Former CDC Director Dr. Frieden’s Thoughts on Dr. Fauci and His Next Chapter

Dr. Tom Frieden

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M arianne O’Hare : Welcome to Conversations on Health Care. This week we welcome Dr.
Tom Frieden, CEO of Resolve to Save Lives and Former Director of the
Centers for Disease Control and Prevention, talking about a major
overhaul at the CDC . Now, here are your hosts Mark Masselli and
Margaret Flinter.

Mark Masselli: Big changes are on horizon at the Centers for Disease Control and
Prevention, as well as the National Institute of Health as we continue
to face COVID and M onkeypox challenges. The CDC is l ooking to do a
better job protecting Americans and Dr. Anthony Fauci officially
announces his departure.

Margaret Flinter: Here to discuss these topics is the Former Director of the CDC, Dr.
Tom Frieden. He's currently the President and the CEO of Resolve to
Save Lives , a nonprofit focused on making the world safer from
epidemics.

Mark Masselli: Dr. Frieden, thank you for joining us, again on Conversations on
Health Care .

Dr. Tom Frieden: Delighted to be here , and looking forward to the conversation.

Mark M asselli: Let's start with the news that Dr. Anthony Fauci will leave his role as
the Director of the National Institute of Allergy and Infectious Disease
in December and President Biden said , “ He has touched all American
lives with his work, the United Sta tes is stronger and more resilient,
and healthier because of him. ” I'm wondering what your thoughts
are, he's your friend, you've worked with him for a long time. Talk a
little bit about his legacy , and also maybe what type of person or
experience should b e looked to fill this important role.

Dr. Tom Frieden: I first met Tony in the 1980s, when I was taking care of AIDS patients
in New York City, trying to get people into clinical trials. And then I
worked very closely with him during the Ebola epidemic of 2014 to
2016 in West Africa , and I really got to know Tony and his
commitment to the public to public health, being focused on what's
the right thing to do, and being able to communicate that very
effectively. It's unfortunate that over the past few years, so many
things, whether it's masks and vaccines or Tony Fauci have gotten
partisan and political . Tony has advised seven Presidents. He was very
close to both Presidents Bush, President Reagan, Presidents Clinton or
Obama, and Tony tells it like it is. He doesn't sugarcoat things.
Unfortunately, at this point, sometimes just stating a fact like
hydroxychloroquine doesn't work may be seen as a political
statement when it's really not. In terms of what comes next for NIAID,
this is one of the larger institut es within the National Institutes of
Health and Tony has played much more than that role because of his

Dr. Tom Frieden

influence with the White House s, because of his influence with both
Houses of Congress with both sides of the aisle, traditionally, and I
think the next director, besides the question of why is he not Tony
Fauci or she is why she not Tony Fauci, the next director will have the
challenge of recognizing that that role may be much smaller than the
various rol es that Tony Fauci was playing.

Margaret Flinter: Well, we certainly share your positive assessment . Dr. Fauci
remember him so well, from the early days of the HIV AIDS epidemic ,
and I know we all love both wish and well and look forward to hearing
what he takes on next. But you led the CDC from 2009 to 2 017 and we
certainly have followed with interest now, the news review team . I
was picked to interview about 120 agency staff and key external
stakeholders , and we understand that you were one of the experts
that they spoke with . The full report we haven't seen yet , but can you
share with us what some of your sort of key recommendations and
guidance would have been when you were interviewed by them?

