March 27, 2020

Tom Frieden

Former CDC Director Dr. Tom Frieden discusses the origins of the coronavirus, the current measures to fight it, and where he sees the pandemic headed. He also discusses how the United States can be better prepared to handle future microbial threats.

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His life’s mission — fighting infectious disease this week on ‘Firing Line.’

Any virus is only a plane ride away.

During his 7 1/2 years as director of the Center for Disease Control, Dr. Tom Frieden helped lead the United States through the swine flu pandemic…
Addressing influenza is hard.

…the Ebola crisis…
The fact is we can stop Ebola.

…and the Zika outbreak.

The key is to protect pregnant women.

But the world had yet to experience anything like COVID-19.

We are at the beginning of the storm.

With the number of coronavirus cases growing…
We were looking at a freight train coming across the country.
We’re now looking at a bullet train.

…more than 100 million Americans on lockdown…
We need to bend the curve in the state of California.

…and so many questions about what’s next…
Easter is our timeline.
What a great timeline that would be.

…what does former CDC director Tom Frieden say now?

‘Firing Line with Margaret Hoover’ is made possible by… Additional funding is provided by… Corporate funding is provided by…
Dr. Tom Frieden, welcome to ‘Firing Line.’

Glad to join you.

You were the former director of the United States Center for Disease Control and Prevention.
You are currently the president and the C.E.O. of Resolve to Save Lives, a global health initiative which works to prevent epidemics.

And you are joining us at this unprecedented moment in American history.
So thank you for being here on video conference as we practice social distancing.

I look forward to speaking with you.

Dr. Frieden, I am two hours outside of New York City, and you are joining us from in your apartment in New York City, which was just this week declared the epicenter of the pandemic in the United States.
The White House has said that anyone who leaves New York City should self-quarantine for 14 days.
Do you agree with that directive?

New York City, unfortunately, is in what we know as the acceleration phase of the pandemic.
That means that cases are doubling very quickly every couple of days.
Unfortunately, the coming week or two are likely to be very difficult for our city.
We’re likely to see a huge stress on the healthcare system with the possibility that there will be too many patients who need intensive care.
There’s also the reality that many healthcare workers are becoming infected.
So right now, unfortunately, New York City is the epicenter in the United States.
This is a warning for the rest of the country and the rest of the world.
This could be you if you don’t act now.

So let’s step back.
It has been roughly four months since the first known coronavirus case appeared in Wuhan, China, 7,500 miles away.
You wrote actually an opinion editorial on January 22nd and you said, ‘We’ll learn more in the coming days and weeks.
As I once heard the legendary Nobel laureate Joshua Lederberg say, ‘We’re outnumbered by microbes by billions to one.
It’s their numbers against our smarts.’ So right now, who is winning, the microbes or us?

Well, this is World War C — World War Coronavirus.
This is the biggest global stress since World War II.
And it is just the beginning of a long war.
And to win that war, we need good strategy and good execution of that strategy.
And we have a growing sense of what it takes to do that.
One thing that’s crucially important is information, intelligence, so we can understand the enemy’s weakness, if you will, how it spreads, how it doesn’t spread, how we can target our efforts most effectively.

Help us understand.
The COVID-19 is a coronavirus, which is a large family of viruses that are common in both people and animals.
Can you explain exactly what a coronavirus is?

A coronavirus, as you say, there are many, many species that affect animals.
But this is the seventh that affects people that we know of.
There are four what we call common-cold viruses.
They account for a third or a quarter of all common colds.
And interestingly, as we all went back and looked a little more carefully, the common cold can also be deadly for people with weakened immune systems or people who are elderly.
So it doesn’t perhaps get the respect it deserves.
Then there are MERS and SARS, two very deadly coronaviruses that are deadlier than COVID-19, but that don’t spread as readily as this coronavirus.
What we’re finding with COVID-19 is it spreads pretty readily and it’s killing somewhere around 1 percent of the people that it infects.

Alright, I’d like you to take a look at something that former Homeland Security adviser Tom Bossert said at the beginning of this week.
And I’ll get your reaction after it.

What I’m trying to communicate to people in this country, though, is that while New York is very bad, the rest of the country can’t take a deep breath and think they’re out of it.
So I think I guess what everybody’s asking is for a prediction.
I’ll give one today, George.
I think we’ve got a six-week growth curve ahead of us in New York City.

Six weeks?

The next two weeks will be the most aggressive, multiples of 10 potentially.

Dr. Frieden, do you agree that we have at least another five to six weeks to go of things getting worse before they get better?

One thing that I think we can say with sadly confidence is that the next one or two weeks at least are going to get worse in New York City.
It’s going to get worse here before it gets better.
Past that, it’s very difficult to predict.

