In this week’s episode of Good Medicine, I am thrilled to sit down with Dr. Anupam Jena. Dr. Jena is a unicorn in medicine—a practicing internal medicine physician at Massachusetts General Hospital and a PhD economist who holds the Joseph Newhouse Professorship of Health Care Policy at Harvard Medical School. He is also the creator of the hit podcast Freakonomics MD and the co-author of the bestselling book Random Acts of Medicine.

Dr. Jena has an unmatched gift for turning everyday curiosities into insights that transform how we think about health, healthcare, and the way doctors make decisions. In our conversation, we explore how he uses “natural experiments”—random, real-world events that mimic randomized clinical trials—to uncover the hidden forces shaping clinical outcomes.

Here are three mind-bending takeaways from our conversation:

1. The “August Birthday” ADHD Bias In states where the public school cutoff is September 1st, a child born on August 31st will be the youngest in their kindergarten class, while a child born on September 2nd will be the oldest. Dr. Jena’s research found that those August-born kids are 30% more likely to be diagnosed with ADHD than their September-born peers. Why? Because doctors and teachers often compare a young child’s baseline maturity to older peers in the same grade, leading to diagnoses driven by relative age rather than underlying biology.

2. When Doing Less is Actually More Returning to the cardiologist question: Dr. Jena studied what happens during major national cardiology meetings when many doctors are out of town. He found that patient mortality for high-risk cardiac conditions actually decreased. The takeaway isn’t that cardiologists are harmful, but rather that when staffing is tight, the medical system pulls back on marginal, high-risk interventions that might cause more harm than good. It’s a powerful lesson in the risks of medicine’s inherent bias toward “doing more.”

3. The Flaw in Value-Based Care We hear a lot about transitioning the US healthcare system to “value-based care,” where health systems are financially rewarded for quality outcomes rather than the sheer volume of services provided. But Dr. Jena points out a massive structural tension: we are asking institutions to be financially accountable to reduce unnecessary tests, but the individual physician still carries 100% of the malpractice liability if they miss a diagnosis. Until we align systemic goals with individual physician risk, changing doctor behavior will be an uphill battle.

Also in this episode:

* How a freak snowstorm in Chicago accidentally launched his career in economics.

* Why getting your flu shot in the morning versus the afternoon might alter your immune response.

* Why surgical outcomes improve with a doctor’s age, but medical outcomes often decline.

* How economists calculate the private vs. social “value” of a human life, especially in oncology.

If you are fascinated by human psychology, behavioral economics, or simply want to know how your doctor’s brain works, please join us for this conversation.If you’re a US-based physician, continue the conversation with Dr. Jena on Roon!

New Good Medicine episodes are released every other week.If you’re a US-based physician, visit: www.roon.comFind us on Instagram and X: @roondoctorsIf you have a question, comment, or suggestion for a future guest, please email us: jane@roon.care

How do we build a health system where everyone can access excellent care, regardless of background? It’s a goal every physician shares, but turning that aspiration into reality is extraordinarily difficult. Fortunately, some leaders have devoted their careers to making the system more equitable—and to showing the rest of us what that work truly requires.

That's why I was so pleased to speak with Dr. Kedar Mate about the the intersection of social justice & healthcare policy with AI as a potentially the great enabler. Dr. Mate, former head of the Institute for Healthcare Improvement (IHI) and now co-founder of Qualified Health, has spent his career proving that biology is the same whether you are in a Boston teaching hospital or in a resource-limited part of Lima, Peru—and that our systems of care must reflect that truth.

Here are the key takeaways that stuck with me from our conversation:

The Roots of Equity: Growing up between the US and India, Dr. Mate observed a stark “standard of living divide” that sparked a lifelong quest for better, more equitable care. His early work with Partners in Health in Peru, inspired by the late Dr. Paul Farmer, proved a radical thesis: complex diseases can be treated in poor countries if you combine clinical excellence with smart policy, such as pooled purchasing to lower drug costs. Their MDR-TB program in Lima’s affected communities achieved cure rates that rivaled those of major academic medical centers in Boston and New York.

From Triple Aim to Quintuple Aim: Don Berwick and co-authors Tom Nolan and John Whittington introduced the “Triple Aim” in 2007 (better outcomes, better experience, lower cost). Others quickly added a fourth goal — workforce well-being — and Dr. Mate explains how he and colleagues evolved this into the Quintuple Aim by adding Health Equity: The idea here was to ensure that health care improvements & innovations are distributed across all population segments, regardless of race, gender, income, or geography. And fast fwd to today: Kedar offers that we must reduce the “quantum of money” extracting value from medicine and return to the sacred duty of benefiting our patients

The Trust Crisis in Medicine: From the defunding of PEPFAR to relaxed vaccine mandates in Florida, Dr. Mate identifies trust as the biggest predictor of future health. He argues that health systems must act as “local translators,” moving away from hitting people over the head with science and moving toward empathetic, iterative communication.

AI: The Great Hyperscaler: After 11 years at IHI, Dr. Mate co-founded Qualified health because he realized that while clinical processes can be improved manually, hardwiring and scaling those improvements requires technology. He views AI as a generational “unlocking force” that—unlike previous IT waves—is being driven by clinician demand rather than administrative supply.

Qualified Health: Navigating the AI Mess At his new venture, Dr. Mate is helping health systems move AI from “digital playgrounds” to enterprise-scale production. The goal is to manage proportional risk: you don’t need the same governance for an AI that schedules lunches as you do for one that detects sepsis.

Hope you enjoy it!If you’re a US-based physician, continue the conversation with Dr. Mate on Roon!

New Good Medicine episodes are released every other week.If you’re a US-based physician, visit: www.roon.comFind us on Instagram and X: @roondoctorsIf you have a question, comment, or suggestion for a future guest, please email us: jane@roon.care

In this episode of Good Medicine, we dive into the future of how we gather and use medical knowledge. There has been lots of ink spilled on how AI can help physicians stay up to date with the seemingly limitless amount of medical literature. But what about all the data a patient generates from their clinic encounters or hospital admissions? What about the real world health data that each patient and community generates? How are we using this data to be BOTH better doctors and stewards of public health?

My guest today is Dr. Monica Bertagnolli, a surgical oncologist and former Director of both the NCI and the NIH. Now, as she takes on a new leadership role at the National Academy of Medicine, she is championing a transformation in how we collect real world evidence and adapt in real time with Learning Health Systems.

Here are the key takeaways from our conversation:

What is a Learning Health System?

Dr. Bertagnolli defines this as a system where every single patient interaction, decision made, and outcome observed is captured as data to create new knowledge so we can continuously learn and adapt. Currently, doctors rely on training, literature, experience, and colleagues. In a learning health system, the system itself “learns” in real-time.

AI: The Great Enabler:

For years, the idea of a learning health system was a pipe dream because the data was too vast for humans to process. Dr. Bertagnolli notes that AI finally provides the “engine” to analyze data at a scale that matches human complexity. However, this engine requires a massive “fuel” source: comprehensive, high-quality data from millions of diverse patients.

The Sacred Requirement: Trust

We can have the best AI tools in the world, but they are of minimal value without trust. Dr. Bertagnolli believes this system can work but only if the system is built on transparency and accountability.

* Data Ownership: She is firm that patients own their data; clinicians are merely the “trust brokers.”

* The Value Proposition: Patients take the risk of sharing data because they want the best evidence-based care for themselves and their families.

Moving Beyond Static Guidelines

Today, millions of people are treated based on clinical guidelines that are definitionally static and don’t neatly fit every individual. As Dr. Bertagnolli notes, “nobody is watching” in a systematic way to see if that guideline was actually right for that specific person using real world data. A learning health system fixes this by tracking outcomes and feeding them back to make patient care more personalized and evidence based each day.

And much more…

Hope you enjoy it!

If you’re a US-based physician, continue the conversation with Dr. Bertagnolli on Roon!

New Good Medicine episodes are released every other week.If you’re a US-based physician, visit: www.roon.comFind us on Instagram and X: @roondoctors

If you have a question, comment, or suggestion for a future guest, please email us: jane@roon.care

One of the most critical skills in medicine is translation: turning messy reality into action without losing the plot. That’s why I was so thrilled to be joined by Dr. Demetre Daskalakis in our latest episode of Good Medicine. Demetre’s career is a masterclass in devising innovative solutions to thorny public health problems where he’s been a leader at the city level, at the CDC and now as incoming Chief Medical Officer at Callen-Lorde Community health center.

At a moment in time where, equity, and evidence feel like they’re in a fight for survival, Demetre shows us how moral clarity can guide the way.

Here are the key takeaways from our conversation:

Communication as Therapy: Dr. Daskalakis didn’t learn to communicate in a lecture hall. He jokes that he honed his bedside manner by talking to drag queens in the East Village. By learning how communicate effectively, he revolutionized HIV prevention by forsaking “doom and gloom” narratives to those that centered joy as a public health outcome.

Mpox: A Redemption Story: When Mpox emerged in 2022, Dr. Daskalakis saw a chance to correct the sins of the AIDS crisis. By ensuring the disease wasn’t framed around identity, he helped curb the outbreak without fueling the stigma that haunted the 1990s.

The “Hijacked Plane” at the CDC: Dr. Daskalakis is candid about why he so publicly left the CDC, describing the environment for career scientists as being on a “hijacked plane.” He recalls moments where critical vaccine policy changes were announced via Twitter (X) before the agency’s own experts were consulted. It’s a key lesson on what to do when your red lines are crossed.

Measles and Inequity: In the face of the resurgence of measles, Dr. Daskalakis dismantles the notion that natural infection is benign. He warns that a return to pre-vaccine norms is a choice to accept preventable deaths that land hardest on the vulnerable: “When you look at who dies of measles, it is all about inequity.”Last time, Mark Cuban spoke about his trust formula(Trust = Transparency ÷ Self Interest). In this conversation, Demetre shows us why he’s one of the most trusted people in public health. I hope you enjoy it!

If you’re a US-based physician, continue the conversation with Dr. Daskalakis on Roon!

New Good Medicine episodes are released every other week.If you’re a US-based physician, visit: www.roon.comFind us on Instagram and X: @roondoctorsIf you have a question, comment, or suggestion for a future guest, please email us: jane@roon.careNB: Transcript posted 48 hours after launch

His message to physicians? You're underpaid, overworked, and dealing with mishigas that shouldn't exist. Here's how we fix it.

New episodes are released every other week, wherever you get your podcasts.

For more from Roon, visit: ⁠https://www.roon.com/⁠

Sign up for our substack: ⁠https://rohanramakrishna.substack.com/⁠

Find us on Instagram and X: @roondoctors

If you have a question, comment, or suggestion for a future guest, please email us: jane@roon.care

What if the most important thing you could do for your longevity wasn’t a grueling gym session or a restrictive diet, but simply hosting a dinner party and having a scoop of your favorite ice cream? As a neurosurgeon, I spend my days focused on the intricacies of the human brain. But as I’ve learned through my conversations on Good Medicine, the health of an individual is often inseparable from the health of the systems that surround them.

In our latest episode, I sat down with Dr. Zeke Emanuel: an academic oncologist, bioethicist, a principal architect of the Affordable Care Act (ACA), the Vice Provost for Global Initiatives at the University of Pennsylvania, and the author of the new book, Eat Your Ice Cream – just released on Jan 6, 2026! Dr. Emanuel is direct, intellectually rigorous, and deeply authentic. Whether he’s talking about the complexity of making award-winning chocolate or the policy “hard-heartedness” of cutting Medicaid, his insights are important for anyone navigating our complex healthcare landscape and seeking to live well.

We cover a massive amount of ground, including:

* The Realities of the White House: The “politics vs. policy” trade-offs including a “malpractice reform” memo that didn’t stand a chance, what effects the ACA really had and the consequences of its future.

* Clear communication is a life-saving intervention: Dr. Emanuel reveals how 1 in 1,600 letters sent just telling people how to sign up for insurance resulted in a life saved.

* Zeke’s vision for a healthy society built on five pillars: Universal coverage, cost control, consistent quality, narrowed disparities, and professional satisfaction. We aren’t there yet, but conversations like this provide the roadmap.

* Complexity as a Systemic Pathogen: There is a trillion-dollar crisis in administrative costs fueled by a lack of standardization, “gaming” of the pharmaceutical marketplace, and a “monopolization” that prioritizes the balance sheet over the patient.

* Combating Health Misinformation: Why doctors need to stop being passive and start meeting patients where they are—even if that means going on TikTok.

* The “Eat Your Ice Cream” Philosophy: Why the “don’t be a schmuck” approach to wellness beats the obsession with data-tracking and why the payoff for social connection is now, not decades away.

* A Prescription for Aging: For those over 60, he breaks down the critical importance of maintaining muscle mass, core strength, and the surprising benefits of fermented foods.

* The Quiet Epidemic: Loneliness and Screens: The “social health” of our younger generations is in danger. Loneliness is not merely a feeling; it is a neurological and physical threat equivalent to smoking 15 cigarettes a day.

* Misreading Risk: We discuss the Risk Perception Gap especially with MMR & polio vaccines, and the need for physicians to move beyond dry data to help patients contextualize risk.

If you’re a physician join the conversation on Roon related to Zeke’s podcasts here!

New episodes are released every other week, wherever you get your podcasts.For more from Roon, visit: ⁠https://www.roon.com/

⁠Find us on Instagram and X: @roondoctors If you have a question, comment, or suggestion for a future guest, please email us: jane@roon.careTranscript:Rohan Ramakrishna (00:00:04): Welcome to Good Medicine, a podcast about the ideas, people, and conversations shaping the future of healthcare. I’m your host, Dr. Rohan Ramakrishna, neurosurgeon and co-founder of Rune. Each episode, we explore how medicine is evolving through honest conversations with leaders and changemakers. Good Medicine is brought to you by Rune, the digital home for doctors. We’re a free physicians-only community to connect, share knowledge, and shape the future of medicine.

(00:00:37): Today, I’m joined by Dr. Zeke Emanuel, a powerhouse in American medicine and policy. He’s someone who spent his career trying to understand how to best improve the health of Americans while navigating the gritty reality of Washington politics. And fun fact, he’s also an artisanal chocolate maker and beekeeper. In this episode, we unpack the formative forces that shaped Dr. Emanuel’s life in medicine and politics. We discuss what the ACA actually achieved—like millions of new people with health insurance—and where it fell short in retrospect. Dr. Emanuel also explains why he thinks healthcare will dominate the next set of presidential elections, what cutting Medicaid funding would really mean for rural hospitals and working families, and why doctors need to get more politically active if we want to successfully combat health misinformation. A few things from our conversation really stuck with me. First, the framework Dr. Emanuel created for allocating scarce medical resources as a medical ethicist—initially criticized on the editorial pages of The Wall Street Journal—ended up significantly influencing COVID vaccine distribution policy worldwide.