Dr. Tom Frieden: I look forward to seeing the full report. I think you have to really
divide problems intrinsi c to CDC, and problems extrinsic to CDC and
you can't sugarcoat the problems that are intrinsic, but you shouldn't
pay for over the problems that are extrinsic. So , CDC is dealing with a
public health system around the U . S . where state and local health
dep artments have been underfunded for decades. It's also dealing
with a health care system that's very fragmented. If you look at
countries like the United Kingdom, Israel, they have a very coherent
healthcare system. So it's much easier to get reporting and figure out
what's going on with whether it's COVID or M onkeyp ox . Also within
the federal government, CDC has had real challenges in the prior
administration. CDC’s advice was undermined, maligned , sidelined,
and even in this administration, by insisting th at moves to all of the
media be done with the White House , you've seen an increasing
polarization of attitudes towards CDC and though most of the media
talks about how CDC has lost the public trust, and it's certainly true,
that the trust levels are substa ntially down . When I was there, it was
the second or third most trusted F ederal agency, the M int always
didn't invest in that in that rating. But it's been primarily among
Republicans, a big drop in trust among Republicans. That partly is a
reflection of t he partisanship that has infected the response to COVID.
But there are also intrinsic problems at CDC and these are things that
have been there for a while need to be addressed. It's very important
to emphasize that, although those problems are real, it's also real that
there are thousands and thousands of d edicated public servants at
CDC, doctors, nurses, pharmacists, veterinarians, who have devoted
their lives to public service and they still are some of the most
knowledgeable and committed people anywher e in the world and the
key is to ensure that CDC has the wherewithal to refocus on
protecting Americans and the world from health threats.

Dr. Tom Frieden

I think many of the recommendations we've heard about make a lot
of sense, focusing on quicker action, more practica l
recommendations . One of the things that will be very important in
doing that is knitting together the F ederal, S tate and local levels by
having a big increase in the number of people who are CDC
employees, but on loan to state city or local health depart ments , and
then after two, three, four or five years, may rotate back to Atlanta.
This is a way of aligning perspectives. It's a way of getting more
people at CDC who understand what it takes to get the job done at
the local level.

Mark Masselli: You know, the current head of the CDC is Dr. Rochelle Walensky , who
has discussed the review and we want to unpack what's been
reported and get your reactions and first, they'll create a new
executive team to set priorities and make decisions about how to
spend the ir annual $12 billion budget with a focus in on public health
impact. I'm wondering do you think that's going to work . Do you think
that's going to help seems to be perhaps a manageable size of a
budget for a few people to decide? Congress can have input o n that .
How do you think that's going to work?

Dr. Tom Frieden: Well, the truth sad or not is that CDC does not set its own budget.
Congress sets its budget in 150 - plus different budget lines and the
D irector or the E xecutive T eam have very little latitude to change that
budget in any way. In fact, when I was CDC director, I was struck by
the fact that as Ne w York City Health Commissioner, a post I also held
for about seven and a half years, I have literally 20 times more flexible
dollars than I did as CDC Director . So , part of this is Congress,
increasing the amount of cross cutting funding that CDC has , so CD C
can focus on m aximizing public health impact.

The organizational issues aren't simple. CDC is a large organization,
there have been a few different attempts to have it run in a
streamlined way. When I got there, there were something called
coordinating centers, I disbanded those, I created D eputy D irectors to
oversee a cluster of centers. As with NIH, you have many different
entities within the larger organization. The most important thing is
that those entities f unction well in their own areas.

Then there are some adjacencies , some synergies that can be
achieved , and the more Congress gives cross cutting funding, the
more CDC can focus on protecting p eople against the biggest threats.
The other thing that I think is an important direction that was outlined
was focusing more on public health action, more on rapid response ,
and that's very important . I think, one of the implications of the fact
that ther e aren't that many people who spent a few years on the
front lines, that there are some people at CDC and that some of the
culture there that's risk averse, that would rather delay a decision

Dr. Tom Frieden

than make a decision that may be wrong .

That gets back to commun ication , because ultimately, a lot of
whether CDC is successful at regaining trust, and it has lost trust of
the American people is how well it communicates ? How well it says
consistently, based on what we know now, here's what we're
recommending. This is why we're recommending it. This is what we
know and how we know it . This i s what we don't know, and what
we're doing to try to find that out and really talk through the details.

People often ask me , do I miss being CDC Director? And the honest
truth is , no , but one thing I do miss is the ability to call up any of
thousands of scientists, who are the world's experts in their area and
that's a precious resource. And whether that's M onkeypox, or polio,
or viruses, like COVID, or tuberculosis, or environmental poisonings,
or what's causing heart attacks and strokes in this country and around
the world, that's a wonderful resource. And the key is to translate
that knowledge into practical, rapid action .

