Former CDC Director Discusses Public Health's Impact on National Policy

This episode features Tom Frieden, MPH, MD, who discusses his background and influence on public health and national policy.

Dr. Frieden was the director of the CDC and is currently the president and CEO of Resolve to Save Lives. Resolve to Save Lives was created in 2017, and works with organizations around the world to prevent epidemics and reduce the burden of cardiovascular disease.

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Christina Madison, BS, PharmD, BCACP, AAHIVP: Hello everyone and welcome to another episode of Public Health Matters, part of [the] Pharmacy Times: Pharmacy Focus podcast series. I'm extremely excited to introduce today's guest, Dr. Tom Frieden. He is just the most delightful person online, so if anyone follows him on social media and the work he's doing, post being the CDC director, with Resolve to Save Lives, you know the impact that he has made on public policy and how we deliver public health in this country. And again, I am your host, Dr. Cristina Madison, also known as the Public Health Pharmacist. And with that, I am going to go ahead and let Dr. Frieden introduce himself and then we're going to dive into some questions. I'm extremely honored and humbled that you accepted my invitation to be on the podcast today.

Tom Frieden, MD, MPH: Thanks, Christina. It's really delightful to chat with you and thank you for that too kind introduction. I'm Tom Frieden. I'm currently the president and chief executive of Resolve to Save Lives. We're an organization working with countries around the world to make the world safer from epidemics and also to reduce the burden of cardiovascular disease.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Fantastic. So obviously, as a clinical pharmacist, we work a lot in the cardiovascular space. From a preventative care standpoint, you know, there's so many pharmacists working to do exactly what you're doing, but not so much on a global scale. But I'm really curious to just dive a little bit into your background and how you came to your current role, through your past engagement with the White House and with the CDC, since that is one of the epitomes of professional goals, you know, and just how you got to be able to impact national policy.

Tom Frieden, MD, MPH: Thank you so much for that question, Christina. The honest truth is I've been extremely lucky. I was trained in medicine; I actually was a philosophy major in [my] undergraduate [and] trained in medicine. I did my master's in public health, I did my internal medicine residency, and then my infectious disease fellowship. And then I joined the CDC as an epidemic intelligence service officer. I was posted to New York City, and there happened to be, unfortunately, multiple outbreaks of multi-drug resistant tuberculosis. I was able to document and help stop those outbreaks, and my first big job then was as Director of the Bureau of Tuberculosis Control and Assistant Commissioner of Health for New York City. And we were able, with excellent outreach from front line health care workers and excellent work from a great team, to rapidly reverse this outbreak—the largest outbreak of multi-drug resistant tuberculosis there's ever been in the United States. And we had extensive drug-resistant tuberculosis as well, [and] we were able to stop that.

That led to interest from the World Health Organization. I always wanted to do global health; that's really why I became a doctor. And they approached me and asked me if I would go to India and work on tuberculosis control there. I did that then for 5 years, from ‘96 to 2002, working on a World Bank-funded program on secondment to the World Health Organization, working with the government of India and states and districts throughout India. It was the hardest job I've ever had by a longshot, but also enormously satisfying. And with a great team, a great set of Indian leaders, we were able to make a lot of progress and save a lot of lives in India.

And then 9/11 happened, and I was born in New York City, I spent most of my professional career there. And when Mike Bloomberg [and] his team called me and asked if I would be health commissioner, I first downloaded the report—every year New York City does a report of causes of death in the city—so I could analyze what's really happening. And I found that tobacco remained the leading preventable cause of death, and it was so dominant as a preventable cause of death. There wasn't much point in coming back unless Bloomberg was willing to take on tobacco. And I said that, and they said he's willing, and I spent seven-and-a-half years as the New York City Health Commissioner. And then President Obama asked me to be the CDC Director, which I did for seven-and-a-half years before leaving New York City, though I helped Mike Bloomberg start his Global Health philanthropy. He's now put extensive resources into tobacco control globally, and his efforts have prevented more than 40 million deaths from tobacco around the world. Leaving the CDC, I looked at what could I do that could save the most lives? And I identified the 2 areas of improved epidemic prevention and control, and improved cardiovascular prevention and control. And that's what our organization works on.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Wow, that is incredible. And you are definitely speaking my love language because when I was working at the county health department in Las Vegas, that was one of my primary roles was to work with immigrants and refugees. I started the first pharmacist-led tuberculosis (TB) [latent tuberculosis infection] clinic in the country. So, you are absolutely speaking my love language. I think a lot of people don't realize that tuberculosis is still an issue in the United States and that up until 2009, that was when the last TB sanatorium closed in this country. And the only reason why I know that is because I actually trained there, which was at AG Holley Hospital, when I did a mini fellowship there right before they closed, when the governor decided to reclaim that land [when] the University of Florida was managing that clinical practice. And so, you know, learned everything from different types of media, and like, you know, gel lager versus liquid medium, and all of these things that you wouldn't even think that a pharmacist would be involved in. But I always say, if there's medication and it's an intensive medication process, and it's a known diagnosis, pharmacists should be involved. And I really love the work that you did within the tuberculosis space and really advocating for the fact that, you know, we could do more. And you probably averted a lot more deaths because of the fact that you were able to come in and sort of halt that multi-drug resistant spread of TB.

