Sophia Crabbe-Field: The U.S. is opening up and loosening COVID restrictions. How do you think the increasing prevalence of the Delta variant should impact the way we’re currently tackling the virus?

Dr. Tom Frieden: So what we’re seeing is an increasingly divided world: divided globally into the vaccine haves and the vaccine have-nots, because there are many countries around the world that don’t have sufficient vaccines; and within the United States, the vaccine wills and the vaccine may nots. And what we’re seeing is this increasing divergence of parts of the country where most people are vaccinated, many states where 70 percent of adults are vaccinated and you’re at very low levels of spread, and other states where there is a moderate level of spread and a high degree of risk of uncontrolled spread as the Delta variant and potentially future variants spread there.

SC-F: And so what does that say for the kind of public health infrastructure the United States needs to build to tackle this pandemic and future pandemics?

TF: We need sustained investment in the public health infrastructure of this country. But that means we need a way of funding it that doesn’t get caught in the year-to-year budget wars. And there’s a recent proposal that just came out from the Bipartisan Policy Council that’s very important in this regard, because it used to be said that partisanship or politics should stop at the shore. And so, once we leave the U.S., we’re all one nation and we shouldn’t play politics about the foreign policy. Unfortunately that’s not really the case anymore, but it should be the case for fighting microbes because we really are all on the same side. There’s only one enemy: the virus. And there’s only one home team, and that’s human beings. 

And that’s why we think it’s really important that there be this focus on having an approach that really does keep that in mind. One is we need sustained funding for public health. Two is we need to align the federal, state, and city and local public health departments because they’re far too separate and separated and they’re not as aligned as they need to be so that’s crucially important.

SC-F: Over the course of the pandemic, the CDC, which you led for a long time, has faced a lot of criticism, and the WHO as well, particularly regarding guidelines, in particular as relates to mask wearing. I wanted to ask you, how fair are these criticisms, and are there changes, in addition to funding, that should be made to both national and global health organizations to respond to COVID and pandemics that might come next?

TF: I don’t think there’s any organization in the world that can look back on how it did during the pandemic and say they got everything right. The biggest problem for CDC was that they were undermined, sidelined, and maligned by the government. So blaming the CDC for failing to function effectively, it’s like blaming someone who was encased in cement for failing to swim. So the biggest problem was the politicization and marginalization of the CDC. But at the same time, there were important pre-existing conditions of weakness at CDC and state, city, and local health departments. One is decades of under-investment. A second is the very poor alignment of federal, city, state, and local public health organizations. And I think that a very important means to address that is to have thousands of staff employed by CDC embedded in state, city, and local organizations.

You already have a couple of success stories. You have the Epidemic Intelligence Service that has about 50 people at local health departments at any one time, 20-30 new people each year. You have what’s called the Public Health Associates Program, which I created during my time at CDC, that has been around 150, sometimes 200 people a year for a two-year program.

And the idea would be that after two to five years, many of those individuals would rotate back to CDC so that there’s more of an aligned vision and perspective and knowledge base about what it takes to get stuff done on the front lines. As I’ve thought about it, I think that’s the single most important operational and organizational change that’s needed to complement the budget change that’s needed. That will help with some of the problems that we see, for example the insufficiently practical information, advice, guidance, grant information from CDC to other entities, and also the need for CDC to be able to think big picture. You have lots of different parts of CDC, and they’re incredible experts within their narrow area, but what you don’t have often enough is the ability to helicopter up and see the big picture.

And part of that is a reflection of the budget structure, because you don’t have a budget that allows crosscutting activities. And so, follow the dollar, or as has been said, “You show me your budget, I’ll show you your priorities.” There’s no budget at CDC for crosscutting activities, for strengthening public health infrastructure, and that’s very much needed because you lack the integrative function of understanding about what’s needed and how well programs are working. And that needs to tie into the practical vision for people who’ve actually run stuff on the ground for years and the resources coming from Congress.

SC-F: And so how much are you seeing the political will for those changes and for that funding?

TF: I’m hopeful that there will be changes. I think it’s really important that it be done in a non-partisan way. There are a lot of pitfalls here and a lot of things that could go wrong in the process of trying to make this happen and happen well. 

