Can We Still Trust the CDC? with Tom Frieden

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The Centers for Disease Control is our number-one resource for preventing and fighting a pandemic. With its credibility very much in question, Andy calls up his former colleague Dr. Tom Frieden, who ran the CDC for eight years during the Obama Administration, to discuss what the CDC does, how it’s doing, and the overall U.S. response to the pandemic.

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[00:05] Andy Slavitt: Welcome to In the Bubble. I’m Andy Slavitt. Tom Frieden is on the show today. Tom Frieden was the head of the Centers for Disease Control in the Obama administration for eight years. He is one of the most prominent public health figures in the country. He is a good friend. We served together. What I want you to hear, what I want to explore with Tom, is what is the CDC supposed to do? How have they done? And I want you to hear from someone who has run the place that I think is a bit different from the guy running the place now. Now, I’ll tell you, Tom, like me, he will do his best not to disparage the political leadership at the CDC. He is very polite. He is incredibly respectful of the researchers and the scientists at the CDC. He led them. He wants nothing but the best for them. And quite frankly, he is not that interested in the political elements of the virus. He is very interested in saving lives. He’s a guy who spent his entire career doing that. So you’ll see that I try a couple times to see how far he will go in criticizing the CDC. He is honest, but he sticks to his knitting and talks about what needs to happen. And in any case, I think, incredibly important for people to understand that, like some of the people we’ve had in prior episodes — Larry Brilliant. David Agus, a guess who is on our vaccines episode. Mark McClelland from the FDA, who was on our vaccines episode. Vivek Murthy, who was the surgeon general. Ron Klain, who ran the response to Ebola. Lanhee Chen, who was the health care policy person for Mitt Romney. There are great public servants out there. There are great people still to run the departments and the areas and the agencies that are the great institutions that make healthcare work. I think you’ll find when you hear Tom, the same level of comfort you heard from those folks. I also think it’ll give us a deeper understanding of how all this stuff works at the CDC. So let’s ring up Tom Frieden. 


[02:29] Tom Frieden: Hey, how are you? 


[02:31] Andy Slavitt: I’m good. Thanks for doing this. So maybe start with telling everyone what is the mission of the CDC, and what do we expect from the CDC in times like these? 


[02:48] Tom Frieden: CDC’s vision is a safer, healthier world. And it works 24/7 to protect Americans from threats, whether those are infectious diseases or other, whether they’re natural or manmade, whether they come from this country or anywhere in the world.


[03:07] Andy Slavitt: And describe a little bit of what the personnel, the people who work inside the CDC, what’s their background, what’s their career aspiration? What kind of folks are we talking about? 


[03:17] Tom Frieden: The CDC is both broad and deep. If you took a medical textbook and opened it randomly to any page, you would likely find one of the world’s experts in that condition at the CDC. Generally, people at the CDC have been there for a long time, sometimes decades, and they tend to specialize in their area. There are twelve or so different centers. That’s why the Centers for Disease Control and Prevention. And those range from injury dealing with opiates, for example, to chronic disease, dealing with heart disease and stroke, to respiratory illness, to HIV, TB, as well as hepatitis and other leading killers. And a global health center as well, because we are really living in an interconnected world. 

[04:05] Andy Slavitt: So when there’s a pandemic, what is the role of the CDC? Maybe you can take us through — we, of course, had a global pandemic while you were running the CDC. So maybe take us through what role CDC is supposed to play to help us as citizens and residents here in the U.S.


[04:30] Tom Frieden: CDC really plays multiple different roles. One of them is to be the technical experts and provide guidance and recommendations. And currently, even with all of the problems, CDC continues to play that role. There’s been 1.6 billion hits on the CDC website on coronavirus. It’s still, with reason, a highly trusted location for advice, recommendations and guidance on public health. In addition, CDC tracks diseases in the U.S. and globally, both through monitoring systems called surveillance systems or disease reporting, and through laboratory networks. And CDC has more than 200 specialized laboratories, which have generally performed extremely well, and been the reference laboratories for the world. Of course, that wasn’t the case here, where there was a significant problem with a CDC lab test early on. It’s since been resolved, but that was very problematic. CDC also supports state and local governments all over the U.S. So that includes sending staff, short term or long term, into governments, and it includes providing a lot of money to governments for what they do in public health. 