And then, I really wanted to kind of talk a little bit about the work that you're doing with Resolve to Save Lives, and sort of how many countries are involved. And then when you talk about cardiovascular disease, I know you mentioned a little bit about tobacco-related, but like, what specific things are you targeting? That's kind of part of the public health and preventative care aspect.

Tom Frieden, MD, MPH: As Resolve to Save Lives, we have 2 broad areas of focus. The first is epidemic prevention and there we work primarily in Africa. We partner with countries, we embed staff and ministries of health, and help to strengthen the public systems as well as advocate for more support for public health infrastructure. We also work at the global level to try to influence policy. We've suggested, for example, as a global goal and mechanism for improving preparedness, that every outbreak would be found within 7 days, reported within 1 [day], and all essential control measures in place within 7 days. That's 7-1-7 as a galvanizing goal for preparedness.

In terms of cardiovascular disease, we work largely in Asia, and we have 3 main efforts. The first is the global elimination of artificial trans fat, and we find globally that trans fat use [is] estimated to kill a half a million people a year. It's a toxic chemical added to our food without our knowledge and consent that might kill us. Fortunately, in the US, and now for nearly 3 billion people, there are regulations that will prevent our children or any of us from being exposed to trans fat, but we have more room to progress because that leaves most of the world still exposed. The secondary is reducing sodium consumption. That can be through getting used to less salty food—more spicy is less salty usually. We're using low sodium salts; the light salts are effective. But that's the secondary. And then the third area, very relevant to pharmacy, is the treatment of high blood pressure. High blood pressure is the world's leading cause of death. More than 10 million people a year are killed by high blood pressure. It kills through stroke, heart attack, kidney failure, and yet around the world, less than 1 in 7 people have their blood pressure controlled. What we've done over the past 5 or 6 years is to work with more than 30 countries to figure out how to treat high blood pressure as a public health problem. Not solely to work at the individual level, but how can we make it a mass program the way tuberculosis control is a mass program and reach the people who need treatment the most and hold our health care systems accountable for outcomes.

I like to say that the definition of an epidemiologist is someone who loses sleep over denominators. A clinician might say, “My clinic is busy every day, I’ve got lots of patients here, I must be doing a good job.” But the epidemiologist says, “How many people are in need in your community? And what proportion of them did you treat effectively?” That was the painfully learned lesson that I gained from my years working on tuberculosis control—that you could do really good work, but if you weren't rigorously assessing your outcomes, you could fool yourself. You could think you were doing a lot better than you actually were. And we put in that kind of accountable system in hypertension control, working with the World Health Organization in many countries around the world. And now millions of patients are being better treated.

