 Good morning and welcome to CSIS. I'm Steve Morrison, Director of the Global Health Policy Center here at CSIS, and we're delighted this morning to again welcome Dr. Thomas Frieden, Director of the Centers for Disease Control and Prevention to come be here with us at CSIS. He'll be discussing new thinking, new data on prevention today, and we're very eager to hear from him. In our own work here at CSIS, at the CSIS Commission on Smart Global Health Policy, we put a great emphasis on elevating prevention to a strategic priority of U.S. foreign policy approaches on global health and made the argument in the Commission report that we needed a big push ahead in building the case for prevention as a lead element and developing better data and analytics and more aggressive experimentation with new combination approaches on prevention. There's no better person in the United States today to speak on these issues than Tom Frieden here today. And the time is ripe. Under the Global Health Initiative, prevention has indeed been elevated. And under the pressure of worsening budgets, increased austerity and increased demands for concrete measurements, efficiencies and cost effectiveness, prevention matters more than ever before. I wish also to give special thanks and acknowledgement for the great help we've received from CDC over the last several years. Don Schreiber, who for many years headed up the CDC office here in Washington and is now dual-hatted as deputy on the Global Health Initiative as well as deputy of the newly created CDC Global Health Office, has been a great friend and ally and adviser to us. We're joined here today by staff who work with Dr. Frieden, Kathy Harbin, Marcia Vander Ford and Arlene Porcel-Farr and we're grateful for their help and for being with us today. CDC is a very special agency with very special capacities and a very special role in pushing forward our global health approaches. Tom Frieden in his testimony, September 29th, before the House Foreign Affairs Committee detailed all the many faceted ways in which CDC is able to bring its special assets to bear. And I think we'll hear more about that today. Tom Frieden is a man of many accomplishments as a public health leader, a person who has broken barriers consistently throughout his career, tested limits and shown considerable innovation and courage and done so in a hurry. He has a BA from Oberlin College, an MD and MPH from Columbia University, infectious seeds training from Yale. From 1992 to 96, he led the New York City efforts, the programs to rapidly control the tuberculosis outbreak including considerable MDR cases which were reduced by 80 percent. Beginning in 96 and for the next five years he worked on TV control in India, a program that reached over 10 million patients and saved over a million lives. 2002 to 2009 he served as the commissioner of the New York City Health Department, his home. His efforts to control smoking reduced teen smoking by 50 percent and overall numbers of smokers by 350,000 and inspired efforts across this country and many other cities and towns to bring much more effective controls and improve the healthy climate for people in restaurants and other establishments. New York City became the first city in the country to ban trans fats in restaurants, to rigorously monitor diabetes epidemic and initiate posting of caloric content in certain restaurants. Under his leadership he greatly increased colon cancer screening, eliminating racial and ethnic disparities in screening rates and he also pioneered community based electronic health records. In his spare time he volunteered to develop the Bloomberg initiative to reduce tobacco use, a strategic initiative that has been joined now with the Gates Foundation, WHO and others in the most important global effort to curb tobacco control, contract tobacco use. In this regard I just want to mention that on Friday, November 12th at 3.30 p.m. we'll be hosting a program here in which we'll be launching a paper authored by Tom Wojci of Center for Global Development commissioned by CSIS on Tobacco Control. We'll be joined we're hoping by some CDC officials on that panel and I invite you all to come. I also just want to mention this afternoon four o'clock Dr. Juma, the Pakistan Director General of Health, will be here to talk about things there. There are many directions that Dr. Frieden has moved to CDC. We've had the creation of the new Global Health Center. We've had his argument about winnable battles, six core winnable battles. We've heard much more detailed discussion about the unique strengths that can be brought to bear today to build capacity, to push on science, to expand the training and making use of the field epidemiological training program and many other things. Please join me in welcoming Dr. Frieden here today. Thank you very much Steve and thank you for being here. I want to particularly thank CSIS for having me here twice in short order and also recognize that this is really a unique and very exciting time. There is widespread recognition of the importance of global health. There is bipartisan commitment to making a sustainable and substantial health impact. And we are poised with new technological developments as well as new capacities around the world to achieve a great deal more. So it's an exciting time. The possibilities are wonderful. And I will argue in the next few minutes that prevention must be the core principle that takes global health to the next level. Our goal is very simple. Jointly it's healthier, safer, longer and more productive lives. And I think that reminds us that this isn't just about health issues. That health is integral to whether a community is vibrant and a community being vibrant will determine whether it's stable, whether it's productive, whether it has more or less strife and whether it can be a stable trading partner, let alone a source of potential infection or a dissemination of infection. Now the next slide is one that I have shown in other venues but the concept I think is an important one that we think of the levels of prevention. What are the things that we do that affect health? And at that most basic level are issues of fairness. Do people have an opportunity to grow up healthy? Do they live in safe homes? Do they have a fair opportunity to get a job, to get educated? Are they breathing in air that's clean? And at the next level are those things that are some of the traditional public health interventions, clean water, clean air, control of toxic substances. Do kids grow up lead free just by nature of breathing the air or crawling on the floors? There is also the issue of safe roads, a major issue which I'll talk about more in a bit. But these are traditional efforts and you can summarize these by saying these are the things that change the default value or to put it more simply you really have to work to not benefit from these interventions. You can for example drink only bottled water and not benefit from the fluoridation of the water supply but you have to work to do that. At the next level are the long lasting protective interventions, vaccines traditionally but also mass drug administration for tropical diseases, indoor residual spraying, bed nets and of course now very encouragingly circumcision to reduce the risk of HIV among men at least. These are areas where you need a light touch but you can have a long lasting impact. One level above those are the clinical interventions, things that require ongoing care, tuberculosis, HIV, high blood pressure, high cholesterol, diabetes, things that require a functioning health care system that has to be there day in, day out around the year. And at the highest level are the counseling and educational interventions, use a condom, get more exercise, eat healthy. These are generally arrayed from the factors that make the most difference to the factors that make the least will make the most impact by reducing poverty, will make the most impact by having safe water rather than encouraging people to boil water or putting fluoride in the water rather than encouraging people to use fluoride rinses. And yet that doesn't mean that we only work at the bottom levels of that pyramid because sometimes we only have the higher levels and a program that's going to be optimal is likely to work at many levels and that's a frame to think about what's possible in global health. Now, just as we've thought about for the United States what are some winnable battles in prevention, we've thought about that for global health as well. And leading that list is to sustain and extend the progress with immunization. Immunization is a wonderful, wonderful technology. We are very close to the finish line. In polio eradication we've seen substantial progress in the past year in Nigeria and in India but we're seeing lots of flare ups and importations and it reminds us that we are all connected by the air we breathe, by the water we drink and by the connections that we have through air travel and others so we need to be focused on getting over the finish line in polio eradication and continuing to extend our progress with measles. 