Seeing the Possible: A Conversation With CDC Director Robert Redfield

ROBERT JOHNSON:
This is Public Health Review, I'm Robert Johnson.

On this episode: we are one-on-one with America's top public health official, Dr. Robert Redfield, talking HIV, opioids, vaccinations, and the lasting impact his family has made on his career as a doctor and public health advocate.

DR. ROBERT REDFIELD:
So, again, this is really important. You hit it on the head. You know, science left on the shelf has no value; and we need to continue to work with the American public and the systems that we have in public health to remove the barriers to science on the shelves.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, a special interview with one guest—Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention. He was named to the position by President Trump last spring. Since then, the president and the secretary of health and human services, Alex Azar, have declared a plan to end HIV in America, an issue that has consumed a large part of Dr. Redfield's work the last 30 years.

We talked to him about that and other issues when we sat down with Dr. Redfield in his Atlanta office just before Easter. Here's our conversation.

So, we're sitting here in your conference room today, we have a great view of Atlanta; what I'm most interested in, though, is the white board. Did the grandkids invade the conference room one day? Are those your grandkids? Is that their handiwork?

REDFIELD:
Yeah, it's really great. I'm gifted with 11 grandchildren—actually, I have three more coming to see me today. It's really interesting to see the excitement and pride that they take that I got the opportunity to serve as CDC director.

JOHNSON:
How old are these kids?

REDFIELD:
These ones right here probably ranged from six years to 12 years.

JOHNSON:
And they know what the CDC is?

REDFIELD:
They sure do.

JOHNSON:
They say it's awesome, but do they know what it is?

REDFIELD:
They sure do. They'll tell you it was one of their best vacation they had. Each of my grandkids have come down in the last four weeks—the last three come in today—to come visit CDC, tour CDC, learn about the museum of CDC, and see what their granddad does at CDC. Part of it was I had the opportunity to finish my first year—I'm in my 13th month—and they just wanted to come down and sorta help me celebrate that. And it's really great. I'm looking forward to the last three coming down tonight, they'll be touring CDC tomorrow.

JOHNSON:
Before we talk about real issues, though, I'd like to know what's been the highlight of the tour for them so far. The germs, or what?

REDFIELD:
I think, you know, they really enjoy it. I mean, if you haven't visited the CDC museum, you really should. It really is a wonderful display of the history of the accomplishments of CDC over the past 70 years. And I think the kids get kind of excited to see that science is just not something that you put on the shelf, that science can actually be applied and put into action. And when it's put into action, it has an enormous consequences on public health.

When they go down and see the iron lung and the stories of polio that I grew up with—not being able to swim in the river, parents being concerned—and then they see, on the other side, that we're about to eradicate polio in the world. I mean, who would have believed in the early—let's see, 1983-ish, 1984-ish—that a group of international Rotarians were sitting around and they said, "You know what we're going to do.?We're going to end polio in the world." It wasn't the WHO that said that, it wasn't CDC, it wasn't some major academic institution. It was a group of Rotarians, international Rotarians that said, "You know, there's over 300,000 cases of polio. Children are becoming paralyzed in their lives. You know what we're going to do? We're going to eliminate polio."

And as I sit here today, cause I'm on—one of the jobs I have as being part of CDC has to be on the global polio eradication program—as we sit here today, we're on the verge of eradicating polo. In 1988 the United Nations thought this was something that was good to do, and WHO, CDC, UNICEF, and the Rotary Club joined forces to build the program. And then in 2006, the Gates Foundation joined, and this year Gavi joined. And as we sit here today, last year we had 33 cases of polio in the world. And they were in Pakistan and Afghanistan.

It just underscores the importance of putting science into action. That science, in this case, was the development of a polio vaccine that was developed in the '50s and early '60s between Sabin and Salk. And then, spending the next 50 years trying to figure out how to put that enormous scientific accomplishment into action.

So, I think when my grandkids, when they came here, I think that's what they left with is that, you know, the ultimate purpose of science, and this is—I love CDC because it's a science-based, data-driven service organization—but the science in and of itself, if you don't put into action, really doesn't have any benefit to anybody.

I remind people of the story of Flemming who discovered penicillin in 1929, and it wasn't until the early '40s that people realized that penicillin had value—sort of a prototype of leaving science on the shelf. Can you imagine how many human lives would have been changed if penicillin had been put into action in 1930, rather than the mid '40s?

We have many scientific advancements that have happened that are currently spending too much time on the shelf. And I think, you know, the truth is I'm a big advocate of the 21st Century Cures Act. I'm a big advocate of investing in NIH and science. Both my parents were at NIH—my father actually died in 1956 when he was at NIH, my mother worked there for many, many years. And I think it's really important to and invest in science.