Officials have said this week that the spread of the coronavirus in each region of the United States will have its own curve.
So then what is the right way to create a federal response?

It’s crucially important that there’s a federal framework and guidelines, that those guidelines are based on the best available science informed by our nation’s health protection agency, the Centers for Disease Control and Prevention, which has been virtually absent in the response so far.
That guideline then rolls down to the state, city, community level.
And that’s where the rubber hits the road.
And it will be different in different places at different times.
In New York City today, the Health Department appropriately is strongly discouraging people with mild illness from getting a test.
Other parts of the country, appropriately, health departments are urging anyone with mild illness to get a test.
It really depends on where you are and when in this pandemic the action is occurring.

You just said, Dr. Frieden, that the Center for Disease Control has been effectively absent.
Why do you say that?

We haven’t seen the CDC or CDC reasoning going into the decisions that are being made.
We’ve seen the White House reverse some CDC decisions shortly after with no justification or rationale for why they’ve done so.
Unless CDC is at the decision table and at the podium, I feel less safe.

Is it fair to say that CDC is not at the table when they are a member of the task force?
The White House Coronavirus Task Force?

I find the organization of this response very confusing.
The Vice President is in charge.
There is a White House coordinator.
There is a chair of the task force.
There is a FEMA acting director who is running an incident command system.
All of those systems could work.
But it’s very unclear who’s on first here.

But the CDC is on the task force.
So it’s not as though their advice and guidance is being explicitly cut out.
Is that fair?

What we saw on a weekend is at the end of the week before, CDC issued very thoughtful guidance on when schools should close, how that should be done.
And then on the Monday that followed, the White House overruled that guidance in a footnote to a one-page document with no rationale, no justification.
And I think because of that, there are schools in this country that are closed today that maybe didn’t have to close.
And that’s very disruptive.

In less than a week, on March 30th, the administration’s 15 days to stop the spread will be over.
And President Trump has indicated what will happen next.
I’d like you to take a look at this.

I’d love to have it open by Easter, okay?
I would love to have it open by Easter.
I will tell you that right now.
I would love to have that.
It’s such an important day for other reasons.
But I’ll make it an important day for this, too.
I would love to have the country opened up and just raring to go by Easter.

Dr. Frieden, what is your response to the idea that we would be open for business again by Easter?

All of us would like to get back to business, back to normal life as rapidly as possible.
The decision on when to stop this social distancing, went to allow people to go back out really is a decision of when, how and what.
And that’s going to have to depend on the conditions locally.
One thing that’s crucial to understand is this is not just about staying home.
This is about staying home while we’re intensively strengthening the healthcare system to get ready for a possible surge in patients needing intensive care, to intensely surge our public health system to be able to test, contact trace, isolate and quarantine people who need to be effectively managed.
China has done contact tracing and 14-day follow-up of 685,000 people.
That is a mind-boggling effort.
And that’s the kind of effort we’re going to need here if we’re going to limit the social and economic damages.
We all want to get back to business as rapidly as possible.
The economic dislocation doesn’t just hurt the economy.
It hurts health also.
But we’ve got to do that without endangering our healthcare workers and patients.

So then, is it your view that because public transportation resumed this week within the city of Wuhan, China, that that was a well-advised policy because the Chinese have caught up with the pandemic?

There’s a lot to learn from China now, and they continue to struggle with a large number of imported or re-imported cases of coronavirus, and they’re worried, I heard on a call this morning, about the possible second wave of cases there.
Bad as it was, in Wuhan, it was still just a small proportion of the population that got infected.
So it could be much worse.

But do you think it’s too early for the public transportation to be resuming in Wuhan right now?

In China, they’re being extraordinarily careful.
They sent 42,000 healthcare workers into Wuhan to help with the response.
And according to their reports, not a single one of them got infected.
So being able to surge effectively and restarting society is something that needs to be done carefully.
When you resume, it’s best to turn the faucet gradually, not open the floodgates.
It may mean that you open certain businesses first, perhaps daycares so parents can work, perhaps infrastructure projects or businesses that can make sure that they check everyone coming in for a temperature and have their hands sanitized with a alcohol-based sanitizer.
There’s lots of things that can be done to gradually reopen.
And what’s crucially important is that we will learn.
The quicker we learn, the better we can act.

So I’d like you to listen to Governor Andrew Cuomo, who just hours before Trump announced his Easter goal, said this.

My mother is not expendable and your mother is not expendable.
And our brothers and sisters are not expendable.
And we’re not going to accept a premise that human life is disposable and we’re not going to put a dollar figure on human life.
The first order of business is save lives, period, whatever it costs.

Dr. Frieden, what is the cost of the public hearing two dramatically different messages from their country’s leaders?

