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President Biden's that Mandy Cohen, MD, MPH, would be the next director of the CDC represented the likely end of an era for the way this position is filled.

The CDC director job hasn't required Senate confirmation, but that's going to change beginning in January 2025, thanks to a provision in the passed by Congress. On page 3,196 of the 4,155-page bill, it states that the CDC director "shall be appointed by the President, by and with the advice and consent of the Senate." Page 3,203 notes that this provision will take effect on Jan. 20, 2025.

Is this a good idea?

"The pros are that Senate confirmation gives you a more exalted status in the eyes of the Congress and in the eyes of the White House, because Senate confirmation is a category unto itself," J. Stephen Morrison, PhD, senior vice president and director of the Global Health Policy Center at the Center for Strategic and International Studies, in Washington, said on a phone call.

"It confers status and gravitas upon that position, and acknowledges that this is truly a leadership position within the U.S. government," Morrison continued. "That, to my mind, is very important because the director of the CDC has often lacked gravitas, lacked access to the president and the president's key folks and been a minor [figure] -- and at times an afterthought -- in key interagency processes, and has lacked political acumen and sway. So that's the pro side."

"The con side is when Congress has malevolent intent," said Morrison. "It can [be] hostile, or antagonistic and skeptical, of CDC when CDC is politicized and weak or in an imperiled position -- which it currently is -- where its performance has declined and public trust and confidence has declined, particularly among Republicans and conservatives. Then a confirmation process can become subject to lots of delays and performative art and not be all that helpful."

Jeffrey Levi, PhD, professor of health policy and management at the George Washington University Milken Institute School of Public Health, in Washington, also addressed both sides of the issue. "It certainly elevates the CDC director to be the equivalent of other operating divisions at HHS," he said in a phone call. But "it conceivably could further politicize the approach to CDC. It depends on how the Senate approaches their work."

No matter how you look at it, the new CDC director will have a tough assignment, according to Thomas Miller, JD, resident fellow at the American Enterprise Institute, also in Washington. "The CDC internal culture became such a mess that it's hard to imagine anyone with the political and managerial skills to straighten it out," Miller said in an email. "But for that reason, it does need to be a politically confirmed appointment, even if those politics are rather distorted recently."

One of the biggest problems Cohen will face once she takes the reins at the agency is a decline in trust of public health officials. "The decline of trust is very broad -- it applies to science writ large, to public health institutions, and to authority" in general, said Morrison. The advent of the COVID-19 pandemic "pushed, exposed, and stressed the institution in profound ways that it had never experienced. And so all of these weaknesses and gaps in capabilities were exposed dramatically, including the inability to communicate very well in a context of out-of-control misinformation, disinformation, and conspiracy thinking."

"The public health world was very slow to come around to understand that since 1998, when the digital world really sort of arrived, that it's been a different world, a different climate, and there are lots of different forces that chip away at the notion that we should be trusting these institutions," said Morrison. "And there's been a kind of sluggish, inertial response to 'How are we going to understand this, and how are we going to deal with it?' So we're playing catch up."

The CDC "remains a still-broken agency," said Miller. "The trains will run less erratically and slowly with new leadership, but where they head will be determined by larger political forces and calculations. Running CDC in a less-polarizing and more-competent management style would be a good first step ... One step at a time."

Cohen also will need to help shore up state and local health departments, Levi said. "We can have a perfect CDC, but if we don't have a strong state and local public health system, then we will still not respond well to the next emergency."

Improving the situation will include strengthening "everything from the data collection to whether you have the analytic capacity, and whether you have the workforce that can do the data work, the community engagement, and the trust-building that you need that is built from the ground up," he added.

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