(00:01:51): It’s a lesson in how rigorous ethical thinking translates to real-world policy. Second, politics beats policy in Washington. Even when the data is crystal clear, Dr. Emanuel walks us through why malpractice reform failed to make it into the ACA and what that reveals about how change actually happens. Third, we discuss his provocative forthcoming book, Eat Your Ice Cream. In a world obsessed with longevity hacks, biohacking, and optimized living, Dr. Emanuel offers a refreshing, data-driven approach to longevity and happiness. He argues that the most important thing you can do for your health isn’t a specific workout or supplement—it’s a holistic approach that anyone can utilize without breaking the bank. Dr. Emanuel brings characteristic directness, deep policy expertise, and a refreshing willingness to challenge both sides. Let’s get into it. Dr. Emanuel, it’s so great to have you here.

Zeke Emanuel (00:02:54): Ah, it’s my great pleasure. Look forward to this.

Rohan Ramakrishna (00:02:57): So as I was preparing for this interview, lots and lots of questions, but I thought maybe the first place I’d start is: how did you get into making honey?

Zeke Emanuel (00:03:10): We moved houses about two and a half years ago. We bought this totally dilapidated house with, you know, three different holes in the roof. The back porch fell off, so the door from the kitchen fell down a whole floor. There was no stove in the house, no refrigerator—it was terrible. We renovated it for a number of years. It’s in a historical district. So anyway, and then we planted a garden, and my rule for the garden was two things: one, no grass, and two, it should be a riot of colors. And I have this pledge that every year I’ll try to do something out of the box for me that I have never done before—new. I’ll learn something new. I’ll do something new. So I’ve made chocolate, I did an MSNBC show for seven episodes—and anyway, so it was like, honey, let’s do honey. Let’s put some beehives in the back and make honey. And so that’s how I got into honey. I think my honey activity is much less impressive than my chocolate activity, you might say.

Rohan Ramakrishna (00:04:26): And the bees in the—no bees in the house?

Zeke Emanuel (00:04:29): No, no, no. The bees are out, and they love it. We have lavender, we’ve had tulips, we have flowers from roughly middle of March to—it’s still flowering, and we’re in November.

Rohan Ramakrishna (00:04:41): Amazing. Yeah. Well, with that, I thought I’d love to get into your career. As you know, you went from medical school to the NIH. You were at the Farber. Did you always know you wanted to mix medicine and policy, or is that a happy coincidence of just these interests colliding in kind of serendipitous ways?

Zeke Emanuel (00:04:59): No, that’s not the way it went. Yeah. Being a doctor was, as I like to say, overdetermined. My father was an immigrant and a pediatrician. I’m the firstborn son of an immigrant pediatrician, and I happened to be in school very good at science. And so the pressure was on me: you’re gonna be the doctor. My two brothers—not good at science. Yeah. Good in many other things, but not science. So I went to college, and during the summers I did a lot of research in labs, academic settings, and I actually didn’t like it that much. I was reasonably good at it, but I just didn’t like it. It didn’t tweak the sort of ethicist side of me. And when I was in college, I did, you know, chemistry and a lot of philosophy. So I was hesitant. I did apply to medical school.

(00:05:56): I got into only two, rejected at many, rejected without interview at many—including several places where I ended up giving the graduation speech later on. But I then went to Oxford instead of to work in a research lab, to see if, you know, maybe I’d missed something, maybe if I devoted myself full-time I’d like it. It didn’t work. I did good work. I got three publications on it, including a Nature paper, but it wasn’t happy-making. But I didn’t have a Plan B, so I went to medical school. And then in the summer between the first and second year, I did journalism, and I was at The New Republic as an intern when it was a real magazine. And I realized I don’t wanna do journalism either, because I didn’t write as fast as the journalists, they write better than me, and I didn’t wanna watch what was happening—

(00:06:49): I wanted to participate in what was happening. But again, I didn’t have a Plan B, so I had to go back to med school. And fortunately, in my second year, I was able to teach at Harvard College in a program called Social Studies, which is basically about reading the great books, you know, from Thucydides to Freud, basically. And that really clicked with me, and it was like, wow, this is what I can do. This is—I get jazzed by this every class. So I then took off after the third year. I took off from medical school. I applied to graduate school. I took off and began doing a PhD. And then, you know, by happenstance, what I was interested in was ethical aspects of medicine, you know, end-of-life care in particular, which is where I started in the mid-eighties when I was still in medical school. Published a bunch of papers on that, a bunch of policy papers about advance directives, how to really improve end-of-life care, stuff on euthanasia.

(00:07:49): And so the policy stuff began interesting me, and I had a, I would say, natural inclination for thinking about policy. I like taking care of patients. You know, as an academic, you take care of patients—in my case, you know, half a day a week. It was satisfying, but it was hardly the thing that drove me, and hardly the thing that—I mean, I love my patients, and I think my patients largely loved me, but it wasn’t as satisfying as writing another paper and publishing. So that was the shift. And then, you know, I went to the NIH, and I began working in policy related to research ethics. And so it just naturally flowed and sort of combined my philosophy with my medicine and my ethics and my real concern of how can you make the world better for more people. Yeah.

Rohan Ramakrishna (00:08:41): So you were at the NIH for a while—more than ten years as bioethics chair. And I’m curious, is there a particular project or initiative while you were there that really stands out to you?

Zeke Emanuel (00:08:54): Yes. Yeah. When I took the job, I was like, well, you know, research ethics is more or less done. We had the Declaration of Helsinki, we had federal regulations, and I didn’t really know much about it when I got the job, you know. And it’s a tribute to my boss—I think he hired me more for my young dynamism. I was under forty at that time, rather than my knowledge, because I didn’t know anything about research ethics, really. I’d never published a paper in the topic. I’d been around it, of course, because I was at a major cancer center and we did a lot of research. But once you read the foundational documents—the Declaration of Helsinki, Nuremberg, the regulations—you realize they got it all wrong. “All wrong” is a little extreme, but they got a lot of stuff wrong, and we had to rethink from the ground up.

(00:09:46): So one of my early papers was, you know, what makes research ethical, what are the things that you need to do to make it ethical? And then we began thinking about the ethics of research with children, the ethics of paying children, how much risk can people take, you know, are phase one cancer trials ethical, why might they be ethical, stored tissue—how do you make that research ethical? So just sort of systematically going through the whole book of controversial research ethics areas was, I think, very important. And having a whole department—being able to create a department—when I arrived there was no department. I was the founding chair. And, you know, one of the exciting things was to be able to put together a department and have people that were doing genetics and pediatrics and psychiatry and all the elements. And I think we had a huge impact on how people think about research differently.

Rohan Ramakrishna (00:10:42): Yeah. One of the papers that I came across was related to, you know, the kind of bridge between ethics and philosophy and policy and health—was allocation of scarce medical resources. Uh-huh. And there’s definitely a lot been written about that. And I’m curious how you came about—is the framework very utilitarianism ultimately, but like applied in a novel way, or I’m curious how you—

Zeke Emanuel (00:11:05): No, no problem. I can answer that question definitively. No. Yeah. So it’s a very interesting process. In 2005, well under Bush, his Secretary of Health and Human Services, a man named Leavitt, who had been governor of Utah—and he came in, and I think he was a little disturbed by pandemic preparedness. I know he was disturbed by pandemic preparedness, and he asked for a report about, you know, how are we going to respond if we have an H5N1 flu pandemic. And there was this report, and we ran something called Ethics Grand Rounds at the NIH, where we would take a topic or a case or what have you and have a presentation on it and then a discussion. And it was hugely popular, hugely popular. And so we had someone come in and talk—Bruce Gellin, as a matter of fact, from HHS, who oversaw the report—talk about it.

(00:12:11): And one of the things that the report said—this is 2005—is, you know, old people, who die more frequently from influenza and pneumonia, should be prioritized to get vaccine. Because in a pandemic, we know there’s gonna be a shortage of vaccine—you just can’t produce enough to vaccinate everyone. And I was—literally, I remember walking up the stairs of the auditorium with one of my colleagues, who was a very smart political philosopher who had gone into retirement, and I brought him out of retirement to work at the NIH because he was really—he wrote on everything relevant to us: consent and coercion and—and I said, that’s gotta be wrong. That can’t be right. It’s gotta be that you actually vaccinate young people first, especially because we know from the pandemic of 1918–1920 that, in fact, young people had a disproportionately high mortality rate—like thirtyfold compared to normal.

(00:13:10): So we worked on that, and we wrote a paper for Science about this allocation proposed by our boss. I mean, remember, Secretary of HHS is the boss of the NIH—essentially criticizing my boss, saying, this is wrong, here’s how you should do it, and that priorities should be given to adolescents and young adults, late teens, early twenties, and then less priority to younger kids and even less priority at the older ages. That was controversial. And I can tell you that my higher-ups didn’t like it. And they did some polling actually, and some focus groups on what we said, and it turned out we were right? Yeah. That’s what the public supports. Then we sought to generalize this. We didn’t have a general framework. We sought to create a general framework by looking at organ donation, where we have shortages—also severe shortages.

(00:14:08): Now, I should say this topic of allocating scarce medical resources had been a backwater, or I would say even more strongly, ignored, because it was maybe the hardest bioethical problem that there was, and no one had a good general framework. So I took this on as a challenge. And my colleague, a man named Alan Wertheimer, and we had a young fellow who had just graduated with a BA from Stanford, and he was working with us—and we wrote this paper, which I think is still one of the landmark papers, certainly in bioethics. And it really created the whole framework. It was published in The Lancet in early 2009 about how to allocate resources—medical resources that were scarce. And it’s not just utilitarian. It’s not “we’re gonna maximize the number of lives”—saying that we’re gonna maximize life-years.

(00:15:01): We created the whole framework that there’s a principle of “benefit”—who benefits and maximizing benefits, minimizing harms. There’s a principle related to respecting the worst off and giving them priority. And we delineated four principles. There’s also a principle that is more utilitarian-like: who’s gonna promote the general welfare through, you know, either seeing patients or donating organs or whatever. Anyway, we created this four-principle framework and different ways of, you might say, realizing the principles. And we showed which principles are ones that definitely shouldn’t be used—like first come, first served: bad principle. Sickest first: bad principle. Should not be using those in allocating scarce resources. But maximizing the number of life-years saved: very important, probably the most important principle. In any case, you know, we created a graph in that paper about priority, and, you know, again, as I said, priority for the late teens, early twenties, decreasing as age increases and decreasing towards younger age groups. And I got heavily criticized for that, including on the editorial page of The Wall Street Journal. They republished our graphic of who gets priority and criticized me that I wanna kill old people. Yeah. Anyway. And then when COVID came around, we had a framework—there was the framework—and that was used by most countries to guide their priority setting for who gets the vaccine, who gets respirators, all sorts of questions. And then we’ve now used it for GLP-1s as well, when they were in very short supply.

Rohan Ramakrishna (00:16:40): Any revisions in the ten-plus years since you published that paper?

Zeke Emanuel (00:16:45): Not really. It’s been fifteen—it was published in, I think, February 2009—sixteen years. We’ve elaborated some finer analysis, but not fundamental changes to the framework. I think that framework is universal, widely accepted, cross-cultural. It’s not like it applies only in the United States but not in China. I think generally it’s the right framework for allocating scarce resources.

Rohan Ramakrishna (00:17:15): Awesome. Well, I wanna move next into your time in the Obama administration. And, you know, you came into government having been an academic oncologist, studied political philosophy, bioethics chair. What were the big surprises that, you know, you felt coming from that world into this, you know, legislative world, the hot political world? What were the surprises to you that you found memorable?

Zeke Emanuel (00:17:43): Lots of things were memorable. Yeah. Yeah. I mean, one of the things is, unlike many places, Washington runs more on who you know, and having a sponsor who’s pushing you, than on, you know, objective assessment of merit. I find the Trump administration talking about, you know, “we should, it should be merit-based and none of these DEI hires,” and I’m like, are you kidding? That’s all Washington is. Yeah. Is, you know, you get hired because someone knows you and trusts you. And, you know, look at his administration—no one will say we’ve got the absolute best people based on merit. Yeah. So I find that, and it’s not just—that’s pervasively true in Washington: who you know is more important than what you know. I also found the sort of processes of Washington, and certainly the process of the White House—how you make a decision, et cetera—a little weird.

(00:18:41): They’re not exactly “best arguments win,” which is more true in academia. I mean, I do think academics—we have lots of flaws, but I think best argument tends to win, best data tends to win. Mm. But in government, there’s, you know, you’re balancing policy with politics: what’s the influence on the voters gonna be? And, you know, is this good politics? So you can have a really solid policy argument and the politics could be terrible—it’ll lose if the politics are terrible, even if it’s right. You can forget about it. I’ll give you a real concrete example that would be relevant to your docs listening. In the Affordable Care Act, there were two doctors in the White House, me and a guy named Bob Kocher, who was at the National Economic Council, and we kept arguing we oughta have some malpractice reform that protects doctors. Not because it’s gonna save money, not for any other reason, than it’s gonna take the monkey and the excuse doctors use for not following guidelines—

(00:19:42): Not actually being—worrying about waste and inefficiency. You know, why do you get that? You’re a neurosurgeon—someone bangs their head, they get a head CT, right, even if it’s not indicated. “Well, I’m worried about malpractice,” you know. Or, you know, we get tons—you hear that all the time in the medical field. So our argument is gotta get that excuse off so they can focus on more effective care, more efficient care, et cetera. And we wrote a memo. We held lots of internal debates. We wrote a memo. We thought—and, by the way, President Obama had written a New England Journal article arguing for malpractice reform before he became president. Yeah. It’s like we thought all the ducks were lined up. Turns out politics weren’t there. Democrats were not for it. Republicans, who normally are for malpractice reform, weren’t engaged in the bill.

(00:20:38): They were just—no, they weren’t saying, “Well, if you add this or add that,” or “Here, we have like six provisions we want.” So they weren’t supporting malpractice reform, they weren’t supporting anything. And the AMA, despite its “oh, malpractice, malpractice,” couldn’t give a s**t about malpractice behind closed doors. What they cared about was payment, money, and the SGR—which, by the way, in the ACA, they lost. They did not get that. And so, you know, my brother told me point-blank, “Listen, shut up about malpractice reform. Every time the AMA comes in here, it doesn’t get mentioned. We won’t win anything from that.” Nonetheless, we wrote a memo, went up to President Obama, and, again, how it goes, and who gets to sign off. And, you know, it basically—you know, there was a comment in the margin that said “politics is bad.”

(00:21:29): It wasn’t from the President, but it was—politics are bad because the plaintiffs’ bar, especially in the South, big, heavy Democratic contributors—this will be bad for them. And there’s no upside politically, because the doctors aren’t critical, the AMA themselves aren’t particularly inclined, and Republicans aren’t gonna support on this one issue. The politics suck—not happening, basically. Yeah. Yeah. So that surprised me a lot, and, you know, I just probably wasn’t paying attention to politics that much. But I think this issue of how you balance politics and policy is something that people not steeped in Washington don’t understand or see or grasp how critical it is. And there are not that many people—there are a few people, but there aren’t that many—who are sophisticated in merging the two. There are some people, I think, who really understand both the policy and the politics, and they’re really, really good, but there, again, just not many of them. Mm.

