by Tom Farley
One of those outbreaks erupted into a national crisis: the epidemic of drug-resistant tuberculosis in people with AIDS, spread mainly within hospitals. Experts around the country—including me—saw the epidemic in nearly apocalyptic terms: it was a sign that AIDS, by making hundreds of thousands of people susceptible to infections, was transforming tuberculosis into an uncontrollable problem. So after his training ended, Frieden took charge of the city’s tuberculosis program to control it.
The solution to the crisis, as he saw it, was not a cure for AIDS, which was at best many years away. The solution was just to make sure—really, really sure—that people with TB took their medicines until they were cured so that they didn’t spread the infection to others. That meant, more than anything, assigning health department workers to watch TB patients swallow every single one of their pills, either at home or in the clinic. That simple process earned the bureaucratic name directly observed therapy (DOT). It had worked in the world’s most destitute countries. Why not New York City?
As Frieden threw his energy into the TB program, he got some management advice from an old hand. “You may work twice as many hours and three times as fast as others,” the man told him, “but that’s still only six people. And what six people do in a large organization is irrelevant.” So Frieden leveraged the panic over the outbreak into millions in additional funding from both the city and the CDC, with which he expanded the TB program’s staff from 200 to 830. Now he had the army to apply DOT to the thousands of New Yorkers with tuberculosis.
One day he gave a tour to a visiting TB expert from overseas, proudly displaying the data he used to track his program. The expert asked Frieden “the single question that changed my life,” as he later called it: “You diagnosed 3,811 patients last year. How many of them did you cure?”
“And I didn’t know!” Frieden told me. “And I was tremendously humiliated.” For all his numbers, he lacked the one that mattered the most. From that point on, he instituted “cohort reviews” of each individual patient and tracked cure rates religiously. The bigger lesson was: measure the outcome.
Frieden’s program worked stunningly well. The 3,811 cases of tuberculosis that were diagnosed the year he took over the program was the highest number on record. Five years later the case count had shrunk to 1,600, and it would soon hit historic lows.
In 1997 the director for tuberculosis control for the World Health Organization asked Frieden to help manage India’s massive TB program. “I got there, and I was at the top of my game,” he told me. “I had written in the New England Journal of Medicine, the Lancet, and everywhere else. I was well known and lauded in the U.S.” During a year of bureaucratic hiring delays, he traveled intermittently to India, reviewed the nation’s program, and sent instructions to Indian public health officials. They ignored him. They hadn’t heard of him, didn’t care what he had done in New York City, and believed anything done in New York wouldn’t apply to their country anyway.
Later, after living in India for a while, Frieden realized they were right: “In fact, I didn’t know the vast majority of what I needed to know about TB in India.” So he began traveling extensively around the country, listening to frontline TB program staff. “Within a year, I knew more about what was happening in the field than anyone else,” he said. He tried to gain Indians’ respect through sheer relentlessness, volunteering for any task that came in his direction. “I’m a mule for work,” he told me. He wrote later, “Every day for the first two years I was [in India], I would leave the office, often at 9 or 10 o’clock at night, and ask myself, ‘1,000 people died from TB in India today, and what the hell did I do about it!?’”
A colleague who traveled to India years later found the Indian health officials in awe of Frieden. “Nobody works harder than Dr. Tom,” they told her. Five years after he arrived, the Indian TB program had trained 200,000 staff and increased the percent of people with TB treated with DOT from near zero to over 50 percent, which amounted to more than 600,000 patients. Frieden needed to estimate how many lives his work would save. He figured that, as of 2002, the TB program in India would save 200,000 lives. To keep a tally after he left, he had the program set up a running “lives saved” counter on its website.
In the fall of 2001, as New York City and the rest of the nation grieved over the 9/11 attacks and trembled over the anthrax scare that followed, Tom Frieden wanted to come home. He spotted an opportunity with the upcoming city election. Rudy Giuliani was ending his term as mayor, and the Democrat who won the primary was Mark Green, the city’s public advocate. In the general election, Green faced an unlikely Republican candidate, a tech-and-media billionaire and political newcomer named Michael Bloomberg. Green was so confident that he would win that before the election his staff contacted Frieden about serving as his future health commissioner. Green’s election looked guaranteed right up to the day Bloomberg beat him.
The world now knows Michael Bloomberg, the confident and sometimes caustic mayor, but he started his campaign as an unknown. The father of the data terminals that were essential for Wall Street traders, Bloomberg paraded his $4 billion fortune as a political asset, saying in a campaign ad, “I won’t ask special interests for a dime.” He played up his differentness: “I don’t do the conventional.” The press wasn’t sure what to make of him, but he kept them entertained. He was a talker, mostly about himself, who kept his aides vigilant by saying whatever he thought. In this heavily Democratic city, he called school prayer “an excellent idea. . . . It is the way I grew up and I didn’t turn out so bad.”
And when asked about health, the other candidates stayed on safe ground by promising to get poor children health insurance, but Bloomberg blazed his own trail. “There’s an enormous number of people who come down with illnesses that could be prevented through education,” he said. “Diabetes, coming through diet, abuse of the diet; asthma, dirty air, and not knowing how to clean; substance abuse; smoking-related illnesses . . . somebody has to focus on those.” Preventing diseases through education? It was so far from ordinary campaign-speak that The New York Times treated it as a gaffe.
