Dr. Tom Frieden, former CDC Director, NYC Health Commissioner, and current President and CEO of the global health organization Resolve to Save Lives, shares the influence of his father, the single question that changed his life, the 3 step formula for impactful healthcare, how to assess levels of certainty, the 6 keys to a longer, healthier life, the low-tech device he uses every day, and the mindset that keeps him moving forward.

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Today's guest is Dr Tom Frieden, a former CDC director, New York City Health Commissioner after 9/11, and the current president and CEO of the global health organization Resolve to Save Lives. His book, The Formula for Better Health, is out now. If you're okay with it Tom, I love hearing the beginning of people's stories that have accomplished a lot in life. So did you always wanted to be Director of the CDC and this amazing medical professional, or tell us a little bit about your early life and journey that encouraged you to take this path.

Dr. Tom Frieden: Sure. Well, actually, the biggest influence on my life was my father, and when I was in high school wondering, What's the meaning of life as you tend to wonder when you're a kid, he had a very simple philosophy, which was, you got to help the people. Later on, he unfortunately developed Parkinson's disease, and he was increasingly disabled, though he kept working for many years with the disease, and he and I went on a hike in the Blue Ridge Mountains of Virginia, and he commented that, you know, in the out of doors, hiking without the pressures of work, he could almost feel like he didn't have Parkinson's so very memorable comment, and it was on that hike he said to me, you know, you seem to like politics and you seem to like science. If you put those two things together, you get public health. And I had never heard the term public health before. So when I applied to college, I said, I want to go to medical school. And when I applied to medical school, I

said, I want to go into public health. He also advised me in college, don't just do pre med. You're going to be doing medical stuff the rest of your life. Do something different. So I was basically a philosophy major in college doing the minimum of pre med and that has been really helpful to me throughout my career. And then in medical school, I was able to also do a public health degree. I went to medical school and did my internal medicine residency in New York City at the height of the AIDS epidemic, and that's a searing experience, because I cared for hundreds and hundreds of patients for whom I could do very little other than to help them die more comfortably. It was a bad time, bad time for the city, bad time for medicine, and especially bad time for patients and their families. I began working on tuberculosis control because I was an Epidemic Intelligence Service Officer for the CDC, and it was at the time when there was an unrecognized but very large outbreak,

in fact, the largest outbreak the US has ever had, of multi drug resistant tuberculosis in New York City. And I started with documenting that and then working to control it. And then in India, where I worked as part of the World Health Organization supporting the government of India, which was implementing a much more effective program.

Wow. And I might have missed this, but your father, was he in medicine?

Dr. Tom Frieden: He was, he was a cardiologist. He was kind of a doctor's doctor. He's the doctor who other doctors went to when they got sick. And he was very rigorous. He practiced what is now called Evidence based medicine. Before the field of evidence based medicine was even invented, every night he'd be sitting in his chair reading the medical journals and ripping out the one the articles that were important and filing them. And when I was in medical school, I had an opportunity. The dean said you can do a preceptorship, which is where you basically spend a month with a doctor, learning what their practice is like. The dean said you can do a preceptorship with any doctor. And I said, Any doctor. She said, Yes, any doctor. I said, Okay, I'll do one with my father. And so I spent one month in medical school, tagging along with my father and I got to see you know, what a really good doctor does? He? He listened wonderfully to patients. The patients loved him. And when I

asked him, Well, why? Why did he use this medicine or that medicine? He was well four years ago, there was an article in the Journal of the American College of Cardiology that indicated that this is better than that. I mean, he was really, really rigorous in what he did, but also very caring in how he helped patients.

What great character qualities. We talk about this a lot, of the power of being a student of the game. So that obviously had some influence in your your rigor that you applied to your own education and your work. Was it the AIDS epidemic that solidifying moment for you to progress into the work that you did for the World Health Organization, the CDC? Do you feel like that was a turning point of sorts for you?