Rohan Ramakrishna (00:22:37): As you think back to the ACA and the constraints you had to work through to get that bill across the finish line, which constraints still bug you—you know, that you had to kind of—

Zeke Emanuel (00:22:46): Oh, you know, I’ll give you a few of them. Yeah. One is, I was very convinced that we had to change how we paid doctors and hospitals. The system of fee-for-service was not gonna work in the United States. It works in lots of other countries, and people point out, well, it’s not unique to the United States. But in those countries there’s a budget, right? In Taiwan, in Germany, there’s a budget, right? You get paid fee-for-service, but, by the way, if those fees go over the budget, they give you ninety cents on the dollar—on the euro, in the case of Germany. Right? And the doctors hate it, but that’s how it is. Like, okay, we’ll pay fee-for-service, but—you know, in the United States, we had a cap. It was called SGR. We never actually enforced it once, you know.

(00:23:32): So it didn’t mean anything. Yeah. So I thought we had to change how we pay doctors, and I did a lot of work on getting all the models that people were doing. One that appealed to me was bundled payments. You know, you’re a surgeon, you know—CMS had actually run some experiments on bundled payments for hip and knee replacements and cardiac procedures that actually worked. I created meetings with CMS, with other people in the healthcare reform ACA group, with experts on the outside, on bundled payments. And I was like, all right, you can’t do bundled payments for everything. But I wanted—I wanted to put in the bill the thing I wanted, was: we’re gonna pay for five medical procedures by bundled payments by 2015. CMS can determine which five, but that is gonna be—we’re gonna begin shifting. CMS resisted it, resisted it, resisted it. “Not ready, not sure.”

(00:24:29): You know, twenty-seven arguments. And the ultimate reason was they didn’t really have the payment systems right. They had the payment system for fee-for-service for paying it out, and computerized and automatic, et cetera, but they didn’t have—they were running those experiments on bundled payments pen and paper, and they didn’t think that by 2015 they could have a computerized system to do bundled payments. Well, so what I ended up getting in the bill is we’ll run a few experiments on bundled payments. Well, you know, we’ve run some. I don’t think the evaluation, you know, we can get into the discussion, but we haven’t really put those on steroids. That’s not the only payment change we need, in my opinion, but I think we have to shift to that. We have enough data that it makes about a 3% difference. It probably makes more, but a lot of those differences are hidden in the hospital savings.

(00:25:28): Anyway, that was one of my big frustrations. Another big frustration is Bob Kocher and I put in administrative simplification. Couldn’t we—we have huge administrative costs—couldn’t we simplify things like billing and claims and save a lot of money? The answer is we can save a lot of money. So we put in administrative simplification, and this is what should be done. And we had a provision in the bill on that, but we failed—utterly failed—for two main reasons. We didn’t say we’ll have administrative simplification in these areas by, you know, January 1st, 2014, or whatever. And the second failure is we didn’t say, “And the overseer of administrative simplification—to report on adhering to the timeline—will be this person,” you know, the Assistant Secretary of Health or, you know, pick ONC or whoever it’s gonna be.

(00:26:27): And that was a bad mistake because when you do administrative simplification, it’s not really the government that makes a lot of money on it. Private payers, hospitals, are gonna be the big winners, and doctors, to a lesser degree—they’re gonna save money. No one in the government is gonna wake up every morning and say, “How do I simplify the system?” Unless you say you are responsible, and you have this date, and this amount of money has to be taken out of the system. And that was just because I was inexperienced and didn’t understand enough that you had to add those other requirements and make someone accountable and give them a date for when they had to finish the job.

Rohan Ramakrishna (00:27:12): That’s fascinating. I think, given the current political environment we’re in with the shutdown, and what the Democrats are arguing for as part of it—our conditions to reopen the government related to the ACA subsidies—probably a great time to celebrate what the successes of the ACA are, right? I mean, looking back, looking present—like, what are the big successes that every doctor, health system should be celebrating and communicating?

Zeke Emanuel (00:27:35): Well, the first one is that we went from an uninsured rate of 18% to an uninsured rate of 8%. That’s important. And it’s partially important because we’ve also learned that providing insurance to people saves lives. Many of your listeners may not know about this experiment. Early on, in 2015, 2016, you actually had to file that you had insurance with your taxes to prove that you were complying with the mandate, or if you didn’t have insurance, you would face a fine, a tax. Basically, the Department of Treasury in the first year had 3.9—I think it was 3.9 million people—who filed taxes and didn’t have insurance. And they sent out a letter saying, you know, “We noticed that you didn’t have insurance, here’s how you can get insurance through the exchanges, your employer, Medicaid, blah, blah, blah.” But, you know, they didn’t have enough money to send it to all 3.9 million.

(00:28:39): They could—they ended up sending it to something like 3.1 million or something. I don’t remember the exact numbers, and, you know, six or 900,000 people didn’t get the letter. So they had a randomized controlled trial of just a letter. A letter telling people where to get insurance turned out that for every 1,500 or 1,600 letters they sent, they saved one person’s life—mortality was down. Now, that’s pretty amazing, right? Yeah. Just a letter, not even giving them insurance. Now, other studies have shown that when you give people Medicaid, you actually can save a life for as few as, you know, one in 300 or so lives. Now, Medicaid patients are probably gonna be sicker than people who are employed and working and paying taxes. Nonetheless, those are pretty remarkable numbers—somewhere between one in 300 and one in 1,500—a lot of people that you’ll save their life just by giving them health insurance.

(00:29:38): So health insurance may not be the most effective way to save lives, but it’s pretty damn good. And so I’m pretty proud. I mean, we gave more than 20 million people insurance, and you know—about 30 million people—and pretty damn good. And, you know, soon after the ACA got people enrolled, and still today, you know, I get stopped by people who recognize me, and they say, “Thank you for the ACA. You got, you know, my brother or my sister or someone—” and, you know, a couple of times it’s like they got a bone marrow transplant that saved their life, or they got a heart transplant that saved their life. And it’s like, you—I mean, that’s fantastic. You can’t do that any other way, you know, big policy and affect millions of people. And I often joke, you know, well, if I was one of a thousand people who was working on the ACA and had a little influence, you know, 25 million people got insurance. That means somehow I affected 25,000 people’s lives. That’s pretty amazing. There was—

Rohan Ramakrishna (00:30:37): There was a National Bureau of Economic Research study. I think it was published in the last year or two, but basically compared expansion states against non-expansion states. And even in that kind of data, as dirty as it might be, there was a mortality benefit in the expansion states. Right? So, to your point, this has been hugely impactful, right, across a huge population in terms of saving lives.

Zeke Emanuel (00:30:57): So, so that’s, you know, getting people insurance, therefore saving lives—important. We actually reduced costs, you know. I was arguing that we’re gonna save money. The ACA is gonna have big impact. And it had a way bigger impact for a lot longer than anyone anticipated. Just blew all the estimates out of the water. We’re still at 17.5% of GDP for healthcare—the same as we were in 2010 when we passed the bill. Now, it’s gonna go up over the next few years. Exactly why is—we can debate—but that is a huge difference. Including, you know, The New York Times two years ago published an article with the title, you know, “Medicare Saved the Government Nearly 4 Billion and No One Knows Why.” Well, we know why. That time period over which that savings is—is the time period of the ACA. What exactly in the ACA did it?

(00:31:51): I have my hypothesis, other people have theirs, but there’s multiple factors. But certainly one of them is the alternative payment models, the change in mental focus of physicians from—we’ve gotta save money. It’s not just doing what we have done. It has made a big difference. People have really focused. So the amount of money we’ve saved is in the trillions of dollars. And what’s interesting is the ACA doesn’t get enough credit for that. Hmm. I would say our weak link has—and this has been pretty disappointing—has been on quality. Quality has not gone up, and in some areas it’s clearly gone down. And I think there are things we can do to change that, but I think you have to say we just didn’t do a bangup job on that. The other things that have gone down—the other two things—

(00:32:46): One is we have worse workforce issues. I have hypotheses why. I was very critical of what we did in the workforce stuff as part of the ACA. It was a little bit of sprinkling pixie dust here, there, and everywhere—every little program we had, we added a little more money to it, but we didn’t really rethink how we gonna change, get more people into primary care, and things like that. There are policies we can do, but they weren’t well done in the ACA, in my opinion. And it was pretty clear those weren’t gonna work. But what’s really, I think, surprised people is, despite the expanded coverage, despite, you know, relative quiet on the cost, we have had huge growth in dissatisfaction with the system—both on the doctor side and on the patient side. And you can know this for two—I have two words for you.

(00:33:40): If you’re in doubt about that, and they’re called “Luigi Mangione.” The response, the, you know, vigilantism, the support for his vigilantism tells you a lot about how dissatisfied people are with the healthcare system. And, you know, that should be a big wake-up call for everyone. And I think that’s only gonna grow over the next few years. I actually—I’ve made this prediction once before on NPR, and I’ll make it again. I think in 2032, the presidential election is gonna heavily focus on healthcare. It’s gonna be like the 2008 election, where healthcare’s gonna be one of the top two issues. That’s my prediction.

Rohan Ramakrishna (00:34:24): Well, you know, it needs, right? This—it’s not a question, you know. I think I—

Zeke Emanuel (00:34:28): I agree.

Rohan Ramakrishna (00:34:29): People need—people are so upset. And for rightly. I mean, even if you have insurance today, you know, you’re effectively—

Zeke Emanuel (00:34:37): You’re a hundred percent right, you know, a hundred percent.

Rohan Ramakrishna (00:34:40): Yeah. So I think, especially coming from you, this is gonna be really important for people to hear. You know, the Democrats are fighting for maintaining Medicaid funding, right? And so what are the consequences of losing so much Medicaid funding in our health system as we know it?

Zeke Emanuel (00:34:58): Eleven million people losing insurance. And if you think my numbers are anywhere close to right, it’s probably about four or 5,000 added deaths a year. Hmm. It’s terrible, you know. And it hits the most vulnerable. Who are the Medicaid recipients? Okay. Let’s just be clear. First of all, two-thirds of them, three-quarters of them, are families where one person is working. They’re not laying on the couch collecting benefits that they’re not entitled to or shouldn’t get. These are working people. It’s just that their employer is not providing them health insurance, and they need the government. Second, it’s mothers with kids. Okay. You’re only gonna punish kids. They didn’t ask to be brought into this world without health insurance.

(00:35:59): And the last two groups are poor elderly—okay, they’re retired, they’re getting Medicare, Medicaid is simply a supplement because they can’t afford the deductibles and co-pays—and then the disabled, who can’t work. We’re not talking about people who are, you know, have all the benefits of American society, and taking stuff away from them is punitive. And it’s coldhearted. It’s like being Scrooge. And that’s not what America’s about. We, you know, we say, you know, you work hard, you don’t get insurance from your employer because it’s retail and they can’t afford it, but we need a system. We learned that a long time ago, six decades ago. We need a system to get those people insurance. That’s what the Affordable Care Act did. And cutting it off is just hurting poor people, and many of those poor people are gonna die. It’s not—I mean, you know, that’s what the data says. Yeah. And, by the way, one of the other consequences—and, you know, now I’m wearing a little too much of my health policy, health economics hat—is, you know, rural hospitals that were in expansion states, as you point out, they did much better because they now were paid for more people who had Medicaid to come in, and the hospital’s balance sheet was better because they were paid.

(00:37:17): Now, those people are gonna lose insurance. The hospital’s gonna be providing quote-unquote “free care,” and their cash flow is gonna look terrible, and many of them are gonna close. You know, the estimates have been something like over 300 are at risk because of this policy change. It is simply hardhearted. And as far as we can tell, this is something the Trump administration is happy to let happen—and all the Republicans, all the Republicans voted for. Yeah. So—

Rohan Ramakrishna (00:37:50): So if we think of phase one of the current political climate as kind of restoring that funding, keeping ACA subsidies, you know, and assuming we get that and then we get to the next fight, how should the ACA be strengthened in the future? I mean, I think Medicare negotiating drugs as part of the Biden administration was a great first step, but I’m curious what you think of initiatives like direct-to-consumer drug marketing, like Cost Plus and TrumpRx, things like that.

Zeke Emanuel (00:38:17): Well, you know, Mark Cuban’s thing—as he and I have discussed, I think the transparency’s important because, you know, the drug market is not one of transparency. But, you know, most of his drugs—the vast majority, over 95%—are generics. You’re not affecting drug costs in America by changing the generic prices. They’re just not—I mean, you gotta get to specialty drugs and the big-ticket items like GLP-1s. And it’s not clear that TrumpRx is gonna do anything. And even the big deal that he’s touting about, you know, GLP-1s—it’s, you know, the fine print—everything’s in the fine print—which part of Medicaid, which part of Medicare. The general population won’t have that. This is one of the problems of the American healthcare system, okay, the complexity. We don’t have a price, for example, for GLP-1s—a price. We have hundreds of prices, right?

(00:39:20): You have a price whether you’re insured by X or this or United or Blue Cross and Blue Shield or Humana or whoever. That’s a different price for Medicaid, different price for the VA, different price for Medicare. And it depends which Medicare plan you have, what you’re—that is a terrible problem, right? I mean, it’s complex, it creates all sorts of gaming opportunities for companies as well as individuals. It’s moronic. And now we’re just multiplying it. So I would say, if I had to say, thinking about the next healthcare reform—and I have ideas about it—there should be two guiding principles. Okay. One is: simplify the system. It’s way too complex. Yeah. And the other is: standardize things. Standardize what insurance companies offer. Standardize deductibles and co-pays. Standardize the contracting between doctors and hospitals, doctors and payers.

(00:40:20): Okay. You need simplification and standardization. And then whatever proposal we have has to realize at least three of the five goals of a well-functioning healthcare system. And those five goals—no surprise to anyone on this podcast—universal coverage. Americans now think healthcare is a right, and Republicans think it too. It’s not, you know, optional. We can discuss that. Reasonable cost control. Has to be flat cost control—no increase above the increase of the GDP. Third, quality has to improve. It has to be regular, high-quality, guideline adherence. Fourth, the disparities—disparities between urban, rural, inner city versus suburbs—has to narrow. Fifth, there has to be satisfaction—patients, physicians, and other providers. Those are the five goals of any healthcare system anywhere in the world. We don’t meet one of them—not a single one. Whatever we do has to be able to meet those five. We have to get universal coverage, and we have to get reasonable costs and consistent high quality. I think those are just—there should be no disagreement about realizing those.

Rohan Ramakrishna (00:41:41): Yeah, I totally agree. I mean, one of the things that I find shocking is there’s a trillion dollars in administrative costs, right, in US healthcare, which is just bananas to me. That’s a lot. You know, a trillion is a lot of money. Yeah. And I wonder—one of the places that I find interesting in this regard is this idea of vertical integration, right, where a payer owns the PBM and some providers, and, you know, basically they can game the MLR part of the equation, right, in the ACA. So do you think that vertical integration as it’s practiced today—is reform necessary? Like, should a payer own the provider and the PBM and the pharmacy?