But the truth is, once we have the science to cure disease, we have to apply it. And this is where I'm a big advocate of making sure that we have as much investment today that we do in trying to find a cure that we learn how to, as a society, to invest in applying that cure to the public that needs to be cured, both here and abroad.

JOHNSON:
Is that as easy as it sounds?

REDFIELD:
Well, it's obviously very complicated.

When I tell you that we had a polio vaccine that was pretty much scientifically solved by the late '50s, early '60s, and it took till the early '80s for a group of lay individuals to say, "You know what? This is a goal that we can accomplish." They saw the possible and they led their organization to act, and then that organization ended up leading the world to act. And I'm now telling you that now, fast forward 40 more years, we're on the verge of actually getting it done.

So, obviously the application of science so we get the full benefit of its public health impact is complicated, and we need to focus as much energy on the application of science to have its public health impact as we do on discovering the science to do that.

JOHNSON:
There've been some very robust discussions this year having to do with vaccinations. I assumed that issue would fit into the same category.

REDFIELD:
Yeah, absolutely. When you look at it, one of my priorities—ending epidemics, eliminating disease, investing significantly in global health security so we can confront the threats both here and abroad and prepare for them domestically—eliminating diseases is really the ultimate end game for science. That's the whole purpose of it.

And so, you mentioned, you know, one of the key areas there is vaccine-preventable diseases. You know, we're in the midst now of 20 state measles outbreak. Measles was eliminated in the United States in 2000. We've had substantially more cases already this year than we did last year. It's probable that we're going to have more cases this year than we've had since we got to the stage in the '90s. The measles vaccine is one of the most efficacious vaccines we have, but it doesn't work if people don't get it.

Take influenza, which is something that's a high priority for me. Influenza last year took the lives of over 80,000 people in this country—or 79,000 something, almost 80,000 people in this country. This year, it's a much milder flu season, but we're going to lose somewhere between 50,000–60,000 people. If you want, just look back to 2008–2018, influenza caused the premature death of 360,000 people—that's more than seven times the people that lost their lives in the Vietnam War, from '50s all the way to the '70s. How does that happen? We have a vaccine!

Now, the flu vaccine is not perfect and we need to do more science to make it work better and better. It turns out to the efficacy of the flu vaccine for preventing flu infection is probably somewhere between, in general, between 40–60%. And so, a lot of the American public feel, "Well, I don't need the flu vaccine because it doesn't work."

But it's the wrong question. Ask the question of what's the efficacy of the flu vaccine in preventing death from flu? It's highly efficacious in preventing death from flu. And as I just mentioned, sadly 50,000–60,000 people are going to die of this year from flu, 80,000 last year, 360,000 in the last decade. And what those individuals have in common is the majority of them decided not to get the flu vaccine. Less than 50% of the American public get the flu vaccine.

We're going to try to get the message out that the flu vaccine is not just to prevent flu—it's to prevent death from flu. Obviously, we'd like to improve the flu vaccine so it actually has higher efficacy against infection, and I'm sure with investment and science that will happen.

Then you have other diseases like measles, where the vaccine is, like, 97% efficacious—it's one of the best vaccines we have. And yet, we have a growing population in the American public that aren't vaccinated. So, they are leaving science on a shelf.

One of my hopes as CDC director is to enter in a dialogue so that more and more people realize they don't want to leave science on the shelf for themselves, for their family, for their community, for their church, for their workplace. They want to get themselves to take advantage. Whether that science is to prevent measles, mumps, and rubella, or whether that science—

Another tragedy still today is women developing cervical cancer or men developing cancer, and women, of the oral pharynx due to human papillomavirus. Totally preventable now. Australia has now almost eliminated cervical cancer, right? And yet, you can't eliminate cervical cancer from human papillomavirus or oral cancer that occurs in both the men and women from human papillomavirus; you can't eliminate it if you don't use a vaccine. You know, here we have an anti-cancer vaccine. If I told you that we could vaccinate you against cancer, what would you do? You'd jump at it. And yet, here we have an anti-cancer vaccine and we still have less than 60% of the public that's at risk taking advantage of it.

So, again, this is really important, you hit it on the head. And, you know, science left on the shelf has no value, and we need to continue to work with the American public and the systems that we have in public health to remove the barriers to science on the shelf.

For vaccines, it's to recognize that many people aren't vaccinated because this is the fear they're afraid of making the mistake for their kids and loved ones. Others aren't vaccinated because they're truly misinformed. Some are not vaccinated because there are barriers in life—to take off from work to get the vaccines they want. And a very small minority are not vaccinated because they have some passionate aversion to vaccine. And we need to begin to enter an effect of dialogue with each of those groups. And hopefully, by the time, I finish as the CDC director, more and more of the American public decide not to leave science on the shelf in terms of vaccines for preventable diseases.

