Effect Measure

The other shoe has dropped at CDC. Yesterday Obama named a new CDC Director, New York City Health Commissioner Dr. Thomas R. Frieden, an infectious disease specialist (drug resistant TB) who worked at CDC prior to going to New York in 2002. Frieden has long been rumored to be at the top of Obama’s short list, so this wasn’t a surprise, but the impressive performance on the swine flu outbreak of Richard Besser as Acting Director suggested to some he might get the job. Besser may be relieved he didn’t:

At the C.D.C., [Frieden] will inherit a host of immediate and long-term problems, including a looming decision about whether and how to produce a swine flu vaccine. Health experts say the agency must resolve serious morale and organizational issues even as the administration struggles to overhaul the nation?s health care system. (Gardiner Harris and Anemona Hartocollis, New York Times)

Problems, indeed. Trying to right the morale and oganizational results of the previous Director, the one-person wrecking ball Dr. Julie Gerberding, will be a challenge. Gerberding was a sycophant unlikely to do anything bold. Frieden is unlikely not to do something bold. In New York he has aggressively taken on some major public health issues like smoking (a pack of cigarettes in NYC goes for about $9 — if you can find a place to smoke them after smoking was banned in workplaces — forced restaurants to disclose nutritional information and banned cooking with transfats in restaurants.

Dr. Frieden has a history of focusing on health threats that endanger large numbers of people, sometimes at the expense of more popular causes. This put him in marked opposition to the Bush administration, which spent more than $50 billion on bioterrorism initiatives and paid far less attention to problems like smoking.

Dr. Alfred Sommer, emeritus dean of the Johns Hopkins Bloomberg School of Public Health, who was on the team that recommended Dr. Frieden as New York?s health chief in 2002, recalled interviewing him shortly after the Sept. 11 attacks. Dr. Frieden had flown to New York from India, where he was living and working on tuberculosis control.

Before he left India, he was asked about his top priority, Dr. Sommer said. ?Oh, well, that?s easy, Al,? Dr. Sommer recalled him replying. ?Tobacco. Tobacco is killing more people, and that?s my top priority.?

?Tom, I don?t disagree that tobacco is a real scourge, but have you heard of 9/11?? Dr. Sommer said he countered.
?Of course I know about that, but bioterrorists are not going to kill more New Yorkers than tobacco is,? Dr. Frieden said. (New York Times)

Public health advocates are singing his praises, but no recommendation is higher than the opposition of the truly odious Center for Consumer Freedom:

The Center for Consumer Freedom, a group funded by restaurants and food companies, put out a statement decrying his selection, saying he was “an overzealous activist who doesn’t give any consideration to the importance of personal responsibility or privacy.” (David Caruso, AP)

I can’t argue with his overall public health priorities. But what he will do at CDC is another question. Or at least it should be. CDC is too small to be the “all things health agency.” Its expertise (before Gerberding side tracked it) was in investigating disease outbreaks and hazards from infectious agents and chemicals. Tobacco is a consumer product best left to the FDA. Obesity is a major problem but should be the overall responsibility of CDC’s parent Department, Health and Human Services. HIV-AIDS and TB should remain part of the CDC portfolio.

Like Besser, Frieden has been in the spotlight around swine flu. I’ve seen him nodding in agreement as Mayor Bloomberg tried to bring calm in the worst way: by constantly minimizing the seriousness of the illness. Yesterday I saw Frieden the same thing. Flu is always a potentially serious disease. This was a teachable moment for seasonal flu that was missed. Besser didn’t engage in this, to his credit.

Still, we remain optimistic, but the jury is still out. CDC took on (and carried) a lot of water during the Bush years. It remains to be seen if Frieden will activate the sump pumps or just try to turn a foundering boat in his own preferred direction.

It won’t be easy.

Comments

#1 Jon Schultz
May 16, 2009

I’m not sure what the Center for Consumer Freedom was referring to in its comments about Frieden, but I absolutely agree with the position they take opposing caps on loan APR rates, which severely violate freedom of commerce and result in less choice for consumers.

