‘Americans are safer and healthier today than they were in 2009’

For nearly eight years Dr. Thomas Frieden has been the nation’s point man on some very scary stuff— Ebola, Zika, MERS, antibiotic-resistant “superbugs,” opioid addiction and more. Frieden, 56, resigned last week as director of the Centers for Disease Control and Prevention after leading the Atlanta-based agency since President Barack Obama appointed him in mid2009. In an interview with Modern Healthcare reporter Steven Ross Johnson, Frieden took stock of the CDC’s work battling national and global health threats and the challenges that lie ahead for whomever President Donald Trump names as his successor. Dr. Anne Schuchat, principal deputy director for the CDC, took over as acting head of the agency last week.

Modern Healthcare: As Republican lawmakers prepare to repeal the Affordable Care Act, what impact do you think the law has had on public health?

Dr. Thomas Frieden: Twenty million more people have health insurance today than did in 2009. That’s really important. Those are people whose lives can be saved by being able to get healthcare more readily. Protecting America’s health safety and security will always be the CDC’s mission, as it has been for the past seven decades and through a dozen presidential administrations. Whatever Congress does regarding the Affordable Care Act, public health will be as, or more, relevant than ever.

One of the things that does concern us is that the Affordable Care Act established the Prevention and Public Health Fund to provide more support for prevention. That fund supports now more than 10% of the CDC’s budget, and these programs are widely supported by both parties in Congress. There are things like the Public Health and Social Services Block Grant, protecting children and adults through immunization, strengthening the capacity to respond to domestic infectious disease threats and preventing childhood lead poisoning.

MH: What do you consider the biggest accomplishments during your tenure?

Frieden: I’m really encouraged that Americans are safer and healthier today than they were in 2009. We’ve strengthened the infrastructure to find outbreaks wherever they emerge and stop them quickly. We’ve helped create a new generation of public health workers. We’ve improved laboratory capacity using advanced genomics. We’ve sounded the alarm and begun reversing antibiotic resistance, and we’ve addressed some of the most serious health threats faced in recent years.

We have doctors, nurses, pharmacists, public health specialists, laboratory experts, communications experts, many people who work 24/7 protecting Americans. And with that, we’ve set some very bold targets.

We have set a target of preventing hundreds of thousands of heart attacks and strokes, and we think we met that. We set a target to dramatically reduce smoking, and today there are 10 million fewer smokers in America than there were in 2009. We have made significant progress on reducing some healthcareassociated infections, at reducing some spread of HIV and at reducing teen pregnancy, which often represents the maternal-to-child transmission of poverty.

MH: What’s the CDC’s role in addressing gun violence?

Frieden: For each of the last few years we’ve asked Congress for additional resources to do research on gun violence. Congress has declined to provide those resources. However, that doesn’t mean that nothing can be done.

The CDC has supported states to establish the National Violent Death Reporting System in more than 40 jurisdictions. That

Advice to incoming CDC head: “First and foremost, protect the scientific integrity of the CDC.”

Regarding the repeal of the ACA: “Whatever Congress does regarding the Affordable Care Act, public health will be as, or more, relevant than ever.”

is a way for states to look at every suicide and every homicide in their jurisdiction and identify not only what could have prevented individual incidents, but also what policy changes they can make at the state level to increase safety. And states like Oklahoma and Oregon have used that information to increase safety for the people living there.

I also have to say that although research is very important, and we need to invest in science to prevent violence, there are things that are welldocumented to be effective. And it’s not a research gap; it’s a policy implementation gap.

MH: What lessons were learned from the CDC’s response to Ebola that can be applied in future outbreaks?

Frieden: The first is that every country has a responsibility to find, stop, and prevent health threats wherever they emerge. And that’s why we have focused on implementing the Global Health Security Agenda.

This is a program that works with countries around the world to improve their ability to stop threats there, so that we don’t have to fight them here. As part of this, we’ve established a very important accountability framework called the Joint External Evaluation that essentially gives a report card to countries and identifies the ways to move forward rapidly. We’ve been able to greatly strengthen the number of disease detectives out there hired by other countries for finding and stopping outbreaks. We’ve expanded laboratory work around the world, and we’re improving vaccination and other preventive measures.

The second was that when a country’s capacities are overwhelmed, the world has to be able to surge rapidly. And in Ebola that didn’t happen as fast as we would have wished. Our goal is to be able to put staff in the field within 48 hours.

It’s also important that the World Health Organization continues to become more effective in emergencies, and it’s important that all countries improve their infection control, because so many infections are amplified in hospitals.

But the important lesson from Ebola was that we can stop an epidemic if we work together. Ultimately, the CDC had 4,000 staff work in the response, including 1,400 people who went to West Africa and spent more than 75,000 work days going to virtually every community where Ebola was spreading.

MH: What about the emergency preparedness of health systems and hospitals in this country? Are they better prepared to handle infectious disease threats now than when you took over in 2009?

Frieden: Hospitals are certainly safer and more prepared, but there’s much more that needs to be done. There are 75,000 deaths per year in this country among people who contracted infections in the hospital. It’s important that we improve infection control, that we improve training, supervision, management. Hospitals have done an excellent job working hard in improving infection control, but we have a lot further to go.

MH: What looks most promising to you in the pursuit of public health?

Frieden: I think some of the new technologies, particularly advanced microbial analysis, looking at genomics and the microbiome, have the possibility of helping us identify outbreaks much earlier, stop them faster, and prevent them more effectively. But one of the key things we need is a public health rapid reserve fund so that when there is the next Ebola, or Zika, or MERS, or Katrina, we will be able to respond rapidly and effectively to protect Americans.

MH: And what are the threats that keep you up at night?

Frieden: We always worry about pandemic influenza because this has the potential to kill so many people. In 1918, 1919, more than 50 million people were killed by the pandemic. That’s why, over the last eight years, we’ve strengthened the strategic national stockpile. We look at stockpiling some of the potential pandemic vaccine strains. We stockpile respirators in case the respiratory support capacity was overwhelmed. We stockpile antivirals for an emergency. But much more is needed to both track influenza better around the world and develop a better flu vaccine.

MH: Why did it take so long to secure funding from Congress to fight Zika?

Frieden: The risk in Zika is a risk to pregnant women, and as far as I know there aren’t any pregnant women in Congress. In addition, it’s a risk that’s pretty far off—six or seven months from the peak of the spread of Zika until you see the first large number of babies born with microcephaly. And we still don’t know what’s going to happen to the babies without microcephaly who may have other neurological damage. This is why we really must have a public health rapid reserve fund so that we can hit the ground running. We had to wait nine months to start some of the key research on how to better diagnose Zika and how to better control the Zika-spreading mosquitoes.

MH: What will you do next?

Frieden: I’m weighing my options. I’ve always made career decisions based on one simple question: How can I save the most lives?

MH: What advice would give your successor?

Frieden: First and foremost, protect the scientific integrity of the CDC. It is one of the most trusted federal agencies, and we’re trusted because people know that we tell it like it is.