In time for last week's one-year anniversary of his election as the nation's 44th president, Barack Obama completed his roster for the nation's public health team. Now these critical players must work together as they battle a global flu pandemic and a host of other mounting public health threats—during a sluggish economy—while federal lawmakers have yet to agree on serious health reform.
What's the game plan?
Integrating medical care, public health will be overarching strategy of Obama's healthcare team
The Senate's unanimous confirmation of Regina Benjamin as surgeon general on Oct. 29 followed the earlier appointments or confirmations of Francis Collins as director of the National Institutes of Health; Thomas Frieden as director of the Centers for Disease Control and Prevention; and Margaret “Peggy” Hamburg as commissioner of the Food and Drug Administration. Representing different HHS agencies, these officials are led by Secretary Kathleen Sebelius, the former Democratic governor of traditionally red-state Kansas who was Obama's second choice for the position earlier this year.
If there is a common thread linking most of these leaders together, it is their experience working as health officers at the state and local levels. Together, they compile a team that Georges Benjamin, executive director of the American Public Health Association, described as “the strongest we've seen in years.”
And a collaborative approach will be essential in addressing some of the nation's most difficult public health challenges, according to Robert Pestronk, executive director of the National Association of County & City Health Officials. “I'm really hopeful because there appears to be a sincere commitment to engaging with the local public health community, understanding the resource constraint and breaking down the walls that can sometimes exist, either psychologically or among local, state and federal government officials,” Pestronk said of the Obama administration's team compared with the Bush administration's. “I think the people who are in these positions now understand there are different roles for each to play. And for people in each type of government to play those roles well, they need to be working together, carefully listening to one another, and making good use from what they hear from one another” to serve the nation, Pestronk said.
Close involvement with local communities is a familiar practice to these public health officials. Regina Benjamin, a MacArthur Foundation “genius” grant recipient who in 1995 became the first physician under age 40 and the first African-American woman to be elected to the American Medical Association's board, is the founder and CEO of Bayou La Batre (Ala.) Rural Health Clinic.
Collins is a physician geneticist who brings both his expertise as a researcher and his leadership experience to his role. Known for leading the Human Genome Project, Collins served as director of the National Human Genome Research Institute at the NIH from 1993 until 2008. He was awarded the Presidential Medal of Freedom in November 2007 and the National Medal of Science—the highest honor bestowed on a scientist by the U.S. government—on Oct. 7 in a ceremony at the White House.
Before being named director at the CDC, Frieden was commissioner of the New York City Health and Mental Hygiene Department for seven years and earlier had spent five years in India, where he helped with national tuberculosis-control efforts.
And Hamburg is a Harvard Medical School graduate who became deputy health commissioner at the same New York health department before she was promoted the following year to commissioner, a post she held until 1997.
According to the APHA's Georges Benjamin, this group has a solid understanding of both medical care and public health. “The Bush administration certainly had good people as well,” Benjamin said. “The difference will be the fact that this administration is very focused on health policy—all the way from the president on down. This is a priority for the president, and I think that's a good thing,” he added. They're focused on ways they could improve the health of individuals and the health of the nation.”
These leaders will need a firm grasp on both medical care and public health, given that these two worlds are intertwined and affect each of their respective agencies. As surgeon general, Benjamin oversees a nation in which obesity accounts for 10% of all medical spending and where obesity-related costs were as high as $147 billion last year, according to research by RTI International and the CDC this summer (Aug. 3, p. 10). The day after those estimates were released, Sebelius attended the CDC's Weight of the Nation conference, where she highlighted that obesity increases the risk of heart disease, certain cancers and stroke. And given that the American Cancer Society estimates that all cancers combined cost the American healthcare system about $93 billion a year, Sebelius said, ending obesity would save the nation 50% more dollars than curing cancer.
For Frieden, the global H1N1 flu pandemic remains the CDC's top priority, especially as vaccine-distribution efforts remain slower than the Atlanta-based agency had expected (Oct. 26, p. 6). Last week, Frieden sent a letter to state and local health officers in which he said demand for the vaccine in communities still exceeds the supply that the CDC has received from manufacturers. As of Nov. 6, there were 38 million doses and the CDC expects another 8 million doses this week. “While vaccine supplies are still limited,” Frieden wrote in his Nov. 5 letter, “any vaccine distribution decisions that appear to direct vaccine to people outside the identified priority groups have the potential to undermine the credibility of the program.” Those priority groups continue to be pregnant women, caretakers of infants less than 6 months old, healthcare workers, children and adults with illnesses such as asthma or diabetes, and people under the age of 25. The vaccine issue also has strong relevance for the NIH, which conducted this year's clinical trials of the H1N1 vaccine, as well as the FDA, which approved the vaccines in September.
One of Collins' major tasks will be shepherding the national effort to produce new forms of care out of federally funded stem-cell research. A ban on such funding was lifted by Obama earlier this year (March 16, p. 6).
