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This is what keeps CDC director Tom Frieden up at night

Hint: It’s not the incoming Trump administration.

frieden

Since he was appointed to lead the Centers for Disease Control and Prevention in June 2009, Tom Frieden, the real-life equivalent of a health official in the movie Contagion, has taken many late-night phone calls. He’s guided the agency through H1N1 swine flu, Ebola, and Zika outbreaks — just a few of the viruses that are spreading around the world faster and more effectively than ever before.

With President-Elect Donald Trump taking office this week, there’s a lot of uncertainty about how the US will handle public health and respond to potential future pandemics.

There’s also uncertainty about what will happen to the CDC budget and vaccine coverage rates under a president who spreads vaccine conspiracy theories. And Frieden’s own future is currently in limbo, as submitted his resignation as director on January 20.

But when we met Frieden at the CDC offices in Washington, DC, last week, he was optimistic.

In two conversations with Vox, he shared his views on Trump and vaccines, the post-truth political era, advice he’d give the president-elect, and what keeps him up at night these days. (Bonus: He also revealed for the first time his ritual for staying calm during global health disasters.) The transcript that follows has been edited for length and clarity.

Julia Belluz

Many people — researchers, members of the public — are concerned about President-elect Trump’s loose relationship with facts. And during a pandemic, facts matter. Communicating carefully and accurately matters. Are you worried about how he might handle facts in pandemic?

Tom Frieden

Facts are stubborn things — and diseases occur, and our ability to prevent them or mitigate their impact depends on science. When you rely on the science, you can get great things done. We are at the cusp of polio eradication. In northeastern Nigeria, Afghanistan, and Pakistan, we are not quite there, but we’re closer than ever. In 1988, there were 350,000 cases of polio. Last year there were 35.

Julia Belluz

We saw Trump stoke vaccine conspiracy theories during the campaign and again last week when Trump met with one of the leading vaccine deniers, Robert F. Kennedy Jr., who claimed he’ll be leading a Trump-appointed commission on vaccines. What are your thoughts on this? Are you concerned about a president who has perpetuated the falsehood that vaccines cause autism and who consorts with vaccine deniers?

Robert F. Kennedy Jr., a leading vaccine conspiracy theorist, talks to the press after a meeting with Trump at Trump Tower in New York on January 10, 2017.
Timothy A. Clary/AFP/Getty Images

Tom Frieden

CDC is willing to work with the incoming administration to protect the American people. I wasn’t there [at the meeting], so I can’t comment.

Julia Belluz

In the meeting with Trump, RFK said they talked a lot about the CDC and “ways to increase the independence from financial conflicts at CDC in the vaccine division,” and that a lot of the concerns Trump and RFK have are about the fact that vaccines aren’t safe and the CDC is not independent enough to vet safety. How does CDC prevent conflicts of interest on vaccines?

Tom Frieden

We’re very committed to transparency. If you look at the Advisory Committee on Immunization Practices, it’s really a best practice for governments, and it’s looked at by governments all over the world. Every meeting is open. All potential conflicts are disclosed. Al presentations are rigorously vetted, and they are available on the web. It consists not just of scientists but of members of the public and others.

Julia Belluz

In your time as CDC head, you’ve gotten the funding to build up some amazing resources to respond to outbreaks, like the Global Rapid Response Team. With the Affordable Care Act, you also got funding for the Prevention and Public Health Fund, which goes toward efforts like immunizations and tobacco prevention. To what extent are these efforts under threat with the incoming Trump administration?

Trump.
Trump is a self-described germaphobe. Tom Frieden thinks that bodes well for his agency.
Johnny Louis/FilmMagic/Getty Images

Tom Frieden

I think the major issue going forward is CDC’s budget. CDC can protect Americans depending on what our budget is. [If the ACA is repealed], that’s almost 10 percent of our budget. It’s $900 million within the prevention fund. They are for programs everybody likes.

[Cutting the fund] would [lead to] tens of thousands of additional illnesses and more than 10,000 additional deaths among people who would have been benefiting from this fund. There’s a lot at stake in that: our emerging infections program, state block grant program, immunization programs, infectious disease control programs.

Julia Belluz

Eradicating diseases like polio, though, requires global coordination. Some researchers have expressed concern that Trump’s promises to build walls and back out of NATO suggest we may see such global collaboration roll back.

Tom Frieden

We often find health can be a bridge. Even at the height of the Cold War, the US and Soviet Union at odds, we collaborated on smallpox eradication. In the 1980s, when the world committed to improving childhood vaccinations around the world, there’s a delightful story about Jim Grant, the then-director of Unicef. He’d call every country and ask: What’s your immunization rate?

Most countries were doing pretty well, but El Salvador had an immunization rate of 30 or 40 percent. [Grant] yelled at the Unicef rep there. “Why aren’t you doing better?” The [rep] said, “Don’t you realize there’s a war going on here?” And Grant said, “Well, stop it.”

And they did. They created days of tranquility where there was a ceasefire so they could vaccinate the kids.

Julia Belluz

So you’re optimistic. Have there been any signs of Trump’s commitment to public health? Has he reached out to you?

Tom Frieden

My staff has been in touch with the transition team. [Trump] made a comment that a federal hiring freeze would exempt public safety and public health. And, as has been stated, being a [self-described] germaphobe, it makes it important to understand what you can do to prevent the spread of germs.

Julia Belluz

Would you be willing to stay on in your current role if you were asked to?

Tom Frieden

I would consider any requests that were made of me to protect Americans.