SC-F: What kind of issues do you foresee potentially coming up?

TF: Well, most importantly, we could enter the neglect phase of the panic-neglect cycle. You’ve got some in Congress who would like to see this as a pretext for getting CDC out of certain areas, such as anti-tobacco work, which is really very important. Half a million Americans are killed by tobacco every year, and that’s largely a preventable cause of illness and death. So there may be some who would like to see a CDC retreat and just work on infectious diseases. That would be a mistake. It would leave Americans further and further behind as we are now in life expectancy. We have the shortest life expectancy of any rich country. And it’s not just a short life expectancy. It’s a high rate of disability for the years that we are alive. And in order for the U.S. to remain competitive and safer against pandemics, we need a holistic and comprehensive approach to addressing public health needs.

Another pitfall is, both nationally and globally, the idea of creating a new institution. CDC was made to fight health threats for Americans. There has been some discussion of creating a new epidemic-fighting entity. If you’ve got problems with how CDC is working, fix them. Don’t create something that’s duplicative. You already have a lot of duplication between parts of the Department of Health and Human Services and CDC, and duplication isn’t good for anyone. It’s not good for the people working in those agencies. It’s not good for the beneficiaries. It’s not good for their partners. The same is true globally. The World Health Organization has to make a lot of significant improvements, but they remain essential to global health safety and to global progress. At the same time, there are other institutions that can step up and do more, including groups like the Global Fund against AIDS, TB, and Malaria, which could play an even bigger role in helping to prevent, prepare for, and respond to emergencies.

SC-F: So shifting to the global aspect of pandemic response, do you think Biden’s budget request provides enough money for global health, including global health security, and also how much of a global role should the United States be playing right now?

TF: Well, it’s certainly a good start. But the key is that it has to be sustained. It’s almost more important to have something that’s sustained than to have something that’s large. I was at CDC when we got a significant amount of money to strengthen global health security; that money fell off the funding plan. It was five-years, and it went away. And what happened was that the rug was pulled out from under partnerships that had taken years to develop. And the CDC had to retreat from the field of fighting microbes in dozens of countries. Now, I know that folks at CDC put a good face on that by saying they we’re opening regional offices, but a regional office is no substitute to a country office. In a country office you’re able to strengthen the country’s capacity, learn what the organizations and individuals are who can be effective and really make a big difference. A regional office often is just a bureaucratic way station. 

So I think we need sustained investments in global health security and that’s important for the safety and security of Americans. The next pandemic is likely to come from somewhere else in the world. And as long as there are so many blind spots around the world, what we don’t know, whether and how new diseases are emerging, and we won’t be able to stop them quickly, we are at greater risk. We ignore the lack of preparedness globally at our peril. This is quite important, and this is why we are going into great detail on a proposal for global preparedness called 7-1-7. Every outbreak should be able to be identified within seven days of emergence: the investigation begun, reporting completed, and response started within one day, and then an effective response implemented within seven days. We outlined exactly what that would look like. So the only way to keep Americans safe is to improve global health security. When countries are stronger there, we’re safer here.

SC-F: Along those lines, the situation in Africa right now seems to be increasingly dire and the head of Africa CDC has been speaking out more and more asking for assistance. So what do we need to do and what needs to be done globally to try to stop the third wave on that continent?

TF: Unfortunately, in many parts of the world, there isn’t enough vaccine. And so we need essentially to do three things. First, we have to implement the things that reduce the spread. That means masking, avoiding super spreader events, and improving the care of patients and the safety of health care. Second, we need to redistribute the vaccine, particularly for people over the age of 60 and for health-care workers, so we can keep health care going and save lives. And third, we need to ramp up manufacturing. 

Quite simply, there isn’t enough vaccine, and we need really a new approach to ramping up vaccine production, particularly with the mRNA vaccines, which are our insurance policies against dangerous variants and against production problems with the other vaccine technologies. That means transferring vaccine technology to regional manufacturing hubs and then, longer term, positioning mRNA technology as a platform technology that may be able to address not only new variants to COVID, if and when they emerge, but other emerging threats to better prepare for the next pandemic. We have a shortage of doses that’s in the billions and the best time to have started addressing that would have been a year ago, but the next best time is today. And I really hope to see that done very quickly, because if we just rely on companies, we’re going to be at the mercy of single points of failure that could result in millions of avoidable deaths.

