Profile

Tom Frieden, bold pioneer of US public health As the US continues to debate health reforms, Tom Frieden, head of the CDC, tells Karen McColl that prevention must be the priority

ealth could hardly have been at the head of the country’s main public Pioneering higher on the US agenda when health agency sends a clear signal that the Frieden qualified as a doctor at Columbia Tom Frieden started his job as administration intends to take a strong line University and went on to get further train- director of the Centers for Dis- on health protection. ing in public health, internal medicine, ease Control and Prevention and infectious diseases. In in H(CDC). Swine flu, healthcare reform, and Need for change the 1990s, with the city’s then health com- the federal stimulus package were just three Frieden is openly critical of the current pub- missioner, Margaret Hamburg, he imple- of the issues in his in-tray on his first day lic health infrastructure, which he says “has mented a ground breaking programme to on 8 June. The high profile of each of these suffered from decades of neglect.” He also control drug resistant tuberculosis. He then issues, he says, has been “enough to have criticises a “healthcare infrastructure that is went to India to help set up a tuberculosis kept it a very interesting time.” poorly coordinated, has poor information control programme there. More recently, Although responsibility for health policy management, and does not focus on pre- as health commissioner, he largely rests with individual states, and vention.” He sees it as an important prior- was leading efforts to control the first con- federal laws are decided in Washington, ity for CDC to try to ensure that whatever centrated outbreak of pandemic flu in the the CDC has a vital role in facilitating fed- healthcare system emerges from the current US right up until he left his post on 7 June. eral, state, and local action. The remit of reform process is oriented towards improv- It is Frieden’s reputation for taking bold the based agency—with an over- ing prevention. action on prevention of non-communicable all budget of $10.1bn “In the United States today The first thing that disease, however, that particularly excites (£6.3bn; €7.1bn) Frieden says when I many public health advocates. Over the and a staff of over if you go with the flow ask him about these past seven years, Frieden and New York 14 000—covers health initial busy months is City mayor, , brought promotion, disease you will become obese or that he has been enor- in several pioneering laws—the city was prevention, and prepa- overweight. Two thirds of mously encouraged by one of the first places to prohibit ration for new health the quality of staff at in bars and restaurants, to ban trans fatty threats. CDC is also an American adults are” CDC. This emphatic acids from restaurant food, and to require important player in global health. statement may be part of his response to fast food restaurant chains to put prominent Although Frieden was nominated by Pres- the agency’s alleged morale problems. The calorie counts on menus and menu boards.2 ident Obama, the appointment did not have CDC has been dogged by widespread All this was achieved in the face of fierce to go through the highly political process of reports of an unhappy workforce since industry opposition. senate confirmation. Nonetheless, as former a major organisational restructure was “We still view obesity the way people health commissioner for New York, Frieden launched in 2003, although recent reports viewed infectious diseases 150 years ago: is well known for his willingness to use the suggest that employee satisfaction has begun as a personal failing, a reflection of some- law to control health risks, and placing him to improve.1 thing wrong that an individual has done,”

