account, the CDC has just a fraction of the connected political staffers that can help other health-focused agencies like the Food and Drug Administration and Centers for Medicare and Medicaid Services in their Washington liaisons. And while deep-pocketed pharmaceutical companies and influential research universities often help agencies like FDA and the National Institutes of Health press Congress for bigger budgets and influence, they have little to gain by advocating for CDC.

Former staffers at the agency, at the Department of Health and Human Services, and the other agencies under its umbrella, also described a culture focused on avoiding politics one that has left the agency unprepared for the political pressure of handling the coronavirus response, or for Trumps onslaught of criticism and pushback.

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The problem that they often have is that they tend to ignore the politics, said David Rosner, the co-director of the Columbia University Center for the History and Ethics of Public Health. Theres a culture there that is conducive to being manipulated.

The agency has no experience with responding to this level of political attack, agreed former CDC Director Tom Frieden, now leader of an initiative to prevent epidemics and cardiovascular disease.

I dont know of any precedent for whats happening, he told STAT in an interview. The key to having an effective public health agency is that it is close enough to the rest of the government for its advice to be trusted and listened to, but far enough [away] for the public to trust that its valid, and for 74 years the CDC has had that role. Its an extraordinary time right now that it doesnt.

The clearest and most obvious marker of the CDCs distance from politics: its headquarters are in suburban Atlanta. Every other federal agency of its size is based in the D.C. metro area.

In a city that runs on handshakes, face time, favors, and gossip, the CDCs absence puts it at a distinct disadvantage, former CDC and HHS officials acknowledged to STAT.

The ability to do your job depends on how effectively you build working relationships and partnerships with people, said Howard Koh, who served as assistant secretary for health during the Obama administration. Logistically, its a lot easier to meet people and build relationships when youre at the [HHS] building [rather] than in Atlanta.

Nicole Lurie, who, as the assistant secretary for preparedness and response from 2009 to 2017, enjoyed an office on the sixth floor of the HHS building in downtown D.C., echoed that sentiment. The ASPR is perhaps the closest parallel position to the CDCs director when it comes to pandemic policy.

Its not only being able to walk into the secretarys office, its lots and lots of other people who surround the secretarys office that are influencers in one way or another, she said. Lurie added that it would be much harder to have done her job if her office was not based in the HHS building.

Frieden, too, said he realized quickly that the job would be easier if he spent time in D.C.

I made between 250 and 300 trips to Washington, Frieden said. I could come up for two days, I might have 15 meetings, a breakfast, a lunch, a dinner, another breakfast, another lunch, and then Id go back.

Adding some insult to the distance:Rather than reflect current practical realities, the CDCs Atlanta address apparently stems from concerns about mosquito breeding patterns back in the 1940s.

The agencys predecessor, the Communicable Disease Center, was founded in 1946 in Atlanta to quell the spread of malaria in the American South. Eventually the CDC gained a permanent foothold in the city, thanks to a land grant from Emory University and a deal struck between Coca Cola CEO Robert Woodruff and President Dwight D. Eisenhower, according to historian Elizabeth Etheridge.

The agency does have a small office in Washington on one floor of a nondescript office building a mile from the Capitol. They spend most of their time answering questions from members of Congress, and serving as a kind of surrogate at HHS leadership meetings.

The office is currently led by an acting director, Anstice Brand Kenefick. She getsrave reviews from congressional staffers, one of whom called her perhaps the only official at her level I feel I can trust in this moment and incredibly competent. But she has not been promoted to the permanent position, which has been vacant since the last director resigned in late 2016.

A CDC spokesperson told STAT that the agency is still actively recruiting for the position, although STAT could not locate a job listing online.

How well the CDC navigates Washington is largely a function of how well its director can move the levers of Washington.

Much of that job, multiple sources told STAT, is focused on doing whats best for public health, while also navigating the roadblocks often created by Washington politics.

The directors are often between a rock and a hard place, they are trying to make the case in Washington for what the evidence-based approaches would be, and encountering politics, and then trying to explain back at the agency how some of the recommendations that are being made [by the CDC] may not be possible given the political environment, said John Auerbach, the president and CEO of Trust for Americas Health and a former associate director of the CDC.

