In Conversation with Robert Redfield, Director of the CDC



thank you so I just went over briefly a tiny fraction of what the CDC has to monitor and deal with in the United States can you talk just about your priorities what it is that you are going to focus on and want to focus on considering the vast mandate that you have you know I think first just to underscore CDC is a science-based data-driven organization and one of the things I really also admire about it's also a service organization I think it's important for people to see that great voyage to get the chance to lead it from a priority point of view we really put three major priorities ending epidemics never thought as an infectious disease doctor that the epidemic that I've been be confronted with was not an infectious disease but it's really the opioid and drug use disorder epidemic really is the public health crisis of our time clearly one has to begin to continue to deal with and worry about pandemic flu which I do think still is wanted that is the most important public health risk to this nation in the world the second is eliminating disease and when science provides you the tools to eliminate disease you got to take it off the shelf and use it otherwise I don't understand what what its value is I'm reminded of Fleming discovering penicillin in 1929 and it sat on the shelf into the mid 40s you imagine how many lives have been saved if people realize in 1930 that penicillin actually had value wasn't just a bread mold we have a lot of science has been done and we continue invest in it meaning we as a nation NIH in particular the academic medical communities industry and when those that science provide solutions it needs to be applied so eliminating disease is really important the targets as you know is HIV infection we have the tool to bring HIV to an end as an epidemic in the United States very proud of President Trump's decision to launch that initiative and I'm confident that will accomplish that over the next decade I'm sure you've heard Tony fact you talk about it for those of you went to some of his presentations the other disease that we need to get off the shelf as you mentioned is is vaccine preventable diseases we need to make sure that that science is not left on the shelf for individuals or families or communities in too many communities that has been will come back and talk about that I'm sure one of the other areas for me and who would have ever believed that we would ever have a cure more or less a treatment for hepatitis C but hepatitis C is now curable and yet last year 18,000 people died of hepatitis C in this country so again I think we have to figure out when science has solutions to public health problems how do we provide those solutions and not leave them on the shelf for individuals and the final area of focus for me is health security I think people underestimate some people underestimate the realities that there are in terms of health security and I think CDC's one of CDC's core functions is sort of to be the tip of the spear in health security the last area for me is it's really remarkable that CDC had done so well for the last 70 years but you know there's really no investment in the core capabilities of public health and so I've really tried to prioritize to get an awareness of how important it is to invest in those core capabilities and what are they data and data analytics we need big data we didn't need data what happened two years ago we need data to tell us what's gonna happen tomorrow predictive data analysis is very important we need laboratory that stays updated I was just in a discussion about our bio watch program and the bio watch program was launched in 2003 to look for haven't issues agents that may come into this nation in different parts of the country and I was being briefed on it by Homeland Security not classified and and I asked for the laboratory background of it because I knew the 2003 but I wanted to see what it was now in 2019 and they said what's the same platform that we were launched in 2003 and the gentleman that was with me pulled out his iPhone and he said you know in 2003 I didn't have one of these and now I'm on my 10th version we've got to invest in bringing the laboratory to public health and finally it's a public health workforce we need a public health workforce you know this is a very exciting time for Public Health because I think we're about to go through a transformation in health in America where I have been part of for many years a disease system I actually think we're on the verge of starting a health system and the underpinnings of that health system is public health you know those of you who are studying medical history know about the history of the development of public health schools with the flexion report back in in 1929 I think it was and there was a strong argument made if we're gonna bring public health in we needed to pull it out of medical schools and develop a separate discipline it may have been necessary I don't know but I'm a big advocate in in in 2019 we need to bring those disciplines back together the interrelationship between medicine and public health the opportunity now to use medical records as public health tools the opportunity to get big data across this nation so again I think I think those are really the areas that I focus on the most right now well that doesn't sound like very much so I do want to get into the specifics of the HIV initiative and the measles issue but what I just heard as you were describing your areas of focus is getting into two of the thorniest issues that we have have facing healthcare one is healthcare delivery and how to get Act access for healthcare for everybody and the second has to do with federal budgeting if you want to expand the systems the data the Public Health Service Corps that requires money and it's not very there there aren't people who are very loose with their wallets in Washington DC and so those aren't specifically science but two shoes it seems like the science might be the easy part right now can you talk first about what role the CDC might have in improving the healthcare delivery so that these solutions that already exist can get