12 million kids didn't die in the past decade because measles immunization has been much more effective. This is a remarkable success but it's frail. We've seen outbreaks of measles in Sub-Saharan Africa in the past year so we know that continuing that effort is critically important. Second, to substantially reduce mother-to-child transmission of HIV and I'll talk about that more in a bit. Third, to eliminate lymphatic filariasis in America as this is doable. Fourth, tobacco control and fifth, reducing motor vehicle injuries. Now we are in, at least in this country and in much though not all of the world we are in lean years and we will be for a significant period of time. So while we have to always recognize that as health professionals our strongest argument and that which we should rely on most is that it's about saving lives and helping people live longer, healthier, more productive lives. We also shouldn't be shy about saying that prevention is the best buy in the health sector. And if we could even have that ounce of prevention for pound of cura, if we could even get one-sixteenth of the budget we'd be very happy for prevention. Healthier communities are more productive. Prevention also increases the health value that we get for our health dollars. You know when you think about how health care is assessed it's assessed in lots of interesting ways. But rarely do you see the question asked what is the return on investment in terms of health for the dollars that we're spending for health care or health programs. And we can drive down per capita health care costs. Now several decades ago working in a community in a remote area in Central America I worked with a group that was building latrines. This is thankless work, believe me. And we found that it was possible to build latrines and actually get people to use them. And some of the things that were important in doing that and having those latrines be effective were very simple. They needed to be at the bottom of the hill, not at the top. They needed not to be right next to the well that was being built at about the same depth. That would not be a good idea. And a simple thing like sanitation can make an enormous difference. And because it is not polite to talk about in polite company it is massively under emphasized in global health but we need to do better. Every dollar invested in sanitation pays for itself many times over. And not only are there infrastructural improvements clean water, clean sanitation but there are also some fixes that are low technology and very effective. Research done at the CDC shows that having a simple vessel that people can't put their hand into and simple bleach powder and teaching them how to use it can reduce the rate of diarrhea by 20 to 30 percent and it is now a core component of a basic package given to HIV positive people and their family all over Africa and that is resulting in many, many fewer episodes of severe illness, children surviving who would not survive otherwise and an example of how with a relatively modest investment and a simple technology it is possible to make a big difference in prevention. In HIV we know that people who know their positive are much less likely to spread infections to others and the only way you can get services is to know your positive. So knowing your positive, knowing your status becomes both a prevention strategy for the community in terms of spread of HIV and a prevention strategy for the individual in terms of progression to AIDS which is preventable. This is a study done with leadership from CDC and partnership with Kenyan authorities on the Kenya AIDS Indicator Survey and this survey is very interesting and important to us because it illustrates how important and transformative data can be. Until this survey, if you had asked policymakers in Kenya they would have said, no, I think we have a good sense of who's positive, most people who are positive know it but what the survey found definitively was that nearly 85 percent of adults didn't know they were HIV infected and therefore couldn't change their behavior, couldn't get care and this drove a change in policy. Male medical circumcision is a new technology that is now well recognized. For a decade or more there was debate about this. There was an ecological correlation between areas that circumcised and lower HIV rates in Africa and it was pretty close correlation. It looked like it was about a twofold reduction in HIV risk in communities that had circumcision but there was always with ecological comparisons the risk that it was wrong and so randomized controlled trials were done and they were definitive. Male circumcision reduces the risk of HIV by about 60 percent reduces female to male risk and the presumptions that people have are often wrong. People say well you'll never be able to scale this up. How could you ever convince men to get circumcised? Well it turns out there is an enormous demand for circumcision. People understand that it's protective and Kenya for example last December performed 100,000 circumcisions in the one month. It is possible to scale up circumcisions but that is going to be done effectively in several different ways incorporating into the healthcare system is one but it will not reach scale. Incorporating into neonatal care is something that can be done it will help the next generation but camp models of surgery like cataract surgery which has been done very effectively and scaled up will enable a rapid scale up of male circumcision. That means though that we need to also scale up testing we need to ensure that female partners are tested and counseled and provided treatment and an exciting new area is serodiscordant couples. So if we identify a couple where one member is positive we know that treating that indexed couple will reduce the risk of HIV in their partner by about 90 percent. That's a big reduction and it emphasizes that treatment and HIV in prevention are not at odds. They don't need to be at odds. It can in fact be synergistic that treatment is prevention. Now mother to child transmission is an example of a glass being around half full or around half empty depending on how you want to look at it. We globally treated about half of HIV infected women last year. That's a big increase from 5 percent just a few years ago but it's shameful when we think of how many children continue to be born every year HIV infected when that could be easily prevented. I visited Nigeria a few months ago and met with a group of mothers, HIV positive mothers and their children and one of them held up her twins. They were nine months old, they were HIV free and she said I can't get my husband tested but I got tested, I got treated and my children are going to grow up healthy and that kind of transformation is something that is occurring every day all around the world. More than 100,000 babies were born HIV free last year because of PEPFAR interventions. Malaria. Malaria kills around a million people a year overwhelmingly in sub-Saharan Africa overwhelmingly children. It is the second leading cause of death in sub-Saharan Africa and causes very substantial health losses, economic losses as well. It's not just economic losses for society it's also an enormous burden on the healthcare system. It can be a third or more