Alumni Profile: Thomas R. Frieden’86

Outgoing Director of the CDC Reflects on His Time at the Helm
Photo: Peter Wortsman

Public health, like politics, is the art of the possible,” says Thomas R. Frieden, the outgoing director of the Centers for Disease Control and Prevention, America’s first line of defense against threats to the health of its people. A self-described “irrational optimist,” still trim and youthful at age 56, Dr. Frieden, who received both MD and MPH degrees from Columbia in 1986, is the second longest serving director in the history of the CDC.

“It certainly has been an exciting time,” he says of his tenure, 2009 to 2017, during which the Emergency Operations Center remained activated more than 90 percent of the time. Whether tackling outbreaks of such formidable microbial malefactors as H1N1, MERS and Ebola, stopping epidemics-in-the-making at home and abroad, confronting smoking and other key preventable causes of death, or convincing a recalcitrant Congress to allocate adequate funding to combat Zika, he has always held to the same basic credo: “Do the right thing, tell the truth, and things will come out okay.” 

In an interview in January 2017 at his office on the CDC’s sprawling campus in Atlanta, he looked back on his eight years at the helm and considered the pressing health challenges ahead. 

 

Focus on Accountability

Among the photographs lining the wall along a corridor on the way to the director’s office are two images that immediately catch the eye. One presents an individual covered from head to foot in yellow protective gear being decontaminated after visiting an Ebola treatment unit in Monrovia, Liberia, with “TOM” scrawled in big bold letters on his hood. Another depicts a somber director touring a cemetery in Sierra Leone where safe and dignified burials are taking place. The photos sum up the depth of Dr. Frieden’s commitment to public health as a calling.  

The son of a scientifically astute cardiologist, he recalls visiting his father in a nursing home toward the end of his father’s life. The younger Dr. Frieden had just been named New York City health commissioner, a post to which he was appointed by Mayor Michael Bloomberg and which he held from 2002 to 2009. “Dad,” he said, “I want to be the best health commissioner.” To which his father, who had committed his own life to evidence-based medicine before the notion had a name, promptly replied with what would be his last words to his son: “How would you know?” The words have stuck with the son as a kind of medical mantra, a perennial call to accountability.

Ever since his first major foray into public health, from 1990 to 1992 as an epidemic intelligence service officer assigned by the CDC to New York City, where he documented the spread of multidrug-resistant tuberculosis—by closely following every case, he and his team helped cut the scourge of the dreaded disease by 80 percent—Dr. Frieden has tackled the big picture one patient at a time. Later applying the same hands-on and doggedly systematic approach in India, from 1996 to 2002 as a medical officer for tuberculosis control for the Southeast Asia Regional Office of the World Health Organization (on loan from the CDC), he and his team helped treat some 8 million patients, saving an estimated 1.4 million lives.

Called back to New York and sworn in January 2002 by Mayor Michael Bloomberg to head the NYC Department of Health and Mental Hygiene, Dr. Frieden studied the city’s health statistics the way an internist pores over his patient charts, on the lookout for significant data to stem preventable deaths. “We had 18,000 people die in the city last year,” he said in a 2005 interview, “about 10,000 of them from clearly preventable causes.” That was 10,000 too many fatalities for Dr. Frieden. 

He initiated unprecedented health surveys to assess critical health conditions in the city, then released an ambitious “Take Care of New York” policy to improve health. With the report, which was based on verifiable data and had Mayor Bloomberg’s blessings, Dr. Frieden took the cause of preventable deaths as a public health call to arms. Among other bold initiatives, he set up a system to monitor tobacco use, pushed for an increase in the tobacco tax, produced aggressive anti-tobacco ads, and promoted and ultimately helped pass the Smoke Free Air Act of 2002, barring smoking from all work places in the city, including bars and restaurants. Based on a CDC report in 2007, such aggressive tactics paid off, leading to a significant reduction in the number of smokers, including an almost 50 percent decline in teen smokers. Under his aegis, the Health Department also launched an attack against another preventable cause of death by banning NYC restaurants from cooking with trans fats, a significant aggravating factor in heart disease. 

The New York Observer dubbed him “a rare visionary.” Mayor Bloomberg pulled out all the stops in his assessment of his health commissioner’s performance. “Hiring Tom Frieden was one of the best decisions I’ve ever made. He is unafraid of big ideas, powerful interest groups, or impossible challenges,” Time magazine quoted the former mayor when the magazine included Dr. Frieden in its 2015 roster of “The 100 Most Influential People.”

 

Confronting H1N1 Influenza, New CDC Director Hit the Ground Running 

In 2009, President Barack Obama named Dr. Frieden the 16th director of the Centers for Disease Control and Prevention. The new director soberly assessed and led the country’s response to an impending global H1N1 influenza pandemic. “We’re faced with a situation of uncertainty,” he told reporters three days after officially assuming his post on June 8, 2009, in the first of many briefings, stating the facts while reassuring the public that “this is nowhere near the severity of the 1918 pandemic.” 