to the people who need them I think the biggest thing CDC can do is provide data evidence-based data evidence-based outcome data to show the impact of different interventions you know I've always said CDC is not an opinion organization you know it's it's it's points of view need to be grounded in data that data is usually grounded in science I think we do the combination of service when we can show evidence-based data about the important health consequences and economic health consequences of for example bringing an end to the HIV epidemic if you look at it right now we're looking at 40,000 new infections per year if we stay status quo we'll have about 400,000 new infections in the next decade let's just around 2015 numbers it's about a half a million dollars a person to treat oh that's a two hundred billion dollar health care costs it's coming it might be to our advantage to invest you know some resources to divert that you can do the same for hepatitis A you can do the same for vaccine preventable diseases so I think our role is in providing data related to the issue and funding I think our role there through data is to be able to show that public health has value and I think that really comes back to it I would argue this is a time where we're highly under invested in public health many of you probably know that the public health dollars at CDC does get seventy percent of those dollars go directly out to state territorial tribal local health department's if you look at most states and territories local tri territorial local public health departments they get over half if not more of their public health dollars actually come from CDC so I think it's a great investment that's something I'd continue to try to advocate for that the nation particularly at this time when I think we're we're at a critical inflection point where as I said we're moving from a disease system to a health system I think this is a time but again those issues are you know higher than me we try to use the resources that were allocated to the best of our ability to meet the public health mission that we have one of the things I hear from people who work in public health is that the only route time people appreciate public health efforts is when they fail and there's a crisis and when Public Health succeeds people forget about it and defund it I don't know if you see that as a trend when you're when you're delivering good public health care and services the problem don't probably don't don't rise to the top as quickly I think that there's a lot of truth to that obviously the the interest in having a highly effective Public Health response is obviously very heightened during a public health crisis I think it's part of the education that we continue to need to go through how important public health is to the underpinnings as we move into what I call you know a value-based health system I'm going to say that a lot of that value-based health system is going to be defined on how effective your public health enterprises okay so let's talk a little bit about vaccine hesitancy obviously you've been dealing with outbreaks across the country and in in very specific communities how do you overcome the the skepticism that has permeated some some parts of the country and some populations about vaccines and their potential dangers and do you think mandates are the way to address the issue I'll start with your last part of the question first ultimately I think we have to change the hearts and minds of individuals to embrace this really important contribution of science to to medicine and public health ultimately that's that what has to happen vaccination is really one of the key tools we have to eliminate disease which you know is one of my three three top priorities I will say it's the only tool we have to eradicate disease and we've seen that with with small pox back in 1976 and we are in the verge to try to accomplish the same with polio right now as many of you know we still have active wild type polio cases in Pakistan Afghanistan but I do believe that in the next several years we'll be able to eradicate wild type polio and then go on to the longer journey to basically switch vaccines to kill vaccines and then eventually say that polio has been eradicated so I think it's really important from that point of view vaccine hesitancy w-h-o who would have believed wh oh this is vaccine hesitancy of one of them most and ten most important health threats to the world so I think it gives you a sense of where we are with vaccine hesitancy we're looking at the measles outbreak in our country where last week it was 1044 cases twenty eight states this is a disease that we had eliminated in 2000 most of the individuals that have gotten in fact did have gotten infected because they were unvaccinated most of the the outbreaks really started because of individuals who traveled you don't think of yourself when you're taking yourself on a vacation to Italy and you might have your four month old grandson with you there you have to worry about measles but there's over 60,000 cases of measles since January and in Europe over 110,000 Ukraine you know over 90,000 in the DRC over 20,000 in the Philippines over 20,000 now down in Venezuela Brazil we have a global measles outbreak and and why do we have a closed only since outbreak some of it is vaccine hesitancy some of it is nations that have unfortunately collapsed whether Venezuela Ukraine etc but it's a big issue you're when you look at vaccine hesitancy I think it's important not to lump everybody together first important in our country 94% of parents choose to vaccinate their children so it's it's not widespread 94 percent vaccinate your children but there are communities words there's more than 30% of the communities not vaccinated there's pockets and these pockets are very susceptible because then they can sustain transmission a certain amount of herd immunity needs to be there for measles not to be able to transmit probably somewhere between ninety ninety-five percent so when you get below that tipping point and you have a traveler come back from the Philippines or Ukraine or Israel as ISM in the case for the major outbreaks we've had in