[05:42] Andy Slavitt: So one of the things that I think is going on in this pandemic — and I know you hear it and I hear it — is people want to know where they can find the most trusted information. Who do I believe? Do I believe my governor? Do I believe the president of the United States? Do I believe Anthony Fauci, who’s not in the CDC. Do I believe scientists at the CDC? How does it implicate my state and local public health officials? And then, of course, do I just believe Twitter? Because you got everybody and their brother who’s a epidemiologist or a pseudo-epidemiologist or a data scientist, all of whom have opinions, some of whom sound credible like Johns Hopkins, and some of whom we’ve never heard before. Who should people listen to? And where should people trust information they get?


[06:32] Tom Frieden: It’s not a simple question. And on the one hand, I would trust the information on because it is very carefully curated and reviewed. It may not always address the latest issue because CDC may be debating internally what does the science show. But I think there you can find reliable information and I encourage people to look there. Our own website, Resolve to Save Lives has useful information looking at coronavirus, and once a week we review the science with the latest information, latest developments. Also, it’s important to be clear about what the question is and what answer you’re seeking. There’s some questions for which we have very clear answers, and others that we really don’t know the answer. And sometimes you want to be really careful about people who tell you with great certainty, we know this is happening because that certainly tends to correlate inversely with the amount of scientific evidence backing their position. Within science generally, the more controversial there is, the more uncertainty there actually is. 


[07:41] Andy Slavitt: Got it. Yeah. So what are the things we say frequently on this show is if your source doesn’t say, I don’t know frequently, you probably don’t have the right source. And you’re someone who is modeled that by being very clear when you’re in the media on what we’re sure of, what we believe, what studies have shown but which isn’t proven, and what’s just completely not known yet, because we have a novel virus. But you’re saying people can take the information they see from the CDC at face value. But I think there’s a question that people have around our politics interfering with the advice they get from the CDC. And there are certain occasions where people have come to question it. Whether it’s because the CDC director appears after the president and the president says something that appears not to be correct or is a little bit outlandish. And then, you know, his aides are left to kind of not totally disagree with him, but come after him. So can you give us a sense, if you’d be willing, how much you think politics is playing into the general things coming out of the administration in general, the CDC in specific?


[08:51] Tom Frieden: I would say that most things coming out of the CDC are straightforward. And our science, especially the weekly bulletin they put out called the MMWR, that’s important, that’s unfiltered and it’s scientific information. And they cover some very dicey issues. And Andy, when it comes to science and administrations, I have to tell you that when I was CDC director for nearly eight years, I had on my wall a quotation from then President-elect Obama, before he had taken the oath of office. It was in a talk he had given. And he said “promoting science isn’t just about providing resources. It’s about protecting free and open inquiry. It’s about ensuring that facts and evidence are never twisted or obscured by politics or ideology. It’s about listening to what our scientists have to say, even when it’s inconvenient. Especially when it’s inconvenient.” 


[10:01] Andy Slavitt: One of the conversations that I’ve had with other folks who’ve served in government before as part of the role that I was supposed to play and you were supposed to play is to allow the staff, the career staff, to do their jobs uninhibited from political influence. Because it’s not as if under any administration, Barack Obama’s, Bill Clinton’s, George W. Bush’s, Ronald Reagan’s, anybody’s, that there aren’t political concerns that you don’t hear about. So knowing that you have such high-integrity people inside the CDC right now, but you look at the administration as a whole, are they respecting that quote from the president-elect Obama? 


