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Thomas Frieden recommends the best books on

Public Health

The director of the US Centers for Disease Control and Prevention takes us inside the world of fighting epidemics, eradicating disease and confronting the preventable damage we do to ourselves

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    1

    Vaccinated
    by Paul A Offit, MD

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    2

    House on Fire
    by William H Foege

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    3

    Inside the Outbreaks
    by Mark Pendergrast

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    4

    Tobacco: A Global Threat
    by John Crofton and David Simpson

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    5

    Rose’s Strategy of Preventive Medicine
    by Geoffrey Rose

Thomas Frieden

Dr Thomas R Frieden became director of the Centers for Disease Control and Prevention in 2009. From 2002 to 2009 he was the commissioner of New York City’s health department, where he instituted a groundbreaking anti-tobacco programme. Dr Frieden started his career in the CDC’s epidemic intelligence service, and from 1992 to 1996 he ran the New York City programme that brought tuberculosis under control

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Thomas Frieden

Dr Thomas R Frieden became director of the Centers for Disease Control and Prevention in 2009. From 2002 to 2009 he was the commissioner of New York City’s health department, where he instituted a groundbreaking anti-tobacco programme. Dr Frieden started his career in the CDC’s epidemic intelligence service, and from 1992 to 1996 he ran the New York City programme that brought tuberculosis under control

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The field of public health seems like a recent invention, but epidemiology is as old as Hippocrates and the Chinese tried immunising in 1000 BC. What is public health? How did it come together as a field and what attracted you to it?

Public health is society’s way of maximising health. When it comes to your personal health, you might think about eating well or exercising. In public health we think about the structure of society and how to encourage people to be healthier, how to make the default value the healthier value. Hippocrates said something to the effect that prevention is always better than cure. Public health is the science of prevention. It goes way beyond healthcare – it includes health in the workplace, healthy water, food and air, and more. Vaccinations provide one of the key approaches to public health and are one of the key aspects that make public health so remarkably successful.

What attracted me to public health was simply that I loved taking care of individual patients as a doctor but I wanted to be able to help even more people by taking care of whole communities and empowering whole communities to live more healthily.

Before becoming the head of the Centers for Disease Control and Prevention you were head of the New York City health department. What does the CDC do to further public health? How does it function in relation to other health actors, like the city health agency you once led?

First, we figure out what’s happening and tell it like it is. We’re a sentinel for health, just like as a doctor checks a patient’s vital signs, we check the vital signs of each community, state, and  in the nation, for ongoing and emerging health problems, whether they’re acute or chronic, cancers, heart disease or infections. We work 24/7 to keep Americans safe and protect health. Second, we support local, state and international health entities to help them work more effectively. In the US, most of our resources actually go out to state and local entities to help them detect and respond to threats. Third, we advance science. We detect and diagnose illness, we help develop new vaccines, we scale up programmes that work and then we communicate that information to those who need to know.

Let’s look at just one example: Tobacco is the leading preventable cause of death around the world. In fact, globally, tobacco will kill more people than HIV, TB and malaria combined. In this century, if nothing is done, tobacco will kill a billion people. It’s difficult for an individual to quit smoking. However, most people in the United States who smoked have already quit and anyone who smokes can quit. Whether an individual quits does not depend only on their individual willpower but on a whole range of influences. Those factors include how much nicotine the tobacco industry puts into their cigarettes and how they engineer the cigarette to make it more addictive, how good the services to encourage people to quit are, what the price of tobacco is, where people can smoke and whether the government is running effective anti-tobacco ads on television and social media that make clear the human cost of smoking. Two-thirds of Americans who smoke want to quit and most Americans who smoke try to quit each year, but without the public health impetus for that and public health action they will be much less likely to succeed. Someone who quits in a state that has really good public health policies on tobacco is much less likely to relapse than someone who quits in a state in the US that doesn’t have good public health policies in place. So there’s an intersection and interaction between individual action and community action, between healthcare and public health actions.

