Thomas Frieden's Reading List

"It’s a wonderful book because it gives both a history of vaccines as well as a biography of a man who most people probably have never heard of – Maurice Hilleman. Although he was not an easy man to work for, there are few people in the history of humanity who have saved more lives than Maurice Hilleman. This book tells his story well. “There are few people in the history of humanity who have saved more lives than Maurice Hilleman” There are tens of millions of people alive and healthy today because vaccines exist. The success of vaccines in addressing a whole range of health problems is amazing. Take polio. There’s a generation that has grown up without fearing polio, but it wasn’t long ago that everyone knew someone who lived in an iron lung, every kid knew you couldn’t swim for fear of catching it, and everyone knew that FDR was in a wheelchair because of it. When I went to medical school there was still an iron lung on the hospital ward. Polio used to disable 1,000 kids a day in the world when CDC, along with our global partners, began a campaign to vaccinate against it and now we’re at the brink of eradication. There are huge challenges that are remaining but I’m confident we’re going to get over the finish line and when polio is eradicated it will be a gift to every child born on the face of the earth for the future of humanity. Vaccines are, in a way, victims of their own success. People were terrified of polio and measles before – now they’re so rare that some parents may mistakenly believe that the vaccine is riskier than the risk of disease. That’s not the case. The more the public understands about vaccines and diseases, the better off we all are. So I think one of the things that the anti-vaccination movement has done is push us to be even more open and transparent. We have nothing to hide. “People were terrified of polio and measles before – now they’re so rare that some parents may mistakenly believe that the vaccine is riskier than the risk of disease” Some people takes the perspective that if my kid has only a one-in-a-million chance of getting a bad reaction from a vaccine but every other kid is vaccinated, my kid doesn’t need to be vaccinated. There are people in the movement who sincerely believe in the danger of vaccines, but there are many parents who may subconsciously make an assumption that I can protect my kid as long as everyone else is protecting their kid. What that brings us back to is the need to understand that we do all live together, we are all connected by the air we breathe, by the water we drink, by the food we eat and the health of any one of us can affect the health of other people. Support Five Books Five Books interviews are expensive to produce. If you're enjoying this interview, please support us by donating a small amount . Tuberculosis spread in the slums of New York City for many years and no one cared. Because no one cared much about what was happening in the slums, TB developed drug resistance and spread widely throughout New York City, infecting healthcare workers, prison guards and many others. If we had cared about those inner-city communities that were suffering from TB earlier on, it would never have become a huge, city-wide problem. Public health is about the connections within communities and strengthening those connections so that we can empower communities and empower individuals to live the lives they want to live."

"House on Fire is a fantastic book about the fight to eradicate smallpox. Before becoming director, Foege led the efforts to eradicate smallpox in India and Africa and came up with a key innovation that led to eradication. As one of the staff at the CDC said of this book, “Even though we know how it comes out, it’s still a page-turner”. It’s so exciting. One of the things this book really brought home to me was how important innovation is. The eradication of smallpox was not inevitable. When we think back on what happened we might assume that we knew what to do, we did it and smallpox went away. That wasn’t it at all. They were continuously innovating, coming up with new ways to vaccinate, a new actual needle to do vaccinations. It wasn’t high tech, it was low tech. It turned out that high speed, pump-powered vaccine guns, where you could vaccinate lots and lots of people in a short space of time, didn’t work well. What did work was a very simple bifurcated needle. They figured out that if you dip that into the smallpox vaccine it had exactly the right amount of liquid and then if you pushed it into the person’s arm 15 times it would result in what’s called a “take” to the smallpox vaccine at a much higher rate, and you could teach a non-literate person to do that in 10 minutes. It wasn’t just innovations like that, it was who to vaccinate, how to vaccinate and how to manage programmes. This book gives the reader a wonderful sense of what it took to get the job done. First, we need to get over the finish line in polio. Second, we need to continuously innovate in small and big ways to figure out, for example, how to get into places where it’s not safe to vaccinate or where healthcare workers may be under attack. For all our health programmes we need to figure out how to put together a community mobilisation. If you look at India, which has been polio free for over a year – India made polio elimination eradication a social mission and that’s the kind of thing that makes a public health programme successful. CDC is a wonderful institution. One of the areas where we can always do better is the integration of our science and our expertise with public health practice on the front lines. We need to make sure that the gears are engaged, that when we take action, when we make recommendations, when we provide funding, the result is a programme that keeps people safer and healthier."

