Three Winnable Battles and Other Wars: A Talk With Thomas Frieden

Eli Y. Adashi, MD; Thomas R. Frieden, MD, MPH


July 15, 2011

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Winnable Battles: What Are They?

Eli Y. Adashi, MD: Hello. I am Eli Adashi, professor of medical science at Brown University and host of Medscape One-on-One. Joining me today is Dr. Thomas Frieden, director for the Centers for Disease Control and Prevention (CDC).

In an earlier conversation, we discussed the battles waged against tobacco, obesity, and healthcare-associated infections. Today, we will focus on the prevention of HIV, teen pregnancy, and motor vehicle-related injuries. Welcome.

Thomas R. Frieden, MD: Welcome. It is great to be here, and welcome to CDC again.

Dr. Adashi: Just for the benefit of our viewers, perhaps a few words about what winnable battles actually are and how we should be thinking about them before we launch into specifics.

Dr. Frieden: There are so many health problems. Sometimes it can be overwhelming. And yet a subset are things that affect many people, even everyone in some cases, things that we know what to do about but we are not yet doing it. And if we implement proven programs, we are going to get great results. For each of these areas, there are big health problems. We know what to do. We are not yet doing it. But if we focus more, we can make a lot of progress.

Dr. Adashi: These are priorities you defined or identified at the beginning of your tenure. Is that correct?

Dr. Frieden: Yes. We really worked with staff at the CDC and elsewhere to identify them. They are not the only winnable battles. There are others, but they are the ones that we are giving the most attention to, for which we have the most ability to make a big difference.

Battle 1: Preventing, Testing, and Treating HIV AIDS

Dr. Adashi: We will begin with HIV AIDS -- very topical in many ways. We just crossed the 30-year mark of the epidemic earlier last month. And yesterday just happened to have been HIV Testing Day. How did that go? And what can you say about the obvious but ever-growing importance of testing?

Dr. Frieden: Despite the great treatments that we have, HIV remains an incurable infection. We have about 50,000 new HIV infections every year, especially among men who have sex with men and especially in African Americans and Latinos. By scaling up testing and treatment, we can make a big difference. CDC initiatives over the past few years have resulted in 11 million people in America being tested for the first time.

And yet we know that testing still isn't nearly common enough. We need to offer testing to everyone routinely. We need to intensify testing for groups such as men who have sex with men, who may need to be tested several times a year. We need to continue to try to reduce risky behavior. And we need to get people who are positive into treatment.

One thing that doctors can do more than they are doing today is to find out who the partners are of people who are positive and to ensure that they get tested. Also [they need] to make sure that once people are tested and found positive, they promptly get into care and they stay in care, so that we can reduce viral load in the individual and in the community and reduce spread in the community.

Dr. Adashi: As we think about AIDS in general, we think about both prevention and treatment. What can we say about current efforts in the United States that focus on prevention first?

Dr. Frieden: We are learning more about how to prevent HIV. We are learning to focus on geographic areas. We are learning to focus on demographic groups, particularly young men who have sex with men. And we are learning to focus more on the programs that work, for example, those with HIV-positive people to reduce their risk-taking behavior, to get people onto treatment, to extend availability of condoms and safe needles. These are all effective and we need to scale them up.

But we are faced with a huge problem. There is a lot of risky behavior in younger men who have sex with men, and this is now driving the HIV epidemic in this country and other countries as well.

Dr. Adashi: With that as a fact, perhaps a word though about the welfare of women in the United States who are coping both with the risk for AIDS and with the actual disease. Where are we with that in the United States since globally there seems to be a rather substantial affliction of women?

Dr. Frieden: There are significant populations at high risk in the United States, particularly African American women and to a lesser extent Latinos. But unlike in other countries, in the United States HIV remains more a disease of men. And it continues to be the men who have sex with men who are accounting for most of the spread of HIV in this country.

