D (7:14)

Great to speak with you. I'm really looking forward to the conversation.

A (7:16)

Now the reason I say good to meet you is there was a time where I don't think I mocked or made fun of you, but on a this American Life segment, I pivoted off an appearance you had done on ABC's this Week and used it as fodder for at least fun that I was having. So thanks for assisting me. Thanks for giving me the, the assist, the alley OOP in that effort.

D (7:38)

It was fun. This was an earlier time when the existence of anti immigrant tropes was really powerful and we're seeing that even more now.

A (7:50)

Yeah, and actually what you were talking about then was an Ebola outbreak that had possibly come to our shores and people forget this. But in New York, in the New York area, there was this great debate between on one side then Mayor de Blasio and on the other side then Governor of New Jersey Chris Christie about whether to quarantine people who had come into the United States. And one was seen as cruel and one was seen as. I think de Blasio had the right part of that argument where he was saying, it's not that there is nothing to fear with Ebola, but we've done everything we can to demonstrate that things are safe in America. But I do think that that gets to something legitimate and fundamental and not just xenophobic, right?

D (8:38)

Absolutely. I began writing this book during the Ebola epidemic 10 years ago because it became really clear that people don't understand what public health is, don't understand why it's important, and within public health, don't always know how to succeed. So that's what I hope to share with a formula of seeing the invisible, believing that what may seem unchangeable actually can be fixed, and then working systematically to create a healthier future with ways to do that both as a society and as individuals, by cutting through the nonsense to know what's really important and what really works.

A (9:15)

Yeah, and I bet since when you first started with the see, believe, create idea, I would bet that different parts of it seemed harder a decade ago than now. So the cutting through the nonsense part now might seem to be the greatest challenge, but maybe 10 years ago it didn't.

D (9:37)

Misinformation is a huge challenge. There's so much in not just the Internet, but even mainstream media that's sloppy thinking or it's hype. And then there's so much that's paid for in social media that's spreading misinformation and disinformation and dangerous and deadly disinformation. That's a problem. What I try to outline in part of this is also seeing the path to progress from an epidemiologic standpoint. It is possible to be clear on. There are certain things that we're really virtually certain of. We're never going to find out that cigarettes are good for you. There are other things that are really likely. Like, it's likely that you should get certain of your lipids down to a certain level, but we're going to learn more, so we have to be humble about it. And then there are things that are. There's some evidence it might be worth doing, but let's be clear, it could certainly be wrong. And then there's a fourth category that's wild guesses that may have great sounding rationales and a lot of money behind them, but are unlikely to do much good.

A (10:40)

And there's a great debate between what's in each category. And even the experts might say, well, this is best practices. And other experts might say, I think it's best practices based on supposition rather than research. And then there's meta debates about what all of that means and the downside of making a mistake. It's hard, it's not easy stuff. Even if you would think that we're all on the same page of trying to save millions of lives.

D (11:09)

I think of a wonderful epidemiologist who I knew, a guy named George Comstock, one of the leading epidemiologists of the 20th century. And he wrote an article in which he called for a certain tuberculosis phenomenon studied. And I was so confused because he had done those studies. And when I asked him why, he said, that was then, this is now. Our immunity might have changed. The microbe might have changed. The amount of microbes coughed into someone's lungs might have changed. And that's really the mark of a great researcher, a great epidemiologist who understands not only what they know, but what they don't know. Because we need to be able to say we're quite confident that this is the case or this is what we think and this is why and this is how we're going to try to find out more. But part of the seeing the invisible is seeing the path to progress. This is hard partly because it's not only, and maybe it's the flip side of the misinformation that you raised earlier. Expert has become a four letter word. There's a rebellion against expert opinion. But when you look at the best scientists, good science doesn't give you certainty, it gives you humility of what you know and what you don't know. But there is a real importance to someone who has the granular information on all of the data out there and how to interpret it. And this study is important, but not that one.

A (12:33)

Yeah. So when you earlier said that's the mark of a great epidemiologist, what immediately entered my head is that is the mark of science. Science is the openness to correction and being wrong or having been right at one point. But then things change. When you saw the lawn signs in this house, we believe science. Or when you heard people rebutting even bad arguments with the argument because of science, did your teeth grit? Did a part of you chafe in that? Maybe, yeah, maybe you're winning the argument in the short term, but you're mischaracterizing what the scientific process is.