In the war on obesity, some may suggest measures such as capping the amount of fat or sugar allowed in foods, and while it may be a wise dietary choice not to overindulge in such, the government is way out of role in forcing people to do or not do things in accordance with its views of what is healthy and what isn’t.
#2 DemFromCT
May 16, 2009

Jon, that might be true if everyone else didn’t wind up paying for bad choices made by individuals.

I hate that CT doesn’t have a helmet law for cyclists, and I love that NY does.

I like this choice.
#3 Jon Schultz
May 16, 2009

DemFromCT: I’m not sure what you mean by “I like this choice” but imagine if you were a cyclist who felt that wearing a helmet decreased your sensitivity and thus increased your chances of getting into an accident. And the government is going to force you to do it for your own good? That sucks.

And even if you can site studies which show that people wearing helmets don’t get into more accidents than people who do, that isn’t necessarily true for every individual – and even if it was true, we should still have a right to take personal risks and even commit suicide if we want. That’s a part of what should be our unalienable legal right to “life, liberty and the pursuit of happiness” as long as we don’t infringe on the equal rights of others to the same.

The logical extension of your view is that the government should prohibit everything that is risky – mountain climbing, football, unnecessary driving, etc. Then we’d live in a very safe society – if we don’t die of boredom…
#4 DemFromCT
May 16, 2009

It’s a pretty hollow argument, made by someone who undoubtedly never had to care for the accident victims, Jon. But the societal point is that the expensive medical and rehab care is paid for by all of us, not just the guy without the helmet, so it’s really not his choice alone. Same with the other issues.

The choice I like is that of the new Director.
#5 Jon Schultz
May 16, 2009

No one has to care for anyone, Dem. There could be a law that if you don’t wear a helmet and get into an accident, you’re not eligible for public assistance.
#6 Jon Schultz
May 16, 2009

Addendum: I’m not sure I’d support it…
#7 DemFromCT
May 16, 2009

LOL… Jon, my friend oaktownadam over at Daily Kos says:

personal responsibility and public health management are mutually exclusive.

They’re just two completely different ways of seeing the world: one focuses on individuals and freedom, the other focuses on large populations and harm reduction.

We were arguing about the same CDC appointment.
#8 Jon Schultz
May 16, 2009

The government should not have a right to infringe on unalienable rights under any circumstances. That’s what unalienable means – sacrosanct – and the idea of such is what our country was founded on.

But for people who are driven by a desire to be seen as one of the good guys, the end justifies the means…
#9 engstu
May 16, 2009

I hope the guy does a good job.

Does anybody know why the CDC hasnt updated the /h1n1flu page on thier website yet? I dont remember it being this late in the day last week. MSNBC has Texas reported the 5th fatality. I wonder if the numbers seemed large and they wanted to double check them.
#10 daedalus2u
May 16, 2009

Jon, I fail to see how driving on public roads without a helmet is any kind of right. If they are public roads, it seems like the public should be able to dictate the circumstances under which they are used, vehicles in good repair, licensed drivers, insurance, and minimum levels of safety equipment.

I think people driving on private roads should be allowed to do so under what ever conditions the owner of the private road considers appropriate.
#11 Jon Schultz
May 16, 2009

daedalus2u, it’s appropriate for the government to require that we be responsible, or not a danger to others, but it’s very inappropriate for the government to try to assume the role of parent and decide the level of personal risk that we wish to take in our lives.

Every dictator who suspends civil liberties is always doing it for peoples’ own good…
#12 revere
May 16, 2009

Jon: Every dictator who suspends civil liberties is always doing it for
peoples’ own good.

Hardly. They are doing it for their own good, as they see it. The idea that helmet laws are akin to the acts of a dictator is overblown nonsense. How do you expect you arguments to be taken seriously when you say things like that? If you adopt a slippery slope argument, then no restraint on a person’s actions is valid. We wind up with today’s economic debacle.
#13 daedalus2u
May 16, 2009

The example wasn’t about suspending civil liberties, it was about what regulations the owner of a highway can legitimately impose on users of that highway. If the owner of the highway is responsible for cleaning the highway, then the owner can require users of that highway to act so as to mitigate the owner’s potential clean-up cost by requiring that helmets be worn.

