TRANSCRIPT: Flying Blind: The US Government’s Pandemic Response with Dr. Tom Frieden
Tom Frieden:
We're learning more every single day about this virus. And the more we learn, the more we can use that collective intelligence to fight it.
Ian Bremmer:
Hello and welcome to the GZERO World Podcast. Here you'll find extended versions of the interviews from my show on public television. I'm Ian Bremmer. On this episode, it's hard to imagine a public health crisis worse than what the world has endured in 2020. Well, there was that one a century ago. But the reality is there could be many other potential pandemics in our future if we don't learn important lessons today. Isn't that the way it always is? Is it possible to stop the next one before it happens? My guest says yes, but it'll take a lot of work and global cooperation. Here's my conversation. Dr. Tom Frieden, former director of the Centers for Disease Control and current president and CEO of the global health initiative, Resolve to Save Lives.
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Ian Bremmer:
Dr. Tom Frieden, he's president and CEO of the global health initiative, Resolve to Save Lives and also the former head of the CDC. Good to be with you, Tom.
Tom Frieden:
Great to speak with you, Ian.
Ian Bremmer:
So nowadays, when we talk about this pandemic, there is so much politics around the parameters of what we're hearing, around how many cases are there really, are we testing enough, do we know what the death count is, can we trust the data that's in front of us? Why don't you tell me right now to the best of your ability what you think the reality of the pandemic is compared to the figures that we're seeing in the papers every day?
Tom Frieden:
Well, you're absolutely right. There has been partisanship infecting our response to this pandemic. And what we see in every country and every community around the world is that the virus exploits the fault lines of society. And one of the fault lines of our society is partisanship. So, even things that really shouldn't be partisan become controversial, masks being one example. But if we look at the US, first off you have to say it's not just one epidemic. There are many outbreaks, all epidemiology is local just like politics. And what you see in many of the states of the Northeast is a relatively cooled down pandemic, still a lot of cases if you compare it with countries in Asia and Europe that have really crushed their curves.
But what you see in much of the south of the US is explosive spread. And one of the things that frustrates me as an epidemiologist is that the media are paying attention to the wrong numbers. And they're obsessed with, are there 11,000 cases in Florida today? Well, we know that we're underdiagnosing by three to tenfold. So people are saying, "Oh, are there going to be 100,000 cases a day in the US because they were 75,000 or 80,000 diagnosed?" Well, they're already far more than 100,000 every day. We're just not diagnosing them all.
And similarly, there's been this obsession with the number of tests, "Oh, we're up with 700,000 tests." Wait a minute, but they're taking a week to come back, 10 days to come back, they're very close to useless in that circumstance. If we really want to get a handle on the pandemic in the US, we have to have a much better view of what risk is and what our response is. And those are the two things that we should focus on. And right now, the risk is very high in much of the country and our response is quite problematic in much of the country as well.
Ian Bremmer:
Now, you mentioned the issue with numbers of cases and the fact that everyone agrees that this is a wild undercount. Do we think when we talk about numbers of deaths, actual deaths of people with coronavirus, we know that in Italy there was probably a very big undercount at the beginning because people were getting buried without having tests of whether they had coronavirus or not. Do we think the numbers we're presently seeing in the United States about people that are dying with slash from coronavirus? Are they accurate numbers in your view?
Tom Frieden:
The best estimate we have is that the undercount in the first few months was about 20%. In other words, there are about 20% more COVID deaths than were reported. So we're up to close to 150,000 or around 150,000. It's probably at least 20,000 more than that in truth. But it's really important to think about all deaths, not just COVID deaths. There was a great British biostatistician, William Farr, who said, "The death rate is a fact, everything else is an inference." And the fact is that in much of the world, we don't have reliable information on who lives and who dies. The Bloomberg Philanthropy along with a number of partners has started a program called Data for Health. And one of the components of that which we at Vital Strategies, the organization that Resolve to Save Lives is part of, have done is to help countries around the world to track the excess mortality in real time week by week.
And that should be available in every state of the US and every country of the world. When we look around the world, we see big gaps between the excess deaths and the reported coronavirus deaths. And there really are two different reasons for that gap. One of them is as you indicated, people who had COVID but didn't get diagnosed. The second are people who are dying because they couldn't get healthcare. They didn't go in for healthcare. In the US, that's mostly people with heart attacks and some strokes. In Africa, that could be kids with measles or malaria. So I'm really concerned about the excess deaths, not just undercounted COVID deaths, but also other cause deaths. And that's something that we really need to watch carefully and emphasizes that our response to COVID has to address not just COVID, but all of the potential harms that COVID causes for our society.