Dr. Tom Frieden: There was really one question that changed my life. I had finished my training become an internal medicine doctor, passed the boards, done my infectious disease fellowship, done the Epidemic Intelligence Service Training, evaluated dozens of outbreaks and helped stop them. Had been appointed director of tuberculosis control for New York City at the height of the epidemic, Assistant Commissioner of Health. I was working around the clock, and I had created a booklet that was all of the details about the patients in New York City. And a man, a doctor named Carol stieblo, who had survived a concentration camp, came to visit stieblo. Had spent 20 years studying tuberculosis, first in Europe and then in Tanzania. And stieblow looked at our information summary, and he noticed trends of the disease that I hadn't noticed, which was pretty galling, because I had written that book. So he was really, really good epidemiologist, but then he asked me a single

question that has changed my life. He said, Dr Frieden, this book told me that New York City diagnosed 3811 tuberculosis patients last year, and it tells me all about what kind of tuberculosis they had, and how old they were, and where they live in the city and other things, but it didn't tell me the most important thing, and I was really offended, what's that? And he said, How many of them did you cure? And I didn't know, and I was so ashamed. Wow. The very next morning, I started a system that Steve Blow had created called cohort reviews, where we would go to every part of the city and review every patient every quarter, and those reviews revealed all sorts of problems, but the bottom line was very simple, did you provide good care to every patient? And that kind of simple system holds the key to improving performance of health systems and organizations, and really, even in personal health, that kind of simple approach can make a huge difference.

Wow, and what a great lesson. You've written an amazing book called The Formula for Better Health, How to Save Millions of Lives, Including Your Own. If you don't mind, I'd love to explore just some observations that I've made, and get some of your take on it. I mean, you know, I grew up in Germany, and it had a very different health system than the health system that we have in the United States. I had parents who lived in Europe and lived in the States, and it, you know, it was such a change to come to the US and have the model that we have when both my parents were opera singers and they were on 1099 contracts and had to have their own insurance plan, etc. So we learned a lot. But I'm curious what you feel about the environment of health care in US, where presumably based on our wealth and our success and so many metrics, how it stacks up compared to the international space. And are there any surprising countries or communities we should be paying

attention to with how they relate to health?

Dr. Tom Frieden: That's a great question, Adam, as you say that the book, the formula for better health, provides a formula, or really an approach, that has already saved millions of lives and can save millions of lives more, including including your own when it comes to health care, on the one hand, the US has Some of the best healthcare institutions in the world, whether it's cardiac surgery or transplant or cancer care, you can get better care here than you can get anywhere in the world. On the other hand, our overall healthcare system performs extremely poorly, and the fundamental reason for that is that we have a very bad primary care system. About 100 million Americans, that's nearly one out of three people don't have a doctor or other clinician who is their doctor, and that's really important, a family doctor. And my father, though he was a cardiologist, he provided general medical care for most of his patients. Is really important. Even if you have the best

specialty care, you need someone who's coordinating, someone who's looking at the whole picture. And in this country, we really lack that. And if we take the formula, the formula is, see, believe create. It's three stages. See the invisible. Believe that what may seem inevitable is not we can make a better future and then work systematically to create a healthier future. If you take that formula and you apply it to something like primary care, and how can we get a better primary care system in the US? First you see what the problems are, 100 million Americans lacking this very basic service, believe that it can be different. You asked about other countries. There are countries all over Latin America, many European countries. Costa Rica is a model. Thailand is a model. Sri Lanka is a model, where they have superb primary health care. So you can believe progress is possible by both recognizing that in the past it was possible, so it has to be possible in the future, you can

also see that there are good examples of it around the world, and then you can make phased progress to build optimism. There are good systems within the US that are more comprehensive, that aren't trying to maximize the number of procedures they do, but optimize the healthy lifespan of patients they care for. And that requires a really systematic approach. It's not enough just to say, oh, let's do this. You have to really see not just the trends, but you have to see what's blocking progress and what's the pathway to progress.