JOHNSON:
Let's talk about your life's work spent on the issue of HIV. Why have you spent so much time on that in your career?

REDFIELD:
Well, I got involved not because of any personal insight. Back when I finished my training in infectious disease at Walter Reed, I was working in the department of viral diseases. And in particular, one of my assignments was to worry about viruses that might be transmitted to soldiers, sailors, and airmen, either by blood or by sexual activity. So, when the AIDS epidemic began, someone above me in my chain of command said that I needed to start paying attention to this new epidemic of AIDS very rapidly as a physician.

The patients that had AIDS within largely the army and to some extent in other aspects of the defense department were sent to Walter Reed and I became their doctor. Rapidly, these men and women became my friends. And it wasn't easy being the doctor taking care of people that were basically five or 10 years younger than me, and I would do everything I could and, despite that, within a year or two they died.

You know, it's interesting. In my career, I went on to be an oncologist. I went on to be an oncologist, but I realized I didn't have the personal characteristics of being able to be a good doctor when, at the end of the day, I failed as a doctor—or what I believed to be was failure as a doctor—and patients died. And in the military, if you took care of patients with cancer—many of them, unfortunately, they were young individuals with leukemia, lymphoma, you know, in their twenties. And I just knew I just wasn't able to deal with the fact that I felt that we weren't successful in being able to keep these individuals alive.

Now, it turns out my own personal life—I ended up losing my first son, John Paul, and I went through the experience of seeing what it like and seeing medicine from a different angle. It was actually very cruel, and it actually—I always say sometimes through tragedy, good things come. Somehow, that experience changed my ability to be a better doctor and not define being a good doctor about whether my patients live, but whether I was a good doctor. And the men and women with AIDS in 1983, '84, '85, they were great teachers.

So, once you have that in your blood and—you know, I always had a passion for science, my mom and dad were scientists. I was very fortunate to be able to work with colleagues in NIH, be part of the early scientific work, to begin to see the power of science unravel this mysterious disease into an illness with a defined etiology, and rapidly was able to see the advancements be applied over the life cycle of the virus to bring new therapies.

I actually was part of the original first study and partnership with the NIH—they used ACT—I saw improvement, and I saw how science could be applied. And, you know, you carry that. Fast forward, now people with HIV infection live natural lifetime.

I saw the huge public health implications of this early. This was in 1984, '85. It was a sexually transmitted disease that was progressively fatal in a majority of individuals—probably in a decade's time—so it had an enormous impact. I obviously realized—though I'd lost my first son, I was gifted to have five more children—I sure didn't want to see one of my children die of AIDS. I thought it was very, very possible—I assumed sometime in life they would be sexually active—and so, became committed to it. Just became absorbed to not only take care of patients, which really was a great gift, probably the one thing I miss most about being CDC Director. And then, to be able to be part of the science that helped unravel this once devastating field of disease, to now have a disease with which you can live a natural lifetime.

And then, to see its consequences as I got introduced to Africa—and I saw through some of my early trips to Botswana and Malawi—I saw the devastating consequences of AIDS in Africa. This is when I then became committed that these advancements that we had in medicine in America and needed to be broadened, and was very proud of President Bush and his decision to bring PEPFAR to life.

I had an opportunity to be one of the programs that operationalized PEPFAR in 11 countries in Africa. We ended up treating over 700,000 people, and you saw the transformation of bringing science into the application, not leaving it on the shelf because it's too complicated to think about how you would actually do this in Africa. To realize that actually our success in treating people—we were much more successful in treating people in Africa than we were in Baltimore, in terms of once they got access to the medicines. You know, our ability to get viral suppression rates in most of Africa was over 85–90%. And we're still struggling in this country to get viral suppression rates up over 60%.

JOHNSON:
Here you are now with a president that wants to end HIV in America. You've got this as a priority and the budget. Talk about that and what it means to you to be leading the CDC with that goal.

REDFIELD:
Well, I think it's—really, it means everything to me. And to see President Trump take the leadership here and, as I like to say, see the possible and lead the nation to act. And Secretary Azar, to make this one of his major priorities and to see, then, the agencies between the NIH versus CDC, the Indian Health Service, and the assistant secretary of health all come together as a single organism and say, "You know, wait a minute, we have the tools to end this outbreak. Let's put those tools into action."

So, it's really another example of what I've said about put science into action.