I think it’s understandable that there’s some difference of opinion here.
On the one hand, you see a terrible pandemic that could kill over a million Americans and over 10 million people around the world.
On the other hand, if you look at the numbers, you say even in the worst hit cities, 96 percent of people don’t get the infection and 99 percent of the people who get it will survive.
We have to put it into perspective.
This is a terrible pandemic, but it’s something that we can manage.

But when you hear two different messages, one from the President of the United States that says we’re heading back to work and the other from the governor of New York, the epicenter of the pandemic, saying ‘We will do anything it takes to ensure that people’s lives are saved,’ how important is messaging being aligned for the public safety and security?

Getting communication right is crucially important.
What we’re seeing around the world is that if communities don’t understand why they’re being asked to do certain things like not go to religious ceremonies or not go to work or not ride on buses, they don’t do them.
So communication needs to be first, right, and credible.
And it needs to provide the basis for the decisions that are being made, both the ethical basis and the scientific basis.

Let me ask you about South Korea, because the very first confirmed COVID-19 case in United States was on the same day as Korea, January 21st.
And throughout February and March, the cases in South Korea exploded, reaching a peak of 909 cases in a single day.
And then less than a week after that, the new number of daily cases declined by 50 percent.
And from there in South Korea, the numbers have continued decreasing.
In other words, South Korea successfully flattened the curve.

Actually, what South Korea did is exactly what we’re trying to do here.
South Korea saw a large peak.
They then went into mitigation mode.
They were able to mitigate it and mop it up and reduce that transmission.
They had some advantages.
Their spread was very focal, associated with one religious group.
So that was easier to contain in one area.
They also did massive testing.
They also had the advantage of a healthcare system that was aligned and private laboratory test producers that had developed them well in advance to do them in high volume.
And it’s, in fact, exactly the South Korea experience that makes us think that we can move from mitigation mode, which New York City is in now, to suppression mode.
That’s our current strategy for the war against coronavirus.

Okay, but that success that you just outlined is going to take tests.
And I want to ask you about an early and major flaw in the American response to coronavirus, which appears to be directly related to the limited testing capability.
I’d like to break down the issues one at a time.
First, it seems that the CDC chose not to use publicly available data from other countries and instead make our own tests here in the United States.
In your view, was that a mistake?

I don’t know the details of how the CDC test was developed.
What I do know is that the problem they had with this one they’ve never had before.
During H1N1, the pandemic of influenza 2009, they developed a test, validated it, got it approved by the FDA in less than two weeks.
And three days later, they began sending out a million tests to every state in the U.S.
and more than 140 countries around the world.
So this system has worked well multiple times and it goes back to administrations.
It was created under George W. Bush.
It was strengthened under President Obama.
Something went wrong with the CDC tests and also probably with the response once they realized that it wasn’t working well to rapidly adjust and make that testing capacity available.
At the same time, the FDA should much sooner have allowed hospital laboratories to develop their own tests.
And the Department of Health and Human Services should have gotten the private providers, the private test developers in to begin work that only began many weeks later.

How many weeks do you believe that it has cost us?

The lack of test availability Definitely put the U.S. behind.
If Seattle and New York City had had more test capacity earlier, there’s a possibility they would have been able to identify the infections earlier and prevent the kind of widespread transmission that you’re seeing now.

Do you think it’s fair to say that that lost time has cost us lives?

I think there’s no doubt that many lives are being lost in this pandemic, not just in the U.S.
but around the world because we’ve failed to invest in public health for many, many years.

I do really want to ask you about this series of mistakes, though.
What is the mechanism for accountability?

I think that really should be an independent evaluation.
The CDC itself has a separate laboratory group.
They may have, I don’t know, done an evaluation of this.
There should be an internal evaluation and there should be an external evaluation by a group such as the National Academy of Sciences, because we need other things.
We need a rapid point of care test.
We don’t have that yet.
We need a blood test, a serology tests.
We don’t have that yet.
These need to be developed because they’re important tools in the fight against this virus.

A vaccine is another tool to fight the virus, and it’s being tested.
One is being tested in Washington state as you know.
Do you believe that until that vaccine is available, we will continue living the way we do now?

I hope that with better understanding of the virus and better understanding of how to limit the spread, we can gradually loosen the faucet and resume much of our everyday activities.
A vaccine is uncertain.
We hope one will be safe and effective.
If it is, it could take a year, year and a half to become available.
But there are lots of infectious diseases for which we’re not able to vaccinate effectively.
Think of tuberculosis, malaria or HIV.
We’ve been trying to develop a vaccine for decades.
I hope we’ll have more success against the coronavirus that’s causing COVID-19, but only time will tell.

How do you assess the prospects of treating the virus with existing medications?