And so, just for somewhat of a simpleton like me, if primary care is world class, I'm guessing in my head that one of the byproducts of great primary care is that you're taking care of problems before they become problems, which is, I think, in any world more ideal than waiting till they manifest. I mean, is that part of where primary has the biggest impact?

Dr. Tom Frieden: Absolutely. And it comes back to the formula. What I do in the book is I apply that formula not just to public health, but to personal health. And what good primary care doctor can do in this see, believe create formula is to see the trends in you that may be within the normal limit laboratory tests or blood pressure or exposures, but they're getting off the normal range for you, and by the time they hit abnormal it's going to be Too late, you're going to have damage to your brain and your heart and other parts of your body, and then to strengthen in you the belief that you can change things, the belief that you can do better, and then systematically, to create a healthier future, looking past fads, because there are a lot of fads out there, and being clear about what's most important for your health, one of the things I talk about in the book is the levels of certainty we have about different health interventions. I don't think this is discussed frankly

enough. When we go into things, we can say we're certain, virtually certain, that this is right, or this is probably right, or this may be right. We have some evidence for it, or, you know, I'm guessing that this might help you. Those are four different levels of evidence. But what you see in social media, in mainstream media, what you see, doesn't make that distinction clearly, and you also don't see the clear description of how much benefit will you get from doing this. So one question is, how certain are we that it's going to help you? Second is, what's our best guess of how much it's going to help you? And that may be a very logical way to deal with things, but I think it also has a strong emotional resonance. You want to live a longer, healthier life doing the things you want to do for longer. There actually are some pretty simple things you can do to succeed.

So, you know, I think you look around and the innovation of technology, one would assume reduce the cost of medical care would increase life expectancy when you see what's available and what's constantly being created. But why do you think that's not necessarily always the case?

Dr. Tom Frieden: Fundamentally, it comes down to misaligned incentives. What makes money isn't what's going to keep you healthy, and therefore our system isn't structured to keep you healthy. I think we can change that. I think that's not a Democratic or Republican issue. I think that's a question of good policy. But it's not easy. If you're a primary care doctor. Her, and you work really hard for 20 years, you will make less than half as much as a surgeon who graduated yesterday. Wow, this is one of the reasons it's really hard to find good primary care doctors. And when it comes to personal habits, people are selling you all sorts of stuff. And I want to be clear, I'm not selling anything other than I encourage people to buy the book, and all proceeds from that book actually are not going to go to me. They're going to go to organizations, health organizations we work with around the world to advance health programs. But there are things that you can do that

will maximize your chances of living a long, healthy life. And I come to these with a rigorous view based on epidemiology and the best scientific evidence, and they're pretty simple. There are six keys to a long healthy life. And although they may sound familiar, the details are really important, because the details aren't what most doctors will tell you they are. The first is blood pressure, which is actually the world's leading cause of death. The second is lipids, or cholesterol, controlling those well. The third is physical activity, the closest thing there is to a wonder drug. The fourth is healthy nutrition, making sure that you're eating healthy. That's probably the most complicated topic, but there are some simple things that are likely right. The fifth is getting enough sleep under recognized, but really important, your body and your brain repair themselves when you sleep. Not so easy for everyone to get good sleep, but important and the sixth is avoiding

toxins. There are lots of toxins in our environment. The most obvious one is tobacco. There are still hundreds of 1000s of Americans who die every year because of tobacco. Alcohol is also a toxin, soot or PM, 2.5 are also toxins, and there are newer toxins that we're just learning more about, like microplastics and nanoparticles and endocrine disruptors. So these six things, there's a lot you can do to be healthier, even if you just take the first most basic one, blood pressure. Everyone says, Yeah, I know that. But actually, the best scientific data on blood pressure suggests proves actually that once your blood pressure goes over 115 for every 20 point, increase your risk of having a heart attack, stroke or dying young doubles. So if your blood pressure you go to the doctor, they say, Oh, 135 it's normal. It's not normal. It's abnormal. It's doubling your risk of dying or being disabled young.