"It really is. This book is for a new generation what a book written by Berton Roueché called The Medical Detectives was, which I remember reading as a kid. They’re detective stories and they’re interesting and they’re human interest and they’re about saving lives. It’s really exciting. In EIS, you get a problem, you don’t know if it’s going to be a big problem or a small problem, you don’t know if it’s going to spread or not, you don’t know if you can stop it or not and you’re working against time. Kate Winslet played an EIS officer in the movie Contagion. There’s a drama to this work that’s real and exciting. EIS takes young doctors and, as Alex Langmuir, who created the programme, said, we basically throw the EIS officers in the water and see if they can swim, and if they start drowning we haul them out and then we throw them back in. So you’re taking young doctors and you’re putting them in charge of huge investigations. When I was in New York City I worked on a typhoid outbreak and helped stop it. I worked on a cryptosporidium outbreak in a homeless shelter. But my time was really dominated by the tuberculosis outbreak – a massive large outbreak of multi-drug resistant tuberculosis spreading through multiple hospitals in multiple parts of the city. I was right out of my training programme and I was basically in charge of how to detect and stop it. At CDC we also have a global mandate, because we can’t keep Americans safe unless we work globally. So what we’ve done is to create EIS-like programmes in more than 30 countries. We’ve helped more than 2,500 disease detectives graduate in more than 40 countries around the world, where lots of diseases aren’t detected and aren’t stopped. About 80% of the graduates of these programmes stay in those countries in leadership positions in public health. So EIS is, in many ways, at the heart of CDC’s work. Contagion I think there’s a misperception that CDC is only about infectious diseases and only about the US. I’m an infectious-disease-trained physician – I did my work in tuberculosis control, I took care of hundreds of patients with HIV. But public health is about empowering individuals and communities to live longer and healthier lives. It’s about protecting people and keeping them safe from threats. Those threats include getting run down by a drunk driver. Those threats include eating food that you thought was safe but is going to give you a heart attack or a deadly infection. CDC has 2,000 staff who work in 50 countries around the world keeping Americans safe and saving lives in those countries. That’s a key part of CDC because we are all connected. Not only within communities – where your not getting your kids vaccinated may endanger my kids – but throughout the world, because a community not knowing that the disease is spreading or not controlling it is just a plane ride away from making people sick or killing them here."

"Sir John Crofton was a wonderful man and he became a mentor of mine. He is the one who actually figured out how we should treat tuberculosis and basically get everybody cured. He wrote not only standard textbooks of lung medicine but also a very simple low-cost text that became the guide for doctors and other healthcare workers around the world on how to treat lung disease. He then turned to tobacco and wrote this book. I had been transitioning from working on tuberculosis to working on tobacco and I had spent maybe a year working on tobacco before I ran across this book. It’s only about 120 pages and it’s just wonderful because it’s so simple and clear. In just a few pages you get all the essence of what it takes to confront the tobacco epidemic, the tobacco threat. Tobacco is a terrible problem. I had a very active correspondence with Sir John over many years. I brought him to India because there was some resistance to the tuberculosis recommendations at the World Health Organization. As a British knight he had a lot of cachet with the Indian medical professionals and he was able to be very helpful there. We became friends and communicated regularly. A couple of years ago I gave the Crofton Lecture and in that talk I showed that Sir John had laid out all the essential aspects of how to reduce the tobacco threat in a simple letter to me a few years before the global community put this together. This is a book I wish every healthcare worker and everyone who cares about saving lives would read. One of the things Sir John notes is that it’s been said that a doctor who smokes is worth $100,000 to the tobacco industry. So getting every healthcare worker around the world to quit and to be an advocate for tobacco control is essential. The book also shows how important it is that we limit the ability of the tobacco industry to do marketing and promotion, which get kids addicted before they reach the age of maturity. It’s just a wonderful book about the burden of tobacco and what to do about it. I’m afraid the answer is human behaviour. Microbes are really tough and we have real challenges in front of us, including the spread of antimicrobial resistance. But even that is largely the result of human behaviour – we haven’t safeguarded antibiotics as we should have. This is a good segue to the last of the books."