I should say that pharmacists have a very important role here. In many countries around the world, they're in charge of drug stock and reordering, estimating the demand for drugs. We have a pharmacist on our staff in one country who helps districts make sure they don't run out of drugs. What we found in hypertension control is that kind of surprisingly, to me, unlike in tuberculosis control, we don't have standard treatment regimens. And because of that, there is too much therapeutic anarchy and sub-optimal care. Ever since the 1970s, there have been clinical trials that have compared nurse-directed care with specialist-directed care. And, you know, the nurses win every time because they follow the protocol. When we go to medical school, they take the neurons out of our brain that allow us to follow protocols. But protocol-based care is better care. That doesn't mean a doctor can't, you know, change the protocol, if there's a good reason to. Just indicate with 3 words why you changed the protocol. And these are the 2 major programs at Resolve to Save Lives.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Wow, that's so incredible. And it's funny that you talked about nursing, because one of the first things that I noticed when I worked at the health department was that literally all of the clinical services are run by nursing. And when I first started, I was like, ‘This is so interesting.’ It was a very different way of thinking because, you know, I'm residency trained, and I was in the VA system. And so, there's definitely that hierarchy where it's like, you know, physician-led care, and then specialty care, which you just talked about. But you're right, the protocols and being able to follow the recipe, right? The secret sauce for how we make people's lives healthier and happier. It deviates from that when you're using different types of providers. And I know, like in the VA system, because it's federal, it's kind of the wild, wild west, so nothing's going to just get done, based on what that provider feels is the best thing to do at the time. Obviously, it's evidence-based medicine. But I agree with you that protocol-based care is really what's needed, in particular for public health. And so, yeah, I think we all need to do a better job of being able to do that, but then also be able to allow everyone to practice at the top of their licensure so that we don't have instances where we see drugs in short supply, where we see lack of access to care because of not having appropriate providers available, because of either provider deserts or pharmacy deserts. You know, I think about Indian Health Services where there are huge expanses of tribal land where they're literally the only provider there is the pharmacist, right? And how do you manage what you're given, you know, in resource-limited fashion, but then maximize it in order to make sure everybody gets the same access to care.

Tom Frieden, MD, MPH: If I can just add, Christina, I agree with everything you've said. When I started as an Epidemic Intelligence Service Officer in New York City, I had already done medical school residency at Columbia [and an] infectious disease fellowship at Yale. I thought I was, you know, pretty good, and I was volunteering in the TB clinics. And it was a nurse, Pearl Branch, who taught me how to treat TB. I didn't know how to treat TB in outpatients. I didn't know how to follow the protocols. I didn't know what the drugs and dosages were. But that's what she did, day in and day out. And so very tactfully, but firmly, she would come up to me if I had written an order that wasn't as per protocol, and she said “Dr. Frieden, don't you want to add pyrazinamide at a dose of 1500 mg to this patient's regimen, because they're in the first 2 months of their treatment?” And she was 100% right. So, I think doctors need to get a lot more humility about working as part of a team.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Thank you so much for saying that. You know, I have had the honor and privilege of working with some incredible physicians in my career and one of the things that I feel like has been the hallmark of that very fruitful relationship is that they were open to suggestions, and they were so affirming of my journey to where I'd come from, and my education and what I could bring to the table. And were never, you know, upset about a suggestion or wanting to alter recommendations or regimens. But then, you know, coming from a place of mutual respect, you know, I didn't go to school to be a diagnostician, you did, or an epidemiologist, but I’m in this learned skill set that I've been able to procure from being in a health department and seeing all of the things that go on with communicable disease management. And I think that we can all bring that lived experience to the table. And that that is how we all move forward. That's how we all impact public policy, that's how we all impact the health and wellness of our communities. And I always say, you know, when you help one, you can help many, especially within the public health space and the preventative care space, because once you have impacted one person, they're going to go off and tell others, and if they have had a positive experience with the health care system, they're more likely to engage and more likely to tell others to engage in the health care system.

So, I'm curious, you know, obviously, it's been a little while since you've been in your role as CDC director, but I mean, that was a huge undertaking. And, you know, we see our current director coming under fire and the CDC being what I consider to not be hailed in the regard that it should be currently. And I think part of that is because of our political climate. But I'm just curious, what was one of the biggest lessons that you learned during your time as CDC director that we can kind of think about now, as we're moving forward in this interesting time.

Tom Frieden, MD, MPH: I think the most challenging area in public health is getting and maintaining public support. And that means support from political leaders, support from Congress, support for budgets. Public health is really good for everyone, a little bit, but it's bad for some groups a lot. So, if we take on the tobacco industry, everyone's going to do better, our kids are less likely to smoke. But the tobacco industry is going to lobby hard against the things that we try to do. This means that structurally, it's really hard to get and sustain support for CDC or a state or city or local health department. And this means it's really important to up our game at communicating the value that we have, at engaging with communities, listening [and] identifying the main concerns that people have and addressing those concerns, getting better at providing data and information in a way that is clear to people, ensuring that we have communication that's 2-way so we're listening to what people's concerns are and addressing those concerns. I think, to me, probably the single biggest challenge is to have a way to increase and maintain support for public health because at its base, what CDC and public health does is to protect people, to work 24/7 to protect people, whether it's from infectious or noninfectious diseases, threats that arise in this country or anywhere in the world, threats that are natural or manmade. The job of public health is to improve societal health.

