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Three years after the start of the pandemic, former CDC Director Dr. Tom Frieden returns to reflect on what we got right and what we got wrong in our response to COVID-19. Andy gets the definitive answer to the question “do masks work?” Frieden also calls out one pharmaceutical company who could have helped save more lives and tells Andy what we need to do to prepare for the next pandemic. Plus, he shares one silent killer that isn’t getting enough attention and tells us what everyone can continue to do to protect themselves.

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Transcript

SPEAKERS

Andy Slavitt, Dr. Tom Frieden

Andy Slavitt 

Welcome in the bubble with Andy Slavitt. Email me, andy@lemonadamedia.com. You can ask anyone who does I respond very frequently. And maybe I’ve missed one or two but not by my own intention. I’ll blame someone else for that. If you email me, I’ll respond. Tell me what you think of the show. Tell your friends about the show. We’ve got another great one. Today Tom Frieden, who was the former head of the CDC is on the show today, Tom has been on before he’s one of the most clear thinkers and clearest communicators when it comes to talking about the issues that we all care about, which is namely, I’d like to live longer and be healthier. And we’ll talk a little bit about how we get into that today. You’ll also find out why we call the show in the bubble because Tom insisted on asking me during the show. So if you don’t know that one already, that the nice delightful moment in the show. I’m also got a point of view on what we need to do better next time. And I kind of go into this with him a little bit. Try to do little Monday morning quarterbacking on the pandemic in a responsible way. What did we do wrong? What to do? Right? What did we overkill? What didn’t we do it some of the things that people wonder about, like, you know, did masks really work. And, you know, he points to the things that worked well. And he pointed things didn’t work? Well, one of the most amazing parts of the show for me and really kind of internalizing it, it’s talked about, if we’d done it better, how many lives would we have saved and fitted down at worse? How many lives did we actually save by not doing it worse? Very interesting. But then he’s got a point of view on a model on a approach and how we should be detecting the next pandemic. He’s going to talk about that as well. It’s one of the reasons I wanted him on the show. You’ll really enjoy this conversation. I know you probably are like, Yeah, I’ve had my fill of pandemic conversations. But no, you haven’t really because if there’s one more you want to listen to. And the truth is, I actually think we are at a pretty good point for people to reflect now that the worst is past knock on wood, to think about some of these questions and times per person to do that. So let’s welcome on to the show here comes down.

Andy Slavitt 

Dr. Tom Frieden, welcome to the bubble.

Dr. Tom Frieden 

Andy Slavitt. It’s great to speak with you again.

Andy Slavitt 

You know, three years ago, four years ago, most of the public hadn’t spent a lot of time thinking about epidemiology or pandemics or viruses. And then all of a sudden, it became something people had to learn it was sort of thrust at them. I don’t know if we’re yet at a point where we have perfect perspective on the years 2020 or late 2020 22, early 2023. But if anybody has perspective, it’s someone like yourself, who has been thinking about these things for a very long time, and has just tremendous wisdom. You bring all these things, you will to sum up kind of how you feel like the last few years went particularly relative to what you would have anticipated A virus like that would have been like and how would have affected society?

Dr. Tom Frieden 

Well, first off, what you have to say about pandemics is they’re unpredictable. No one would have predicted that h1 N, one would emerge in Mexico, that MERS would have emerged in the Middle East. Or that the biggest pandemic of the century would not be flu, but another respiratory infection that previously mostly was known for common cold. And also SARS, which was controllable. So I think it’s really important. The key lesson is, as a great line from Shakespeare, the readiness is all right, we really have to be ready. Because if we’re not, they’re going to be a lot of deaths, and most of them are going to be have been preventable. If we look at kind of big picture like it’s a fog of war. What happened during COVID? Well, a lot of things worked really well. And a lot of things didn’t work nearly as well as they should have. And the way I look at this is excess mortality. That’s our biggest kind of gold standard of what really happened. And most of the groups that have looked at excess mortality, I’ve come to very similar conclusions that within the first three years globally, well over a million people died in the US and well over 20 million people died globally. And yet, as deadly as it was, it could have been a lot deadlier. And there were three things that really made a difference. Vaccination, most of all, measures to reduce infections, especially closures of indoor activities, and mask wearing, and medical care, including hospital care, and antiviral medications. And if you just look at all of those things, bottom line, we saved at least as many people’s lives as were killed, here in the US and globally. So it could have been twice as bad. But we also failed to save at least half of the people who died who didn’t have to die, if we had done a better job.

