Flu Cases Rising: “It’s Not Good,” Says Former CDC Dir. Dr. Tom Frieden

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Mark Masselli (00:04)
Our guest has been on the frontline of America's public health challenges and has distilled his experience into a
framework to understand healthy lives. He shares his thoughts in a new book.

Dr. Tom Frieden (00:15)
What we've seen from Europe, and Europe usually has an earlier flu seaso- season than we do, is they're having
the worst flu season they've had in years this year. So, if that comes here and we have lower flu vaccine rates,
that means more hospitalizations.

Margaret Flinter (00:29)
Dr. Tom Frieden served as director of the Centers for Disease Control and Prevention, and he served as
commissioner of the New York City Health Department. He now leads Resolve to Save Lives, which works
with partners to accelerate action against the world's deadliest health threats.

Dr. Frieden (00:45)
So, the superpower of public health is to see the invisible. We can see things that aren't apparent. It may be
microbes spreading in certain ways or toxins hurt- harming people in certain ways, or programs that we thought
were doing great that are actually failing, or vice versa. And to see the rigorous pathway to progress, that if you
do X, you will get Y, in terms of health outcomes.

Margaret (01:09)
This is Conversations on Health Care.

Mark (01:22)
Well, Dr. Frieden, welcome back to Conversations on Health Care.

Dr. Frieden (01:26)
It's great to speak with you again.

Mark (01:28)
Your book is titled, The Formula for Better Health: How to Save Millions of Lives, Including Your Own. You
criticize the Food and Drug Administration. Right now, there are press reports that the Trump administration is
frustrated with the leadership of the current FDA commissioner. What's your take on his management of the
FDA?

Dr. Frieden (01:49)
I really can't comment on that. I don't know what's going on inside of the administration. What I do know is that
we have a way to save a lot of lives, and if we use this proven approach, this formula, we can save millions of
lives and we can apply it to primary care, we can apply it to personal health and wellness. And the formula is:
see, believe, create. So, take an FDA action on something like sodium. The FDA has the power to improve our
food. Or on tobacco, it has the power to reduce the amount of addictive nicotine in cigarettes, but it's not doing
it. So, if our focus can be single-mindedly on making our society such that if you just go with the flow, you're
not going to end up sick, disabled or dead at a young age.

Mark (02:46)
So, it's not really personal, it's really professional, your observation of what's happening there.

Dr. Frieden (02:53)
Yeah, I think, what we see, when it comes to health progress is that there's a reason that bad things happen. It's
not just that people are mean or- or not paying attention, it's that the economic forces and our personal
perceptions are such that it makes health challenging. And that's why this formula of see, believe, create is
essential. We need to see the threats, see the trends, see why we're not taking action, and see the rigorously
proven path to progress. We need to strengthen belief that we can change things, 'cause if you think it's hopeless,
you're not gonna try to change things. And we need to work systematically to create a healthier future.

Margaret (03:47)

Well, let me, pick up on that a little bit, 'cause it- it seems if we were starting at baseline, and I think it's
probably been, two years or so since we've had a chance to chat with you, our work would be cut out for us,
right? If we were starting at baseline of where we've been with all of the issues you described, from tobacco to
sodium to, diet and everything else. but you've also noted that we are at a time where we've been seeing a- a
destruction or deconstruction of our public health protections. And I'm wondering how you see the opportunity
to achieve some of the goals you just laid out, by rebuilding public health. Where- w- where's the most
important place to start in rebuilding what we seem to have been somewhat taking apart in public health?

Dr. Frieden (04:33)
Well, first, I think we have to do everything we can to stop the destruction. There are big problems happening
with our vaccine policy, with, attacks on the CDC. Quarter of the staff have been fired or left. Most of the
leadership has left or been fired. We have political appointees running the organization, in a- in a big group.
That's never happened before. second, medical institutions, states, cities, localities, academic institutions need to
fill gaps when they're needed. for example, the American Academy of Pediatrics giving vaccine
recommendations that are based on facts and protecting children. so, I think stop the bleeding, patch where
possible, but also, we're never going back. We need to go forward. And that involves a public health system
that's faster, that listens better to communities and communicates more effectively, that has alliances and
partnerships with primary healthcare and many- many other entities, and that delivers benefits that people can
feel.

