Outgoing CDC chief talks about agency’s successes — and his greatest fear

Outgoing CDC chief talks about agency’s successes — and his greatest fear

CDC Director Tom Frieden is pictured at his office in Atlanta during the Ebola crisis in 2014. (Michel du Cille/The Washington Post)

Tom Frieden, the director of the Centers for Disease Control and Prevention, has been a central player and one of the most public figures in fighting infectious diseases in the United States. Appointed to his position in 2009 by President Obama, the 56-year-old New York native has led the Atlanta-based CDC longer than any director since the 1970s. His tenure has been tested by major disease outbreaks, including the 2009 global H1N1 swine flu pandemic and deadly respiratory virus known as MERS, the Ebola and Zika epidemics, and a growing domestic overdose crisis.

Like all political appointees, Frieden has submitted his resignation to President-elect Donald Trump and expects to leave his job at noon Friday. Anne Schuchat, who was chief health officer during the H1N1 pandemic and has been principal deputy director since 2015, will take over as acting director.

While in Washington late last week to take part in a National Security Council exercise for top officials across agencies who are coming or leaving, Frieden talked with The Washington Post about the accomplishments and frustrations of his tenure. He spoke about the successes in reducing smoking in this country, the importance of continued global leadership on fighting diseases abroad — the best way to protect Americans at home, he said — and the challenges ahead.

The exchange that follows has been edited for length and clarity.

TWP: What worries you about reports that the president-elect has discussed creating a vaccine commission with Robert F. Kennedy Jr., a leading proponent of a scientifically discredited conspiracy theory that vaccines cause autism?

Tom Frieden: The CDC is ready to work with the incoming administration to protect American people from threats. In terms of immunization policy, we arrive at these recommendations through the Advisory Committee for Immunization Practices. ACIP is a model for transparency. It involves not just doctors and nurses but professional organizations, community groups and consumers. Every single deliberation of that committee is open to the public. All of the materials are available on the Web. We’ve always found that sunlight is a good disinfectant.

When it comes to parents vaccinating children, the vast majority vaccinate their children on time and per physician recommendations.

TWP: Congress is in the process of repealing the Affordable Care Act. Aside from health insurance, the law funds prevention and public health. What’s at risk?

Frieden: Currently, more than a 10th of our budget comes from the [ACA’s] prevention fund. It goes for programs which are broadly supported: the block grants for state governments, immunization programs, the epidemiology and laboratory capacity programs that find and stop threats, tobacco control programs.

These are programs that save lives and save money. And they are at risk. It’s a budget decision more than any other decision. Regardless of what happens to the prevention fund, it’s extremely important to Americans’ health and safety that those programs continue.

TWP: You’ve been the longest-serving CDC director since the 1970s. What have been CDC’s biggest successes during that time?

Frieden: Fundamentally, Americans are healthier and safer because of the work CDC has done over the last eight years. Americans are safer because we have better capacities in place, better infrastructure in place in this country and around the world to find threats early, stop them quickly and prevent them wherever possible.

We’ve done that through laboratory work that looks at microbial genomics so we can stop outbreaks sooner. We’ve done that by training the next generation of public health specialists — more than 1,000 of them, fresh out of college and graduate school — deployed out to state and local governments. These people will be protecting Americans for decades to come.

Globally, we’ve increased laboratory, surveillance, epidemiology and response capacity around the world so we can stop diseases there and don’t have to fight them here. And then, of course, in addition to strengthening the infrastructure, we’ve responded [to] and stopped some of the deadliest threats that we’ve faced in recent years.

Ebola was the largest mobilization of CDC in history. We had 4,000 people work on this, including 1,400 people who spent 75,000 work days in West Africa.  They went to virtually every community where Ebola was spreading to improve contact tracing, infection control, health communication, incident management, laboratory work. And in significant part, because of their work, we stopped Ebola, particularly we stopped it in Lagos [Nigeria] where it could have gotten out of control and become a global catastrophe.

We sounded the alarm early and often on the opiate epidemic. We’ve been able to strengthen the ability of states to take action about opiates. We still need to do a much better job managing both pain and addiction.

[And] because of efforts by the federal government, including CDC and partners throughout society, there are 10 million fewer smokers than there were in 2009.