Andy Slavitt 

That’s just a fascinating way of thinking about it. Let me just repeat that for my own benefit. So of the 20 million or so people who died globally and the million who died in the US, half were preventable, it could have been if we’d have done a great job, we still would have lost a lot of people, but it would have been about half. But if we hadn’t come up with vaccines or taking some other measures, it could have even been twice as bad. That’s a very interesting and quite clear way of thinking about that. And what leads you to those conclusions. Tell us what were the things that we we really miss out on the most and the things that really helped us the most?

Dr. Tom Frieden 

Well, the thing that helped us the most by far was vaccination. And it’s easy to take it for granted. You know, we have so many shots, there’s one more shot might not have happened, right, the the deadliest pandemic in our lifetimes is HIV, and we still don’t have a vaccine for it. So and it might be the next pandemic, we don’t have a vaccine for. There are estimates millions of lives saved in the US through vaccination. And that’s what’s allowed us to get back to more like normal. At the same time, huge failure to share a vaccine, even when there was enough huge failure, especially of the Maderna company to share technology when they couldn’t scale up production as much as what was needed when it was needed. Even without increasing production, you could have prevented millions of deaths around the world just by more equitable distribution. Because it’s mostly older people who’ve been dying. And there aren’t that many older people in lower Millennium countries, you could have vaccinated them with a small fraction of all vaccines. So that was one real failure. Masking is a second, it’s really controversial, but shouldn’t be because the data is actually quite clear. It’s just you have to think clearly, masks are useful in two different contexts. One is to prevent people from spreading it. That’s source control, and the other is to prevent people from inhaling it. That’s personal protection. And when there’s a lot of spread and everyone wears masks indoors, it dramatically reduces spread. That’s probably why East Asia has a tiny fraction of the deaths of the West because mask wearing is quite common there. And even now, if someone is immunosuppressed or worried about long COVID Or just doesn’t want to get COVID wearing an n95 mask is a really good idea in indoor areas where COVID spreading and where fluid is spreading.

Andy Slavitt 

Do you think those conclusions about maths are controversial? Are they very clear cut? There seems to be a very, I think predictable Monday morning. quarterbacking of almost everything, saying that we went too far and saying certain things didn’t work and things, certain things were over promised. I wonder, can you help us sort through that? And I do get a lot of people still asking, because they have friends and neighbors that have seen some study where they’ve been told that no masks really didn’t work?

Dr. Tom Frieden 

No, I think it’s actually remarkably clear that masks are very effective at reducing spread. But they’re not a panacea. That kind of the best metaphor was the the Swiss cheese metaphor that every protective measure we have, is going to have some limitations, including vaccination, which is not perfect. But if you layer them, you’re much, much safer. And I think, unfortunately, there was one analysis that was done that got a lot of media coverage that purported to show that masks didn’t work. And that analysis, it was a Cochrane review was really poorly done. It’s an example of that first point I made about data analysis, you really have to be able to look at the data carefully. So if you looked at that study carefully, first off, they excluded hundreds of studies because they only looked at randomized controlled trials. Now, randomized controlled trials are great to compare medications. But they’re pretty bad to compare public health interventions, because you usually can’t do them on public health interventions. So they basically blinded themselves to 90% of the data. And then they lumped together data on influenza with data on COVID. And they’re not the same. And then on COVID, there were just two studies, and both of them actually showed protection of masks. And they said, well, the conclusion is it doesn’t work. So it really bad science. And you have to understand, it’s great that they’re more preprints. That’s great. There are more people writing, but there’s kind of good science and very good science and great science, and you need to be able to read and analyze it. But things are important, fit is important type is important. You know when and where and whether to mandate is important, what the social norm is, whether people are wearing them correctly, where they’re wearing them, where it’s getting spread, if they weren’t getting it at home, not many people are going to mask at home, even if somebody is known to have COVID. So, again, it’s not perfect, but it’s a very powerful tool. The same is said of closures, closures really worked, closure turned off the tap of spread, but they’re very costly on the environment. So on the our social and economic and educational environment. So one benefit of mask is you can keep things open, you can keep schools open, you can keep businesses open.