And tell us why your $10bn budget is a good investment.

Public health is a best buy. For every dollar we spend on immunisation we save the healthcare system $3 and society $10. Public health is about getting the most value from our health system. Generally, we spend pennies on prevention for every dollar that we spend on treatment. Not only does prevention save lives for less money, but it also helps prevent disability and helps people live independently for longer.

Vaccines are known as the most cost-effective public health tool. Vaccinated: One Man’s Quest to Defeat the World’s Deadliest Diseases by Paul Offit is your first selection. Please tell us about the book and its author.

It’s a wonderful book because it gives both a history of vaccines as well as a biography of a man who most people probably have never heard of – Maurice Hilleman. Although he was not an easy man to work for, there are few people in the history of humanity who have saved more lives than Maurice Hilleman. This book tells his story well.

There are tens of millions of people alive and healthy today because vaccines exist. The success of vaccines in addressing a whole range of health problems is amazing. Take polio. There’s a generation that has grown up without fearing polio, but it wasn’t long ago that everyone knew someone who lived in an iron lung, every kid knew you couldn’t swim for fear of catching it and everyone knew that FDR was in a wheelchair because of it. When I went to medical school there was still an iron lung on the hospital ward. Polio used to disable 1,000 kids a day in the world when CDC, along with our global partners, began a campaign to vaccinate against it and now we’re at the brink of eradication. There are huge challenges that are remaining but I’m confident we’re going to get over the finish line and when polio is eradicated it will be a gift to every child born on the face of the earth for the future of humanity.

Offit is also the author of Deadly Choices: How the Anti-Vaccine Movement Threatens Us All. Many members of the public persist in believing there is a link between autism and vaccination. How has the anti-vaccine movement impacted public health and how do you combat that impact?

Vaccines are, in a way, victims of their own success. People were terrified of polio and measles before – now they’re so rare that some parents may mistakenly believe that the vaccine is riskier than the risk of disease. That’s not the case. The more the public understands about vaccines and diseases, the better off we all are. So I think one of the things that the anti-vaccination movement has done is push us to be even more open and transparent. We have nothing to hide.

Some people takes the perspective that if my kid has only a one-in-a-million chance of getting a bad reaction from a vaccine but every other kid is vaccinated, my kid doesn’t need to be vaccinated. There are people in the movement who sincerely believe in the danger of vaccines, but there are many parents who may subconsciously make an assumption that I can protect my kid as long as everyone else is protecting their kid. What that brings us back to is the need to understand that we do all live together, we are all connected by the air we breathe, by the water we drink, by the food we eat and the health of any one of us can affect the health of other people.

Tuberculosis spread in the slums of New York City for many years and no one cared. Because no one cared much about what was happening in the slums, TB developed drug resistance and spread widely throughout New York City, infecting healthcare workers, prison guards and many others. If we had cared about those inner-city communities that were suffering from TB earlier on, it would never have become a huge, city-wide problem. Public health is about the connections within communities and strengthening those connections so that we can empower communities and empower individuals to live the lives they want to live.

Your next choice is an autobiography by former CDC director William Foege. Please tell us about House on Fire.

House on Fire is a fantastic book about the fight to eradicate smallpox. Before becoming director, Foege led the efforts to eradicate smallpox in India and Africa and came up with a key innovation that led to eradication. As one of the staff at the CDC said of this book, “Even though we know how it comes out, it’s still a page-turner”. It’s so exciting.

