r. Tom Frieden arrived on the Atlanta campus of the Centers for Disease Control and Prevention to take on the job of CDC director on June 8, 2009 — three days before the World Health Organization declared the first flu pandemic in 41 years, caused by the H1N1 virus. That into-the-deep-end start set the stage for the next seven and a half years.
Frieden, who had been New York City health commissioner, steps down on Friday at noon EST. During his tenure, the country’s premier public health institution faced back-to-back-to-back health crises. The largest ever Ebola outbreak. A multi-state outbreak of fungal meningitis, triggered by contaminated steroid products made by the New England Compounding Center in Framingham, Mass. The Zika epidemic in the Americas.
The CDC’s Emergency Operations Center, which is only stood up in times of outbreak responses, operated during more than 90 percent of Frieden’s tenure.
As the clock ticks down on his time in office, Frieden, 56, reflected on the frustration and joys of being CDC director, the scariest moment of his tenure, and his thoughts about the public health challenges still facing the country. His remarks were at times candid and at others guarded, particularly when questions touched on the challenges the incoming administration may pose for the agency and his as yet unnamed successor.
Frieden’s conversation with STAT has been edited for length and clarity.
Did you have a discussion with the transition team about staying on?
No. I’m the longest serving director in 40 years and the second longest ever.
I’ve made clear that I’m willing to contribute to a smooth transition in any way possible and that I remain committed to supporting public health.
Will you tell us what you’ll being doing next?
I’m weighing options currently. And what I’ve always done to determine my next job is to ask the simple question: How can I save the most lives? And that’s the formula I’ll be using going forward.
When I decide, I will let you know.
What surprised you about the job of CDC director?
I really had thought it would be more similar to being a big city health commissioner. And it’s really very different. Because you’re working in partnership with others, you’re implementing through others, to get things done.
So rather than propose a law, pass a law, implement a law, which is what you do in New York City, you are supporting cities, states, jurisdictions, other organizations for them to do what’s possible in their areas to make the most difference.
What frustrated you about the job?
The pace of things at the federal level is very frustrating. These are emergencies and it’s almost physically painful to have the kinds of delays that we know are costing lives. Sometimes you just feel like screaming. Because you know that a delay — for example, in Ebola, in deploying staff, in contracting — that delay will cost lives.
Bureaucratic as city government can be, the federal government is quite remarkably bureaucratic. And unlike FEMA, CDC does not have emergency authorities.
Even after we had ample money [for Ebola], we didn’t have emergency authority. And that meant it took six months to write a contract for things. And that wasn’t because people were lazy or not hard-working. Quite the contrary: People were working around the clock, seven days a week. But you can’t break the law and you can’t do a contract in less than that without breaking the law, unless you have emergency authorities.
So it’s really important going forward that there be emergency authorities for emergencies. Money is critical. But in addition to money, there needs to be the administrative freedom to act quickly.
What will you miss most about the job?
The people at CDC, without question. The CDC staff are so dedicated, they’re so expert. I learn from them every single day. They’re enthusiastic. They’re hard-working. They’re at the top of their field.
What were the high points of your tenure?
One high point was when we realized we’d broken the back of the epidemic of Ebola in West Africa. Because for a while, I was encouraging our staff who were getting very discouraged. But truth be told, we weren’t 100 percent sure that we would be able to stop the outbreak.
Many people remember Ebola for [cases in] Dallas but for me the absolute scariest moment of my tenure was when, not only was there a cluster [of cases] in Lagos, [Nigeria, Africa’s most populous country,] but the first incident manager there was incompetent.
And he spent hour after hour after hour debating what to do with an embalmed corpse that had transited through Liberia and was at zero risk for Ebola. And while this was happening, no contacts were being traced, health care workers — doctors and nurses who had cared for the first patient — were desperately ill and were in fact dying and no one was figuring out where they could be treated. Basically nothing was being done.
In Lagos we were days away from Ebola spreading throughout Nigeria, throughout Africa, for months and months and potentially years, killing people not just from Ebola but basically shutting health systems and killing people that way.
I think that’s what’s less understood: how close the world was to an abyss.
Do you have any regrets?
I wish we were over the finish line with polio [eradication]. I thought we would be.
President-elect Donald Trump has some ideas about vaccines that aren’t science-based. He met with Robert Kennedy Jr., who definitely has concerns about vaccines and doesn’t think highly of CDC staff. Are you worried we may be seeing a resurgence of anti-vaccination views, and at a level that could do a lot of damage?
CDC is ready to work with the new administration to look at all issues openly and objectively. We think it’s very important that there be transparency, and that’s why all of the deliberations of the advisory committee for immunization practice are public. Everything is available online. All even potential adverse events from vaccination are online.
I am certainly hopeful that moving forward CDC will continue to have the technical independence to protect the American people.
What about CDC’s international work? The president-elect seems to feel the United States is carrying too much water for the international community, as reflected, for instance, in his comments about NATO.
That exactly what we’ve done with the Global Health Security Agenda. We’re keeping America safer by getting other countries to step up in terms of staffing, transparency, laboratories. We’ve been able to support them with some leveraged investments that have resulted in they’re spending more money, devoting more staff, and being more transparent about what the health threats are. As a result, they’re safer and we’re safer. But it’s not finished.
Should Congress free up CDC to study gun violence?
CDC is not prohibited from studying gun violence. It’s just not funded to do it. Congress has declined to fund requests to do the studies.
If they don’t fund it, you can’t do it?
Right. If you do something that is not directed by Congress, it’s against the law.
There are many things that we wish we knew more about in terms of how to reduce gun violence, but there are already some things that are clearly effective at reducing gun violence. For example, safe storage. For example, restrictions on access to guns for people who have restraining orders because of domestic violence. For example, universal background checks. There is strong evidence for all three of those policies.
The gap there is not a research gap. The gap is a policy gap. And that’s a policymaker call of what to do.
The US accounts for something like 84 percent of all firearms homicides in all OECD countries. So we are an outlier. But there is not consensus about what to do about it.