That is one reason why we are seeing a very interesting phenomenon. It used to be that prevention was here, treatment was here, and they were very unrelated. Increasingly, we are seeing the convergence of prevention and treatment by getting people tested, into care, and on treatment. We are not only helping them to live longer and healthier lives, but [we are also] reducing the risk that they will spread HIV to others.

Dr. Adashi: Is testing today, being all important as it obviously is, an opt in or an opt out option for individuals?

Dr. Frieden: No one should be forced to be tested for HIV and no one should be tested without knowing that they are being tested. CDC recommends that testing become routine, that it be screening as we screen for other common and treatable infections.

Dr. Adashi: It might also be useful to say a word about our national strategy for the management and hopefully eventual control if not eradication of AIDS. It is my understanding that we now have the first ever national US AIDS strategy. What can you tell our viewers about its genesis, its high points, and its goals -- perhaps more importantly?

Dr. Frieden: There is a real commitment in the government to do more to address HIV. There is a real concern that 30 years on, we have too much complacency within the government and within communities about HIV. It remains a leading preventable cause of death in this country. It remains an incurable infection. And we are seeing it increase in some population groups.

The national strategy says: Let's do everything we can to reduce the spread of HIV, ensure effective treatment of those living with HIV, and reduce inequalities and disparities in HIV in our communities, with the understanding that we now know more than we ever have about HIV so we can be more effective in the programs we implement. That is part of what's behind our effort at CDC to focus more on geographic areas, demographic groups, and programmatic interventions that are going to make the most difference so we can get the most health value for the health dollar that we are using.

Dr. Adashi: Recognizing that we are not likely to treat our way out of this epidemic any time soon and recognizing that prevention may well be imperfect, what is the best we can hope for in the next quarter century, since it is unlikely that, for some of us at least, the decisive end may not [occur] in the course of our lifetime?

Dr. Frieden: A quarter century is a long time to look into the future, but I certainly hope that we will have a vaccine for HIV in that time period. I also hope we may have better treatments that may be easier to take. And even if we are not able to eradicate the infection from an individual, perhaps the treatment will be easier to take, less burdensome, and at least as effective.

Ultimately, what we hope to see is a more effective and coordinated system so that we can bring down infections, identify the few infections that happen more prominently, get people into care, and see HIV receding from its current situation of continuing to expand in some groups.

Dr. Adashi: To the extent that the numbers are known, how many Americans today may be eligible for therapy; but for one reason or another may not be accessing the treatment?

Dr. Frieden: It is important to divide that question into subgroups. We estimate that as many as 1 in 5 Americans living with HIV, which could be more than 200,000 people, don't know that they have HIV. Some significant portion of them could benefit from treatment, therefore protecting themselves, their partners, and their communities. That's one group.

A second group are people who are tested and yet don't enter care. As we've looked at this more carefully, we have been quite concerned by the high number of reports. It may be about a third of people who test positive but don't promptly enter care. That is a second big concern.

The third concern is people who may have started care and then dropped out. Maybe they got tired. Maybe they had a problem with drugs or had a side effect and they didn't want to continue taking medications. We don't yet have good systems in many jurisdictions to offer those people so they will come back into care. No one should ever be forced to take treatment for HIV. But that should not allow society to be off the hook for offering that care to someone and going back and offering it again, if perhaps they're at a better place in their life where they can take it.

One of the things that we have looked at is care in correctional institutions, where you have many people [who have] HIV. They may account for a significant proportion of those who are not adequately treated in society. How can we make sure that they are linked to the kinds of services that we have in the community? We certainly should make sure that anyone who wants to be treated for HIV in this country can be treated with state-of-the-art care.

Dr. Adashi: It would seem though that on balance it's not so much a question of supplies. It is a question of reaching the individuals who are eligible for therapy who may not be accessing it for a whole host of reasons, which you have so eloquently listed.