TWP: What’s still on the to-do list?

Frieden: First and foremost is the establishment of a rapid-response fund by Congress. I think there’s good bipartisan support for this, but CDC needs to be able to move quickly when there’s an emergency. FEMA [the Federal Emergency Management Agency] doesn’t go to Congress every time there’s an earthquake or a hurricane and say “We need money.”

We had to wait nine months to contract for improved diagnostics and mosquito-control technologies because of the delay in the Zika supplemental [funding]. A rapid-response fund would allow us to do the equivalent of stopping an earthquake.

Frieden receives his annual flu shot from Sharon Bonadies during a 2016 news conference in Washington to stress the importance of influenza vaccination. (Win McNamee/Getty Images)

TWP: What scares you the most? What keeps you awake at night?

Frieden: The biggest concern is always for an influenza pandemic. Even in a moderate flu year, [influenza] kills tens of thousands of Americans and sends hundreds of thousands to the hospital. That increase in mortality last year may have been driven in significant part by a worse flu season compared to a mild flu season the prior year. So flu, even in an average year, really causes a huge problem. And a pandemic really is the worst-case scenario. If you have something that spreads to a third of the population and can kill a significant proportion of those it affects, you have the makings of a major disaster.

The Bush administration made important investments in public health, global public health and in influenza preparedness, and in the Obama administration, we have built on those. It’s a baton that gets passed. Preparedness is really important.

One of the things we learned from H1N1  is that the best way to respond to an emergency is with an everyday system that can be scaled up, not a “break-glass-in-case-of-emergency” system. So in the H1N1 pandemic, when vaccine became available from the manufacturers, we were able to send out over 300,000 doses to more than 70,000 places without a glitch. We used the Vaccines for Children program and its provider — it was an everyday system that already provides half the childhood vaccines in the country. We were able to scale it up. The company that did that did a terrific job. They said it was the largest effort they had done in their 120 years. But you don’t hear about that because it went so well. The point is, it was an everyday system. And because it could be scaled up, it went well.

TWP: At a time when world is more globally connected than ever, coinciding with more emerging pathogens and an incoming administration that is considering just how to engage with the rest of world, do you worry that CDC will be less immune from politics, less able to do its job?

Frieden: Just as you need the Department of Defense to protect America from security threats, you need CDC working around the world to protect Americans from health threats. Health often is a bridge. Even at the height of the Cold War, the U.S. and the Soviet Union worked together on smallpox eradication. In the 1980s, wars were stopped for childhood immunization programs.

I was just with President [Jimmy] Carter the night before last, who was remembering the [1995] cease-fire they were able to broker in Sudan for six months so that they could move forward on Guinea worm eradication. It’s still remembered, years later, as the Guinea worm cease-fire.

If the resistant organisms emerge in one part of the world, they will inevitably come to other parts of the world. Flu virus spreads like the air around the world. You can’t change that. And I think a pragmatic approach will rely on proven programs that protect Americans.

TWP: You’ve often talked about your frustrations with how slowly the federal bureaucracy moves. Were there times you were almost not willing to toe the line, even if it meant losing your job? 

Frieden: I’ll mention one thing that was public. We were told not to do social media when there was the [2013 federal government] shutdown. But I was so pissed off that, [at] 10 o’clock at night, sitting at my desk working, I typed into my iPad that “Today, CDC had to furlough 8,754 staff. Yesterday they protected you. Tomorrow they can’t. We are less safe.” I hit “enter.”

I was fairly new to Twitter at that point, and it went viral. It was on all the news the next morning because no one was giving any official interviews. … It was a real problem. Because of the way the law is written, the people who keep working during a shutdown aren’t necessarily essential staff. They’re just on different funding streams. And the people who I would consider as essential don’t meet the criteria as essential. So we can respond to an outbreak, but we can’t determine if there are outbreaks. We had to shut down a lot of our monitoring systems.

I went to our central lab — it’s a whole floor in one of our huge buildings. It’s usually bustling with people doing tests and producing diagnostic kits. It was empty. And there was a machine beeping, an alarm going off. It was terrible, like something out of a movie. It turned out to be nothing life-threatening. But it was an example. There are real-life implications of what decisions are made here. If a tobacco program gets defunded, 16,000 more Americans will be dying from tobacco-related disease.