We have all the science we need to end the AIDS epidemic in America. The challenge, as you mentioned, is how do you put the science into action to accomplish that. The president's decision to take the leadership; and the secretary, his decision to take the leadership to see that into reality. We're going to do that. And you're going to see that over the next 10 years, we're going to bring an end to the AIDS epidemic in America. Science wasn't the problem, we had the science; it's the leadership to operationalize the science so you don't leave it on the shelf.

And it's going to be hard, it's not going to be simple. But I can tell you we have a clear, decisive path and how to accomplish it. And I'm extremely confident that we will accomplish the goals that we have, which has to reduce new infections in America by 75% in the next five years and by 90% in the next 10 years. And finally be able to say that we're no longer leaving science on the shelf, we put an end to the AIDS epidemic in America. And hopefully, that will serve as a beacon to other countries to do the same.

JOHNSON:
Is the plan done? Are you still working on the plan? What's the status of this objective now?

REDFIELD:
So, the way this has evolved is first, you had to be able to translate what may have been seen by many as an aspirational goal to end the AIDS epidemic in America—which you alluded to it as something that's been with me for a long time, but I have to say aspirational—to convert that into something that wasn't once a dream, but now could be a reality.

And one of the things that happened is the AIDS epidemic in America at its peak, about 130,000 people got diagnosed or infected every year. Since 2012–13, we stagnated to about 40,000 a year. We're not making any progress, and that's despite having the tools where if you diagnose somebody and you treat them and they become undetectable for their amount of virus in their blood, not only are they now gonna live nearly a natural lifetime, but they're no longer infectious. So they can't transmit the virus, so the community refers to it as U equals U—undetectable means uninfectious.

And then, you couple it with an enormous advancement that happened recently was that no longer, if you are at risk for HIV infection, is your only tool to protect yourself from becoming infected—the only tool that you had in the past was the choices you made. Now, we had a biological mechanism. You could take advantage of taking a medicine we call PrEP. And if you take that medicine, the truth is even if you are exposed to HIV by a method known to efficiently transmit it, you will not become infected.

The question then is just to apply those two things.

When we looked in the United States and asked the question, "Where is the epidemic today of new infections?" I think it shocked all of us. I know it shocked me when the CDC experts brought me—I ask them to redo the analysis by looking not at per hundred thousand, but just map every one of those 40,000 people and show me where they are. Turns out, 50% of the new infections in America occurred in only 48 counties, District of Columbia, and Puerto Rico. If I showed you the map, you would say, "Wow!" You know, out of more than 3000 counties. And when that graphic was shown to everybody, everybody said, "Wow, this is aspirational. We can do this." And so, that's—obviously, the secretary recognized that, became a strong advocate. This is one of his major goals and was able to take the proposal to the president.

The way this is in the process of operationalizing is that these 50 jurisdictions now are identified, and now they are tasked to develop their strategy, how they think they can augment their ability to reduce new infections in their community. I always say this is a program that has to be developed by the community, for the community, in the community by these local jurisdictions. This is not a CDC plan. This is not a HHS plan. This is the president, and the secretary, and those of us in these agencies are providing the leadership, the motivation to work with these individual jurisdictions to help them develop their plan. We will carefully monitor and evaluate that plan.

Central to that plan is really five things. You've got to diagnose HIV infections. Sad to say that today about 50% of the people diagnosed last year had been infected for at least three years. It turns out tha 70% had actually seen a healthcare individually in the year prior to being diagnosed. So, there's unfortunately become a diagnostic complacency—15% of the people in our nation that are assumed to be with HIV are not diagnosed.

Second thing you gotta do is you've got to treat people. To treat people, you've got to get them into care, and you've got to keep them in care. And unfortunately in some communities, although some people are diagnosed, a lot of them don't stay in care. And that goes back to your earlier question about how hard it is to put science into action when you have it, 'cause you gotta treat people.

Third thing you have to do is you've got to give people at risk for HIV infection the tools to prevent themselves from becoming infected. We talk about comprehensive evidence-based prevention. For people that use IV drugs, that's access to safe syringe programs. I'm very proud of the state of Georgia, they recently signed the ability to provide safe syringe programs to help individuals at risk. For individuals that are sexually active at risk for HIV, it means access to PrEP. Turns out there's an estimated about 1.2 million or more individuals in our country at risk for HIV infection—less than 20% are currently getting access to comprehensive prevention. That's gotta change.

A fourth is when we do see occasionally hotspots of HIV transmission like we saw in Scott County. We need to recognize those early health—those health programs to be able to get a handle on it in those communities so the transmission can be curtailed.