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Frieden “has last month, Frieden issued a similarly stri- and objective information to enable them to dent message.3 The fact that he also floated weigh up the pros and cons of different pol- done a lot the idea of a “soda tax” within two months icy options. “Often the decisions will need of good, of taking up post in the city that is home to to be made by others,” admits Dr Frieden. Coca Cola’s global headquarters won’t have “But at least we can identify what the win­ whether with gone unnoticed by those who hope that the nable battles are, and what the health ben- the trans- new administration will not be afraid to efits would be if we were to win them.” challenge industry interests.4 ban, calorie Medical and public health groups warmly Political will labelling, welcomed Frieden’s appointment. “Dr While Frieden—and the health department Frieden is a bold leader who has the cour- he headed—clearly pushed forward the tobacco age to shake up the status quo if science and ambitious public health agenda in New ban in evidence show that change needs to hap- York, the mayor’s political leadership was pen. He doesn’t shy away from the tough also important. Speaking to me last July, restaurants, problems,” said Jeff Levi, executive direc- Frieden insisted that “reasons one, two and or household tor of public health advocacy group, Trust three” for New York’s bold approach to pub- for America’s Health. Lanny Smith, asso- lic health were Mayor Michael Bloomberg, surveys to get ciate professor of medicine at Montefiore and he praised the mayor’s willingness to data” Medical Center in the Bronx, has known take the political heat.2 Frieden since he was a junior doctor, and In his new role Frieden will be working they shared an interest in health and rights with former colleague Margaret Hamburg, CHIP EAST/REUTERS CHIP in Central America. “As the saying goes, he who now heads the Food and Drug Admin- explains Dr Frieden. “And while, on the one ‘cleaned up well’ and fights the social justice istration, and he will, of course, be looking hand, we can’t absolve people of personal fight from within the mainstream now,” he to President Obama for political leadership. responsibility to eat well, be active, and live says of Frieden. “He has done a lot of good, The president has already seen how health healthily, on the other hand, in the United whether with the trans-fat ban, calorie label- issues can overheat—especially when they States today if you go with the flow you will ling, tobacco ban in restaurants, household threaten vested interests. Frieden, though, become obese or overweight. Two thirds surveys to get health data, or opening health emphasises the administration’s commit- of American adults are, and that number offices in the Bronx and Harlem.” ment to science. “President Obama talks has doubled in the past two decades—and But there have also been a few dissent- about ensuring that facts and evidence are this doubling is not because our genes have ing voices. As health commissioner in New never obscured or twisted by politics or changed or we’re more gluttonous or lazier York, Frieden clashed with some commu- ideology,” he says. “And with that as our than we used to be. It’s because the structure nity AIDS groups who have criticised his guiding principle we can achieve an enor- of our society has changed, and the only approach.5 There were also critics of his mous amount, both in this country and way we are going to change it back is by attempt to remove one of the obstacles to ­globally.” changing the structure again.” These will voluntary HIV testing by eliminating the Karen McColl is a freelance writer be welcome words to people involved in requirement for separate written consent for [email protected] fighting obesity, who continually struggle to an HIV test.6 Competing interests: None declared. 1 Young A. Morale at CDC shows healthy convince policy makers that the problem And in the 1990s, Richard Coker, now improvement. Atlanta Journal-Constitution 2008 won’t be solved by simply telling people to professor of public health at the London March 25. www.ajc.com/homefinder/content/ eat less and exercise more. School of Hygiene and Tropical Medicine, metro/stories/2008/03/25/cdcmorale0325. html?cxntlid=inform_artr. Dr Frieden is well aware that the real raised concerns about the implications for 2 McColl K. New York’s road to health. BMJ challenge will be to persuade politicians to marginalised groups of changes to the law 2008;337:a673. take action on some key issues. “If it has introduced as part of the tuberculosis pro- 3 Kahn LK, Sobush K, Keener D, Goodman K, Lowry A, Kakietek J, et al. Recommended community strategies 7 to do with making healthier foods cheaper, gramme Frieden led in New York. These and measurements to prevent obesity in the United making unhealthier foods more expensive, legal changes—which were only a small part States. MMWR 2009;58(RR07):1-26. 4 Roehr B. “Soda tax” could help tackle obesity, says US or restricting where junk food can be sold of the wide ranging programme—enabled director of public health. BMJ 2009;339:b3176. or marketed, then those are controversial coercive methods, such as detention, to be 5 Housing Works. Health commissioner hijinks. AIDS areas. But if we want to address obesity, used to improve adherence to treatment. issues update, 20 May 2009. www.housingworks.org/ news-press/detail/doubting-thomases/. which is not only costing billions of dol- This tension between protecting public 6 Chan S. Rifts emerge on push to end written consent lars but undermining health for millions of health and individual freedom is one that for HIV tests. New York Times 2006 Dec 25. www. Americans, these are issues that we’re going health policy makers are regularly faced nytimes.com/2006/12/25/nyregion/25hiv.html?_ r=1. to have to consider,” he added. with. A key part of CDC’s role is to equip 7 Coker RJ. Public health, civil liberties, and tuberculosis. At the launch of CDC’s recommendations decision makers—whether in Washington or BMJ 1999;318:1434-5. for community measures to prevent obesity at the state and local levels—with unbiased Cite this as: BMJ 2009;339:b3565

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