Where would you start if you were charged with keeping the nation healthy? Dr. Thomas Frieden, director of the Centers for Disease Control and Prevention, has chosen six priorities — winnable battles, he calls them.
They are smoking, AIDS, obesity/nutrition, teen pregnancy, auto injuries and health care infections. These are long-standing, major challenges that get a lot of attention already.
But elevating a handful of problems above dozens of others is a bold move for a public health official. So far, it's been received like a bucket of cold water — invigorating some, infuriating others.
Many advocates, legislators and others in public health have devoted their lives to problems that did not make Frieden's short list. So there are complaints.
A CDC employee blog is peppered with postings like, "I guess climate change is not a battle worth winning," and "Don't we still owe the patients of tomorrow an investment in things that may not pay off immediately?"
Some advocates wonder aloud just how targeted federal public health dollars are going to be. A particular point of concern is hepatitis C, a long under-recognized liver-destroying virus which has infected more than 3 million Americans. Some experts consider the issue a ticking time bomb and have called for the government to step up efforts to prevent it and better diagnose and treat people who already are infected.
Hepatitis B and C already are "badly neglected" by the CDC, and their omission from Frieden's winnable battles list is more bad news, said Bruce Burkett, past president of the National Hepatitis C Advocacy Council.
"I was very disappointed that it wasn't on there. This is going to affect millions by not being on there," he said.
Frieden, who took over CDC in June last year, already had a reputation as something of a public health maverick. When he started his previous job as New York City's health commissioner in 2002, he began by identifying the city's most pressing health issues. He led campaigns to ban smoking in the workplace, tax soda, cut salt in processed foods, and ban artificial trans fats in restaurants.
It's no surprise that he is boldly painting targets at the CDC, said Dr. Jo Ivey Boufford, president of the New York Academy of Medicine. She's a fan of Frieden's who worked with him as a member of an advisory council to the city health department.
Frieden's CDC job, ironically, does not provide the same kind of power he had in New York City to engineer bans or tax increases. But Frieden calls his new short list "winnable battles" because, he says, proven programs can save lives and reduce harm from each of these health problems. He believes government can make dramatic improvements if available money and manpower are focused.
"In each of these areas we know what to do to make a difference and we need to do it to a much greater extent," he said in an interview.
Frieden, with a low-key demeanor, has said relatively little about this to the public, though he seems to be building support within the public health community.
There is some nervousness about how far Frieden's going to take this.
"I think everyone is going to be cautious in how the focus on winnable battles is balanced against other areas" that are also deemed important but may not be as easy to dent, said Jeff Levi, who heads Trust for America's Health, a research group.
Top CDC officials have been quick to say they have no intention of walking away from other public health missions. They couldn't even if they wanted to, because much of the agency's funding is directed to certain causes by Congress. According to one estimate, less than one-tenth of 1 percent of CDC's $6.6 billion budget is discretionary money that can be channeled into the winnable battles campaign. Indeed, the agency has been asking for more flexibility.
But there's power in perception, especially concerning CDC's grant money to states. Nearly a quarter of that is targeted at the six battle areas, which already were major areas of interest. State health officers say they're acutely aware of Frieden's priorities and want him to know it when they apply for CDC money.
"We're in the position of focusing pretty much on what we can get federal funds for," said Will Humble, director of the Arizona Department of Health Services.
Humble and several other public health leaders applaud Frieden's priorities as an overdue attempt to narrow the public health message and better market health improvement to Americans.
"You can't market if your message is too diffuse," Humble said. "If we're all on the same page and working in the same direction, we can get a lot more momentum."
This isn't how many public health officials traditionally operate, partly because they tend to worry about alienating employees, legislators and advocates, observed Stanton Glantz, a University of California-San Francisco expert on the health effects of smoking.
Other top federal health officials have not been as specific. U.S. Surgeon General Dr. Regina Benjamin, the government's chief health educator, has made the broader themes of prevention and wellness her focus.
But Frieden clearly has the blessing of his Obama administration bosses to set clear targets.
"Getting focused, and getting some quick wins under your belt, is terribly important," said Victor Strecher, a University of Michigan health behavior expert.
Progress in these areas has long been measured by health statistics. What exactly will constitute a win? Frieden hasn't said yet.