Tom Frieden on Trump and RFK Jr.’s Attack on Public Health

When Donald Trump vowed to let Robert F. Kennedy Jr. “go wild” on America’s health in October, he meant it. The Health and Human Services secretary has overseen a bloodbath at America’s public-health agencies during his brief tenure: More than 2,400 people were laid off at the Centers for Disease Control, which currently has no director, and 10,000 at HHS. Though some staffers have since been rehired, the widespread cuts, carried out in chaotic and indiscriminate-seeming fashion, have laid siege to some of the agencies’ core functions. The DOGE-ified federal government has also canceled or impeded billions of dollars in health grants and cynically frozen crucial funding to institutions like Harvard. RFK Jr. himself has used his powerful perch to cast doubt on the efficacy of vaccines amid a measles outbreak among other dubious claims. Recently, he fired all members of the esteemed Advisory Committee on Immunization Practices (ACIP), which sets recommendations for vaccines nationwide, and replaced them with eight handpicked members, multiple of whom have expressed anti-vaccine views.

Just how badly has the Trump administration damaged American health care over a mere five months? To get a sense, I spoke with Tom Frieden, who served as the CDC director for almost the entirety of Barack Obama’s presidency. Before that, he was New York City’s health commissioner (he oversaw the ban on smoking in bars and restaurants). Since 2017, Frieden has been the president and CEO of Resolve to Save Lives, a global organization that combats epidemics and cardiovascular disease and promotes healthy eating. He is also the author of a forthcoming book, The Formula for Better Health: How to Save Millions of Lives — Including Your Own.

RFK Jr. has unilaterally fired all the members of the ACIP and replaced them with eight new people, some of whom are pretty heavily involved in the anti-vax movement. I wanted to get your initial reaction to these new picks. Maybe I’m putting words in your mouth, but were they as bad as you feared?
I don’t want to speak about the individuals; I think the broader issue is what ACIP is and why it’s important. ACIP has been a model for evidence-based, transparent, fact-based decisions on whom to recommend vaccines to for decades — it’s been around for 60 years. When I was CDC director for nearly eight years, people came from all over the world to watch the ACIP meetings because the quality of evidence being presented, the clarity with which it was presented, the openness of discussions, and the involvement of pediatricians and parents and others in the process were truly models of effective policymaking. And that’s why essentially every doctor in America used the ACIP to decide whom to recommend vaccines to. That process has been completely upended, and it was upended based on at least two untrue assertions.

The first is that there were terrible conflicts of interest — Secretary Kennedy refers to a 2009 report. I was the recipient of that report when I was CDC director, so I remember it. Secretary Kennedy has portrayed that report as saying that 97 percent of ACIP had severe conflicts of interest. What the report actually showed was that 97 percent had some problem or other with a form they filled out, not that anyone had a conflict of interest. Before I became CDC director, I was on an advisory committee, and I had to fill out that form. It is an incredibly tedious form. It makes your income taxes look easy. If you forget to initial every page, it counts as a lapse, and that’s the kind of administrative problem that was found. It is true that there were problems with the process. For example, the person guiding people to fill out those forms was not as highly trained as they should have been. They were a lower-level staff member.

Not exactly a conflict of interest, though.
Right. So this was classic misinformation. There’s a kernel of truth — yes, there was a report and it said there were problems. But when it comes to conflict of interest, there are 17 slots on the ACIP. Sixteen of those 17 people reported no conflicts of interest. One reported a conflict of interest: a distinguished pediatric infectious-disease physician who also happened to do research on vaccines. And so she recused herself from the decisions on those vaccines.

Some federal committees, not at CDC, but at other agencies, take a different view on conflict of interest where they say it’s fine for you to be part of the decision or the discussion as long as you disclose your conflict of interest. That’s never the position the CDC has taken, or at least not in recent years, certainly not since I was there. You can’t be part of the discussion if you have even the appearance of a conflict of interest. And we’ve looked at the kind of conflicts that people disclosed, and there are things like they’re on what’s called the Data Safety Monitoring Board, DSMB, which is an independent unit that looks at whether a vaccine trial is being done correctly. And even in that kind of situation, they recuse themselves from discussions. So what was actually a best practice was, with misinformation, skewed to be a problem. Now, does that mean it was perfect? No, of course, you can always be better with conflict of interest.