Mark Masselli: Wonderful .

Margaret Flinter: Well Dr. Frieden the kind of communication outward timely
communication that may help regain the public's trust, of course,
depends on communicating efficiently in word , and we understand
that the review has indicated that two scientific divisions will now
report directly to Dr. Walensky ’s Office. And that seems to be a
change that's aimed at speeding up the delivery of data to that office
as the key individual that's going to then communicate it outward to
the country .

When you ran CDC, was slow data delivery an issue and does that
really change internally as CDC? Or is that a function of the massive
network of local and state health departments out there?

Dr. Tom Frieden: Well, there are a couple of questions in there; one of them is about
data. And yes, slow data is a bi g problem, it's a big problem, it's not
going to be quick to fix. It's a reflection of weak local health
department's , weak of information systems in the healthcare system.
And an approach at CDC that sometimes is not as efficient as it needs
to be. There has been progress, but not nearly enough , and to be
really frank with people, this is not going to get fixed overnight, this is
going to take years to fix , but if you focus on the most important
information and getting that information in and out quickly,
understanding that you know, done is better than perfect , and perfect
should never be the enemy of the good. This is a really important
concept.

I think part of the challenge is now there's kind of a gotcha attitude
towards CDC, Oh, you made this mistake. And CDC needs to be

Dr. Tom Frieden

comfortable saying, based on the best information we have today,
this is what we believe , this is what we're recommending. This is why
and that may change as we get more information, and getting that
kind of expertise and recognition , t hat's very important.

The other part of your question has to do with direct reports to the
CDC Director . I actually created the laboratory unit, because I
recognized that there was weakness in the oversight of our
laboratories , and I do think making that u nit stronger, particularly
because of the really serious mistake that happened early in the
pandemic with laboratory tests, you need to have much more control
over the laboratories. That office needs to be more powerful, when
that's done by having it repor t directly to the D irector or have, for
example, budget authority over the different laboratories in the
agency we’re hiring a sign off on key hires. There are lots of ways to
do it , but I do think that office needs to be even stronger.

Mark Masselli: You know speaking of being frank, I'm wondering if you can give us an
assessment about Dr. Walensky , in terms of her ability to make these
changes, what are the qualities that she possesses to make her that
leader? And what are the limitations that she has tha t she may need
assistance or to be focused in on?

Dr. Tom Frieden: Well, I'm not there now , and so I don't want to second guess her, the
amount of pressure she's under really can't be underestimated. She's
coming into an agency at the time of the worst pan demic in a
hundred years, with staff who have really been beaten down for a few
years, they've been working really hard, but not recognized. A lot of
great work done, not appreciated, and a lot of challenges through the
federal government, through the Cong ress , through the country. It's a
very difficult position , and I think the key will be to enlist in this very
appropriately directed effort the people within CDC, who understand
the need for change, who have been working hard for dedicated
public health an d public service, and who will be the only way that
this succeeds is if you bring the people along with you , and I think
that'll be crucially important.

Margaret Flinter: Well Dr. Frieden, I think it goes without saying among all of us , that in
government, there is always constraints and hurdles and obstacles
and opportunity , but I have to say that I was shocked by what you said
earlier, which I had just heard a few minutes before we started the
show, that Congress actually sets all those line items of the budget for
CDC. I was unaware of that , w hich seems like a very bad idea when
we never know what the next thing is that's coming, that is going to
pose a real threat. Is that part of the advocacy work that's underway
and did that -- do you think contribute to some of the issues around
what we're seeing, and I know, we may talk more in a minute about
M onkeypox, or even COVID, about the ability to pivot on a dime, and

Dr. Tom Frieden

put your energy and your resources where you need to?

Dr. Tom Frieden: I do think that the fr agmented budget of CDC is a big part of the
problem , b ecause what it means is that the incentives within CDC are
to work within your narrow area, one of more than 150 areas. Only in
the last couple of years, Congress has begun providing cross cutting
fundi ng in substantial amount and that's very important, and that
needs to continue and that needs to expand.