[10:42] Tom Frieden: I’m not there, so I can’t comment directly, but the things that we’ve seen that are concerning are things like the mask recommendation. The day the CDC recommended it, the president said, I’m not going to wear a mask. Now, that may have been reasonable to say, for example, everyone around him is tested. So I’m not going to wear a mask. But at the minimum, we would have expected the head of state to say, I agree with his recommendation. I encourage you to do it. Or as the head of state, he could have told CDC, don’t make that recommendation. That’s within his authority. But if they’re going to make the recommendation, then it should be supported. More recently, we heard from unnamed sources at the Department of Health and Human Services that the Department of Defense will be distributing a COVID vaccine if and when one becomes available. Now, I don’t know what that means. The Department of Defense has zero experience delivering vaccines to doctors in this country. On the other hand, the CDC delivers half of all of the childhood vaccines to doctors in this country. And during the 2009 H1N1 influenza pandemic, we were able to use that infrastructure to have a very smooth delivery system for the H1N1 vaccine. So one of the real lessons of emergencies is use systems that work every day and make those systems work better. Don’t try to create a new system in the middle of an emergency unless there’s really no alternative.


[12:11] Andy Slavitt: Why do you think that’s happening, and why do you think we’re also seeing recently the CDC was displaying information on hospitalizations and that got changed and apparently moved over to Health and Human Services, although it’s not yet current. There was a controversy over recommendations around schools that CDC put out. And there was a subsequent release, additional work. What do you see going on? 


[12:37] Tom Frieden: I guess to be perfectly frank, the fundamental issue for me appears to be the lack of a coordinated national response. When Ron Klain came in as the Ebola coordinator, some people were critical because he didn’t have much public health background, but he served the essential function. He made sure that everyone got together, there was robust debate and then we agreed on what would get done, and then he focused on getting it done. So there was an organized approach as a whole community. And I don’t see that happening in this response. And the examples you’ve given are kind of illustrations of that, that is not happening on a regular basis, whether it’s reporting or vaccine planning. It doesn’t give you the sense that there is a clear line of command. And that’s the first thing you do in an emergency. You establish an incident management system with a clear line of command, with clear roles and responsibilities. I joked Ron when he left the Ebola response, that before he arrived, getting documents cleared was a long and painful process. And after he arrived, it was no longer a long process. 


[16:33] Andy Slavitt: So let’s see if we can get a question from Zach and then we’ll get into some of the details on how we’re doing and where we are and what people should expect. 


[16:40] Zach Slavitt: I was wondering, will the current CDC being so politicized hurt the credibility going forward of public health officials, and how can we keep politics out of public health? 


[16:50] Tom Frieden: It’s a great question. I wish I knew a foolproof answer. I do think that the CDC’s credibility has taken a hit and it’s going to take time for that to recover. Some of that hit is well-deserved because of problems they had with testing early on, and some of it is not deserved. I’ve said before that blaming the CDC for failed COVID response is like blaming someone who was bound and encased in cement for failing to swim. At the same time, how we protect public health going forward is a real challenge. Some of that is what we as a society do to understand science, to respect science, to understand that all voices have the same value when it comes to political opinions, but not all voices have the same credibility or validity when it comes to scientific information. And then I think Congress and the executive branch going forward will need to look at what are ways to ensure adequate independence of public health data and public health decision-making without being unrealistic. Because our decisions in public health are political decisions. Whether to close bars, whether to open schools and how, who should be prioritized for testing or vaccine. Those are both scientific questions and also political questions. So you want to be clear that, yes, public health has an absolute role to play. But policymakers also have a role to play. And you need to keep that separate. That’s why in public health, we try to avoid making policy recommendations that aren’t within our wheelhouse. At the same time, we wouldn’t want public health recommendations to be overruled by politics and not based on science.


[18:38] Andy Slavitt: OK, so how are we doing? Here we are. It’s August of 2020. I think we’re four or five months into the virus hitting the shores here in the U.S. How are we doing and how are we doing compared to how you thought we would be doing, if you look back to February when things really started to happen here?


[19:00] Tom Frieden: As a country, as a whole, we’re not doing well. We’re an outlier and a laggard globally. You just look at the curves in the U.S., where you have this huge peak and then a little bit of decline and another big peak. And Europe, where you have a peak and then a big decline, and Europe is opening up again. Countries all over the world are doing a better job than we are because they have an organized response. And what you’re seeing at this very time in parts of the South is some progress. Positivity rates are coming down. Hospitalizations are coming down. But at a very high level. So although it’s better, it’s still not good. And lots of disease spread means a great deal of difficulty getting kids to school, getting back to work, recovering our economy and saving lives. The U.S. will hit 200,000 deaths well before the end of this year. And that’s a terrible milestone. If we had the same death rate as Germany, we would have a quarter of the deaths we have now. And we’re going to close out this year, 2020, with COVID being the third leading cause of death in the United States after heart disease and cancer. If we had the same death rate as Germany, COVID wouldn’t be in the top 10.