Hamburg's agency also shows the integration between public health and medical care through its Safe Use Initiative, a program the FDA rolled out last week to reduce preventable medication errors. Still in the early stages, the program would require FDA officials to work with healthcare professionals and other stakeholders to identify drugs, drug classes and therapeutic situations that are associated with high levels of preventable errors and harm.
The work of the FDA is valuable to groups such as the National Association of Psychiatric Health Systems, the Washington-based organization that represents for-profit behavioral health providers. Mark Covall, the association's executive director, said there has been a “constant, growing awareness” during both the current and previous administrations that mental health and substance abuse fit into the broader array of medical care.
Covall also said Joshua Sharfstein, the deputy director at the FDA, is a solid choice. A pediatrician, Sharfstein is the son of Steven Sharfstein, a psychiatrist who is the president and CEO of the Sheppard Pratt Health System outside Baltimore in Towson, Md. Sheppard Pratt is a not-for-profit behavioral healthcare organization that treats children, adolescents, adults and older adults.
“FDA is important to behavioral health because medications is one of our major technologies,” Covall said. “Making sure those move as quickly as possible is key. Josh will be added-value.”
Behavioral healthcare is a segment that has a place in prevention and wellness efforts, according to Chuck Ingoglia, vice president of public policy at the National Council for Behavioral Healthcare, which represents about 1,400 community-based mental health programs. “The administration's emphasis on chronic-disease prevention is an admirable one, and one that we share,” Ingoglia said, “particularly because not only is mental illness a chronic illness—as well as addiction disorders—but people with mental disorders tend to have other chronic disorders.”
That's why some of the administration's other public health selections are of even greater importance to groups such as the National Council and the NAPHS.
These appointments include Pamela Hyde, Obama's choice to become administrator of the Substance Abuse and Mental Health Services Administration, and Sherry Glied, who was selected to become assistant secretary for planning and evaluation at HHS. Hyde served as the secretary of the New Mexico Human Services Department since 2003, and Glied is professor and chairwoman in the health policy and management department at Columbia University's Mailman School of Public Health. There's also Mary Wakefield—named one of Modern Healthcare's Top 25 Women in Healthcare earlier this year—who oversees the Health Resources and Services Administration. Together, Ingoglia explained, HRSA and the CDC received funding from the American Recovery and Reinvestment Act of 2009 for prevention efforts against obesity and smoking.
“The two centers have responsibility for tracking health disparities,” Ingoglia said. “We're of the mind that the incredible morbidity and mortality among this population should be considered a health disparities population.”
As Obama's public health officials tackle these and other issues, they will inevitably encounter the same challenges that previous administrations faced, such as funding constraints. For example, President George W. Bush requested a total of $7.1 billion in emergency funding for pandemic flu-preparedness activities in late 2005—of which $6.7 billion was intended to implement the HHS Pandemic Influenza Plan (April 6, p. 6). But the plans were not fully realized.
This issue was highlighted in a federal hearing in Washington last week, where Rep. David Obey (D-Wis.), who chairs a House panel that controls funding for HHS, discussed problems with funding levels for national emergencies since that time. “Congress responded by appropriating $1.1 billion less than the president requested,” Obey said of Bush's 2005 funding request. Then, two years later, Obey's appropriations committee proposed nearly $1 billion in supplemental funding for pandemic preparedness, but the effort was unsuccessful. In January 2009, the committee again tried to boost funding, this time with a request for $420 million in the House version of the stimulus law, only to see the measure stripped in the Senate.
“Frankly, this committee—in my view—has had both a positive and negative effect on the issue of preparing the nation against the threat of pandemic,” Obey said as he began the briefing that also included Anthony Fauci of the National Institutes of Health, Frieden of the CDC and Nicole Lurie, the assistant secretary for preparedness and response. Pestronk of the NACCHO echoed Obey's assessment last week. “I think that the previous administration did lay a good foundation, but what we saw over time was the foundation erode,” Pestronk said. “There wasn't a consistent interest in supporting the preparedness work over time, particularly as it was related to the resources made available to state and local health departments.
And those are the departments that must deal with the nation's most pressing public health issues today, said Dan Hawkins, senior vice president for public policy at the National Association of Community Health Centers. According to Hawkins, these issues include chronic conditions like diabetes and high blood pressure, which relate to diet, obesity and lifestyle, as well as environmental conditions, such as improving air and water quality in America's cities.
“I think so much of the focus after 9-11 was on a terrorist attack, and I'm not going to sit here and say that was a wasted effort,” Hawkins said. “But I think this team will focus more on the hazards and dangers that affect us day-to-day as a country that are real.”
Pestronk said there needs to be sufficient and sustainable funding (Oct. 19, p. 28) to build a stronger public health infrastructure throughout the country—something that he worries will be especially difficult in the current economic climate. Nevertheless, he thinks the team Obama has chosen is well-prepared for the tasks ahead.
“I think they understand that health is physical and mental and public and economic and educational,” Pestronk said. “I think they do get it.”
—with Matthew DoBias
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