Andy Slavitt 

So I want to go take a quick break. I do want us to two things before the break. One is for the audience’s sake. And then the other is to where we go next for the audience’s sake. Your time answer that question. Know that Tom is one of the very few people that when I see studies out there, and I want to know what to make of it, I call and always tells me the ground truth, the good and the bad. And what what, what the limitations are, what the constraints are. So I think asking you these questions, is just a little bit different than asking, you know, your cousin Joe, the question either because juncture is very, very smart. We’ll take a quick break. Tom has done some amazing work about how we need to prepare for and beat the next pandemic. We’ll come back and talk about that right after this.

Dr. Tom Frieden 

I think there were things that were unpredictable with COVID. We didn’t expect it to evolve this rapidly. So the Delta variant was, was a real surprise. And, and that’s kind of a 2020 hindsight critique. But many of us, myself included, were adamantly opposed to closing schools, because we had done the tabletop exercises, we had done the estimates. And we knew that if you close them, it’s going to take a long time to get them reopened. And the costs are massive, not just in educational, social development, and not just in the very important social nutritional benefits that schools have, but also to society. Because what parents do when their kids are out of school, it makes it much harder. So I do think that schools closures weren’t handled as well as they should have been. I also think we weren’t upfront enough with what our reasoning was. Every community can make its own decisions. But you should be transparent about that. You know, one country that actually did this, well, during the pandemic was South Africa, where they said, they had they had a lot of closures and had a lot of spread. And then they realized, people were starving, people were running out of food, people couldn’t work. And so they said very explicitly, we’re going to reopen with masking and we know they’re going to be more cases, we know they’re going to be more deaths from COVID. But we think that will be counterbalanced by the benefits of getting our economy going again, that’s fine. Every community can do that. But areas where we went overboard, I think schools closures is one and masking outdoors is another there’s almost no spread outdoors. So you really don’t need to wear a mask outdoors. Now, never say never, if you’re in a crowded stadium, and everyone’s around you. And as as one of my staffers pointed out, you know, I had three errands to in three different stores, what was I going to do take off the mask and put it back on between them. So again, never say never. But these were examples. But Edie I think the bigger lesson is how do we get ready as a world and in this country, because we have two deadly cycles. One is the cycle of panic and neglect. And we are going you know, full force into the neglect neglect phase of that cycle. Now, with money getting cut from COVID, with ignoring new outbreaks with like, people feeling it’s over, and no risks are there. And the second cycle, it’s more of a inside baseball cycle about public health is planning and more planning. When we when it comes to pandemic prevention, having the readiness be all we ended up with big plans, they don’t get implemented, then another event comes then we start planning again. So we have worked with more than a dozen countries around the world to try to come up with a tool that could break those two cycles when we call it 717. That every outbreak would be found within seven days, reported to public health within one day, and all essential control measures in place within seven days 717. And what we find is, that’s a really powerful tool to accelerate progress to advocate for resources and to give accountability about whether or not we’re really making progress and it breaks those two Circles, we’re seeing 717 alliances that we’re hosting at my organization, resolve to save lives with a dozen countries. And we’re seeing initial countries use this to very rapidly see that they can with every single outbreak, where did they go? They go well, and what can they do to strengthen that the enabling factors? And what were the bottlenecks? And what can they do to break those down?

Andy Slavitt 

So seven days to discover a day, how to report it to the public health agencies? Yep. And then seven days, to what have an ever workable plan?

Dr. Tom Frieden 

No, seven days to actually implement all of the essential measures for control. So that’s very well defined and actually seven different domains. Do you have an incident management system? Have you started applying countermeasures? Basically, it’s it’s a structured way of using a yes no, have did this community did this public health entity do a good job, whether it’s for monkey pox, or yellow fever, or cholera got a lot of emergencies around the world a lot of opportunities to improve?