of all visits to health facilities, a half of all of the blood that's available. So if you reduce malaria substantially not only do you drastically reduce deaths among children by 20, sometimes 30 percent but you also free up that capacity in the healthcare system. You free up that capacity as with HIV treatment not just by reducing the number of patients but by increasing the resilience of the healthcare staff and you also have an enormous effect on school going, on mortality, with impregnated bed nets drastically reducing infant mortality. I visited a small community in Ethiopia where there had been about 100 cases of malaria diagnosed in just about 1500 to 200 people present in that community year after year and for the past four years with bed nets and rapid treatment there had not been a single case of malaria in that village. That meant that the health workers had time to spend with other people. It meant that they had a sense of success that it's possible to make a big difference in malaria and the challenge here of course is going to be persistence continuing the effort long after the headlines have gone. Childhood pneumonia. Treatment is very important and can reduce deaths by a third or more but there are also critically important ways to prevent childhood pneumonia. Exclusive breastfeeding for six months saves money for the mother, helps the mother stay healthy and also reduces pneumonia by about a sixth to a quarter. Reducing indoor air pollution both tobacco smoke and from unclean cooking, cook stoves. Better cook stoves can reduce pneumonia by 20 to 30 percent and they're a triple win. They protect the environment, they improve health and they improve security and economic well-being of families. Scaling them up is a major priority and something which Secretary Clinton has announced a new initiative on and we're looking forward to seeing that as one of the core components of scaling up prevention. Vaccination. Hib and conjugate pneumococcal vaccination are new vaccines, they're being implemented and they are major potential wins. Tuberculosis treatment. In tuberculosis treatment is prevention. The cost of treating a patient with drug susceptible tuberculosis in India is about $10 or $20. The cost of treating that person in the U.S. can be a half a million dollars or more. We are all connected by the air we breathe and the spread of drug resistance anywhere in this world is a threat really to all of us. I used this slide and I think I told this story last time I was here so I didn't want to tell it again, but I cared for a patient in New York City in the 1990s from India and we spent over $100,000 to get him cured. It was very toxic treatment. He ended up having a lung removed. It took two to three years. It was very difficult and arduous. I was treated and I went years later by chance to his village in India where we were able to establish a treatment program that would have prevented his case of multi-drug resistant TB for $10. Tropical diseases which I hope will soon be able to call something other than neglected tropical diseases remain major causes of disability, death, and suffering around the world. And by rigorously evaluating the programs that we implement, we can optimize them and stretch them further. This is an example from Orissa, one of the poorest states in India where a rigorously evaluated trial was done looking at simple mass drug administration and you think everyone's going to want the medication. Well actually 42% of people got the medication when you just provided it. Well what if you add to that care of people with the complications of filariasis, wound management, and palliative care. You increase that to about 53%. What if instead of doing that in other communities you educate, you explain to people how important it is to take this medication. Well you increase pretty substantially to 75%. But if you do both of those things together you get a big, big synergy. And you get compliance over 90% for very little additional dollars. So we need not only to prevent, but we need to rigorously evaluate our prevention programs and optimize them along the way. Now I want to talk about how the world is changing in some very important ways. Five, seven years ago I wrote an article in the American Journal of Public Health called A Sleep at the Switch. Public health departments in this country were asleep at the switch from communicable to non-communicable diseases, and we weren't addressing non-communicable diseases effectively enough. And I think we are at risk of being asleep at the switch on global health as well. For the first time in world history more people live in cities than in rural areas. There are more people who are overweight than underweight. There are more deaths among adults than among children. And there are higher rates of the non-communicable diseases among developing countries than developed. And one of the many myths we have about non-communicable diseases is that they are diseases of affluence. They are not. They are diseases of poverty. And they are diseases of poor countries and they are diseases within most countries of poor people in poor countries. Non-communicable diseases now kill more people around the world than non-communicable diseases. They are also increasing as a burden and as a threat to socioeconomic development. They are driving up health care costs. Within 10 years, four times as many people will die from non-communicable diseases as from communicable diseases. And they affect the people, the poorer people, not only at a greater rate, but at a younger age. And I'm reminded of one of the most troubling public health officials I ever met who was put in charge of the highest priority program in his country at that point. It was malaria in Central America and he was leading that program very effectively. At the age of 35, he had a massive stroke and he became unable to work. Now this story actually, believe it or not, has a happy ending because they put him into a program that nobody cared about because it was a sleepy backwater that nobody cared about. And over the next few years, he gradually regained his power of speech and began running a very effective tuberculosis control program and became a model for Latin America and the world really in effective tuberculosis control. But the concept that we are in many countries losing many of our most productive people and heart attacks in their 30s and 40s is something that we need to adapt to and adjust our thinking. Now, 40 years ago, I just want to spend a minute on this, this is a striking, striking trend. 40 years ago, there were about 15, 16 million deaths among adults age 15 to 60 and there were about the same number of young children. Over the past 40 years, through many excellent programs, immunization leading the way, but care of diarrhea, socio-economic development, respiratory care, we've seen a substantial decrease in childhood deaths. So we're now down to around 8 million childhood deaths, far too many, but it's real progress. And what's happened to deaths among young adults, they have increased such that from the same number 40 years ago, there are now three times more deaths among young adults than there are among kids. That's a combination of the fact that the population is growing in that age group because people are surviving into adulthood and that the death rate is not falling nearly as rapidly as the death rate is falling among kids. This is not only HIV, this is a wide variety of health threats led by things like cardiovascular disease and injury which are eminently preventable. Non-communicable disease now kills far more people in developing countries than in developed countries and what you can see even in the low income countries a much higher rate of non-communicable diseases than of the infectious and nutrition-driven diseases and people in poorer countries are more likely to die prematurely from non-communicable diseases. So in high income countries only about 10%, 1 in 10 deaths of non-communicable diseases occurs in someone under the age of 65, it's almost 40% in the lowest income countries. Tobacco is now the world's leading single cause of death. It kills more people than AIDS, TB, and