Why would they say it's normal?

Dr. Tom Frieden: Because that's the tradition. We have traditionally said that 140 is the level. But if you take a public health approach, an epidemiologic approach, and you look at it, you say, actually, it's not normal. And there are some really fascinating studies. In fact, my father worked with a wonderful doctor who did studies in the 1980s in 28 countries. He showed that blood pressure increases with age in most societies, but not in all. They identified four societies where there was no age related increase in blood pressure. People had a blood pressure of 90 over 60 when they were 16 years old and 90 over 60 when they were 60 years old. The reason for that, almost certainly was that they consumed very little sodium. We consume way too much sodium, so we may not be able to get down to that level, but if we reduce sodium and increase potassium, our blood pressure will come down, and there's a really easy way to do that, by potassium enriched low sodium salts. You can get

them at the supermarket or an Amazon, and use less salt.

Oh, that's wonderful. Sometimes keeping it simple is the key to staying healthy.

Dr. Tom Frieden: Absolutely.

You know, I think also, if you talk about all that you said, you know, diet, it can be the more complicated one, and it's typically the most marketed one. I think what are some rules of thumb for the every man or every woman could use to filter the noise around health?

Dr. Tom Frieden: I think getting the basics right is really important, getting your blood pressure and your lipids not just in the so called normal range, but in the really healthy range, that means a blood pressure under 120 that means what's called LDL C, ideally under 70, apo B, under 70. You're talking about big benefits, physical activity at least 30 min. A day, at least four days a week, at least moderate activity, that can be a brisk walk, outdoors, four days a week, if you get regular physical activity, you're less likely to get cancer, heart disease, stroke, kidney failure, arthritis. You're going to sleep better. You're going to be more likely to live independently. You're going to be less likely to get depression. Nobody's going to make money on you taking except maybe the shoe company. You're taking more brisk walks four days a week. But it's really, really important for your health, and nobody's going to do it for you. You have to do it, but you can do

that by making it easy, by making simple changes in your life that make it more likely that you'll continue, that we never succeed really reliably when we ask people to do things they don't want to do or don't enjoy doing. So rather than deny yourself pleasures, find things you love doing that are healthy and do more of them. Maybe it's walking with friends, maybe it's dancing, maybe it's playing sports, maybe it's walking your dog. There are lots of things you can do to get more physical activity. When it comes to nutrition, there are a couple of really simple things that we really believe would make a big difference. One is to consume more potassium and less sodium. So there are lists of high potassium foods, and actually, the more of those you eat within reason, the better. So you don't have to deny yourself all the things that you want to do, rather find things that you love doing and do more of them. And then on the on the toxins front, really important to quit smoking. If

you smoke, if you smoke, there is nothing you can do that will give you as much benefit to your health as quitting. Most people who have ever smoked have already quit, especially for people who smoke a lot or smoke early in the morning or have difficulty not smoking. Really important to get medications and support, they can double or triple the likelihood that you will succeed. We don't do enough to reduce potential toxins in our environment. There's a lot of PFAs and other contaminants in our water. About half of the water in America has PFAs in it, and we don't really know all of the harms of PFAs, but it's not good for you, that's for sure. When I tried to find valid information on food that wasn't somebody trying to sell something, it was remarkably hard. But there are certain foods that are generally healthy, unsalted or lightly salted, nuts, vegetables that you enjoy, fruits, olive oil and fish, basically within reason, you can have almost as much of those as you

want, not necessarily deep fried and with lots of salt on them and other things you need to try to have less sugar and less sodium. For the potassium, it's pretty interesting, because it's not only the amount of potassium that's in the food, but the amount that is absorbed by you. This includes things like sweet potatoes, salmon, spinach, white beans, avocados. Everyone thinks of bananas as having potassium, and they do, but so does yogurt, pistachios, tomatoes, mushrooms, so there's lots of foods and you don't have to deny yourself things you like.