Do you sometimes feel like you’re wasting your time pushing back on these false claims? Because by the time you do, there’s another one out there. It doesn’t really matter to these people.
There’s still a point in telling the truth because facts matter. Even if they’re twisted, even if they’re misused, even if they’re ignored, facts matter, especially in health and disease. Because when people are sick, when people are disabled, when people die, those are facts that do not change on the ground.

The other piece of misinformation from Secretary Kennedy was that the ACIP is just a rubber stamp, and that’s absurd. If you’ve actually seen how it works, there are various debates about what to do. They vote on things, and sometimes the votes are close. They’ve voted down vaccines.

Just last year, there was a new vaccine, the RSV vaccine. It’s a good vaccine, but there’s what’s called a safety signal. So there’s a slight chance of  a rare serious adverse effect. So they erred on the side of caution and they said, “We’re going to scale back the number of people, the different groups we recommend to get that vaccine.”

So these were two absolute falsehoods that were really insulting and wrong to the people on the committee and misrepresented what the ACIP did. In terms of the latest appointments, several of them have, as Secretary Kennedy does, fringe beliefs on vaccines that are not supported by a fact-based review of the evidence.

I’m trying to figure out how worried to be about all this. Do you think the new panel could actually remove vaccines that we all have come to know and trust from the market?
It’s important to be clear about who does what. The FDA determines that a product is safe and effective. That’s their role. The CDC then determines who should use it, and the biggest impact is on the Vaccines for Children fund, the VFC. The VFC provides about half of all of the childhood vaccines in this country. If ACIP recommends it, VFC must pay for it. And if ACIP does not recommend it, VFC will not pay for it.

So they can yank recommendation of, say, the MMR vaccine and then people are on their own. That’s the worst-case scenario?
You’ll have to pay for it, and the costs are high.

But those vaccines will still exist for people who want them. 
And who can afford them. But it’s not just childhood vaccines, it’s what vaccines to give pregnant women and when. These are really complicated questions. Look, I’m an infectious-disease epidemiologist. I was an Epidemic Intelligence Service officer. I did my infectious-disease training at Yale. I was the New York City health commissioner. I worked on tuberculosis for ten years. I was the CDC director. And I have trouble with these issues. It’s not that it’s too complicated for anyone to understand. It’s really complicated. So you need someone who really understands the issues.

Some of these people RFK Jr. appointed are well credentialed, but I don’t know what that means in terms of expertise.
There’s a real difference between credentials and expertise. When it comes to interpreting data, it is really important to understand the science behind the data, to understand how it was collected and what it means. Because what we see often, even among people who have M.D.’s and Ph.D.’s, is a real misunderstanding of what certain studies mean or what certain studies showed or how they were done. And I’m not sure of how to deal with that problem because it’s not a question of, “Oh, trust the experts.” That’s not what I’m saying. What I’m saying is if you want to try to understand an issue, you really need to talk to someone who understands it very, very deeply because some of the issues are really quite complex.

Let me get into a related issue about vaccine recommendations that I think is important to understand, which is why recommendations change from time to time. Is that because we made a mistake? Could be. But more often, there are four things that change.

First, the viruses or bacteria change. They evolve, whether it’s Omicron or a new strain of COVID or a flu or even of whooping cough, pertussis. Second is that our vaccines change. We get vaccines that are more effective or less effective or easier to use or harder to use or have different dose schedules. Third is that our immunity changes. One of the reasons COVID has become much less deadly is that virtually everyone has immunity either from prior infections or from prior vaccinations or both. And that’s really changed how our bodies interact with the virus. The fourth is there’s more information. One of the things that’s been discussed is the RotaShield vaccination where there was a very serious adverse effect and it was pulled from the market and ACIP stopped recommending it. This was almost 20 years ago. No matter how well you study a vaccine among tens of thousands of people, when millions and millions of people get it, you may see a one in a million side effect.

And so with the changing world, it’s really important that scientists and public-health people start their statements with, “Based on what we know today, here’s what we recommend.” And also listen to what people are saying. People say, “I’m the kind of person who doesn’t want to get a vaccine.” You say, “Hey, here are the pros and cons. You decide.”