malaria combined and unlike those conditions which are decreasing it is increasing as a cause of death up to 8 million over the next two decades and probably doubling after that. In fact in the kind of number that's impossible to really grasp unless we take urgent action in this century 1 billion people by tobacco. Every time I say that number I think I must have miscalculated it and you go back and recalculate and it is in fact the case. So it is absolutely the highest priority in terms of reducing deaths around the world from non-communicable diseases and it's a winnable battle. Tobacco control interventions work, they're just not being used. We have here an implementation gap and we have a marker of good governance because not only does it save lives but it also saves money and it doesn't cost a whole lot of money to do. The World Health Organization released a strategy known as the Empower Strategy monitoring both tobacco use and tobacco control policies protecting people from secondhand smoke offering help to quit warning about the dangers of smoking and forcing bans on advertising promotion and sponsorship raising taxes on tobacco. If you do these five things you will reliably get encouraging results. However 9% not even 10% of the world's population benefits from any one of these key strategies. In New York City we implemented what we could at a local level. For 10 years there had been no decrease in adult smoking with fiscal crisis which is the leading predictor of whether people increased tobacco taxes tobacco taxes were increased and for the first time in a decade there was a substantial reduction in adult smoking. The next year we implemented the Smoke Free Air Act and smoke free places save lives and protect workers and we saw another substantial decrease. Fortunately we had implemented and established a monitoring system that allowed us to track every year what was happening with smoking and I will tell you that the most exciting time of my year was in early May when we got the results of the previous year's annual survey and we knew what was happening and I was eagerly anticipating a further decrease in smoking which happened and we then did the other thing that we could do at our level which was hard hitting ads they cost a little bit of money a dollar per person per year or two dollars per person per year hardly have the expenditure when you think about how much we spend on healthcare and we saw dramatic further declines in smoking such that we reduced the number of smokers by 350,000 saving at least 100,000 lives. Now Uruguay when the World Health Organization looked at every country in the world and said what's the status of implementing empower Uruguay rose to this top as the country which had by far the best tobacco control policies in the world and there was a simple explanation for that. The president of Uruguay at the time was an oncologist and he decided that they were going to reduce smoking so he did a series of things including smoke free the first country in the Americas to go smoke free comprehensively a comprehensive ad ban large pictorial warnings which Philip Morris is now suing them about cessation services and high taxes and this decline in just two years it's a 25% decline in just two years that's three times as fast as the decline I just showed for New York City and we look forward to seeing what will happen in the future which really shows how rapid progress is possible with these interventions which not only are effective individually but have important synergies so for example when the Smoke Free Air Act goes into effect what we did in New York City was to run hard hitting ads about secondhand smoke and what we found to our surprise was that many people made their homes smoke free we hadn't anticipated that but once people understood that they were not only harming themselves but killing other people with their tobacco they reduced their use unfortunately what we found nationally is that if you smoke your kids are virtually certain to be exposed to toxic chemicals we've looked at this and the Anne Haynes data set 98% of kids who live with a smoker have measurable tobacco toxins in their body predicting a higher risk of cancer so understanding that secondhand smoke kills and it doesn't just kill the smoker it kills people around now remember that initial pyramid this is an attempt to monetize that a little bit so I think of increased taxes as something that changes the default value or even the socioeconomic factors and you increase taxes and it doesn't cost you anything in fact it gains you lots of revenue even if smoking decreases it gains you lots of revenue smoke free laws cost almost nothing to implement sometimes some education or enforcement costs initially anti tobacco adds cost money and they might cost about $100 per life per smoker quitting quit lines cost a little bit more you have to pay for staff to be there clinical care costs a few thousand dollars if you do it in the context of clinical care now does that mean we shouldn't be doing smoking and clinical care no in fact this shows how dramatically different the two worlds of community prevention and clinical prevention are if you look at cost effectiveness from within all tobacco control interventions clinical cessation is at the bottom but if you look at clinical interventions to promote health tobacco cessation is one of the most cost effective of all it's more expensive to save lives one at a time than it is to save them thousands or millions or a community at a time and that's what community interventions do most people will report taxes as being in a comprehensive program the dominant reason for reducing smoking now I was thinking about road traffic safety as I got here in the car do you have a distracted driver law in Washington DC if you don't you need one but I was also thinking about a very wonderful TB specialist who I worked with for years and was one of the world's top expert in TB loved to teach was a rigorous demanding instructor but brought people to the next level when I was in India we had her come and teach our different cohorts of new doctors and she was wonderful at it and she was killed consulting on a TB program in Eastern Europe in a road traffic accident and that's a terrible loss to the world in fact road traffic injuries are the leading cause of death among Americans abroad and they kill 1.2 million people a year around the world injuring maybe 50 million or more and mostly young people and mostly vulnerable road traffic users mostly people who are walking or biking or riding vehicles legal interventions work and as with tobacco it's really a symptom of good governance it's an indicator of good governance are you able to control speed are you able to regulate roads are you able to get people to wear seat belts and not drive drunk it's not that complicated what will happen over the next 25-20 years unless we take urgent action is that road traffic injuries will increase from 22% of all deaths the 3.5% of all deaths they will become the fifth leading cause of death around the world they're already one of the leading causes of death in this country and yet we've had real progress with some interventions road traffic death rates are twice as high in low-income countries as they are in high-income countries evidence-based interventions work lower blood alcohol levels, seat belts child restraints, helmets, speed limits Vietnam is a real success story here from around the world they decided that people they looked at the data they had lots of motor vehicle injuries from motorcycles and from head injuries there were whole floors of hospitals that were full of people who had had severe head trauma for motorcycle injuries whole floors of hospitals full, two to a bed and they would send people home all too often basically to die because they didn't have the space they decided to do something about it and again that political will they had a very simple enforcement technique if you're not wearing a motorcycle helmet we take your motorcycle and surprisingly they got 100% compliance up from a single-digit compliance before so it's possible to make a big difference here speed limits also very important there