Ian Bremmer:
When you compare the Northeast to the rest of the country in deaths, the Northeast looks horrible. So if we look at excess deaths, tell me from your perspective, how does the United States stack up? Are all of these new, where we're dealing with the coronavirus right now, with all of the media attention, is it actually as bad as people are saying?
Tom Frieden:
Well, there are a few things going on with death trends in the US. We have lots of cases in the south of the US. But unlike earlier, you see more young adults. Young adults are much less likely to die from this disease. So, you're going to have a lower case fatality ratio there. Second deaths lag by about three weeks from cases. So it's not so much a question of we don't have a lot of deaths as we don't have a lot of deaths sadly yet. Third, we have gotten better at caring for people with COVID. So understanding early use of oxygen, remdesivir, may have an effect reducing deaths. Some steroids like dexamethasone, probably when given late, may reduce some of the serious complications. So we've gotten better at treating it in hospitals and that should also bring the death rate down. But still, you have a disease that's very hard, particularly on the elderly.
Ian Bremmer:
So you've said that a big piece of the problem with data is actually at the federal level, not at the state. And I'm wondering where you think the federal government has fallen down? Is this resolvable in the near term?
Tom Frieden:
One of the things that we can do soon is get a much better standardized sense of how we're doing in every state and every county of the US. There should be standard definitions of the most important indicators. We released a list of 15 essential indicators, and what we found was if we went onto state dashboards, no state had even half of that information and most states had less than a fifth of it. So we're flying blind in this epidemic.
And the more the federal government empowers states and counties, defines clear indicators and expectations, and the more we in the public and the media insist on it, we'll have a much better sense of two crucial facts. One, what's our risk, and two, how well is our response going? What can we do to get the virus into better control? What we call boxing the virus in with strategic testing, fast isolation, effective contact tracing, and supportive quarantine. You do those four things, you get the virus in a box that's smaller and smaller so we can come out more. And right now, we don't know how that's going really in any community in the United States.
Ian Bremmer:
People are more concerned now in the United States about reopening schools than almost any other factor. I heard Bill Gates the other day saying he thought it would be safe to reopen schools in fall 2021. Now, you've come out with a public plan for the steps that need to be taken. Want to sort of give us a broad outline and what, if anything, you think can be done for this fall?
Tom Frieden:
Well, first and foremost, the single most important thing to get our schools to be able to open is to control the infection in the community. If you have explosive spread as you have now in Phoenix and parts of Texas, Florida, it's not going to be possible to open. Of course you can open, but the real hard part is to stay open. And once you have a lot of cases in a school, you're going to have to slam back shut. So the most important thing all of us can do is work together and stay apart. Wear a mask, wash your hands, watch your distance, the three Ws, can allow us to bring the infections down in governments where there are lots of cases have to shut bars and indoor dining because those are major propagation points for the virus.
Once it's down to a lower level, it's certainly possible and really important for schools to reopen if at all possible. That means shielding the most vulnerable. Teachers and students with underlying conditions are going to need to continue to teleschool, rearranging how things work in schools so there aren't as many commonly touched substances, keeping students apart and in pods or cohorts so that if there is one case, you don't have to shut the whole school. You can quarantine one small class or a grade. And universal masking, really important.
But none of those things in and of themselves is going to ensure that there are no cases. So every school needs to have a protocol and be prepared for when there are cases so they can take appropriate action and minimize the loss of education. Schools are important not just for education, they're important for social and economic development. They're important so parents can get to work. They're important so that kids can get healthcare, and nutrition, and mental health services. So we all want the schools to open. The key is to open them in a way that they can stay open.
Ian Bremmer:
So you ran the CDC. We still have a CDC in the United States. It has management. We've also got the much celebrated Dr. Fauci, we've got Dr. Birx, they're still out there talking to the media all the time. How are the health professionals doing? How are they holding up right now in the United States?