Andy Slavitt 

So want to dig in a little bit? Because this is a reason why I think people are listening to this show, because I think people do feel that this panic and neglect cycle is destructive, they do feel like, at the very least responsible people ought to be saying, what are the lessons learned? What are the minimum viable steps we need to do to be aware and on the lookout the next time, and you came out with a framework, which is now getting more broadly adopted, not just for the US, but for countries around the world. And it’s something to shoot for, help us understand how 717 would have worked with COVID. It feels like it took a long time for us to even know that COVID was airborne, and various other things which would seem to make those measures very difficult to implement if you didn’t know those sorts of things.

Dr. Tom Frieden 

Now, 717 is primarily for the early phases of an outbreak response. It’s not the be all and end all of preparedness and response. And it reflects the fact that timeliness is crucial. Rapid detection, rapid notification, makes the difference between a cluster and an outbreak, an outbreak and an epidemic, an epidemic and a pandemic. And that kind of start to end assessment of how fast it’s done, allows you to figure out how to get faster now, what could that have done in COVID? Hard to say the counterfactual. But let’s put it this way. We don’t know when it really emerged and whether it could have been stopped. But maybe if it had been recognized early, it could have been stopped before it spread.

Andy Slavitt 

There’s something in human nature, which I want to pick in to, which is I feel like it’s it’s a denial or it’s a hopefulness that, you know, because we you know, even today, we read about, you know, some bacteria thing here, and we read about another potential virus here. And we know most of those times, and we’re talking about as an individual, not as a professional public health person, but most of the times as an individual, you tell yourself, well, I don’t really need to worry about it yet. You know, it’s happening somewhere else on the globe, these things tend to peter out, I got enough to worry about in my life. And I’m not even talking about the kind of President Trump level denialism, which was a whole different level that someone in position responsibility. But when you think about these 717 type of response, and you think about the number of things that ended up not amounting to that level of scale, is this something that the public should feel is working in the background so that that it can prevent having to worry about a lot of these things? Or is there a danger that we’ll be too vigilant in the I might do some people?

Dr. Tom Frieden 

Well, we’re too vigilant if we take action that’s disruptive, when there isn’t a problem. But we’re not too vigilant if we’re investigating every alarm to make sure a is it a real problem? Or is it a false alarm? And B, if it’s a real problem, can we stop it before it spreads? But that’s not what the general public should need to worry about or think about? It’s more when things then are spreading? How do we protect people? How do we communicate that? How do we communicate levels of risk? I think we should expect our public health agencies to be just like our fire department to be on the ready and investigating alarms. And if they turn out to be false alarms. Well, thank goodness it wasn’t a real crisis. But at least we’ve got the system to investigate it and stop it. Because unless you investigate In a few false alarms, you’re going to miss a big one.

Andy Slavitt 

So how achievable is it for most countries to implement this 717?

Dr. Tom Frieden 

We think it’s quite achievable. It’s interesting, there’s quite, we’ve now done close to 100 assessments of past outbreaks, and most of them fail. But most of them fail on something that’s quite fixable. And they, they fail on one of those three metrics. So the key is to get all three done. So if you can usually get one done or two done, but you’re missing one or the other. And what’s more interesting in a way is the way they fail is instructive in how to fix it for next time. So in one community, for example, the community knew that a disease was spreading, but they didn’t trust the health system. So they didn’t go in for care. So it wasn’t diagnosed till it spread more widely. In another, the private doctors didn’t know they were supposed to how to diagnose a disease, or how to report it. And so it went undetected for a long time, that was actually Ebola in Uganda. The first was monkey pox in Nigeria. So in each of these cases, there’s a fix. Now, it might not be a quick fix, but it’s a real direction to move in. And it leads to the larger plan. We know we need better laboratory networks, we know we need better surveillance systems, we know we need more trained staff, we know we need more rapid response capacity. And we should continue building out those things. But when you do a 717 analysis, you may have 100 actions that you’re trying to do and say, Oh, these three are really important. Let’s do those now. And it may not take much time, but let’s get it done.

