Dr. Tom Frieden - Former Director, U.S. Centers for Disease Control
Dr. Tom Frieden, president and CEO of Resolve to Save Lives and former Director of the U.S. Centers for Disease Control joins host Dr. Rishi Desai to discuss U.S. response to the coronavirus crisis, the need for expanded access to testing, and examples of effective responses by governments in Asia.
DR RISHI DESAI: Hello, I'm Dr. Rishi Desai, Chief Medical officer at Osmosis. I'm here today with Dr. Tom Frieden, President and CEO of Resolve to Save Lives, an initiative of Vital Strategies. Dr. Frieden is also the former Director of the U.S. Centers for Disease Control and Prevention (CDC), and former Commissioner of the New York City Health Department.
Thanks for being with us, Dr. Frieden. I want to just dive right in and start by asking you: how do you feel our current situation impacts our future responses to disease outbreaks? What lessons do you feel we've learned?
DR. TOM FRIEDEN: I hope this pandemic will result in a stronger society and healthcare system where we recognize that we're all in this together, we recognize that time is lives, and the quicker we respond, the better off we'll be. And also that we recognize that our public health system in the U.S. and around the world is crucial to all of our safety.
DR. RISHI DESAI: With that in mind, are there certain things that you feel the general media isn't focused on, but should be more focused on?
DR. TOM FRIEDEN: This is a 24-hour-a-day media cycle, and it isn't so much that things are being missed as that there isn't a sense of the priorities. The priorities are to structure the response well, to make sure at the national level there is clear, consistent guidance (which is science-based), and then there's support for implementation at the state and local levels. That's crucial for an effective response. What we sometimes see is kind of running to where the ball was a week ago or a month ago, rather than going to where we need to go to keep people safe.
DR. RISHI DESAI: Do you feel like there are long-term consequences this is going to have on our U.S. healthcare industry?
DR. TOM FRIEDEN: I think this will help us recognize that we need to make healthcare much safer. Far too many healthcare workers are getting infected in this outbreak and patients are getting infected in healthcare systems. In an average year at least 70,000 Americans die from infections that they pick up in the healthcare system. This should help us change to become much safer in how we give care.
DR. RISHI DESAI: I came across a letter you recently wrote to Congress. I'm curious what specific issues led you to write that letter?
DR. TOM FRIEDEN: What we see is an under-investment in keeping us all safe. Within the U.S. we have had some support for what's called global health security or global health protection. We're all connected by the air we breathe, the water we drink, the food we eat, the trains and planes we ride on. It's crucially important that the U.S. invest in global health protection: we invest in our health security by helping countries around the world find threats faster, stop them sooner, and prevent them wherever possible. We'll be safer: stronger there, safer here.
DR. RISHI DESAI: How specifically would that increased funding better prepare us for future outbreaks and pandemics, and why is that specifically important? And to follow up to that, could the rapid spread of COVID-19 have been contained earlier if we had the funding that you're suggesting?
DR. TOM FRIEDEN: With additional investment, we'll be able to help countries find threats when they first emerge. That means having early warning systems, rapid response systems, so that countries can identify a threat, respond to it, and warn others before it spreads widely.
Frankly, if Guinea in West Africa had had core public health services in place in 2013, the Ebola epidemic of 2014–2016 may not have happened. It could have taken just a few weeks and a few thousand dollars to stop that cluster. Instead it became a terrible epidemic that affected three countries and cost tens of billions of dollars globally.
Similarly, if China had closed its wet markets in 2003 after the SARS outbreak, it's possible that this entire pandemic might not have happened. The next threat is just around the corner: whether it's a tick-borne disease in Asia or an animal-borne disease in Africa, the microbial threats are with us. It is inevitable that there will be another threat. What's not inevitable is that we will continue to be so underprepared.
DR. RISHI DESAI: Can you offer some insights into how the CDC has handled outbreaks in the past? Was this one handled differently, in your opinion?
