See, Believe, Create: Dr. Frieden’s Health Leadership Formula

Dr. Tom Frieden, former director of the Centers for Disease Control (CDC) and author of "Formula for Better Health: How to Save Millions of Lives, Including Your Own," joined Professor Brian Lowry for a discussion on leadership in divisive times. Dr. Frieden shared insights from his career transition from infectious disease physician to public health official, his "See, Believe, Create" formula for health, and his experiences during the COVID-19 pandemic.

From Individual Care to Public Health

Dr. Frieden's journey into public health was shaped by his work in tuberculosis control in New York City during the height of the HIV-TB epidemic. He realized that while individual patient care is crucial, it's insufficient if societal and governmental efforts to control diseases are lacking. Public health, he explained, is about supporting communities and individuals to maximize health within available resources, considering community preferences and involvement.

The "See, Believe, Create" Formula for Better Health

Dr. Frieden's book introduces a three-part formula for saving lives and improving health:

1. See the Invisible: This involves identifying trends in microbes, toxins, or program successes and failures. It also means understanding why action isn't taken on these trends and discerning the technically rigorous path to progress, rather than relying on hunches.
2. Believe the Impossible: This step encourages shattering the illusion of inevitability. Many societal issues seem fixed, but often, they don't have to be. It involves systematically strengthening belief in the possibility of change.
3. Create a Healthier Future: The most challenging part, this involves collaborative efforts to organize effectively, simplify processes, communicate clearly, and overcome barriers. Health programs invariably face obstacles, but systematic approaches can help surmount them.

This formula can be applied to public health to prevent future pandemics and to individual health for a long, healthy life.

Involvement in the COVID-19 Pandemic

During the COVID-19 pandemic, Dr. Frieden was no longer at the CDC but was leading Resolve to Save Lives, an organization he founded. His organization partnered with dozens of countries, particularly in Africa, to strengthen incident management systems and facilitate rapid responses. He noted the tragic lack of a structured response from the U.S. government in 2020.

As a former CDC director, Dr. Frieden received numerous media requests when the CDC was effectively silenced. He used these opportunities to promote a fact-based approach to COVID-19, filling a void left by the CDC's inability to communicate directly with the public. He believes there hasn't been a full reckoning of what went right and wrong during the pandemic, and what needs to be done for a healthier, safer future.

Communicating Evolving Science and Uncertainty

A significant challenge during the pandemic was the constantly changing guidance on issues like masks and vaccines. Dr. Frieden emphasized that science is not static; it evolves. Effective communication in such situations requires starting every discussion with: "Based on what we know now, here's what we recommend, and this might change." He recalled Dr. Nancy Messonnier's accurate but politically unpopular warnings in early 2020, which led to the CDC's silencing.

He stressed the importance of leveling with people: telling them what is known, what isn't known, how knowledge is acquired, and what steps are being taken to learn more. He categorizes scientific certainty into:

• Virtually certain: Highly established facts (e.g., smoking's link to death).
• Strong scientific evidence: Supported by robust studies, though not infallible.
• Some scientific evidence: At least one well-done study, but potentially incorrect.
• Hunches: A mix of misinformation, wishful thinking, and unproven or disproven ideas.

He highlighted that good science fosters humility, not absolute certainty, and that the public needs to understand these degrees of certainty.

Navigating Political Viability and Community Differences

The challenge of asking the public to make significant sacrifices (e.g., not going out, avoiding gatherings) when scientific certainty is still developing is politically complex. Dr. Frieden believes effective communication, starting with listening, is key. Understanding what people hear, see, believe, and their information sources is crucial.

He advocated for a risk alert level framework, similar to ozone levels or wildfire risk, where objective data (e.g., COVID-19 prevalence, hospitalizations, deaths) informs community-level decisions. Different communities, even at the same risk level, might make different choices based on their values and priorities.

Regarding diverse communities, Dr. Frieden shared an example from his time as New York City's health commissioner. His team mapped 41 distinct communities based on language, immigration, culture, politics, and geography. They then identified information and decision architectures within each community, including opinion leaders and institutions, to facilitate engagement before emergencies arose. Public health, he noted, must reach all segments of society, including those who feel disaffected or distrustful of government.

Addressing Political Polarization and Building Trust

Public health is inherently political, involving decisions on issues like taxation of unhealthy products, environmental regulations, and policies to reduce drunk driving. Dr. Frieden lamented the rise of partisanship and emphasized the need to build trust through better communication, highlighting shared values, and connecting through stories.

He recounted a meeting with vaccine-skeptical Trump voters, organized by the Debont Foundation and Frank Luntz. He learned that these individuals felt deeply disaffected and that their reasonable questions about vaccine development and safety had been ignored or met with vilification. He stressed the importance of answering such questions respectfully.

Despite polarization, Dr. Frieden pointed out that a significant majority still supports vaccines. A recent poll showed 84% believe vaccines are safe and effective for children, with only a small difference between Democrats (93%) and Republicans (81%). This indicates a substantial common ground that can be built upon.

Individual Choice vs. Community Welfare

The tension between individual choice and community outcomes is a recurring theme in public health. Dr. Frieden outlined three fundamental areas where government plays an essential role:

1. Information Sharing: Providing accurate data, requiring disclosures, and testing environmental factors or drug safety.
2. Protection from Others' Harms: Regulating activities that harm others, such as pollution or drunk driving.
3. Collective Action: Addressing issues more effectively as a community, like providing safe drinking water.

He clarified that these governmental roles do not absolve individuals of personal responsibility for their health (e.g., exercise, sun protection).

Leadership in a Fraught Moment

For leaders navigating current challenges, Dr. Frieden advises situational leadership, understanding the environment and context. He emphasizes identifying "winnable battles"—issues that can be addressed with effort and are not futile.

He shared advice from James Q. Wilson, a prominent government analyst: leaders must secure support from outside government to implement and sustain initiatives. Resolve to Save Lives embodies this by strengthening the public sector, empowering civil society to advocate for and support the public sector, and enhancing monitoring to ensure accountability and progress.

Dr. Frieden concluded by encouraging students and listeners, emphasizing that despite current difficulties, there is immense potential for progress in public health. He believes that using skills for good can improve society, enhance health, and lead to greater personal fulfillment.