If a skull is not broken open, the clean-up cost is less.
#14 Jon Schultz
May 16, 2009

Revere: What I meant, which I thought was obvious, was that dictators always *say* they are suspending civil liberties for the good of society – and I wouldn’t be surprised if, in at least some cases, they believe that.

And I wasn’t trying to adopt a slippery slope argument in the sense of implying that helmet laws will necessarily lead to martial law, but they do create an extremely bad precedent which can be used to justify further intrusions on civil liberties, in addition to possibly causing some accidents by creating a distracting sensation (including, in some cases, resentment) which lowers sensitivity.

I’m not sure what restraints on activity you think would have avoided today’s economic conditions. If you’re talking about lenders having a so-called responsibility to ensure that borrowers can repay their loans, you’ll really get me going…
#15 SusanC
May 16, 2009

revere,

Like Besser, Frieden has been in the spotlight around swine flu. I’ve seen him nodding in agreement as Mayor Bloomberg tried to bring calm in the worst way: by constantly minimizing the seriousness of the illness. Yesterday I saw Frieden the same thing. Flu is always a potentially serious disease. This was a teachable moment for seasonal flu that was missed. Besser didn’t engage in this, to his credit.

Seems like I’m not the only one not entirely impressed with Frieden’s performance around this flu outbreak. It’s early days yet, but thank you again for telling it like it is.
#16 DemFromCT
May 17, 2009

The new guy in NYC isn’t going to make Jon very happy.

An infectious-disease specialist and a longtime advocate of using government to promote healthier behavior is expected to be named New York’s health commissioner by Mayor Michael R. Bloomberg on Monday, according to people who have been briefed on the matter.
Dr. Thomas A. Farley of the Tulane School of Public Health and Tropical Medicine will replace Dr. Thomas R. Frieden, the high-profile and sometimes controversial commissioner who on Friday was named by President Obama as the new director of the Centers for Disease Control and Prevention.

http://www.nytimes.com/2009/05/17/nyregion/17health.html
#17 DemFromCT
May 17, 2009

SusanC, if they picked anyone who impressed us, that’d be scary.
#18 Jon Schultz
May 17, 2009

Dem, I’m all for the government providing accurate health information to the public, but the question then is what is accurate – because I think most health issues are in fact not that well understood and the views of the “medical establishment” are often highly debatable and suspiciously allied with the desire of large pharmaceutical firms to sell their products – and in any case people should certainly be allowed to make their own decisions after the information has been presented.

I also think the government should be conducting studies with compounds which the drug companies have no interest in because they are not patentable, i.e. BHT (see the article at aids.org). And even after attention has been focused for years on the possibility of an H5N1 pandemic, has the government done sufficient research to determine just how effective respirators and other types of masks would be in the next pandemic? To my knowledge they have not, and if that is correct then it is a terrible and inexcusable failure on the part of our government and its health agencies.
#19 SusanC
May 17, 2009

Dem,

if they picked anyone who impressed us, that’d be scary.

why should that be scary?
#20 cjon
May 17, 2009

30+ years ago, when I was hired into Public Health (then a Division of Social Services) in Missouri, I went to new employee’s orientation. All of the section chiefs addressed the assembled new employees to tell them what their sections did.
The state epidemiologist at the time was H. Denny Donnell Jr, MD. He asked the assembled newcomers what the difference between a Private Medical Practice and a Public Health Practice was. Getting no answers he liked, he proceeded to tell us that the Private Medical Practitioner focused on a single patient, mostly with the aim of restoring him or her to good health. The Public Health Practitioner focused on the Community with the aim of preventing ill health and disease. In that regard, the patients of the Private Practitioner represented the failures of Public Health. He went on to say that he didn’t think that we’d be running the private docs out of business anytime soon. For 30 years, I’ve tried to keep that in mind.

If Friedan can help us move toward that goal, I say good on him. I think Besser has done a pretty good job with the current mess, given the uncertainties of dealing with anything flu.
#21 Cassie
May 18, 2009

Here are Frieden’s comments from Jan 09 on why he thinks regulating salt is the right thing to do:

“Education is important but in this case is not enough…”

http://dinersjournal.blogs.nytimes.com/2009/01/30/more-from-dr-frieden/

Eek! Personally speaking, I am extremely wary when somebody tries to coerce me into doing (or not doing) something “for my own good”. I am more along the lines of education and awareness eventually changing cultural norms – as has been the case with tobacco smoking. These things take time, sometimes decades, but once the cultural shift occurs it tends to make people alter their behaviors accordingly.