Dr. Frieden: It is very important to take a public health perspective on this. In many public health programs, we think about monitoring the outcome of every patient; again not to mandate treatment, but to hold providers accountable. If you started 100 people on treatment and you have lost half of them, if you don't know that they are getting care somewhere else, you are not doing a good job. We need to empower clinicians and healthcare systems to monitor and track that information for themselves so that they can improve it.

If you are not monitoring it, you are not going to manage it and identify the kinds of interventions you need to help keep people on treatment. They might be mental health treatments. They might be drug treatments. They might be social services. They might be more patient-friendly healthcare environments. Whatever it takes to get people to enter care and stay in care is going to be very important.

Dr. Adashi: Yes. So clearly there are a whole host of social and cultural factors that enter into the equation. It is far from a simple matter of have drug will treat.

Battle 2: Teenage Pregnancies

Dr. Adashi: Perhaps we can move now to the teenage pregnancy challenge, wherein we can note some good news in the sense that the latest number available from 2009 appeared to suggest a nadir, the lowest ever incidence of teenage pregnancy in the United States. Perhaps we can start by saying something about what made that possible? What kinds of efforts converged to give us this set of positive numbers?

Dr. Frieden: I have a somewhat different take on it. Teen pregnancy is a terrible problem. It is one of the things that continues inequality and problems of social and economic and educational development in our society to a very great degree. In fact, if you look at everything in the healthcare sector, perhaps one thing that we can do that may be as or more important than anything else would be to drive teen pregnancy rates down.

Our numbers are not good. If you compare us with other countries, we are 2, 5, 10 times higher than other developed countries in terms of our teen pregnancy rate. And it's not primarily because of the level of sexual activity of our kids. It is fundamentally because of 2 things. One, a social norm that doesn't say kids shouldn't be having kids. And second is easy access to comprehensive reproductive healthcare services for kids.

What we can see is that in communities around the country and around the world that have had more progress with reducing teen pregnancy, you might see some slight change in the age of onset of sexual activity with a number of partners. However, what you primarily see is a big increase in contraceptive use. I know that's controversial , but every doctor who cares for a teen should be taking a sexual history. This is the standard recommendation of the American Academy of Pediatrics and others. There is nothing controversial about this.

Making sure that healthcare providers provide services that are teen friendly is extremely important. I know of jurisdictions that have gone out and surveyed providers who present themselves as being teen --friendly and often they're not. It means being sensitive about how the teen wants to be related to, about how the teen and [his or her] parents want to be related to, about what the legality is of providing services to the teen with or without the knowledge and consent of the parents, about where to send bills or Medicaid bills, or to get access to family planning services. These are all important issues that doctors can do a lot about.

We also have to look at different contraceptive technologies. There are a lot of misconceptions, for example, about intrauterine devices (IUDs). The latest scientific evidence does not suggest IUDs increase pelvic inflammatory disease. In fact, they are a great choice for many women and some girls as well, but they are not nearly as widely used as they should be.

Getting school-linked services [is important]. I have seen so many inner city schools where kids are dropping out because they're pregnant, where kids are really condemning the next generation to grow up in poverty because of pregnancy. We can do a lot to decrease this. It is going to take, though, a real commitment on the part of doctors to ask teens, to advise them, to provide services, to be teen friendly.

So this is an area where, although we did see a slight decrease last year, really the numbers are so much higher than they should be. Even within the United States, we see a huge variability between one state and another, but [the teen pregnancy rates of] even the best states in the United States are far higher than in other countries. I think we can do a lot more to reduce teen pregnancy and we must.

Dr. Adashi: Points very well taken. We may have made progress, but not enough and lots of work to do. What can we, in fact, learn from other developed countries that are so far ahead of us on this issue? If there were one or two lessons we could emulate, what would those be?

Dr. Frieden: It is very interesting to look at what other countries have done. If you go back 30 or 40 years, they started out with rates of teen pregnancy that were a little lower than in the United States. Over the past 40 years, our rates have come down a little. Theirs have come down tremendously. So you see this huge divergence of rates.

