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HEALTH POLICY AND ETHICS: Janlori Goldman, Sydney Kinnear, Jeannie Chung, and David J. Rothman New York City’s Initiatives on Diabetes and HIV/AIDS: Implications for Patient Care, Public Health, and Medical Professionalism Am J Public Health 2008; 98: 807-813 [Abstract] [Full text] [PDF]

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Response to Goldman et al., New York City's Initiatives on Diabetes and HIV/AIDS

Thomas R. Frieden   (28 April 2008)

Response to Goldman et al., New York City's Initiatives on Diabetes and HIV/AIDS 28 April 2008
Thomas R. Frieden, Health Commissioner, New York City NYC Department of Health and Mental Hygiene Send letter to journal: Re: Response to Goldman et al., New York City's Initiatives on Diabetes and HIV/AIDS tfrieden{at}health.nyc.gov Thomas R. Frieden	April 23, 2008 To the Editor: Goldman et al present themselves as protectors of the doctor-patient relationship and suggest that the Health Department exceeds its mandate in addressing non-communicable disease. Yet outreach for non-communicable conditions, often using confidential information, has long been an essential part of public health practice (e.g., newborn visits, lead poisoning programs), as has involvement with clinical management of patients (e.g., asthma, school health, and primary care provision). Facilitating letters from doctors to their patients with diabetes extends this tradition. Letters include educational materials, and the service is supplemented by resources given to providers for patients (e.g., glucose strips, blood pressure cuffs, and recreation center memberships). The registry gives providers information about glycemic control that, in the absence of electronic records in practices, most would find difficult to obtain. If electronic records were universally adopted and their registry potential utilized, our department’s A1C registry would not be necessary. The Department, in a separate initiative, is promoting precisely this approach by extending electronic health records to providers caring for the sickest patients in NYC. Diabetes disproportionately affects people of color. To claim that services mainly benefiting Blacks and Latinos will “racialize” diabetes confuses a “racialized” disease with the actions to address it. Failing to prioritize vulnerable populations because of concern about “racializing” condemns people to inadequate care. Goldman et al. also question the Department’s proposal to remove the requirement for separate written consent for HIV testing. Ironically, the NYS law they defend actually deprives physicians of their autonomy to use judgment about how to counsel patients. In September 2006, CDC issued revised guidelines recommending routine HIV testing and removal of separate written consent. Currently only 10 states require separate written consent for HIV testing. Written consent is a barrier that impedes early treatment and risk-reduction counseling for HIV-infected people. People who know they are HIV-positive decrease risky sexual behavior by about half. Separate consent procedures result in delayed diagnosis, premature death, and continued spread of HIV. Furthermore, 71% of Blacks, 63% of Latinos, and 65% of whites think “HIV testing should be treated just like routine screening for any other disease”. The system that Goldman et al. defend is failing miserably to deliver appropriate care for common and devastating diseases, despite the fact that the U.S. spends far more than any other industrialized country on health care. Diabetes and HIV/AIDS are major epidemics of our era, disabling and killing millions in this country, particularly people who are poor, Black, or Hispanic. Public health agencies have an obligation to intervene to slow these epidemics and reduce their impact. Thomas R. Frieden, MD, MPH Commissioner New York City Department of Health and Mental Hygiene Requests for reprints should be addressed to Thomas R. Frieden, MD, MPH, New York City Department of Health and Mental Hygiene, 125 Worth St, Room 331, New York, NY 10013 (tfrieden@health.nyc.gov). Acknowledgements: The author thanks Shadi Chamany, Lynn Silver, Mary T. Bassett, Monica Sweeney and others in the Health Department for their dedication to monitoring, understanding and working to reduce the burden of chronic disease and HIV/AIDS in New York City. Human Participant Protection: The public health interventions discussed in this letter are based on established scientific understanding and do not require human participant review. References: 1. New York City press release. Mayor Bloomberg and Commissioner Frieden unveil state-of-the-art electronic health record technology. Accessed at: http://www.nyc.gov/html/doh/html/pr2008/mr064-08.shtml 2. Branson BM, Handsfield HH, Lampe MA, Janssen RS, Taylor AW, Lyss SB, Clark JE. Centers for Disease Control and Prevention (CDC). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17. 3. Marks, G, Crepaz N, Senterfitt JW, Janssen RS. Meta-Analysis of High-Risk Sexual Behavior in Persons Aware and Unaware They are Infected With HIV in the United States: Implications for HIV Prevention Programs. JAIDS. 2005;39:446-53. 4. Kaiser Family Foundation. Survey of Americans on HIV/AIDS. Washington, DC: Kaiser Family Foundation, 2006. Available at http://www.kff.org/kaiserpolls/upload/7513.pdf. 5. Frieden TR, Mostashari F. Health care as if health mattered. JAMA. 2008;299:950-2.