Furthermore, it's crucially important that there be sustained funding
for public health . Public health has worked in kind of a boom and bust
mentality and experience . If there's an emergency , billions of dollars
come in, they need to be spent quickly . It’d be better to get less
money but more stable money. I don't mean a cut from their existing
budget. But rather than get $5 billion to spend in a year, i f you had $4
billion to spend over four years, that would actually do much more
good. And that's why whatever mechanism, the ideal would be that
Congress would identify certain budget lines that are required for our
country's health defense. And then take those budget lines out of the
budget dance, let them be funded by Congress based on an accurate
assessment of need without having to rob Peter to pay Paul, without
having to cut Head Start or Alzheimer's research to fund something
that could save 1000s or millions of American lives. That kind of
reliable sustained funding will be very important for avoiding the kind
of vulnerabilities that we've had for COVID and other health threats.

Mark Masselli: You know, speaking about the threat of COVID we've had Dr. Fauci,
Dr. Topol, Dr. Hotez, many others who've been on the show, all talked
about the next pandemic as well. That this isn't the last pandemic
we're going to face. And I'm wondering what your thoughts are about
the bipartisan call on Capitol Hill for an independent COVID - 19
Commission modeled after the 9 / 11 Commission? Where do you
stand on that idea or conceptually about how do we analyze what
we've just gone through so we can be better prepared for the future?

Dr. Tom Frieden: I think it's very importan t . There needs to be a clear look . More than a
million Americans are dead. And if the U . S . had a death rate of
Canada's, for example, most of those people will still be alive. What
went wrong but more importantly what do we need to change so that
preventab le deaths like this in response to a health threat never occur
at this level? You know, that the U . S . is an outlier. If you look at death
rates for 100,000 people in high income countries, the U . S . has a
much higher rate than most other countries. And that 's not something
where the U . S . should be number one. That's something where we
shouldn't be a leader. And this kind of review is very important. I
became CDC director after 9 / 11 and we look really carefully at the
9 / 11 Commission recommendations and those recommendations
changed the way government does business. Did they fix everything?

Dr. Tom Frieden

No. Did they make it better? Absolutely. And there's also kind of a
reckoning, it's important that that get done so that people who want
to know the truth can know what rea lly happened, what went right,
what went wrong?

Margaret Flinter: Well, Dr. Frieden, we still obviously are in COVID and very concerned
with continuing to address COVID. But the global Monkeypox
outbreak didn't wait fo r the COVID pandemic to be over. That' s
arrived on our doorsteps and we’re very engaged in the response to
that here in our own state . But there's been criticism from the former
FDA commissioner Dr. Scott Gottlieb that CDC had once again failed to
expand testing fast enough in the early days o f Monkey pox. I wonder
if you agree with that criticism, and generally if you'd like to comment
and how we're doing in responding to the Monkeypox epidemic ?
Certainly vaccines have been challenges in terms of shortages,
although I think the pathway of getti ng them out to communities we
learned a thing or two from the COVID pandemic, but what are your
thoughts on that?

Dr. Tom Frieden: There's a real commonality between the challenges we're facing in
COVID, in Monkeypox, and also in the polio transmission in New York
and elsewhere . And it has to do with community engagement .
Community engagement and building of trust is absolutely essential.
When it comes to Monkeypox, this is overwhelmingly spread among
men who have sex with men. And it's really important tha t local, city,
state, federal and global public health agencies work really very, very
closely with community members, community leaders, sharing
information, sharing dilemmas, sharing resources, prioritizing
vaccines, treatments, diagnostics of those who are most at risk, and
doing everything possible to control the outbreak .

We are seeing a reduction in cases in some countries in Europe, and
maybe a reduction starting in the U . S . , but we have a long way to go.
And we don't have enough vaccine. That's som ething else that should
be looked at that was under a different part of the F ederal
G overnment that was taken away from CDC . The vaccine that is
available is being sent out in ways that are not very efficient. So that's
something that we didn't look at. Bu t right now, the key is to engage
communities. For example, we need to go to this fractional dosing
approach . You get five times as many people vaccinated . Are we
happy that we have to do that? No . We wish we had much more
vaccine .