We really need to understand what works to reduce the risk that someone will get severely ill or die from this virus.
There are close to 70 different medicines that are being studied.
The first really rigorous study was of two of the most promising drugs that together kill viruses.
And it didn’t work.
So it’s one thing to have a promising substance or anecdotal evidence, and it’s quite another to show that it works.
We all hope there’ll be effective treatment.
That may come much sooner than a vaccine that would make a big difference.

Dr. Frieden, would you be willing to set the record straight on the President’s pharmaceutical recommendations?
President Trump tweeted, ‘Hydroxychloroquine and azithromycin, taken together, have a real chance to be one of the biggest game changers in the history of medicine.
The FDA has moved mountains.
Thank you.’
He also after that suggested that this combination of medicines actually saved the life of a man.
What is your response?

I think really the President is trying to find things to hope for and is expressing the hope that these medicines will work.
I also hope they’ll work.
But as a physician, as a scientist, I want to know whether they work.
It’s one thing to have anecdotal or even promising evidence.
It’s another to have proof.
And all too often in healthcare, we have a treatment that is touted as a miracle cure.
And then when it’s really looked at carefully, it doesn’t work.
Now, chloroquine may well work, but we don’t know.
It works in a test tube, but lots of things kill viruses in a test tube.

It boggles the mind that just a few months ago, the word corona meant something very different to most people.
And now as we look around the corner, are there other microbial threats that are lurking around the corner that we should think about more carefully before they become a global threat?

On average, we discover one new pathogen each year, and 2020 is off to an early start.
It is inevitable that we will continue to have infectious disease threats.
What’s not inevitable is that we’ll continue to be so underprepared both in the United States and globally.
And what concerns me most is our lack of awareness of what’s happening in many parts of Africa and Asia, where we know of close to 10,000 life-threatening gaps in our preparedness.
We know where those gaps are, what they are, how to close them, what it costs to close them.
But we haven’t been doing the hard work that’s going to be needed year after year to make the world safer.
When countries are stronger there, we’ll be safer here.

One of the major stories this week in the fight against COVID-19 is the scarcity of medical supplies and medical equipment that our doctors on the frontlines have at their disposal in order to safely treat this onslaught.
Why weren’t we prepared?
Why didn’t we have enough respirators in our stockpile or enough masks on hand?

One of the challenges is that healthcare, like much of the economy, has gone to a just-in-time delivery mode.

What do you mean by that?

Like most of the economy, instead of having large warehouses in hospitals, there’s delivery just when there is a need.
And that is everything from medicines to medical supplies.
And that means there’s less slack in a system that can be taken up when there’s an emergency like this.

Some of the world’s largest and most major ventilator manufacturers, while being American-owned, are not completing the manufacturing here in the United States.
Does that seem like a problem to you from a health security standpoint?

I think we’re all recognizing now the vulnerabilities in the global supply chain, what’s inside of most of our medicines.
Most of that comes from China, and that’s seriously disrupted now.
We’ll have to look at how to have more redundancy in our healthcare system, in our society, even if that may be less efficient or a little more expensive in the short term.

Can this virus make us more aware and prepared for something that could be, God forbid, even worse?

There are worst-case scenarios.
As an infectious disease specialist, I think about some of the viruses and bacteria that are spread by ticks in other parts of the world that can cause a disease as severe as Ebola.
What if that came to the U.S.? There are so many diseases out there.
We know there will be another one.
The world is underprepared.
There are blind spots all over where diseases may be spreading and evolving and becoming resistant.
Unless we strengthen our global early warning system, our global rapid response system by working with countries throughout Africa, Asia and other parts of the world to strengthen their early warning systems, we can be caught unprepared.

So then, Dr. Frieden, what is the number-one thing we should be doing that we’re not doing now?

There is so much that we need to do right now.
It’s an all-hands-on-deck response to the coronavirus pandemic.
And that means we need a structured federal response with clear guidelines that are science-based and rely on the nation’s top experts at the CDC.
And we need to engage with the world.
This is World War Coronavirus, World War C, if you will.
And all of us need to work together.
As Josh Lederberg said, it’s their numbers against our brains.
But unless we really work together, the virus is going to take far too many lives.

Dr. Frieden, I’d like to show you an image of doctors that is circulating on the Internet right now, sending a message to all of us here at home.
Why is that message so important?

Healthcare workers are our most precious resource.
They’re the frontlines of the fight against this virus.
We all need to support them.
We need to make sure that they are first in line for protective equipment, first in line for treatment and vaccines when they’re developed.
And we can do our part by staying home.

Is there any positive news this week of the COVID-19 pandemic?

If there’s one thing that does encourage me, it is that there is increasing global recognition and collaboration, that we are all in this together.
We do have a common enemy and that enemy is a dangerous microbe.
Working together, we have the best chance of success.

Alright, Dr. Frieden, thank you very much for your time and for being here, even socially distanced, on ‘Firing Line.’

Thank you very much.

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