One of the things this book really brought home to me was how important innovation is. The eradication of smallpox was not inevitable. When we think back on what happened we might assume that we knew what to do, we did it and smallpox went away. That wasn’t it at all. They were continuously innovating, coming up with new ways to vaccinate, a new actual needle to do vaccinations. It wasn’t high tech, it was low tech. It turned out that high speed, pump-powered vaccine guns, where you could vaccinate lots and lots of people in a short space of time, didn’t work well. What did work was a very simple bifurcated needle. They figured out that if you dip that into the smallpox vaccine it had exactly the right amount of liquid and then if you pushed it into the person’s arm 15 times it would result in what’s called a “take” to the smallpox vaccine at a much higher rate, and you could teach a non-literate person to do that in 10 minutes. It wasn’t just innovations like that, it was who to vaccinate, how to vaccinate and how to manage programmes. This book gives the reader a wonderful sense of what it took to get the job done.

What lessons do you draw from that book and how do you apply them?

First, we need to get over the finish line in polio. Second, we need to continuously innovate in small and big ways to figure out, for example, how to get into places where it’s not safe to vaccinate or where healthcare workers may be under attack. For all our health programmes we need to figure out how to put together a community mobilisation. If you look at India, which has been polio free for over a year – India made polio elimination eradication a social mission and that’s the kind of thing that makes a public health programme successful.

Foege’s directorship is most strongly associated with his development of a scheme for mass vaccinations and the elimination of smallpox, which Bill Gates has called “the world’s greatest public health triumph”. What do you want your legacy to be?

CDC is a wonderful institution. One of the areas where we can always do better is the integration of our science and our expertise with public health practice on the front lines. We need to make sure that the gears are engaged, that when we take action, when we make recommendations, when we provide funding, the result is a programme that keeps people safer and healthier.

You began your career as an officer in the CDC’s Epidemic Intelligence Service. The EIS is the subject of the next book you selected, Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service. Tell us about the book and EIS – is it like CSI for communicable diseases?

It really is. This book is for a new generation what a book written by Berton Roueché called The Medical Detectives was, which I remember reading as a kid. They’re detective stories and they’re interesting and they’re human interest and they’re about saving lives. It’s really exciting.

In EIS, you get a problem, you don’t know if it’s going to be a big problem or a small problem, you don’t know if it’s going to spread or not, you don’t know if you can stop it or not and you’re working against time. Kate Winslet played an EIS officer in the movie Contagion. There’s a drama to this work that’s real and exciting. EIS takes young doctors and, as Alex Langmuir, who created the programme, said, we basically throw the EIS officers in the water and see if they can swim, and if they start drowning we haul them out and then we throw them back in. So you’re taking young doctors and you’re putting them in charge of huge investigations.

When I was in New York City I worked on a typhoid outbreak and helped stop it. I worked on a cryptosporidium outbreak in a homeless shelter. But my time was really dominated by the tuberculosis outbreak – a massive large outbreak of multi-drug resistant tuberculosis spreading through multiple hospitals in multiple parts of the city. I was right out of my training programme and I was basically in charge of how to detect and stop it.

At CDC we also have a global mandate, because we can’t keep Americans safe unless we work globally. So what we’ve done is to create EIS-like programmes in more than 30 countries. We’ve helped more than 2,500 disease detectives graduate in more than 40 countries around the world, where lots of diseases aren’t detected and aren’t stopped. About 80% of the graduates of these programmes stay in those countries in leadership positions in public health. So EIS is, in many ways, at the heart of CDC’s work.

You mentioned Contagion. In 2011 EIS and CDC got the Hollywood treatment in that Steven Soderbergh film. You called it “a fair and accurate portrayal”. So I guess readers can watch it for a glimpse of what you do, but I wonder, what are the most common misperceptions about how the public health community works?

I think there’s a misperception that CDC is only about infectious diseases and only about the US. I’m an infectious-disease-trained physician – I did my work in tuberculosis control, I took care of hundreds of patients with HIV. But public health is about empowering individuals and communities to live longer and healthier lives. It’s about protecting people and keeping them safe from threats. Those threats include getting run down by a drunk driver. Those threats include eating food that you thought was safe but is going to give you a heart attack or a deadly infection. CDC has 2,000 staff who work in 50 countries around the world keeping Americans safe and saving lives in those countries. That’s a key part of CDC because we are all connected. Not only within communities – where your not getting your kids vaccinated may endanger my kids – but throughout the world, because a community not knowing that the disease is spreading or not controlling it is just a plane ride away from making people sick or killing them here.

