by Tom Farley
SAVING
GOTHAM
A Billionaire Mayor, Activist
Doctors, and the Fight for
Eight Million Lives
TOM FARLEY, MD
W. W. Norton & Company
Independent Publishers Since 1923
New York • London
To Alice, who enables my eccentricities,
and Emily, Joanna, Helen, and Rebecca,
of whom I am very proud
Contents
Preface
PART ONE
1 “Things are going to get really exciting.”
2 “I need a one-pager on lives saved.”
3 “I thought, this nutrition stuff is so controversial.”
4 “We were failing and we didn’t know why, and we had to succeed.”
5 “Are you sure this will save lives?”
6 “I just went on a field trip to Dunkin’ Donuts.”
7 “Now, for the first time ever, she could see for herself.”
8 “There’s no doubt our kids drink way too much soda.”
9 “In the end, it’s just ketchup.”
PART TWO
10 “All I could think of was, welcome to New York.”
11 “They can’t even be bothered to sue us?”
12 “We were outgunned.”
13 “Would you like us to say, ‘That’s not our responsibility’?”
14 “We are in a coalition with major food companies for one reason only; that is, access to power.”
15 “They always had two nuclear weapons.”
16 “I hear that your mayor wants to ban soda!”
17 “The NSRI’s success is far from guaranteed.”
18 “This is an attack on small business.”
19 “It keeps me up at night.”
20 “That is, ultimately, government’s highest duty.”
Notes on Sources
Thanks
Index
SAVING GOTHAM
Preface
In June 2006 I flew to Atlanta to give a talk at a conference on public health law. The attendees were mostly lawyers, professors, and officials from state health departments and the Centers for Disease Control and Prevention (CDC)—a rumpled, polite, and long-winded group that debated topics like government-mandated vaccination registries. But the keynote talk was to be delivered by Michael Bloomberg, then in his second term as mayor of New York City. At the packed closing session, Bloomberg strutted into the conference hall wearing a Wall Street suit, surrounded by a pack of large men wearing coiled security earphones. Trailing him was a compact, boyish, but intense-looking man with a bounce in his step whom I recognized as Tom Frieden, the city’s health commissioner.
At the time I was a professor of public health in New Orleans. I had worked for the CDC and for the state health department in Louisiana, where I had learned to be contemptuous of politicians. None of them understood anything about health except that people demanded medical care regardless of the cost; the Democrats wanted to give people more of that care and the Republicans wanted to cut government spending on it. I knew little about Bloomberg except that he was a Wall Street tech billionaire who had banned smoking in bars. I slouched in the back, not expecting much.
But when Bloomberg began talking, reading his speech at ticker-tape pace in his Boston accent, I straightened up in my chair. He spoke about smoking as the nation’s biggest enemy. About getting illegal guns off the street. About why the city was distributing its own brand of condoms and giving sterile needles to drug users. Public health people talked like that, but a mayor? “We rely on the forceful application of law—democratically debated and approved—as the principal instrument of public health policy,” he said. These ideas were political losers. This guy was very, very different.
Tom Frieden sat in the front row holding a binder in his lap, hanging on his boss’s words. He had a reputation for being smart and pushy. Though I had never met him, I knew that he had gone through the same training program at the CDC that I had. It hit me that Frieden was behind the ideas in Bloomberg’s speech. A smart, powerful politician was actually listening to a man with life-saving but politically dangerous ideas. The two were a combination I thought I’d never see.
Those of us who work in public health fight diseases in entire populations rather than one person at a time. Rather than treat sickness, we prevent it by acting “upstream.” If the tools of medical care are drugs and surgery, the tools of public health are information, policies, and laws. Doctors treat cholera victims with intravenous fluids, but public health people prevent cholera by mandating clean water and sewage systems.
A year earlier, a colleague and I had published a book arguing that, just as we had beaten cholera, we could beat the leading killers of our time with public health actions. Nearly four in ten people in America died from chronic diseases like heart disease, cancer, and diabetes. People could avoid those diseases by behaving in a healthier way, particularly avoiding smoking, eating healthier food, and being physically active. But most people can’t behave that way consistently because they are preoccupied and stressed and living in world that, day after day, makes it easy to do what is unhealthy and difficult to do the opposite. If we want to be healthy as a nation, my colleague and I wrote, we should change our everyday world to make healthy behaviors easier. Now Bloomberg was saying the same thing. He told the conference, “Public health succeeds by making the healthy choice the default social option.”
Every important action taken in public health incites opposition, because it means changing society. And that often makes the work of public health heartbreaking. Those of us who do it see people suffering and dying from preventable diseases, and we dream of taking simple actions to fix the causes. And then, because we face strong political headwinds, we often end up running insignificant pilot programs or writing proposals that are ignored. On the plane home from Atlanta, I couldn’t stop thinking about the combination of Bloomberg and Frieden. This looked like a once-in-a-century aligning of forces, a chance to do something big.
Two weeks later I e-mailed Frieden to ask if I could work for him at the New York City Department of Health and Mental Hygiene. He invited me to come to New York to talk, and a few months later I began a year as his adviser.