And finally, the fifth element is we really do have an opportunity to build what we call the HIV workforce, both in terms of public health workforce and the medical workforce. I think it's going to be exciting to be part of something that we're actually doing to win, as opposed to just slog through it—we are actually going to win. And it's most important to develop an effective community work force that will be able to reach.

The other thing about the outbreak is that in America today, it's not only geographically very focal, but when you look at the people within those areas that acquire HIV, it's also very demographically focal. So, if you were to look at our progress, for example, in African American men who have sex with men, you would say we're doing pretty well, 'cause it's starting to come down. But if you redid the analysis by age, you would find out between the ages of 25 and 34, it's up over 60%. So, we're not doing very well in that group. Or if you looked at Latino men who have sex with men, we have had a slight increase. But if you look at Latino men between the ages of 25 and 34, we've had almost 68% increase. So, there's pockets where we're not doing so well. So, we're not only going to focus geographically in these 50 jurisdictions, but we're also going to focus demographically. And I think by using data, putting it into action, we're going to be able to make major impact.

The last thing I'll say about the initiative is that we recognize that some of the HIV infection in this nation is not confined to urban environments. So, those 50 jurisdictions are all urban environments. We do have the complexity of HIV in rural America. And so, in addition, we did an analysis of those states that were rural, those areas that most of their HIV acquisition was rural, and those that had the most rural HIV acquisition. And they identified seven states—they all happen to be in the South—which we've also included in this initiative so we can begin to learn how to be effective in a progressively eliminating new HIV infections also in rural areas where the complexity is different.

You know, obviously the issue of stigma is very high in some of these areas, particularly in some of the tribal nations, and we need to learn how to be more effective in that environment. And one of the things I've always said—and we talk about with opioids—to remind people that stigma really has no place in public health. That's the enemy of public health. You've really got to get people to understand the subtle ways that we stigmatize, and we really need to move away from having stigma having a negative impact about whether people choose to get access to comprehensive prevention or, in some cases, that inhibits people to choose to go and get access to treatment.

JOHNSON:
It's a big barrier.

REDFIELD:
Huge barrier.

JOHNSON:
Did you think when you took this job—maybe you did because you've been in this kind of work most of your life—that communication would be such a big piece of it? You know, all the science of it, getting people to agree to go see a doctor, getting them to be willing to get the vaccination, all of these things—so much of it is more like social and behavioral science than it is actual science, isn't it?

REDFIELD:
Well, communication is the key. And I think as CDC director, I am becoming almost everyday, become more and more aware of how important it is. I mean, people like yourselves—obviously we've talked about people in the media. They're key to be able to get out the accurate public health message and how to effectively communicate to people in a language that they hear. You know, you've probably known that there are a lot of great communicators, and people hear things differently. So, you really do need to learn how.

It was easier for me in my early career because I was an officer in the United States Army in infectious disease. And once I'd develop a proposal—for example, how we might be able to prevent hepatitis B infection in men and women being assigned to Korea—I just had to convince the head of infectious disease for the army, the surgeon general, and then, eventually, the armed forces epidemiology board, and it was a done deal.

Much different in the real world, okay, where you have to figure out how you translate your public health message in a manner which then gets converted to action by the individual in the public. And I think the great example of the challenges we have there are what we talked about earlier—you know, the full embracement of vaccination for preventable diseases.

It's really a really important part, how to effectively communicate. I think you've seen some of the CDC campaigns that we have right now—for example, in tobacco—and I think, you know, really getting people to tell their story quickly, some of those ads are pretty compelling. I think you're going to see, you know, similar attempts in the opioid epidemic and drug overdose epidemic. I think we have to do the same thing for vaccines: let the American public and parents know the complications that have occurred in families that have chosen to be timid about vaccination.

So yeah, the communication is critical, obviously, at a time of crisis. You know, I hope nothing happens during my watch; but if it does, communication is really, really critical to making sure the American public is informed effectively so we can all pull together and to work through whatever crisis comes.

JOHNSON:
Let's talk about opioids now. You've referred to that quickly a couple of times today. What's the latest thinking on how to attack this problem?

REDFIELD:
Well, I think first and foremost, the most important thing is for us to acknowledge and believe what I say in our hearts is that, you know, addiction—whether it's opioids or whether it's amphetamines or other issues—that addiction is a chronic medical condition. It's not a moral failing. It's personal to me, and people know—you learn a lot when you experience things in your own family. I was a doctor in Baltimore. I probably cared for hundreds and hundreds of individuals with heroin addiction and other addictions. I thought I understood addiction as well as anybody. I was chair in medicine at one of the hospitals, I had a division of addiction medicine. You know, I'd say, you know, sometimes maybe 50% of the patient population we served in our HIV clinic had addiction issues.