Andy Slavitt 

There’s an interesting element of this that I’m curious about, which is this idea that you are supposed to report quickly, which you’ve explained very nicely with the benefit of that is that it should be self evident. If you’re catching something that grows exponentially early, there’s a huge advantage than catching it later. But it also seems that there’s this element where if a country reports a public health outbreak, there is some amount of punishment that goes along with it. And the punishment may be that they people stop allowing flights from that country to come into their country, it may be some other kinds of economic isolation, etc. How do you deal with the incentives in a way that allows people to say, You know what, it’s, it’s the right thing for me to do, it’s a safe thing for me to do. And if I do it, that only may I’m not gonna get punished, but I’m gonna get supported?

Dr. Tom Frieden 

That’s a great question. And I don’t think we have a great answer. There are discussions of new global agreements that might do something on this. But what you’d really hope is that a country is essentially reimbursed for the loss that they’re going to get by reporting, because there’s a huge negative incentive. Even if you look at some work of countries that identified a dangerous variant, and then they got slammed with reduced travel, and other problems. So I think you have to look at the incentives. Ultimately, the accountability is to make sure that governments are accountable to their people to be honest and open about what’s happening and do what they can do to mitigate the risk. And speed really matters. Time is live. So I’ll tell you a story from from the Ebola epidemic that, you know, we lived through 2014 2016, we had a terrific epidemiology team in Liberia, led by a epidemiologist named Kim Lin blade, and they started something called right R I T, rapid isolation and treatment of Ebola. And what they realized was, what was happening was people were leaving the capital city of Monrovia, going out into rural areas with Ebola and causing clusters in those areas. And if you could get out there within three or four days, you could stop it. You can find the contacts, isolate them, and you’d have maybe one or two generations that spread and it would fizzle out. If you waited even a week, it was too long, and it was going to spread widely. So ultimately, you could make the government understand that speed would make this problem much less for them and they’d be able to get back to normalcy much sooner.

Andy Slavitt 

Got it. What didn’t take one final break, and then we’re going to come back and wrap up have a little bit of fun with my friend Tom Frieden. We’ll be right back.

Andy Slavitt 

Back with Tom Frieden. So Tom, you had a question for me before we started recording,

Dr. Tom Frieden 

Which is why is this called on the bubble?

Andy Slavitt 

Well, the real reason is because when my son Zach came to me and said, Dad, we got to do a podcast. And I looked at Zach, who was 17 at the time and said, Do you want to do a podcast about? And he said, Well, Dad, you know, you talked to all these people all day long. And some of these conversations sound really interesting. Why don’t you just record them and turn it into a podcast, and it was during the pandemic, and we had all this free time on our hands. And I think the last time I signed it asked me to actually do something with him was probably when he was five years prior. So if he just said, Dad, let’s mulch the yard, we would have him the bubble yard vaulting service right now. And then Lana, my wife said to me, I know what the title should be, it should be in the bubble. And for some reason, it stuck because it had so many different meanings. First of all, the community we live, we lived in people. teasingly called it the bubble, there’s a dine in Minnesota. We don’t live there any longer, rather, that bubble. But it was even before the NBA referred to these sort of isolated groupings as bubbles. But we got into this sense that we were bringing people into a conversation, an intimate conversation with someone that if they could have at their dinner table or dining room table, to talk about that topic with what’s the conversation they would have in their own bubble. And I really wanted to use my access to people like yourself and others, to say, let’s open those doors up and let you get into the bubble with us. So we’ve we’ve created all kinds of meaning for it. But the truth is, Lana gets all the credit.