DR. TOM FRIEDEN: When there's an emergency, the Centers for Disease Control and Prevention activates its Emergency Operations Center. It marshals a response and calls on many of the 20,000 professionals who work at CDC. It calls on the long-standing relationships that CDC has with all 50 States and with countries all around the world.
In this response—as of mid-March—unfortunately, CDC is not having the kind of central role it has had in every other disease outbreak the U.S. has ever faced. That makes me worried; that makes me feel less safe. Fighting this disease without CDC at the table when decisions are being made and at the podium when they're being communicated is like fighting with one hand tied behind your back.
DR. RISHI DESAI: What would you say are 3–5 lessons we've learned from other governments in terms of response to COVID-19?
DR. TOM FRIEDEN: We're learning from countries around the world, both positive and negative. One thing that we're learning is that time is lives—every day matters. If you look at northern Italy, they were not able to act quickly and they're dealing with a devastating situation as a result.
If you look at the provinces outside of Hubei, China, they were able to contain this—as have Hong Kong, Singapore and Taiwan—with a very aggressive system of case detection, contact tracing, isolation. That prevented them from having to go into these large shutdowns of society. That's a critically important lesson. And from South Korea we're seeing that even when it gets very large, if there's a very extensive effort which uses advanced methods to find contacts and makes testing widely available, you can tamp down what has already become widespread transmission. And, very hopefully in Singapore, we're seeing the absence of healthcare worker infections using standard precautions.
In general, it’s not a question of being super careful or using super advanced materials—it's more a question of meticulous attention to every single aspect of infection control.
DR. RISHI DESAI: Can you speak a little bit more about testing and your thoughts on where we are with that right now?
DR. TOM FRIEDEN: Testing is critically important. Anyone with pneumonia in the U.S. needs to be tested for COVID-19. We also need to set up systems to track this over time so we can see if it's waning, waxing, and where it's happening. We need to investigate clusters and stop transmission in healthcare facilities and nursing homes (if there are clusters) using intensive testing. And we need to use it for intensive investigations to answer some of the questions I mentioned. But in areas like New York city today, where COVID-19 is spreading widely, we need to discourage people with only mild symptoms from getting tested, because doing that is unsafe for them, it's unsafe for others, and it undermines the effectiveness of the response. With time, that will change: as we are able to tamp down the number of cases, we can ramp up testing (as South Korea has done) to try to find every infection and contain every cluster.
DR. RISHI DESAI: Dr. Frieden, do you have any tips for the general public on how they can help flatten the curve?
DR. TOM FRIEDEN: Flattening the curve is really important, and there's something that each and every one of us can do. Wash your hands frequently. Don't go out if you're sick. Cover your mouth and nose every time you cough or sneeze using a tissue that you throw out, or the crook of your elbow. And most importantly, where COVID-19 is spreading widely, follow the local government's advice: avoid all nonessential contact within six feet of everyone else. We're all in it together, but we all need to keep separate to do as well as we can.
In New York city (as of late March in 2020) it's crucial that if you're just mildly ill, you do not seek care or testing. That's because by doing so, you may infect others. In the process of traveling to or getting tested, you may use up scarce testing supplies including personal protective equipment. You'll add to the overcrowding in healthcare, which makes it less safe for patients and healthcare workers. If you're negative, you may end up getting infected in that process, and if you're positive, it's not going to change what you do: stay home, isolate yourself, don't infect others. All of us can play a part in flattening the curve and improving the outcome for all of us. What each of us does individually is important to all of us.
DR. RISHI DESAI: Can you speak specifically on what role you think online education will play in flattening the curve?
DR. TOM FRIEDEN: Online and digital resources are tremendously important: helping students learn, helping healthcare workers learn, and conveying information about this as we're all hunkered down in our homes. Broadband is important and online information is important, particularly valid information and ways we can all collaborate online and work together from a distance.
DR. RISHI DESAI: Do you have any tips for healthcare system administrators and healthcare workers about ways they can help to raise the line or expand healthcare capacity?