Zeke Emanuel (00:42:23): I think the FTC and the Department of Justice have not kept up with the dynamics of the healthcare marketplace, right? And we need more antitrust enforcement. And I think that’s very, very important to getting costs under control. I think there are many other things we could do for that. I think hospitals gobbling up doctors and forcing, you know, doctors to only refer to their hospital—and they’re being able to drive up other costs—very bad, very bad. And we need to stop that also. And medical groups can’t get so big that they can, you know, they’re the only neurosurgeons in town, and they can—or that they can—I mean, our solution to surprise medical billing was, I think, should be seen as a disaster. Yes, the patient doesn’t see it anymore, but the costs have risen, because the way all the adjudication goes is higher and higher, instead of, okay, it’s in-network payment—sorry, guys, you don’t get out-of-network payment, withdraw from the network, contract, so you can make more of that. No. So I think we—there—we need much more focus to prevent the monopolization. I do think vertical integration’s one part, but it’s only one part. Mm.

Rohan Ramakrishna (00:43:54): All right. So last question before we get to your book, which is, you know, one of the things at Rune is that we talk a lot about misinformation and disinformation, how it affects people’s understanding of health. And you lived through this in a way in that “death panels” era, where I think that something you said was sort of grossly mischaracterized. And so I’m curious, what did you learn from that, from the perspective of how do you debunk misinformation and disinformation? Because I think so much of medicine is reactive versus proactive. Yes.

Zeke Emanuel (00:44:27): Yes. So—

Rohan Ramakrishna (00:44:28): Curious your thoughts.

Zeke Emanuel (00:44:30): Yeah, we definitely need to have a different approach now. I think one thing that the medical community has not done well is to recognize that the media environment has changed dramatically. And this idea, you know, you’re in your white coat with a stethoscope, and you’re on CNN, and you’re on NBC or ABC or CBS—that’s not the media environment. And the media environment is very, very different, and we need to adapt to it. It’s much more peer-to-peer. It’s much more about authenticity. And we worry, well, if we go to where the media environment is, we’re gonna lose our rigor. And so we need to figure out a way to marry rigor with the media environment that rewards intimacy and authenticity and directness. And I think we need to change. And more than I think we need to change—now I’ve recently, in part because of my book and wanting to publicize the book, I’ve gotten onto TikTok and Instagram and whatever else. The fact of the matter is, first of all, I get a lot of responses, including responses from older people who I wouldn’t have expected to be on those platforms.

(00:45:47): They’re on the platforms too. So that’s where media’s going. We, as experts, have to go there without sacrificing our rigor and recognizing that that’s an approach. The second thing I would say is we have to get more politically active and engaged. One of the major problems that allows misinformation to circulate—we know that lies travel faster than the truth on the internet—is the bubbles people live in. And we have to disrupt, and get the government to disrupt, the algorithms that allow people to stay in a bubble. That is not good for society. It’s particularly dangerous for a democracy. And I think that’s one thing. Now, we have an article coming out in The Lancet about combating misinformation. These are two of five suggestions that we have for how the medical community and the public health communities need to combat mis- and disinformation. We have a responsibility to be much more proactive, and not just—and, you know, we, I think we can rightfully complain about the media environment, but we have to do something about it. We can’t just complain.

Rohan Ramakrishna (00:47:02): Yeah. The one problem or challenge with the algorithm problem that you mentioned is just, you know, people now can tune their own algorithms, right? That is—so you can kind of choose the echo chamber you want. And that’s a problem, right? It’s just like you forget—okay, tune into Fox News or MSNBC or whatever your thing is. You don’t—you can choose to not be exposed to a diversity of opinions or facts or whatever it is.

Zeke Emanuel (00:47:25): Yeah. I would say one other thing about that. That is true, but it’s also the case that the media environment chooses you by what you search for—they give you stuff. And so, a lot—I mean, for example, one of the things in looking at—in researching my book—one of the things you notice is that people get health information—90% of the people get health and wellness information that they didn’t actually ask for. It comes to them passively, at the top, or, you know, through some other feed. And so there’s a, you know, I’ve searched for whatever, and suddenly I’m getting people’s postings and an X feed that highlights that. Well, wait a second. You know, that means that the media environment—it’s not just how people use it. It’s the fact that they’re being passively bombarded with certain views that they didn’t actually ask for.

Rohan Ramakrishna (00:48:21): Yeah. No, I totally agree. It’s such a huge problem that I think physicians have to get out in front of. Yes.

Zeke Emanuel (00:48:28): Exactly. I totally agree with that. And I think we’ve been too passive and too “woe is me” in our view.

Rohan Ramakrishna (00:48:36): Awesome. So with that, for the last fifteen or so minutes, I wanted to really get into Eat Your Ice Cream, your brand-new book. So, congratulations on doing this. I loved all the chapter titles. And before, you know, we get into the substance of the book, I was curious—did you debate the title between “Eat Your Ice Cream” and “Don’t Be a Schmuck”? I love that first chapter.

Zeke Emanuel (00:48:59): Yes. Yeah. That was a big debate. My files—my research assistants’ files—are still, you know, “Don’t Be a Schmuck.” But I think actually, upon reflection—okay, I can now see Eat Your Ice Cream is a better title, because it’s sort of a bit ironic that this is a book about wellness and longevity and telling you to eat your ice cream. And I think that people are gonna be, well, how does this go together with wellness? And so I think it’s probably a better approach. You know, maybe—and not maybe, it’s certainly true—that “Don’t Be a Schmuck” is kind of inside my family a way better title. Well—

Rohan Ramakrishna (00:49:45): You know, given your background and experience in bioethics and drafting, you know, incredibly impactful legislation when it comes to healthcare, what motivated you to write this book and get into the wellness game? I mean, obviously it’s very top of mind, right, for—

Zeke Emanuel (00:50:01): Not for me. So what happened is I got—and I don’t remember how I got it—I got Peter Attia’s Outlive.

(00:50:12): And I read it, and it made me furious, for multiple reasons. One, the obsession with wellness. Two, the obsession with exercise, and, you know, the sort of total ignoring of social relationships in wellness and longevity—except in, he’s got a little, basically two-page afterword. And I’m like, this is totally wrong. It sort of might remind your listeners of what happened when I went to that presentation about what happens if we have an H5N1 flu pandemic, and how are we gonna allocate scarce resources? You know, someone said something, and I said, I know that’s wrong. And now I gotta show what’s wrong with it and what the right answer is. And so I literally sat down, and my wife will tell you—classes, I think, I’m finishing reading it sort of the Thanksgiving weekend or something. Classes ended the next week, and I sat down, and I just furiously wrote 35,000 words about, you know, basically how to think about wellness in these six categories, and, you know, what the data are in each one of them, to try to counteract both the obsession—you don’t need to be obsessed, you shouldn’t be obsessed—

(00:51:31): And it’s not all exercise. As a matter of fact, that’s not even the most important thing you can do for your own wellness. So that’s how it came about. And I wasn’t intending—you know, as a matter of fact, I sort of wrote it, sent it to my agent—to my agent. You know, it’s like, “It’s gotta, you know, can’t go in like this,” blah, blah, blah. And so I sort of—all right. And then I had dinner with Kara Swisher and Adam Grant, when Kara Swisher visited Penn, and they were like, “Yes, you’ve gotta publish this.” So then I took renewed interest. So I wasn’t actually anticipating that I would—I really gotta become a wellness guru, like everyone else. I wasn’t doing that. I was just—man.

Rohan Ramakrishna (00:52:15): You know, it’s interesting. You know, I—obviously, I don’t think the sequencing was potentially intended, but, you know, you wrote that famous article in The Atlantic about “Why I Hope to Die at 75.” And then this book comes out. So—and in that article you famously kind of argue for declining health-extending interventions after the age of 75. But I’m curious—that doesn’t render optimization and healthful living pointless. So I’m curious, what are your—and you talk about this a little bit in your book—but what do you see as the highest-yield longevity hacks for someone over the age of sixty? Like, what should they immediately start to do?

Zeke Emanuel (00:52:49): So the first thing to recognize is the most important thing you can do for your health, longevity, and happiness is establish and reaffirm your social relationships. That’s just way more important than anything else you’re gonna do. And I like to say one of the benefits of that is the payoff is now—you don’t have to wait your whole life to get it. Having friends over, making, cooking dinner, and having a social meal—you know, a dinner party with, you know, two, with four other couples, or whatever it is you’re doing—you know, that payoff is today. You’ve just had a wonderful dinner. It also has long-term health benefits, it turns out, and allows you to live a long time. So if you ask me: be more social. You know, have more dinner parties, go out with people, casual conversations, you know. And I notice personally, I get into an Uber, if the driver isn’t, you know, someone I talk to, or doesn’t respond, or doesn’t really wanna engage—

(00:53:58): So it’s a worst ride, you know. It’s just—I can, yeah, I can read my book, I can make calls, I can do—but if there’s a driver and I’m learning—oh, you know, I was in Tampa yesterday, and the guy driving me—and, you know, we began talking. He was complaining about something in Tampa. And I said, so why are you living here? And he says, well, I lived in France for seventeen years. And then we got into his—how’d he get to France? And what was—you know, the fact that he’s a jazz musician. And, you know, it was like—and then he came to the United States, and he put on fifteen pounds because the food is worse here and better in France, but, you know, keeps your weight down because it’s healthier for you. Anyway, we had a great time. You know, I didn’t know this guy, and I’ll never see him again, but it was a wonderful trip, and I learned something about him and living in France.

(00:54:44): And anyway, those are the kind of things that are really good for you. One of the biggest things you have to worry about over sixty is your loss of muscle mass. Hmm. And so exercise, you know, is important. It shouldn’t be an obsession. It doesn’t have to be an obsession. But doing aerobic exercise—for me, it’s, you know, bicycling. I like to bicycle about fifty miles on the weekends, or thirty, forty-five miles on the weekends. Some strength training. And then flexibility and balance. And I do yoga every morning, along with core exercises, every morning. Those are important to try to prevent or limit the amount of muscle mass loss you are going to have inevitably. Staying mentally engaged as you age—really, really important. You know, one of the reasons I do things like honey-making and chocolate, you know, whatever the next crazy thing is—and I know what it is for 2026—you know, staying mentally engaged, using your brain, really important.

(00:55:59): So those are the kinds of things you really—you know, do you need to eat well? Absolutely. My recommendation is start with two noes: no sodas, sugar-sweetened beverages—stop those or reduce them. Reduce your cakey, cookie snacks. Over the last few decades, Americans’ consumption of things like, you know, packaged cakes, muffins, cookies shot up 500 calories a day. We do a lot of snacking in the US on that. Reduce that or eliminate it. And if you want a positive, the positive is fermented foods, whether it’s yogurt, kefir, kimchi, sauerkraut. Those are gonna be really, really good for your microbiome, which we’re learning every day more and more about and how important it is for you. So those would be the sort of package of things.

Rohan Ramakrishna (00:57:03): You know, one of the things—going back to social connection—you know, it’s like loneliness—you know, Vivek Murthy’s—and you put this in your book too—wrote a major report on the impact of loneliness on people’s health. You know, loneliness is like smoking fifteen cigarettes a day or something like that in terms of contextualizing it. And a book I think you might really enjoy is by my friend named Ben Rein. He’s a neuroscientist. He wrote a book recently called Why Brains Need Friends, right? And why social connection is actually incredibly important for your own mental health, cognitive health, overall physical health. And it strikes me also that—how do you, from a policy perspective, or is there a policy solution to this? Like, how do you get people to do more of that, right? More social connections. It’s like, maybe there isn’t a policy prescription for this. I’m curious how you would think about this from a public health lens.

Zeke Emanuel (00:57:59): Oh, there are actually many things that we can do from a policy standpoint. And let me give you my current hobby horse, which I wrote about in The New York Times. You know, getting rid of cell phones and computers in schools is really, really important for this effect, because one of the things we notice is kids have a lot of loneliness. And one of the problems is they actually don’t know how to interact with people. They don’t know how to make friends. And it’s a social—it’s a skill, like everything else that you have. And if you don’t learn it early and use it all the time, you don’t get it. Schools that have actually implemented bell-to-bell no cell phones in the school—one of the things they notice is schools are louder. Why are they louder? Kids are talking to each other.

(00:58:57): They’re not on their cell phones, right? Being quiet, but being miserable. And that noise—as long as it’s communication between people—really important. It also decreases violence and sort of attacks between students. And so—that is one social policy. I’m actively working in Pennsylvania trying to get that policy enacted because I think it’s good. I’ve enacted it in my own classrooms at the University of Pennsylvania. You can’t have a cell phone, can’t have a computer or iPad linked up to the internet while I’m in class. And I can tell you, my students are way more engaged. No one is shopping, because I can’t shop while I’m talking and while, you know, guest lecturers are there in school. So that is one major difference. I think another one that we have to keep our eye on is what Australia’s done, which is to prohibit access to social media platforms like Instagram and TikTok for kids under—pick your age—8, 15, 18, whatever it is.

(01:00:04): I mean, they actually know exactly how old you are when you log in. I mean, Mark Zuckerberg’s not stupid, you know. They target—and what are they selling? How are they making the money? By selling to the advertiser: “We can target an individual. You know who wears polka-dot socks, is 47 years old, you know, lives on this block.” And so they know exactly. And we’ve got to look at that experiment in Australia. I think it’s gonna be really powerful, and we have to institute something like that. You gotta get people to break the habit of using screens early on and to encourage the skill development of how to be social and interact. And those are some of the policies that I would introduce.

Rohan Ramakrishna (01:00:52): You talk a lot in the book about vaccines and how this is such a great—and it is a great—public health intervention. But how we don’t properly, as a society, contextualize risk, right? Peanut butter is actually much more risky relative to taking a vaccine. Like, how do we teach relative risk to our population better, right? If the people don’t understand that polio is really bad, measles is really bad—because they’ve never seen it—and short of having an epidemic of those things, we’re already seeing a little bit—well—

Zeke Emanuel (01:01:25): We’re doing a good job to make those epidemics come back. Yeah.

Rohan Ramakrishna (01:01:29): But how do we better communicate this to people, that this is not the hill to die on from a cultural war, political war perspective?

Zeke Emanuel (01:01:39): I think you actually have two different things you’re asking there. One is, why are people sort of opposed to vaccines—and polio vaccines in general, or MMR? And the answer to that is that they’ve been so successful. Right? And you said it yourself: they’ve not seen anyone with polio, they’ve not seen anyone who has measles and might die of measles or be hospitalized because of measles. Because of the success, the threat of these infections has gone way down. And all this cohort that’s been born way after these threats have been reduced—if not to zero, pretty close to zero—they, you know, don’t see the reason why I should take the risk of a vaccine. We have to educate people about those risks. So that’s a kind of history that needs to be better taught, the education to people about relative risk. That goes to a different issue, which is: math skills are terrible.