That tension has been on full display in recent days as CDC Director Robert Redfield has attempted to defend the CDCs school reopening guidelines amid calls from Trump and Vice President Mike Pence to significantly water them down. Political pressure from the White House forced the CDC to shelve similar guidelines on reopening community spaces, like churches. A senior HHS official even accused the CDC of undermining the president after it released a report on the risk of coronavirus for pregnant women.

The CDC director is also naturally a weaker figure than other agency chiefs like the FDA commissioner or the NIH head.

Unlike those and other top health positions, the CDC director is not Senate-confirmed. Even jobs like surgeon general technically below the CDC director in the HHS hierarchy go through the confirmation process.

The Senate confirmation process can be bruising, but it also builds relationships between lawmakers and officials. Most endure countless one-on-one meetings aimed at convincing skeptical senators that theyre ready for the job.

When you have a Senate-confirmed person in there it signifies a level of agreement and support from both the president and the senate about the direction of the agency, said David Lewis, a professor of political science at Vanderbilt University who studies the political appointment process. It gives the head of the agency some political clout.

That fact has even left career HHS officials scratching their heads. No one STAT spoke to could articulate why the CDC director is not Senate-confirmed.

I never understood that, Koh, the former assistant health secretary, who was himself confirmed by the Senate, told STAT with a laugh.

The CDC directors weak position often forces them to rely instead on the HHS secretary for political support.

The relationship between the CDC director and the HHS secretary is really important, because the secretary can either use their political connections in the White House to protect and support the CDC or they can take a step back and let the CDC be hung out to dry, a former CDC official told STAT. Its kind of crazy: This huge, highly influential agency and we had almost no political heft behind us.

Some of the blame for the CDCs failure to ward off political pressure this time around should fall on health secretary Alex Azar, former HHS Secretary Donna Shalala told STAT in an interview.

When the White House wants to interfere, theyll interfere not directly through the CDC director, but through the secretary, Shalala, who now serves as a Democrat in the House of Representatives, said. The secretary has to make it very clear: Do not touch.

In the case of Redfield, there are tensions with the White House beyond the usual structural ones: While Redfield was once dubbed the MAGA whisperer for his willingness to appeal directly to Trumps ultraconservative base, Trump has beaten up viciously on the CDC. Rumors have swirled for months that Redfields job is in danger because of Trumps ire.

The directors tenuous relationship to D.C. politics as well as the agencys physical distance from D.C. have trickled down to the staff, too, former staffers said. The agencys roughly 20,000 employeesignore politics far more than other federal agency staff.

When you live in D.C., you read, you converse, you breathe the political atmosphere, its not something you have to stop and think about its second nature. And thats not true in Atlanta, said the former CDC official, who added that most staffers in Atlanta had the false impression they were protected from politics.

They would rather not pay any attention to the political back and forth, remarked Lurie, the former assistant secretary.

Even Frieden, the former CDC director, alluded to the ways CDC officials had a false sense of protection from politics.

CDC scientists used to say to me, Isnt it great we are in Atlanta? We dont have to get bugged by the folks in Washington all the time. But wow, why is our budget so low? Frieden said.

Some of that is by design.

The CDC has an unusually small cadre of political appointees, the staffers who are installed by the White House and often have backgrounds on Capitol Hill or in political campaigns.

Politicalappointees across the federal government have often been accused of undermining policies for fleeting political reasons. Yet there can be advantages to integrating political considerations into an agencysoperations something that rarely seems to happen at the CDC.

Political people can help you secure the resources and political support you need to do the job youve been asked to do, said Lewis, the Vanderbilt University professor. Career people just arent as good at that.

Nearly all other federal health care agencies are chock-full of these staffers. As of August 2018, HHS had more than 30 political appointees and the FDA alone, which, like the CDC, is a sub-agency under the HHS umbrella, had at least 14, according to records obtained by the advocacy group American Oversight. They often occupy key positions like chief of staff and assistant secretary, but even schedulers and executive assistants are often also political appointees at some agencies.

But as of April 2019, there were only three political appointees currently employed at CDC, according to the records obtained by the advocacy group. That number appears to have recently increased: A CDC spokesperson told STAT there are currently six appointees currently employed at the agency.