[20:21] Incredible. At the next level down, below that organized response, what do you owe say the principal differences are in Europe and Asia has responded than how the U.S. has responded? 


[20:31] Tom Frieden: Well, I’d rather look forward and say what can we do to get to a better place? And the first, foremost thing I think we have to do is be transparent about the risk of infection and the quality of our response. At Resolve to Save Lives, we reviewed the dashboards of all 50 states and we found just not enough information that would allow people to know what’s my risk, and how’s my community doing to decrease that risk? That’s not a minor issue. That’s a major issue. Because if people know what their risk is, they can protect themselves better. And if they know how their community is doing to control that risk, they can get involved in driving that risk down. Right now, you’re seeing very low rates of the most important indicators. Take, for example, the proportion of new cases that occur among people who had been identified as contacts and were quarantining themselves so that when they got sick, they didn’t spread it to anyone else. That individual is a dead-end for the virus. They may do well, may do poorly, most of them will do quite well, but the virus will end with them. And right now, there are only a handful of communities anywhere in the U.S. reporting that number. And those that are reporting it, it’s pretty low, down around two, five, 10 percent. It’s OK if it’s low, but report it so that we can all focus on collaborating, working together so we can get it up to 30, 40, 50, 60 percent or higher. 


[22:05] Andy Slavitt: So that sounds like an important benchmark. Is there a particular benchmark you’d look for? And are states making an effort to report that information? 


[22:14] Tom Frieden: We’ve been told that many states are going to start reporting this information. Frankly, when you have a massive number of cases, you’re not going to have a good number in this regard. So you have to wait till it cools down some. We have seen countries around the world get to 50, 60 or 80 percent in that benchmark. And you’d really like to see that, because that implies you’re making a big difference in the spread of the virus. 


[22:37] Andy Slavitt: Do we know what Europe achieved in that regard? Spain and Italy and France?


[22:44] Tom Frieden: I don’t have specific numbers on that indicator for individual countries. What we have seen is in some of the countries in Africa where we work, they’ve reliably been above 50 percent. In Singapore, they’ve tracked that number carefully and they’ve had it at 30, 40, 50, 60 percent reliably, sometimes more than that. Hong Kong, Taiwan, very high levels. But that requires a really intensive program. On the one hand, to reduce the overall number of cases. On the other hand, to do strategic testing, rapid isolation, rapid contact tracing and supportive quarantine. There are a lot of things that we haven’t even begun to do at scale that are really important, like offering people who are infected, but not very sick, a place outside of their home to isolate until they’re no longer infectious. This is what a lot of countries do because otherwise you’re going to infect many other people in your household. They will then go on to infect other people. And we’ll all have to keep avoiding work and school for another month or two. So some of the hard decisions of today will lead to a lot more freedom tomorrow. 


[23:53] Andy Slavitt: Okay, so you talked about transparency. You talked about the contact tracing and isolation resources. What else, as you look forward, are there things that we need to do? 


[24:04] Tom Frieden: One thing that we have to be really clear about is the role of a vaccine. In public health, we love vaccines. Vaccines are one of the greatest inventions that people have ever made, and they’ve saved literally hundreds of millions of lives. But a vaccine against COVID faces three big hurdles. Will it work? Will it be safe? And will people take it? And each of those hurdles is a high bar. Will it work? Well, is it going to work in all people for a long time? And will the different vaccines — because there are a lot being worked on — work at the same level? Or will some work a lot better than others or for a lot longer than others or for different people, different groups than others? 


