Interview with Dr. Thomas R. Frieden MD MPH, Director, U.S. Centers for Disease Control and Prevention

Dr. Thomas R. Frieden was appointed Director of the U.S. Centers for Disease Control and Prevention (CDC) by President Barack Obama in May 2009. Previously, Dr. Frieden had been Commissioner of the New York City Health Department, since January 2002. There, he introduced programs that cut the number of smokers by 350,000, increased cancer screening, reduced AIDS deaths by 40%, improved data collection on community health, and implemented the largest community electronic health records project in the country. From 1990 to 2002, Dr. Frieden worked as a CDC Epi-demiologic Intelligence Service Office, focusing on multidrug-resistant tuberculosis. From 1996 to 2002, he served in India as a World Health Organization officer on loan from the CDC; there, he worked with the Indian government to develop a tuberculosis control program that is credited with delivering nearly 10 million treatments and saving more than 1.4 million lives. Dr. Frieden, who has published over 200 scientific articles, received his MD and MPH degrees from Columbia University and completed infectious disease training at Yale University.

As New York City Health Commissioner, you placed a lot of emphasis on combating preventable diseases – can you give an overview of your focus there?

Figuring out what are the leading causes of illness and death and what’s needed to prevent them, and identify­ing what are winnable battles in public health. That includes making a big dif­ference by using things we know today. In New York City, we were able to reduce the number of smokers by 350,000 and cut teen smoking in half through a com­prehensive approach to tobacco control.

In New York City, you introduced measures like banning smoking in restaurants, bars, and workplaces, eliminating artificial trans fats from menus, and requiring restaurants to post calorie information. Some of these policies are now found in various places across America, but at the time, you encountered a lot of resistance. Was this mainly due to the cost of implementation or the anticipated financial hit for busi­nesses or were there other issues involved?

Well, the costs of regulations to im­prove health tend to be quite small for the public, and if you look at something like the Smoke-Free Air Act, it did not hurt business at all. If you look at the trans fats, they were relatively minor costs compared to the much broader benefits for the public and the public sector.

Some of the approaches you’ve used for communicable diseases focus on testing, monitoring, and then re­porting some of the data to patients’ doctors. How would you weigh con­cerns about patient privacy against being able to take preventive action against the public health issues that such programs aim to address?

Patient privacy is obviously of para­mount importance. As a recent article in the American Journal of Public Health showed, there are risks in the information era – you could lose a laptop or someone could hack into a database. There are people who have serious and very valid concerns. At the same time, if you’re ex­posed to meningitis, you would like to be warned and given a chance to get preven­tive treatment. So if we didn’t process information so that we can tell you that, a lot more people would be upset than if we do. To take another example, in the electronic health sector, there is a lot of focus on information sharing, but the irony is that doctors can’t get their own patients’ laboratory results, and that’s one of the biggest lacks in the health IT area. So a lot of what needs to be done isn’t as controversial as it seems or sometimes is portrayed to be, but the issues are quite serious and valid in terms of the impor­tance of confidentiality and respecting privacy.

Coming into the CDC, what were your primary priorities?

First, strengthening surveillance epi­demiology. Second, improving our abil­ity to strengthen state and local health departments. Third, improving our im­pact in global health. Fourth, addressing policy change that promotes health, and fifth, through those four things and more, better addressing the leading causes of ill­ness, death, and disability.

In your time at the CDC so far, what have been the primary challenges, transitioning from New York City, where you could actually imple­ment these policies on the ground, to more of an advisory role at the CDC?

The CDC is a fantastic organization, and the strength it has in epidemiology, program implementation, and laboratory science are really remarkable. I think the challenge going forward is to work with the experts here and partners throughout the federal government and state and lo­cal governments to identify and imple­ment the policies and programs that will make the biggest impact.

Before New York, you spent six years in India working with the In­dian government on tuberculosis control. When you arrived at the CDC, how were you able to apply what you encountered in India with regard to implementing national health policy goals at state and lo­cal levels?

Both India and the U.S. have federal structures, so health in both countries is a state affair. The national government can be effective when it provides resources, technical guidance, staff, and accountabil­ity to the individual states and localities. In India, I was able to assist the govern­ment of India to implement the program that’s now treated more than 10 million patients for tuberculosis and prevented more than a million deaths.

A lot was done with the national gov­ernment really playing a very hands-on role in helping state and local govern­ments and understanding their needs. In big cities, the national government can be most effective working directly with the local government, but ultimately, to have a sustainable system, you really need to work with the states and develop solid policies.

How does the CDC work to expand promising state or local health ini­tiatives, of the type that you led in New York City, and what kind of up­take have you seen in other locali­ties adopting such programs?

One of the key functions of the CDC is to find best practices, to identify what’s really working in one part of the coun­try, and to help other people learn from it and emulate it. That’s a key function of the national government. We’re seeing it take place in a very encouraging way. With H1N1, for example, we’re seeing re­ally successful school-based vaccination programs spreading from state to state.

Do you believe the current health insurance reform going through Congress will meaningfully impact the CDC’s goals in disease control?

Absolutely. I think prevention hap­pens in two ways. It happens in com­munity preventions, where we implement programs to improve the health of an en­tire community. Both House and Senate versions having significant resources for something like a prevention trust, which would help to scale up proven preventive policies or develop new ones. Second, prevention would become a more cen­tral part of the logic of what we do in the healthcare system. In both of those ways, healthcare reform has the potential to make an enormous difference in the health of Americans.

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