"I’m sorry that I didn’t know about this book until pretty far on in my career – but it’s a fantastic book that explains why and how disease occurs in society. We think of the need to treat people who are very ill, and of course we need to do that. What Rose talks about is that for most human illnesses there’s a bell curve distribution. If we just treat people for disease that will do some good, but we can do much more good by shifting the distribution of that bell curve. That’s the essence of prevention, that’s the essence of maximising health by reducing the number of heart attacks and strokes. It’s not either/or – we can do both. So, for example, to reduce the number of heart attacks and strokes we can treat people who have high blood pressure and that’s very effective, but we can also get people to exercise more, be at healthier weights, eat lower sodium food and that will shift the bell curve so that many fewer people need treatment and the people who need treatment won’t need it as badly. I don’t think it’s an either/or for population health and individual health. But I do know population health tends to get the short shrift. Until around the middle of the 20th century virtually all improvements in health were the result of prevention, not clinical care. Clinical care might occasionally have saved someone through surgical or other interventions but it wasn’t effective enough or widely accessible enough to actually make a meaningful difference with how many people lived or died overall. “Until around the middle of the 20th century virtually all improvements in health were the result of prevention, not clinical care” That started getting better with antibiotics and with the treatment of cardiovascular disease. In the US between 1980 and 2000, the death rate from heart disease was cut in half. Half of that decrease was from community prevention, particularly tobacco control, and half was from clinical care, such as taking care of people while they were having heart attacks. That tells me that both community and clinical care can make a huge difference. Interestingly, there was a similar study in the UK that showed that 80% of the life years saved were saved through community prevention. Community prevention measures saves lives at a younger age. That’s really what Rose emphasises – the tremendous power of even small changes in the population prevalence to make huge changes in health. I have my underlined copy of Rose in front of me, open to a certain page, which I’ve often thought of because Sir John Crofton mentioned something similar. I underscored a passage where Rose wrote, “Of all the threats to human health, it is alcohol which causes the widest range of injury. It shortens life, being variously held responsible for between 1% and 10% of all adult deaths in industrialised countries. It shrinks the brain and impairs the intellect. It causes failure of the liver, heart and peripheral nerves. It contributes to depression , violence and the breakup of personal and social life. It has been blamed for a quarter of all deaths on the road – divided about equally among drunk drivers, drunk pedestrians and innocent victims.” Alcohol is a really tough area. Sir John always encouraged me to do more on alcohol control. The issue is problem drinking. In the US, binge drinking causes a huge proportion of the harms. Yet problem drinking is a challenge to address. I think we can at least begin to address this problem with a focus on kids and understanding that you want people to make decisions that are going to affect the rest of their lives when they’re adults, not when they’re kids. There’s been various work done in economics that suggest that although we spend a lot on healthcare, we get a lot for it. We want to have our hip or knees fixed so we can walk again. We want to be kept healthy. This is a delicate area but I will say that I wish we could just have a more open discussion about end-of-life issues. As a physician I’ve taken care of patients who died horrible deaths that they wouldn’t have wanted because they had not had a conversation with their families about what they wanted, and for whatever reason their families felt that we should continue to prolong the life of someone who is not really living but dying. And I will say that for my father and my grandmother, both of whom I was very close to, the last two years of their lives were very unpleasant. This was really something they would never have wanted and yet we are not able as a society to have clear discussions and decisions about that so that people can choose how they want to live and how they want to die. I would highlight one: The need for strong public health institutions in poorer countries. Improving health entails getting data to drive decisions – data on what’s making people sick, data on whether the programmes that are designed to help are actually working, data on whether the healthcare system is doing what it needs to do, data on what works in different communities to protect people from threats, and data on what threats are spreading. To get all that data you need strong public health institutions. I think CDC does a great job in the US. When I travel in Africa, Asia and Latin America I virtually always get asked: How can we create a CDC for our country? That is the next big global challenge for public health. There are economic interests that can make it challenging. The tobacco industry is a primary example. Tuberculosis bacteria don’t lobby politicians. It doesn’t rebrand itself as light TB or get a movie star to make TB look sexy. So one is the economic interests. Second is the need to get clear about responsibility. There are people who say if the government does this it will sap individual responsibility, or, it’s because you’re not treating people as autonomous adults. It’s not either/or. Take driving as an example. The government has a responsibility to make sure that traffic lights work, that the speed laws are enforced, that people don’t drive drunk. But that doesn’t absolve individuals from their responsibility to drive safely, to not drink and drive – it’s a shared responsibility. We need that for tobacco, for alcohol, for heart disease and cancer. We can now vaccinate against cancer from hepatitis B so maybe one day we’ll be able to use vaccines for heart disease, stroke and smoking. But not yet and we shouldn’t wait because we do have effective things that we can do today that will save millions of lives. Saving lives requires good information, good management and focused action. These books really highlight that. They show how understanding what’s causing disease, finding the tools to stop it and working together as a society can save millions of lives."