(01:02:49): Hmm. In, you know, I notice in my students, interpreting graphs, interpreting tables, interpreting p-values—atrocious. They really don’t have those skills. And we have not done a good job. I mean, innumeracy is very high in America, and we have not done a good job of training kids with good math skills. And, as you point out, relative risk—how do you compare the risk of A with the risk of doing B—is poor, because people don’t understand, you know, “I have a one in a hundred chance of, you know, dying if I do this, and one in 2,700 chance of dying if I do that.” They don’t understand that. And, you know, putting those things into context is important. And that’s why I think, as you pointed out, one of the good things Vivek Murthy did in his report on social loneliness is to put it in kind of, “Well, it’s like smoking fifteen cigarettes a day.”

(01:03:42): No one really knows what smoking fifteen cigarettes—but they know that smoking fifteen cigarettes is really bad for you, right? It’ll kill you. It’ll kill you early. And so that’s how people have understood—can understand that. So we, again, in the public health community, have to make things more salient. But we also need to teach kids better about math, and not make it onerous. You know, some of us love that kind of stuff. I’m a sort of—I don’t—you will know when—because you’ve read my stuff—I’m not that good about telling stories, and I’m much better about using data, just because that’s the way I think. But people in general are better at the stories than they are about the data. And we have to respect that and try to give analogies like the fifteen cigarettes.

Rohan Ramakrishna (01:04:32): All right. So this is the last part of the interview. We call it the lightning round. Oh no.

Zeke Emanuel (01:04:37): So the last lightning round I failed—not with you, but with someone else.

Rohan Ramakrishna (01:04:43): So, most impactful mentor?

Zeke Emanuel (01:04:48): Many people fit that bill. Yeah. And when I was in Oxford and doing basic research, that mentor told me, you know, when you write, no more than ten words in your sentence. Americans can’t write these long sentences. Just ten words in a sentence and make them short and sweet. That was really important for my writing. Probably my most important mentor is a man named Dennis Thompson, Professor of Government and Political Philosophy at Harvard, and ran the Ethics and the Professions program—now called the Safra Center for Ethics at Harvard—and had me as the first fellow in that program and really shaped how I think about ethics in public policy and bioethics. He really, really was helpful, and we became lifelong friends. He recently, a few months ago, unfortunately died in his late eighties from prostate cancer, of all things. Mm.

Rohan Ramakrishna (01:05:45): Book recommendation?

Zeke Emanuel (01:05:46): Book recommendations. Well, every year I invite people in to be guests—yeah—guest teach my classes, and I always send out a book. I’ll just tell you what I’m sending out this year, right? Is a book called James, which was published a few years ago and is a book about Huck Finn—a Huck Finn book from the perspective of Jim, the slave. And it’s a fantastic novel. You can see on my bookshelf King—Jonathan Eig—also a one-volume biography of Martin Luther King, which is brilliant, and a brilliant encapsulation of the whole moment of the late fifties all the way to ‘68. I think just a terrific book.

Rohan Ramakrishna (01:06:35): If there’s a documentary produced about you, what’s the intro music?

Zeke Emanuel (01:06:40): Oh, you’ve got me in the wrong place. Music is not my strong suit. It was my father’s strong suit. I think probably some Bob Dylan. Strong, maybe “Like a Rolling Stone.”

Rohan Ramakrishna (01:06:51): I don’t know if you see that—it’s a Rolling Stone book behind me. Uh-huh. Rolling Stone covers with Bob Dylan.

Zeke Emanuel (01:06:57): So I came of age in the sixties, and my first concert that I went to myself was one of Bob Dylan’s Rolling Thunder Revue concerts. So I think 1975 or ‘76, I’m not sure. And it made a lasting impression on me. And pretty amazing guy.

Rohan Ramakrishna (01:07:22): And then last two questions. Life lessons from making chocolate and honey?

Zeke Emanuel (01:07:28): Life lessons from them.

Rohan Ramakrishna (01:07:30): Yeah.

Zeke Emanuel (01:07:31): Things are a lot harder than you think. Doing things very, very well—at the top, you know, to win awards and to really be first-class—one of the—I would say one of the traits of the Emanuel brothers is we don’t like to be second. But trying to do something at the high end—it’s hard work. It’s really complicated to do. And appreciating how—you know, people often tell me, you know, fifteen dollars for a bar of chocolate? I said, yeah, it should be fifty dollars, because: A, there’s a lot of labor in it, and B, it’s complicated. You gotta get the right cacao from the right place. You gotta winnow it, or first you have to ferment it, then you have to dry it, then you have to roast it, winnow it, separate out the cocoa nibs, then you conche them, and then you temper them and package them.

(01:08:25): It’s a lot of work. It’s also getting the roasting just right—you know, there are only two places flavor is made: the fermenting time and the roasting time. And you gotta get both of them right and play around with those. The flavor—the creativity in those things—and trying to really make the best bar you can, and what’s the flavor profile you wanna create? So I think one of the lessons is, you know, things are harder than they might look—all the time, even for simple stuff. You know, I’m always appreciative of woodworking, you know. I work with a lot of woodwork. I have a lot of interesting pieces of wood in my house—furniture. My dining table is reclaimed chestnut wood, which you don’t have in America anymore. And, you know, understanding the woodworking process and the, you know, meticulous work and the vision that people have—I’m just amazed. And so I think I’ve learned that from making chocolate and honey. You know, every time I do chocolate, it’s about a week in Missouri, where I make it with a chocolate maker, Askinosie, and, you know, I appreciate the camaraderie, and I also learned to appreciate the complexity.

Rohan Ramakrishna (01:09:39): All right. Last question, which is: your ideal job in the future, Rahm Emanuel administrator?

Zeke Emanuel (01:09:49): His heckler. I love the question, and I’m sure he’ll love it even more. Yeah. I’ll empty the garbage cans for Rahm. Yeah.

Rohan Ramakrishna (01:10:03): All right. Well, look, I want to thank you, Dr. Emanuel, for your time. This has—

Zeke Emanuel (01:10:07): This has been a wonderful interview. It’s been terrific—real, really great questions and very thoughtful. And I appreciate all the prior work and study you put into it.

Rohan Ramakrishna (01:10:18): For everyone, the book is called Eat Your Ice Cream. When’s it available?

Zeke Emanuel (01:10:23): You can order it now, and it’ll be delivered. It’s January 6th, 2026, when it’s being sent around, released in the bookstores.

Rohan Ramakrishna (01:10:33): It’s a wonderful book. I encourage everyone to get it. It’s got Dr. Emanuel’s characteristic humor and directness, which I really appreciated while reading it. So again, thank you—means the world—really loved having you on Good Medicine.

Zeke Emanuel (01:10:47): It’s fantastic. Thank you for the interview.

Rohan Ramakrishna (01:10:54): Thanks for listening to Good Medicine, and a special thank you to Dr. Emanuel for sharing his perspective. If you’re a physician, we’d love for you to join the community at Rune.com and continue the conversation. That’s www.Roon.com. You can also help us grow by sharing this podcast with a colleague or friend. Till next time, thanks for being part of the conversation.

Discussing his new book, The Formula for Better Health, Dr. Frieden breaks down his “See, Believe, Create” framework and the critical difference between regulation and the “nanny state.” They dive deep into why hypertension remains the world’s deadliest—and most neglected—pathology, the failures of COVID-19 communication, and the “Big Six” lifestyle behaviors that actually determine longevity. Whether you are a clinician or a policymaker, this conversation offers a masterclass in how organized, rigorous action can save millions of lives.

For more from Roon, visit: ⁠⁠

https://www.roon.com/

Find us on Instagram and X: @roondoctors

If you have a question, comment, or suggestion for a future guest, please email us: jane@roon.care.

Transcript:

Rohan Ramakrishna (00:00:04): Welcome to Good Medicine, a podcast about the ideas, people, and conversations shaping the future of healthcare. I’m your host, Dr. Rohan Ramakrishna, neurosurgeon and co-founder of Roon. Each episode, we explore how medicine is evolving through honest conversations with leaders and changemakers. Good Medicine is brought to you by Roon, the digital home for doctors. We’re a free, physicians-only community to connect, share knowledge, and shape the future of medicine.

(00:00:42): You often think of medicine as the interaction between one doctor and one patient, but what happens when the patient is an entire city, a country, or even the world? Today’s guest, Dr. Tom Frieden, operates at that massive scale. As a former director of the CDC and NYC Health Commissioner, he has faced down some of the most terrifying threats of the modern era, such as leading the U.S. response to the spread of Ebola, battling tuberculosis in India, and transforming New York City’s approach to smoking and trans fats. On the heels of his newly published book, The Formula for Better Health, we explore the high-stakes decisions made inside the cramped quarters of the White House Situation Room and the critical, often invisible work required to build trust in a skeptical world. We also dive into his framework of See, Believe, and Create—a method for making invisible threats actionable—and breaking down the surprising “Big Six” behaviors that actually determine how long and how healthy you’ll live. But as you’ll hear, his approach isn’t just clinical. It is rooted in his background as a philosophy major grappling with logic and his early days as a disease detective. Whether you’re a physician, a policy worker, or just someone trying to live a healthier life, my conversation with Tom Frieden offers a masterclass in how organized action can change the world.

(00:02:09): Welcome to Good Medicine. It’s great to have you.

Tom Frieden (00:02:12): I’m looking forward to the conversation. Thank you for what you do.

Rohan Ramakrishna (00:02:16): So I want to start with your pre-medical career a little bit. If I read correctly, you were a philosophy major at Oberlin. Is that correct?

Tom Frieden (00:02:23): Yes. Yes. I actually, my father said, “Look, you’re gonna be doing science and medicine the rest of your career; do something else in college.” And so I studied philosophy.

Rohan Ramakrishna (00:02:36): It’s funny you said that. My, I had an English teacher in high school who told me the exact same thing. She’s like, “You must promise me that in addition to something in science, you do some hard humanities.” And so I picked philosophy, but you know, I bring that up because, you know, there’s a utility—a potential utilitarianism—to public health and sort of your guidance there. So I’m curious, did that influence you in ways both conscious and unconscious?

Tom Frieden (00:03:02): I’m not sure. I do think that the very simple, clarifying question of “How can we save the most lives?” is a great way of thinking about how to build an organization or a career. And obviously, there are lots of different ways to approach it that are all valid and important. The specific area of philosophy I worked on was Wittgenstein and philosophy of conception [perception?], and trying to apply that to ethical issues, recognizing that you can have philosophically inconsistent perceptions of a problem which are both valid. And I think that’s been something that has helped me to understand the world a little better.

Rohan Ramakrishna (00:03:51): Yeah. That’s awesome. And so I’m curious, like, did you always know you wanted to go into medicine, or was that something that evolved over time?

Tom Frieden (00:03:59): I remember that my application for college said, “I want to go to medical school.” My application for medical school said, “I want to go into public health.” So I guess I was a little bit ahead. I knew what I wanted to do, but in my career, I’ve been really fortunate to have great mentors and great opportunities. And with that, I’ve learned, and I’ve tried in this book to convey what I’ve learned, and I learned a lot more actually in the process of writing this book.

Rohan Ramakrishna (00:04:29): Yeah, that’s great. Now public health is not, I would say, the usual path for someone who goes into medical school. So I’m curious, what started that fascination with public health? Because so many people go into medicine with this idea, “I’m gonna take care of the patient in front of me,” but public health is all about taking care of millions, potentially. Right? And so I’m curious, where did that—if you can call it that—kind of occur for you?

Tom Frieden (00:04:54): Well, one thing is I actually love taking care of patients. There are some people who go into public health because they’d rather not do clinical medicine. I love clinical medicine, but I had done some policy-oriented stuff in high school and in college, and I was hiking with my father in the Blue Ridge Mountains of Virginia. And he said, “You know, you seem to like policy stuff and you like science, and if you put those two things together, you get public health.” So that was the first time I’d ever heard of the term public health. And then I’d done a residency in internal medicine after medical school—I’d done my MD and MPH—and I was working in tuberculosis control, which has such relevance both in the U.S. and globally. And it was really through tuberculosis control that I came to understand some of the real details of what works in public health.

Rohan Ramakrishna (00:05:53): Yeah. I think related to that, you tell a story in the book about how you’re talking with your father and he asks you, “How would you know whether you’re gonna become the best health commissioner?” Right? And that seems—that idea of impact is, seems to be very profound throughout in your life.

Tom Frieden (00:06:12): Yeah, it was a very emotional moment. He had Parkinson’s disease and he was fading. He was in a nursing home and he was saying less and less. And I had just come back from India where I had been on assignment for five years working on tuberculosis. I was going to be the health commissioner for New York City. I told him—not that I’m competitive or anything—I told him that I wanted to be the best health commissioner. And he said, “How would you know?”

Rohan Ramakrishna (00:06:39): Yeah.

Tom Frieden (00:06:40): And they were actually the last words he ever spoke to me. Wow. Because his health was going downhill. And it’s a great question. He was a cardiologist, he was very rigorous in his thinking. He practiced evidence-based medicine before that term was invented. And it raised the question of, “All right, what’s killing the most people, and what are the things that we can do to address it?” And that’s really something that led to The Formula for Better Health, this approach: See, Believe, Create. See things that may not be readily apparent; Believe and strengthen the belief that you can make change; and then Create a healthier future with organized, simple, well-communicated programs that overcome barriers.

Rohan Ramakrishna (00:07:29): I love that. And we’re gonna definitely get into the formula, which I think is—hopefully for the rest of the conversation, we can talk about how those different aspects of that formula relate to these different inflection points in your career. You know, where you start in the book, which I think is a fascinating one, is as an Epidemiology Intelligence Officer in New York back in the early nineties. So first, can you tell me what goes with the training of some of our young officers that get deployed? And then also, you know, paint the picture of New York at that time.

Tom Frieden (00:08:00): Sure. Wow. So the Epidemic Intelligence Service is the disease detective service of CDC. Right? And there were a series of magazine articles, mostly in The New Yorker by a man named Berton Roueché who described these mysteries that disease detectives would solve, many of them at the New York City Health Department or elsewhere. It was a program that started in the Cold War, actually. A physician named Alexander Langmuir began this at the CDC, and he got funding for it by saying, “Hey, we may have biological war and we need some disease detectives.” So he was kind of clever in getting the funding for it. And the program has existed now for many decades—more than a half a century—and has a great reputation. They take somewhere around 60 or 70 in most years—doctors, veterinarians, dentists, PhDs—and put them through a two-year service learning program.

(00:09:08): When I went through it, the initial course was about three weeks, if I remember correctly, where you are taken through a series of trainings in surveillance, how to evaluate a surveillance system. It sounds obvious; it’s actually one of the most important skills in public health to see whether a system to track a disease is accurate, timely, practical, useful—and a series of rigorous assessments. And then you do an investigation. And I still remember our investigation. It had something to do with car seats and what was the likelihood that people were using car seats if they had a kid in the car. This was 1990 and we did an observational study outside of a shopping center. And you know, within a week we had an interesting finding. So it’s this idea of practical epidemiology or interventional epidemiology where you’re getting data to actually change something.