Fundamentally I believe they have done 2 things. The first is to change the social norm, to make sure that it's not okay for kids to have kids. It's a real problem. It's not socially acceptable. At the same time we have to recognize that some teens will have children and we need to help those children in every way possible. But that social norm is very important.

The second [thing] is ready access to contraception. This is much more normal in many of the countries that have decreased their rates substantially, in Europe and Canada and elsewhere. This is a part of life, whereas here, there may be some skittishness about talking about contraception. I think [in other countries] it's just the norm and it would be odd not to talk about it. So those are 2 changes in the social norm in society and in doctors' offices.

Dr. Adashi: You made reference to significant variability among states. Are there other differences, if you will, that relate to racial and ethnic background or perhaps high-risk groups that tend to have higher rates of teenage pregnancies than others?

Dr. Frieden: Unfortunately, it is the groups that frequently have too large a burden of a whole range of health problems, including African Americans and Latinos. Poor teens are more likely to have kids. There is also a geographic effect. Some states have much higher rates than others. However, some states have made a lot of progress. California took concerted action to reduce teen pregnancy, and in all racial and ethnic groups they have seen a substantial reduction. So progress is possible here.

Battle 3: Reducing Motor Vehicle Accidents

Dr. Adashi: Perhaps we can move on to vehicle-related injuries, which I suspect most of our viewers, including myself, may not recognize as a top 10 challenge, and that among the various causes of death that Americans experience, this is a significant one.

You obviously identified this as a worthwhile preventable target. Where are we today on this score? And are we moving in the right direction?

Dr. Frieden: We have made a lot of progress in reducing motor vehicle crashes and fatalities, but we still have a lot further to go. Once again if you compare the United States with the world leaders, we have 2 or 3 times higher rates of fatal motor vehicle fatalities. Motor vehicle crashes remain the leading cause of death for 5- to 34-year-olds in this country.

That is a striking statistic if you think about it: 5 to 34 are crucial years. All of us would recognize the terrible tragedy of anyone in that age group dying, and the number-1 cause of death is motor vehicle crashes.

We know to a great extent how to reduce motor vehicle crashes. We know the progress that we have been making is related to the efforts that have been undertaken in the past -- safer roads, safer cars, less drunk driving, less alcohol-impaired driving, graduated driver's licenses -- so that kids who are not yet mature as drivers are less likely to get into trouble driving. Motor vehicle restraints or car restraints, child seats, as well as better enforcement of traffic laws and other measures can substantially reduce motor vehicle crashes and fatalities. Primary seatbelt laws are very important.

If you look at what has happened over the past decade or two around the country, states have enacted stronger laws to ensure people wear seatbelts, don't drive when they are alcohol impaired, use booster seats for kids, have graduated driver's licenses for new drivers. Those interventions are making a big difference. If we continue to make that kind of progress, we can save many more lives, save a lot of money, and have our roads safer places to drive, walk, and bicycle.

Dr. Adashi: You made mention of several risk groups beginning with teenage drivers, obviously young children, the driver under the influence, and others. More recently there has been a great deal of emphasis on the distracted driver, the one who might be texting or speaking on the phone while driving. Where do you see that? Where do you stand on that now that we have had that debate for probably about a year or 2?

Dr. Frieden: I think there is a broad and growing consensus that distracted driving is a serious problem and that it is appropriate for governmental action to reduce it. You don't want your kid to be run over by a car on the way to school because the driver was texting. This is a big issue for our kids, who may be very tied to their phones and other mobile devices.

It is one of 2 big trends that we need to address in motor vehicle safety. One is distracted driving, particularly among the young. The second is impaired driving among the elderly.

Dr. Frieden: As our society ages, more and more people need desperately to drive to maintain their independence, but they may not be able to drive safely. We as a society need to think [about] and understand, analyze, and study better ways to address both of those important problems.