are other things that are very important as well injury surveillance system so we can track what's happening find the hotspots our field epidemiology training program in Tanzania I believe I may have the country wrong one of the things that the trainees did was to document the burden of road traffic injuries in the capital city and that led to a new statute that required seat belt use in that city safer roads and vehicles including pedestrians and bicycle traffic reducing speed graduated drivers licenses this is what's happened in the US this is deaths deaths per 100,000 population and these are deaths per 100 million vehicle miles traveled and you see very substantial decreases in the US now cardiovascular disease is the leading cause of death globally 17 million deaths about a third of the total it's not only the leading cause of death among people over 60 it's the second leading cause among people aged 15 to 59 and it's the leading cause of death in the developing world everywhere other than sub-Saharan Africa where it's competing with HIV half or more of strokes and heart attacks are attributable to high blood pressure and it disproportionately working age adults and this is the kind of sad commentary on what we anticipate happening, no change many different risks attributable major risks physical inactivity obesity, high cholesterol tobacco, high blood pressure sodium is a leading contributor to high blood pressure after tobacco control the most effective and cost effective intervention may well be the reduction of sodium intake reducing the salt content of processed food could probably prevent about 14 million deaths over the past 10 years and there is an absolute linear correlation between both salt intake and blood pressure and blood pressure and mortality and the bad news here is that treatment isn't going to resolve the problem because your risk of having a stroke or heart attack and dying from it begins to go up when your systolic blood pressure goes above 115 and it doubles for every 20 millimeters of mercury that your blood pressure increases that means that before your doctor reaches for the prescription pad and hopefully tells you to take the right medicine if you want to know what the right medicine is I'll tell you later but before that even happens your risk of dying from a heart attack has doubled so that even if we were perfect in our healthcare system we diagnosed everyone with high blood pressure as soon as they got it we put them on good drugs they took the drugs and their blood pressure was controlled we would still miss around 40% of the cardiovascular events, strokes, heart attacks and deaths especially heart attacks and deaths we would have a higher proportion we would prevent so we need to do things that reduce blood pressure increasing physical activity will do that reducing obesity will do that but reducing sodium intake will do it as well in this country it's largely processed and restaurant foods about 80% of our sodium intake it's not what you put on at the table or in the kitchen in fact very interesting study you show that if you take half the salt out and tell people put as much in as you want they only put it in 20% back so we want to empower people put into your hand into your hand that salt shaker you can put it all you want but you can't take the salt out of the lasagna when it comes out of the oven if you bought it at the supermarket you have to have that control and if we gradually reduce the amount of sodium that we take in we won't notice the difference in the world in some countries which are leading in the UK they set ambitious goals they have met those goals in many cases Ireland France, Australia, New Zealand Finland also important models of reducing sodium intake and oil change is another way to really improve your health the island of Mauritius in 1987 realized that they were using palm oil this was very unhealthy they switched to soybean oil and they reduced their average cholesterol by 30 milligrams per deciliter that's a huge reduction it's an example of a society doing an oil change and making a huge difference now in the US we have a lot of artificial trans fat it got into our food supply because we thought it was healthier it turns out to be less healthy there has been substantial progress over the past few years reducing it we have a lot in our system and what's happening in developing countries in terms of processed food restaurant food new products in supermarkets what's happening we don't know because we don't have surveillance systems in place we know that in China for example in urban areas there is a dramatic change in dietary patterns and that change is likely to result in a lot of preventable illness and we could guide that so that it doesn't lead to this inevitable increase in non-communicable diseases the medical complications of obesity are extreme it affects virtually every part of the body it's expensive to care for everything from cancer to lung disease to heart disease to pancreatitis to depression cataracts are increased by obesity and encouraging environments that promote physical activity it's very important I meet periodically with colleagues from China and I remind them that Beijing used to be a bicyclist's heaven and we are now in this country spending lots of money to try to put in the bike paths that they have paved over with four lane highways or four lane roads over the past few years changing the way our environment is structured is going to be very important changing the way pricing of products is done so that healthier products are more affordable and more accessible is going to be very important simple things like encouraging stairway use is going to be important global cancer prevention is another area where we can make lots of progress lots of deaths, lots of preventable deaths and again think of that pyramid tobacco control could prevent a million and a half cancer deaths per year increased vaccine coverage could prevent about 600, 700,000 cancer deaths a year alcohol control policies could prevent about 300,000 alcohol associated cancer deaths per year increased fruit and vegetable consumption a million deaths per year clinical care could also prevent deaths about 650 close to a million from colon cancer and cervical cancer but these are not easy to scale up but possible prevention can allow us to break the cycle of transmission in HIV and other communicable diseases to prevent non-communicable diseases tobacco control sodium reduction, healthy oils to change the food and physical environment so that if we go with the flow we'll end up healthy regulatory and policy interventions and enforcement can improve road safety so that people can go to and from work and school without risking being named or killed and we can improve the clinical care of non-communicable diseases although community interventions are going to be more cost effective than clinical care now the world was riveted by one issue in the past few weeks in global health and it was the inspiring and miraculous rescue 33 miners trapped in Chile I think part of our challenge in global health is to translate that sense of altruism that sense of caring to the cold numbers that we speak of all too often in global health 5 million people killed by tobacco how many times does 33 go into that of 4 million people killed by lung infections pneumonia, 2 million by real disease 2 million by AIDS 1 million from tobacco from tuberculosis and malaria 1.2 million from traffic and still more than 100,000 from measles each year we can do that we can make people recognize that prevention is about people's lives long productive and healthy lives and prevention is the best way to get us there thank you Tom we have about 30 minutes I'm going to open up with one broad question then we're going to open to the floor we have microphones that we'll bring around and we'll take a round of different questions but my opening question really is how do you make the best argument to the American people in this time you stand at the intersection of both trying to engage the American people about their own domestic prevention agenda and to change that as well as the international agenda that you've talked