Tom Frieden:
Well, first and foremost, I think we need to do a much better job protecting people on the frontlines. Every time I see the numbers of healthcare worker deaths, I see another healthcare worker dying, it's just heartbreaking. Here in New York City, Steve Kamholz was someone who I've worked with for years, who's 72 years old, he wanted to go in and help people. He got the disease, he was teaching from his bedside trying to help people. He was just a totally committed physician. And to see someone like that die from this is horrifying. And I think it's largely preventable. If we use a systematic way of preventing infections and we get much better about face shields, and reusable protective equipment, and environmental and engineering controls, source controls, universal masking in hospitals, we should be able to dramatically reduce the number of healthcare worker infections and deaths. And that's crucially important. One of the 15-
Ian Bremmer:
We're six months in, Tom. Are you saying we still aren't getting basic health protocols around coronavirus in place in hospitals? Are we lacking supply chain? What's the principle miss here?
Tom Frieden:
Well, I think one of the most important things that we must do is be much more transparent with information. There have been more than 500 deaths of healthcare workers that we know of in this country and more than 80,000 infections of healthcare workers that we know of. These are mind-boggling numbers. When I, early in my career work on tuberculosis, and we had a single death of a healthcare worker, it was such an outrage that there was national action to protect healthcare workers. So, I feel like in some ways, we're getting inured to this.
And we recently released 15 essential indicators that every state and every county should release every week, or in some cases every day, one of those is weekly, the number of healthcare workers infected in your area. If we knew that every week and every area, I think there would be pressure to get that number down towards zero. Because it's possible, there are other countries that are not having this kind of infection rate in their healthcare workers, and we have to do much better.
I would also have a shout-out to the public health workers all over this country, at the CDC, at state governments, at local governments. They're working around the clock. It's been month after month. In some cases, they've been attacked and vilified. In other cases, they've been sidelined at undermined. But if we look around the world, the places that have supported public health and have been guided by public health have done better. They've had fewer deaths, less disease, and less economic devastation. And as we come out of this, we're going to have to think of what can we do to strengthen public health more so that we don't fall into this kind of a situation again when it could have been prevented.
Ian Bremmer:
There's a broad logic. You could even say it's a conventional wisdom about the United States that we have the worst system that is the most expensive among the advanced industrial democracies. That's not new. This has been something that people have talked about under Republican and democratic administrations. To what extent is that true and how has that played out in terms of our inability to effectively respond to this coronavirus?
Tom Frieden:
Well, when you come to our healthcare system, there's no doubt we spend twice as much on average per capita and our outcomes aren't good. In fact, if you look over the last couple of decades, we've gone down in the ranking tables while we've gone way up in the spending table-
Ian Bremmer:
And the cost tables.
Tom Frieden:
Something is definitely not working for us here. And some of that has to do with the cost drivers of care, our overpayment for medications, our overuse of procedures. But the one thing that I think could be most important in our healthcare system is to drastically change and improve the role of primary care. We have a very weak primary care system, and it's being slammed by coronavirus because people aren't coming in for visits. And a lot of our primary care works on a kind of piece work basis. Patient comes in, you get paid, they don't come in, you don't get paid.
We need to move to a place where everyone has a right to a primary care physician, where primary care physicians work in teams with nurses, pharmacists, social workers, outreach workers, where there's a panel of patients and a responsibility for that panel, where you have capitation with positive and negative incentives, that the outlines of what we need to do to improve healthcare in the US aren't actually that complicated. It's pretty straightforward. You'll have some debate around the margins, but it's pretty straightforward. We need to do much better primary care. We need to assign responsibility for patients. We need to follow up protocols. We need to incentivize quality and value, not volume. What's hard is the politics of it.
So leaving that aside for a minute, in public health, we have an ongoing cycle of panic, neglect, repeat, panic, neglect, repeat. And one way that we could break that cycle is to change the way we fund a subset of core public health programs, what we call the Health Defense Operations budget designation. And what that would do was have funding, be budget cap exempt for a limited number of lines that Congress would designate and that the administration, the executives would be required to have the health professionals submit an honest take on what is needed without that getting cut to smithereens by the Office of Management and Budget.
That would give you kind of the one two punch against viral sneak attacks of saying, "Here's what we need and you can spend it, Congress, without having to rob Peter to pay Paul, without putting it into mandatory funding that may become a political football." So we think there are ways forward in the US, but it's going to need sustained funding and a new way of addressing, frankly the political economy. Preventing pandemics doesn't win in the budget battle because it mean a pandemic may not happen before in the next electoral cycle.
