Thomas R. Frieden, MD, MPH The Future of Public Health
Clinical Innovators | Interview by Katlyn Nemani, MD
Tom Frieden. MD, MPH, has been the director of the U.S. Centers for Disease Control and Prevention (CDC) since being appointed by U.S. President Barack Obama in 2009. He served as Commissioner of the New York City Department of Health and Mental Hygiene from 2002-2009. During this time, he championed efforts to combat cardiovascular disease including eliminating trans fats from restaurants, launching a campaign that reduced the number of smokers in NYC by 350,000, and establishing the country’s largest community-based electronic health records program. Dr. Frieden received his medical degree and masters of public health degree from Columbia University and he completed infectious disease training at Yale.
How did you become interested in public health?
My father was a gifted cardiologist. He practiced rigorous, evidence-based medicine before anybody talked about evidence-based medicine. As I was in the process of trying to decide a career path, my father and I went hiking in the mountains. We talked about our mutual desire to help people through medicine, and my interest in public policy. He suggested I consider public health. One of his favorite sayings was, “You gotta help the people.” That is why I chose public health—to improve not only the health of individuals but entire communities.
In your recent New England Journal of Medicine article, “The Future of Public Health,” you emphasize the interdependence of the health care and public health fields and allude to the history of distrust and disrespect between them. How did this dynamic evolve, and how can the two fields work together better?
Medicine and public health are becoming increasingly and necessarily interdependent. This is a time of change in our health care system with increased insurance coverage, payment reform, and new models of care that create new opportunities for health care and public health to work together and to improve the health of entire communities, not only individual patients.
One way to think about the impact of health interventions is a pyramid divided into five sections. At the base of the pyramid are social determinants such as housing, education, and income. Public health can have impact by measures such as increasing healthcare coverage to reduce disparities in access to clinical care due to poverty. At the next level up—level 4—are public health interventions that make the default choice the healthy choice. A good example is clean drinking water. Level 3 includes long-lasting protective actions which require one-time or intermittent action by clinical providers, such as vaccination. At level 2 are clinical interventions that require long-term or daily care, such as blood pressure control. Lastly, level 1, at the tip of the pyramid, helps people find gains from counseling and education—think nutrition and exercise plans for weight loss.
Interventions at the bottom of the pyramid usually help more people than the interventions at the top of the pyramid. But it is on levels 3 and 4 that public health and clinical medicine can cooperate more effectively. We can work together to make the default choice the healthy choice, and to encourage wider adoption of long-lasting protective actions.
You launched a “Tips from Former Smokers” campaign that helped at least 300,000 smokers quit. What made this campaign so effective?
CDC’s Tips campaign was unprecedented in scope and success. It was the first-ever paid national tobacco communication campaign. The ads are effective because they are emotional and hard-hitting. We used real people, not actors. The ad participants show the tragedies that real people face every day as a result of smoking in a way that statistics cannot. These courageous people let the public know that smoking doesn’t just kill; it disables, disfigures, and robs its victims of independence. A man named Roosevelt began smoking in his teens, had a heart attack at 45, and later needed coronary artery bypass surgery. The ads also showed smokers whose loved ones were impacted by it, such as Kristy’s baby, who was born too early because of Kristy’s smoking. Each real story represents tens of thousands of Americans suffering from similar illnesses caused by smoking.
This is money well spent. This campaign saves lives and saves dollars. We asked smokers and they said these are the kinds of ads that they want to help motivate them to quit. Running Tips ads for just 12 weeks in 2012 resulted in 1.6 million quit attempts, 100,000 smokers quitting for good, and averted at least 17,000 premature deaths. The Tips campaign costs less than $500 per smoker who quit, less than $400 per year of life saved, and less than $3,000 per life saved, far less than commonly accepted cost-effectiveness thresholds. The money spent on this campaign is equal to the amount of money the tobacco industry spends on advertising and promotion in about three days, so we must continue to invest in hard-hitting media campaigns.
You have spoken about the fact that better blood pressure control could save more lives than any other clinical intervention we have to offer, though just over half of adults with hypertension have it under control. How have some communities, such as Minneapolis-St. Paul, improved control rates to 70%-80%?