But work with community leaders, work with community members,
get the vaccine out as quickly as possible , and see if there are people
within those communities who may be able to carry the message that
until you've been the recipient of two doses of vaccine, you might
want to lim it the number of sexual partners to people with whom

Dr. Tom Frieden

you're having ongoing relationship to reduce the number of
anonymous partners because that's, this is largely spreading, and to
provide clear information that Monkeypox, which is an unfortunate
name is r eally uncomfortable. We haven't had deaths yet in this
country, there have been deaths globally. But even people who are
only mildly ill from it feel pretty miserable for weeks. And you don't
want that spreading . We hope it won't spread for a long time or to a
lot of society. But we don't know what will happen. It spread through
intimate contact, which means that people who are other than men
who have sex with men are not immune from it. And this is a real risk.

Similar thing happening with polio, you see very low vaccination rates
in some communities . Unless there's engagement with those
communities and building of trust, it's going to be very difficult to
control. And that's the case in upstate New York, as it is in Afghanistan
and Pakistan, and elsewhere around the world where p olio sadly
continues to spread.

Mark Masselli: Well, what a great prescription of building engagement to get to trust
as something all of our institutions should be engaged in. And, you
know, criticism continues to follow CDC . It’s loosens its COVID
guidelines for isolation and testing in schools and ended a previous
recommendation that students quarantine if exposed to someone
positive for the virus. And it said that schools should no longer
conduct routine COVID testing for asympt omatic or unexposed
students. Some critics have said the CDC is moving too fast. What's
your take on this?

Dr. Tom Frieden: The situation now is really very different than what it was before. And
I will say I've been very consistent about this in March of 2020, that
we need to keep the schools open and functioning, because it doesn't
make that much difference in terms of spread of COVID. And it makes
a huge difference in terms of not just educational outcome but social
development, economy and other things. So working to keep schools
open and functioning as normally as possible is extremely important. I
think CDC is in a position where whatever it recommends, there are
going to be people saying too stringent, not stringent enough. That's
why communication is so important. So it's not just a
recommendation put on the web but one hour press conference with
the top C DC experts in COVID, in schools, in transmission, in contact
tracing and testing, to answer every question that media has . Why did
you make these re commendations? What are they based on? What
are the pros and cons ?

And ultimately, the recommendations, school districts and state local
city health departments will make their own determinations and the
more CDC lays out why it's saying those things, the more consistency
there will be understanding that different communities may with all

Dr. Tom Frieden

validity come up with different conclusions. They may decide we want
mask s or we don't want masks. We want them in this situation or not
in that situation. But at least i t should be explicit about what you're
doing and w hy, and recognizing that the COVID situation today is
really very differe nt, for at least a few reasons.

One , COVID the virus is hitting a wall of immunity from both prior
infection and from vaccination. A nd that prior immunity, although it
doesn't protect very well from getting infected, does protect a great
deal from getting severely ill and hospitalized and dying. And that
transforms COVID from something that was much deadlier to
something that's much le ss than. Second, we have great vaccines and
apparently very effective treatment with Paxlovid. And that also
transforms this pandemic to something that's much more
manageable. We also understand how to control it more, and for the
people who remain quite v ulnerable t hose who have underlying
conditions who are elderly and frail , in addition to vaccines and quick
treatment with Paxlovid , you have also got ample N95 masks, which
can be very helpful. So that people can make a determination , w hat's
the risk , w ha t's the benefit , and what do I choose to do that I can go
about my life as healthil y and productively as possible.

Margaret Flinter: Well, Dr. Frieden, we want to thank you for sharing your insights with
us. We want to thank you for all of the great work t hat you've done in
public health over a long career . And thank you to our audience for
joining us today to o for thi s important conversation.

You can learn more about Conversations on Health Care and sign up
for our updates at www.chcradio.com . Dr. Frieden, thank you so
much again for joining us today on Conversations on Health Care .

Dr. Tom Frieden: Thank you. It's been a pleasure.

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