CSU 32/2009: DOLL AND HILL ON SMOKING AND LUNG CANCER/ THOMAS FRIEDEN, NEW HEAD OF CDC
|Tuesday, 19th of May 2009|
THOMAS FRIEDEN, NEW HEAD OF CDC
Doll and Hill are separated from Frieden by half a century, but united by their interest in tobacco and smoking. It was the New York City Health Department, under Dr Frieden's leadership, which led to the smoking ban in bars and restaurants.
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1) DOLL AND HILL ON SMOKING AND LUNG CANCER
Rarely has a ten page article caused such an impact as 'Smoking and Carcinoma of the Lung: Preliminary Report,' published by Richard Doll and A. B. Hill in the British Medical Journal in September 1950. The authors carefully review, and demolish, the alternative explanations to a causal relationship between smoking and lung cancer.
'Consideration has been given to the possibility that the results could have been produced by the selection of an unsuitable group of control patients, by patients with respiratory disease exaggerating their smoking habits, or by bias on the part of the interviewers. Reasons are given for excluding all these possibilities, and it is concluded that smoking is an important factor in the cause of carcinoma of the lung.’ (see full text available at http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=14772469 ).
Giving credit where due, Doll and Hill reference in 1950 the earlier work of German and American researchers on the same subject. Knowing that their analysis of hospital records would draw criticism, they followed this 'preliminary report' with a prospective study of comparative mortality in smoking and nonsmoking British physicians. This confirmatory study, published in 1954, is at http://www.bmj.com/cgi/reprint/328/7455/1529
Before his death, Doll gave an interview to Cancer World, accessible at www.cancerworld.org/CancerWorld/getStaticModFile.aspx?id=269
Herewith, excerpts from the interview:
'Sir Harold Himsworth, the Secretary of the Medical Research Council (MRC), who had commissioned the study, accepted the results straight off. But most cancer research workers did not accept it, and in fact they advised the Department of Health that they shouldn’t take any action because they were uncertain about what it meant.
'It wasn’t until 1957, when the Government asked the MRC for a formal opinion as to whether our conclusion was correct or not, that the MRC formally considered it and said it was correct and advised the Government to that effect. The result was that the Minister of Health in 1957 called a press conference to announce the results of the MRC consultation.
'He announced that the MRC had advised them that smoking was the cause of the great increase in lung cancer. While he was reporting this to the media, he was smoking a cigarette himself!'
. . . 'The tobacco industry in America . . . tried to get a colleague of mine, Ernst Wynder, sacked from his job with the Sloan-Kettering. They put pressure on the Director not to allow Wynder to publish anything that claimed smoking caused disease, and the Director did try to suppress his studies. Wynder, however, responded by setting up his own organisation and getting support from somebody else to carry on doing the research. So when he published his results, they didn’t have the Sloan-Kettering stamp. Sloan-Kettering came out of it very badly. However, despite this sort of pressure, the leading epidemiologists in America all got together fairly early on – in the late 1950s – and said they regarded it as proved that smoking causes disease. The trouble was the American law courts. The industry made it so expensive to sue them that it wasn’t for some years that you got very wealthy groups of lawyers who were prepared to take them on. The industry could make it so expensive by raising objections and making it last a very long time.'
Reviewing, in the Bulletin of the World Health Organization, the early reactions to tobacco research,
Michael Thun, of the American Cancer Society, wrote about 'when the truth is unwelcome' at
2) New York City Official Is Obama Pick for C.D.C.
By GARDINER HARRIS and ANEMONA HARTOCOLLIS
Published: New York Times, May 15, 2009
WASHINGTON — President Obama announced on Friday that he has chosen Dr. Thomas R. Frieden, the New York City health commissioner, as the next director of the Centers for Disease Control and Prevention.
Skip to next paragraph Dr. Frieden, a 48-year-old infectious disease specialist, has cut a high and sometimes contentious profile in his seven years as New York’s top health official under Mayor Michael R. Bloomberg. He led the crusade to ban smoking in restaurants and bars, pushed to make H.I.V. testing a routine part of medical exams, and defended a program that passes out more than 35 million condoms a year.
In a morning email to C.D.C. staff, Dr. Frieden, who worked at C.D.C. for 12 years during his career, wrote, “I love C.D.C.; I am honored and humbled by the challenge and privilege of working with the greatest public health agency in the world.”
At the C.D.C., he will inherit a host of immediate and long-term problems, including a looming decision about whether and how to produce a swine flu vaccine. Health experts say the agency must resolve serious morale and organizational issues even as the administration struggles to overhaul the nation’s health care system.
“I think the administration selected Tom Frieden because he can take public health to a new place,” said Jeffrey Levi, executive director of Trust for America’s Health, a nonprofit public health advocacy organization. “He’s a transformational leader.”
Dr. Frieden said that he will begin work in early June. With his appointment, which does not require Senate confirmation, New York City will have former commissioners in two of the nation’s most visible health positions; Dr. Margaret A. Hamburg, who held the job in the 1990s, is nearing confirmation as commissioner of the Food and Drug Administration.