Mark (05:47)
You know, Margaret, I was thinking back to the beginning of the pandemic when we were talking about,
everybody talking about public health- ... and how its, stock, rose during that time. And Dr. Frieden, you were
just talking about, maybe it's not gonna happen out of Washington, it's gonna happen at the state and local level.
Doesn't seem to be a lot of conversation going on at that level or the resources needed. So, is that, is- is that
something we can count on or- or do we have to maybe look s- elsewhere?

Dr. Frieden (06:17)
Well, we are seeing a northeast collaborative that's bipartisan- Yeah. ... of health departments getting together.
we're seeing other groups, work. But I think there's no substitute to a competent federal government. Right. It
has to be there. It has to do things that no other entity can do. But if it's not doing those things, then we have to
do, what we can to protect people and keep the, the, the health safety net that is so essential going, whether that's
finding and stopping outbreaks sooner, or supporting smokers who want to quit, or preventing cancer.

Margaret (06:57)
Well, at this moment in time, that we're talking, we're at peak season for flu and COVID. certainly seeing that-
Yeah. ... in our own organization. There are news reports, that the change in federal guidelines about vaccines
have created confusion, have resulted in fewer shots in arms. I think, vaccines are less readily available in some
areas and costing more money- Costing more money. ... which is another factor. from where you sit, are, are you
following the data on this? How do you think things are looking, both in terms of protection with vaccines, but
also, in terms of actual cases?

Dr. Frieden (07:29)
It's not good. we're seeing a, a significant decrease in uptake of both COVID and influenza vaccines. possibly a
dec- decrease also in the RSV, vaccine. and I think we have to be really clear that, things change over time. And
in, in the book, The Formula for Better Health, I outline what it is to be technically rigorous. We have to
recognize that microbes change with time. Our immunity changes. Vaccines change. The environment changes.
I think people have gotten used to that for influenza, that every flu season is different. the only thing you can
predict about influenza is that it's unpredictable. but what we've seen from Europe, and Europe usually has an
earlier flu se- season than we do, is they're having the worst flu season they've had in years this year. So, if that
comes here and we have lower flu vaccine rates, that means more hospitalizations, more sick days, less
productivity in the economy, and sadly, more deaths. Now, the flu vaccine is not ideal. It's not one of our best
vaccines, but it is the best tool we have to protect against the flu.

Mark (08:47)
You know, I wanna pick up on vaccines and, and in particular, COVID vaccines. You have stated that you do
not believe that certain institutions should have mandated health professionals to get COVID vaccines. That's a
controversial take- ... in some circles. talk to us about the evolution of your thinking here.

Dr. Frieden (09:06)
Sure. That's not quite what I say in the book. So, what, what I outline is the mandate for mandates, right? So, I, I
started my career as a tuberculosis specialist, and we had patients in New York City who had been admitted to
hospitals more than 30 times and had, walked out, and they then had multi-drug-resistant tuberculosis that they
spread to healthcare workers, family, and others. so, in that situation, we were able, with full respect for, civil
rights, to make sure that they were detained in a healthcare facility and we, we couldn't forcibly medicate them.
That's a very messy thing to do. You have to put a nasogastric tube down somebody. That's not something w-
want. But we were very clear, "You're gonna stay here 'til you're cured. So, you can either take your medicines
and leave, or you're here indefinitely." And they all took their medicines. But that, I think everyone can agree
on. when the initial data came out about COVID, the COVID vaccines, in the first month or two, they seemed
amazing. The people who had gotten vaccinated, in that first month or two, didn't get infected, and so the initial
hope was that the COVID vaccine would prevent you, would block infection. As months three and four and
more time passed, it became clear, no, actually, that protection fades after a month or two. But there's still a
protection for at least three to four to six months against hospitalization- ... and much less of a reduction in the
risk that you will spread to others. When that information came out, the COVID vaccine stopped being more
like a measles school entry requirement so other kids don't get measles, and you don't have a big outbreak in the
school, and more like a motorcycle helmet mandate, where you're mandating some- one to do something for
themself. And that's a much higher bar that we need to get r- Remember, public health does various types of
mandates. Most of them are not on individuals. Most of them are on companies. don't pollute our water. Don't
poison people with contaminated food. I think people understand that type of mandate. But mandating people to
do something for their own good, that's something that you have to step back and say, "You know, it's a tough
decision. each community should make it in a democratic way and then live with it." I do say that there is an
exception for employers. If you're an employer and you need to keep your workforce healthy or you need to
make, a reduced risk of your workers infecting others, then there may well be a case for an employer-based
mandate. But that's different. And I have to say in this, the, the issues are pretty complicated. So, flu vaccination
of healthcare workers, there's legitimate controversy on, how much does it protect, others? Some of the articles
that came out were very strong, that there was a huge protection. There's been critiques of those articles, so I
think, you know, w- science doesn't give you certainty. Science gives you humility, that you need to learn more
to figure out what's happening.