Frieden and Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, testify during a Senate appropriations subcommittee hearing in early 2016 on the Zika virus and emerging health threats. (Michael Reynolds/European Pressphoto Agency)

TWP: Public health covers an enormous number of issues, from heart attack and smoking to emerging infectious diseases. Their risks are very different. Do you think those require different kinds of communication? After Ebola and Zika, what should your successor know about the most effective way of communicating those risks when he or she inevitably confronts the next emerging threat?

Frieden: CDC has some of the top communications scientists in the world. Their key principles are be first, be right, be credible. You have to get it out there quickly even when the information isn’t complete, and that’s very uncomfortable for scientists, uncomfortable for doctors. We like to get all the information before we make a determination. But you often have to go with what you know. What I’ve always tried to do is tell people what we know, tell them what we don’t know. Tell them what we’re doing to find out the things we don’t know. And give people specific things to do.

One of the challenges with Ebola was, there wasn’t any specific advice to give people. With Zika, you got people to wear mosquito repellent. If you’re pregnant, don’t go somewhere where Zika is spreading. With things like tobacco, we’ve learned that what really motivates people to quit are the real stories of real Americans showing their suffering and their disability with smoking.

TWP: Do you think the risks from Zika were dealt with a little bit more upfront than they were with Ebola? CDC and federal officials said fairly early on about Zika that there will be other cases and that we’ll see this in places like Florida and Texas. 

Frieden: We said there could be local [Ebola] cases but there wouldn’t be spread. But we didn’t expect it to spread [from a patient] to two nurses in Dallas, and I think that contributed to the concern. And we were deeply concerned about the safety of health-care workers. We had initial infection-control guidance that we believed would be sufficiently protective. It had been for 20 years. We had done clinical care of Ebola in West Africa before. But the diagnosis was initially missed. By the time [the patient] came back in he was deathly ill. The nursing care was very intensive, and we felt terrible the nurses got infected. And so we rapidly improved the infection-control recommendations.

TWP: CDC labs have experienced numerous and repeated safety lapses. Even though CDC talks a lot about transparency, it has not released much information about what actually happened and where. 

Frieden: CDC has more than 150 labs with around 2,000 laboratory scientists. We do well over 1 million laboratory tests per year. We have the broadest range of pathogens and environmental risks that are tested for of any laboratory in the world. And we often work under time pressure that’s unlike any other lab in the world, with a life-and-death decision — that will be made based on whether [the pathogen is] botulism or anthrax or plague, or whether it’s resistant or not — to be determined overnight. 

Improving laboratory safety is very important. And when there was an incident in one laboratory, we immediately began a thorough review of all aspects of our laboratory work. I specifically got the best outside experts I could find and told them “no holds barred.” … They gave us a large number of recommendations, which were implemented. We now have an associate director for laboratory science and safety. This wasn’t one of their recommendations, but it’s a great thing. We’ve started a laboratory leadership service analogous to and coordinating with the Epidemic Intelligence Service. This is a group that will be making labs safer and better for decades to come.

We also have worked hard to improve the culture of safety in our laboratories. So we encouraged reporting of not just incidents but near-misses, so that we can work with the laboratories to minimize the risk. And we’re encouraged that we’re seeing more reports. It doesn’t mean we’re less safe. It means we’re more transparent.

I think that the broader lesson on lab safety is that we must minimize, but it is impossible to eliminate, the risk of working with dangerous microbes. I think that this means that we should ensure both that we do everything possible to minimize risk and that we reconsider how many laboratories are doing research on these pathogens and how they are doing it.

TWP: What’s next for you?

Frieden: I’m weighing the options. I’ve made all my career decisions by asking one simple question: How can I save the most lives? That’s the question I’ll ask in making my decision.

Read more:

CDC director’s challenge: Deadly Ebola virus and outbreak of criticism

CDC confirms Zika causes microcephaly

The United States already has a vaccine safety commission. And it works really well, experts say

‘My name is Amanda and I smoked while I was pregnant’

Lena H. Sun is a national reporter for The Washington Post, focusing on health.

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