(00:10:11): I was born in New York City. I also went to medical school there, public health school there. I did my internal medicine residency there at the height of the AIDS epidemic between 1986 and 1990 and ’89. And what that meant was that I spent an enormous amount of time taking care of people for whom I could do very, very little other than try to help them die comfortably. It was a terrible, terrible experience. I had volunteered to work in a men’s shelter that had 800 men sleeping on a drill floor. 200 of them had serious mental illness, and by state law, they needed a once-a-year physical examination and primary care visits. So I was doing once-a-year visits for these 200 homeless, mentally ill men. It was a time of a lot of homelessness. A lot of drug use. Treatment of HIV was still ineffectual.

(00:11:08): And so I had friends and colleagues who were dying from the disease. It was a rough time, a really rough time. And as I started, I got a call from a doctor I had known from some other work I had done saying she thought that multidrug-resistant tuberculosis was on the rise in New York City. And this was a hot tip about something that, you know, as a police detective looks for a hot tip, a disease detective does also. And that led to a big study that documented that she was absolutely right. It was a massive outbreak, the biggest the U.S. has ever had, and that led to my being appointed Director of Tuberculosis Control and Assistant Commissioner of Health to help stop this terrible outbreak.

Rohan Ramakrishna (00:11:53): So you know, thinking about your framework of See, Believe, and Create, can you talk me through, you know, how that applied towards the tuberculosis epidemic in New York City?

Tom Frieden (00:12:04): Sure. So it’s, you know, I’m gonna give a little bit of the short version because the long version takes the whole book. But yeah, right. So it’s three phases: See, Believe, Create. For each of those phases, there are multiple aspects. For the “See,” it’s see the trends, see why we don’t take action, see whether programs are succeeding, and see the rigorous path to progress. So it’s a series of things that have to be seen. The first thing that we had to see was—was this doctor, whose name is Karen Brudney, was she right that multidrug-resistant tuberculosis was increasing? That wasn’t easy to figure out. I had to travel by subway around to many of the 72 labs that grew cultures to get them to ship it to CDC. CDC had to reculture them and do it. And in fact, there had been a big increase in multidrug tuberculosis; nearly one of every five patients in the city was spreading multidrug-resistant tuberculosis. The next question—the next mystery to solve to see the invisible—was where was it spreading? And we did actually the first community-wide genomic epidemiologic study. And what that showed was that it was spreading in hospitals primarily—that hospitals were the epidemiologic pump, sending out these patients with terrible infection control and resulting in a lot of spread and death. Once we could see that...

Rohan Ramakrishna (00:13:38): The pus buckets. Right? Isn’t that what they...?

Tom Frieden (00:13:40): Yeah, my supervisor. I was so wide-eyed and, you know, wet behind the ears. I came back from these places collecting the samples and I said, “These places are totally disorganized.” And she said, “Yeah, we call those places pus buckets.” And she was right. Many of them closed since, and the rest of them, my hope, have cleaned up. I know they’ve cleaned up at least some. But so we were able to see that—this is where it was spreading—and then we were able to see the pathway to stopping it with good infection control, good treatment, good follow-up. That was the See part of See, Believe, Create. The Believe part—we began doing something to show that it could work because part of strengthening belief is you don’t try to get from, you know, A to Z on day one; you go A to B to C and then you say, “Oh yes, we really can make progress.”

(00:14:38): So we systematically tracked the outcome of each patient. We stopped each outbreak, and with each step, we built confidence of the program that we could make progress. I remember I was put in charge of the tuberculosis control program. There were 148 staff of the program. It was bombarded with patients. They were running 10 clinics. The clinics were falling apart, they couldn’t get enough doctors. Some of the outreach workers were not doing—they were shopping instead of working. It was a mess. And I called the whole staff together and I said that I was proud to be part of the organization that would control tuberculosis in New York City. And people were shocked ‘cause they didn’t think they could control it. But having that optimism is really important, and in fact, it became possible. So the belief is partly about optimism, but it’s not blind faith; it’s rigorously proven optimism.

(00:15:39): And then the Create part is the hardest part. And that means organizing. So we had to organize well and simplify. And here I was taught a huge lesson that has changed the way I think about everything since. There’s a remarkable scientist named Karel Styblo. He had created the global strategy for tuberculosis control. He came to New York City. I had been in charge of the program for about seven months. I’d been working around the clock and he looked at our data and he said, “Dr. Frieden, this data shows me lots of things, but it doesn’t tell me the most important thing. How many of the 3,811 patients that you diagnosed last year did your program cure?” And I didn’t know, and I was terribly ashamed. And at that moment I began this simple approach of tracking the outcome of every single patient. And so See, Believe, Create: See that there was a problem, see how to address it; Believe we could do it so you have the confidence; and systematically Create an organized, simple, well-communicated system to stop it. And that worked. MDR-TB went down by 90% in the next few years—multidrug-resistant tuberculosis.

Rohan Ramakrishna (00:16:57): It’s an amazing accomplishment. And I think one of the things that I don’t think gets lost, but shouldn’t get lost, is that it’s not just a technocratic thing of implementing strategies and tactics to solve these public health issues. Because I was struck by the story of a patient named Jorge and the outreach worker named Christian—neither of whom spoke the same language, but who had bonded over trust. And I think this idea of trust in public health is so important. So can you tell me a little bit more about that story and what it taught you about trust and, you know, more than just sort of the hallmark hard piece of it?

Tom Frieden (00:17:32): Yeah. So it’s a striking experience I had from when I started as an Epidemic Intelligence Service officer. I had volunteered in the tuberculosis clinics on Tuesday mornings, one particular tuberculosis clinic, ‘cause it was really near Junior’s. So I could stop by and get a delicious sandwich and a piece of cheesecake at the end of the session. And one day Jorge, not his real name, came into my office. He was a man with hemophilia from Latin America. He was not legally in the U.S. He was working in an off-the-books factory. He had hemophilia, he had had transfusions—so this is 1990, I assumed he was gonna be HIV positive. And he had TB and he didn’t really wanna get treated. He didn’t really wanna deal with us, but he felt pretty miserable from his TB. But he was careful about his health; we got an HIV test, he was negative. So we were so pleased by that, but his tuberculosis bacteria was resistant to one of the antibiotics.

(00:18:39): And that meant that at that time, the recommended treatment would be thrice-weekly directly observed treatment. And he said, “There’s no way I can go to the clinic. I’m working from 8:00 AM to 8:00 PM, I gotta support my family.” So I tried to convince him, and I speak passable Spanish. I’ve lived in Latin America. I get by in Spanish; I do. I spoke a lot of medical Spanish ‘cause a lot of my patients were Spanish-speaking. And he absolutely refused to participate in directly observed treatment. But he has drug-resistant bacteria; it’s a thrice-weekly regimen. You really can’t give it except with directly observed treatment. And then Christian Nwigwe, which is actually his name, came in and he was our outreach worker. And he had been a salesman in Nigeria. And he convinced Jorge to take twice-weekly therapy. Every Monday, Wednesday, Friday, Christian would go to a street corner about a block and a half from the factory.

(00:19:35): Jorge would... he was on crutches. He would come out on crutches, joints destroyed by the hemophilia, sit in the car, take his medication. Christian would bring him a snack and something to drink, juice. And after nine months, we checked and documented that he had been cured. And what astonished me so much was that Christian and Jorge did not share a language. Jorge spoke only Spanish; Christian spoke Nigerian [languages]—several languages from Nigeria—and English, but not Spanish. But it was just his... he was a salesman, he cared, he expressed it. And I think this is one of the things that is so important and one of the lessons of COVID: that we don’t listen well enough, often enough, and often the first step in getting a message across is understanding where someone’s coming from and how they understand the situation.

Rohan Ramakrishna (00:20:33): Yeah. So building on this theme of trust, I think one of the stories that I found absolutely fascinating was, you know, this time around 2014 when you were at the CDC around Ebola and how you had to break the news, showing these projected million cases of Ebola, potentially infecting so many different people. So I’m curious, leading up to the moment where you had to describe this—the table drop moment—can you walk me through sort of that hairy data preparation process? What does that look like when you’re the head of the CDC? And how did you know the data was... when did you know and how did you know that the data was good enough for you to confidently march in there and give everyone marching orders?

Tom Frieden (00:21:13): Yeah. So Ebola was the biggest crisis of my time at CDC. It was the first Ebola epidemic ever. It was the first time there had been Ebola in these West African countries of Liberia, Sierra Leone, and Guinea. And it was the first time there had been Ebola in an urban area. Ebola was really spreading explosively in the urban areas. And in the past, we and other organizations—MSF and WHO—had been able to work with countries, with communities, to stop Ebola epidemics or Ebola clusters. This was different. This was kind of... these countries were in free fall. Their health systems were shut. More people died from malaria than Ebola because people weren’t coming in for care. Women weren’t coming in for cesarean sections, and so babies and women were dying. It was a real mess. And we couldn’t quite express to people just how bad it was.

(00:22:15): And so there’s a disease modeler named Martin Meltzer. He had done infectious disease modeling for influenza and other conditions. And he did a deep dive into the Ebola data to see what was happening, what would happen, and more importantly, in that See part of the See, Believe, Create, to see not only what was happening, but to see the path to progress—what would it take to control it? And what he showed was things were increasing exponentially. Once we correctly looked at all of the case data, it was not... you know, an exponential increase is very hard to convey to people because it’s just, we don’t think in terms of exponential increases, but it showed that, yes, there would be a million cases within less than a year unless we took urgent action. I didn’t know that I believed him, and he and I went over and over and over all of the data, all of his assumptions, all of his models until after midnight day after day after day until I was just sure, yes, this is correct.

(00:23:22): His model also predicted something really important, which was: if cases... if you could get 70%—at least 70%—of the people sick with Ebola cared for safely and at least 70% of the people who died from Ebola to be buried safely, the cases would decrease just as rapidly as they would had increased. I didn’t expect that. Didn’t think that made sense, but that’s what the model showed. The risk of this explosive spread did galvanize us and global action, and we were able to get to the more than 70%—more than 70%. And the result was that cases decreased in exactly the timeframe and the amount that Martin had projected. So it’s a real example of seeing the invisible; getting belief that you can do something about it—it’s not hopeless; and then organizing with Incident Management Systems, simple approaches to safe burial and safe care, speed—which was crucially important, rapid control to prevent it from spreading—effective communication with communities that were affected because changing burial practices is very difficult, and with that success in disease control.

Rohan Ramakrishna (00:24:44): Hmm. So you know, part of being a public health leader is convincing folks, right? That what you’re saying is something that needs to be done. And so you know, you talked about going to the Situation Room. So first talk, what is the Situation Room like? It looks very small. It is small...

Tom Frieden (00:25:01): It is small. There’s a... you fit about 12 people around the room, and then there’s a couple of rows on the outside, one row or circumferentially around it for people on the outside who aren’t at the table. And there are a series of levels of meetings from kind of lower level to the highest level with the President. And there was in the administration a very careful, systematic approach to vetting information and bringing it up a series of meetings, many of which would be either in the Situation Room or elsewhere, up to generally the main policy advisors to the President, the Chief of Staff to the President, and then when necessary to the President.

Rohan Ramakrishna (00:25:48): Mm. It seems also like, you know, I don’t know if you watch that old film Ghostbusters where they’re doing experiments in small rooms and increasing temperatures to, you know, make create more anxiety, but it kind of reminds me of that. You know, like highly detailed, highly anxiety-inducing information, small room, small group of very ambitious, energetic people. Seems like it could be, you know—what’s the word—energetic inside that room? If that’s a good way to describe it.

Tom Frieden (00:26:16): I mean, you know, different administrations have different perspectives and different ways of working. So Ghostbusters, I’ve never thought of in that context before, but you know, it’s certainly a high-pressure environment. Yeah. Because the decisions are really life-and-death decisions, but frankly, life-and-death decisions are not limited to the Situation Room at the White House or even to state or city governments. Those kind of life-and-death decisions happen every day in doctors’ offices, in budget decisions, and in what we do day in and day out.

Rohan Ramakrishna (00:26:57): So speaking of life and death, I think you talk a lot about COVID and how just basic organization was part of the big problem. So can you talk us through like what we didn’t do in COVID and hope what we need to do the next time?

Tom Frieden (00:27:12): So for See, Believe, Create, the first part of the Create part of this approach is to organize in an emergency. This is what’s called an Incident Management System or IMS, and IMS comes from firefighting, actually—wildfires. And what the firefighters found was that if you break a big problem into less big problems, then you can manage them better. And if it expands even more, you then have a modular way of addressing those other problems as well. Incident Management is what got us out of the Ebola crisis in West Africa, because we were able to support the governments to establish Incident Management Systems and they broke down the problems into logistics, clinical care, community education, research, fundraising—a series of different pillars, each of which could be managed to help the entire situation get better. But that’s really just a special case of the importance of prioritizing.

(00:28:21): But if you look at 2020, the first year of the COVID pandemic in the U.S., there was no organization within the White House. You had many different factions doing things, and because of that you really didn’t have an organized response, and that was a big part of the problem. Another big part of the problem early on was the lack of effective communication. That the CDC literally wrote the book on how to communicate in an emergency: Be first, be right, be credible, be empathetic, give people practical, proven things to do. And the Trump administration, first Trump administration, did none of that in 2020. I think the Biden administration also got communication wrong because they insisted that CDC speak from the White House. And you know, a lot of people didn’t like President Biden, didn’t vote for him. We’re in an increasingly polarized environment, and telling people from the White House “get vaccinated” is not going to get people who don’t like President Biden vaccinated.

(00:29:22): So I think in both cases, communication wasn’t done as well as it should have been. And in terms of the next pandemic and what to do next, a lot of this has to do with supporting public health in the U.S. and globally. This is one thing that my organization, Resolve to Save Lives, works on—helping and partnering with other countries so they can find threats faster and stop them sooner. Because that’s how we’ll be safer here. If they’re stronger there, it’s more efficient, more effective, and better to stop diseases when and where they emerge, rather than waiting for them to come to our shores.

Rohan Ramakrishna (00:30:02): Right. Speaking of the next pandemic, as you reflect on the CDC today and you talk about in the book all the time about how public health is willfully underfunded, but what does the CDC need? You know, obviously everyone would want lots more resources, but do you like tactically, if you had to spend, you know, money, where would you put it at the CDC to really make it infinitely more effective, let’s say, for the next pandemic?

Tom Frieden (00:30:26): Well, first, let’s say that CDC really is under assault. These days, its budget is being devastated. Half of its national centers are being closed. More than 2,000 of its staff have been laid off or otherwise removed from their jobs. These are people who kept us safe and they can no longer do that. The CDC for the first time ever has had its director fired by a politician. It is now for the first time ever being run by political appointees. When I was CDC director, I was the only political appointee in the agency. There are now something like a dozen or more and they’re running the agency. This is really scary. This is a hijacking of CDC now.