In this situation, educating people about the high amounts of salt in processed foods as compared to fresh foods and measuring the salt amount on food packaging in teaspoons as well as grams might go a long way in changing people’s understanding of the problem. Getting all heavy and making threats to the food industry about regulation doesn’t really seem like a long-term solution. As one of the NYTimes posters writes, food manufacturers will just put something else in to mimic salt which is probably worse for us anyways…

And Frieden’s response of “that won’t happen” isn’t very convincing.

*************

I hope this guy works out for CDC, and I have very high hopes about his ability to restore morale. But I just have questions about the “coercive”, regulatory emphasis in public health. CDC is not a big agency (14,000 people total). How are we supposed to coerce people or industries into anything? We don’t have the enforcement powers for one thing, and we also don’t have any inspection staff. Just sayin’.
#22 S
May 18, 2009

Sump pumps first. Redirecting the foundering boat (in any reasonable direction) second. There’s no reason we can’t have both, posthaste.
#23 Carolyn
May 18, 2009

Frieden is an activist, but his approach does lean toward the coercive. He believes in taxing sodas but there really isnt any evidence that sodas are the cause of the obesity epidemic or that taxing them is the cure. So unfortunately when it comes to his prescriptions, he seems not to be too concerned about the science base. And what is CDC, which is not a regulatory agency, supposed to do with this kind of activism? I am not 100% convinced that this is a good pick.
#24 S
May 18, 2009

Re comment # 23:

Agree. We (public first and agency second) don’t need yet another crusader taking us in this direction or that, especially if the science and the data aren’t there. Let’s hope this won’t be the case. We’ve been all through this in recent years.

I would like to think that the mission of this agency (the CDC) remains critical. It is salvageable. But it doesn’t seem likely that it can withstand another hard hit from a new round of mismanagement. That is why it is so critical that the incoming director seeks to remedy matters at hand before launching into major new initiatives. There will be a time for that, but the time isn’t now.
#25 Rich
May 19, 2009

This appointment has brought out the crazies and the tangential, everywhere. Also, CDC has about 7-8,000 employees, not 14,000.

“Structural” interventions (laws, policies, etc. to encourage behaviors, enhance access to services) have been the source of much talk, but little action in the last decade. Frieden seems willing to move in this direction, which is long overdue. CDC’s course has been to push guidelines without attending to structural factors–the recent shift in HIV testing guidelines has not been followed-up by useful steps, in fact the health insurance that most feds carry won’t pay for HIV testing! Friden may help get the agency beyond its tendency toward retreating into the worst sort of black box epidemiology and technocratic minimalism. Partly by virture of being in Atlanta, CDCers whine about “politics” and because of it, wind up being ineffectual on many fronts. The lack of political savvy is one reason the Bush Administration captured the agency so easily. Gerberding’s desire for higher office didn’t hurt, but the political studpidity of CDCers would have made it easy for any number of career CDCers to cave as easily as she did.

As for obesity–CDC’s chronic disease mission is unlikely to get jettisoned any time soon and it represents real public ealth needs. There’s no real home for this elsewhere at HHS. It doesn’t fit well with NIH’s institute by disease mission and USDA lacks jurisdiction to go beyond its wooly guidelines. Also, Agriculture’s sensitivity to agri-business lobbying.
#26 Cassie
May 19, 2009

“This appointment has brought out the crazies and the tangential, everywhere. Also, CDC has about 7-8,000 employees, not 14,000.”

Quick Fact check:

The CDC has 9,587 people with FTEs and 5,600 contractors, which adds up to 15,187 employees.

And yes, this appointment has brought out the crazies!
#27 Jon Schultz
May 19, 2009

Calling someone a “crazy” or “tangential” is not only an invalid ad hominem argument – frequently used to denigrate a position when one is unable to respond – but is also very disrespectful of a fellow human being who just might be telling you something that would benefit you.

But what do I know, I’m one of them…