You could say the term public health has a bit of an image problem. It bubbles into the collective consciousness whenever there's a disease outbreak. Measles, legionnaires, Zika, Ebola, and of course, COVID. Oftentimes, it gets a bad rap. And that's because missteps and controversies generate huge headlines. But the incremental successes, they often happen quietly behind the scenes. And it's easy to see how if something like public health is out of sight. It quickly becomes out of mind as well.

Public health is often invisible.

Dangers fade from public consciousness. Budgets and funding get cut. Then institutional knowledge and valuable programs, they get lost and we risk losing much of the progress that we've made. We're living through some of this now.

Nobody in the whole world, eight billion people, nobody woke up this morning and said, oh, thank goodness I didn't die from smallpox yesterday.

'My guest today has been on the front lines of public health for decades, most notably as former head of the Centers for Disease Control and Prevention, and before that as commissioner of New York City's Department of Health and Mental Hygiene. Today, Dr. Thomas Frieden runs the non-profit Resolve to Save Lives, a global initiative to combat the world's deadliest health threats. His book, The Formula for Better Health, is out later this month. It's part history lesson, it's part memoir, and it's part blueprint. And it can be boiled down to three words: see, believe, create. Today, you're goin to hear from Tom about his formula and what steps you can take on the personal level to stay safe. I'm Dr. Sanjay Gupta, and this is Chasing Life.

Congratulations on the book. Why did you decide, first of all, to write this book, [The] Formula for Better Health?

I started writing this a decade ago during the Ebola epidemic of 2014 to 2016, and what became really clear to me is that people didn't understand what public health was, they didn't understand why it was important, and the people doing it didn't always understand how to succeed. The book provides a formula, a new approach really. See, believe, create. That's proven. It has saved millions of lives and it can save millions more and it's even relevant for personal health. So I think this is a new way of thinking about public health that has real potential to save lives.

I want to talk about those three components, but first of all, let's just make sure we are getting some terms right. What is public health? How do you define it?

Public health is the organized actions of society to make people safer and healthier. It's our way of working as communities, as organizations, as individuals who are part of communities, so that the default value, if you go with the flow, you're not going to get hurt or killed or disabled.

When you were thinking about public health, you talk about this in the book, I guess you were taking a walk and your father basically said, hey, you seem to be interested in science and you also seem to interested in politics. And public health combines both of those things. You might enjoy it, your father said. First of all, was he right?

I can say that I spent most of my training, internal medicine, public health, infectious disease residency, epidemiology, the epidemic intelligence service, learning about the science part of that. The politics was much harder. And there is this misconception that, oh, you've got to keep public health and politics separate. They're not separate. What you'd like to keep separate is public health and partisanship.

I think what you're saying is it's difficult to disentangle anything from politics, but there did seem to be at least a platform of truth when it came to public health and medicine and science overall. What have you seen over the last few years of your career?

Famously, Senator [Daniel] Patrick Moynihan said that you are entitled to your own opinion, but not to your facts. And what I'm afraid is that now people feel entitled to their own facts. And we really don't have a shared conception of reality. This is a big problem because there are truths. Facts are stubborn things. And one of the things I talk about in the book is that medicine and public health and science, we haven't been sufficiently clear about the levels of certainty that we have. There's some things that we say that they're proven. We're never going to find out that smoking is good for you, for example. There are other things that are likely to be the case, but we have to be humble because science changes. And then there are other things that are just wild guesses. They're just hunches about which we really have no data. So we always have to be humble in science. Science doesn't give you certainty. Science gives you humility because everything you learn opens new questions for you to figure out. And that's something that I think we need to explain better. And any time we're making a recommendation, say, look, based on what we know now, this is what we recommend. Here's what we now, here's what don't know. For what we know, here is how we know it. For what don't know, here what we're doing to try to figure it out and when we might know.

I've got to say I think you were particularly good at that when you were handling Ebola and you would get up and do those press conferences in front of the CDC. Today, here's what we know and here's what we don't know and we're still trying to figure out. And I thought you provided a really good template for that. I think we got away from that to be quite honest during COVID, where I think it became much more dogmatic. And those press briefings, instead of happening from the CDC, were happening from The White House. So just even optically and otherwise, they were politicized.

I think probably the biggest failure in the U.S. during COVID was a failure of communication. And communication isn't just about talking. Communication is about listening. To get communication right, you need to have the right message, and that changes over time, and the right messengers and the right timing.

