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Public Health Priorities

Speaker: Dr. Thomas Frieden
Source: Office for State Tribal, Local, and Territorial Support
Running Time: 00:16:43
Release Date: 09/20/2011


In this next session, I'd like to review some public health priorities for CDC and for public health around the country.

First, I'd like to review with you the steps that CDC has taken to be better aligned to address public health priorities. First, we've improved our focus on excellence in surveillance, epidemiology, and laboratory services so that we know better what's going on. Second, we've strengthened our support for state, tribal, local, and territorial public health entities so that we can help you better. We know that the rubber hits the road at state and local public health entities, and we want to help you succeed. Third, we're increasing our global health impact. Fourth, we're using scientific and program expertise to advance policies that promote health.

Often, policy change is both the most effective and the most cost-effective way to get health improvement. And through all of these and other initiatives, we're better preventing illness, injury, disability, and death. On the screen and in your packages is a table of organization for CDC. We hope you'll get to know the key counterparts in the major areas and be able to work closely with those from whom you need support.

Dr. Judy Monroe can be a key linkage and liaison between all of the leaders of CDC and all of the entities within CDC and your organization. Supporting health departments is a core mission of CDC. Supporting state and local public health capacity is something that we do through resources, staff, technical support, and increased accountability. We also are working to improve our recruitment, development, and management of CDC's own field staff. We want to ensure that we have shared leadership of public health policy and practice, and we want to support health and public health information technology implementation. One example of this commitment is the Public Health Associate Program. The program expanded from 25 to 50, with a possible goal of as many as 200 each year. These individuals should become the leaders of tomorrow and the next generation in public health at the state, local, and national levels.

Winnable battles are six areas where we can have a big impact. Each is an area which causes a lot of injury, illness, disability, and death. There are evidence-based, scalable interventions that exist but are not yet widely applied. Our efforts are likely to make a difference, and we can get results within one to four years, but no one of them is easy.

Tobacco. Tobacco remains the single leading preventable cause of death in the United States. From the 1964 Surgeon General's report on tobacco until 2005, more than 40 years, tobacco use declined steadily in the United States. For the past five years, we have stalled nationally, and there has not been a further decline. This is the first time in two generations this has happened, but we can resume that decline. It's possible, and, in fact, I'll go over some of the things that you can do in your area.

Nutrition, physical activity, obesity, and food safety. This is a leading challenge these days, and there's a lot more that we can do to reverse the obesity epidemic. Healthcare-associated infections that kill far too many people and that cost us a lot of money and that we can help prevent. Motor vehicle injuries, which remain the leading cause of death of young adults and older children in this country and can be largely prevented. Teen pregnancy -- something that perpetuates a cycle of poverty from this generation to the next and has heavy social and economic costs. And HIV, which remains a terrible epidemic in this country and in which, in some ways, we are losing ground.

Tobacco is still the leading preventable cause of death in the U.S. About 46 million Americans still smoke, and tobacco causes nearly one but of every five deaths in this country, more than 440,000 deaths per year. That's more than 1,000 people killed by cigarettes today and every day this year. And for every death, at least 20 other people suffer tobacco-related illness. This costs us nearly $100 billion in medical costs every year and also about another $100 billion in lost productivity. Many Americans are left unprotected, especially people working in the service industry. 26 states still lack smoke-free laws. In New York City, there was a rigorous monitoring of tobacco use for 10 years, and that showed no decline in adult tobacco use. "MPOWER" is the WHO-recommended strategy to reduce tobacco use. The city then raised taxes on tobacco at both city and state level, and that led to a substantial reduction in tobacco use, the first reduction in more than a decade. The city then protected all workers from secondhand smoke by passing smoke-free legislation, and that led to a further substantial decline in tobacco use. Because the city had rigorous, ongoing monitoring of tobacco use, it was able to determine in the next year that there was no further decline in tobacco use, and therefore it began a systematic program of hard-hitting anti-tobacco ads warning about the dangers of smoking, and these ads led to a substantial resumed reduction in tobacco use, resulting in 350,000 fewer adult smokers, more than 100,000 deaths prevented in just six years. In just six years, the city was able to reduce adult smoking by 25% and teen smoking by 52%. Cigarette taxes are the single most effective way to reduce cigarette use. A 10% increase in price leads to about a 4% drop in cigarette consumption, and kids are particularly less likely to start smoking when prices are high and increased. Taxes need to be adjusted to offset inflation and the attempts of the tobacco industry to control retail prices through things like promotional discounts for retailers who reduce cigarette prices. Smoke-free laws save lives and don't hurt business. Smoke-free laws result in an approximately 17% reduction in heart-attack hospitalizations among non-smokers in places that implement smoke-free laws. They help motivate smokers to quit, and it's a worker safety issue, not a personal nuisance. All workers deserve equal protection, and the only way to protect non-smokers from secondhand smoke is comprehensive smoke-free legislation, without separate smoking rooms and without any loopholes. Smoke-free workplace laws don't hurt business. There's no tradeoff here between health and economics. Tobacco counter-marketing campaigns save lives. The tobacco industry spends more than $10 billion a year on marketing, promotion, and sponsorship. Youth are especially susceptible to these activities. Counter marketing needs to have sufficient reach, frequency, and duration. This is measured in something called "gross rating points." CDC recommends GRPs of about 1,200 per quarter for ad campaigns. That would result in about one ad per week -- 80% of the public seeing about one ad per week. We're only about 1/10th of that today in the U.S. Even though they're expensive, they're highly effective, so you need to look at your tobacco control funding and ensure that you continue or expand funding for counter marketing.

