As The CDC Falters, How Do We Fill Public Health Gaps?

FLORA LICHTMAN: This is Science Friday. I’m Flora Lichtman. As you likely saw, the world lost scientist and humanitarian Jane Goodall on Wednesday. We have a special remembrance from Ira, including some lovely highlights from their conversations over the years, on the podcast.

Later in the hour, how a young scientist’s eureka moment changed ocean science in Sri Lanka. Plus, can helmet technology prevent concussions? But first, a look at our country’s ailing public health system. Between layoffs at the CDC and a shakeup of its leadership, changing vaccine guidelines, a government shutdown, declining public trust, where do we go from here? Can state and local public health agencies pick up the slack? Are there other solutions?

Joining me now to talk about it is Dr. Tom Frieden, former CDC director under President Obama and President and CEO of the global public health organization Resolve to Save Lives. He’s also the author of the new book, The Formula for Better Health, How to Save Millions of Lives, Including Your Own. Tom, welcome back to Science Friday.

TOM FRIEDEN: Great to speak with you.

FLORA LICHTMAN: OK. So we’ve talked a lot on this show about what’s happening right now with the cuts to public health and cuts to science, vaccine skepticism. So I really want to look ahead. We heard from former CDC scientists that now is the time for state and city public health agencies to step up. Do you agree?

TOM FRIEDEN: It’s absolutely the time for lots of organizations, especially state and local governments and also philanthropy and non-governmental organizations, to fill the gap, as one thing that needs to be done, even though there is no replacement for a competent national public health system or public health approach. And second, to begin not building back, but building forward, figuring out and trying new things so that public health can be faster, with more impact, better at communicating, including listening, with stronger alliances, so that we can make more progress.

And really, that’s what the formula for better health is about. It’s an approach, an approach that has been proven to save millions of lives. It’s see, believe, create, three steps, to see things that are not apparent and make them apparent, to build confidence, belief that we can make more progress, and the hardest part, to create a healthier future by organizing, prioritizing, simplifying, communicating, and overcoming barriers. Because there are always barriers to public health progress.

FLORA LICHTMAN: I want to get into the details a little bit. I mean, before leading the CDC, you were the NYC Health commissioner. What do state or city public health departments have control over?

TOM FRIEDEN: It varies. So New York City is a special case because the city is part city and part state. It has its own health code, its own regulatory authority. So there are lots of things that states and cities can do to try things out. Sometimes the state and the local health departments are the same organization. Sometimes they’re different. Sometimes they get along. Sometimes they don’t.

But everywhere you have the possibility to say what matters to people, what can we make a difference with? And what I do in the book is I outline, what does technical rigor really mean? And it starts with finding the right problem to address, a problem that has a large burden and that is amenable to intervention. We don’t want to just try things that are impossible. We don’t want to have big programs for small problems. We want to identify those big problems that we can do a lot about.

TOM FRIEDEN: Give me an example of a problem that the NYC Health Department took on.

TOM FRIEDEN: We took on smoking in restaurants and bars. Nobody thought that could be changed. That was the way bars and restaurants were. And what we did was we first made visible the problems. We showed that a smoky bar was way more polluted than places like the traffic tunnels that New Yorkers think of as the most disgusting, polluted places in the city.

We also made visible the personal impacts, a pregnant waitress who testified in front of the city council saying, why does my baby have to be harmed so people can smoke at my restaurant? We made those things visible, and then we made clear that the restaurant industry was going to fight back. But we pre-bunked. Because we regulated restaurants, we knew how many closed every day.

And I had a press conference the day before the law went into effect. And I said, starting tomorrow, the Restaurant Association is going to claim that every single restaurant that went out of business went out of business because of this law. But I can tell you, this is the number that go out of business on an average day. And we’ll tell you, each month, whether it’s increased or decreased. And actually, it decreased, because turns out that people like to eat in places that don’t smell like an ashtray.

FLORA LICHTMAN: I remember I lived this in New York, and I remember what a reprieve it was for– I remember–

TOM FRIEDEN: Even smokers liked it. Even smokers didn’t like eating in places that smelled terrible.

FLORA LICHTMAN: Yeah. OK, so you said New York is a special case. I mean, do you think that, generally speaking, state and local health departments are equipped, have the resources, have the purview to actually step up in places where the CDC falls short?

TOM FRIEDEN: I don’t think the gap can be fully closed, but there are fantastic health departments out there. Creative, innovative, great folks. Take the issue of unsafe water. Traditionally in public health, we got the bacteria out of water. We got the parasites out of water. Now we’ve got to get the PFAS, the forever chemicals, and the microplastics out of water. And that’s an area for innovation, for action at the household level, but more importantly, at the community level.