Next, a book by Sir John Crofton, who was knighted for establishing a cure for tuberculosis. Tell us about Tobacco: A Global Threat.

Sir John Crofton was a wonderful man and he became a mentor of mine. He is the one who actually figured out how we should treat tuberculosis and basically get everybody cured. He wrote not only standard textbooks of lung medicine but also a very simple low-cost text that became the guide for doctors and other healthcare workers around the world on how to treat lung disease. He then turned to tobacco and wrote this book. I had been transitioning from working on tuberculosis to working on tobacco and I had spent maybe a year working on tobacco before I ran across this book. It’s only about 120 pages and it’s just wonderful because it’s so simple and clear. In just a few pages you get all the essence of what it takes to confront the tobacco epidemic, the tobacco threat. Tobacco is a terrible problem.

I had a very active correspondence with Sir John over many years. I brought him to India because there was some resistance to the tuberculosis recommendations at the World Health Organization. As a British knight he had a lot of cachet with the Indian medical professionals and he was able to be very helpful there. We became friends and communicated regularly. A couple of years ago I gave the Crofton Lecture and in that talk I showed that Sir John had laid out all the essential aspects of how to reduce the tobacco threat in a simple letter to me a few years before the global community put this together.

This is a book I wish every healthcare worker and everyone who cares about saving lives would read. One of the things Sir John notes is that it’s been said that a doctor who smokes is worth $100,000 to the tobacco industry. So getting every healthcare worker around the world to quit and to be an advocate for tobacco control is essential. The book also shows how important it is that we limit the ability of the tobacco industry to do marketing and promotion, which get kids addicted before they reach the age of maturity. It’s just a wonderful book about the burden of tobacco and what to do about it.

What is harder to alleviate – public health problems that come from microbes or from human behaviour?

I’m afraid the answer is human behaviour. Microbes are really tough and we have real challenges in front of us, including the spread of antimicrobial resistance. But even that is largely the result of human behaviour – we haven’t safeguarded antibiotics as we should have. This is a good segue to the last of the books.

Rose’s Strategies for Preventative Medicine

by Geoffrey Rose is your final recommendation. Tell us about it.

I’m sorry that I didn’t know about this book until pretty far on in my career – but it’s a fantastic book that explains why and how disease occurs in society. We think of the need to treat people who are very ill, and of course we need to do that. What Rose talks about is that for most human illnesses there’s a bell curve distribution. If we just treat people for disease that will do some good, but we can do much more good by shifting the distribution of that bell curve. That’s the essence of prevention, that’s the essence of maximising health by reducing the number of heart attacks and strokes.

It’s not either/or – we can do both. So, for example, to reduce the number of heart attacks and strokes we can treat people who have high blood pressure and that’s very effective, but we can also get people to exercise more, be at healthier weights, eat lower sodium food and that will shift the bell curve so that many fewer people need treatment and the people who need treatment won’t need it as badly.

I don’t think it’s an either/or for population health and individual health. But I do know population health tends to get the short shrift. Until around the middle of the 20th century virtually all improvements in health were the result of prevention, not clinical care. Clinical care might occasionally have saved someone through surgical or other interventions but it wasn’t effective enough or widely accessible enough to actually make a meaningful difference with how many people lived or died overall. That started getting better with antibiotics and with the treatment of cardiovascular disease. In the US between 1980 and 2000, the death rate from heart disease was cut in half. Half of that decrease was from community prevention, particularly tobacco control, and half was from clinical care, such as taking care of people while they were having heart attacks. That tells me that both community and clinical care can make a huge difference.