D (13:11)

Believe in science is a terrible idea. You know, follow the facts and follow the science is misleading. Science doesn't tell you what to do. It gives you facts with which you can make a judgment for yourself, or we as a society can make a judgment for ourselves. But there is an excellence here that there are certain things that we know. So one thing that I talk about a lot in the book, it may sound common and boring, but it's high blood pressure. Hypertension, high blood pressure. Nobody in the world had measured it until 1896, when an Italian physician used a bicycle inner tube and a mercury gauge to measure blood pressure for the first time. And it was another 50 years, 60 years before we had a single medication to treat it. It was another 10 or 20 years before we figured out that for every 20 point increase above 115, as the top number was called, the systolic, your risk of dying young from a heart attack or stroke doubles. So lower is better. And it was another 10 years, 20 years before we figured out that treating down to 120 or less can dramatically improve your chance of living healthy and also reduce your risk of dementia. So there is a truth there. Now, I would also say it works on hypertension a lot. There's a lot we don't know. But at least we know this, that this is what you can do to live a longer, healthier life. And this is what we as a country can do to do better with it.

A (14:44)

Yeah. So that's in the category of, oh, high blood pressure. Everybody knows this, but not everybody knew that. And not everybody knew that for a long, long time. And it was unbelievably important in terms of having it become common knowledge to help save lives. And there are many other things that I don't know if they're in the category of everybody knows, but everybody should know to at least give credit to what epidemiologists first sought to quantify, then sought to address. And I think a lot about the small particulate matters in the air, because in my lifetime, and I was born in the last couple of days of 1971, there's been a sort of miraculous revolution or amelioration of this killer. And no one really talks about it except me too much on the show. But just tell us a little bit about the strides we made in that one particular too small to see thing.

D (15:40)

It's really important. There are lots of toxins in our environment, and we've had huge progress getting what's called PM2.5 or particulate matter, 2.5 microns in size, decreasing in our air. There's still way too much Globally. And there's way too much in many parts of the US from fossil fuels, from wildfires and from other causes. It increases the risk of heart attack, stroke, high blood pressure, dementia, a range of problems. One of the challenges of public health is that you don't see what you don't see. So nobody, 8 billion people in the world today, not a single person woke up and said, oh, thank goodness I didn't die from smallpox yesterday. And yet, until the 1960s, smallpox killed millions of people a year around the world and scarred millions more. Particulate matter is a good example of progress, but incomplete progress. I think sometimes in public health, we're reluctant to talk about progress because it sounds like saying, mission accomplished, foot off the accelerator, things are okay. Yeah, there's been huge progress with PM2.5, but the estimate is it still kills 100,000 people a year in this country. In the US now, how about India?

A (16:57)

How about Indonesia?

D (16:58)

Millions around the world. Millions around the world. And figuring out who, what are the scalable programs I discuss in the book. There are good ideas, but they're not simple enough and practical enough to scale where there are good ideas, but they run into a buzzsaw of economic interests or political inertia. And there are systematic ways to overcome those, both as a society in public health and as individuals doing a few things that make a really big difference for our own health.

A (17:29)

What about lead? You talk a lot about the early, early. I didn't even know the name, her name.

D (17:34)

Alice Hamilton.

A (17:35)

Alice Hamilton was an early researcher who, if we had paid attention to her, our lives as Americans would be so much better for decades. But she identified the dangers of lead and eventually we got around to taking it out of the gasoline and paint. So it's a two part question, but give us a idea of how many lives we saved or lives we improved by that. And are you a big believer? Because there's a lot of scholarship that still points to lead as one of those silent factors behind a lot of sociological phenomena like crime rates and other things. So how much of a believer are you in that? If you could take both parts of those questions.