About one in three U.S. adults—an estimated 68 million—have high blood pressure, which increases the risk for heart disease and stroke, the leading causes of death in the U.S. However, only about half of all Americans with high blood pressure have it controlled. But we know there are communities, health care systems, and health care providers who are making a difference. They are showing that control rates of 70% to 80% are possible.
Minnesota and some of the Kaiser Permanente systems are great examples of successful strategies to control blood pressure. The rate of blood pressure control in Minneapolis-St. Paul and nationally was around 30% in the mid-late 1990s. However, Minneapolis-St. Paul has since made much more rapid progress than we have nationally to improve blood pressure control—the control rate there is up around 70%. They got there by addressing multiple drop offs in the blood pressure cascade. They got more people with high blood pressure onto treatment and improved control among those treated. If the U.S. had the same control rates as Minnesota, about 14 million more Americans would have their blood pressure controlled, preventing millions of heart attacks and strokes. Minnesota has done many things that have contributed to the increase in blood pressure control—including establishing agreed upon treatment protocols and quality measures, providing feedback on performance to providers, and reporting performance publicly through Minnesota Community Measurement.
Kaiser Permanente is another health system that has succeeded in improved blood pressure control rates. Did they do it the same way?
Kaiser Permanente Northern California made a number of changes to improve blood pressure among patients. This included the creation of a disease registry to identify and track patients with uncontrolled hypertension and the use of team-based care around the patients. Over the course of a decade, the organization was able to increase its hypertension control rate to more than 85% and was recognized as a 2013 Million Hearts Hypertension Control Champion. Kaiser Permanente Southern California improved the hypertension control rate of all patients while also reducing the blood pressure control rate gap between African Americans and whites from 6% to 3.8%. They accomplished this through several methods, including the development of a hypertension registry with treatment and testing reminders, as well as tapping medical assistants to take walk-in, 10-minute blood pressure checks.
We have learned from these and other top performers that there are common elements of successful programs. These include standardization of care, patient-centeredness, team-based approaches to care, rigorous monitoring of outcomes, and continuous innovation.
Accountability for outcomes has been a topic of debate. While holding providers accountable will likely lead to improved care, there is a concern that providers will be incentivized to take on panels of healthier patients who are compliant with treatment as opposed to those who may be less compliant and need the most care. How can we hold providers accountable while taking into account the heterogeneity of patient populations?
Accountability for outcomes is key to improving patient outcomes. Implementing systems that are patient-centered and reduce barriers to care and medication adherence, and using team-based care and innovation through programs that extend care beyond the doctor’s office can improve care across patient populations.
With tuberculosis, we are accountable for knowing how many patients we have cured. With HIV, we know that treating to viral load suppression both improves the health of the patient and dramatically reduces the risk of HIV transmission to others. With blood pressure control, we need to see real, rapid improvements in rates of blood pressure control across the U.S. The rate of blood pressure control has been increasing gradually over time, but reaching our Million Hearts goal of 70% blood pressure control will require much more rapid progress. Reaching this goal will mean that at least 10 million more Americans’ blood pressure will be under control—and we’ll see fewer heart attacks and strokes.
What advances in public health do you hope to see in the next decade?
Antibiotic resistance is probably the biggest public health threat we face today. Without immediate, decisive action, we risk entering a post-antibiotic era. The way we practice medicine and treat patients is at risk. Treatment of cancer, chemotherapy, organ transplant, dialysis—each depends on our ability to successfully treat infections. We are looking at the very real possibility that we may not be able to treat many of our patients. With some patients and organisms, we are already there.
We can make some immediate advances by having programs in every community to address this problem. Every hospital needs to have a stewardship program. Each outbreak needs to be tracked. It can be done. By implementing core infections control programs, hospitals in Illinois were able to cut CRE by half. The best way for us to win this battle is to work together. It can’t be done alone. Hospitals, nursing homes, and the community—each has a role to play.
If fully funded by congress, we would be able to have programs in all 50 states to address anti-microbial resistance. This would support centers of excellence, expand testing, and detect outbreaks. We think we can prevent half a million infections, thousands of deaths, and millions of dollars in medical care spending.
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