(00:31:15): I don’t think it was perfect before, and there are lots of things that I tried to improve while I was there. I think we made some progress, but not as much as I would’ve liked. The areas where I think CDC needs to be better—a better CDC—one: to be more tightly connected with state and local governments. Because I’m not saying that it should be dictating what state and local governments are doing; quite the opposite. I think it should be understanding what local realities are. I was fortunate that I became CDC director after I had been Health Commissioner for New York City. So I had a much better sense than many people of like, “Oh, this isn’t gonna fly in a local level,” or “They really need this and we haven’t provided it.” And I think you do that by putting thousands of people interested [in public health] in local health departments early in their career and having them then either move up the ranks in the local health departments or rotate to CDC where they can say, “Hey, this is how it works in the field.” So more practical is one thing. And faster is another. I think as CDC got bigger, it got slower. And when I joined CDC in 1990, we were told, “If a state, city, or country requests assistance, either you will be on the airplane by sundown or someone else will be.” And that kind of urgent response is still very much needed.

Rohan Ramakrishna (00:32:42): Hmm. You know, as you think about the assault on CDC, do you find an expertise just generally being under assault? Are you worried about the pipeline of future people coming into CDC and public health work? Or have you seen tangible evidence that that potential decrease in talent has already started?

Tom Frieden (00:33:01): I think there’s a huge amount of worry in the schools and training programs, understandably, because many thousands of public health jobs are disappearing. At the same time, there’s a lot of excitement. It’s a great field. This is a place where you can believe in what you do. You can, if you’re successful, prevent deaths—potentially millions of deaths. You can learn constantly because we’re always trying to learn more about how to be more effective. And you can work with folks who are really dedicated to their jobs. So it’s a great career, but it’s currently under great risk. And because of that, our health is under great risk.

Rohan Ramakrishna (00:33:45): Right. In addition, you know, we talked about trust in getting public leaders to trust you, and then there’s also getting the public to trust you, which I want to get into for a second. So you know, one thing I read that I found fascinating was that, you know, we’ve lost more Americans with COVID than all the wars put together, right? That the U.S. fought. And so I’m wondering, you also talk about the fact that there’s this Cassandra curse in public health where you can predict what’s gonna happen, and yet no one takes heed. And so I’m curious like as you think about that and as your role as CEO of Resolve to Save Lives, what is the coalition that can be mobilized to help restore trust? Right? So much of it is coalition building and strategy. What do you think can be done, you know, to solve this trust deficit?

Tom Frieden (00:34:35): So trust is built over time and can be destroyed in an instant. So I don’t think this is going to get better fast. There are certain things public health can do. It can communicate better. And that includes listening better. It can have small wins—things that people notice and care about and that it delivers. And in terms of mandates, it can avoid mandates unless absolutely necessary. You raise a really important issue of coalitions, and coalitions are really important. We are stronger together. And we’ve seen coalitions of different groups. If you just look at what some of the industries that block public health work do—Coke and Pepsi hate each other, right? But they get together to block things like soda taxes that would be really effective at improving health. So we in public health need to make coalitions, whether it’s with healthcare or education or insurers or any other area.

Rohan Ramakrishna (00:35:44): Great. I wanna stick on trust for—on the concept of trust, but you talk about mandates, right? And so obviously this was a hugely controversial piece of the COVID puzzle. And in your book, you talk about the different lighting system, right? Like red being the time where a mandate might be most useful and that they shouldn’t, if I read it right, be mostly enforced through at the state or local level. Can you describe how your thinking on mandates has evolved? Because I think one of the things I took away from your book is that you need like laws and regulation are like hugely important levers, right? You know, like banning smoking in public spaces as an example, rather than relying on purely on behavioral change and convincing people. But it seems like for something like COVID that’s so potentially deadly and you’re dealing in an uncertain environment, a mandate—into doing a mandate quickly might be really important. So how do you balance those two things? You know?

Tom Frieden (00:36:36): So I think we really need to distinguish regulation of industries that are harming people from regulation of individual behavior, for which the bar has to be a whole lot higher. For example, when we went smoke-free in New York City, we didn’t fine smokers; we told the restaurants and bars, “You have to make sure your place is smoke-free or you will get fined.” So that’s much more acceptable than fining individuals. With COVID, we learned more. Initially, if you remember when the first trials came out, it looked like these vaccines were so good that they would stop spread of the infection. They were what’s called sterilizing vaccines. So they prevent people from getting it in a way they could spread it. It then became clear that that protection—that very strong protection—it fades after about a couple of months. And so you didn’t have anymore this ethical case to be made that, “Hey, you have to get vaccinated to protect other people who may not be able to protect themselves.” And the reality is that once we learned that, it became clear that preventing or mandating someone to get vaccinated is more like mandating someone to wear a motorcycle helmet ‘cause it’s mostly to protect themselves. And that’s something that’s controversial and best done at the state and local level where you’re going to have to enforce it.

Rohan Ramakrishna (00:38:15): Yeah. You know, or believe in trust. I think intersect is, is sort of telling the public where the wins are. You know, talked about smallpox was a huge problem. It’s eradicated, it’s invisible. No one remembers it anymore as a huge public health triumph. And so how do we operationally tell the stories of the successes in public health so that they’re not forgotten?

Tom Frieden (00:38:39): One thing that my organization, Resolve to Save Lives, does is we have a periodic publication, Epidemics That Didn’t Happen, and we shine a spotlight on great work being done by healthcare and public health workers all over the world to prevent epidemics, because that’s a way of seeing the invisible—seeing the invisible, what didn’t happen. I think also we need to show progress. We need to say, let’s identify problems, whether they’re environmental contaminants or infections or cancers or other diseases. And let’s document how big the problem is—the See. Let’s do a systematic phased way of scaling up programs that work—Believe. And then let’s Create a healthier future and show people that we’ve made that difference.

Rohan Ramakrishna (00:39:32): Tell me what you think it is. I really think public health is akin to civics in school. You know, should public health be part of a civics curriculum? Because I think it is part of being a good citizen is understanding, you know, how we take care of each other, how we take care of society. If that is the basic framework for citizenship and seems to be public health as a part of that, how does that grab you as a call to action?

Tom Frieden (00:39:56): I think public health is the organized action of society to protect individuals and society. And in so doing, not only help people live longer, healthier lives, but give us a more productive environment, a more robust economy.

Rohan Ramakrishna (00:40:18): One thing when it comes to trust is like sort of this idea of government overreach, right? And so I think whether it’s banning trans fats or making workplaces smoke-free, there’s this maybe insult of “nanny state.” How do you deal with that criticism, you know, when you’re a public health official?

Tom Frieden (00:40:36): I think you have to go into the details: what are the specific things being recommended and what is being done? And for many things, it’s really about empowering people with information—giving people information so they can take control of their lives. For some of the things, it’s protecting people against harms of others. You don’t want your kid being run over by a drunk driver. You don’t want your water being poisoned by the factory that’s upriver. This is no more nanny state than making assault and murder illegal. And then there are some things in public health that can only be done when we really collaborate together. Getting a clean water supply, you really can’t do it as an individual. You have to do it as part of a community. And this isn’t nanny state; this is responsible government.

Rohan Ramakrishna (00:41:35): I totally agree with you. I wonder before we move directly onto your book, what do you think the role of the modern physician is when it comes to public health? I think we don’t get taught how to communicate public health issues in medical school, let’s say on a regular basis to our patients. And so as I reflect on COVID, it seems like it was pretty easy to villainize one person. If that was your goal, you know, like Tony Fauci as an example, you know, he could be the piñata, but it’s hard to get mad at your primary care doctor. And so I wonder, do you think that there has to be more of a role with everyday physicians and being able to communicate effectively with our patients?

Tom Frieden (00:42:14): You used a crucial term, which is primary care. By one recent study, a hundred million Americans don’t have a primary care provider. That’s just terrible. We spend four and a half trillion and primary care is crucial. Even with all the specialty care in the world, you need someone who coordinates it, you need someone to speak with the patient to understand them, to understand their priorities. And then based on that understanding, to guide them with the options of how they can live a longer, healthier life. I think for individual physicians, some of the things that are really important are having a connection with your local health department so that you do know what is going to be most effective. What are the pathogens that are circulating in your environment at any one time? What are the recommendations that may be locally different for treatment of infections? And you can contribute to the knowledge of the health status of your community and you can benefit from that knowledge to take better care of your patients.

Rohan Ramakrishna (00:43:23): Yeah, absolutely agree. All right. So moving on to your book, you know, what inspired you to get to write this book? What was the galvanizing... sounds like you were writing this for 10 years, but you know, love to hear the origin story.

Tom Frieden (00:43:35): Yeah. During the Ebola epidemic of 2014 to 2016, it became painfully obvious that a lot of people didn’t understand what public health is and didn’t support it, and some of the people doing it didn’t have all the tools they needed to succeed. And so for that problem, I thought it would be really important to tell the story of what really is public health and how can it succeed. Why should people care if their health department is effective, and what can it do not just in the past, but in the future? Yes, it’s had great accomplishments before, but what can we do now to make an even healthier future to answer that critical question of “How can you save the most lives?” So it took a long time to do the research and to frame it and to recognize actually that there is an approach that’s been proven to save millions of lives—the formula: See, Believe, Create. And that was new. And getting that clear to people and understandable, cutting out the parts that people would skip, making a book that I hope people will enjoy reading and will also give them useful information for their own lives and for their communities. And also be helpful for doctors and people working in public health. That’s the goal.

Rohan Ramakrishna (00:44:59): Yeah. No, I love reading it. And one of the things that I found striking is your advocacy of treating hypertension. And what’s striking to me is in the halls of medicine, you know—I’m at a medical school, big university—the discussion of hypertension is so minimal relative to its, you know, public health impact in our daily lives as physicians that I really found that astonishing. So can you talk about, you know, why hypertension really rose to the top of your framework for, you know, these invisible pandemics?

Tom Frieden (00:45:34): High blood pressure is called the silent killer for a reason, right? Most people don’t have any symptoms until they have a heart attack or stroke. And even the concept, “Oh, I can tell if my pressure’s up ‘cause I have a headache”—usually wrong. So it is the kind of absolute paradigm of a silent killer, of an invisible but high-priority condition. And it is so neglected. I will tell you when I was Health Commissioner, we started an initiative to put electronic health records into the poorest, sickest neighborhoods in New York City: South Bronx, Harlem, and Bedford-Stuyvesant. And Dr. Farzad Mostashari, who’s now our board chair at Resolve to Save Lives, was the head of digital health in New York City, and we proposed a program to put in these electronic health records and we got it funded. And then we were meeting in my office and we asked the question, “Well, how can we save the most lives with healthcare?”

(00:46:33): And it’s a very straightforward question, but amazingly, 10 million plus articles in Medline, not one of them answered that question. So we had to do the analysis ourselves. And the answer is crystal clear: it’s treat hypertension well. And if you look in the U.S. or globally, it’s a mess. I mean in the U.S., our control rate is less than 50%. So for four and a half trillion a year, we can’t even get the single most important thing done half the time. And that’s with the target of 140 over 90. People with diabetes who certainly have a target of 130 over 80... I have hypertension; my target for myself is 120 over 80 because that’s the healthy level. Starting at 115 over 75, your risk of a heart attack, stroke, or death doubles with every 20-point increase. The medications are safe, they’re effective, but we don’t do that kind of simple program that Karel Styblo showed for tuberculosis: How did each patient do? How did we really do with control? So hypertension’s so important, not just because it’s a huge burden, but because it’s quite controllable. If you look, though, at global health, this is an astonishing, astonishing statistic. There’s a lot of money that goes into global health. That’s a good thing. High blood pressure kills more people than any other cause. It kills more people than COVID killed in the worst year of COVID. And at a younger age. It kills more people than all infectious diseases combined—HIV, TB, malaria, all of them. And it gets less than $1 out of every $1,000 that goes into global health.

Rohan Ramakrishna (00:48:26): That’s crazy.

Tom Frieden (00:48:28): And that’s... I mean, that’s part of the reasons we created Resolve to Save Lives to try to change that. And we’ve now worked in more than 40 countries and supported programs that currently treat more than 40 million patients. We’ve identified what the real bottlenecks are and challenges, and we’re working with countries and with donors to try to overcome those challenges. But this is why all of the proceeds from the sales of this book will go to programs like the hypertension treatment and epidemic prevention programs around the world, because this is an urgent problem that’s not being well addressed and we’re implementing the formula to save millions of lives.

Rohan Ramakrishna (00:49:14): So you talk a lot in the book about, you know, in these various public health challenges you’ve encountered, about technical packages. So what is the technical package for treating hypotension [hypertension]?

Tom Frieden (00:49:26): So a technical package—I learned from this same amazing scientist, Karel Styblo—all too often, people try to do everything, but it turns out that if you can keep it simple, identify 5, 6, 7 at most things that need to be done and done right, you can get great results. So for hypertension, we worked with the World Health Organization, the CDC, and others to come up with what’s called the HEARTS technical package. And it’s really five components. Choose a protocol—a simple linear protocol to treat patients. Second, make sure you have enough medications and validated blood pressure monitors. Third, make the caregiving part of a team, because team-based care with nurses, outreach workers, [is] much better than individual patient care. Fourth, make the services patient-friendly, and that means make the medications free or as close to free as possible. It’s an asymptomatic condition. If you have large co-payments, people aren’t gonna continue for a lifetime. And fifth, have a powerful information system so that you can actually see how patients are doing and improve how they’re doing.

Rohan Ramakrishna (00:50:41): Got it. As you’ve implemented this across so many countries, it seems like Africa tends to be—so many of the countries in Africa tend to be a really successful sort of staging ground for all these efforts. What has gone really well? What has not gone as well as you’ve expected or hoped for?

Tom Frieden (00:51:01): One thing that’s gone very well are choosing protocols, because it turns out there really are only three medications that you need to treat at least 80% of people effectively, and they’re all generic, they’re all low cost. The costs have come down astonishingly. It now costs less than $5 a year to treat someone, including with statins if they need them, ‘cause statins are much underutilized. We’ve also found in many countries, not all, a real willingness to do team-based care and task sharing. So that’s been very positive. We’ve also found a willingness in some countries, not all, to really make services patient-friendly, free of cost, decentralized so they’re really close to the patient’s village and they don’t have to travel long distances. The two areas that haven’t gone well are medication access in some countries and information systems in most countries. Medication access, some countries don’t have a problem.

(00:52:00): So countries like Philippines, Indonesia, India, they’ve got strong production capacity, they’ve got strong funding capacity, and they have a commitment to provide medications. Not really an issue that, you know... there may be bumps in the road as you scale up the program, but they can get it managed. For the lower-income countries—Bangladesh and most of the countries in Africa—even $5 a year is too much for their current budget. So that’s a challenge that has not been addressed and we hope philanthropy and drug companies that are willing to donate can build local capacity to make these drugs affordably and provide them free of charge to patients, but that hasn’t happened yet. The other area is information systems. And here it’s been painful to watch. We built a system, it’s called Simple, Simple.org. It works super well, but every country wants its own system and it wants it to do everything.

(00:53:00): And what we’ve found in most countries is that the digital systems that are being used are very ineffective. They’re very cumbersome, they’re not helpful for healthcare workers, they’re not accurate, they’ve cost a lot of money. And you basically have this dynamic where country leaders think an information system is gonna be quick, cheap, and easy and the vendors tell ‘em, “Yes, yes, it will be. Just give me a million dollars, and then another million and another million and another million.” And so in literally dozens of countries, we’ve seen information systems that have been expensive and are not meeting the needs of healthcare workers or patients. And that’s a problem that can get addressed, but it’s going to take some hard work and prioritization.

