Johns Hopkins Bloomberg School of Public Health
Convocation – May 19, 2015
Speaker: Dr. Tom Frieden
Director of the Centers for Disease Control and Prevention
TRANSCRIPT
Dr. Michael Klag:
I now have the honor to introduce our convocation speaker, one of the world’s outstanding
leaders in public health. Dr. Tom Frieden was appointed by President Barack Obama to direct
the Center for Disease Control and Prevention in June 2009. As the director of our nation’s
health protection agency, he works to control health threats from infectious diseases, respond to
public health emergencies, and tackle the leading causes of suffering and death in the US and
around the world. Dr. Frieden started his career as an epidemiologic intelligence service officer,
assigned to New York City. He led New York’s tuberculosis control program to success by
reducing multi-drug-resistant cases by 80%. Afterwards, he worked in India to building a
tuberculosis control program that has saved three million lives.
Dr. Frieden returned to New York to serve as the Commissioner of the New York City Health
Department from 2002 to 2009, where he led the effort to reduce smoking, eliminate trans fat
from restaurants, and initiate the country’s largest community-based electronic health records
project. Dr. Frieden received his undergraduate degree from Oberlin College and his MD and
MPH degrees from Columbia University. He completed residency training in internal medicine
at Columbia Presbyterian Medical Center with a fellowship in infectious diseases at Yale
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University. He has received numerous awards and honors, and has published more than 200
scientific articles.
We are privileged to have with us today a visionary leader who has profoundly improved the
health of people around the world and saved lives. Please join me in giving a warm welcome to
Dr. Tom Frieden. (applause)
Dr. Tom Frieden:
Welcome, and thank you so much for allowing me to be with you here for a few moments to
recognize your accomplishments. I want to also recognize not just the students, but the faculty,
the staff, the community, and most of all, the parents. So don’t forget to thank your parents,
especially if you may need to move back in with them after graduation. I’d like to start with a
confession: I actually get quite nervous about giving commencement addresses. A
commencement speaker is kind of like the person who sings “The Star Spangled Banner” at the
World Series. Nobody came to hear you, (laughter) and you’ll only be remembered if you mess
it up. (laughter) Now I saw Mike Bloomberg last week, and he put me at ease. He assured me
that I would do fine, and reminded me that if I didn’t, it would destroy Hopkins forever.
(laughter)
In June of 1979, while I was in college, I went on a hiking trip with my father in the Blue Ridge
Mountains of Virginia, not far from here. The rhododendron were in glorious bloom. My father
was dealing with the onset of Parkinson’s disease. And we walked through the mountains on a
glorious summer day, and he commented that he was struck by the fact that when he walked in
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that quiet, beautiful countryside, he could almost feel free from the stiffness of Parkinson’s
disease. He was a wonderful cardiologist. He was a doctor’s doctor. He was a kind and
rigorous. He didn’t say much, but what he said always had a big impact. And as we walked
along, he said, “You know, I’ve noticed that you like science and you like politics. And if you
put those two together, you really have the field of public health. You might want to consider
going into that as a career.” [For the?] first time, I had heard of public health, either as a career,
or even as a phrase.
Now exactly 100 years ago, in 1915, the Welch-Rose Report called for the creation of schools of
public health training. The report reflected the different perspectives of Welch, who wanted to
focus on research, and Rose, who wanted to focus on practice. But in fact, research and practice
are not a true dichotomy. If there is one thing that I hope you’ll remember from these few words
that stand between you and your diplomas, it is the importance of practicing interventional
epidemiology throughout your careers. (laughter) Now interventional epidemiology will never
be as lucrative as interventional cardiology or interventional radiology, (laughter) but it will save
many times more lives. Our goal is not merely to study the world, but to change it. And to do
that, both research and practice, both science and politics, are essential.
I’d like to tell you about two questions. One of them changed my life and one of them enabled
public health to save millions of lives. On March 9th of 1993, a man named Karel Styblo came to
New York City and reviewed the Tuberculosis Control Program, which I had been running for
nearly a year. Overnight, he reviewed an information summary booklet that I had written and
produced. And the next morning, he pointed out to me, to my great chagrin, many aspects of the
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epidemiology of tuberculosis that I had missed, but were apparent to him from reviewing that
information summary. He then asked me, “Dr. Frieden, this book tells me a lot, but it doesn’t
tell me the single most important thing.” And I was quite offended. I said, “Well, what’s that?”
“That last year, you diagnosed 3,811 patients in New York City with tuberculosis.” And I said,
“Yes.” And he said, “Well, how many of them did you cure?” And I didn’t know. I couldn’t
answer the question. And I was terribly ashamed, and the next day, I began a system of cohort
review to monitor the progress and outcome of every single patient diagnosed with tuberculosis
in New York City, a system, incidentally, which would greatly benefit our healthcare system for
many conditions, ranging from HIV to hypertension to diabetes.
Globally, because of Styblo’s work, more than 50 million patients have had their care rigorously
monitored. Eleven million people who would have died from tuberculosis have been cured.
And this was done because of this rigorous and systematic evaluation of the outcome of each and
every patient, along with effective program management to respond to what that rigorous
evaluation showed. Program without evaluation is often rudderless, but evaluation without
program is all together pointless.