Dr. Tom Frieden 

Great. Well, you know, within this bubble, I’d like to tell you about one other thing that we haven’t talked about so far. And that’s heart disease and stroke. It’s the number one cause of death in this country. It’s the number one cause of death globally. Globally, it causes about two thirds of all of the burden of disease, and it gets less than 1% of the global donations for global health. It’s a real failure of implementation. And 15 years ago, I helped Mike Bloomberg start his Bloomberg initiative to reduce tobacco use, and they have helped countries pass policies that will prevent 40 million deaths from tobacco. And six years ago, we started resolved to save lives, in addition to the epidemic prevention work, to reduce cardiovascular health risks and prevent 100 million deaths from cardiovascular disease by three main interventions. First is the elimination of trans fat, which we’ve now done in the US. And we’ve also helped more than 50 countries do it around the world, protecting more than half the world’s population that will prevent at least 5 million deaths in the coming years. The second is reduction in salt. And what you can do is you can buy low sodium salt, and that contains 20 30%. Potassium, as long as your kidneys are normal, you don’t have kidney failure. And the reason to reduce your sodium intake, it’s a double benefit, because we consume too little potassium and too much sodium. And so that can reduce your risk of heart attack and stroke by just 10 or 15%. Just by changing the brand of salt you use. And the third is to treat hypertension, high blood pressure is the world’s leading cause of death, more deaths than COVID at its deadliest, more deaths from all infectious diseases combined. The leading single greatest cause of the difference between life expectancy between black and white Americans. And yet you can treat high blood pressure with cheap, safe, effective medicines that are just once a day. And what we’re seeing is that healthcare systems aren’t doing it. We were not able to make much progress in the US but we’re learning how to make progress globally, with simple regimens, simple technology, patient centered services, helping millions of people get their blood pressure under control and we need that in the US as well. You should have your blood pressure down, at least below 140 over 90, ideally below 120 over 80. We know that starting at once 115 over 75, for every 20 millimeter increase in blood pressure, your risk of dying from a heart attack or stroke doubles.

Andy Slavitt 

I was surprised Rob Kaler told me yesterday that we are still losing 500,000 Americans who died from using combustible tobacco every year in the US today. And we think smoking is way, way, way down. So, and that, as you say, is only a part of the challenge. But I want to pick up on something that you said, because it’s something that I believe is true about many, many, many things in medicine and health. Which is, it’s not that we don’t know the answer. In this particular case, as you pointed to, we have evidence based solutions. And we’re not using them as well as we could or we should. But this is different than say 200 years ago, when people were dying of things, that when they got sick, we had no ability to even know what to do. We now can prevent many people from dying of cancer, not everybody we can prevent. With the right, taking the right steps early enough, we can prevent people from dying of cardiac or vascular disease. And so it’s a different type of challenge. Right. You know, you talk a lot about primary care, and access points around the world and distribution. And I think it’s it’s real information, fighting misinformation. There’s just a whole bunch of things that are beyond the science. That is that feels like it’s a big part of that delta.

Dr. Tom Frieden 

And that is actually our space that resolved to save lives. We help communities and countries close the implementation gap. There’s a huge knowledge gap. We wish we knew lots of things that we don’t know. But there’s an even bigger implementation gap. We don’t do a lot of things that we need doing and to get those done. You need that combination of rigorous science, good management and savvy politics.

Andy Slavitt 

Tom Frieden. Thank you for being an example of that. Thank you for being a colleague. Thanks for being a friend. And thank you mostly for being in the bubble.

Dr. Tom Frieden 

A pleasure to be here with you. And that great conversation again, Andy, thanks very much for the conversation and for the work that you do.

Andy Slavitt 

Thank you, Tom Frieden for that fantastic interview. Thank you for tuning in. We got some more great shows coming up. You’re going to love what we have ahead. Zeke Emanuel, we have our first live show. Unless you already heard it. We have the new head of the CDC. Lots of great stuff coming up. Thanks for tuning in. Don’t forget to email me and eliminated media.com Have a great week.

Andy Slavitt 

Thank you for listening IN THE BUBBLE. If you like what you heard, rate and review and most importantly, tell a friend about the show. tell anyone about the show. We’re a production of Lemonada Media. Kyle Shiely is the Senior Producer of our show. He’s the main guy, and he rocks it with me every week. The mix is by Noah Smith. He’s a wizard. He does all the technical stuff and he’s a cool guy. Steve Nelson is the vice president of weekly content. He’s well above average. And of course, the ultimate big bosses are Jessica Cordova Kramer and Stephanie Wittels Wachs. They are wonderful, inspiring, and they put the sugar in the lemonade. They executive produced the show along with me. Our theme was composed by Dan Molad and Oliver Hill, and additional music is by Ivan Kuraev. You can find out more about our show on social media at @LemonadMedia where you can also get a transcript of the show and buy some in the bubble gear. Email me directly at andy@lemonadamedia.com. You can find my Twitter feed at @Slavitt and you can download in the bubble wherever you get your podcasts or listen ad free on Amazon music. It’s a prime membership. Thank you for listening.