Dr. Thomas R. Frieden became the director of the Centers for Disease Control and Prevention (CDC), and administrator of the Agency for Toxic Substances and Disease Registry in June 2009, following a seven-year stint as New York City Health Department Commissioner. He has worked on tuberculosis issues in New York and India and spent 12 years with the CDC earlier in his career.
What management lessons did you learn while serving as New York City Health Commissioner?
One was the importance of data. This is really core. We live and die in public health based on how good our data is. Take tobacco control in New York City. I was surprised to find in the epidemiologic information that tobacco was still, by far, the leading preventable cause of death. When I was approached for the job I said, "I've looked at the epidemiology and it's clear that tobacco is your number one problem and there's a way of addressing tobacco that's not being done. It will be very controversial. Are you willing to do that?" Mayor Bloomberg said, "Absolutely, yes." The first thing he did was increase the tobacco tax.
Next, I proposed we make all workplaces smoke free. Data showed that going smoke-free would save over 10,000 lives. We also showed that the level of pollution in a smoky bar was more than 50 times worse than the level of pollution in the most polluted place that people in New York City can think of: the entrance to the Holland Tunnel. It was a simple study done with a low-cost tool.
In six years, tobacco use went down by 25 percent among adults and 52 percent among kids. When the city started facing huge budget cuts, I was excoriated by the city council for spending so much money on anti-tobacco advertising when we had to reduce our staffing levels. Yet surveys allowed me to say, under oath, with complete certainty, that for every $1 million in anti-tobacco ads we spend, we save at least 1,500 lives. The data at every point in the effort was essential to define the problem, delineate the solution, determine if what we did was working and defend the program. Another example was the community health survey. We did a 10,000-respondent, random digit-dial survey in 43 neighborhoods. We learned that our educational activities about West Nile virus were completely ineffective. Instead, we just handed out mosquito repellant at senior centers. We were able to cut out an ineffective program and pay for the survey by reducing the ineffective educational efforts.
Another lesson was the importance of focus. There is a wide variety of issues in public health — communicable diseases, environmental risks, injuries, chronic diseases. You have to manage them all or they will manage you. You have to focus on where you can make a difference.
Where do you get your program ideas and how do you work to involve employees?
You build on the culture of the organization and support the front-line staff and managers so they’re free to suggest, “I think there's a better or cheaper way to do this.” We opened public health offices in the three sickest, poorest neighborhoods in New York City — Bedford-Stuyvesant, Harlem, including East Harlem and the South Bronx. We canvassed the community asking, “What's your biggest problem?” This may not be the greatest thing to talk about but, resoundingly, we got back something we never would have expected: rat control. Widespread infestations gave people a sense their community was not being attended to or valued. It's not so easy to get rid of rats. But through a multi-year effort, we found the best urban rodentologist in the world and piloted new ways to implement programs. The approach seems to be having significant success.
Great ideas are everywhere. We accomplished a lot in New York, but very little originated with us. California had gone smoke free previously. Denmark had eliminated trans fats. The menu labeling idea was around for a long time. We did a lot of innovative things, but we didn’t have to invent a new mouse trap.
How do you manage and motivate employees, and get their feedback?
I manage by walking around and interacting with staff. We’ve had great feedback resulting in better processes. Cash awards and bonuses are important. We also want to make sure that our evaluation system recognizes excellence. I highlight effective programs from around the agency, things that people may not know about that are exciting. But if managers don't address performance problems, it undermines morale throughout the federal government.
At CDC there's a real sense we're not here to worship what's known, but to question it. If someone gets up and gives a fancy talk they're really proud of, it's not rude to stand up and say, "So what? How is this going to help people?" We're here to have the maximum health impact, so that irreverence is important. We promote an atmosphere of openness and encourage people to bring up issues or problems. We have an internal blog and if people have concerns...bring 'em on, even if they’re challenging. Let's have free and open debate.
What are your top challenges?
Besides the budget, it’s that prevention is often invisible. Each year in the U.S. 40,000 people don't die because of the immunization program. Twenty million infectious disease cases don't happen. Fourteen billion dollars in medical care costs and $69 billion in societal costs are averted. Making that clear and maintaining support for programs are big challenges.
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