Frieden’s Next Act: Heart Disease and Preparing for New Epidemics
After running the Centers for Disease Control and Prevention for eight years under President Obama, Dr. Thomas R. Frieden is starting a global health initiative that will focus on two big areas: heart health and epidemic preparedness.
Called Resolve, it is funded with $225 million over five years from an array of global and American health organizations, including Bloomberg Philanthropies, the Chan Zuckerberg Initiative and the Bill and Melinda Gates Foundation. The program will be based at Vital Strategies, a public health nonprofit in New York, the city where Dr. Frieden served as health commissioner under Mayor Michael Bloomberg.
In a conversation with The New York Times, Dr. Frieden discussed his new work, and looked back on some old battles. This is a condensed and edited version.
On targeting heart disease and stroke
We think we can trigger efforts that will save 100 million lives.
Why are we only focusing on sodium reduction, trans fats and blood pressure control? There are other things that either work but haven’t been scaled up, or that we don’t know how to do. So if you can get everyone eating a Mediterranean diet? That’d be great. Show me how to do it. If you can get everyone to be more physically active? That’d be great. Show me how to do it. No society has done that overall in a sustainable way.
Eradicating trans fats
Trans fats should be out of our food environment. It increases bad cholesterol and decreases good cholesterol. Just as we are working to eliminate certain diseases, I think we should try to eliminate this toxic product. It wasn’t put in with bad intentions. It prolongs shelf life. But we’re more concerned about human life than shelf life.
Trans fats are hard because you have to ban it and you have to ensure the ban is being complied with. There are about 40 governments that have done that at various levels.
(In 2006, when Dr. Frieden was New York City health commissioner, he led an effort to ban trans fats in the city’s restaurants. Industry resisted.)
There was a sky-is-falling thing. Then McDonalds came to us and said, ‘O.K., We took it out six months ago. No one can tell the difference. But please don’t tell anyone. Because if they hear it’s not there they’ll say it doesn’t taste as good.’
Dunkin’ Donuts came to me and said, ‘We can’t do it. We need another year.’ We already gave the deep-fry places another year because they had a whole supply chain to arrange. But Dunkin’ Donuts said, ‘The sprinkles keep falling off the frosting and we have to solve this!’ So we made a donut hole exemption at the last minute.
Why reducing salt is really difficult
There are two drivers for sodium in food. One is what you add and the other is what you buy in restaurants and in packaged foods. It’s different in different countries, and in different parts of countries and within different population groups. In some parts of Asia, for example, people put huge amounts of salt into their tea. In Tibet, it’s the main source of their salt — salty tea.
But the good thing is you don’t have to take it all out right away. A gradual reduction. Tastes change. You’ve got to get industry to work voluntarily to lower sodium. And you’ve got to change habits about how much salt people add at the table and to their cooking.
Our goal is 30 percent reduction in sodium in less than 30 years.
But not impossible
The U.K. has shown a substantial sodium reduction in food and a reduction in mortality. Wal-Mart reduced sodium by 20 to 25 percent in all their products in five years. The same product can have a quarter or four times the sodium with no difference in sales.
There are some innovations, like crackers. People learned to put sodium on the outside rather than into the batter and they could cut the amount of sodium enormously. It still tasted salty because it was salty on your palate.
The top priority
Hands down, blood pressure control is the most important thing you can do in health care. Globally, we’re at 14 percent control. U.S. is about 54, 55 percent. At the C.D.C. we did a couple of pilots; Malawi went from 0 to 35 percent in 15 months.
You can have big improvements, but you’ll only do that if you simplify treatment, if you decentralize it so people close to the patient can do it and if you use an information system that tells you how you’re doing.
All the medicines are generic. The costs that people are paying and that governments are paying are probably well over twice as much as they need to be.
If you decided as a country or a state or a province or a world, we’re going to use these four drugs, your costs would come down many many fold.
It’s a bigger problem than people think
Of the 1.5 billion today people with hypertension 1.1 billion don’t have it controlled.
I’ve got to tell you a story. Heartbreaking. At the height of Ebola in Sierra Leone we had a beloved driver, a wonderful man in his mid to late 40s. One evening he started bleeding and seizing and died in the parking lot. He died of a stroke. He had hypertension that was untreated. Nothing to do with Ebola.
I was in northern Nigeria, probably 2011, at a health camp for polio. I pick up a stack of forms toward the end of the day, of everyone over 35. And there was so much hypertension. Nearly half had hypertension and a third had what we would call malignant hypertension. Really, really high. And nobody was treated.
And that’s what’s happening all over the world. A billion people, every heartbeat, every second is slamming their brains or their hearts or their kidneys and causing a lot of damage.
Preparing for the next health crisis
Post and even we recognized there were huge gaps in world preparedness and that we’re all vulnerable because of them.
We have real success in Uganda. They’ve gotten much better at finding and stopping outbreaks. That’s what’s needed in lots of places — mostly in Africa but also some in Asia and some in the Middle East.
How countries can improve
You do an assessment to see where you really are. Then you do a plan and see how much money you need. Then you get the money. Then you implement the program and then you figure out how to sustain it. So, five steps along the way. Two years ago, we were at zero for all five. Now we have 54 countries that have gone through the assessment, four or five that have done plans, and none for the next three levels. We’re going to move that along.
A blind spot anywhere is a vulnerability everywhere. It’s so unpredictable. No one could have predicted that H1N1 could have come from Mexico. That MERS would arise in the Middle East. So the only insurance policy is to strengthen everywhere.