I thought I knew addiction cold—until it enters your own family. And then, you see it from a different angle. First, you see someone that you love very dearly ashamed of who they are. Nothing saddens me more than to see anyone ashamed of who they are. They are who they are, they're—the ultimate joy in life is to be proud of who you are, whatever you are. And to see people stripped away of that because of these labels—you know, I don't like the word addict. I think it's stigmatizing. I think the way we handle addiction in general is stigmatizing. I think when you have somebody with a dependency on, say, opioids, and the first thing you say, "You're an addict. You need to go see a psychiatrist and get into a detox program," that's very stigmatizing.

I tried hard to bring addiction medicine back into a primary medical care. That's where I think of belongs, and that's where I really came to understand—much more so than I ever understood in the 20 something years I was an AIDS doctor—that stigma has no place in public health. And to rebuild the ability for individuals that are struggling to overcome addiction, to rebuild their confidence in who they are, and for them to recognize that their condition is a medical condition. And yes, it's a chronic medical condition; and yes, as a chronic medical condition that may relapse. But we don't make people with neoplastic disease that go into remission all of a sudden feel very bad about themselves 'cause they have a relapse of cancer. But I will tell you I've witnessed so many people that put the burden of relapse on the individual rather than the condition.

So, one of the things that I like to emphasize and continue to emphasize is that addiction is a chronic medical condition. It's not a moral failing. And I do think we have to be much more aggressiv, and I'm very excited the president's made this a priority. We are seeing progress. The secretary has made this one of his four major pillars. CDC is obviously an important component of that, but I think really fundamental to it, at the broader sense—we can talk more about what CDC is doing if you're interested—but the broader sense is bringing treatment to people that have addiction and bringing treatment that works.

When my own family member was confronted with this—I have two other children that are doctors and both of them made sure I understood at the time that it was unlikely that their sibling was not going to go through recurrent treatment failure, because that's just reality, and to get prepared for it. My view is that treatment success should be the rule, not the exception.

So, this week we're going to celebrate because my child went into recovery on Easter Sunday four years ago. So, this is going to be four years are in recovery, and actually is going to be joining us this week. So, we're going to celebrate. Everyone should be celebrating that. Treatment success should be the rule, not the exception.

One of the reasons I am an advocate for safe syringe programs is obviously it has an enormous impact on whether you get HIV or hepatitis C. But what many people don't know is it also has an impact—if you just go to a safe syringe program, you are five times more likely to go on treatment for your addiction. And if you do go in treatment, you're two times more likely to succeed for the long haul. So, why not expand that when we're dealing with what I call the public health crisis of our time, which is the opioid epidemic.

You know, I didn't think as a CDC director trained in infectious diseases that I'd be coming down the leading control of an epidemic that wasn't an infectious disease. But the reality is the epidemic of our time is the opioid epidemic. The same thing that we saw back in the '80s—and those people who saw that if we apply the science, what was all too often a fatal disease in young people. Now, if we saw a progressive improvement today, you can live a natural lifetime. And if you do get exposed to HIV, don't have to be infected cause there's ways to prevent it. That same understanding that science is going to solve the problem has to be here as we confront addiction in America, particularly opioid addiction, but also amphetamine addiction.

The science is going to solve the problem. But as science gets the tools to solve the problem, we in society need to confront the problem. And that's why we need to do the diagnosis surveillance that we do and make sure we understand the extent of the problem. We need to get treatment out wherever it's needed.

I mean, I was literally taking the train the other day. When I'm in Washington and I have to work, I frequently stay in Baltimore, and then I take the train into Washington for my meetings. Up in the front of the train, there was a, you know, a very business-dressed individual, a woman probably in her mid-thirties that was getting CPR by an individual. You know, I thought it was—I couldn't tell the age at the time, so I thought it was an older individual that probably had a heart attack. And I was way in the back, and there were already like three doctors over there and they're doing CPR. And then, eventually the train stopped at New Carrollton and an EMT team came on and they continued the CPR. And then about 10 minutes later, another emergency medical team came on and this one, there was a young individual—probably in their 25s—they have something in their hand and they put something in the person's nose. And all of a sudden, this was now not a 70-year-old heart attack. All of a sudden, this 35-, 37-year-old well-dressed individual going to work, stood up after being resuscitated for over 20 minutes. It was a drug overdose.

So I think, you know, the current opioid epidemic is, as I said, it is the public health crisis of our time. We are going to beat this epidemic, science is going to give us the tools to do it; but in the meanwhile, we have to have the courage. And when I would ask people that are listening, having been through it at a personal level—everyone in our society, we really need people to support and help ot only the individual that's confronting recovery from addiction, but don't underestimate to support the family's need to confront addiction. Addiction has so much potential to destroy families. The antithesis is to have so much potential to bring families together and have families be supported to win the battle against the addiction.