Mark (12:34)
Could science have made a difference at th- at that point? It seemed to be such a dramatic point globally, the
COVID, epidemic, um. And also, there was real quick sort of evaluation of the COVID vaccine at that time,
right? Because there was a rush to get it out there. it seems like it was just a- a different type of environment
than you're necessarily describing with smaller, discrete problems. This is, this is a global one, so um ...

Dr. Frieden (13:08)
I mean, th- there's, one issue is making it easy for people to get vaccinated. Still the major reason people don't
get vaccinated is that it's not easy, so make it easy in pharmacies, improve primary healthcare so everyone has
their own doctor. Yeah. I, I had a close friend, in his 90s. he's, he's passed since. living in the UK, and when the
vaccines came out, you know, he was way up on the list. He got a call from the l- nurse saying, "Would you like
to come in next Tuesday for a vaccine at 11:30? You're gonna have to stay for 15 minutes after." He said, "Yes."
She said, "Okay, come in." I mean, what a difference in a country that has had a competent, primary care
system.

Margaret (13:50)
Well, we certainly spent a lot of time during the COVID pandemic getting vaccines in the arms of folks.
(laughs) but I, I know that you are very excited about your, new book and I'd love to have you, talk about the
formula that you described, this, and you referenced it a few moments ago, the see, believe, and create formula.
Tell us, where that idea originated and how it works.

Dr. Frieden (14:15)
I've been working on this book for a decade because I realized that there's a huge gap between what we know
and what we do, and I've been trying to work through, how do we close that gap? And I, I, run the organization
RESOLVE to Save Lives. I founded it eight years ago, and in creating this organization, I had to kind of
systematize the lessons, not just from what I've done, but from what people have done in public health for
hundreds of years and to really analyze what works and why and what's replicable, what will really make a
difference. And it does come down to these three phases: see, believe, create. And see is about understanding
what the threats are, understanding if our programs are working, understanding why we don't take action, and I
think we should come back to that, and understanding the path to progress. So, the superpower of public health

is to see the invisible. We can see things that aren't apparent, it may be microbes spreading in certain ways or
toxins hurt- harming people in certain ways, or programs that we thought were doing great that are actually
failing, or vice versa, and to see the rigorous pathway to progress, that if you do X you will get Y, in terms of
health outcomes. But you then have to believe you can change it, and there are systematic ways to strengthen
that belief. Recognizing past progress, making phased progress in multiple areas, and cultivating optimism. And
then you have to do the hard part. After you see the invisible and believe the impossible, the really hard part is
to create a healthier future, and to do that you have to be very systematic. You have to organize your activities,
you have to prioritize, you have to simplify, you have to communicate effectively, you have to overcome
barriers. Because there always are barriers to health progress.

Mark (16:10)
You know, you write about how the public health, m- falls victim to what you call the Cassandra curse. I'm
wondering if you could tell us about, it and the strategies you suggest for overcoming it?