the country in New York and state of Washington and California then you can begin to start transmission within those pockets I think when you look at that community who makes up most of it I don't think it's anti vaccine most of the people don't vaccinate their children or the worried well they don't want to do anything to their children that might harm them and in order to get them to change we can't just criticize them we have to enter a dialogue and get people to understand that we understand their concern but that actually the diseases that they protect are actually more concerning and you know I'm hoping the grandparents can get involved we need trusted sources in those discussions the medical community's got to spend a little time in these discussions they just can't pontificate you should be vaccinated and that's it so I do think I will say from a research perspective one of the areas we want to do is that I don't think we know exactly what works in changing the world worried well to an acceptor and we need to understand that then you have the group of truly misses warm people well do you have I mean before we move to the truly misinformed the worried well I mean is there also a minimization the dangers of measles or I think you I mean most of the people I mean that are younger have not seen measles most the people haven't seen polio most of people haven't seen many of the vaccine preventable diseases whether it's pertussis diphtheria tetanus and this is one of the reasons I was hoping the grandparents might help out a little you know those people like me I had measles you know so I do think the lack of appreciation for the risk they don't really understand the risk I think that does drive and if there's no risk why take any risk if you're worried well and I think that's part of the dialogue we have to go through many people also don't think they're harming anybody by not being vaccinated my choice if you want to get vaccinated good vaccinia but they don't realize the real group at risk is the children under what used to be the children under one we now recommend if people are in an area of risk if you're six months or older you get your first measles vaccine but those children that are under six months are at real risk and so there are people not just people with medical illnesses they can't get vaccinated they're at risk pregnant women that hadn't been vaccinated or at real risk but those of us that are newly born and under six months of age we're all at risk and it really is I think the more you get people to understand it's not just about them it has a broader issue I think you can begin to change that the misinformed I think it's going to take even more time of interacting and not criticize them for their disinformation but understand their disinformation and then get credible sources to help get them the proper information unfortunately a lot of government entities including public health agencies like our own that are highly trusted in public health sometimes aren't the trusted source that's going to make the change so I do think we have to be much more aggressive we have a portal that we have now for parents at CDC on this issue they can get into our portal ask a lot of questions I'm hoping ultimately that will change the hearts and minds of people I come back to that not leave science on the shelf for themselves I think I do think getting better data on the vaccination status of the American public so people have a better idea I mean there are some schools in this nation that have vaccines status less than fifty percent and you know I think we need to begin to reverse that I think this measles outbreak is sort of a wake-up call okay well let's move on to HIV and especially talking about the science and the education issues it's it's continues to spread continues to expand and the president has announced this initiative try to eliminate HIV new new cases at least you know over I think the next decade there are a few tools and one of them is is greater sex education ways to prevent the spread of HIV there's prep what is it that the CDC what is your role in promoting prevention prevention of further spread of HIV well I think it's important to emphasize again it's it's a direct consequence of science you know the science that has been brought to bear for HIV is really really in my view on precedent as a clinical doctor that cared for patients in the early 80s I didn't you know I didn't see this coming is even though for many it may seem slow as quickly as it has I mean the patient's I cared for in 1983 84 85 had less than a year survival no you're talking about the fact that you can now live with HIV as a chronic can live a natural lifetime or in your natural lifetime but it goes to prevention even more importantly the way an infectious disease goes from one person to another is by the the infectious agent and we now know that if you go in antiretroviral therapy not only is it going to improve your health so you can now live a normal lifetime you're really becoming capable of transmitting that virus to another person so actually treatment is one of the most important prevention strategies that we have and truthfully if we couldn't prevent a treat diagnose and treat everyone in this country and now the treatment really has gotten very very very good it's really as close to bulletproof in terms of treatment failures you can get that if everybody was diagnosed and treated and virally suppressed there would be no HIV transmission now when you talk the other side of the coin we've got prevention and in the early years all we had was behavioral messages and I think behavioral messages did what they did they did the best they could but now we have biological mechanisms to prevent HIV transmission those biological mechanisms are the ability to take a medicine pre-exposure prophylaxis and if you take that medicine and you are exposed to HIV infection you will not get infected it's very unlikely for you to get infected so you've got two mechanisms now to stop transmission I do think there's other evidence-based prevention methods that have to be embraced I'm a big advocate for safe syringe programs those communities that have