Public health at the center

“We have to adapt our society using public health principles to protect our economy and society so we can continue to grow and save lives.” Words spoken by Dr. Thomas Frieden at an extraordinary online discussion this week. Organized by the Jodhpur School of Public Health in India, there was an impressive array of speakers.

The most compelling were the two doctors, Dr. Smrati Bajpai Tiwari in Mumbai, India and Dr. Abhishek Swami based in Michigan, USA. Both were clearly excellent clinicians who were working at the frontlines, but who both became infected with COVID-19. Their stories of their fears for their family, their own health and their perspectives on how the disease itself is being treated in patients and in their pubic health systems were the beating heart of the discussion. There was something intensely moving about their ability to straddle the public and personal. When they spoke about their hopes and fears they had years of practice to back their emotions.

Perhaps surprisingly, Dr. Tiwari’s assessment is that India has done quite well given its disadvantages, whereas Dr. Swami is deeply concerned about the situation in the USA.

Frieden was the keynote speaker and expertly navigated his perspective on the COVID pandemic. He is former director of the US Centers for Disease Control and Prevention and former commissioner of the New York City Health Department. Currently president and CEO of Resolve to Save Lives, a global non-profit initiative that works with countries to prevent 100 million deaths and to make the world safer from epidemics. Dr. Frieden is also Senior Fellow for Global Health at the Council on Foreign Relations.

Though he was speaking from New York, Friedan’s global experience with infectious diseases and epidemiology in India (on tuberculosis) and overseeing the work that helped end the 2014 West Africa Ebola epidemic lent his words a gravity and texture that he wore lightly.

At the heart of his talk was the centrality of public health: that we are in the midst of a public health emergency and that public health must guide us forward. Friedan bluntly assessed the US as having failed its people. “What’s really stunning is that six months in, we have no clear leadership, no clear plan, no accountability, no shared metric, no standard approach, no vision. It’s really striking and I can’t explain why that is the case, I’m not in the government now. I can just say that it’s quite unlike anything that’s happened before. I fear that public health entities will be in the unenviable position of being seen as having failed when in fact the failure was on the part of political leaders to trust and support public health,” he said.

COVID-19 is a long term threat to public health, he contends. It is the most disruptive infectious disease threat the world has faced in a century and the risk of explosive spread remains until there is a safe and effective vaccine; that could take months or years and the risk will not end with a vaccine. If you look around the world, Frieden points out, places that are guided by and fully support public health have less disease, death and economic devastation.

This pandemic is just beginning. In many countries (including the USA) it is not being controlled. A comprehensive response is needed to reduce spread, stop cases/clusters, use data to drive progress and protect ongoing healthcare.  Protecting healthcare is particularly important in lower to middle income countries like the Philippines, where the interruption of healthcare can result in large and devastating outbreaks of infectious disease and big increases in AIDS, tuberculosis and malaria deaths.

One important reality that is affecting the statistics that have become a daily indicator for people around the world, like the weather, COVID-19 is more severe for people over 60 and those with underlying health conditions like the 1989 flu pandemic in that it is very transmissible and severe, for those under 19 it’s more like a mild to moderate flu season. This aspect of the disease is very unusual and for those in between 19 and 60 it has real implications. The age structure of society is a major factor in the infection: fatality ratio which may be dramatically lower in places like India (and the Philippines) than in Europe simply because there are fewer people proportionately over 60 and with underlying health problems.

Another key aspect of Friedan’s talk was the need to transcend what he called “false dichotomies.” It is not a question of “closed versus open” because, he says, we were never fully closed and we won’t be fully open until there is a safe, effective, accessible vaccine. What’s needed is a more nuanced approach depending on the data about the way infections are happening. As he put it, it’s a dimmer dial, not an on off switch.

Another such dichotomy is the view that it’s “health vs economy.” The economic downturn is itself deadly, and we can only protect livelihoods by protecting lives. “Public health is the road to economic growth and recovery and you can see that in countries around the world that have used the pubic health approach and are getting their economies back,” said Friedan.

Nor is it a question of “overblown” views of the threat posed by the coronavirus versus views that it is “catastrophic.” It is indeed a severe pandemic, especially for older people and the medically vulnerable, and it is also a mild or no illness for most children and many others.

“When we look around the world we see that responses that trust, rely on and engage communities’ responses, that are organized, based on data, that learn continually – there’s a lot that we still don’t know, we’ll see what a vaccine can do, we’ll see what different treatments can do, we’re learning more all the time, but that’s not a failure, that’s a success – those are the responses that work.”