Ian Bremmer:
But you expect it's going to win at least a little because we've just had one, right? I mean, usually you spend an enormous amount on preventing or fighting the last war, preventing the last crisis.
Tom Frieden:
Well, this is my concern. If you look at what we've done in past pandemics, there's usually a big slug of money that's a supplemental appropriation. And then everyone says, "Ah, we've done it." But supplementals, as they're called, actually are very hard to manage and you can't build programs effectively with them. If you're trying to hire the best staff, they look and they say, "Oh, that's just a couple year program. I'm not applying." If you're partnering with a state, or a country, or a company, they say, "Eh, that money's going to dry up. I don't really have to take that too seriously. It's not a long-term source of income."
So the reality is that to build programs, you can't do it well on supplemental funding. In fact, we saw that with pandemic prevention. After Ebola, significant resources were provided for what's called global health security. It's basically global health protection, stronger there, safer here. And a lot of progress was made by CDC, Department of Defense. And what we saw then was that money dried up. And when it dried up, CDC had to pull back, including from China. So the supplemental approach is very limited. After 9/11, what Congress did is said, "Okay, we put all of this money in, we need an off wrap."
And they created the Overseas Contingent Operations, OCO or OCO budget designation. That's been criticized because it was something of a slush fund. And so, when we've proposed a Health Defense Operations budget, we've learned from that didn't make it agency specific, rather budget line specific, tied it to a professional judgment that bypasses OMB and gives Congress the authority to determine how they're going to spend that, how they're going to allocate it, how they're goi;ng to hold it accountable.
Ian Bremmer:
So macro picture here, globalization, people travel faster and faster, more and more across the globe, and livestock too, that clearly raises the risk of pathogens being transferred. On the other hand, technological improvements happening exponentially allowing us to identify, and respond, and collect data much more quickly. Given those two competing trends, do you think the risk of global pandemic's overall is going up, going down, or staying the same, and why?
Tom Frieden:
Well, I think the risk is going up because of our increasing interconnectedness. We have a gap in that now because of the basic stopping travel because of COVID. But we are increasingly globally interconnected. And that will probably resume at some point in the next couple of years. And we're also encroaching more and more on the animal habitat. And that's where three-quarter of these new infections come from. So, I think we face the inevitability of future pandemic. There are lots of animals, the microbial kingdom outnumbers us. A wonderful microbiologist, Josh Lederberg, he won a Nobel Prize, I remember him saying, "The microbes outnumber us trillions to one. It's their numbers against our intelligence." And that intelligence means setting up early warning systems around the world, closing the gaps in preparedness.
We talked about the US but globally, through the World Health Organization and others, we now have for the first time pre-COVID, a very good sense of where the gaps are. And they're close to 10,000 life-threatening gaps, lack of tracking systems, or lab systems, or rapid response capacity all over the world especially in Africa and parts of Asia. And we're really not doing what we need to do to close those gaps. And that means we're all less safe. We've estimated that it'll cost about $10 billion a year for about a decade to make substantial progress, reducing the risk of pandemics around the world. But that's a tiny price to pay compared to what we're paying for failing to prevent this one.
Ian Bremmer:
So as someone who deals with a lot of these really horrifying diseases, which one kind of freaks you out the most? And I mean sort of personally, right, I mean, do you wake up in a cold sweat occasionally thinking, "Oh my God, I just contracted X."
Tom Frieden:
Well, I think most of us have feared pandemic influenza the most, because something like the 1918 pandemic, if it happened today, could cause tens of millions of deaths. What you're worried about is something that spreads like flu and kills like SARS. Now, COVID is-
Ian Bremmer:
It's not that.
Tom Frieden:
... not that, but it's not all that far away. It spreads more than flu, but it doesn't kill anything like SARS. So you've got really a bad one, but we could get a worse one. And one of the things that I've said for years is we can't predict what the next one will be. No one would've predicted that H1N1 influenza would've emerged from Mexico. Usually, new flu strains emerge from Southeast Asia for whatever reason. Nor that we'd have MERS in the Middle East. So it's hard to predict what's going to happen next, but it is predictable that there will be a next time. So we know what we need to do, early warning, rapid response, prevention wherever possible. And that is a best buy.
Ian Bremmer:
And before we go, I got to talk about the vaccine. Because we know there's well over 150 in various stages of development right now. Where do you think we stand?