FLORA LICHTMAN: Yeah, because we know, actually, at the federal level, that those regulations are being rolled back around PFAS.

TOM FRIEDEN: I think it’s so important to look at what this administration is saying versus what they’re doing.

FLORA LICHTMAN: Yes.

TOM FRIEDEN: They’re saying they want to address chronic disease. They’ve eliminated the tobacco, cancer, and heart disease programs at CDC. They’ve rolled back regulation of tobacco, our leading cause of chronic disease. They say they want to address environmental issues, but they’ve rolled back, as you say, the PFAS requirements and, even more impactfully, the PM2.5 requirements. Soot or PM2.5 is estimated to kill 100,000 Americans a year already. And if it gets worse, it’ll mean more deaths. That’s one of the things the formula can make clear. See the real harms that are happening and then build confidence that we can change it.

FLORA LICHTMAN: But do you feel like states can really do all of this by themselves without the resources of CDC?

TOM FRIEDEN: There are some things that are going to be impossible to do, both because of the deep technical resources of CDC and because of the money. A great quotation by a public health leader of more than 100 years ago named Hermann Biggs– he said, “Public health is purchasable. Within natural limitations, a community can determine its own death rate.”

And with the formula, communities, and individuals can make a lot more progress to see, What are the threats that we can control? What’s the way to control them? to build confidence that we can do it, and then to overcome the barriers, whether it’s inertia or misinformation or companies that sell deadly products, so that we can live a longer, healthier life.

FLORA LICHTMAN: Well, as we talk about building trust, I mean, do you feel like we can trust the guidance coming from CDC right npw?

TOM FRIEDEN: I never, ever thought I would see the day when I couldn’t trust things coming off the CDC website. But we’ve got more than a dozen political operatives running the agency. And we have an ideologue who ignores the facts running HHS. So, no, I don’t think we can trust it. And that’s a big problem.

FLORA LICHTMAN: I want to talk about trust in science. You know, I think a lot of people think about the loss of public trust, especially in public health, starting around COVID. Do you agree with that? Was that the inflection point?

TOM FRIEDEN: I think that certainly accelerated the lack of trust enormously. And it does break down somewhat among partisan lines. So it’s a much bigger breach of that trust among Republicans than among Democrats. And that’s unfortunate, because this shouldn’t be about Democratic versus Republican. This is about fact versus fictions, simple truths versus simplistic misinformation, health versus disease.

I think public health needs to listen well. One of the most striking conversations I had during the height of COVID was coordinated by Frank Luntz, a messaging guru. And he put together about 15 or 20 vaccine skeptics. And we spent almost three hours talking. And I really learned a lot.

These were folks who had totally legitimate questions, very, very reasonable questions. And they felt not only had their questions not been answered, their questions hadn’t even been addressed, and they felt they had been vilified for even asking them. So you have to, I think, distinguish between the people who are profiteering on valid concerns and the valid concerns that need to be addressed.

FLORA LICHTMAN: Well, right, and parsing the difference between things we’re certain about and things that were not certain about.

TOM FRIEDEN: Oh, that’s so important. I review this in the book. First, it’s almost certain. We’re almost– we’re basically never going to learn that smoking a cigarette is good for you. Second, things that are really quite likely, but we have to be humble, because good science doesn’t lead to certainty. It leads to humility.

So I think that measuring your blood pressure and keeping it under 120 over 80, which is lower than most people aim for, is the right thing to do. But there’s some nuances there. How do you measure it right? We’re going to learn more. But you always have to make a recommendation based on imperfect data. If we waited for perfect data, we would never make any recommendation, and that would be making a recommendation to do nothing. There are other things that we have some evidence for– one well-conducted study– and there are still others that are theories that may sound convincing, but we have no valid evidence for them or actually evidence that they’re not correct.

FLORA LICHTMAN: What do you think individuals or communities should be doing? Should we be creating GoFundMes for epidemiologists or just going straight to the UK’s National Health Service website for info? What’s your directive to us?

TOM FRIEDEN: As individuals, support your local health department. It is your health protection, just as your fire department and your police department is. We can also advocate for a better health care system. It is scandalous that we spend $4.5 trillion on health care, and a third of Americans don’t have a primary care provider, don’t have a doctor or nurse who they can call up when they have questions. So advocate for better health care. Advocate for primary care. Advocate for your local health department. There are lots of things that we can do at every level.

FLORA LICHTMAN: Dr. Tom Frieden, former CDC director, President and CEO of the global public health organization Resolve to Save Lives, and author of the new book, The Formula for Better Health, How to Save Millions of Lives, Including Your Own. Tom, thanks for joining us today.

TOM FRIEDEN: Thanks so much. It’s been fun discussing this. And yes, we can make progress, but it’s not going to be easy.

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