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

Modern Healthcare - - Q & A -

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.

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