SC-F: How optimistic are you about WHO plans to set up these sort of manufacturing hubs in South Africa, in India, and how quickly do you think we could set up these hubs to start making mRNA vaccines?

TF: I don’t see how the WHO hubs are going to work because they don’t have the technological transfer capacity to make them work. And they don’t have the intellectual property rights. The concept is strong. CEPI could be helpful for this, but I think the U.S. could play a fundamental role here working, for example, with governments such as the South Korean government, which has a very strong industrial policy, strong national producers, a strong supply chain, the ability to produce nucleotides, and you could have, through that kind of approach, billions of vaccine doses in six months or less potentially, but you have to start now.

SC-F: And why do you think that COVAX [Editor’s Note: COVAX is a global initiative aimed at procuring and providing COVID-19 vaccines to countries in need around the world to ensure equitable access.] has fallen so short of its goals and what do you think that says about our attempts at global solidarity or the lack thereof in addressing COVID?

TF: COVAX basically didn’t get money soon enough to place orders. It didn’t get enough money to place enough orders, and it really hasn’t delivered what the world needs. At the same time, it is a step toward global collaboration. We need to learn from that and see how it can be done better. But COVAX’s biggest problem is not internal to COVAX. It’s that it didn’t get enough money and there isn’t enough vaccine to buy even if it had enough money. If you look at the Asian Development Bank, they’ve been sitting on $9 billion that they have available to buy a vaccine. There isn’t a vaccine to buy. 

SC-F: And so do you feel that the United States could be using more tools at its disposal currently, for example the Defense Production Act, to push for generic production of vaccines?

TF: So the Defense Production Act and the discussion of intellectual property may be helpful, but the bigger issue is to use carrots and sticks to induce Moderna to share technology transfer with a hub so that you’re doing a trainer-to-trainer approach, you’re doing a hub approach, you’re doing a one-to-many approach, and you can get multiple manufacturing lines up. This should be done and it would make a big difference.

SC-F: What kind of carrots and sticks would we be talking about more specifically?

TF: Well, the carrots are pretty clear. Let’s suppose you’re able to produce another two to five billion doses a year, and Moderna gets $1 or $2 a dose, that’s $5 or $10 billion a year that they wouldn’t have gotten otherwise. That’s a pretty big carrot, right? In terms of sticks, there is an act of Congress known as the Bayh-Dole Act, and it allows the government to “march in” and take the technology that it has paid for. And I think Moderna needs to know that the U.S. government will do that if they don’t willingly share technology.

SC-F: My final question to you is: Are there specific steps that we need to take to address more broadly zoonotic spillover and zoonotic transmissions? 

TF: That’s a good question. So there are two broad areas where we need to shore up our defenses and there’s this debate about how COVID started and we may never know. But whatever the reality is, we know we need to do a much better job in two separate areas. One is reducing the risk of dangerous spillover events, and two is improving laboratory safety. And just to go into each of those briefly: For spillover events, humans are encroaching on more animal territory and terrain. There are more animal-human contacts in Africa and Asia and elsewhere: exotic animals, wet markets, bush meat. These are all areas where the world could take much more concerted action through global compacts, through enforcement mechanisms, through verifiable commitments. And it would be good for the environment, it would reduce the risk of a future pandemic, and it would be good for a conservation of species.

The second broad area is laboratory safety and we know that there have been multiple laboratory accidents over recent decades. The last case of smallpox to occur in the world was because of a laboratory accident in the United Kingdom. It is likely that an influenza pandemic spread around the world because of accidental release from a Soviet laboratory in the late 1970s. That’s not proven, but likely. It is known that the SARS virus, SARS-1 in 2003 and 2004, escaped from laboratories several times, including causing lethal illness in one person. So whatever happened in China, the fact is we need better ways to prevent pandemics, upstream by reducing the risk of spillover and reducing the risk of dangerous laboratory errors. And that’s going to require global collaboration.