about and we know that communication of the prevention priorities is a difficult one that inherently it's difficult to even though it's a very much a best buy it's also something that's less visible it competes with other priorities and we're in an unsettled environment right now in terms of our own politics our own level of uncertainty and fear uncertainty around the future for our own economy and also the question around support for international engagement and so the argument you're making at the face of it about prevention as a best buy things that we know work things that can bring major gains it seems to me those are winning arguments for a very very uncertain time but they're going to take special care to connect and I just wanted to ask you because of the special place that you occupy right now in your leadership position at CDC how do you see that how do you think about that I think this is one of the most important and most challenging questions that we have to address in the past decade the US has stepped up to the plate in global health in a way it never has before we've committed resources to PEPFAR to the malaria initiative to a series of other programs which are saving lives around the world and there are many ways to argue for global health I think they're valid and they're complementary one of them is that this is about our security if we stop outbreaks closer to where they emerge do we save lives not only do we save money but we protect ourselves the next outbreak might be something like SARS it might be something like H1N1 it might be something like H5N1 become much more spreading much more easily which could be a very severe influenza pandemic there are many possibilities for what could happen around the world the only thing certain would be the thing that we're planning for but planning and preparation will make all of the difference strengthening the world's capacity to detect and respond to outbreaks strengthens our own security you may have read about some of the new resistant organisms and there are many of them we have the risk of inherited the antibiotic era from the pre-antibiotic era we are at risk of ushering in a post-antibiotic era for some pathogens there are some cases of tuberculosis for which there is no treatment now there are some cases of what are called gram-negative rods the enterobacteraceae that are highly resistant and you may have read a few months ago news reports or the MMWR which reported that from the Indian subcontinent we've identified a few people who have very very resistant organisms in a type of resistance that can spread very rapidly now the fight against drug resistance is an unfair fight because it pits our brains against bacteria's genes and bacteria replicate so often and have the ability to change so fast that they are always going to be able to outsmart us unless we invest in both new tools and unless we preserve our tools so whether it's a drug resistant organism or a spread of SARS or influenza or Ebola or Marburg-like or West Nile-like situation a pathogen around the world it's in our interest to improve global health we will not be able to build a bacteriological moat around this country but if that doesn't convince you it's important to promote the productivity and stability of the countries that we interact with countries that are undergoing look at what happens with cholera we have cholera still in many parts of the world a reflection of failure to provide clean water and adequate sanitation when a country gets cholera a cholera outbreak it's devastating not only because it kills people and makes people sick but because they experience huge economic disruption and losses their stability gets less it's euphemistically called acute watery diarrhea we had a big outbreak of acute watery diarrhea so reducing the burden of infectious and non-infectious diseases will increase the productivity and the stability of our partners and reduce the number of people living in extreme poverty in a way that is destabilizing for countries and if that doesn't convince you the US does a lot to try to convince other countries to play well with their neighbors to relate well with us to recognize that the US is and should always be a force for good in the world that health diplomacy as it's called or soft power is very effective when we help a country get rid of an epidemic they recognize that the US has made a direct impact on their lives but ultimately though I think that all of those reasons are valid ultimately the argument that for me is strongest is the moral argument we have with modest increases in resources we have the ability to save millions of lives and as a great country that's something that I think we have not only an ethical obligation to do but I think that as people learn about what our taxpayer dollars are doing around the world we'll be very very proud of thank you why don't we open the floor and what we'll do is take three or four questions please identify yourself be very brief and we'll come back for a second round Lois here and then Sam and then we'll come over on this side thank you thank you I'm Lois Pace from American Cancer Society Department of Global Health thank you for your thorough review of the global burden of NCDs and what could be done to address them and also for your leadership in tobacco control my question is around the upcoming summit at the UN the NCD summit scheduled for September 2011 and we just wanted to know what CDC is doing to prepare for the summit and also what you need from those of us in the community who have been working globally on NCDs for a number of years and have access to stakeholders and solutions that are around thank you thank you Sam Sammy Lodini Jones HHS two quick questions one of the one question they're actually related let me frame them into one question one long question instead of two quick questions you get one long question from the from PEPFA and HIV globally one is that you need you need a commitment from the government and the other one okay let me stay with that one question and we've talked about how you persuade the US government the other component is how do you persuade foreign governments I know most of your visits you actually talk mostly with clinical people ministers of health those are easy to convince but how do you convince the heads of state that people will make decisions that prevention is a critical component of what they have to do yeah Jim Shelton USAID I also want to compliment you on your good public health approach and the structural what I would call structural interventions my question though is actually about your pyramid because I did notice that you put the behavior at the top and yet in your example about tobacco control you actually showed that the behavior change was about if I got it right about 400 times more effective than what was on the next year which was the clinical intervention and one reason I'm raising it is I actually thought that on your points about HIV you were a bit light on the behavioral sort of components of HIV given the nature of the epidemic and what we know about what works great so I think in terms of the non-communicable disease summit coming up less than a year from now we have to I hope focus on the interventions that are going to make the biggest difference I think sometimes we conflate two different ideas one is does something work and the second is does it make a big difference and I think this is the case in the US as well where we may have interventions that are very effective but they're not scalable or they're not scalable for the kind of resources that we're likely to have any time in the near future so thinking of the interventions that are likely to make the biggest difference is very important focusing on that is important it would be possible to squander the commitment to global NCD control by focusing on the lowest impact interventions in terms of how to get governments committed I think that nothing succeeds like success I moved to India in October of 1996 and in that month India vaccinated for polio against polio more than 100 million children and their number of polio cases plummeted and everywhere in India you see the survivors of