People do want to think of medicine and science as a hard science, like you would math or physics, you know, this idea that two plus two equals four, the earth is round, just things that we take as absolute facts. And I think the point that you make in the book is that there are levels of certainty. What is the level of certainty that you require? As a public health expert before you'd start to make recommendations.

Well, I think we have to start with the fundamental reality that in an emergency, you're always going to have to make decisions based on imperfect data. That not making a decision, not taking an action is a decision. And you have to recognize that the alternative isn't necessarily a different decision. It's no decision. And that may result in more deaths. That doesn't mean we never know enough to take action. But it also means we have to be frank about what is our level of certainty.

How do we be up front? Because I think in some cases you're talking about throwing more more data at them Or is it more of a cut to the chase sort of thing?

'Sanjay, you talked earlier about COVID. One of the things that was very controversial were some of the mandates during COVID. And what my organization, Resolve to Save Lives, recommended at the time was a risk alert level system. As you have for wildfires or ozone, where you're empowering people with information and you're making decisions in communities, where you say, all right, this is how hard it's raining COVID in your community now. That is a fact. What you do with that is an opinion. And you might say, hey, look, if you're immunosuppressed, you may wanna not go out or use an N95 mask when you go out. That's your decision, you decide. We're empowering you with that information. A community might say hey, our hospitals are overwhelmed. People are dying at a very high rate, and we're going to close some indoor spaces. That's a community-wide decision best made by the community that has to implement and adhere to that decision if it's made. So it's about empowering people with information.

'But that is probably one of the real learnings, I think, from COVID as well. I do think this idea that, look, this is the best that we know now. Things may change. Science evolves. But at the same time, again, I have tremendous respect for people who have to make decisions for masses of people in the moment. It's easy to look back on this and sort of be the Monday morning quarterback, but to say, hey, look at that time with what we knew, here's what I thought was the best decision. And by the way, I made those same decisions or recommendations for my own family, for my eight-year-old parents, for my teenage kids, et cetera. So I think there's probably a real learning in there. And I think it gets at one of the other core messages of your book, this sort of see, believe, create. With see, you talk about this idea of Cassandra's curse. Maybe you could define that and explain the relevance.

Cassandra was a mythological priestess from ancient Greece and she was blessed with foresight. She could see the future, but she was cursed that no one would believe what she predicted or change their behavior to avoid the tragedies that she could foresee. And for all too long, public health has been just like a Cassandra. We could see oh, a billion people will be killed by tobacco in this century around the world. But we couldn't get people to change the behaviors and the societal decisions that could prevent that tragedy. To a large extent, the formula is about how can we break the Cassandra curse for society and for ourselves? And it starts with understanding where the curse comes from. And this is something I learned in writing the book. Fundamentally, the curse comes from inaccurate perceptions. Inaccurate perceptions of ourselves, of our world, and of the future. When it comes to ourselves, we think, we assume that all of our decisions are decisions that we make, we have complete free will, but there are lots of ways where we don't have the kind of control. That's why we need to work with others to make it easier, whether it's to get physical activity or eat healthy food. When it comes to understanding our world, we may not see some of the economic interests that drive decisions, and I think this is something driving a lot of the controversy today. There are inappropriate economic drivers of our healthcare system, of our pharmaceutical industry. And that's one reason people have such suspicion. I also talk about something called the prevention paradox, which is that changes that help a lot of people a little can make a much bigger difference than changes that helped a few people a lot, but they're much less visible. And the final misperception is about our future. It's a fancy term, it's called hyperbolic discounting. And what it basically means is we discount the future. And I think of this in terms of a patient I cared for as a medical student. She was an older woman. She was feisty, and she was just a wonderful patient. But she had smoked her whole life, and she had terrible COPD. And she regretted so much that she had smoked, but you can't go back in time. So in a sense, what we do in public health is try to make vivid that future reality so people don't go through things that make them say, or I wish I had done this differently then.

To be fair, there are situations where public health experts have been able to, based on modeling data and other things, predict the future. So I think a lot of times we are critical of things that didn't go well, but there are a lot of things that did go well.

Absolutely. In fact, my organization Resolve to Save Lives, we work globally to create and scale solutions to some of the world's deadliest health threats. And one of the things that we do is have a periodic publication called Epidemics That Didn't Happen.

Right. I saw that.

