Public Health

Tom Frieden, MD, on building a risk alert system to safely reopen the country


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



AMA Chief Experience Officer Todd Unger speaks with former director of the Centers for Disease Control and Prevention (CDC) Tom Frieden, MD, on updates regarding COVID-19 including a risk alert system that can help to safely reopen this country during the COVID-19 pandemic.

Learn more at the AMA COVID-19 resource center.

Unger: Hello, this is the American Medical Association's COVID-19 Update. Today, we have a special guest who will be discussing the truths about COVID-19. I'm joined today by Dr. Tom Frieden, former director of the US Centers for Disease Control and Prevention and president and CEO of Resolve to Save Lives in New York. I'm Todd Unger, AMA's chief experience officer in Chicago. Reopening safely is on everyone's mind. What can you tell us, Dr. Frieden about the pathway to do that?

Dr. Frieden: Today, we released a new report with new recommendations. We scoured the world looking for the best practices in how to reopen without rekindling. And what we recommend is a risk alert level system with four levels: red, orange, yellow, green. The triggers to get between those levels all objectively defined and accepting that this isn't open versus closed. This is various degrees of open versus various degrees of closed, and it's not health versus the economy. It's about how we can restart as soon and safely as possible because if our economy tanks, health is going to be bad also. We're in it together. We need to get through it together, and I think a health risk alert system, for the information and for our website, that's applied that the US states. Now what we find is if you do this, you do three things. You empower people to protect themselves. You hold governments accountable for providing the data and making progress, and you accelerate progress. So everyone can see what do we need to do to get from red to orange, orange to yellow, yellow to green.

Unger: So give me some more details about that. What are kind of the key underlying principles of moving along that spectrum?

Dr. Frieden: First off, we outlined seven proposed indicators to track to see what's happening with the virus, what's happening with health care and what's happening with public health. And then at each of those four risk levels, we give, what are the implications for nursing homes, for doctors, for nurses, for mask wearing. And we have a really good table I think, on when to wear a mask as per the recommendations. But let me go through those seven indicators, just for a moment.

The first two are about the disease. How many cases you have per million population per day. And do you have a signal in syndromic surveillance? That's really important. That's been the earliest signal of resurgences or outbreaks of COVID and a signal to lock down more quickly so you don't have an explosion as we did here in New York City.

Second, health care, and we've looked at two indicators in particular. One, can our intensive care units surge if they need to? That needs to be ready in case there's a big wave.

Second, and very importantly, is the number of health care worker infections zero or decreasing? It's outrageous that tens of thousands of health workers have become infected with this virus. It's not necessary. We can do better. We need to use elastomeric, half facepiece respirators. There's no reason these haven't been made widely available, and we need to use a comprehensive approach to source control engineering, environmental controls and good personal protective equipment to protect the people on the front lines against this virus.

The third component is the box it in strategy. It's about testing and contact tracing. Are you testing enough? Are you're testing the right people? What's your positivity rate? And are you doing contact tracing so well that most of your cases are arising from quarantine contacts? Because when you're doing that, you're on the road to recovery, both health and economic.

Unger: So people are clearly a hungering for a plan. And what we're hearing from you makes a lot of sense. What are the challenges in getting a plan like this adopted across all 50 states?

Dr. Frieden: We'll need governors, mayors to do this. We've been working closely with Bloomberg Philanthropies and a coalition of mayors with the Johns Hopkins University. And we'll be providing this to mayors. We've interacted with the National Governors Association as well. And we need doctors and nurses and the informed public to go on to and ask their state whether they're going to do that and support the state to do it. We're all in it together. And the more we're working off the same page, the more we're looking at the same information and working toward the same goals, the more we can restart our economy, rather without rekindling the epidemic.

Unger: Many states, of course, are loosening stay at home orders right now. Are any states across the country really adhering to the kind of guidelines that you're setting out there, or even close?

Dr. Frieden: Well, we've just released them. So for example, we couldn't find data on health care worker infections. That's bad. Every state should be telling us of their cases, how many are in health care workers? And we should be able to see that go down, not who, but the numbers. And right now we're not yet doing the kind of contact tracing we need to. That's really important to scale up. So it'll be a work in progress for some time, but the sooner we do it, the safer we'll be.

One thing we do recognize in this recommendation is that we can't ignore the economic and social impacts. And so we give latitude to jurisdictions to go down one, but only one, notch. If the economy really needs a boost, yes, we can go down one notch, but safety measures in place, physical distancing, face masks, hand-washing, sheltering the vulnerable. So they stay home. In our health care facilities, it's going to be masks for everyone for a while. Anyone who's ill should wear a mask. When you're at red, everyone needs to wear a mask when they're outside. When you've come down to orange or yellow, it's very different. And we have a matrix that looks at indoor versus outdoor, within six feet or not within six feet. And what is the level of risk in the community? That's the kind of data driven policy that's going to help us start sooner and safer.

Unger: So talking about data, what has been the most surprising data we've seen to date, or that you've seen in terms of fighting COVID-19?

Dr. Frieden: I have to say what's been so surprising is we've learned a lot. Two or three months ago, I wrote an article on 19 critical questions about COVID-19 that we need to answer. And most of them have been answered. Not all of them. There's still some really important things to figure out. Unfortunately, most of the answers have been bad news. Yes, it spreads from asymptomatic people. Yes, it can spread from fomites, contaminated surfaces. Yes, it can cause severe disease even in people without underlying conditions. Yes, it can be very highly infectious. This is deadlier than flu. It spreads more readily than flu, and we don't have any natural immunity. It's a dangerous virus. It would be a big mistake to under estimate the damage this virus can do.

Unger: There's been a lot of questions about how it does compare to the flu. Do you have any perspective for the audience on that?

