Dr. Tom Frieden, one of the nation’s leading experts on public health and infectious disease, spoke with USA TODAY’s Editorial Board on Tuesday as New York Gov. Andrew Cuomo warned that the new coronavirus is “spiking” in his state and President Donald Trump said he wants “the country opened up and just raring to go by Easter.” Frieden, 59, is a former director of the Centers for Disease Control and Prevention and former New York City health commissioner. Questions and answers have been edited for length and clarity:
Q. Where are we on the arc of this outbreak, and where are we headed?
A. Sadly, New York City is in the rapid acceleration phase, and I fear this week will bring two things. The first is extreme stress on our intensive care capacity, with the possibility that there will be not enough intensive care beds for the patients who need them. And the second is an increasing number of infected health care workers. I already know medical school classmates and colleagues, and quite a few health care workers, who are infected in New York City. These are the two real tragedies that we're seeing now, and it's a warning to the country that you need to really take this seriously and take appropriate action so that you can mitigate the impact as effectively as possible.
Q. Should the whole country be on lockdown, or should states and localities make their own decisions?
A. Actually, it's very important that different decisions are made in different places. This is one of the areas where I think we really have to get it right. We need to think about this with three essential phases. First, the containment phase, where you're really trying to prevent a Wuhan-, Italy- or New York City-type situation. Second, the mitigation phase, which is what we're in now in New York City, where you really need to turn off the tap of more infections while you aggressively strengthen your health care and public health systems. And third, the suppression phase, where if you can drive down the cases, you're then going to be dealing with little clusters of cases and keep trying to aggressively respond to those.
Q. How long will we need to hunker down?
A. This is something that will be determined based on a couple of things. It’s very important to understand the reasons for the sheltering in place. One, everyone has seen the “flattening the curve” idea, so we don't overwhelm the health care system. The second, which is equally important, is to ramp up our health care and public health systems so the risk that it will get out of hand again comes down. So I think it's going to be different in different places. Instead of opening the floodgates, we’ll be turning the faucet. And it'll be different for different people. People at higher risk are going to have to hunker down for longer, and it'll be different for different parts of the economy and different types of work.
Q. What about reopening schools?
A. Schools need to be looked at very carefully, because we don't know if kids commonly spread this infection, and therefore, we don't know if it's really very helpful to close schools. You also need to recognize that in schools there will both staff and students who are medically vulnerable, and they will need to be able to participate by distance, if at all possible. That's just one of the many ways in which our world is changed forever with this.
Q. Can you understand why the public is confused about the severity of the threat?
A. (Even in the world’s hot spots) we estimate that maybe 3% or 4% of people are infected. So, 97% of people don't get it, and of those who get it, 99% of people survive. So I can understand the question, "Why are we shutting the whole world for this?" This is a good question.
Q. And what’s the answer?
A. I think the answer to that has to be because of the scenes you've seen in Wuhan, China, the scenes you've seen in northern Italy and, I fear, the scenes you may soon see in New York City of overwhelmed hospitals, of health care worker infections.
Q. You’re speaking to us from New York City. How bad is it there?
A. Remember, the severely ill patients today were infected about 10 or 12 days ago. It takes five days to get sick and about five to eight (more) days to get very sick. Unlike SARS (severe acute respiratory syndrome) or flu, where you get sick a lot at once, this kind of crescendos. What we're seeing in the ERs all around me in New York City today are the people who were infected two weeks ago. That means we've got two more weeks of cases coming in where there was still an exponential increase in the number of patients, and we're seeing doubling every day or two in New York City. So very, very concerning.
Q. If you think you might have COVID-19, should you try to get tested?
A. In New York City, the health department is strongly recommending that no one get tested other than people that need to be hospitalized for coronavirus. If you've got mild symptoms, stay home. If you seek testing, you're gonna use up equipment — protective equipment, staff time, test kits — that's scarce. You may infect others as you travel to or get care. And if you're positive, it's not gonna make any difference. You're gonna be told "stay home," unless you have trouble breathing, then you need to go into the hospital. And if you're not infected, and you try to get testing, you might get infected.
Q. What if you don’t live in a hot spot?
A. In an area that doesn't yet have a lot of cases, you really do want to find every case and try to contain it.
Q. Does it concern you that the CDC seems to be largely on the sidelines of this crisis?
A. This is the first outbreak in the last 75 years that CDC hasn't been centrally involved in making decisions at the table. Not that it's the only group that makes decisions, but it's got unique expertise in communicating those decisions. And frankly, I feel less safe because of that.
Q. Why it is so important to have CDC at the table?
A. CDC has the National Center for Immunization and Respiratory Diseases (NCIRD). There are 700 professionals working there. They've worked, on average, for 20 years on respiratory viral infections. They're really good. Look, I'm an infectious disease specialist who's worked on lung infections, and I wouldn't trust myself to make these decisions. I would trust them to bring the best decisions out. … The public health experts are the folks at CDC, and not having them there is just not safe.
Q. How about communicating with the public?
A. If you’re asking people to stay home, you have to communicate transparently. You have to be credible. You have to give the reasoning. You have to be transparent. So priorities matter. And when I hear a press conference that spends close to half its time discussing border control with Mexico and Canada, which have lower case rates than the U.S. … this is no way to run a railroad. It's certainly no way to confront an epidemic. Fighting an epidemic without CDC involved at the decision table and at the podium is like fighting with one hand tied behind your back.
Q. Why isn’t CDC playing a more prominent role?
A. I'm not there, so I can't know for sure. I suspect that the testing problem resulted in a loss of trust and credibility for CDC. I will feel more safe when I know that CDC is integrally involved in making the decisions here. … The CDC website is still the best place for information on this virus.