Dr. Frieden (16:22)
Yeah. This is the crux of the matter. In fact, the working title of the book was How to Break Public Health's
Cassandra Curse, but not many people remember or realize though

Margaret (16:32)
New diagnosis. (laughs)

Dr. Frieden
(laughs) So, Cassandra, again, the priestess from Greek mythology who could foresee the future, but no one
believed her warnings, so the tragedies that she could foresee came to pass. And it, all too often, not just public
health, but we as individuals have a Cassandra curse where we can tell what's going to happen in the future, but
we don't act on it. So, the first question is, why does that exist? And the second question is, how do we break it?
And why does that exist ends up a pretty complicated question, and I think it comes down to one fundamental
concept: our perceptions are inaccurate. You know, we trust our eyes, we trust what we sense, but we don't see a
lot of things, and our perceptions of ourselves, our perceptions of the world, and our perceptions of the future,
all of those are inaccurate. And I'll mention two of them in particular. one of them is our perceptions of the
world. We may not recognize what causes the greatest health harm and the greatest health gain. a, a wonderful
public health thinker by the name of Geoffrey Rose coined the term the prevention paradox, and what the
prevention paradox says is the biggest health changes in society come from little changes in lots of people rather
than big changes in a few people. Now, for example, if you reduce lead, maybe nobody senses the difference,
but collectively, the difference is massive. If we eliminate trans-fat, and my group, the Resolve to Save Lives,
has worked with more than 50 countries to ban trans-fat, nine million people aren't gonna die from heart attacks
as a result. But not one of them will know that their life was saved by this action. So, you have what the
economists and political scientists cause cost, call, concentrated costs and diffused benefits. So, let's put a pin,
and we're gonna come back to that. That's one of the causes of the Cassandra curse. Another cause is that our
perceptions of the future are inaccurate. There's something called, to use another fancy term, hyperbolic
discounting, which is basically short-changing the future. and I'll, I'll make you an analogy from, time
management. I used to accept speaking engagements, and I'd show up and I'd think, "Ugh, why did I accept this?
I'm just too busy to do this now." so once I learned about hyperbolic discounting, I use a, a, a heuristic. I say,
"Okay, if I get an invite, if it were tomorrow, would I want to do it?" And if the answer is no, then I don't do it,
if I can get out of it. this is understanding hyperbolic discounting and using that understanding to break our
short-changing of the future. Look, half of tobacco users will be killed by cigarettes. If, smokers knew they had
a 50/50 chance of dropping dead after their next cigarette, not a lot of people would smoke. Right. So, we have
to break those two things. But I wanna come back to this issue of concentrated costs and diffused benefits, that
we help everyone a little bit, and some groups, whether it's the tobacco industry or the junk food industry or,
whoever, are strongly opposed. To overcome that, we need to be very systematic and not just say, "Oh, we need
more political will." We need to say, "Okay, who are the winners and losers? Who are the deciders and
influencers? what's the advocacy approach and who are the partners who can take it over the finish line? What's
the timing, what's the window of opportunity? And what pragmatic compromises may, w- we have to make?"
Because we can make progress, but it requires being very systematic to overcome the fact that, yeah, everyone's
gonna benefit, but nobody who benefits is gonna organize and push for it. So, we've got to arrange that.

Margaret (20:49)
So interesting. I think it's been about two years since we've, last chatted with you. And I, I remember at the time,
it really stuck with me that you said, "If, all of us engaged in primary care had a absolute laser focus, almost a
singular focus, on ending hypertension, it would be the most important thing, that we could do." and, and now I

know that you predicted that heart attacks and strokes will become as rare as forgotten killers, another incredibly
positive, and, and somewhat, dramatic, statement. But I'm really curious, where do you, where do you, find the
optimism on that one? What's the base on which you're saying that? Aspirational, or do you see some
indications this might actually be something we can do?

Dr. Frieden (21:35)
I, I actually think it will happen. w- we ignore how deadly the epidemic of heart attack and strokes is. and it's,
it's deadly, despite it being largely preventable. most heart attacks and most strokes can be prevented with
today's technologies. And they come down to the, the six keys to healthy living that I review in the book.
Healthy blood pressure, healthy lipids, physical activity, get enough sleep, avoid toxins, and eat healthy. And,
and there are a lot of details on what that means. But with blood pressure, it's increasingly very clear that
anything over 120 is not healthy. And optimally, you really want a control to that. we have really good
treatments for, for lipids now, not... Statins are, are great, and there are other medications as well. so, I think we
have the real potential to make heart attacks and strokes quite rare. there was just a fascinating article published,
this week of Swedish medical recruits. Their blood pressure was measured at age 18 and their coronary arteries
were imaged decades later. And those who had even, quote-unquote, "mild" elevations in blood pressure had
much more atherosclerosis in mid a- middle age. Now, if you go back to some traditional studies, communities
that consumed very little sodium had no hypertension. Their blood pressure was 90 over 60 at age 16 and 90
over 60 at age 60.