I wasn’t disappointed. Frieden indeed had huge ambitions, and he was leading a band of activist doctors on a mission to save the life of every New Yorker. He also had Mayor Bloomberg’s ear. As Frieden and his true believers changed the focus of the health department to modern health problems, they were transforming that agency and redefining public health. I joined the club and advised him on subjects as wide-ranging as drug overdoses and salt levels in food. It was a thrilling time. But Bloomberg’s second term was drawing to a close, so at the end of the year I returned to my job as a professor.
Afterward I began writing a book about the New York City health department. In late 2008 and early 2009, I interviewed Tom Frieden and two dozen of his staff for the book. Then things changed. President Barack Obama asked Frieden to be the director of the CDC; the New York City Council revised a law so that Bloomberg could run for a third term; and Bloomberg asked me to succeed Frieden as health commissioner. So in the spring of 2009 I put the book aside and moved to New York City.
During the Bloomberg years, the city health department attacked what we saw as America’s biggest killer—smoking. It then went after heart disease, stroke, hypertension, and obesity by mounting assaults on trans fats, salt in processed food, and sugary drinks. None of these initiatives happened easily. They took place only after painstaking—often repeated and circular—review and skirmishing within the health department, followed by wrangling within City Hall. Many ideas died in the process. Others made it into the sunli
ght, only to be killed by the state or federal government or by the courts. Still others survived and thrived.
In the early 1990s Al Sommer, then dean of the School of Public Health at Johns Hopkins University, approached businessman Michael Bloomberg for a donation for his school. In their first conversation, Sommer compared public health to medicine, hitting hard on the idea that public health actions save lives wholesale instead of retail. “Mike got it like that,” Sommer said to me, snapping his fingers. Later a Johns Hopkins administrator said to Sommer, “I don’t know what you told Mike Bloomberg, but he’s going around telling everybody that the School of Public Health saves more lives than the medical school will in its entire history.” Sommer and Bloomberg, who later became friends, liked the phrase. Over the years, they played with it and made it into a slogan that Sommer trademarked for what is now the Johns Hopkins Bloomberg School of Public Health: Protecting health, saving lives—millions at a time.
This book tells the story of what happened when a group of dedicated people tried in the nation’s largest city to make that slogan real—to save lives, millions at a time.
PART ONE
1
“Things are going to get really exciting.”
Near midnight Chris Gallin was at home at his desk, paying bills, when he felt his left shoulder and arm getting stiff. He had smoked his last cigarette of the day an hour earlier. In his job managing a family construction business, he didn’t lift or carry things, but he thought he might have pulled a muscle somehow. Then his shoulder started to hurt. He tried moving it, but that didn’t help. He wondered if it was heartburn, so he tried an antacid, but the pain only grew worse. And that’s when he knew. He walked to his bedroom and told to his wife to call 911, because he was having a heart attack.
At the hospital, the doctors told Gallin and his wife that he had a complete blockage of the artery that supplies the main part of the heart. They called it “the widow-maker.” They were surprised that he had made it to the hospital. He was forty-six years old.
• • •
At eight a.m. on January 22, 2002, Tom Frieden climbed the steps from the number six subway into a small triangular park in lower Manhattan, lugging a roll-on suitcase that held a stack of papers and his laptop. He had flown in from India at ten o’clock the night before and had slept a few hours at a friend’s apartment. He paused, looked across the park at a ten-story building—the headquarters of the Department of Health and Mental Hygiene—and thought: This is it.
The gray building is graced with art deco touches from the 1930s. The exterior walls feature octagonal silver medallions with muscular Greek-looking figures washing themselves or grinding medicine with mortar and pestle. Nearer the top, chiseled in stone on all four sides, are the last names of twenty-six heroes in health. There is Jenner, who invented vaccination to tame smallpox, and Lind, who eradicated scurvy with lemons. There is Semmelweis, who discovered that deadly infections were being spread by doctors in hospitals, and Nightingale, who showed how to prevent those infections. And Koch, who discovered the bacteria that cause many diseases, and Ehrlich, who produced the first antibiotics to kill them.
In 2002 the building headquartered two departments, the Department of Health and the Department of Mental Health, Mental Retardation, and Alcoholism Services. The two answered to one commissioner—as of that day, Frieden. The combined agency, with some 6,000 staff and a budget of $1.6 billion, was a conglomerate. The health department tested the city’s drinking water, inspected restaurants, enforced vaccination requirements for children, repaired peeling lead-based paint that poisoned toddlers, and traced contacts to control the spread of tuberculosis and sexually transmitted diseases. It issued millions of birth and death certificates and used the data to calculate health statistics. It supplied nurses to more than one thousand schools and inspected tens of thousands of day care centers. Its mental hygiene arm funded treatment for alcoholism, drug addiction, mental illness, and developmental delay. What the health department didn’t do was provide basic medical care. That was the job of private doctors, federally funded community health centers, and the city’s Health and Hospitals Corporation. In fact, the city health department had little involvement with the medical care system.