embraced them have seen major impacts not just in transmission of HIV and hepatitis C but one of the other reasons i'ma became a big advocate for safe syringe programs is that if you enter a safe syringe program you know you're three to five times more likely to get treatment for your addiction well we have a public health epidemic of addiction right now and I need to give people into treatment and if you do go into treatment you're two times two three times more likely to succeed so again I'm those are the the methods you know I was very proud that governor Kemp and Georgia signed the safe syringe program hopefully hopefully other jurisdictions will look at the data seriously and reconsider their decisions if they haven't embraced them I think this is really the tools we have now we just need to apply them we need to apply them I will say the last thing I'll say what we're done is we've looked across the nation and there's 50 jurisdictions that make up more than 50% of all the new infections in the United States they're all urban so we also looked across the United States to see where rural HIV acquisitions occurring because some of the complexity particularly with stigma is going to be different in the rural environment we found seven States to be leading in rural acquisition they happen to all be southern states so we've included those seven states in this concentrated effort to start the ultimate in games the whole country but we want to start in a concentrated way to get this done to to bring an end to HIV transmission the most important people though in the success of this program and one of the biggest challenges that I go around in the country now to try to embrace is is the young men and women that do get infected in the first couple years of this initiative we need those young men and women to come forward and have the courage to be our teachers to tell us what didn't work we don't need to tell them what didn't work we need them to teach us what didn't work because we're confident that there are gaps in both treatment and prevention in the communities that people don't really understand some places that may be housing stable housing so we need to if we can get the young men and women who do become infected in the first year to be part of the solution and to help teach us how to improve it I think we'll really get better and we'll bring it in to new HIV acquisition in this nation which I think will be very important beyond HIV it will show that we can invest heavily in science make an enormous contribution in science where we had an incurable disease now it's not only curable but it's preventable and we can apply it in a national level and bring an end to this epidemic hopefully we'll be a beacon for other countries to do the same so tell me how you bring young men over nearly like what how did that work through well it's gonna be important as we go through the Z's right now this this initiative the way it's going to roll out as each of the jurisdictions have been given the task to make up their own plan this is not a Washington driven plan this is not a department Health and Human Service plan is not an NIH CDC plan they need to come up with their plan they know what they've been doing for the last 20 years and they know what what's what their results are we need them now to come together I say that most importantly is not just the public health officials and the medical community I say the most important contributors to that plan or it's you know for the community by the community in the community because the group were trying to get into care and treatment now are the group for whatever reason decided to stay out of care and treatment the people we diagnose fly in the last two years over 50% of them and have been infected for more than three years why did they stay out of the system the same thing for the young the individuals at risk for HIV infection right now less than 20% of the people who could benefit from pre exposure prophylaxis are taking it so you got to get through and try to figure out what are the barriers to that how to correct them but the people who know best what they are truly are not the state public health officials not the CDC director the people know best what they are the men and women that are in the communities that are actually affected by it so I do think I'd like to see the public health community look at every new infection as a sentinel event and ask those young men and women to come forward and help teach us what didn't work for them so and then have them help be a beacon to to maybe be a better credible source to express it to back to the people that are walking in their shoes so that they now will learn how to take advantage of whatever we figure out we need to now offer I'm very confident that with the full cooperation the young men and women in the community that this will be a highly successful program and hopefully it will lead to the ability of other programs I mean one of the other ones I'd love to see launched is obviously a program to bring an end to hepatitis C in this nation it's curable HIV is I got to treat it for life and it's gonna be an irritable you know near normal if not normal life if ty sees curable but this nation is probably at this point in time we've probably cured less than 20% I know my friend bill hazel teens in the audience he may want to comment there's other nations around the world that he's worked with that are actually far ahead of the United States in terms of putting science into action when it comes to carrying hepatitis C so when you talk about HIV and addiction and syringes one of the biggest contributors to getting new patients into addiction treatment has been the expansion of Medicaid in the states where it has been expanded that's something that the Trump administration officially opposes what do you think about the expansion of Medicaid and have you been vocal about it you know my focus is really trying to figure out how to get the public health systems to work you know in the AIDS initiative I'm confident that we have the mechanism to get everybody access to care and treatment independent of insurance plan I'm also confident that we'll be able to