JOHNSON:
Speaking of winning battles: so much of this battle, whether it's opioids or other drug issues—frankly, any issue that you're dealing with—it's all happening out in the states and the cities and the counties.

What do you need from those public health professionals, or what can you do to help them? How does that relationship work in your mind, and how's it going?

REDFIELD:
Well, it's critical. I mean, the reality is the public health infrastructure of our nation is defined by local, county, tribal, territorial, and the state health departments. What many people don't realize—and you know, it's important for people to realize this, including people that are on the Hill—is that much of the infrastructure and funding for that local, city, county, territorial, tribal, state health department actually comes from the Centers for Disease Control. You know, a majority of our funding goes out to support those health departments. They are the front lines of public health, and we operationalize whatever public health initiatives that we have obviously through the local public health community. And whatever observations that are made of what needs to be done from the field then gets communicated back here, and we try to figure out how it is to do it.

So, that is the public health infrastructure over the country. So, it's integrated, it's really a complement to that. My predecessors over the previous 70 years, they've successfully built in the subject matter experts here and the health officials in the states, tribal, local, county, territorial health departments—they all have enormous respect for one another. I mean, I would say CDC has high regard for the local, at the local level, and I would say vice-versa.

You know, the ability for us to confront the measles outbreak right now—at the front lines of that are the health departments that are confronted in the 20 states that we currently have it. We're there to help provide technical assistance, we're there to help develop new diagnostics that we can get into their public health laboratories.

We're there to help augment their workforce. We have a wonderful program that my predecessor Tom Frieden started called the Public Health Associate Program, where we take young people out of college who think that they may want to get involved in public health, and the local jurisdictions can apply to get several of them to go work for two years in their health departments. And then, that stimulates them to understand what's next for them: is it public health, is it epidemiology, is it that they want to go to medical school, they want to stay working in the health department, or they want to just to be thankful that they've got a better idea of public health and go on to something else. So, you know, we have the ability to help them.

We also have the ability to help build systems that help them with surveillance. Opioids is a great example. When I came here, the turnaround time for understanding what the extent of the overdose epidemic was, at least at a national level, was about two years—very hard to respond to a problem when you're using data that's a couple years old. It's very hard to take the point of view of putting data into action when the data you're using is probably no longer actionable. I can tell you today, it's 48 hours. Now, we didn't make that happen—the states made that happen, the cities made that happen, the local counties made that happen. Actually in the state of Oklahoma, it's the same day, real time.

So again, this is a really important partnership, whether it's in surveillance, whether it's in laboratory, whether it's in the workforce, and whether it's in coordinating our response across the globe. When it comes to the president's HIV initiative, at the end of the day, that's all going to be operationalized by local health departments. In the context of, as I said, in communities, by the community, for the community, in the community. That's where it is going to happen.

JOHNSON:
Before we wrap up, let's talk quickly about the next 18 months. What are you hoping to accomplish in your role at CDC as the nation's top public health official?

REDFIELD:
I think, you know, those individuals that are privileged to get the opportunity—and it truly is an opportunity of a lifetime. As I said, I love science, I love data. I didn't realize how much I missed service. I'm surrounded by really wonderful human beings that are here for service. I had that when I was in the Walter Reed; but when I went into academia, it's a different environment. I'm surrounded by service.

And you do have to look at, you know, what do you think you can accomplish that has lasting value? Obviously, one of my primary hopes and prayers and dreams was to be part of helping galvanize our nation to have an initiative to bring in the AIDS epidemic to an end, and obviously seeing and doing our part to help operationalize that. Again, enormously appreciative to President Trump and Secretary Azar for their leadership to see the possible and lead to do that.

I think the second thing for me right now that I'm really want to do is stay on the theme of not leaving science on the shelf. And so, let's get the American public to accept vaccination. It really saddens me to see literally tens of thousands of people die each year from flu because they don't get flu vaccine, or to hear what we're now dealing with with measles, or to see another woman diagnosed with cervical cancer when I know that it didn't have to happen, or a young man developed oral pharyngeal cancer because of human papillomavirus. So I think, you know, that's going to be a big one for me.

I think I would like to make sure that I can do my part to ensure that CDC has a global health security, global health threat structure, and domestic preparedness structure that's going to serve this nation for decades beyond. I say that global health security is something that we're going to need in this nation as long as we're a nation. Global health development programs will come and go, but global health security, we need it for as long as we're a nation.