D (18:16)

So first, Alice Hamilton was a wonderful physician. She was the first woman appointed to the faculty at Harvard University. She created the field of occupational health or worker health in the US and she helped clean up a lot of factories and get them to stop poisoning their workers with lead and mercury and other toxins. She tried to stop the industry putting lead into gasoline, but it went forward. She testified in 1925 that I'm not One of those who believe that you can ever make this leaded gasoline safe. And for 50 years, lead spewed out of every tailpipe. And all of us who grew up in those years, or not all of us, but the average lead level was 15. That's a level that would cause emergent, urgent assessment today. That level is less than 1 in 3,000 kids today. So in terms of the benefit, there's a huge improvement in heart health, a huge improvement in general functioning. If we had listened, if the government had listened to Dr. Hamilton in 1925, we would have had a completely different country. Less violent, less chronic disease, smarter, higher income levels. The research is pretty clear that lead is a neurotoxin and it also causes heart problems. You can debate whether it's 1 million lives around the world that are still killed, 1 million people around the world still killed every year, or 5 million. But it's certainly a huge. And one of the things it changes is the mortality from PM2.5, because a lot of the lead is inhaled in different particulate matters and not just spread on fingers or things that you touch.

A (20:02)

Are you saying that people, your average person in 1960, if you just tested them for lead, would have a level that today would be considered an emergency?

D (20:16)

Not an emergency, but a call for urgent investigation and follow up. The earliest rigorous data we have on lead levels comes from the mid-70s. And the average level then was 15 in kids. Yeah. Yeah.

A (20:30)

So when we say, oh, when I was a kid, this was the condition, I turned out pretty good. I mean, maybe it turned out good, but you could have turned out 5% IQ points smarter. We just don't know.

D (20:41)

And you know what that highlights is what's called the prevention paradox, that the things that make the biggest difference as a society often make not very much difference to individuals. And that's one of the reasons we have a hard time getting public health policies approved. Some of those policies are really bad for a few powerful industries like the tobacco industry. Other of those policies may not be understandable. You may have read in the news that the current Vaccine committee was considering eliminating what's called the birth dose of hepatitis B vaccine. It's a great example of something where we used to have 10 or 20,000 kids infected with hepatitis every year, and a quarter of them could go on to die from it, usually in their twenties or around then. And by having a simple approach of vaccinate every kid, that's now about 1,000, maybe 2,000, it's a 90% reduction, but it helps every kid very Little, because only a few of them have the protection, because they have the exposure. But the aggregate benefit is massive. And this is one of the structural challenges for public health progress. And it also applies to your personal health. Some of the things that you do, you won't feel different, but if you do them reliably, you're going to have a huge benefit in the long run.

A (22:03)

So I have been lately very interested in the differing birth rates between the US and Western Europe. So this is not some ideal. These are countries that are by and large not even as wealthy as US on a per capita basis, but France, Germany, uk. I'm not doing the thing where you only take the Scandinavian countries. I'm talking about countries that in many measures the US does better at, and they're doing better in lifespan. And I've looked into this, I know you've looked into this, and it's not one big thing. So the deaths of despair and opiates, that is a large part of it. And I think maybe to the extent that people are aware of this is a problem, they fixate on that. So let's not diminish that. But what are the other major factors that are just making Americans not live as long as the French? And what can we do about it?

D (22:51)

Part of it are outside of the healthcare system. If you look at the healthiest populations in the us, they do as well as anywhere in the world. But if you look at the average doesn't do well, and if you look at the below average does really poorly. Part of that is access to healthy nutrition, access to clean air, provision of things like support to stop smoking, which is still an issue, still kills almost half a million Americans. Treatment of high blood pressure kills about 600,000Americans every year. And we do a lousy job. We only control about half of the people with high blood pressure in this country. So if you've got high blood pressure, it's really important to get your numbers in control. I think a lot of this reflects that we don't have a good primary healthcare system. A primary care doctor or clinician, nurse is someone who knows you, who can interpret the evidence for you and apply the best scientific knowledge to your individual health. And many of the countries that do better than us, including places like Costa Rica and Thailand, which have higher life expectancies than the US have really good primary healthcare systems. 100 million Americans don't have a primary healthcare doctor. And this isn't a right or left Democratic or Republican issue. Entities like community health centers, primary care clinics, these are really Important. And they're not strong here for a straightforward reason. It doesn't pay. If you work in primary care as a doctor, and you're really a great doctor, and you do it for 20 years, you will make less than half as much as a surgeon who graduates today.