Rohan Ramakrishna (00:53:48): You know, speaking of information systems—I’m glad you brought that up—and sort of Incident Management Systems. Did these get recreated from scratch every time, or are there like in... like actual health infrastructure, digital health infrastructure, or reporting infrastructure that can easily kind of [be] deployed and scaled up? I’m just curious like how that might work in your life.

Tom Frieden (00:54:11): Yeah, we don’t really have the modular approach. There are some systems out there. One of them is called DHIS2. It’s used in more than 70 countries, but it’s mostly an aggregate reporting system. We’ve collaborated with them to rebuild our Simple approach in their software because many countries use that. Often what you have is kind of like the power plug problem—that each country has its own and they don’t want to change. So what we’ve found within the U.S. and globally is countries either have something they’re using and they wanna stick with it, or they want to build something that’s theirs. And it’s good to build something that’s yours, but it’d be really good to do it based on the best practices from around the world and a realistic assessment of: What’s the connectivity? What’s the electrical supply? What’s the hardware?

(00:55:10): What’s the computer literacy? How much time do health workers actually have? We’re very focused on a user-centric approach to digital design. Everyone talks about user-centric, but not many people do it. See how long did it actually take the nurse to do that work with our Simple app? The team looked over and over and over and they said if it takes more than 20 seconds to do data entry, it’s not gonna be used. And they got it down to 13 seconds for more than a million patients a month. But oftentimes you have really smart, very dedicated people working at the central level saying, “Well, I want all of this information.” Well, if you’re getting all of that information, it’s gonna take the health worker maybe three or four minutes, and maybe they only have two or three minutes for the patient, so you’re not gonna get it done. So you have to be realistic about what’s out there.

Rohan Ramakrishna (00:55:59): I love that. The other question I have for you is that given the burden of disease of hypertension, right? You talked about how one of the most effective pillars of treatment is this team-based approach. So how do you see team-based care scaling, right, to be... if we’re gonna kind of manage the actual incidence of disease?

Tom Frieden (00:56:18): Yeah. I think actually team-based care is more scalable than other forms of healthcare, because what you’re doing is essentially getting the average salary cost down by involving community health workers, nurses, advanced practice nurses, community health officers as a team. You’re able to provide better care for less money. And that’s really important.

Rohan Ramakrishna (00:56:47): I agree with you and I wonder, you know, how’s AI going to be able to help us if everyone has a free or nearly free AI coach? I...

Tom Frieden (00:56:55): I gotta say, I think for healthcare providers, also AI will be transformational. You know, I was on a flight recently and a fellow passenger was ill, and I didn’t feel comfortable taking care of them without consulting AI. And in fact, AI raised a possibility that I had never heard of and that might have been relevant in this case. So interesting. Yeah, I think I think of AI as another member of that healthcare team. We talked about team-based care. Well, AI is a team member, and it’s a team member that has really bad judgment, but an amazing store of knowledge. And some of the tools don’t make any of that knowledge up. So I think it’s become an indispensable part of care. I would not feel comfortable caring for patients without access to AI. I think it’s that essential these days, but it’s not yet widely available, particularly in lower- and middle-income countries. It needs to be. We haven’t really figured out how to integrate it into primary care. That’s really exciting. We have some projects at Resolve to Save Lives where we’re working on that and we’re looking for funding to do that and other things. That’s the kind of things that we’ll be able to fund with any of the proceeds from the sales of The Formula for Better Health.

Rohan Ramakrishna (00:58:18): That’s amazing. So as we hit the home stretch here, I’m curious, you know, so much of your book is not just about the next public health leader, although it applies to that, but also individuals in their everyday lives. Right? So can you walk us through some of the most impactful everyday actions we should be taking to live a healthier, more productive life?

Tom Frieden (00:58:39): When you take an epidemiologic standpoint, you look at what’s really proven to make a big difference. You get the “Big Six.” And the Big Six are: Control your blood pressure, ideally to under 120 over 80. Control your lipids, ideally to get your LDL on your ApoB under 70. Get physical activity, at least 40 days a week [minutes/days? Context suggests regular activity], at least 30 minutes each time of at least a brisk walk, ideally outdoors. Sleep enough, seven to nine hours of sleep. Avoid toxins, particularly tobacco, alcohol, but also PM2.5 and some of the newer toxins. And then the toughest one is to eat healthy. And with eat with nutrition, there are a lot of debates about what’s healthy, but there’s some things that are very clear. If you—we have a potassium deficiency, most of us. If you consume more potassium than sodium, you’ll have major benefits.

(00:59:39): If you reduce sugars, you’ll have major benefits, especially sugary drinks. If you eat more fiber, there’ll be some benefits. If you avoid processed meat, there’ll be some benefits. So those six are really quite accessible and it gets lost in a clutter of hype, of grifting, of sales of stuff that isn’t proven, of sloppy thinking. There are another set of things that are helpful that I go through in the book to reduce the risk of dementia, because dementia is such a risk, but we can prevent about half of all dementia with currently available things. And that starts with things like controlling blood pressure. But it also includes some things that are more surprising, like speaking a second language regularly or playing a musical instrument.

Rohan Ramakrishna (01:00:30): The other one, I don’t know if you’re familiar with him, but Jonathan Rosand runs the McCance Center for Brain Health at Harvard, and so they have the Brain Health Scoring. Among those things—and the brain health score are your A1C, I think your blood pressure, and then the strength and social connections, you know? And so while it’s hard to like action that sometimes for some people, I do think that that’s incredibly important is to like maintain healthy social connections in your life as a health strategy. You know?

Tom Frieden (01:01:01): It’s a really good point, Rohan, and the data on it is pretty strong. There’s a... I reviewed in the course of researching this book, I reviewed in detail every single one of these things, and going back to all the major studies, assessing them, seeing strength and weaknesses. And actually the data for social connections promoting longevity and reducing dementia is real and probably accurate. What is challenging is exactly what you say: is how actionable is it? If someone is not socially connected, there are actually no studies that document interventions to increase that social connection. But you know, if you are an individual, there are things that you can do. You can join groups, whether it’s at a local something or with friends. You can connect more with family—so important. But harder to do. We talk about burden and amenability. The burden is really high. Amenability is more challenging, but possible. The other thing that is quite strong is the evidence that correcting vision and hearing reduces the risk of dementia and prolongs life. You know, there’s this emerging data that the Shingrix vaccine may reduce the risk of dementia. So interesting stuff.

Rohan Ramakrishna (01:02:21): You know, you talked about exposure to toxins as part of the six. And you know, as I think about the MAHA movement, right? And you know, while I disagree with much of what it’s said, I wonder whether, you know, does is... is the broader point about what’s in our food supply, what are we exposed to, something where there’s common cause to be had? You know, PFAS, microplastics. You know, I’m sure you saw that study of microplastics in the atheroma of people’s carotid arteries and in the brain, you know, the endocrine [disrupters], the sutures, the PFAS, et cetera. So I’m curious, is that the next frontier of public health? Like you talk about a little bit in the book about how there’s a difference between proving it’s harmful versus it’s safe. How would you tackle this problem?

Tom Frieden (01:03:07): I think with respect to the current administration, it’s really important to separate what they’re saying from what they’re doing, because a lot of what they’re saying makes a lot of sense and it taps into a real suspicion and concern and valid worries about what’s in our food, what’s in our water, what’s in our air. Where I think there are problems are: first, when you’re rolling back protections against known problems—ending, for example, the tobacco control activities of CDC, stopping the regulation of tobacco companies. This isn’t taking on chronic disease; this is opening the door to chronic disease. And yeah, it’s great to say, “We’re worried about PFAS,” but what has it done? It’s actually delayed cleanup of our water from PFAS. PM2.5—so it causes an estimated hundred thousand deaths a year in the U.S.—they’ve rolled back regulations that protect people against it. It’s in the name of deregulation; it’s open season on our lungs, basically, from polluting industries. But for the kind of newer... I consider them the big three: microplastics, endocrine disruptors, and nanoparticles. There are real risks here. We need to learn more about them and we need to restrict them wherever possible and appropriate. There is a challenge. They’re pervasive in our environment and figuring out which are the most deadly, which can be dispensed with, which may be okay... that’s really important. And that’s going to take time, resources, and rigorous science.

Rohan Ramakrishna (01:04:49): All right. Last big question, which is, you know, you’re very outspoken in the book about the pernicious effects of misaligned incentives in healthcare, you know, the importance of primary care, how it’s not funded appropriately. What do you think are the strategies to get us to a better place? Are you excited about value-based care, where that can go? You know, is our current system of payers, you know, between insurance and, you know, a government gonna get us there? Single [payer]? I’m curious like are there health systems where you are very envious of how they achieve outcomes and the outcomes they achieve?

Tom Frieden (01:05:23): Well, there are health systems around the world that have strong primary care teams: Thailand, Costa Rica. I’ve seen both of those country programs and it’s really impressive where you have a group of health professionals working together who take responsibility for a community and understand the needs of that community and deliver really useful healthcare for that community. There are countries around the world where primary healthcare is much better in many countries in Latin America, Europe, Scandinavia. You have really strong primary healthcare systems and that improves outcomes and reduces costs. Where I think there’s a real challenge in the U.S. is we have a system that’s very expensive and not delivering high value. It provides great, highly specialized care. If you have a complicated medical problem and you get into the right institutions, you’re going to get the best care in the world. There’s no question about that. I’m not maligning the expertise of our health system, but if you wanna stay out of that problem with a good preventive care, we need to change the economic incentives. And there are programs like the physician-operated accountable care organizations where basically—look at Kaiser Permanente. Kaiser Permanente takes care of millions of patients and they do that as well as any health system in any country anywhere in the world.

(01:06:53): Why? Not ‘cause they’re smarter doctors, but because their economic incentives are aligned. They are both the payer and the provider. So if they reduce illness and therefore reduce utilization, they do better financially. If they fail to reduce illness and therefore there are avoidable hospitalizations, they do worse financially. So their incentives, the provider’s incentives, and the patient’s incentives are all aligned. We need to put that into more of our healthcare system, so that if a primary care doctor does a great job and their patient doesn’t get hospitalized, that primary care doctor should make more money. And there are some examples of programs like that in the accountable care organizations that are physician-operated. I think that’s one way forward to show phased progress, but it’s going to take a commitment to primary care. That’s not simple, especially with an aging population that has a large number of conditions that need long-term care. We’ll only get great care if we make a big change in how we finance healthcare in this country.

Rohan Ramakrishna (01:08:08): Love that. All right. So now we’re onto the last few, this last section, which we call quick hits. So most impactful mentor in your career for life?

Tom Frieden (01:08:19): My father. My father said, “You gotta help the people,” and just focused on rigorous, proven interventions to make the biggest difference. He was a deeply caring physician and he showed what it is to be evidence-based, rigorous, and able to save a lot of lives.

Rohan Ramakrishna (01:08:39): Book recommendation?

Tom Frieden (01:08:41): Factfulness by Hans Rosling. Wonderful book, teaches us a lot about how to see the world more accurately.

Rohan Ramakrishna (01:08:50): And that dream dinner guest that is alive?

Tom Frieden (01:08:53): Oh, dream dinner guest. Well, it’d be fun to talk with Socrates.

Rohan Ramakrishna (01:08:59): Hmm. You seem like a cerebral guy, so I can see why that would, you know, get you excited. And then for the next episode of Good Medicine, who should we have and what would you ask them?

Tom Frieden (01:09:15): Oh, wow. That’s a tough one. I think it would be really important to talk to someone who’s run a health system effectively. For example, you could talk with one of the leaders from Thailand who helped their system get established, like Dr. Suwit [Wibulpolprasert], who has been a passionate advocate for healthcare and primary care for many decades.

Rohan Ramakrishna (01:09:42): Lovely. Well, that is our episode of Good Medicine. Thank you so much, Dr. Frieden. This was the amazing conversation, and I’m so inspired by the work that you and your organization have done, and I hope everyone picks up a copy of your book. And last question actually is, how can people support the great work that your organization is doing?

Tom Frieden (01:10:02): You can get onto our website, Resolve to Save Lives, or rtsl.org. You can see what we’re doing. You can donate and all of the proceeds from both the sales of the book, The Formula for Better Health, and also the Substack that is called The Formula, go toward supporting programs like the ones we’ve talked about to stop epidemics sooner and treat hypertension better.

Rohan Ramakrishna (01:10:26): Amazing. Well, thank you, Dr. Frieden, this was great.

Tom Frieden (01:10:29): Thank you so much. All the best.

Rohan Ramakrishna (01:10:36): Thanks for listening to Good Medicine and a special thank you to Dr. Tom Frieden for sharing his perspective. If you’re a physician, we’d love for you to join the Roon community at roon.com. That’s www.roon.com. You can also help us grow by sharing this podcast with a colleague or friend. Until next time. Thanks for being part of the conversation.

· Dr. Mukkamala shares the harrowing moment his symptoms began during a public speech and his rapid transition from surgeon to patient.

· He discusses why seeing risk percentages from the other side of the gown changes everything and argues that family support should be treated as a vital clinical intervention.

· The conversation then pivots to the critical work ahead for the AMA.

· They explore the fight to index Medicare payments to inflation, the crushing impact of administrative burnout, the erosion of private practice, and why protecting NIH research funding is a matter of life and death.

· This is a deeply personal and policy-focused look at the fragile state of our healthcare system.

New episodes are released every other week, wherever you get your podcasts. For more from Roon, visit: ⁠⁠https://www.roon.com/⁠⁠ Sign up for our substack: ⁠⁠https://rohanramakrishna.substack.com/⁠⁠ Find us on Instagram and X: @roondoctors If you have a question or suggestion for a future guest, please comment!

New episodes are released every other week, wherever you get your podcasts.

For more from Roon, visit: ⁠⁠https://www.roon.com/⁠⁠

Sign up for our substack: ⁠⁠https://rohanramakrishna.substack.com/⁠⁠

Find us on Instagram and X: @roondoctors

If you have a question, comment, or suggestion for a future guest, please email us: austin@roon.care.

New episodes are released every other week, wherever you get your podcasts.

For more from Roon, visit: ⁠https://www.roon.com/⁠

Sign up for our substack: ⁠https://rohanramakrishna.substack.com/⁠

Find us on Instagram and X: @roondoctors

If you have a question, comment, or suggestion for a future guest, please email us: austin@roon.care.

Good Medicine is a podcast about reclaiming what's essential in healthcare. Hosted by Dr. Rohan Ramakrishna, neurosurgeon and co-founder of Roon, each episode features honest conversations with physicians, researchers, and healthcare leaders who are shaping the future of medicine.

New episodes are released every other week, wherever you get your podcasts.

For more from Roon, visit: https://www.roon.com/

Sign up for our substack: https://rohanramakrishna.substack.com/

Find us on Instagram and X: @roondoctors

If you have a question, comment, or suggestion for a future guest, please email us: austin@roon.care.