DR. TOM FRIEDEN: In healthcare, the key concept is safer surge: healthcare facilities need to be ready for large numbers of people who are not seriously ill to be rapidly and safely seen. This can be done, for example, using tents and outdoor areas and parking lots. They also have to surge intensive care capacity—capacity to provide oxygen to people who are having trouble breathing. This is something that's very challenging, but it means not just ventilators, but materials, supplies, training, cohorting of patients, and creative ways to safely care for as many patients as possible.
We're also going to really have to look carefully at how to maintain our healthcare system, how to care for people with chronic illnesses such as hypertension, diabetes, seizure disorders, to make sure that they get the care they need to stay healthy, not just for those conditions, but because we know that people with underlying conditions are more susceptible to COVID-19 severe disease.
DR. RISHI DESAI: What's your current estimate for when we'll start to see the number of new cases fall in the United States?
DR. TOM FRIEDEN: There's no way to predict what's going to happen with this virus over time. We can hope that it fizzles out as warmer weather comes, but there's no certainty that that will happen. We don't know to what extent it will spread. We don't know when we'll have proven treatments and a vaccine is at least a year or two away, if it's developed at all.
DR. RISHI DESAI: Do you believe the general public is overreacting by buying up toilet paper and hand sanitizer, or do you believe the lack of information is contributing to the frenzy?
DR. TOM FRIEDEN: There are really important things that everyone can do. For example, not going out if you're sick, minimizing contact with others, washing your hands regularly, coughing into a tissue or the crook of your elbow, but mass buying of things like toilet paper isn't helping. Buy enough for what you need. Easy to say, hard to get people to follow that advice! We're particularly concerned about healthcare supplies like surgical masks. Those need to be preserved for healthcare until there are ample numbers for everyone.
DR. RISHI DESAI: What advice do you have to offer local, state, and federal public health workers?
DR. TOM FRIEDEN: The key characteristic of a great public health response is that it uses real-time data to make appropriate decisions to protect people as well as possible. We need to collect information, use that information, share that information openly. We always want to be first right and credible with the information that we provide to the public. We also want to be collecting information about the key questions that we still don't fully understand. How can we best protect healthcare workers? Do people without symptoms or before they have symptoms spread this infection or not? Do children spread this infection? Who is most at risk for severe illness? These kinds of questions need to be urgently answered so we can protect people as well as possible.
One crucially important development in healthcare is the much broader use of telemedicine and online medicine. For patients who have a regular provider who uses an electronic messaging system, that's a great way to get refills and consultations. For patients with a provider who doesn't use that kind of an online system, we need a way to make that happen. And for people who don't have a regular provider, we need to provide them with care so they can continue to get the life-saving treatments they need and consultation for COVID-19 if they're concerned.
DR. RISHI DESAI: That's a great point, and I'm curious: what role or other roles do you think online education will play in raising the line and preparing more healthcare workers to join the front lines in fighting COVID-19?
DR. TOM FRIEDEN: Online education can be extremely important in sharing lessons on how to prevent infection, how to care for patients, how to optimally structure healthcare. It may also be important in contact tracing, and we see from South Korea and some other places the very sophisticated use of cell phones and geolocating systems to identify who may have been exposed.
DR. RISHI DESAI: If you could go back and change 2–3 ways that the CDC and WHO have responded to the spread of COVID-19— given that you said time equals lives—what would you change?
DR. TOM FRIEDEN: I'm not sure it's useful to go back now and say, "What could have been done differently?" Let's wait until we get through it, and focus on what we need to do differently now.
One thing we must do better is get answers to critical questions: how can we best protect healthcare workers? Do asymptomatic and presymptomatic people spread this disease or not? Do children spread this infection or not? These are crucially important and answerable questions, and the sooner we get answers, the better off we'll be.
It's also crucially important throughout the United States that we follow the best practice of dealing with emergencies. That means using an incident management system where there's one clear person in charge, there are different lines of work, and there are frank communications by the scientific experts on the best ways to protect ourselves against this pandemic.
DR. RISHI DESAI: Thank you for your time, Dr. Frieden.