The Escherichia coli Threat and Investing in Food Safety

Dr. Adashi: In the time remaining, moving to a very different sphere, most of our viewers, like the rest of the nation, have followed with great interest the events in Europe as they are related to a particular virulent strain of Escherichia coli that created a hemolytic uremic syndrome in a substantial number of European citizens, mostly in Germany and to some degree in France. Have we been involved with that effort or have we been mostly observing? What if anything can be learned from that episode in general and about the possibility that something of this nature could reach our shores?

Dr. Frieden: CDC has been consulting informally with the authorities in Europe on this from the early days of the outbreak, both in terms of the epidemiology and the laboratory aspects and some of the tracing of food. I think that the lesson is a broader one. The lesson is about food safety and the importance of maintaining our vigilance on food safety, of being prepared.

We are right now in a terrible time. States throughout the US are laying off public health staff. They are closing public health laboratories. They are less and less able to detect and respond to health threats such as food-borne illness. We have to preserve the core public health functions of this country or we will [have] avoidable illness, economic loss, and destruction of the whole chain of production.

There is a more specific message about sprouts, which is a challenge. Sprouts can be contaminated within the seed. Even if you grow them in sterile conditions, you can have a huge amount of microbiologic contamination. So this is a real concern for sprouts.

For 15 years, the Food and Drug Administration has recommended that the very young, the very old, pregnant women, and immunosuppressed people not consume uncooked sprouts. This is something that I think not many people realize. Unfortunately, though, [sprouts are] a vegetable and we promote consumption of vegetables. There are real problems with [growing sprouts] in a sterile environment and avoiding contamination, but that is a very specific issue.

The broader issue is the importance of investing in our public health infrastructure and in our capacity to identify problems quickly and respond quickly. I will give you an interesting example on the E coli O157H7 hemolytic uremic syndrome. Earlier this year, just about a month before the German outbreak, we had a cluster of cases in 3 different states. It was a small cluster, only a handful of cases, ultimately only 8 cases. Because we do DNA fingerprinting on all of the O157H7, we were able to promptly identify that these cases, which among other sporadic cases, were linked, then do an epidemiologic study, identify one particular nut as the source, and get that nut removed from the shelves to prevent an outbreak. That is the kind of success that public health can have and we need to continue to invest in [that] so we can continue to have and continue to build on the progress that we have made in food safety.

Dr. Adashi: I take it that obliquely you are making reference to some of the pressures that are currently being brought to bear on all budgets because of both the national and state pressures to cut costs and increase revenues. I think the point you are making is that breaches in our public health defense lines can lead to significant adverse consequences.

Dr. Frieden: If we don't maintain our defenses, it will cost us lives and money, and it will have an economic impact on our country as we lose confidence in some food sources. State and local governments around the United States are facing fiscal crises of a severity that they have not been seen in years, decades, or even a generation or 2. At the federal level, we're also seeing problems.

We all understand the need to get our fiscal house in order. But what we're saying in public health is let's not implement cuts that cost people's lives.

Dr. Adashi: An ounce of prevention is still applicable.

Dr. Frieden: Absolutely.

Dr. Adashi: If I may on a personal note say that you have dedicated your professional life to the betterment of health in general and perhaps public health in particular. At what point did you realize that this is what you actually wanted to do with your professional life, and why?

Dr. Frieden: Well, I love clinical care. I love taking care of patients. My father was a cardiologist, and I got a chance to observe him caring for patients and spent a month with him as a preceptorship in medical school. But I wanted to really have a broader impact on health. I think the wonderful thing about public health is that we have the ability not just to diagnose and provide treatment and advice to individuals, but [also to] detect and provide information to communities, to help communities take control of their health and reduce avoidable illnesses and deaths.

Dr. Adashi: Well, it is good to have you at the helm.

Dr. Frieden: Thank you very much.

Dr. Adashi: On this note, sincere thanks to Dr. Frieden and to you our viewers for joining Medscape One-on-One. Until next time, I am Eli Adashi.


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