The city had established the health department nearly two hundred years earlier as a committee to battle epidemics of infectious diseases. Since then the agency had grown fitfully as it took on new jobs—from administering polio vaccinations to establishing methadone clinics—in response to subsequent crises. But like most health departments in the year 2002, New York City’s did very little to combat the city’s biggest killers: heart disease, stroke, cancer, and diabetes.
• • •
When I first met Tom Frieden, I was struck by his youthful looks and his frenetic energy, which gave him the look of a twelve-year-old boy playing commissioner. He seemed to speak twice as fast as the hyper New Yorkers around him. Listening to him was like watching a game of pinball, as he ricocheted among numbers, biology, history, anecdotes, and local politics. He kept two folded-up three-by-five index cards in his shirt pocket, and he would often stop abruptly in midsentence, pull them out, and make cryptic notes in five-point font. Then he’d refold the cards, slide them back in his pocket, and start racing again, usually on a different topic. He quoted obscure scientific papers and the sayings of political rogues. Running over statistics, he sounded like a combination of a science professor gushing about his experiments and a beat reporter rattling off the details of a juicy scandal, describing numbers with words like fascinating and extraordinary. His intensity was fierce but also joyous; he often interrupted himself with rapid-fire one-liners, laughing with his entire torso.
When I arrived at the health department in 2007, Frieden briefed me as only he could, streaming ideas that were both detailed and grandiose. His antitobacco program wanted to slash the number of stores selling cigarettes, but he couldn’t figure out how to do it legally and politically. He was creating a $27 million electronic medical record system and installing it in a thousand doctors’ offices. He was writing an opinion piece for the Journal of the American Medical Association on how to restructure the $2 trillion U.S. health care system, but he didn’t have time to finish it, so could I help? Then he took a call from a labor leader who had built his own health care system for his union members, which was second to none. “We need to learn from that guy,” Frieden said. The New York State Restaurant Association was suing him over the department’s requirement that restaurants post calorie counts on their menu boards. When the health department did a first-ever citywide examination survey of New Yorkers, they found sky-high levels of mercury in the Chinese, who Frieden suspected were acquiring the metal from fish caught in polluted waters. To get more new mothers to breastfeed, he was pushing every public hospital to banish giveaways of infant formula. New Yorkers were losing their hearing—maybe because of the screeching subways—and he wanted to figure out how to fix the trains because the MTA wouldn’t. There was so much more, but he had to get back to his e-mail.
Those index cards with daily to-do lists were a habit Frieden had picked up years earlier as a medical resident. He divided each card, always folded exactly in half, into tiny sections—people to call, papers to read, e-mails to send. If at the end of the day he wasn’t able to cross an item off his list, he had to rewrite it on the next day’s card—a personal failure for which, according to an assistant, “he could not be consoled.” Frieden also kept weekly to-do lists, which he numbered for each week on the job in New York. And he kept monthly to-do lists. And yearly to-do lists.
Frieden suffered from a burden of urgency that was almost painful to watch. People were dying from preventable causes in New York City, and he took every death personally. It was as if a Code Blue were called every day and only he could run over, slap on the paddles, and shock the victim back to life. He walked so fast that people had to break into a trot to keep pace. When he asked people questions, he often inter
rupted their answers after the first few words because knew where they were going. When answering e-mails, his response was often one letter only—Y or N. “Have you seen him eat?” one of his assistants said to me. “He doesn’t chew!” And sure enough, one day when we met for lunch, I noticed that he dropped his head and seemed to vacuum the food in one long slurp.
• • •
Tom Frieden grew up in New York City’s suburbs, the son of a cardiologist in solo practice who took calls from his patients every night but also aspired to be a scholar, reading medical journals voraciously. Frieden idolized his father, who raised Tom on medicine and politics. “You gotta help the people,” the father told the son.
During the summers between his terms in medical school, Tom Frieden traveled to Nicaragua. The country had just seen the Sandinista revolution overthrow the Somoza dictatorship. In the 1980s the revolutionary movements in Central America became a kind of siren call to American leftists, especially in health. The Sandinistas were copying Cuba, which, despite its poverty, had higher immunization rates than did New York City. “The Sandinistas early on were very inspiring,” Frieden told me. They “had very good health campaigns. Vaccination, oral rehydration. They did clinic building. They did maternal mortality stuff.” He began working with a New York City–based organization called the National Central America Health Rights Network, creating a newsletter on Central America that he edited for ten years. While working on Central American issues, he dealt with a tall young man named Bill de Blasio, who would later become mayor of New York City. As the years went by, Frieden grew disenchanted with the Sandinistas: “They became very corrupt.”
After he finished his medical training, he joined the Epidemic Intelligence Service (EIS), a two-year program run by the Centers for Disease Control and Prevention (CDC) to turn doctors into disease detectives. The CDC farmed out many of its EIS officers to state and local health departments for training. Frieden angled for and landed the spot in New York City, where he investigated an astonishing twenty-four disease outbreaks in two years.