A (24:30)

Yeah, yeah. But I would say compared to Costa Rica and Thailand, you'll be doing a lot better. The diets of those two countries are much better than the United States. Obesity is a huge factor in the lifespan, but so are little things. And there's a new push to look at some of these epidemiologically. Even seat belt usage, which is high in the United States, it's in the low 90s, but it's in the high 90s in places like Ireland and France. And the cars are smaller. It all factors in.

D (25:00)

I'm saying there are lots of things that are driving our higher mortality. But I think the most important is that we don't scale up what works. Whether it's continuing to make progress, reducing tobacco use, there's been progress, but not enough, or doing better with the treatment of high blood pressure. Also, on nutrition, there are certain things that we know are really important. Important. If we reduce free sugars, reduce sugary beverages, that is the single largest driver of increased calorie consumption. We can also increase potassium. We have a potassium deficiency. Most people consume only about a half or two thirds the amount of potassium they need. And the good studies suggest that the strongest predictor of how healthy your heart is is your ratio of potassium to sodium. If you consume more potassium than sodium, you're likely to have a much healthier heart and actually to feel more energetic.

A (25:56)

Oh, you're saying I shouldn't be salting my bananas? Oh, okay.

D (26:00)

Well, you can get a low sodium salt. You can get a low sodium Salt that has 25% or more potassium, and then just making that slight change reduces your risk of a heart attack or stroke or early death.

A (26:12)

I know all these things about micronutrients which seem so simple are. It's not so applicable in wealthy countries. But when you look at the reality, changing effects that they could have micronutrients, couple of pennies, iodine, you know, just giving them in adequate supply to the people who need them could save so many lives. I don't know. Is that to a person like you, is that inspiring or frustrating? You could look at it both ways.

D (26:40)

This is part actually of the believe, part of the see, believe, create formula. We have to believe that progress is possible or we won't take action. And Part of the way you believe it is by recognizing how much progress we've made already. Take iodine that you mentioned. Iodization of salt and other foods has prevented a huge number of birth defects around the world, but there are still too many. There's still too many people consuming salt that's not effectively iodized. There are still too many preventable birth defects. I think in public health sometimes we are reluctant to recognize past progress because it sounds like trying and things are okay. But I think that should give us confidence that we can make more progress. If we've done that much before, we can do more now. And the way to build that confidence is to make phased progress, to expand to new programs, new areas to show it's not just yes, you can make progress, but yes, we have made progress in these areas. We do that at my organization, Resolve to save lives. We work with dozens of countries to co create and then scale up with them programs that are life saving, that are appropriate for their system. But you have to start with showing it works there and that you can make phased progress.

A (27:57)

And we'll be back with Tom Frieden, author of the Formula for Better Health. We'll be cracking that formula wide open in about a minute. Life's been a little crazy lately. Perhaps you've been hearing some of the segments on the show or just looking out the window and things. So you gotta unwind and right around here in Gist HQ in Peachfish aq, one helpful tool in helping many of the members of the Gist family unwind are Cornbread Hemps CBD gummies. A natural way to both relieve aches and disappointments, discomfort and calm you down and help you get to sleep. Different gummies for different things. Lots of peace of mind. Cornbread Hemps CBD gummies. They're made to help you feel better. They handle stress, discomfort, just the relaxation part of it that's not so easy to get. It's a simple word, has an X in the middle. So maybe it's a little exotic, but it is elusive. Relaxation, is it not? So jump start that or ease into it with a Cornbread hemp CBD Gummy. You know it's third party lab tested and USDA organic to ensure safety and purity. Right now just listeners can save 30 off on their first order. Just head to cornbread hemp.com the gist and use code the gist that's cornbread.com the gist or use code the gist. We're back with Tom Frieden who is the former director of the CDC and is now author of the Formula for better health. But Dr. Frieden, during your time with the Obama administration, I haven't dug up the quotes, but I'm sure I could find many where you and other members of the administration talked about the benefits of what's come to be known as Obamacare, such as the prediction that after the ACA Obamacare was enacted, we would see results, we would see changes in the lifespan of Americans. Now we've talked about how the lifespans have declined relative to our other neighbors in the oecd. But my question is, is the aca, did it have that discernible effect in lifespan, it's just been overtaken by these other negative trends we've been talking about? Or is there just no way to know if the ACA actually increased or would have increased the lifespan of Americans were it not for countervailing trends like opioid addiction and increasing obesity?