[24:47] Tom Frieden: Second, will it be safe? We can’t cut any corners on safety. Vaccines generally are extremely safe. Billions of doses given every year with very rare problems. And vaccines have to be safe because we give them to healthy people. A treatment you might accept some adverse reactions because you’re saving someone’s life who is already very ill. But most of the people who get a vaccine aren’t going to get that infection. So you have to have a very strong safety profile for that. And one thing that concerns me is that a lot of the illness of COVID is not from the virus. It’s from our immune reaction to the virus. And there is therefore the theoretical risk that some of the vaccines could trigger a harmful reaction in some proportion of people. We hope that won’t happen. There’s no reason to think it will necessarily happen. But we necessarily must study to see whether it happens. 


[25:45] Andy Slavitt: How long will it take to really have an adequate answer to that? The president talks a lot about October, which is just two months from now. Will that be sufficient time to have enough phase-three data to judge that adverse effect? 


[26:02] Tom Frieden: There are lots of different levels of tracking safety. And it continues even after the vaccine is released, because the phase-three trials happen and thousands of people, but we give the vaccine to millions or tens of millions of people. And a rare adverse reaction, one of the thousand, one in ten thousand, one in hundred thousand, may not be found until after it’s given to large numbers of people. That’s the plain truth. In the phase-three trial, you can find some early signs that there may be a problem from blood tests or how people feel. But if, for example, a vaccine could cause a more severe reaction if someone were infected subsequently, that may not be apparent for many months. 


[26:45] Andy Slavitt: And you were talking about the third issue. 


[26:47] Tom Frieden: The third big issue is will people take a vaccine? And part of that is logistics. Can you get it out to people? It’s a huge job filling, finishing, finding the bottles. There’s a bottleneck in bottlenecks. There’s not enough vials now. And you’ve also got to educate clinicians, educate the community. Some of the vaccines have to be delivered at zero degrees. You have to figure out how to transport them and store them at the right temperature. It’s a big job, but even bigger than that is keeping people’s trust. There’s already a lack of trust in vaccines, and we can’t afford to undermine the trust that people have. That’s why it’s so important that this be done openly, transparently, that the FDA advisory board, which is the Vaccines and Related Biologics Advisory Committee and the CDC Advisory Board, the Advisory Committee on Immunization Practices, look at this in open meetings, look at all of the data, outline exactly the methodologies used, and then make their recommendations in an open, transparent way. That’s essential if we’re going to build, maintain and earn people’s trust. 


[30:51] Andy Slavitt: One of the things that I think you have said continuously for people who have followed you is even without a vaccine, we have the tools to do what Europe has done. We have the tools because of the way COVID-19 spreads, which increasingly we understand is sharing the air, sharing the breath with other people, being close to others without wearing a mask, as you’ve pointed out. There’s an enormous opportunity here. There’s an enormous opportunity. When I look at the projection from Johns Hopkins that 70,000 people are projected to die between now and the election, I look at that and I say, wow, when we had an opportunity to make a bigger difference than to save as many of those 70,000 lives as possible through our own actions, and we know what they are.


[31:45] Tom Frieden: I think that really is the bottom line. Vaccine or no vaccine, we can make a lot more progress against this virus than we have by working together but staying physically apart. And that means having a lot of discipline about making sure that we’re reducing spread. And when it does occur, finding it and stopping it. And we’re protecting the most vulnerable among us, whether that’s in nursing homes or elsewhere. There is real progress possible. I’m sitting in New York City where the cases are way down. Now we’re at risk of a resurgence because we’re not immune from the explosive spread going on in much of the country. But even the Northeast shows that it’s possible to do it in this country. But it does require basing decisions on data, being disciplined about avoiding spread of the virus, and being focused about stopping that spread when it does occur. 


[32:40] Andy Slavitt: This, for many people, is their first exposure to what public health is. And so one more question to help people understand how we can make this a more important part of our lives going forward. 