The Trump administration will make whatever decision it decides. Congressman Dr. Price [the nominee for health and human services secretary], if he’s confirmed, will be the director of HHS, and should have a team in place that [he] thinks best protects Americans.

Julia Belluz

The Ebola outbreak is over. Zika has died down. So what’s keeping you up at night these days?

Frieden getting his annual flu shot on September 29, 2016, in Washington, DC.
Win McNamee/Getty Images

Tom Frieden

Flu is always the most concerning. It killed 50 million people plus around the world in 1918, and can make a huge impact now. There’s nothing quite like flu in terms of the risk.

But there are lots of other diseases. With the global health security funding, we have been expanding the monitoring of deadly diseases. In India, we found two tick-borne hemorrhagic fevers that are much more widely distributed than had been realized. There’s already been one [Crimean–Congo tick-borne hemorrhagic fever] case in Spain. Could you imagine if ticks in the US could give you Ebola?

Julia Belluz

During the Ebola outbreak, you were all over the media, you were in a daily press briefing, you were dealing with the White House, your own staff, the outbreak response, a political firestorm here in the US. Yet you always seemed so calm. I heard you meditate. Is that your secret?

Tom Frieden

This is true. I have not said this publicly before. But yes, for 40 years I have been meditating twice a day. Twenty minutes, twice a day.

Julia Belluz

How did you get into meditation?

Tom Frieden

My brother was into it, then I got into it, and it becomes a self-reinforcing habit. I find — and I don’t recommend it for others; people should do whatever they find is best for themselves — but it makes me more efficient. It gives me more equanimity.

Julia Belluz

I’m sure there were many moments during your tenure that were really scary, but does any one in particular stand out?

Tom Frieden

July 23, 2014, when the [Ebola] cluster hit Lagos [in Nigeria]. Lagos has a population that is the same as Guinea, Sierra Leone, and Liberia [the center of the Ebola outbreak] combined. It has travel in and out that’s 10 times more. So if Ebola had gotten out of control in Lagos, it would have spread all over Nigeria, all over Africa, and could have continued to spread for years.

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The Ebola epidemic in October 2014, just after transmission of the virus peaked.

Now, initially, the Nigerian response was not good. It was disorganized, and the person in charge of it was focusing on irrelevant issues. They spent literally three, four, five hours debating what to do with an embalmed corpse that had transited through Nigeria but was of zero risk. At the same time, no contact was being traced. No place was being identified to put people who were sick. The nurse and doctor who cared for the initial [Ebola] patient were dying — one of them in the back of an ambulance for 12 hours. Our staff were beside themselves. Lagos is 20 million–plus people — it’s not possible to get contract tracing on that many people.

Julia Belluz

How did you deal with this potential catastrophe?

Tom Frieden

I took our best staff and said, “Get on a plane today.” There was a very good Nigerian physician who became the incident manager for Ebola. I spoke to the health minister multiple times a day. The [Ebola response] team snapped into place. They organized the response, identified 794 contracts, did 17,000 home visits measuring body temperatures, identified 43 people with symptoms, 19 of them with confirmed Ebola. They stopped the outbreak. It was really just a few days away from a catastrophe.

Julia Belluz

Around this time, President-elect Trump was saying things like, “Keep them out of here, about health workers who had helped the Ebola effort. He also called for sealing up our borders to keep out the virus. Science-minded folks like yourself were advising that the government move in the opposite direction, that these policies would likely drive people underground, punish impoverished economies, potentially worsening the outbreak, and encourage countries to hide Ebola cases. Are you concerned that countries may be less inclined to report outbreaks now under Trump?

Tom Frieden

When you’re in the position of making decisions, sometimes things look different. Americans are safest when we rely on the science. What we have been able to do in the last few years is strengthen our capacity. We have recruited the next generation of public health specialists — we’re recruiting them out of colleges, master’s programs, and sending them out to state and local health departments. Those people will be protecting Americans for decades to come.

Julia Belluz

What is your advice for the next president?

Tom Frieden

Heath threats will continue to arise. We can keep Americans safest if we prepare for them well by strengthening ourselves and having partnerships for other countries so we can stop diseases there and don’t have to fight them here. When threats emerge, getting information and basing decisions on the best available science is crucial.

President Barack Obama speaks to the media about the Zika virus, accompanied by Frieden and other health officials, on May 20, 2016, in Washington, DC.
Mark Wilson/Getty Images

Julia Belluz

In an ideal world, what would you like to see the next administration do to further support public health?

Tom Frieden

A rapid response fund. Both houses of Congress on both sides of the aisle want one. Funding was desperately needed in Zika. We had to wait nine months on starting critically important projects. [A fund] would allow us to get a running start on things.

And that kind of rapid response money needs not only money — it also needs authorities. Even when we got money in Ebola — because we can’t break the law, it took months and months to do contracts and hiring that we should have been able to do much quicker. If it takes 27 steps to do something when there’s not an emergency, it doesn’t make sense to have those steps in an emergency. So money and authorities are important.

Julia Belluz

Global health is inherently political, but do you think it’s even more so now? The experience with funding for Zika seemed extreme — as you say, nine months to get the funding.

Tom Frieden

Zika was kind of a special case. It is a particular risk for pregnant women, and as far as I know, there aren’t pregnant women in Congress. It’s remote. It’s six to seven months away after the peak before you see kids with microcephaly. It’s hit Puerto Rico very hard. It’s changing travel patterns. But it was not as graphic as Ebola or as potentially devastating as a flu pandemic.

Julia Belluz

What’s next for you, after CDC? Meditation teacher?

Tom Frieden

Ha. I’m weighing different options.

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