Watch the AMA's COVID-19 Update, with insights from AMA leaders and experts about the pandemic.

In today’s COVID-19 Update, AMA Chief Experience Officer Todd Unger is joined by Tom Frieden, MD, MPH, former director of the CDC and president and CEO of Resolve to Save Lives in New York to discuss how we can use lessons from the past two years to strengthen our public health system and pandemic response.

Learn more at the AMA COVID-19 resource center.

Speaker

  • Tom Frieden, MD, MPH, former director of the CDC; president and CEO of Resolve to Save Lives

AMA COVID-19 Daily Video Update

AMA’s video collection features experts and physician leaders discussing the latest on the pandemic.

Unger: Hello. This is the American Medical Association's COVID-19 Update video and podcast. Today we're talking with Dr. Tom Frieden, former director of the CDC and president and CEO of Resolve to Save Lives in New York, about how we can use lessons from the past two years to strengthen our public health system and pandemic response. I'm Todd Unger, AMA's chief experience officer in Chicago. Welcome back Dr. Frieden. It's been a while since we've talked to you. Our conversations over the past few years have really punctuated constant moments of change during the pandemic. And I was struck by one of your quotes that said, "The important lesson of COVID is that the only constant thing is change." How does knowing that now better inform our response?

Dr. Frieden: Todd, we often talk about lessons learned but I think we should instead be talking about lessons that need to be learned. For me, the pandemic has the three Rs. We need a renaissance in our public health programs. We need a robust primary health care system that's at the center of our health care system and we need resilient populations more able to withstand health shocks and health threats. Each of these three things is going to require focused, sustained attention and funding.

If we just do what we've always done, we're going to get the results we've always gotten. That's an underprepared public health system, a weak and fragmented primary care system and a populace that is far too susceptible to infectious disease threats. So we have a lot of things to get done but we have perhaps the most teachable moment that we will have in our lifetimes. So this is a now-or-never moment to make health care, and public health and people's health stronger.

Unger: You know, the three Rs that you lay out, it sounds like a big ask because especially right now it seems like the half-life of memory around the pandemic is very, very short. In fact, I read an article in the Atlantic recently where the author said that the next wave may be less of a BA.2 wave and more of a so what wave. Mainly because people just seem to be very tired of two years of crisis. Given that mentality, how does affect the ability to execute those three Rs?

Dr. Frieden: We have for many years had cycles of panic and neglect, and I'm afraid we're heading full steam ahead into the neglect part of this cycle. But I am optimistic that given the enormous suffering, and economic and educational dislocation from the pandemic, we will learn the lesson better this time. And we will have a greater opportunity to make a real difference, to make the kind of investments that are needed. I think often public health is kind of ignored by business and industry but no one could ignore the more than $10-trillion price tag from this pandemic.

The fact is, that most of the deaths in the U.S. snd globally did not have to happen. And much of the disruption in the U.S. and globally did not have to happen. Now, there are very specific things that need to be done for COVID, such as increasing our vaccination rate, particularly among seniors and people who are medically vulnerable. There are about 15 million people over the age of 65 in this country who are not up to date with their vaccination. Most of them have been vaccinated. This isn't an anti-vaccination issue. This is a failure of health systems to ensure that people are up to date and that gets to the issue of primary health care. That's a bigger lift.

But we do have to look frankly at the fact that no one's accountable, no one's responsible. We're not paying for primary health care. We pay lip service to it. But every person in the U.S. should have someone who they can trust as their primary care practitioner. And every practitioner should benefit from doing a good job taking care of their panel of patients. We're currently in kind of a chaotic system in terms of our accountability or lack thereof. And in terms of resilience, Todd, I just outlined in an essay what we can do about a pandemic that's deadlier than COVID. Cardiovascular disease kills twice as many people as COVID did at its most deadly, at a younger age, and it's more preventable.

There are three core things that we could do that could prevent most heart attacks and strokes. First, we can end the epidemic of tobacco use. That can be done not just by hard-hitting campaigns, and helping people quit and making smoke-free places but very importantly, by changing the amount of nicotine allowable in cigarettes. The Food and Drug Administration has had the authority to do that for more than a dozen years but hasn't done it yet. If we reduce nicotine in cigarettes down to a non-addictive level, we can end the tobacco epidemic.

Second, is to control hypertension, to prevent and control it. That's possible also by reducing sodium intake and focusing on hypertension control. You know, Todd, less than half of Americans with high blood pressure have it under control. We spend over $3 trillion a year on health care in this country. Medicines for hypertension don't have to cost more than a few dollars a month at most, maybe even a few dollars a year for the best quality medicines there are. And yet we get the single most important thing in health care, hypertension control, if you're going to count it by lives saved, we get that right less than half the time.

Third, we need to do a much better job reducing what's called PM2.5, Particulate Matter 2.5, kills about 60,000 people a year in the U.S. but as many as six or seven million globally. Much more can be done in that area. So this is our chance to recognize that we are all connected, we can make a big difference but it's going to take focused effort and the expenditure of both financial and political capital.

Unger: That's interesting because I think most people associate public health of course during the last two years with this pandemic response. But it's really what you're pointing out is, we were already in a state where chronic disease like heart disease was a major problem and this huge opportunity that you're pointing out. I mean are we looking at then like kind of a battle on two fronts? Because obviously we have a lot of work to do to prepare for future pandemics but also, as you're pointing out, this other pandemic with heart disease.