Dr. Frieden has long been expected to be Mr. Obama’s choice. Although he is widely admired in the public health community, some C.D.C. veterans began lobbying in recent weeks on behalf of the agency’s acting director, Dr. Richard E. Besser.
Dr. Besser has been the government’s chief scientific spokesman during the swine flu epidemic, winning rave reviews for his confident performance. He will return to his post as head of the agency’s coordinating office for terrorism preparedness and emergency response.
In an early morning email to C.D.C. staff, Dr. Besser praised Dr. Frieden as a “consummate innovator” and added, “I know C.D.C. will be in great hands with Dr. Frieden.”
After the announcement, conservatives criticized Dr. Frieden as a liberal crusader. Jeff Stier, associate director of the American Council on Science and Health, a free-market oriented consumer group, said Dr. Frieden had long overstated the dangers of second-hand smoke. “He plays the politics game better than he does good science,” Mr. Stier said.
Dr. Scott Gottlieb, a resident scholar at the American Enterprise Institute and a former deputy commissioner of the F.D.A., said that a technocrat like Dr. Besser would have been a better choice because C.D.C. should be above politics.
“I think people four years from now will regret this appointment,” Dr. Gottlieb said.
Dr. Frieden and Dr. Hamburg, who worked together for years in New York City successfully fighting a growing tuberculosis epidemic, will play important roles in how the government decides to fight swine flu next fall if the virus returns with a vengeance.
Their relationship will be tested in the effort to improve the safety of the nation’s food supply, in which both agencies play crucial parts. Mr. Obama has made food safety a top health priority; a government working group that includes the food and drug agency, the Department of Agriculture and other agencies is already at work on the problem; and Congress has proposed a variety of legislative fixes.
Any changes are likely to affect the disease centers, which play a central role in monitoring and solving outbreaks of food-related illnesses.
In a prepared statement announcing the appointment on Friday morning, Mr. Obama said “Dr. Frieden is an expert in preparedness and response to health emergencies, and has been at the forefront of the fight against heart disease, cancer and obesity, infectious diseases such as tuberculosis and AIDS, and in the establishment of electronic health records.”
Also facing Dr. Frieden will be a set of decisions about how to organize the agency. Dr. Julie L. Gerberding, who left in January as the agency’s director, undertook a reorganization that lasted years and has been widely criticized as overly bureaucratic and the cause of a raft of top staff departures. But still another administrative overhaul would create its own set of headaches.
“Morale is the weakest thing at the agency right now,” said Dr. James M. Hughes, former director of the C.D.C.’s National Center for Infectious Diseases. “He has to really listen to people, and I think there are too many bureaucratic layers.”
Dr. Frieden said in a prepared statement on Friday morning, “I look forward to learning from and working with the wonderful staff of the Centers for Disease Control and Prevention.”
Like other federal agencies, the disease centers added thousands of contract employees during the Bush administration. Deciding which functions are best fulfilled by contractors and which should be brought back inside the agency is another delicate problem for Dr. Frieden.
“Health care reform also needs to be on his plate,” said Dr. Jeffrey P. Koplan, who served as the centers’ director from 1998 to 2002. “There is a huge opportunity there to improve public health, and it’s one in which any C.D.C. director will want to be a player.”
Mr. Obama referred to the issue in his announcement: “Dr. Frieden has been a leader in the fight for health care reform, and his experiences confronting public health challenges in our country and abroad will be essential in this new role,” he said.
However Dr. Frieden decides these questions, he is bound to kick up controversy, say those who know him.
“I found he’s willing to challenge the status quo in an effort to make a difference,” said Dennis deLeon, president of the Latino Commission on AIDS in New York City.
Mr. Bloomberg said in a prepared statement on Friday, “Because of Tom’s leadership and the hard work of the men and women at the Department of Health and Mental Hygiene, New Yorkers are living longer.”
Dr. Frieden has a history of focusing on health threats that endanger large numbers of people, sometimes at the expense of more popular causes. This put him in marked opposition to the Bush administration, which spent more than $50 billion on bioterrorism initiatives and paid far less attention to problems like smoking.
Dr. Alfred Sommer, emeritus dean of the Johns Hopkins Bloomberg School of Public Health, who was on the team that recommended Dr. Frieden as New York’s health chief in 2002, recalled interviewing him shortly after the Sept. 11 attacks. Dr. Frieden had flown to New York from India, where he was living and working on tuberculosis control.
Before he left India, he was asked about his top priority, Dr. Sommer said. “Oh, well, that’s easy, Al,” Dr. Sommer recalled him replying. “Tobacco. Tobacco is killing more people, and that’s my top priority.”
“Tom, I don’t disagree that tobacco is a real scourge, but have you heard of 9/11?” Dr. Sommer said he countered.
“Of course I know about that, but bioterrorists are not going to kill more New Yorkers than tobacco is,” Dr. Frieden said.
Jon Elsen contributed reporting.