Are you still in touch with a lot of people at the CDC? I’m just curious what the mood is there with all this stuff going on. Are people totally demoralized?
I’m not in touch with a lot of people there, but what’s happening to the CDC is horrific. You have to look very carefully, not at what the administration says but what it does. Secretary Kennedy says he wants to address chronic disease. What are just about the first things the administration did? It ended the menthol rule, which would’ve protected people against cigarettes, on day two of the administration. It took lots of money from the tobacco industry in its campaign and it eliminated the CDC Office on Smoking and Health. No other part of the federal government tracks tobacco use, supports comprehensive action by communities, counters threats of new forms of tobacco products. This is a gift to big tobacco, and it’s going to guarantee more addiction, more disease, more death. The only winners are the tobacco industry and cancer cells. So you see programs that have existed for decades and people have spent their whole careers building ended overnight. It’s terrible.

Is this something that can even be built back, if a Democrat wins in 2028?
The only thing irreversible is death.

That’s a good motto.
But it’s going to be hard to rebuild. It’s so much quicker and easier to destroy than to build, especially in the government and public sector, because it means bringing people on. It means setting up systems again. It means rebuilding connections and partnerships with organizations and states and other countries. The amount of damage that’s being done — some of it is very apparent and some of it will only become apparent over time, but there’s just enormous damage being done to the CDC. This idea that you’re going to take CDC units and put them as part of an HHS entity is going to be more efficient — well, you’re combining groups that do nothing similar. From an outside perspective, you say, “Oh, both of these groups work on heart disease so they can work together.” Yeah, well, one of them runs clinics and one of them does studies and figures out how to implement programs that are going to prevent heart attacks and strokes. Those are completely different skill sets.

Now, I do think one of the challenges of this current time we’re in is that there may be a temptation to say, “Hey, everything was great before.” And everything wasn’t great before. There are real problems that have to be addressed. The federal government can be too bureaucratic. It can be inefficient. There are programs that don’t have the kind of impact you’d want. I felt that before I became CDC director, and I made some progress there, but there were still problems when I left eight years later. I felt that the organization didn’t move fast enough, that it had sometimes too much of an academic approach rather than a practical approach. And it didn’t have a tight enough connection with state and local health departments. I felt we made progress in all of those three areas, but there’s obviously unfinished business. It’s not the time to think about rebuilding, but I do think fundamentally, CDC is about working with communities, with doctors and nurses, providing information to the public so people can decide what they want to do to live longer, healthier lives.

And that’s what’s being disbanded. It’s terrible that people are losing jobs, but the real, real tragedy is that in communities all around the U.S., there’ll be outbreaks that don’t get stopped quickly. There’ll be cancers that develop that didn’t have to develop. There’ll be kids who get diabetes who didn’t have to get diabetes. There’ll be adults who have strokes and heart attacks who didn’t have to have those strokes and heart attacks. And that’s what’s hard to see about the damage that’s going on now.

In a situation where the CDC continues to deteriorate, especially on the issue of vaccines and other recommendations, where do you think people should turn to? Do you see some sort of alternative infrastructure popping up or something?
We may have to look at what other countries are recommending. We can also look at what the American Academy of Pediatrics and other high-quality entities say. But those groups have always relied on the ACIP. And it’s not just that these are 17 smart people. They rely on really in-depth data provided by the CDC staff that staff the committee. And some of those staff are leaving. So it’s not just like you could say to those 17 people, “Hey, come over here and tell us what you think about these things.” Because you really do need in-depth analysis of the situation.

I’ll give you an example of the complexity of this. It was actually before my time as CDC director, but it was fresh in the memory of people. One of the charges of the committee is to look at the cost-effectiveness of different vaccinations,  because they are costly. There’s a great vaccine against meningitis and it’s very effective and it’s very safe. But it’s very expensive per case prevented, because meningitis is a relatively rare disease. So the recommendation going into the committee was not to recommend it. And a parent spoke up and said, “My kid had meningitis.” I don’t remember if the kid died or was severely disabled as a result. That tragedy, if we can prevent it, how could we not prevent it? And the committee changed its mind. And that wasn’t because it was in the pocket of pharma.