Mark (23:20)
You know, your book offers a look back to the launch years of the Million Hearts initiative. And the goal was to
prevent one million heart attacks and strokes over five years. And you write candidly that the, I guess, the
community aspects of the campaign failed. What did we all learn from th- that experience?

Dr. Frieden (23:39)
Yeah. I go through in the book successes and failures because the only real failure is one you don't learn from.
And so, the community aspects failed because of this concentrated costs and diffused benefits problem. The
tobacco industry, the food industry, the beverage industry, in particular blocked those actions. But the clinical
part of Million Hearts, failed because of the economic structure of our healthcare system that, as you know well,
we don't prioritize primary healthcare. And this is a deadly problem. Um-In most of our healthcare system, if
you put in a lot of extra effort and your patient doesn't have a heart attack or a stroke, your healthcare system
will make less money. If you fail to control their blood pressure and your patient has a heart attack or a stroke,
your system will make a lot more money. Now, I don't think there's a single doctor in the country who wants
their patient to have a heart attack or a stroke. But because that's the way we structure our healthcare system,
that's what happens. And if you look at Kaiser Permanente, the per- the, the group that pays is the same as the
group that provides the care. And they realized, "Oh, we really have to control blood pressure." So, they're at
90% control. The rest of the country is at 45% control.

Margaret (25:00)
You know, most of these things that we're talking about, all have a tie back to, "If only," right? We could do a
better job with prenatal care. We could do a better job with early childhood and certainly preventing obesity in
kids, in- in activity, in kids. Where, where does that fit in with your view of, where we should be as a country
with public health and initiatives to get to this end goal of n- as you say, the 19-year-old having a blood pressure
of 90 over 60 and still having it years later? What do you see around children's health in particular that you find
hopeful in the country or promising?

Dr. Frieden (25:35)
We, we all, I think, can agree that we want to live in a world where our children reach adulthood, with healthy
habits of sleep and use of digital and not addicted to drugs or alcohol or tobacco, at a healthy weight with
healthy nutrition, habits. But right now, that is a rare exception. And that's not because parents are bad. That's
because we have a lot of influences in society that make it hard for us as parents to raise kids in a healthy way.
So, we can get together, without any, discussion of partisanship or- ... values other than that we value our
children and we want them to reach their full potential and think about how we can adjust our communities to
maximize the likelihood that that will happen.

Mark (26:35)
You know, I want to spend a little time on the work that you're doing now. You lead the nonprofit Resolve to
Save Lives. It's attracted lots of, philanthropic support. Congratulations. I'm wondering if you could explain how
it works on epidemic, prevention, blood pressure control, and other threats.

Dr. Frieden (26:53)
Thanks. Resolve to Save Lives, works in more than 40 countries. Actually, the proceeds from this book will go
to groups and projects that Resolve to Save Lives supports to work for health, and the, the fundamental concept
is that we partner with communities and with countries to scale up solutions to the world's deadliest problems.
We identify a way forward and then work with countries to prototype approaches to address the problem, to
prove that they can be scaled up and to scale them up and sustain them. So, we, we partner with countries. We
kind of walk the pathway of knowledge. We don't have special knowledge. We have experience from multiple
countries that we can bring to bear in other countries, and we're there to, to build capacities, to start systems, to
scale up systems that we'll be able to sustain long term to make the world a safer place and a healthier place,
because health is not a zero sum. Health is a win-win. If other countries are healthier, we're better off also, less
at risk from outbreaks, living in a world that has a more vibrant economy with people who can buy our stuff or
sell us stuff that we want, with less civil strife. So, the focus is maximizing health, taking a really rigorous view
to what works and what can be sustained.

Margaret (28:22)
Well, thank you so much, Dr. Frieden, for joining us. thank you to our audience for being here. Just a reminder
to be sure to subscribe to our videos on YouTube and find us on Facebook and X and share your thoughts and
comments about this program. Take care and be well. Dr. Frieden, thank you so much for joining- Absolutely. ...
us again on the show.

Dr. Frieden (28:41)
Thank you so much and thank you for what you do.

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Margaret (28:46)
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