Why public service projects are a good investment

Tom Frieden

• From the October 2016 issue of The Rotarian

Tom Frieden is a little out of breath. He just climbed the stairs from a meeting to his office on the top floor of the 12-story headquarters of the U.S. Centers for Disease Control and Prevention in Atlanta.

“I did that because we have a beautiful stairway in this building. I can look outside, and I get better email coverage on the stairs than I do in the elevator,” the CDC director says. His trip up the stairs sums up his view on one of the tenets of his work: “The sweet spot of public health is making the healthiest thing to do the default value — in other words, the easiest thing to do.”

Frieden took his post in 2009 after stopping the largest outbreak of drug-resistant tuberculosis in U.S. history in New York City, helping establish TB treatment programs in India that have saved more than 3 million lives, and serving seven-plus years as health commissioner of New York City. There, he worked with Mayor Michael Bloomberg to make all restaurants and bars smoke-free, making New York the first major city to do so outside California. His controversial policies had him criticized as a “nanny” in some circles, and lauded as a visionary in others.

‘The thing that worries us from a public health standpoint … is the potential of an influenza pandemic. … We’re still not as prepared as we’d like to be. We don’t have the vaccines we’d like, and the virus is … constantly mutating.’

As head of the U.S. public health system, Frieden has taken on everything from ebola to the flu. But, where his work most closely intersects with Rotary’s is in polio eradication –- CDC joins Rotary, UNICEF, the Bill & Melinda Gates Foundation, and the World Health Organization (WHO) as a core partner in the Global Polio Eradication Initiative. CDC deploys scientists to investigate outbreaks of polio, identify the strain of poliovirus involved, and pinpoint its geographic origin.

“Rotary has done such a phenomenal job for so many decades on this, and now we are poised to get over the finish line and end polio once and for all,” Frieden said in an interview with Rotarian senior editor Diana Schoberg about ending polio and the best buys in public health.

THE ROTARIAN: Polio has been eradicated in the U.S. since 1979. Why does CDC stay involved?

FRIEDEN: CDC takes polio eradication very seriously. We focus on supporting the front lines wherever polio continues to spread. I am deeply engaged with all aspects of the response and support for our team. That includes laboratory work, community outreach, organization of the response, extension of the capacity of local doctors and outreach workers, and tracking cases so we can target our responses and get to the last bastions of polio in the world.

TR: The estimated funding gap to eradicate polio is $1.5 billion. Why is it such a large number?

FRIEDEN: It costs a lot because as long as there’s still polio anywhere, every country needs to continue to act as if polio could get reintroduced. Every year polio is not eradicated will cost another $800 million. You need vaccines, surveillance, and social mobilization. All of that takes people and money. Up to 400 million children still need to be immunized every year, and surveillance in up to 70 countries needs to not only continue, but be intensified, to ensure we are finding all possible cases of polio for as long as polio may be spreading.

TR: The U.S. government has invested $2.9 billion to end polio over the years. How will you be sure those resources aren’t wasted when polio is eradicated?

FRIEDEN: I think that’s a very important point. Eradication is the ultimate in both equity and sustainability, because it’s for everyone and forever. But also we want to make sure that the systems that were built for polio eradication are used for other initiatives, especially to strengthen efforts to save children’s lives. We continue to deal with outbreaks of vaccine-preventable diseases like measles, as well as other outbreaks that emerge in other parts of the world. If we can stop those outbreaks at the source, it will save lives there and save a lot of effort and money here.

TR: How do you work with other governments to transition the systems built for polio eradication to these countries themselves?

FRIEDEN: One of the main ways to make programs sustainable is by training staff. The staff that we train tend to stay in their home countries to establish and build their careers. By upgrading their skills, we’re contributing to the public health stability and development of that country. Also, success breeds success. So when countries eradicate polio, it gives them more confidence that if they invest money in immunization or child survival, they can really make a difference in saving lives.

TR: What are the most important things for Rotary members to do in the next few years to support this effort?

FRIEDEN: First, don’t let the pressure up on polio. Rotary has been terrific in informing people everywhere about the importance of eradicating polio and working around the world to support the effort. Rotarians’ continued support for global polio eradication efforts is critical. Once polio is eradicated, we have to continue to apply the lessons learned from its eradication to get to the next public health victory. We want to make sure that the assets from polio eradication can be used to address other major public health problems.