You’ve also been outspoken about the foreign-aid cuts under the Trump administration, which have affected funding for malaria and HIV prevention among other things. How bad is it, and do you see any hope for this funding to be restored? I know Bill Gates has been trying.
I don’t know what’s going to happen. Our group, Resolve to Save Lives, works with 60 countries around the world. I think the reverberations of these unplanned, abrupt, devastating reductions are truly measured in lives. And it’s ironic because the programs were Republican initiatives that were drafted by George W. Bush. Not just PEPFAR, but the Millennium Challenge Corporation, the President’s Malaria Initiative, and pandemic influenza programs.

Again, the only thing irreversible is death and there’s a lot of death that’s going to happen because of this and some that’s already started to happen. Starting with the malaria cuts — you probably saw the LinkedIn piece I wrote on that. Malaria is, of the global-health programs, kind of the canary in the mine shaft because it’s the one where you have the most immediate impact with kids who don’t get treated, kids who aren’t under bed nets, spraying programs that got stopped. So there will be more cases, and it’s coming at a bad time. And just as I said, there were problems with the CDC, and there were problems with how USAID worked.

Everyone prefaces their criticism about these program cuts with “it’s not perfect.” But throwing out the baby with the bathwater is not the way to go.
You don’t improve a program by ending it, you improve it by improving it. The scope, the depth, and breadth of the harm is enormous. The malaria deaths are the most immediate and pressing problem, but stepping back from tuberculosis control means more drug resistance and more deaths. Destabilizing PEPFAR means more infections, more costs, more deaths. Stepping back from Gavi, the Vaccine Alliance, means not just more child deaths around the world but less ability to deal with emerging infections, yellow fever outbreaks, cholera outbreaks, emergencies around the world. And ending support for the polio program — the world has been working for 40 years to eliminate and eradicate polio. It’s had a series of setbacks, and this is a really big setback. I don’t want to go back to the days when there were a thousand kids getting paralyzed by polio every day, and we’re not immune to these problems in this country, especially with vaccine rates falling.

But more to the point, health is an area, globally, that really should be a win-win. If other countries are healthier, they’re less likely to have wars, they’re more likely to buy our stuff, their economy will be more productive. It’s not a win-lose. It’s a win-win. And this is a lose-lose because they’ll die and we’ll be at higher risk. To give you one small example, the fact that we’re pulling out of the World Health Organization. Again, as with CDC and USAID —

They’re not perfect.
WHO needs to do better. Just remember, the greatest weakness of WHO is how we created it. We helped write the charter. And if every country has to agree to something, it’s hard to get things agreed to. But the fact that countries have a sense of ownership — every country has a say at WHO — also means that countries pay attention to what it says and that it can project into countries where we as Americans cannot go. The staff we had embedded at WHO were practically half of the professional staff in the global-immunization program. And when they are, from one day to the next, told to pull out, immunization programs all over the world suffer for that and we are less safe. I think if there’s one thing to be clear about, with the actions of this administration from HHS to the devastating cuts to CDC, is that we are less safe, plain and simple.

And pulling out of WHO means that we don’t have access to information about what threats are coming our way, means that things like a global measles and rubella alert network that we supported stop, means that polio-eradication activities that we were doing through WHO stop. We only had a handful of staff embedded with WHO, but it’s a great partnership. It’s a win-win. We get to send people where they couldn’t go otherwise. They have an outsize impact that they couldn’t have working for the U.S. government. And WHO gets super high-qualified staff so they can do a better job.

So we really are tying our hands when we need to be fighting against a rise in drug resistance and vaccine-preventable diseases and other things.

Do you have anything making you the slightest bit optimistic about the near future of public health? I know we’re all pretty depressed about it, and this conversation has, if anything, made me more depressed.
I do think that individuals and communities are resilient and local city and state health departments existed before CDC existed. They rely on CDC for lots of things, but they also can be a source of innovation. Countries around the world are saying that we’re going to see what we can do more efficiently with more sense of country ownership.

I don’t think there’s a silver lining to the kind of life-threatening and life-ending decisions that are being made. But I do think, to repeat what I said earlier, that facts are stubborn things. And even if they’re suppressed or misused or ignored, they remain facts. And ultimately, we will face rising health-care costs, decreasing productivity, increasing preventable illness, injury, disability, and death, unless we get past inaccurate statements and focus on effective actions.

This interview has been edited for length and clarity.