After considering the data and reviewing established recommendations that favored the young as recipients of a monovalent flu vaccine, he noted a significant health threat to 50- to 64-year-olds and modified the proposed vaccine policy to include that age group among the targeted cohort of recipients. 

Dr. Frieden raised hackles at one press conference in which he was challenged to justify the delay in vaccine production contracted for by another part of the federal government. “The vaccine is grown in eggs,” he calmly explained, “and even if you yell at the eggs, it won’t grow any faster. We’re not going to have enough vaccine when people want it. And then we’ll have a lot left over after the peak of the outbreak.” Reality check notwithstanding, and despite the delayed vaccine production, the CDC helped prevent an estimated 1 million cases, 18,000 hospitalizations, and at least 600 deaths. And though skeptics in retrospect accused the director of crying wolf about the gravity of the pandemic, Dr. Frieden soberly responds that “there were 1,500 fatalities among children and might well have been many more had we not taken appropriate action.” 

 

“We’re Most Successful When We’re Most Invisible”

“Remember that big outbreak of MERS in the U.S.? No, because it didn’t happen. We stopped it,” he recalls with an unmistakable feeling of pride, referring to Middle East Respiratory Syndrome coronavirus, a potentially life-threatening illness first reported in Saudi Arabia in 2012. Two isolated cases of infected travelers from Riyadh were diagnosed and successfully treated in the United States in 2014 and the CDC helped control outbreaks in the Middle East and elsewhere. “It could have been a big outbreak,” he adds, “if we didn’t have diagnostics and we hadn’t educated doctors and worked with the health care system to be ready.

“I sometimes get asked: Why should the CDC work on global health? Shouldn’t we rely on the World Health Organization for that?” Dr. Frieden poses the question. To which he promptly replies: “Well, why do we need the Department of Defense if there are United Nations peacekeepers? The CDC works 24/7 to protect Americans from threats, whether in this country or anywhere in the world, whether those threats are infectious or environmental, natural or man-made.”

In today’s global environment, there is no such thing as an isolated incident. It’s only a matter of time until microbes and other serious health risks cross borders. The least costly defense in lives and dollars saved is preparedness. “When you strengthen the systems that are in place, the laboratories, the doctors in the field, the monitoring, and the rapid response abilities,” Dr. Frieden says, “you can stop outbreaks there so that we don’t have to fight them here. It’s doing well by doing good. Public health really is a best buy.” 

He prizes the efficacy of established preventive efforts, such as the Field Epidemiology Training Program, which comprises some 55 working operations in 72 countries. It’s a network of programs started by the CDC, many of which now function independently. This effort, greatly enhanced under his watch, has helped train some 3,000 local disease detectives to date, “so that they can do what we do.” Adds Dr. Frieden, “It may well be the single most important program we run globally.” Nigeria, for instance, thanks to the hard work and thoroughness of local CDC-trained field workers, is practically polio free, with the exception of a small area controlled by Boko Haram.

“We’re most successful when we’re most invisible,” the director avows. Inevitably, however, some dire health conditions make the news. 

President Obama with Dr. Frieden at a press conference to discuss Ebola

Ebola: “On the Edge of an Abyss”

“The Ebola outbreak was the most stressful and challenging threat that I’ve dealt with as CDC director,” Dr. Frieden says. “Not Ebola in the U.S.,” he insists, much as the public health threat stateside was whipped up to a fever pitch by some politicians and members of the media. “We always said there could be some cases and it would be controlled, and that’s exactly what happened.” 

It was the situation in Africa, where the CDC sent some 1,400 trained personnel and to which he made four trips in the course of the epidemic, that really worried him. “I visited one Ebola hospital where there were 60 corpses of people who’d died there that couldn’t be removed, so the living had to lie next to the dead. There was one doctor for 120 patients, not enough food, not enough water. It was horrific, really an apocalyptic type of situation. But that wasn’t what frightened me the most.

“When one infected individual flew from Liberia to Lagos, Nigeria, with a population of more than 20 million,” he recalls with a chill, “it could have easily surged into a global catastrophe.”

Following initial incompetent handling, a new Nigerian incident manager was put in charge and members of the CDC-trained Nigerian team, which had helped stop polio, leaped into action, building an Ebola treatment unit in 14 days. Identifying 894 contacts, they performed 17,000 home visits, found 43 people with suspected Ebola, and diagnosed 19 cases. The same painstaking process was repeated when an infected individual traveled from Lagos to Port Harcourt.

Dr. Frieden shakes his head at the memory. You can almost hear his heart beating. “Those three or four days when we were transitioning from not-competent to excellent management, those were the most stressful days of my eight years as director of the CDC. We knew we were on the edge of an abyss. If we didn’t stop it there, it would have spread all over Nigeria, all over Africa, for months and possibly years, and could have become a global catastrophe.”

Ultimately, the system functioned. “We got one laboratory up and running in Sierra Leone that worked for 421 days without a break. They set up in the field, high-throughput robotics, and performed 27,000 Ebola tests. Every worker risked infection and death.” Dr. Frieden adds with unabashed awe: “The commitment of our staff and trainees is truly inspiring!”

