Thursday, June 7, 2007

Interview with the Commissioner of Health

Public Health, Public Resistance

The passionate and often controversial city health commissioner, Dr. Thomas Frieden earned his stripes as a physician during the early days of AIDS in New York after getting degrees in medicine and public health at Columbia. Mayor Michael Bloomberg, with whom he shares a passion for health issues, brought him back from his work fighting tuberculosis in India with the promise of giving him free reign to fight tobacco addiction here.

The results have been remarkable, with the city having 200,000 less smokers today than it did five years ago. HIV is a top priority for him as well, but he has run afoul of many AIDS activists on issues like changing testing laws and exploring adult circumcision as a viable prevention strategy. Frieden lives in the city with his wife and one child.

CHRISTOPHER MURRAY: What sort of relationships should a public health leader have with different constituencies?

DR. THOMAS FRIEDEN: One thing to recognize about any intervention is that all public health is local and although New York is one city, there are enormous differences between neighborhoods and populations. To be effective, we have to both understand each neighborhood as well as possible and have good linkages with each of the groups or individuals within a community that can have the most impact.

CM: How would you characterize your relationship with the LGBT community?

TF: I think some issues have worked better than others. The whole issue of HIV has been very conflictual. We've done a lot of things that I think people agree with, whether it's some of our work with condoms or crystal methamphetamine or some of our funding of anti-stigma campaigns. These are all firsts for the city in terms of many of the things that we've done.

We've also made progress with some issues like housing and health care, but clearly there have been a couple of issues that have been conflictual. One of them has been with HIV counseling and testing. I think it's fair to say that there have been a diversity of opinions within the LGBT community and there are people, very prominent people, who completely agree with what we're trying to do on HIV counseling and testing. There are others who think it's terrible and we've had really hundreds of hours of meetings with different groups.

Sometimes you get to where you agree to disagree. But at least I think we are much further along and that everyone agrees, and this was not the case five years ago, everyone agrees that it's in everyone's interest for more people to know their HIV status. I think you still had some reluctance on that score a few years back, so that's positive.

The other area that's been difficult is the whole issue of transgender birth certificates. It's an area that's really complicated, probably more complicated than we recognized when we began getting into it, but at least we're in a situation, which was not the case a few years ago, where if you've gone through a transgender procedure, you can get a birth certificate with the new gender on it. That wasn't the case a couple of years ago. So, I know the community didn't by any means get everything it wanted, but at least we're better off than we were in terms of what the community sees as its needs.

CM: To what extent did political factors play into the decision about transgender IDs?

TF: I think the transgender ID issue was just, I think we underestimated the complexity of it. I think, for example, there are significant differences between male-to-female and female-to-male in terms of the relative likelihood of surgical intervention being integral to the process. In addition, there obviously were concerns not so much political as operational and legal concerns from a variety of other organizations, agencies, and institutions. I think I've said it pretty plainly before that I think we should have done our homework better before we moved that proposal forward.

CM: I know you are concerned that half the gay men infected with HIV in our city are unaware of it. Your proposal to move from written to oral consent for HIV testing met with intense resistance from some. What creates resistance to a measure like the one you suggested?

TF: Well, I think there are real problems that I can't be very effective addressing. But If we look at the issue of number of partners and the amount of unsafe sex, if you think about the importance of somebody to behave responsibly, whether that involves sero-sorting which is a form of harm reduction, or more reliable use of condoms or a lower number of sexual partners or all of the above, any of those things would make a really big difference in terms of HIV risk.

But, you know, I haven't been hearing that from the gay community. I haven't been hearing it. And if I say it, it will be at best counter-productive. It really needs to come from within the community. This is still an epidemic that's devastating the gay community and I am opposed to anything that would criminalize sexual behavior, but if someone who's HIV-positive has sex without a condom, insertive anal sex without a condom with someone whose HIV status they don't know, that's wrong. It's ethically wrong and the community should be saying that, I shouldn't be saying it, the community should be saying it.

CM: You said that in some ways that message has to come from the gay community. Do you think there is a role for public health in a discussion about sexual ethics?

TF: I don't know. It's not something I've thought about a whole lot. I think the health department can provide information. We have a lot of information about what's going on out there that people may not be fully aware of. We are one of many possibilities for convening discussions on things. We're probably not the best possibility to convene a discussion on that topic.

CM: Would you support a gay community organization that developed a program to increase sero-sorting among HIV-positive men, but not among HIV-negative men?

TF: I'd need to see the details, but one thing that we've found with some of the analysis that we've done is people do a lot of lay epidemiology. We've had a series of investigations where we've talked with men and they make assumptions about who is positive. They'll say, "Well, that guy's always a top, so he's probably not positive," and those assumptions wind up being wrong a large number of times. So, one of the problems with sero-sorting is - you get it wrong, you are in big trouble. That said, among people who know they are positive, if someone who is positive is going to have unprotected sex, I'd much rather them have it with someone else who is positive, than with someone who is negative. From an infection-prevention standpoint, I think there's a lot of that going on. The risk of super-infection isn't nil, but it's clearly a lot lower than infecting someone who's negative.

CM: You mentioned leaders who supported new HIV testing policies. I know both Dennis de Leon of the Latino Commission on AIDS and Spencer Cox of the Medius Institute for Gay Men's Health were people who supported that. Do you think you have strong relationships with the community?

TF: They could certainly be better. They are not always terrible. I think some of the groups engage in what has been called the politics of opposition, so whatever we propose they are going to be opposed to because we proposed it. That really is unhelpful. There is also a certain divorce between reality and what some of the groups are saying that's really problematic. When we go out to interact with patients for testing and diagnosing people, we hear things that are very different from what some of the community groups are saying when they allege to represent the community. So, that's unfortunate.

What I've said before and I will say again, HIV is a terrible epidemic. The virus is very difficult to deal with. It's killed close to 100,000 New Yorkers and we have more than 100,000 people living with HIV today. Globally, of course, tens of millions. And our tools to fight it are weak. We don't have a slam dunk here. We don't have a cure, we don't have a vaccine. We don't have any intervention, public health or social, that can in and of itself turn the tide.On top of that, the few interventions we have are all controversial and either the right or the left opposes them. So, we end up with an epidemic that has benefited enormously by the advocacy to increase resources and attention and focus, but that has suffered enormously by the politicalization of our interventions.

CM: In what way has AIDS touched your life personally?

TF: I trained as a doctor in New York in the '80s. I took care of hundreds of people who died of AIDS. I had close friends who died from AIDS. When I left New York City in 1996 to go to India for five years, I had several close, personal friends whom I thought I would never see again because they were terribly ill and there are two I think of particularly who are now working full-time. I have to say that of all the areas in the purview of the department that are really important, I think HIV is the one that we've made the least progress on.

©GayCityNews 2007

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