Where we we highlight a success story because public health is often invisible. Nobody in the whole world, eight billion people, nobody woke up this morning and said, oh, thank goodness I didn't die from smallpox yesterday. And yet for most of recorded history, smallpox killed a huge proportion of people and bad deaths, painful, horrible deaths. So that hyperbolic discounting, where we discount or shortchange the future, is also retrospective. We don't recognize the past, the huge progress that there has been. And that's one way to make progress on the believe component of the formula. Whether it's environmental contamination or lead poisoning or vaccine preventable disease or tuberculosis or smallpox or even cancer and heart attack, things are a lot better than they were. That doesn't mean we can relax and things are OK. That just means that, hey, we've made more progress in the past, so we can make even more progress now.

I feel like this is something that again extends not just to societies but to individuals. You know if I tell you to eat right and exercise and engage in these healthy behaviors and hopefully as a result of that nothing happens to you. It's not the most inspiring message because you know if there's a problem everyone focuses on the problem but if there is no problem no one really knows why there was no problem. Was it the food that I ate or didn't eat? Was it my exercise? It's challenging.

'Yeah, but when it comes to personal health, there are aspects of the formula, many of them, that really do make a big difference. We talked about how for a public health program, you always have an information system that tracks whether you're succeeding or failing, because you can think you're doing a great job, but you look and it turns out you're stalled or you're failing. The same is true for our own health. If you track things like your blood pressure, your lipids, you can be in the normal range, but heading toward abnormal. And if you keep them in the normal range, you can stay healthy. I mean, just to tell a little bit about my personal health, I was very distressed. A year ago, in a routine blood test, I had a slightly elevated HbA1c. It actually defined me as pre-diabetic. It was a shock. I eat healthy, I exercise all the time, I have no diabetes in my family. How in the world did I end up being pre-diabetic? So for the last year, I've eaten healthier, I've gotten more physical activity, and just this week I got my follow-up A1c level and I'm no longer in the pre- diabetic category. So I'm celebrating that. I was like, this is terrific. What's terrific? A normal lab test, right? So I think it's really important to track things and recognize past progress.

Tom, you and I have had just similar experiences within the last year where I had an abnormal or an elevated blood test as well. And I remember almost having this philosophical discussion with myself, which was, what's it all for? Like, I've done everything right and here we are. And then I went down the rabbit hole of, should I just engage in better living through chemistry? Meaning, you know, these GLP drugs seem fantastic and should I be taking one of those? They seem to be very very helpful with regard to blood sugars. You did the right thing, arguably, where you just doubled down on your fitness and your diet, but you were already doing a good job. What do you think the message is there for everybody else?

'There's a lot of nuance here. Let's take blood pressure. Blood pressure is the single most important problem in the world and the most neglected. It kills 11 million people a year. That's about one out of every five deaths in the word. And in the U.S. It's also the leading cause of health inequalities between Black and white Americans. So when we try to maximize the effect of public health programs, we look at what's the population that will benefit the most? What are the programs that we can run that will make the most difference? The same is true for personal health. What are things most likely to kill or disable you, and what can you do best to control them? So that might mean take medicines for high blood pressure. That might mean get more physical activity. Physical activity, Sanjay, as you know, it's the closest thing there is to a wonder drug. You know, it improves everything you'd want to improve, even if you don't lose an ounce of weight. You are gonna have less cancer, less heart attacks, less stroke, less dementia, less depression. You're gonna have better sleep, more mobility, more independence, and that's just a partial list. It really is a miracle drug, and it's within reach of just about everyone. The easiest thing is a walk. Take a 30-minute brisk walk four days a week, ideally outdoors. But I think we can walk and chew gum at the same time. We can do the preventive activities in our own lives and, when necessary, take the medicines we need. It's a real misconception to think that, oh, taking medicines is a failure. We want to use everything we can to live the life we want to live and do the things we want to do for as long as possible.

We'll have much more with public health expert Dr. Tom Frieden when we come back.

Let's talk about create, which was chapters five through eight in your book. Um, see, believe, create. That is sort of how you, you organize the book. Tell me about the create part of the formula.

Create is by far the hardest part. It's hard enough to see the invisible and believe the impossible, but we can do it and there are ways to do it. But to create a healthier future as a society and for individuals really takes a systematic approach and it starts with getting organized. The most important thing is simplicity. You have to keep things simple. If you try to do complicated stuff, it doesn't scale up. So, simplicity gives you the potential to quickly scale up to entire communities. Communication is the next area. We talked about it earlier. And the final is really overcoming barriers. The odds are against public health. We talked the prevention paradox earlier, that there are many more people who gain a little bit. You get a big gain, but nobody knows. Nobody knows that they didn't have smallpox because of public health. But there are ways to overcome those barriers by building coalitions, figuring out who wins, who loses, finding champions and advocates, and coming up with a way forward.