get everybody access to pre exposure prophylaxis independent of your insurance plan I'm gonna do my part how do you do that well there's again there's a variety of different mechanisms for for HIV people with HIV we've had a Ryan White program in this nation for a long time for people that don't have HIV but need to be prevented that's part of what this initiative is about is how to put that structure in place both through community health services units as well as working and how to provide prep directly from pharmacies to individuals that are uninsured so I think you'll see that that's the commitment to make sure we're not going to be an effective program in eliminating HIV unless everyone is in fact it gets access to treatment and everyone who has it risk its access I will do my part to continue to try to show the data with our CDC subject matter experts to jurisdictions about the advantages of safety wrench programs ultimately those are local jurisdictions decisions but we at least want them to see the data so they're not making that decisions based on data from 15 years ago so I think that's the role we'll continue to try to do I do think the more we can get in individuals both in the state and the federal level to see that one of the best ways to improve the financial situation for healthcare is actually to treat and respond and eliminate those diseases that science has provided the tools to do and then reinvest those dollars into the next stage I'm gonna bring in you know if you have questions I'd love to have everyone here participate in the conversation if you've raised your hand and wait for the microphone to come to you that would be great we have the gentleman with the blue jacket right here hi Bob mentioned my name bill Haslam I've had the privilege of spending time with the program in Egypt which is controlling actually making a systemic effort to control hepatitis C infection hypertension diabetes and obesity and the way they did that is to create a screening program that is basically housewives and and you know are no ordinary people trained for a day to do the screening programs they've added some elements we don't think about which is compulsory not compulsory but you can't get a driver's license if you haven't been screened you can't keep or have a government or military job if you haven't been screened now what they do is in in less than five months they've screened the entire country 60 million people everybody over the age of 18 and high school students with their parents permission for those diseases and are providing free treatment this gets into another question how much does that cost all right fifty cents for a serology tests from Abbott for hepatitis C five dollars for a PCR viremic test and something that costs us eighty-seven thousand dollars for treatment cost them forty five dollars for treatment for the entire nation how they're going to do the long term treatment for hypertension and for diabetes is something that they're working out but they're committed to do the money for that by the way came through a World Bank alone and the energy came from their government so there are things we can do now other countries what my foundation works on is taking good ideas like that and trying to have other countries do them India China where you have other diseases like TB HIV they can be done and they can be done in a cost-effective effective way if you get both community involvement and you get the government behind it okay I think the comment I made with Bill's comments and he continues to do great work around the world I had a privilege to work with him many years ago he's also an outstanding HIV scientist back then the I think one of the advantages of meetings like this the idea meeting is as you heard me say I would excite me more than define a path to how to have the 21st century implementation of the cure Act in other words once science has given us the tools once penicillins been discovered what's the cure for hepatitis C has been figured out then we have we need to put some bright minds together to figure out well how does that then get applied so that it's public health impact can do that I don't pretend to have all the answers it's complicated but as bill said there are countries that are have chosen to do it Egypt I think you've also Georgia I was recently in Georgia of the Soviet Union there they've already treated 2/3 of their hepatitis C cases so there are ways to put science into action to do this it is going to require people from different points of view to get together and figure out the path nothing would please me more to see that I'm glad our nation has invested in the 21st century cure act because we have to invest in science and more cures will come but I will say we need to figure out the complexity how to see those cures applied nothing hurts science more I think in the long run to see it there know it can work and to make sure people don't get access to it but this gentleman brings up a good point about cost the cost of treatment and you mentioned hepatitis C the cost of hepatitis C treatment in this country is still much higher than many other countries I know there are state public health officials who don't want to do comprehensive testing because then they can't afford to treat yeah I think it's a complicated area obviously secretary a czar has drug pricing as one of this key priorities but it's a complicated area it's obviously something way over my pay grade but I will say that there are groups that have worked to figure it out I mean these countries Egypt worked to figure it out Georgia worked to figure it out the VA has worked to be able to treat they think they've now cured over 85 percent of the VA so they've worked state of Louisiana I don't know if the senators here I saw him the other day but it's the weight of state of Louisiana he is working on a whole new model of trying to figure out how to bring a hepatitis C therapy to the people Louisiana so I would encourage groups to continue to try to figure it out you know what I mean because you know our nation has really is one of the biomedical research engines of the world the private sector is really important in bringing