The lack of appointees at the CDC is so striking that one former HHS official described it as a failure, and added that an agency of that size should have at least twice as many.

The lack of political appointees at CDC has caused somewhat of a culture clash between CDC and HHS officials too, officials from both acknowledged.

Theres always the balance between wanting to be well-integrated into the department, which is stocked with political [appointees], said a second former CDC official. If you stand off and you dont engage then you dont know whats going on and you arent very effective, particularly in sending things back to Atlanta.

Some of the CDCs defenders insist that the agencys cultural clashes with Washington arent entirely its fault. Some of that friction comes from the fact that public health departments are often the bearers of bad political news, they insist.

Public health departments at all levels of government are often thought of as not team players, said Trust for Americas Healths Auerbach. They make people uncomfortable because they release information that is not always politically appealing. Thats true of CDC, its true of state health agencies and city health agencies we do make people uncomfortable.

Auerbach too, however, added that he was really struck by how people [at CDC] are not politically focused.

At least some of the power and influence an agency yields in Washington comes from the industries it regulates.

Take the annual government appropriations process, in which lawmakers haggle over how much taxpayer money will go to every federal agency from the SEC to the EPA. Many of the countrys most powerful industries have a stake in making sure the agencies they rely on have the funds to be efficient. So they aggressively lobby Congress to make sure theyre well-resourced.

Pharmaceutical companies, for example, regularly lobby Congress to fund new FDA staff positions in hopes of speeding up the drug approval process or getting more attention on a certain priority. Research universities press lawmakers for new funding for NIH in hopes of eventually getting access to new federal grants and other research funding.

There is a political economy problem, Frieden said. If you look at the NIH, the NIH gives most of its money to universities, universities are in every state in the U.S., every congressional district just about, and they have boards. The boards are powerful people, they donate money to politicians.

Frieden contrasted that to the public health departments that typically benefit from CDC funding. When compared to research universities, public health departments are schlubs, basically, he said.

Even the Association of State and Territorial Health Officials, which represents state health departments, wont always advocate for increased CDC funding because so many state health departments are overseen by Republican governors who oppose increasing taxes, Frieden said,adding that ASTHO is still a very good association. .

Michael Fraser, the executive director of ASTHO, acknowledged the limits of what his organization can do to boost the CDC.

Just in terms of money and influence, we are very different from the NIH that has universities and deans, FDA which has industry and consumers, Fraser said. Public health has had a much smaller advocacy voice.

Public health groups have been complaining for years over the CDCs chronic underfunding. A 2019 report from Trust for Americas Health found that the CDCs budget fell by 10 percent over the last decade, when adjusted for inflation.

The Trump administration has also proposed massive cuts to the CDCs budget, although Congress has rejected those requests. The administrations 2021 budget proposed cutting $1.2 billion from the CDCs budget and roughly the same amount in 2020.

CDC scientists used to say to me, Isnt it great we are in Atlanta? We dont have to get bugged by the folks in Washington all the time. But wow, why is our budget so low?

Tom Frieden, former CDC director

While advocates admit the agency is ill-equipped to deal with political attacks, theyre also not sure they want the agency to become more political.

Many told STAT they see the CDCs ability to ignore politics in favor of science as an achievement, not a fault.

CDC continues to be the worlds premiere public health institution and should be treated as such during this pandemic. It is a scientific organization that functions best as an apolitical agency trusted to guide the strategy of our nation to be healthier and safer. We must amplify the unfettered voice of CDC, not stifle it, nearly 350 public health groups wrote to HHS Secretary Alex Azar earlier this month.

Advocates pushed back strongly against any proposal to make the agency more politically savvy, including installing additional political appointees that potentially could help the agency navigate Washington.

To protect the science, you have to protect the professionalism, said Shalala, the former HHS secretary, who pushed back against the idea that adding political appointees would help the agency navigate Washington.

But its abundantly clear too that no one knows exactly how to help the CDC at this moment.

How do you deal with that situation politically when the leader of the country isnt following your guidance and youre trying to stop an epidemic? ASTHOs Fraser said. I dont think anybody even thought that was a possibility. Maybe we should have, I dont know.

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The CDC is an apolitical island. That's left it defenseless against Trump - STAT