polio disabled and suddenly not just the health sector but the political sector said wow we can succeed in something in health and that paved the way for a lot of the progress that the government was able to do in tuberculosis control which in many ways is very challenging polio you can increase routine vaccination you can increase AFP surveillance which can allow you to target interventions you can do the national immunization days in TB you have to have the whole healthcare system working day in and day out to diagnose and treat people so it's a much harder situation and yet you had given the government a sense that they could do this, they could succeed and I think governments all over the world are looking for successes and that's critically important in terms of the pyramid I often get that question and I think and in fact some of the versions of it make clear I think that what the anti-tobacco messaging does effectively is change the social norm around tobacco and I think of that not so much as a one-on-one counseling intervention but as an intervention that changes the context within which behavior occurs think about what happened in the US in the past 50 years or even 30 years we changed from a culture in which it was common for friends or acquaintances to ask would you like a cigarette to a culture in which he asks do you mind if I smoke that's a huge cultural change and that's the context that contributes to the behavior now as a doctor working in New York City in the 1980s I cared for hundreds and hundreds of men dying from HIV and I saw a dramatic change in sexual behavior of the gay population in New York City with a substantial reduction in the number of partners and a substantial increase in safer sex that is disappearing in this country a combination of people saying I can just take a drug for it people who didn't grow up seeing their friends all die and the all too human capacity to rationalize whatever course of behavior were intent on taking so there is a difference I think between mass communication and individual communication efforts and for each of them you have to look at two things one does it work and the second is it scalable so in this country the CDC spends lots of money supporting state and local governments to do HIV prevention and one of our real lessons is that even though targeted one-on-one individual counseling can make a difference it can be an effective program among the highest risk HIV negative people is very very difficult on the other hand scaling it among HIV positive individuals is very possible every infection with HIV starts with someone who is HIV positive and if we can increase the number of people who are aware of their status engaged in care and involved in counseling we can drive down infection rates we think what we want to do what's most important is that we rigorously evaluate it because we're not certain of what the implementation of this will look like in the field we hope that we'll be able to monitor incidents in a real way in HIV and use real rigorous evaluations of our programs to get the results we want to get because ultimately our goal isn't to do this program or that program it's to get results not necessarily only by rigorously evaluating not only what we decide to do but how it's working in actuality Am I to take it from your answer the question about the summit the NCD summit that your answer on biggest impact interventions would be the first answer would be tobacco that we should be as we look forward to next September that should be the top item of a coordinated approach is that fair I think so I think tobacco we're looking for others blood pressure reduction primary prevention of high blood pressure salt if you include in non-communicable injury certainly would include road traffic there injury is kind of the Rodney danger field of public health it gets so little resources and attention relative to the burden on society with health and economic and there are interventions that work look at the kind of success that we've had and the numbers I showed for the US positive as they are are nowhere near as impressive as the number for some of the Scandinavian countries which have committed to getting to zero that's their concept get to zero road traffic fatalities through a comprehensive approach they drink just as much they drive just as fast no safer believe me and they have one third the death rates that we have from motor vehicle injury so success is definitely possible in these areas thank you gentlemen in the back here and we've got a couple of other hands that have been thanks Steve and Dr. Frieden again appreciate your candor your openness and your willingness to answer some hard questions from a lot of people here and on the Hill I'm Jeff Meir I'm with the Public Health Institute and my question today has to do with maternal mortality the recent MDG summit there was a lot of discussion about maternal mortality being the one of the development goals that has probably achieved the lowest progress so far and the one that's least likely to be achieved by 2015 and yet that is an area where there is a lot of good evidence about what works what we already know how to do interventions that the United States has led on for years and years particularly in reproductive health and family planning where we have already a leadership role what do you as head of CDC see as your leadership and your responsibility in terms of both global work and encouraging others in the U.S. government to continue our work thank you. Thank you Jeff there's another person right. Jill Gay lead author of what works for women and my question for you is a follow on to Jeff's which is for women living with HIV who become pregnant the issue of unwanted pregnancy and also the recent WHO just released guidelines that say if a woman's CD 4 count is above 350 then she only needs treatment during her pregnancy and breastfeeding and then should be taken off and there's a NIAID study that started a few months ago to see what the impact would be on women rather than just preventing transmission and if you could comment on the ethics of that. Thank you. Judy. I'm Judith Coffman an independent consultant Dr. Frieden underlying much of what you say is of course the need for strong health systems and that includes not just the professionals who work in the field but supply chain how people get to clinics how they're served to me that's an even harder sell to those who fund because it's the unglamorous work and I'm wondering how you can link prevention what we're doing in treatment but to the overarching thing of how do we build stronger systems. Thank you. Let's take one other question right here. Is that working that microphone? Hello I'm Jerry Martin the director of the health sector at DAI and in the last year CDC has issued procurements for international technical assistance some of them very large ceilings half a billion dollars another one for 200 million dollars for global epidemiology services I'd like to know how does that fit into your global health center strategy and also since those are not those are ceilings is there actually the kind of funding and funding to follow up with the goals of those procurements described great so let me start with discussing a little bit about the global health initiative which I discussed more last time I was here so I didn't go into any great detail here but really is important for many of the issues that were raised the global health initiative is to address your question the attempt to combine a focus on outcomes with a focus on strengthening systems I think one of the problems with strengthening systems is that it means many different things to different people and we need to make it specific enough in the field and in our communication so that people can understand yes this is really important it might mean ensuring that there's a way to diagnose conditions so you can find an outbreak to stop it it might mean making sure that there are drugs in the clinic so that people are treated it might mean that the public health institution of a country is able to track their own problems to optimize resources and save money so there are many things that health