some of those discoveries into products that actually impact health I don't think we are served at all though if we can't figure out then after that how do we get them applied this is where I would come back to people like you all that are here ok what's the path I know Louisiana's gonna pilot a new path where it's it's called a subscription model where for a certain amount of money the state of Louisiana is going to get all the drug they need to treat as many people as they decide to treat that year so that's kind of an interesting model because now the reluctance to diagnose more which you midget it's gone away actually the more people you bring in the the you will justify the cheaper each cost is so there are different models that are being tried and I think we need to look at how you know how do we pull down the barriers you know so that we can apply these advancements and again it's you know it's beyond the expertise that I have within running CDC I'm focused on the public health part of it but I do think one of the areas that we help is by showing you know doing outcome evidence based research and showing the economic consequences of that and then hopefully people will see wait a minute you mean it's it's more beneficial if I treat people than if I don't treat them I did an analysis once before for the state of Maryland 70,000 hepatitis patience I could treat them all and you could estimate what that would cost you know several hundred million dollars but the truth was there was a twenty billion dollar health exposure over the next twenty years if you didn't treat them so you have to decide and I think this is the kind of discussion that has to happen CDC can help by providing some of that data so policymakers can look at that data and then decide how they want to use it again it's over it's over my paygrade I think we had two questions here upfront first this lady in blue and then over here first of all thank you so much for your service and all you've done to advance health in the public domain in that regard so much of what you know is in the public health domain is driven by behavioral choices and have you found the magic cure for modifying behavior that can impact public health or many different behavioral magic such a soft ball you know I always know when someone compliments me to start that I got to get ready because something's coming you know I I didn't mean it was softball I one of the reasons I'm excited about our ability to bring an end to the HIV epidemic as we know it in America is we're no longer solely dependent on behavior I mean we do have a biological tool that we can now now it does take behavior to take the tools so I understand that so there's still there's still behavior involved and and you know I'm not I you I don't even know right now what works to make a young mother doesn't want to vaccinate her child vaccinate your child I need we need to learn that behavioral science really needs to really embrace science and really get into the science nitty-gritty so we really do understand I mean I'm dealing with right now in the Ebola outbreak in eastern Congo you know we have a whole community that doesn't trust the response they don't trust their own government they've been at war for over 25 years there's at least a hundred different rebel fractions fighting each other and we have a expanding a bull outbreak going on that so the question is how and Oh 30 to 50 percent of the people with Ebola who get sick figure out they have a bola but they don't trust the system so they stay home and the first time we find out they have a bolas when they die how do I get people who don't trust to trust how do I get women who don't want to vaccinate their children to change their mind I think this is really important areas for a real scientific research and I know right now you know we're looking at ourselves we don't know for example the Ebola outbreak we don't know how to convert people who don't trust to trust now we do believe you need to have trusted messengers but then who are the trusted messengers so I think there's important questions I'm hopeful that the behavioral community I mean there's a lot of new resources coming in because of the opioid epidemic hopefully some of those resources will be used in meaningful ways that can help us understand how do you impact individuals to embrace healthy behaviors rather than the behaviors that may cause self-injury okay so we're gonna go right over here this gentleman named Emmett I'm just going to mention that they're probably men who also don't want to vaccinate their children oh I should say parents and I will jive it's always a learning curve I'm learning you know I mean woman getting help won't even the job for about 15 months and now parents who don't vaccinate their children i dr. Redfield I want to echo ladies thanks and also ask a quick question about data I'm encouraged that you are so bullish about gathering data the CDC HHS a few years ago gathered data from all of the federal agencies related to health into a single health data clearinghouse which was curated by CDC and I think they're about $200,000 dedicated in the CDC budget to supporting that enterprise and a year or two ago for reasons that are unclear to me the Clearing House was dissolved the the data are still out there they're they're now accessible through individual agencies but I'm wondering if yeah if you've if you were aware of this and if you had any thoughts about trying to reconstitute that that resource which would be terrific for the population health community first I I'm not gonna have to look into it and I will look into that second I would like to use it as an opportunity to reiterate how important I think it is for us to modernize our data and data analytics not just for CDC but for the nation for the public health when I became CDC director one of the first things I asked for was a briefing on the status of drug use disorder and opioids when I finished that briefing I asked the subject matter experts to update me what the data was through they said March 2015 I looked at my iPhone took it out and I said but it's April 2018 and they said but that's the most recent data we had that's