Obesity causes problems throughout the body and throughout our society. In addition to medical and societal costs, there are complications of obesity in virtually every organ system. There is a policy package to prevent and reverse obesity. This is based in large part on our experience with tobacco control, understanding what works. First is price -- to decrease the cost of fruits and vegetables and water. For example, make cool, clear water available in all lunch lines. Kids like it, they drink it, and it displaces beverages that have calories. Second, increase the cost of unhealthy foods, something that various jurisdictions have considered. The second broad area is image. Our children are still exposed to far too many images of unhealthy foods. As parents, we want to control what our kids eat, and we want to encourage them to eat healthy, and our efforts to do that can be undermined by aggressive marketing of junk food to kids. We need to show the human impact of nutritionally harmful beverages and foods without ever stigmatizing or, in other ways, harming individuals who may be overweight or obese. And access -- we need to make exposure to healthy foods and water routine. Having supermarkets in neighborhoods throughout our jurisdictions, having healthy food available at workplaces, and we need to work to make schools, healthcare facilities, government institutions free of junk food, including sugar drinks.

Healthcare-associated infections affect about 1 in 20 patients per year in U.S. hospitals. They increase the cost, length of hospitalization, and they increase the risk of death. Infections in bloodstream, urinary tract, and surgical sites are preventable, and there's a lot that we can do. Strengthening national surveillance through the National Healthcare Safety Network, something that now tracks infections in 5,000 hospitals around the country; increase implementation of evidence-based prevention guidelines; and public reporting so that data is used for action; and also looking at reimbursement policies to encourage adherence to infection control. The Partnership for Patients is a way to ensure better care at lower costs. It's a public-private partnership to help improve quality, safety, and affordability of health care for all Americans. It has core goals keeping patients from getting injured or sicker in the healthcare system and helping patients heal without complication by improving the transition from acute-care hospitals to ongoing primary care and other care settings. Over the next three years, it has the potential to prevent more than 60,000 deaths and save $35 billion, including $10 billion for Medicare.

Motor vehicle injuries kill more than 30,000 Americans every year and cause more than four million emergency-department visits. The economic impact costs our society more than $230 billion every year, and it's the leading preventable cause of death in young people. In fact, if you look at years of potential life lost, motor-vehicle injury ranks about third in our society, and there's a lot that we can do. Increasing seat belt use, reducing impaired driving, both drunk driving and alcohol-impaired driving, as well as distracted driving. Strengthening graduated driver's license policies, which can substantially reduce injuries and death. Graduated driver's licenses are working. They're reducing motor-vehicle injuries and deaths, but we can do more by strengthening laws that exist in nearly every state. And we need to collaborate with the transportation sector and other agencies to promote road safety and not just for motor vehicles, but also for bicyclists and pedestrians.

Teen and unintended pregnancy perpetuates a cycle of poverty. It increases infant death, low birth rate, pre-term birth, and healthcare costs, and it costs taxpayers more than $9 billion a year. We can increase access to long-acting, reversible contraceptives, improve reimbursement policies to cover family planning, and work to change the social norms, both in the healthcare industry as well as in society so that teen pregnancy becomes something that isn't normal so that not only do we support teens who do become pregnant, but we prevent that from happening in the first place, both through our actions and through our attitudes and, in the healthcare field, through services that are readily available and effective. The use of long-acting, reversible contraceptives is very important, but studies done by CDC and others have shown that even in family planning clinics, these are not as widely available as they should be, and others who care for teens, whether they're family practitioners or pediatricians, also need to do more to increase access to long-acting, reversible contraceptives.

HIV prevention is critically important. More than a million Americans have HIV, and as many as one in five are unaware that they are infected. Increasing unsafe sex and the spread of syphilis and HIV in young men who have sex with men shows us that we are failing to continue to make progress in HIV prevention. Men who have sex with men are about 50 times more likely to be HIV infected than other men. There's a lot that we can do. Having people know their HIV status makes a big difference. Once people know they're HIV positive, they reduce their risky behavior by about half, and they're also able to enter into care and treatment to protect themselves and their partners. We can improve the linkage to care so that everyone who starts treatment stays in treatment, and we can improve prevention with positives, working with people who are HIV positive to protect themselves, their partners, and their communities. And we can expand prevention programs to reduce risky behavior. HIV can be prevented.

We need to do more to succeed. Living in a time of fiscal restraint and of real questioning about what the appropriate role of government is, public health has a crucial role to play. Prevention is the best buy in the health sector. We can save lives, we can drive down healthcare costs, we can help Americans live longer, more productive lives with lower healthcare costs. But to do this, we need to focus our actions. We need to effectively monitor data. We need to establish clear priorities. We need to communicate those strongly, powerfully, and personally. We need to be strategic about affecting policy. There are plenty of challenges to running a public health agency day-in and day-out, and there are also wonderful opportunities, and we look forward to exploring those opportunities with you and helping all Americans live longer, healthier lives.

Thank you.

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