 

Zika, a Looming Threat

While the world could declare victory in the battle with Ebola, another insidious threat of infectious disease still looms elsewhere in the Aedes aegypti mosquito. “Zika has not been the media sensation that Ebola was, but it has been and continues to be an enormous challenge,” Dr. Frieden says, remembering another bone-chilling moment in his tenure when the CDC’s chief pathologist, Dr. Sherif Zaki, called him in to view stained neural tissue of infants from Brazil who had died of severe malformations. “We were able to see the Zika virus invading the neural tissue of these infants. It was really horrific. Two days later we issued a travel warning, telling pregnant women not to go to areas where Zika was spreading.”

The CDC kicked into action, engaging some 2,000 personnel in deployments to affected areas. They created a test, got it approved, and produced more than 1 million test kits. 

“We took action and made a recommendation when the data were strong enough. We established an unprecedented pregnancy registry to track pregnant women with Zika in the U.S. and its territories. We recommended a modern strategy of mosquito control using ultra-low volumes of pesticide in targeted areas in Florida. We identified sexual transmission of the disease and determined the linkage to Guillain-Barré syndrome. But there’s still a lot we don’t know.”

Unfortunately, adequate funding was not forthcoming. Dr. Frieden offers a sober assessment: “The main threat is to pregnant women and there aren’t any pregnant women in Congress. And that threat is six or seven months in the future, and Congress usually thinks a week or two in the future.” His successor will bear the burden of tackling Zika. (See related story on P&S Zika research in P&S News.)

 

Smoking, Obesity, Hypertension, and Other Battles 

While forestalling or quelling epidemics at home and abroad may have been the most dramatic of his tasks, the silent killers concerned him most in his day-to-day operations. Hard-hitting anti-tobacco ads produced by the CDC in its “Tips from Former Smokers” campaign directly influenced hundreds of thousands of Americans to stop smoking. Dr. Frieden likes to cite the assessment of a former CDC director, Bill Foege: “Public health is at its best when we see, and help others see, the faces and the lives behind the numbers.”

Obesity is another pressing issue among the top of CDC’s priorities. “We don’t have definitive evidence of what has caused the obesity epidemic in America,” Dr. Frieden says, “but we do know that we’re consuming more calories than we’re burning.” His pragmatic approach has been to focus on achievable objectives. Acknowledging that “we’re much more likely to be able to prevent childhood obesity than to reverse adult obesity,” he used the CDC to promote childhood programs at the national and state level. Consequently 19 states showed decreases in childhood obesity for the first time. And despite stiff opposition from vested interests in the soft drink industry—Atlanta is Coca-Cola’s home base—he pushed for government-mandated remedies. “It’s a matter of public record that I proposed a one penny an ounce soda tax back in 2009 as being quite possibly the single most effective thing to reduce the obesity epidemic.”

Dr. Frieden has written about what he calls “a health pyramid,” addressing “how we can impact behavior at different levels of society.” He identified the need to reduce teen pregnancy as a factor in the inter-generational transmission of poverty, calling that effort among the key battles outside traditional health care that could succeed in saving lives and money. He is pleased to report that “we now have the lowest teen pregnancy rates ever in the U.S.”

Another daunting priority he cited is hypertension control. “If you want to do one thing right in the health care system, it would be to control blood pressure. That can save more lives across the board than any other measure.”

Dr. Frieden also has spoken out about the need for what he calls “a reciprocal revolution” to include improving the country’s mental health in the mission of the CDC. “Depression,” he says, “remains under-recognized as a major cause of ill health.”

The current epidemic in overdose deaths from opioids is another pressing concern. Prescription painkillers are a major part of the problem. Under Dr. Frieden’s direction, the CDC issued new guidelines for prescribing opioid medications for chronic pain. 

 

“Developing the Capacity of Society to Address its Own Problems”

Dr. Frieden is philosophically committed to systems that foster home-grown solutions to health concerns. “I like to develop the capacity of society to address its own problems. Public health is the organized activities of society to be healthier.”

Among the programs he had a hand in creating, and of which he is the proudest, is the Public Health Associates Program, in which the CDC recruits, trains, and sends out to state health departments a cohort of what he calls “the next generation of public health leaders.” Between 3,000 and 4,000 applicants with bachelor’s or master’s degrees vie annually for 200 positions. “We send them out to states to be in the front lines of public health. They will rejuvenate, diversify, and make even more practical our ability to protect the health of the nation. They are the future.” 

Self-help is part of his own personal regimen as well. In addition to eating healthy and bicycling regularly, several times a week he plays squash with friends, a vigorous, aggressive game he first took up as a student at P&S which he describes, tongue-in-cheek, as his “homicide prevention program.”

 

What’s Next?

As per protocol, Dr. Frieden submitted his resignation effective Jan. 20, 2017, when the new presidential administration began. So what’s next?

“Being a native New Yorker, I like to quote the great philosopher Yogi Berra whenever I can: ‘It’s tough to make predictions, especially about the future.’” Pressed to be a bit more specific, he allows: “I’ve made every career decision in my life by answering the simple question: How can I save the most lives?”