Yeah, I'm gonna try to write them all down so I can cook tonight. I appreciate that. You know, one of my other concerns moving from Europe to the states was my reaction to, like gluten and wheat and and processed grains in the States, as a as a parent, to and I can't, I don't know if it's placebo or if there's something to it, but when I go to Italy and I, you know, dine on Pasta, etc, the just the feeling seems to feel so different than when I do the same when I'm taking grains from the state. So I don't, is there any relevance to the use of Roundup and these type of things that comes back, or is this just another thing where it's probably more exaggerated?

Dr. Tom Frieden: Well, I always emphasize that there are things that we know and there's things that we don't know. There is really no evidence that the grains in the US are less healthy. It is true that carbohydrate quality is generally higher in many European countries, but that's more about the dietary pattern than the actual food itself. We have a lot more fat, sugar and salt that increases your risk. But carbohydrates can have a lot of fiber. They can have more whole grain. They can have less added or free sugar that improves health outcomes reduce. Diabetes reduces the risk of of death, but really it's more about eating more vegetables, fruits, nuts. We continue to have in this country a lot of low quality carbohydrates. And what I what I can say is there's a lot of debate about different things in nutrition. What you'll generally see is the more uncertainty there is, the more debate there is nobody debates whether or not gravity exists. I can tell you with a reasonably

high degree of certainty that increasing your potassium, reducing your sodium and reducing your free sugar is going to make a big difference. There are other things that are not so certain. Processed meats are probably pretty unhealthy, but really it's more a question of what's the big picture. If you want to live a long, healthy life, individually, if you want your organization to succeed, you need an approach, and the formula of seeing, believing and creating is an approach that can save lives, can help organizations succeed, and really can make a big difference, not just in whether you live a long and healthy life, but also whether you enjoy it while you're doing that.

I love that. Let's go to a quick fire round of questions, if you don't mind, Tom I'd love to do that with you, so a piece of technology that you have chosen to embrace, maybe from a health perspective, or the opposite of that you could also comment on, is technology that you are banning because of health effects.

Dr. Tom Frieden: I really don't use much technology. One thing that I use is a simple bathroom scale, and I weigh myself in the morning, because I really like dessert. I like some high calorie food and beverages. And unless I weigh myself every morning, I know I will gain 15 pounds quick. And I'm able to with that feedback loop, I'm able to say, well, heading up, I need to just cut back a little bit and have a little bit more physical activity, and that really helps me stay on track. So pretty much every morning, I weigh myself and I adjust accordingly.

I love the low tech. What's one thing that you do to help manage stress? I mean, your environment has been riddled with it, and I know stress has a health implication. How do you protect yourself against the damage of stress?

Dr. Tom Frieden: I don't recommend this to others, because I don't want to be proselytizing, but I do meditate. I meditate for 20 minutes twice a day, every day. I've been doing that now for almost 50 years, and I find it very helpful, whether for you that is prayer or taking a walk or spending time with friends or a quiet moment or exercise, I think it's really important to have time when you can rebalance and get centered, and it works for me.

You know, your father was such an amazing figure to you, I can't imagine he would. He must be so incredibly proud of what you've accomplished and who you've become as a person. The question I always love to ask is, what advice, though, would you give that 21 year old Tom who is still exploring his future?

Dr. Tom Frieden: Stay optimistic. Despite setbacks in my career, I've had some really tough moments where decisions resulted in the disruption of programs that I had worked years to develop, and it felt like the world was coming to an end, but in fact, we were able to put things back together, get staff rehired, start programs again, learn from the program problems and failures, and do even better. So I think I'm kind of naturally optimistic, but there are times when things seem hopeless. And just to tell that younger self, or tell folks when things really look down, things can get better, they will get better one step at a time, use a simple formula of seeing the path forward, believing you can make progress and then creating a more successful, healthier future.

Great words for our listeners. Tom, thank you for joining us and helping us all become healthier. So thank you for your work.

Dr. Tom Frieden: Thanks very much and all the best.