D (30:41)

What the ACA did primarily was to give tens of millions of people access to health care, which they didn't have before. It also ensured that you waived co payments for preventive care and preventive measures. And those are really important. But there are counter prevailing trends. We have a healthcare system that still basically rewards the number of visits and procedures not keeping people healthy. So what you reward is what you get and that's what we get in the healthcare system. So like many areas of social change, it's progress.

A (31:17)

But is there any way to measure though the progress to norm for everything else and say, or has anyone done that because of Obamacare? Our lifespans, even though they're not as long as France and Germany, are eight months longer in aggregate than they would have been without. Has anyone done that survey?

D (31:36)

I am not familiar with that, so I can't comment on it. There was an analysis of Medicaid expansion in states that showed that early on what you get is a huge pent up demand of people who didn't have any access to care for care or better care. So it was certainly possible to measure an improvement in access and in some outcomes. But costs actually could increase because you had this pent up demand.

A (32:05)

Yeah, I know, but you get my point, right? It was a huge lift. The resources and priorities of the administration went there at the time. I still do think it was the right call, but I would like to see it showing up in data somehow, even if it doesn't mean that we lived longer without the opioid epidemic. But someone could have perhaps studied it and put together a plausible analysis of that. It did in fact lead to better life outcomes.

D (32:32)

There have been studies and especially in the states that had Medicaid expansion because that's the poorest, highest need population. And you see a reduction in all cause mortality in those places and reduction in disease related mortality that really depended on how much coverage expanded because if it didn't expand, you didn't get the benefit.

A (32:56)

There are so many changes going on now with the cdc, which you ran. I don't even necessarily know how to concentrate my mind or perform triage on. These are the important things and these are the things that if Tom Frieden were running it wouldn't be the case, but perhaps we could live with. Could you give us your bullet points of what you think the most alarming things are?

D (33:16)

It's hard to know where to start. What we have is basically it's not Democratic versus Republican, it's fact versus fiction. It's health versus disease. It's simple truths versus simplistic misinformation that's dangerous and deadly. And you see this in so many different areas. The immunization issue is in the headlines and it's really striking. You have essentially the hijacking of a very rigorous, open, transparent process with the accusation that this was previously corrupt and conflicted, which was not true, and the installation of people who do have conflicts of interest into that process and really don't have the kind of detailed knowledge of vaccines that we rely on to set rational policies. Just to give you example, watch what they do, not what they say. They say they're interested in chronic disease. They have closed the CDC program on tobacco control that led to progress having less than decreasing by more than half our smoking rate nationally. They say they care about chronic disease, but they've stopped the cancer and cardiovascular programs at cdc. They say they care about the environment, but they've dialed back our protections against forever chemicals like pfas and particulate matter and mercury and arsenic. They say they care about health, but they're really undermining a lot of our protections of health. And that really bothers me because it means that we're less safe. It means that people will have fewer choices, less information and more risks.

A (34:47)

Well, just take the cancer part of it. A couple weeks ago, New York Times put together a huge list of all the research that has been canceled. Improving the effectiveness of immunotherapy and improving childhood cancer survival rate. Studies and techniques, Techniques for colorectal cancer. Cancel, cancel, cancel, cancel, cancel. The headline was Trump is shutting down the war on cancer. This gets to one of your premises we might not even know if a family member had cancer. You might come out of the meeting with a doctor saying, my God, I didn't realize what strides we'd made, especially in certain kinds of cancer. But how not theoretical, how tangible do you think this is gonna be? How many more people will be dying because of these decisions?

D (35:33)

It remains to be seen. If we see the kind of decreases in healthcare coverage that the recent legislation has been projected to result in in the coming years, that will mean more colon cancer, more breast cancer, more cervical cancer. If we see decreasing access to new treatments and decreasing research, we may never know what discovery might have been really helpful for cancer patients, but has been canceled because we're not doing research with certain technologies.