Q. What went wrong with the testing for COVID-19?
A. CDC made a mistake with testing. We can talk about what went wrong, not just the CDC, but also with FDA (the Food and Drug Administration) not allowing hospital labs to develop their own tests quickly enough and with HHS (the Health and Human Services) and the private sector not getting into the game fast enough. All three of those legs didn't work.
Q. Does that surprise you?
A. The CDC is the most surprising of the three, frankly, because in all prior outbreaks, this has worked extremely well. When I hear President Donald Trump say, "We inherited a broken and, frankly, terrible system of testing," it's just wrong. They inherited the system that has worked in every prior emergency. Now, it's fair to say this is an emergency like no other. But CDC tests were never supposed to meet the entire need for the United States.
Q. Why did we end up with so few testing kits?
A. I don't think anyone kind of stepped back and said, "Even if CDC tests worked great, it's not going to meet the need." We need tests in clinical settings. So FDA was very slow to tell private labs that they could develop their own tests, and HHS didn't convene the manufacturers and say, "Hey, everybody get on board with this." I think if you step back, you can say, on the one hand, this is a really unusual event. This is not something that was anticipated. The scale and scope of it is enormous.
Q. Weren’t warning signs flashing from Wuhan?
A. I think things just seemed unreal to many people when it was happening in China. It somehow seemed like, you know, that's over there, and it's never gonna happen here. Then when it hit Italy, people realized, oh, this isn't just a one-off situation. But by that point, it was really too late to do the scale-up that was needed.
Q. Are cruise ships a significant part of spreading diseases?
A. We know it from the norovirus outbreaks. We know it from other outbreaks on cruise ships. We know the average age of people on cruise ships is pretty advanced. And so they're at higher risk for serious illness. I actually didn't know, even as former CDC director, whether CDC has the authority to issue a do-not-sail order. But since the public health service came from a naval background, it certainly makes sense.
Q. Why weren’t cruises shut down sooner?
A. There was concern for the economic impact on the cruise industry that prevented that from being done. There aren't always conflicts between public health and economics, but here there really was one. And I don't think many people — certainly I didn't — recognize just how huge this industry has become. There were, I was told at any one time, on average, 99 ships out at sea with 365,000 Americans on them. Just as mosquitoes spread malaria and ticks spread Lyme disease, cruise ships have been spreading coronavirus.
Q. At this point, what are your biggest concerns?
A. I have three broad fears. The first is that … hospitals will be overwhelmed. That's why doing things like having tents in parking lots, as is done in flu season, is so important. The second is that they'll be unable to manage the number of patients who need supplemental oxygen and ventilator care. And the third is that our routine medical care system is going to be so badly hurt that a lot of damage will be done that way.
Q. What precautions should health care facilities be taking?
A. Every health care facility in the country needs to be treating any patient with cough or fever, and possibly every patient, as potentially infectious with COVID, and that means patients need to cover their mouths. And that can be with a surgical mask, that can be with a scarf, that can be with a bandanna. That can be with clothing. But basically, that's source control. When you cover your mouth, you stop producing huge quantities of the virus that can infect others. Getting our infection control right is so important. Otherwise, we'll lose health care workers, and we'll lose health care capacity.
Q. How about intensive care?
A. Intensive care we need to look at very carefully, because it's not just about ventilators. It's also about rooms. It's about the materials that you need, supplies and materials to run ventilators, not just oxygen, but suction tubing, other things. It's about the people who run them. They're very complex machines, and you don't have enough respiratory therapists, so you're going to have to train nurses and others to run them. This is not a surprise. We've known for more than 15 years that this is one of the biggest chokepoints, if you will, in saving lives in a pandemic.
Q. Are young people more vulnerable than we originally thought?
A. We have tens, if not hundreds, of thousands of infections already in the U.S. Kids don't get very sick with this. But we're hearing more and more stories of 30-year-olds, 40-year-olds, 50-year-olds, who were previously healthy, in intensive care.
Q. Once you get COVID-19 and recover, will you be immune?
A. We don't know. … I have a very good friend who was a medical school classmate. He's got it. He tested positive. And he said, "I'm rooting for that immunity." I said, "Don't count on it." We don't know how immunity's gonna be. This idea that you can send these now supermen and superwomen who are recovered into the line of fire because they won't be killed by coronavirus, we don't know that that's the case.
Q. Could a treatment or vaccination be available soon?
A. We have a lot of hope that we'll have treatments or vaccines. Treatments may come a lot sooner than vaccines, but still some months away. Antibody treatment is a promising one. It's hard to scale up, so we don't know if it's effective. We don't know that if you develop antibodies, you're protected against this. That's not something that is known.
Q. And vaccines?
A. I don't know any more than you do from listening to Tony Fauci (director of the National Institute of Allergy and Infectious Diseases). It's usually a year to two. I would just add that we don't know a vaccine is going to work. We shouldn't have certainty about this. We've been trying for an AIDS, a TB (tuberculosis) and a malaria vaccine for decades and we don't have one. There was a vaccine against SARS that made it worse, not better. So, by all means, we should pull out all the stops and try to make a vaccine, but we shouldn't count on it.
Q. This isn’t the last pandemic we’re likely to experience, is it?
A. We can't just protect America within our borders. If China had closed the live (animal) markets after SARS in 2003, it is possible that none of this would have happened. We don't know that, but that's possible. If Guinea in West Africa had stopped Ebola quickly, it would have taken a few weeks and a few thousand dollars; instead, it took tens of billions of dollars and killed tens of thousands of people. And we know there will be another one. It's inevitable. What's not inevitable is that we continue to be so underprepared.