TR: Is the work we’ve done on polio eradication a helpful paradigm for other public health issues?

FRIEDEN: Yes, there are important lessons, including the use of laboratory data, surveillance systems, emergency operations centers, rapid response teams, and social mobilization. All of these practices have been honed during polio eradication and are relevant to other areas as well.

For example, the same staff involved in polio eradication in Nigeria was then essential in stopping ebola when ebola hit Lagos. They staffed the emergency operations center, identified and traced contacts [people who came in direct contact with an ebola patient], and prevented what was a cluster of ebola in Lagos from becoming an outbreak that could have spread throughout Nigeria and Africa.

TR: On another topic, you’ve said antibiotic resistance may be the most serious infectious disease threat we face. Why?

FRIEDEN: We are facing the possibility of a post-antibiotic era. The loss of effective antibiotic treatments will not only cripple our ability to prevent and fight routine infectious diseases, but could also undermine treatment of infectious complications in patients with many other diseases. Many advances in modern medicine – joint replacements, organ transplants, cancer therapy, and treatment of chronic diseases such as diabetes, asthma, and rheumatoid arthritis – are dependent on our ability to fight infections with antibiotics. If that ability is lost, our ability to safely offer people many lifesaving and life-improving modern medical advantages will be lost with it.

TR: Is CDC involved in getting new antibiotics in the pipeline?

FRIEDEN: It will be great to have new antibiotics. At CDC, we’re developing libraries of resistant organisms so that pharmaceutical companies can develop antibiotics that work against those organisms. But we’re not going to invent our way out of this problem. We need to protect the antibiotics we have. That means all of us, from hospitals and doctors to patients and families, need to use antibiotics correctly –- only when they are needed, and correctly when they are prescribed.

TR: A 50-year-old American is probably more likely to be killed by cancer or diabetes than ebola or zika. How do you prioritize where to put the limited funds you have?

FRIEDEN: I ask questions. Where can we save the most lives? What is a unique CDC role? What are we likely to get Congress to support? What can we do with our existing resources? Our way of prioritizing is straightforward: We work 24/7 to protect lives and then we figure out how, within our budget and our capacity, we can make the biggest difference.

TR: What are the best bang-for-your-buck buys in public health?

FRIEDEN: There are a lot of best buys in public health. Every dollar spent on immunization saves $3 in direct health care costs and $10 societally. If you look at our work preventing hospital-associated infections, we can save billions of dollars and tens of thousands of lives a year with the interventions we’re undertaking, such as preventing infections and their spread between patients in health care facilities, and using antibiotics when necessary and appropriate –- and not using them when they are not needed, for example, for colds, most sore throats, and many sinus infections.

If you look at our work on noncommunicable diseases, our “Tips from Former Smokers” campaign, where we produced hard-hitting ads to inform people about the effects of smoking on their health, was incredibly cost effective -– less than $3,000 per life saved in this country. Public health is a best buy. It saves lives, it saves money, and it keeps Americans safe.

TR: What’s going to keep you up tonight?

FRIEDEN: The thing that worries us from a public health standpoint -– in addition to things like antibiotic resistance and emerging infections –- is the potential of an influenza pandemic. Influenza really is the big one. Flu could result in a mass number of illnesses and deaths, and we’re still not as prepared as we’d like to be. We don’t have the vaccines we’d like, and the virus is not only constantly mutating but also exists in the animal world in various ways that are potentially risky, so flu is the big one that we can never forget about.

TR: It’s such a mundane thing.

FRIEDEN: Even in a so-called good year, the flu kills a lot of people in the U.S. Sometimes we don’t see problems because they’re so close to us. Take the example of cardiovascular disease, heart attack, and stroke. It’s the leading cause of death in the U.S., but most heart attacks and strokes are preventable with tools we have today that aren’t being applied –- the things we call the ABCS: taking aspirin if directed by your health care professional, controlling your blood pressure, managing your cholesterol, and quitting smoking.

TR: You’re in charge of society’s health. What’s your personal prescription for good health?

FRIEDEN: First off, do the things that you enjoy. If you find healthy foods that you like, whether it’s red peppers or sweet potatoes or whatever, have more of them. If you find physical activity you like, whether it’s dancing or walking or playing basketball or bicycling, do more of it. It shouldn’t be about denying yourself pleasures. That’s not what we’re about. We’re about making life more enjoyable, and that means not being sick and doing things to protect your health.

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