system strengthening means and I think that one of the core principles of the global health initiative maybe the core concept is this combination saying that just as treatment and prevention don't need to be antithetical in HIV health system strengthening and specific health outcomes don't need to be antithetical in global health we in fact need to have stronger systems but you don't have stronger systems in the abstract you have stronger systems that deliver specific programs and in that same way that success breeds success a system that's able to deliver services effectively is able to become stronger as well you strengthen systems by doing things well so I think this is a harder sell but we can understand I think that it's a way of doing it better, cheaper and more sustainably if we do it right and communicate it right within the global health initiative maternal and child health is a core principle strengthening and reducing gender inequalities looking at maternal mortality really as a leading indicator if not the leading indicator of how responsive a health system is I would take some exception to your statement that we know what works in maternal mortality reduction we certainly know that family planning works because the maternal mortality risk of a pregnancy that doesn't occur is exactly zero and there is an enormous unmet need for an unmet desire for family planning around the world and this is something that not only the US but host governments and other donors and other organizations need to address and need to address much more effectively than we can than we have so far because we can do so the government of Ethiopia I think will have enormous progress in this area they have decided that they're going to use long acting reversible contraceptives for any woman who wants them and they have a plan to provide millions of women with implantable long acting contraceptives using lay health workers and they're seeing the demand so high this is about empowering women to have control over their lives and I heard in my travels in several continents over the past year I heard the same story over and over again which is basically that women need a method of contraception that will not be objected to by their partners and that the implantable contraceptives are a new technology which will enable that beyond that reducing maternal mortality faces I think some real challenges we know of some things that are really important we know about safe birth referral systems access to blood in even this country often lack of access to blood fast enough is a leading cause of maternal death and that's even more the case in many developing countries transport the presence of health care workers at health facilities in Tanzania we reviewed one program where they had gone into hospitals and done a simple analysis and the labor and delivery suite was closed from 4 p.m. to 6 a.m. if you had an emergency then you were out of luck so simple and workflow and blood supply can make a huge difference I think we need to rigorously look at what works to drive down maternal mortality I think there are some valid debates and disagreements and we need to study them and learn one of the challenges is monitoring maternal mortality fortunately it's not as common as infant mortality that also means it's more challenging to document to decrease in maternal mortality and one of the things that undermines our ability to do that is the lack of accurate vital registration information from around the world it's shameful that most of the world is born and dies without any legal record of their existence and having at least in some areas vital registration systems that are accurate could go a long way to helping us assess whether maternal mortality reduction initiatives are working based on I'm in a little bit of a minority view based on my read of the literature and experience in the field I think that we have under emphasized scaling up emergency obstetrical care particularly caesarean sections and other involved care and if you look at Mozambique, Tanzania and a few other countries that have used surgical technicians to do caesarean sections in remote areas they've gotten good results but the met need is still very low so looking at met need as a core indicator of how we're doing we have you know like so many things we have under nourished people and we have obese people we have areas where fewer than one in a thousand women get caesarean sections and we have parts of the world where more than half of women get caesarean sections and neither of those are healthy options and in terms of your question about treatment of pregnant and child bearing age women to reduce maternal child transmission and the ethics of stopping treatment in women who have um CD4 counts above 350 and are not breastfeeding in Africa we see many situations where transmission is occurring that could be easily prevented and we need to continue to scale up maternal child transmission prevention this is not easy overall there are many countries that have rates of attended births in the single digits and that makes it very challenging it is not ethical that there is not enough money to treat the conditions that we would like to treat around the world but one of the things that I think is worth looking at and just in touch with some of our staff to look at this um last night is the issue of the relative cost effectiveness of treatment of pregnant women because most pregnant women in developing countries have a high likelihood of becoming pregnant again and giving full heart rather than a limited regimen may result in some short term increase in costs but long term savings if you reduce resistance and reduce infection rates further in the infants so this is something that I think we need to look at very carefully um traveling in Ethiopia we saw women were supposed to come in for care but didn't at time of delivery and so the risk of transmission was much higher and we need to look at that recognizing that resources are not unlimited but that we should be able to drive down maternal child transmission substantially more than we already have and finally the way CDC uses task orders is to establish an umbrella contract so that we can have specific jobs done the ones that you're referring to the larger one was specifically about focused on PEPFAR and track one transition and um that term which I didn't know a year ago so for given if you don't know is the concept that we're in countries that have large PEPFAR programs where we've been working largely with international partners we are bringing them to national partners now CDC already spends about 45 cents on the dollar on national partners ministries of health local NGOs faith-based organizations that are in country uh we would like to see that increase to around 60 percent or more over the next few years but it is going to take work to strengthen the local partners so that they can do that and this task order is to do specific things to strengthen the local partners to do that so it may look like it's paradoxical and increasing our support for non-indigenous organizations but actually it's a route to increasing our ability to rely on and report to congress reliably on the performance of those organizations it represents about four percent of our PEPFAR commitment even if it's fully operationalized over the next five years which is the term of the contract thank you we're at the end of our hour and this has been an extraordinarily rich discussion I think you've given us Tom an enormous amount to think about and I want to thank our audience for coming and for great questions and give you the last word I told you about the woman whose twins had been saved from HIV by the prevention programs in Nigeria what I neglected to tell you was that she was carrying the twins and they had on an outfit which made my blood run cold they were wearing a sweatshirt that read Lucky Strike and she had purchased it in the market and this to me epitomized the challenges that we have we have to protect this generation and the next from infectious diseases while also warding off the impending epidemic of non-communicable diseases through prevention thank you very much thank you