Dr. Frieden: Well, we can walk chew gum at the same time. We spend trillions of dollars on health care. We're not getting the kind of value that we should. There are stunning reports from the Commonwealth Fund that look at OECD or mostly rich countries and how we do in terms of how much we spend per person on health care and what kind of outcomes we get. And the U.S. is a stunning outlier. We spend way more than any other country on health care and we get way less than any other country on health care. In fact, I would submit that it would be pretty hard to spend as much as we spend and do worse than we do.

To do better on health, to make up for our laggard status in terms of health care, we need to do those three basic Rs, resilient populations, robust primary health care and a renaissance in public health. And that means that our public health system needs to have the data it needs, the communications skills it needs, the connections with the health care system. There are areas of excellence. There are real success stories and it's important not to lose those, both because we should give credit where credit is due and because they show that progress is possible.

One of them is in the collaboration among nursing homes, the Center for Medicare and Medicaid Services and the CDC. These three players work together to get lots of seniors vaccinated quickly at a high level to make it safer in nursing homes. And if you look at the estimates, more than two million lives have been saved, many of them through this nursing home program in the U.S. So we're talking about, yes, the tragedy of a million lives lost in the U.S. and most of those didn't have to be lost.

But we're also looking at the tragedy that didn't happen. Another two million lives, three million total, a death toll that could have been three times as bad as it was that was avoided through concerted collaborative action, and the stunningly effective vaccines we have and appropriate use of masks, which are our second most powerful tool and increasingly the importance of rapid testing and treatment for COVID.

Unger: You know, it's interesting because you're really talking about a much broader sense of a recovery plan than just the part of the pandemic from a practical standpoint. You also pointed out I guess the sense of coordination and leadership to make the connections like you're pointing out. Where does that come from?

Dr. Frieden: I think it needs to come from all sectors. You need to see the government, private sector, work together to coordinate. And frankly, I think we need more advocacy. At my organization, Resolve to Save Lives, we've looked at primary health care systems around the world and most, as in the U.S., are pretty weak. They're not at the center of the health care system. They're not robust. They don't have a sense of accountability for their patients. But there are a handful of countries that have very strong primary health care systems.

The common denominator of those countries is that the primary health care system is valued. It has political salience. In those countries, ranging from the United Kingdom, to Thailand, to Costa Rica, political parties, whether of the right or the left, don't compete on how much they can cut health care, they compete on how much they will strengthen primary health care. And if there's a shortage of medicines or staffing or funding, in primary health care, that becomes a major political issue. I think that health care workers can play a very major role here in advocating for stronger primary health care.

Now Todd, I have nothing against specialist care. It's enormously important and all of us will need specialist care at some point. Specialists can do a more efficient job if the primary health care physicians identify the conditions that specialists need to treat more promptly at an earlier stage of disease and manage the conditions so that the specialists can do specialist care and the primary care system can do the primary health care.

Unger: Any pointers for our audience physicians out there as to how they can advocate more effectively for this increased focus on our ability to respond to both the pandemic and this epidemic of chronic disease?

Dr. Frieden: I think in all three of the Rs that we covered, individual clinicians can have a major role. First and foremost, with your own patients. Every clinician can have a very important influence on their patients by encouraging patients to quit, if they smoke, at every visit, by measuring and controlling blood pressure at every visit, by advocating for vaccination. We've come close to stalling in our progress getting Americans vaccinated. Clinicians are the most trusted source of information.

And after all of the culture wars and political debates, when a doctor says to her or his patient, "I've been vaccinated. I really want you to get vaccinated because I'm concerned that you might die if you're not up to date with your vaccine," that has a powerful impact. At the same time, clinicians can advocate for primary health care to be stronger and can advocate for stronger public health systems at the local level, the state level, the national level and the global level.

Unger: Well, final question for you and it's on the subject of trust which you just brought up. I mean you recently joined a number of other former CDC directors to talk about the way forward for the CDC and rebuilding trust in our institutions. That seems to be something that we've lost a little ground on. What are your thoughts there?

Dr. Frieden: I don't think this is going to be quick. I don't think it's going to be easy. Trust cannot be surged during a pandemic. Trust needs to be earned over months and years. Trust is lost by the bucketful, but gained by the spoonful. We've lost bucketfuls of trust in this country. We need to gain that by communicating clearly, being frank about what we know, what we don't know, how we know what we do know and what we're doing to find out what we don't know. We need to build linkages, engagement with all the communities that may be alienated, urban, rural, whatever race or ethnicity, whatever political party.

We need to find the right messages and the right messengers. Because fundamentally, Todd, we really are all connected and you can only control your own health. If your society is making the healthier choices the default choice, whether that's healthier food, not smoking, controlling blood pressure, getting vaccinated, reducing the risk of traffic crashes, there's a lot that we can do as a society that individuals cannot do as efficiently or as well as individuals.

Unger: Dr. Frieden, thank you so much. It's great to see you again and really, really appreciate your perspective. That's it for today's COVID-19 Update. We'll be back with another segment soon. Thanks for joining us. Please take care.

Dr. Frieden: Thank you.


Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.

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