A (36:05)

But then again, if we went back for the last eight, ten, however many years and put together a timeline, we would see all these amazing discoveries. So wipe them out, or wipe out the future version of those discoveries. Again, I don't know how many people know that while it's true that there is no quote, unquote, cure for cancers, the survival rates for so many types of cancer have just improved so much. And unless you had cancer, I don't know how much people know that.

D (36:35)

There is definitely amazing innovation in cancer treatment. There's also a lot of prevention that's possible still. A huge proportion of our cancers are related to tobacco use or alcohol use or exposure to particulate matter or radon. So there's a lot we can. You know, it's great to be able to treat cancer better. It's even better not to have cancer.

A (36:57)

Do you think that during the pandemic, or maybe a little before and since, that the imperative for advocacy within the public health community at times went beyond the science?

D (37:14)

I think Covid created a lot of problems, and public health created a lot of problems. In Covid, the. The first really was the failure of the CDC lab test. This was a really costly mistake because this meant that here in New York City, there was no way to prove that the virus was spreading widely because the CDC lab test had failed for a few weeks. And that was a very costly mistake. The next big mistake was the first Trump administration silencing the CDC. If you go back and look at what Dr. Nancy Messonier, who was the head of the respiratory branch at CDC and had spent her whole work career preparing for this moment, she got it picture perfect. She said, it comes down to the need to be humble, but this could be really severe. Disruption to everyday life may be severe, but there are things that we can do now. To reduce the risk. And that was out of step with what the first Trump administration was saying, which is, this is all going to miraculously go away. There won't be any problem. And she was silenced. CDC was silenced. So it's hard to criticize them for not communicating well when they were not.

A (38:21)

She literally was allowed to do one press conference conference and then never spoke before the public again. Right.

D (38:26)

She had several briefings that were quite accurate. You go back there five and a half years later, you wouldn't change a word. But I do think vaccine mandates, for example, were a bad idea, because when it became clear that the vaccine primarily, not exclusively, but primarily protects the person vaccinated, then a vaccine mandate is more like a motorcycle helmet mandate to protect the person mandated or rather than a school entry requirement that protects all the kids in the school similarly. I think some of the closure decisions were very problematic. They should have been, and we advocated this at the time. So this isn't entirely hindsight. I didn't think schools should be closed. I thought they should be renovated quickly. Yeah, I got criticized by the then Governor Cuomo administration because I said that repeatedly on tv.

A (39:17)

Oh, yeah, now I remember.

D (39:19)

Yeah.

A (39:19)

I mean, if I'm being generous, I would say certainly we can agree that the closures went on too long. But you were among those saying, no, there's a way to keep them open and distanced or open for. Were you saying that all kids can come back or, you know, hybrid learning would be instituted?

D (39:33)

We had done careful studies before the pandemic of school closures in influenza and had documented that the impacts on education and the environment and the economy. Education, environment, the social situation, are devastating. And they're not effective unless you keep them open shut for a very long time. So closing them, you know, may be necessary in some environments at some times, but definitely went on way too long. And what we also recommended was using data to adjust decisions. Look at how hard it's raining Covid. And then you decide as an individual or as a community, what you want to open and what you want to close and do that in a modulated way. I think all too often Covid is seen as a failure of public health, and it's more accurate to say that it was a failure to use public health principles accurately. And the places that did, like Singapore, I mean, this is a stunning statistic. The death rate from COVID in Singapore is 200 times lower than the death.

A (40:38)

Rate in the US Tom Frieden was the Director of the CDC. From a personal point of view, he saved me hundreds of dollars and dry cleaning fees since we don't smoke in New York City anymore in bars. And when he was commissioner of the NYC Department of Health and Mental Hygiene, he was instrumental in getting that rule passed. His new book is the Formula for better Health, how to save millions of lives, including your own. Thank you so much, Dr. Frieden.

D (41:05)

Thank you. It's always a pleasure hearing your voice and it's been great speaking with you.

A (41:14)

And that's it for today's show. Cory War is the producer of the Gist. Ashley Khan does our coordination of production, which is one way to say it. Jeff Craig runs our socials. Kathleen Sykes helps me with the Gist list. Michelle Pesca helps more than helps. Really orchestrates it all from above. Pulling the strings, sort of a Svengalian robes. When she wears a robe, a bath throat, sometimes it's white, it's not black. And thanks for listening.