Dr. Frieden: Well, as I say, we don't have immunity. We don't have a vaccine. It spreads more readily, and it's deadlier. Those are four bad things. But we're trying to do things to control COVID that we would never try in flu precisely because it's so deadly. That's where our box it in strategy comes. People have focused on testing and testing is really important, but there's not one thing we need to do to stop this virus. We need a comprehensive approach. The box it in strategy is test, isolate, contact trace and quarantine. Each one of the four corners of that box is important. If we do them all together, we can put the virus in a box so we can have more space in society. Testing means every patient who's hospitalized. Every contact of every case, every health care worker with symptoms and some individuals without symptoms. For example, anyone in a nursing home where there's an outbreak. Isolation means much better infection control in our hospitals, nursing homes, correctional facilities, homeless shelters and at home.

We may not be telling people in the future, go home, you've just got mild COVID. We may see, say, check into this hotel for 10 days so that your grandmother doesn't die. That's what other countries are doing, and we probably have to do that in some of our communities. Contact tracing, hard work, gaining the trust. Public health needs immediate information on who's testing positive so that we can go out and provide services for them, get them out of their home voluntarily if they may be infecting vulnerable people there and they're willing to. And find out who their contacts are so we can warn their contacts. And we need to tell every patient who's diagnosed, you should expect that someone will call you and help you identify everyone you may have unknowingly infected so that they can be warned. Your name will never be shared with them, but they need to be warned so that they don't spread it to their family.

Quarantine is the fourth corner of that box. And if any one of those corners is weak, the virus can get out, explode, endanger people on the front lines, families and communities and our economic recovery. This isn't about open versus closed. It's about levels of open. This isn't about health versus economy. It's about protecting lives so we can protect and restore livelihoods.

Unger: So you recently spoke at the House Appropriations Committee hearing on pandemic response. You laid out a lot of truths about COVID-19. You now have this new set of guidelines. What kind of reception do you anticipate and how can you advance and gain support for that?

Dr. Frieden: I'm encouraged. We have bipartisan support in the House for a new approach to protecting Americans. We call it the Health Defense Operations Budget Designation. Let me tell you how the budget dance works. I did this for eight years. Really good doctors and PhD scientists determine what's needed. Then it goes through about 10 levels of review. It gets cut to smithereens. Then it leaves the agency and it goes to the larger agency. It has to compete with really important projects. Do you want to create a vaccine or cure Alzheimer's? Do you want to educate with early headstart or track deadly viruses? That's an impossible question. But after that, it goes to the Office of Management and Budget which slashes it further to make it fit some spreadsheet. Then it goes to Congress, which quite frankly ignores it and bases what they do on last year's budget.

If we keep on doing what we've always done, we'll get the results we've always gotten. And that means we'll be vulnerable to attack, microbial sneak attack. And so the Health Defense Operations proposal, HDO, that we along with a group of other people, including bipartisan former Senate leaders proposed says, let's do this differently. Let's exempt from the budget caps, our health defense just as we do our military defense. Only specific areas that are about keeping Americans safe, protecting us from threats and let's require what's called a bypass professional judgment, very technical. What it means is that scientist whose work got cut to smithereens, they're going to talk directly to Congress and the American public. This is what we need to keep you safe. It is inevitable that we will face another pandemic.

What's not inevitable is that we have to be so woefully under prepared. And the Health Defense Operations budget will help us protect Americans, save lives and protect our economy. As Tom Cole, a Congressman who has emphasized this for years said, "It's a no brainer to spend billions to save trillions." And Congressman Cole has said for years, "You are much more likely to be killed by a pandemic than by a terrorist." Our health defense is central to American safety, security and prosperity.

Unger: Absolutely. One thing I wanted to ask you, I didn't hear in the kind of four principles of your response, anything about serological testing. Obviously a lot of talk about that. What's your perspective.

Dr. Frieden: We still have to learn a lot about serology. First off, we have to get the lousy tests that are on the market, off the market. They're junk, and they shouldn't be on the market.

Second, we have to see whether antibodies mean immunity. We hope they will, but we don't know if they will. If so, to what degree and for how long? Those are all really important questions to answer. And the sooner we know the safer we'll be. I would say this to a health care worker. If you had infection, you've recovered, you have antibodies, you may be protected but don't count on it. Don't let down your guard. We hope you'll be protected. We think you may well be, but we wouldn't want a fatal mistake that might result in you getting reinfected or infected if the antibody test wasn't accurate. So don't let down your guard, stay safe, but let's see if those antibodies work and let's see if monoclonal antibodies or plasma with antibodies harvested from people who've recovered will help people. It may well. And if that does work, it will be important to try to scale that up.

Unger: Last question, any perspective on where we stand on a vaccine?

Dr. Frieden: We hope for a vaccine, we need an all out effort to get one. Only a vaccine would get us back to our pre-COVID reality, but getting a vaccine is a long road. It has to be proven to be safe, proven to be effective, manufactured at an adequate quantity, we need the ACIP to tell us who should get it when. We need prioritization and health care workers should come first. You need a system to get it out there, a way to pay for it, you need to track adverse events, you need to communicate and educate the public and monitor the uptake rates. So getting a vaccine is crucially important. Don't count on it. It might not come soon but do try to make it come as soon as possible. Once it's here, understand it's going to be a big job to get it delivered to the people who need it.

Unger: Well, thank you very much, in the meantime, while we wait for that vaccine, I appreciate the work that you and your team have done on the plan to get us back up and running. Dr. Frieden, thank you so much for your fascinating plan and perspective here today. That's it for today's COVID-19 Update. We'll be back with another segment tomorrow.

In the meantime, for more resources on COVID-19, go to the AMA COVID-19 Resource Center at Thanks for being with us here today and take care.

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.