I will argue that one of the CDC's core missions is just to keep the American public safe. And one of the key challenges for us to do that is to have a sustainable foundation on a global scale to confront global health threats. And to continue with our domestic preparedness, which you already alluded to, is fundamental to our partnership—making sure the local, and the county, you know, the tribal, territorial, and state health departments are strong because they are domestic preparedness and we're there to help them do that.

I think I would like to then—if we can get others to see the possible on some other key areas. One of them for me is—as I mentioned already, I love the 21st Century Cure Act, but I want to implement the cure. It does bother me as someone who spent my life in clinical neurology to know that we've had a cure for hepatitis C since 2013, but 18,000 people died of hepatitis C last year, that less than probably 70% of the people living in our nation with hepatitis C haven't been treated yet. To try to see how we could figure out how to get that done.

Obviously we want to then encourage people to look at our strategic plan. We have goals to have the American public make meaningful progress in diabetes. Obviously I think we're—we've got challenges with vector-borne diseases and tick-borne diseases, trying to establish meaningful programs that begin to make a meaningful impact.

The challenge with a job like this is you'd like to have it for 20 years, because then you could see a lot of things through. The challenge then is to understand what are the foundations you can lay that are going to make sure in 20 years or so those things happen. And that's kind of what I've been trying to focus on—laying the foundations for meaningful action, where science is put into action to improve the public health of the American public.I think the HIV initiative, the vaccine initiative, the global health security initiative, and then looking carefully at some other issues.

Fundamental to that is to sort of recalibrate the agency itself to be able to have the resources it needs for its key core capabilities, which is data analytics: we need to be predictive with data and not reactive with data. We need laboratory capacity. You know, you are seeing more foodborne illnesses defined in the press. Really it's not because they are more, it's that we finally got laboratory capacity to detect them. Well, we need to do that in many other areas also. We need to stimulate young people to want to go into public health. And, and then obviously I mentioned the global health security.

I will say one thing before I close. I'm excited that I think we're about to see a transformation of public health in America. And what I mean by that is what I said about the opioid surveillance systems, where we went from data that was maybe one or two years old to data now that's measured in days.

How did that happen? What happened because of the states and jurisdictions, along with CDC, adopted a new way of doing surveillance. The old way was, you know, a doctor would see a problem, they'd call it up and report it to a health department. The health department, they have forms filled out, and then we'd go back to the health department. Eventually, it would make its way to some consolidated data report.

What's happening now with syndromic surveillance is electronic medical records are being utilized to define the surveillance. So, what that really means is we have a whole new cadre of public health workers. We're about to change the whole system. The key frontline public health workers now are no longer the city health department. They're actually the doctors, nurses, PAs, nurse practitioners, social workers that are filling out the electronic medical records and those electronic medical records now are a very important public health tool for the front lines. It's going to change the whole way we look at public health.

I know many years ago, I was always a critic of the Flexner report—obviously a brilliant man from Hopkins back in the '20s—but what they did at that time was made a strong argument that public health schools have to be separated from medical schools. I would make a strong argument that public health is intrinsic to the practice of medicine. It needs to be fully reintegrated with the practice of medicine. It's not a separate discipline. We need the expertise of those people trained in public health at the highest level, but we need to reintegrate public health into every individual that's practicing in the aspect of medicine.

Sort of what's exciting about the future for me—the most exciting thing about public health for the future is that transformation, that all of a sudden we have just enhanced the public health workforce geometrically. We've developed a system now by extrapolating electronic medical records and laboratory information at its source that basically is going to be a powerful tool for public health leaders in the future. And I think it's going to open up unbelievable opportunities to make progressive step-wise improvement in public health, even in complex situations like obesity, diabetes, addiction.

The truth is the infectious disease areas are easier because we have clear solutions, but I think in these more complex areas—particularly those that we're now realizing are more influenced by what we call the social determinants of health—these are going to be so dependent on this broader surveillance strategy that fully engages the full capacity of medicine in our nation and direct that towards public health.

JOHNSON:
It's a pleasure to meet you and to have this opportunity, and I hope that maybe we'll get to do it again.

REDFIELD:
Thank you, Robert. Thank you very much.

JOHNSON:
The CDC's Strategic Framework headlines the agency's priorities as a bold promise to the nation. The Plan and CDC's FY 2020 budget proposal are detailed online. You can find links to these documents in the show notes for this episode.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues.

And if you have comments or questions, we'd like to hear from you. Email us at pr@astho.org—that's PR at ASTHO dot org.

This show is a production of the Association of State and Territorial Health Officials.

For Public Health Review, I'm Robert Johnson. Be well.