The simplicity thing is so interesting, Tom, because it's like we are a society program to want the home run hit, the knockout punch, something that's a quick fix. And I get that. And it's not just medicine. I think it's many facets of our society where we sort of, we feel that way. And what I have found in 25 years now of being a medical journalist is that simplicity is really important. But there's a fascinating story to tell. In addition to layering the levels of certainty as you talk about, also just layering in the story of the scientific process. Here is how we got to this sort of understanding of something. I think that goes a long way. I really do. I think it goes a along way with patients, but probably to large communities of people as well.

I think that's right. I think we have to draw back the curtain and show people how we learn what we learn, what we know and don't know. And really, that's what I've tried to do with this book, The Formula for Better Health, to draw back the curtain on how public health works, when it succeeds, how it fails when it failed, so we can learn from that. There's a story that's told often in public health schools about a village and there's a stream, a river that runs through the village and a child comes thrashing down the stream, almost drowning and the village people pull the child out and then another child comes down and they pull that child out, and then, another, and another, another. And soon, like all the village, people are trying to pull these kids out before they drown and one guy turns around and starts running in the other direction. And the villagers say, what are you doing? I'm running upstream to try to figure out how they're falling in and stop them. That's public health.

That's a great story.

You know, it's hard to talk about public health nowadays without touching on the reality, which is what is happening to our country's public health system right now. In fact, the evening before I conducted this interview with Dr. Frieden, the CDC director, Dr. Susan Monarez, was forced out.

I am sort of wondering about your overall enthusiasm for the state of public health right now? You saw what happened with the CDC I mean, they just confirmed her at the end of July, and here we are not even at the end of August and she's ousted. What we're seeing now is unprecedented.

'Unprecedented, Sanjay. No CDC director has ever been fired. Public health is under assault. CDC for 80 years has been a beacon of hope and a beacon of facts and fact-based programs, not just for the US, for states and cities and doctors and nurses and the public, but for the world. What's happening in the US really shows that that beacon is in grave danger of being extinguished, and that will endanger all of our health. This inappropriate partisan takeover of public health and spread of misinformation by the current health secretary is really dangerous. Every day that not only misinformation, but actions that undermine our health security continue, every day that happens, we become less safe. As a country and less likely to get healthier. This is not about freedom. This isn't about health. This is about the ideological takeover of organizations like the FDA and CDC, which for decades have been there to protect Americans.

So where do we land then? I mean, I think I'm an inherently optimistic person. I think you are as well, especially after reading your latest book. I get that sense about you. And yet I hear despair in your voice.

'Well, certainly there's no silver lining to what's happening now. And this will have life and death consequences, not just in the US, but around the world. So I do think ultimately, and this is what gives me confidence and optimism, I think facts are stubborn things. I think although there are things we're not certain of, there are certain truths. We can focus on how to save lives. We can focused on empowering people. So I do think that bad as it is currently, we will see improvements. And look, no organization is perfect. CDC has never been perfect. And at some point in the future, there will be the opportunity to put the pieces back together in a way that's even more effective, that implements all those aspects of the life-saving formula of seeing the invisible, what's happening and what's the road to progress, believing it's progress by trying out things and seeing if they work, and systematically creating a healthier future. The truth doesn't change, even if people deny it, subvert it, or abuse it.

I think you're basically saying that in the end, truth will prevail, which I would believe as well. I just hope there's not so much damage done in the meantime.

I think, Sanjay, that COVID has accelerated some of the divisions in society. But ultimately, we really are all connected. We're connected by the air we breathe, the water we drink, the food we eat, the fact that we live in a world where an infection can spread from one part of the world to another in a day or two. Where positive things spread also, new technologies, new ways of working, new ways of preventing disease. Ultimately, those connections are real, even if they're fractured at the moment. And strengthening those connections has a real potential to help us get to a healthier place.

I love chatting with you, Tom. I think these conversations are more important than ever, so thank you for joining us.

Thank you so much, Sanjay, and thank you for the work you do. I'm very gratified and flattered to hear that you like the book and encourage people to read it.

I've got my signed copy sitting on my bookshelf and I'm delighted, I show it off to everyone, so thank you for that.

Thank you.

'That was Dr. Tom Frieden, the former head of the Centers for Disease Control and Prevention, former Commissioner of New York City's Department of Health and Mental Hygiene, and today he runs the non-profit Resolve to Save Lives. Thanks so much for listening.