[32:54] Tom Frieden: Well, first, you know, there’s an old definition of public health that’s well worth remembering. Public health is the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals. Basically, it’s about getting together so that we’re all healthier. And Andy, I’ll leave you with one last thought. And it is the importance of primary care. Public health is sometimes thought of as healthcare for poor people. That’s really not what it is. So there are some clinics that deal with diseases of poverty that health departments run. Public health is about everyone being healthy. Public health is about protecting all members of society. And in so many countries — and my organization works in more than 50 countries around the world — including in the U.S., primary care is weak. It’s the poor relation in the healthcare landscape. It doesn’t have the status, the power, the resources needed. And yet, primary care is the primary way we can improve health. And changing that is really going to require being frank about the economic incentives in our healthcare system, and how they need to change so that we’re not paying so much for such poor healthcare outcomes. And primary care is central to that. And in the pandemic, we’re seeing primary care suffer economically because our economic model makes no sense. You get more money the more often people come in. That’s not a way to keep people healthy outside of systems like Kaiser and Geisinger and others. And we’re seeing good trends also: the expansion of telemedicine, which, if done right, is a great way to break down barriers for patients and make care more efficient. So one of the things that I hope will come out of this pandemic, in addition to more support and respect for public health, is a greater focus on fixing the primary health care system of this country.


[35:05] Andy Slavitt: Well, I look forward to collaborating with you on that and also in any other way that I can be helpful to you in your leadership. You’ve got a wonderful organization, Resolve to Save Lives, that we will have a link from the show notes. And I want to thank you first for being a great colleague. I learned a great deal in the short time that we were both in the Department of Health and Human Services together. Second, for showing the country what a public servant looks like, who is looking out for the interests and the mission and the vision of the American public. I think it is important for people not to lose confidence in the great institutions that we have built up, and the great scientists we’ve built up, to know that whatever questions there may be about the CDC or other things today, the backbone of the CDC, very much the researchers, the scientists, the people that are still there and the leaders like you are people who will continue to be so important for us going forward. Grateful to you, Tom. 


[36:08] Tom Frieden: Well, thank you, Andy and Zach. And it’s been great speaking with you. And I would just reiterate your last point. There are still thousands and thousands of really hard-working professionals at the Centers for Disease Control, the CDC. They’re there to protect you. And they will continue to be there doing whatever they can do in the context that we have. Thanks very much. And look forward to continuing and having future conversations. 


[36:31] Andy Slavitt: Hope you enjoyed and learned from that conversation with Tom. I really, really wanted all of you to get a sense for what it’s like inside the CDC when it’s functional. Tom was a very, very strong leader. He and I talk frequently. We talked this weekend. We talked about some things going on in the CDC, and he agreed to come on and just continue our chat. That was what we did. 


[37:06] Andy Slavitt: And I think he demonstrated everything that I hoped he would demonstrate. Now we have another podcast episode coming up on Wednesday. It is Connie Schultz and Sherrod Brown. That’s going to be fun. You know who they are. If you don’t, check them out on Twitter, they’re married to one another. One’s a senator. One’s a journalist. The following week, very exciting week. First, the start of the Democratic National Convention, we have Neera Tanden, who is going to kind of report on what’s going to happen at the convention. Then on Wednesday In the Bubble goes in the bubble. That’s right. We’re going inside the NBA bubble to talk to one of my favorite people, Steve Kerr, who’s the coach of the Golden State Warriors. As you may know, there is a bubble in Florida where all of the basketball players in the NBA are. And we’re gonna find out how that’s going. And we’re also going to talk to one of the most interesting activist voices in sports. Steve is someone who has been very outspoken about rights and justice issues. He was a great player with the Chicago Bulls when I was growing up. And you will have to indulge me a little bit if he’s willing to talk about sports. But mostly we’re going to talk about the pandemic, players’ response, NBA and a lot of the social justice issues. So that will be great and that will be the week after this. OK, talk to you Wednesday. Over and out. 


[39:00] Andy Slavitt: Thanks for listening In the Bubble. Hope you rate us highly. We are a production of Lemonada Media. Kryssy Pease is our producer. Ivan Kuraev is our editor. Jessica Cordova Kramer and Stephanie Wittels Wachs executive produce the show and run our lives. My son Zach Slavitt is my cool co-host and onsite producer. Music is by Dan Molad and Oliver Hill. You can find out more about our show on social media @LemonadaMedia. And you can find me at a @ASlavitt on Twitter or @AndySlavitt on Instagram. If you liked what you heard today, please, please, please tell your friends to come listen, but from a distance. And for now, stay safe. Share some joy. And we will get through this together. And #StayHome.


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