Interestingly, there was a similar study in the UK that showed that 80% of the life years saved were saved through community prevention. Community prevention measures saves lives at a younger age. That’s really what Rose emphasises – the tremendous power of even small changes in the population prevalence to make huge changes in health.

According to Dr Rose’s criteria and your own, which diseases does the world community overspend on and which threats to public health are being insufficiently addressed?

I have my underlined copy of Rose in front of me, open to a certain page, which I’ve often thought of because Sir John Crofton mentioned something similar. I underscored a passage where Rose wrote, “Of all the threats to human health, it is alcohol which causes the widest range of injury. It shortens life, being variously held responsible for between 1% and 10% of all adult deaths in industrialised countries. It shrinks the brain and impairs the intellect. It causes failure of the liver, heart and peripheral nerves. It contributes to depression, violence and the breakup of personal and social life. It has been blamed for a quarter of all deaths on the road – divided about equally among drunk drivers, drunk pedestrians and innocent victims.”

Alcohol is a really tough area. Sir John always encouraged me to do more on alcohol control. The issue is problem drinking. In the US, binge drinking causes a huge proportion of the harms. Yet problem drinking is a challenge to address. I think we can at least begin to address this problem with a focus on kids and understanding that you want people to make decisions that are going to affect the rest of their lives when they’re adults, not when they’re kids.

Are you willing to take on the question of what public health problems are overly focused on or overspent on?

There’s been various work done in economics that suggest that although we spend a lot on healthcare, we get a lot for it. We want to have our hip or knees fixed so we can walk again. We want to be kept healthy. This is a delicate area but I will say that I wish we could just have a more open discussion about end-of-life issues. As a physician I’ve taken care of patients who died horrible deaths that they wouldn’t have wanted because they had not had a conversation with their families about what they wanted, and for whatever reason their families felt that we should continue to prolong the life of someone who is not really living but dying. And I will say that for my father and my grandmother, both of whom I was very close to, the last two years of their lives were very unpleasant. This was really something they would never have wanted and yet we are not able as a society to have clear discussions and decisions about that so that people can choose how they want to live and how they want to die.

Your selections have highlighted some of the most acute and most chronic threats to public health – what are the most acute and the most chronic problems in the international public health system? What are the greatest challenges that you face?

I would highlight one: The need for strong public health institutions in poorer countries. Improving health entails getting data to drive decisions – data on what’s making people sick, data on whether the programmes that are designed to help are actually working, data on whether the healthcare system is doing what it needs to do, data on what works in different communities to protect people from threats, and data on what threats are spreading. To get all that data you need strong public health institutions. I think CDC does a great job in the US. When I travel in Africa, Asia and Latin America I virtually always get asked: How can we create a CDC for our country? That is the next big global challenge for public health.

Moving beyond the infectious disease agenda seems clearly to be a focus of your work – what challenges do you face as you do that? What are the political, cultural and social challenges?

There are economic interests that can make it challenging. The tobacco industry is a primary example. Tuberculosis bacteria don’t lobby politicians. It doesn’t rebrand itself as light TB or get a movie star to make TB look sexy. So one is the economic interests.

Second is the need to get clear about responsibility. There are people who say if the government does this it will sap individual responsibility, or, it’s because you’re not treating people as autonomous adults. It’s not either/or. Take driving as an example. The government has a responsibility to make sure that traffic lights work, that the speed laws are enforced, that people don’t drive drunk. But that doesn’t absolve individuals from their responsibility to drive safely, to not drink and drive – it’s a shared responsibility. We need that for tobacco, for alcohol, for heart disease and cancer. We can now vaccinate against cancer from hepatitis B so maybe one day we’ll be able to use vaccines for heart disease, stroke and smoking. But not yet and we shouldn’t wait because we do have effective things that we can do today that will save millions of lives.

Saving lives requires good information, good management and focused action. These books really highlight that. They show how understanding what’s causing disease, finding the tools to stop it and working together as a society can save millions of lives.

Interview by Eve Gerber

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