curated and incomplete from all the different states based on who you know reported and and I did and I didn't mean to be facetious when I said this but I was very you know direct I said when I became CDC director I didn't realize I was becoming a medical historian you know that I wanted to use data in real time actually I want to use data predictably so you'll see there's a big push that I'm trying to push and others are advocating for us to get as heavy investment into allow us to modernize modernize our data system not just for CDC but obviously for the states and territories so we can have a public health system where that population-based data can be available so but I'll look into the specifics of what you asked for but I do think we've under invested and I do think the private sector is getting way ahead of us because you know as we move to outcome based stuff the private healthcare companies let me tell you they're starting to collect a lot of data and I think we need that same data capacity in the public health system in this name one one organization that's been very involved in this discussion is the National Committee on vital health and Statistics that advises the Secretary of State so that may be a place to start thank you right back here in the brown shirt dr. Redfield also Eckerd the thanks of all of the previous tankers and compliment you on your commitment to science your bold vision your ambitions very inspiring to hear you I want to ask you about one public health threat even an emergency that hasn't been mentioned yet and that's climate change thinking about the heat waves the severe weather events the rise of some infectious diseases the nutritional impacts and so on what do you think CDC's role is both in spotlighting the health impacts of climate change and in protecting the public first I think there's absolutely no question that you know climate and extreme climate has enormous impact on health and you know when I've gone around whether it's the changing tick population that we're seeing across the country whether it's the wildfires when I look at those firefighters they're out there twenty six weeks a year and I'm trying to see how often do they get pulmonary function test they get them twice a you know once in the one they do and once and they're off I kind of would like them like a concussion protocol you know if you're out in the fire and you've lost some lung capacity maybe you shouldn't go out next week to another fire you know we were down in Florida recently you know red tide huge impact you know related obviously the cholera outbreaks that are happening around the world or changes in water temperatures so I think we have a critical role in focusing on the health consequences of climate we're not gonna get in the debate of what causes it or not but I want to look at the health consequences of it they're right in front of us we need to do that I'm hoping Congress gives us resources to expand that work and in particularly you know you can look at them that you can lately you know you can probably lay some others but the ones I've laid is ticks you know since 2006 we've had multiple new pathogens identified in ticks you know we you know it's not just Lyme disease we've got lots of tick pathogens now and more to come I do think the wildfire workers health we don't need to be creating a new group of coal miners who are just trying to protect this nation from wildfires and I think we need to be much more aggressive there and I do think as I mentioned the the area that I talked about in terms of red tide cholera and the water temperature so I I think they're brought her and I think this needs to be a major effort and then I think we need to start studying how we adapt to those things that we're not going to be able to change to make sure they don't have the health consequences that they currently do we have time for one more question as long as it's a quick question and not a short speech over here was that directly to me no okay you can talk as long as you want to repeatedly the health of our population comes in comparison of those of other countries and health of our population comes up below many other developing countries we all know that I would like you to list your top five reasons you believe not our health care in our hospitals but the health of our populations is below that of other developed countries you know that's a really a very good question I think it's probably a question that requires a substantial thought and discussion from different points of view it clearly is highly disconcerting when you look at our maternal infant mortality rates you know how how come we don't have one of the best survival rates in the world I you know and obviously we have programs now trying to understand 700 women lost their lives last year as a consequence of pregnancy and to really understand exactly why and what could have been done to prevent that not to mention infants I was very excited to see some of the new strategies that people are thinking about protecting newborns against infectious disease by maybe saying hey let's vaccinate the mother so the babies that can't be vaccinated at birth you know clearly you know whether it's access to the care that people need or the willingness to get access to people the care they need I don't know all the answers I'd be interested in having that debate of what are the top five reasons why our health care system isn't where it needs to be or the top ten I think it would be a great discussion to get people from multiple points of view and you know I think maybe I'll add that to one of the discussions that I'll try to get others to you know to have and say what do you think the top five reasons are and then more importantly for myself as CDC directors not what do you think what's your opinion what's the evidence what's the data to support that those are the top five and then then we can design interventions what our interventions were designed to correct them but I think it's a very very important question unfortunately we don't have a lot of time we are out of time so thank you very much thank you thank you [Applause]

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