Christina Madison, BS, PharmD, BCACP, AAHIVP: So interesting that you said that. The first thing that popped in my brain when you said that is like no one would say something negative about the fact that we're all asked to wear seatbelts in our vehicle. But for those of us who are old enough to remember when that wasn't the norm, it seems like a no-brainer, right? Like, of course, you would wear a seatbelt. And of course, you would protect yourself and your children, of course you would have your child in a car seat, right? I remember when I was little and we had a station wagon, and, you know, they’d throw me in the back and like, it'd be nothing. And I was like, I think I was like 6 or 7, and I absolutely should not have been in the back of the station wagon, right? God forbid, we had gotten into an accident. But like, these are the things that I don't think a lot of people realize. You know, clean water, safe streets, having a sidewalk to be able to walk on, having a clean environment to breathe, clean air—all of these things are public health and we've just gotten so used to it because these are like, first world problems that we forget that these are structures that have been put in place that haven't always been there, for the safety and wellness of our communities.

Tom Frieden, MD, MPH: And many of them were controversial at the time. Whether it's creating reservoirs for safe water or closing down polluting factories in cities, or making them not pollute, or seatbelts, or even drunk driving laws. They were very controversial at the time, and I think the same is true [now]. So, each generation is going to have to struggle to advance health and safety. But between that, the support of the public, [and] explaining things well, it's going to be really important.

Christina Madison, BS, PharmD, BCACP, AAHIVP: I think one of the biggest lessons that I learned during the pandemic, in particular, was how important communication was and how important having the right person communicating that message is, in particular to vulnerable populations or minoritized communities. Because when you had people who didn't look and sound like you, you were much less likely to take their recommendation. And then also because you didn't have the perspective of thinking that this person understood your lived experience. So, it's like, how can this person be telling me what I need to do if they have no idea what my struggles are?

Tom Frieden, MD, MPH: It's about the message and the messenger.

Christina Madison, BS, PharmD, BCACP, AAHIVP: 100%. I couldn't have said that any better. Goodness, I could literally just talk to you for hours, but I know that your time is precious, and I do want to make sure that I am honoring that. So, before we leave, I do have 1 more question for you. So, how do you see the role of public health in the future? And how do you see other health care professionals, not just physicians and pharmacists, but just health care professionals in general? How do you see our ability to support public health efforts?

Tom Frieden, MD, MPH: Well, I think the main lessons of COVID are the need for the three R's—or renaissance in public health, robust primary health care, and resilient individuals and communities. And in all of those, health care professionals can do a lot, whether that's ensuring there's good infection control in your facility, supporting primary health care, supporting community-wide action, whether it's on walkable spaces, or tobacco control policy. These are all things that health care workers can do that can make a big impact. Health care workers and public health workers need to decrease the chasm between us. We need to ensure that there are ways that we can work together that are synergistic so that public health can make health care more efficient and more productive and higher impact. And health care is essential for delivering to communities the services needed to keep people safe and healthy. I think, to end with one last thought, there is a big chasm sometimes between public health and clinical health care. And the more we bridge that chasm, the better off both clinical and public health services will be and the more we address the policy environment, whether that's promoting telemedicine or promoting tobacco control. We'll all be safer and healthier.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Thank you so much, Dr. Frieden, this has been such a wonderful conversation. And I'm so excited about the work that you're doing and continue to do in order to impact the public health of our communities, and then your global reach as well. So, if people want to find you, if they want to follow what you're doing, if they want to support your efforts, how can they get in touch with you? How can they see what you're doing?

Tom Frieden, MD, MPH: You can check our website, ResolvetoSaveLives.org, or follow me on social media at Twitter @DrTomFrieden, or LinkedIn, or any of the other social media platforms. Thank you so much, Christina, it has been delightful chatting with you, and thank you for the work that you do.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Oh, thank you so much. That's incredibly kind of you to say and I am so grateful for the ability to chat with you and to learn a little bit more about what you're doing, and how we can incorporate these principles into our everyday practices.

Tom Frieden, MD, MPH: All the best.

Christina Madison, BS, PharmD, BCACP, AAHIVP: Thank you. So again, my name is Dr. Christina Madison. I am your host of Public Health Matters, part of Pharmacy Times’ podcast series. You can find me at the Public Health Pharmacist on your favorite social media de jour, and remember Public Health Matters.