Tom Frieden:
Well, it is encouraging. Some of the data suggests that people get natural immunity. We don't know that yet, but some of the immune responses are quite robust. We don't know how long people will be immune, to what extent they'll be immune, whether that immunity will be in all groups, the older people as well. So I'm guardedly optimistic that we will have more than one vaccine that is protective within sometime the next six to 12 months.
What concerns me is that we make sure it's safe. And vaccine safety is really important because remember, you're injecting something into people who aren't sick and you're going to do it millions and millions of times. And even if there's a rare adverse event, it's going to be a big problem, not just for that individual, not just for COVID, but for vaccine confidence. That's why we can't cut any corners on vaccine safety. There are some things that do concern me. I'm particularly worried about this Kawasaki like disease, multisystem inflammatory syndrome in children-
Ian Bremmer:
In kids.
Tom Frieden:
Yeah. So that's an excessive immune response and what's to say that won't happen or something like that with a vaccine. So I don't want to create fear, but I want to be completely transparent. One of the other things that concerns me about COVID is this loss of sense of smell and taste-
Ian Bremmer:
Taste.
Tom Frieden:
... implies that there is damage. It's not to your nose, it's to your brain. And how long is that going to come back? Does that imply that there might be some long-term sequelae? I'm not trying to be sensationalist or scaremongering. I think it's important that we be completely transparent about the things that we're concerned about and we'll track so that we can look closely and see if it's a concern or not.
Ian Bremmer:
So how do you think about that personally? I mean, when the vaccines come out and they're available for public use, the first line workers that need them have gotten them. So you don't feel guilty about the fact that you have access to one. But we still don't know as much as we could. You can control your own behavior to a degree, but once you've taken a vaccine, you've taken the vaccine. How long would you personally wait before you decided, "I'm going to do this?"
Tom Frieden:
Well, first off, I want to know that the Advisory Committee for Immunization Practices is doing a deep dive into this. The ACIP as it's known, is probably the single best vaccine advisory body in the world. It's hosted at CDC. It has parents on it, the best scientists in the world, the best primary care doctors, specialist doctors, public health experts, immunologists. It is a fantastic group. And that's the group that needs to assess the efficacy, and safety, and recommendations of this virus. There's a very good committee that's just been formed at the National Academy of Medicine headed by the two best people in the world to head it, Will Foege and Helene Gayle. It's a great group that'll feed into the ACIP considerations.
But I'll look to the ACIP. I'll read every word of what they've written. I'll go into the information, and if I feel confident, I won't have any hesitation taking it. If there are some signals that may suggest a problem, that'll give me a second thought. But I think all of us really hope for a vaccine so we can get back toward a new normal. One thing that's really important to remember is that even with a vaccine, COVID's not going away. We're going to not have one thing that's going to make this go away, not travel restrictions, not face masks, not testing, not contact tracing, and not even a vaccine. Because we'll still have cases. We have a great vaccine for measles, and we have 100,000 deaths a year for measles. We have a not great vaccine for flu. It's the best thing you can do to protect yourself against flu but it's not great. We have to get it every year and we still have hundreds of thousands of hospitalizations. And we don't know where on that spectrum the vaccines against COVID will be.
Ian Bremmer:
Have you been tested yet?
Tom Frieden:
No, I haven't had a reason to be tested, thank goodness.
Ian Bremmer:
No, I'm just kind of wondering. I mean, what would you feel psychologically, would you feel like better knowing that you actually had antibodies if you did or would you be concerned because we don't know knock on effects of what this disease is going to do down the road?
Tom Frieden:
No, I know people who have been ill and then have gotten a test and have been rooting for antibodies because they think it may give them some degree of protection. We don't know that yet. And a lot of the antibody tests on the market haven't been validated. We don't know what antibodies mean. We don't know if it means you're immune. If you are, we don't know to what extent and for how long. So right now, there are lots of unknowns and that's another reason we have to follow the science here. We're learning more every single day about this virus. And the more we learn, the more we can use that collective intelligence to fight it.
Ian Bremmer:
Tom Frieden, thanks for helping us chart out some of this uncertainty, really appreciate it.
Tom Frieden:
Thank you, Ian.
Ian Bremmer:
That's it for today's edition of the GZERO World Podcast. Like what you've heard? I hope so. Come check us out at gzeromedia.com and sign up for our newsletter, Signal.
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