Five years later, working in New Delhi, supporting the National Tuberculosis Control Program,
we had made some progress, but the program was stalled because of bureaucratic infighting and
corruption. It could only be unstuck with political intervention. And in the Indian version of ‘I
know a guy who knows a guy,’ my Indian counterpart knew a politician who could get a
message to the prime minister who would read it on the floor of parliament the next morning,
and that would create enough pressure to get the program unstuck. But it had to be exactly right.
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And so it was that after four years of college, four years of medical school, three years of internal
medicine training and infectious disease fellowship, two years of epidemic intelligence service,
five years running the program in New York City, and two years in India, and 19 years after that
walk in the -- on the trails of the Blue Ridge Mountains, I found myself at ten o’clock at night,
crouching out of sight in the back of a drab, beaten up, ambassador brand car in New Delhi, with
a laptop computer and portable printer to rework the paragraph, if needed. In public health, you
have to do whatever it takes to succeed. The speech worked, the program got started again, and
India has now prevented more than three million deaths from tuberculosis. Politics and science
are both necessary ingredients to interventional epidemiology.
Now to the second question. Soon after I became New York City Health Commissioner, I
crafted a proposal to make the city smoke-free. I pitched that to Mayor Bloomberg, who
reviewed it carefully, and then asked me, after the preliminaries, one essential question: was I
certain that this would save lives? And because of the rigor of the epidemiologic studies of
smoke-free ordinances, I was able to reply with absolute certainty, yes. And he said, “Then we’ll
do it.” Now I tried to warn him that it was going to be pretty controversial, and I described the
kind of opposition we would get. And he cut me off right away, and he said, “Do you know
what the first rule of sales is?” And I said no. He said, “Once you make the sale, leave.”
(laughter)
Politics, like public health, is the art of the possible. Unfortunately, there are a limited number of
times where you can have a confluence of opportunities to make rapid progress. And the
historian John Duffy, who analyzed public health over the years, wrote that “encountering
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apathy, ignorance, and avarice is the lot of all conscientious health officers.” As preventive
measures in the health area are more successful, the public is less inclined to support programs
which ensure this success. Interventional epidemiology uses valid, rigorous science to drive
progress through program, evaluation, and legislation. When Mike Bloomberg took tobacco
control global, science and politics, program and evaluation, have combined to prevent more
than 12 million deaths, including close to five million from smoke-free ordinances, which now
protect a billion more people than when the program was launched, in 49 countries, including
places such as Brazil, Turkey, and even Russia, in 28 of the world’s 100 largest cities, including
exotic places, such as Hong Kong, Jakarta, and Houston. Next week, on June 1, Beijing will
become smoke free, at least tobacco smoke free. (laughter) A rough calculation suggests that
Mike Bloomberg’s investment in global tobacco control will save as many lives as many of the
most successful public health programs in history and will do so at a cost of less than $50 per life
saved.
The world’s first Ebola epidemic provided another example of the critical importance of
interventional epidemiology. The epidemic has gone through phases: first, delayed recognition
and response, a failure of politics and of science on the part of these countries and on the part of
the world. Next, the exponential increase in Ebola and the world’s first urban Ebola epidemic.
Following that, breaking the back of exponential growth of the epidemic through mobilization of
global resources to provide, and sensitive community outreach to encourage the acceptance of
safe care and, when necessary, safe burial. The next phase has been track and traced – core
classic public health work of finding cases, finding contacts, monitoring them, gaining their trust,
ensuring that if they become sick, they’re promptly cared for. In this latest Ebola phase, the
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urban poverty pockets have become the last areas where Ebola has spread. In Liberia, an area
known as the St. Paul Ridge area harbored many patients who didn’t trust society. They didn’t
come forward. They had the confluence of poverty, unemployment, alienation from government,
poor housing, and illegal activities. And that called for enormous hard work and sensitivity of
community members, Liberian health workers, epidemiologists from the Centers for Disease
Control and Prevention, and many others to find the chains of transition to provide the sensitive
outreach, and ultimately, to stop the outbreak.
I know that all of you are focused, engaged, and committed to addressing the root causes of
inequality and ill health in Baltimore and elsewhere. Cities have a very special role to play in
this effort. It’s not enough to mean well. We have to have effective programs. The road to hell
is truly paved with good intentions. We not only need to scale up the implementation of
evidence-based practices. We need to expand practice-based evidence: trying things, joining
coalitions, seeing what works, rigorously evaluating through both science and politics, programs
to attack the roots of inequality. Albert Schweitzer wrote that “I don’t know what your destiny
will be, but one thing I do know, the only ones among you who will be truly happy are those who
have sought and found how to serve.” The right time for public health is now. The right time for
interventional epidemiology is now. There’s never been a clearer understanding of both the need
and the importance of our field.
On my first day of medical school, the dean told us that half of everything we would learn would
be wrong, but since they didn’t know which half it was, we would be tested on all of it.
(laughter) On this, the last day of this phase of your public health training, I think the good news
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is that there is so much still to be learned. Through both science and politics, through both
knowing more and doing more, we can, with interventional epidemiology, save millions more
lives. Thank you. (applause)
Dr. Michael Klag:
So please join me in thanking Tom for an inspirational talk. (inaudible)
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