After his surprise victory, Bloomberg had to choose heads for more than forty city agencies. Because he had financed his own campaign, he didn’t have to repay favors with political appointments. He had a formal transition committee, but for informal advice on a health commissioner, he turned to his friend from Johns Hopkins, Al Sommer. After the committee turned up Frieden’s name, Sommer remembers getting phone calls from people he hadn’t spoken to for a long time, calling just to say hello and incidentally mentioning that Frieden, whom they happened to know, would make a terrific health commissioner.
Back in India, Frieden began plotting a health strategy for New York City. He started by downloading the fifty-page book of statistics published annually by the health department. In the year 2000, the city had just over eight million inhabitants. They were grouped in five boroughs, each of which was crowded enough to qualify as a city in its own right: Manhattan (the borough most visitors think of as New York City) with 1.5 million people, Brooklyn with 2.5 million, Queens with 2.2 million, the Bronx with 1.5 million, and often-overlooked Staten Island with 440,000. The city had no majority race or ethnic group. The largest group, non-Hispanic whites, made up just 35 percent of the population, Hispanics followed at 27 percent, and non-Hispanic blacks at 24 percent. More than a third of New Yorkers were immigrants, and over half of the babies born in the city were to immigrant mothers.
Of the eight million New Yorkers that year, 60,839 had died. The ways they died reflected the twentieth century’s revolution in health. In 1900 the leading killers had been tuberculosis and pneumonia; heart disease and cancer had been relatively infrequent causes of death. By 2000, tuberculosis was rare and pneumonia an uncommon killer, but 24,768 of the deaths—or over 40 percent—were caused by heart disease. Another 14,100, nearly a quarter, were due to cancer.
Smoking was behind many of those deaths. To estimate how ma
ny, Frieden did a back-of-the-envelope calculation, assigning rough percentages of deaths attributable to smoking for each cause—for example, 30 percent of heart attacks, 90 percent of lung cancers, 30 percent of other cancers, and 50 percent of strokes. He quickly concluded that roughly 20 percent of all the city’s deaths were caused by smoking. Like everyone else in public health, he had known that smoking was a big killer, but the size of the problem shocked him. For the previous ten years he had been immersed in tuberculosis: “I thought, wow, they haven’t controlled smoking yet?” He decided then that if he got the New York City job, smoking would be his top enemy.
Frieden remembers getting an e-mail from Sommer asking if he wanted to be considered for health commissioner. He wrote back that his taking the job “would only make sense if he [Bloomberg] is willing to take on tobacco, and that’s very political. . . . It wasn’t a condition, I just didn’t want to waste everyone’s time.”
Sommer remembers the exchange differently. It was over the telephone, and Sommer casually asked Frieden what health problems he would tackle if he got the job. Smoking, Frieden said emphatically. Sommer was incredulous. The World Trade Center site was still smoldering, and the anthrax-laced letter mystery remained unsolved. “Tom, ever hear of nine-eleven?” he asked. “Ever hear of bioterrorism?” Sommer said Frieden told him, yes, of course he’d deal with bioterrorism too, but smoking would kill far more people.
Frieden flew to the United States to interview. Sommer must have tipped off Bloomberg, because according to Frieden, the mayor—a former smoker—spent the first twelve minutes of the interview all but ignoring him and haranguing his deputy mayor of operations, Mark Shaw—who still enjoyed cigars—about smoking. Do you know what a huge problem smoking is? he said. It would be like three jumbo jetliners crashing into a mountain every day. It’s the biggest public health problem of our time. We’ve just got to do something about it.
When Bloomberg finally got around to talking to Frieden, as the mayor’s chief of staff Peter Madonia put it, “I don’t think it was five minutes into the conversation that it was clear to me there was a complete mind-meld between Mike and Tom.”
When I first met Frieden, he had on his bookshelf a framed picture of Bloomberg shaking his hand. Taped to it was a piece of paper with the words that the mayor had said to Frieden and his other new commissioners: “It’s your agency. Don’t screw it up.”
• • •
When Frieden arrived in January 2002, the New York City health department was, in the damning words of one employee, “a standard government agency.” It was “process-oriented instead of outcome-oriented.” Under former mayor Giuliani, its job had been less to promote health than to respond to complaints. Other employees were much harsher about the agency culture. The workers “punched a clock. They didn’t collaborate. They hid data that made them look bad.” The city’s practicing doctors, if they knew anything about the department, thought it “a sleepy, backwater place that would probably never change.” Within the two weeks of my own arrival at the department in 2007, I met two people who had quit in frustration in the late 1990s and then rejoined after Frieden took over.
Donna Shelley, a physician, had joined the department in 1999 to run a new tobacco control program. At that time, money had come to the agency from the “Master Settlement Agreement” between state attorneys general and the tobacco companies over Medicaid costs. Shelley, impatient and demanding, fumed at what she saw as the lazy atmosphere. When she asked one of her employees to meet with her at 4:55, he would look at his watch and say, “Well, I’m leaving in five minutes.” “Ninety percent of the people there deserved to be fired,” she told me. “It was impossible to get anything done. I was bumping heads with everybody all the time.” One day a senior department official called her into his office and told her to back off. She was upsetting too many people.
Even before he came to New York, Tom Frieden made it clear that he would run a different kind of department. From India, he sent e-mails to high-level department staff, demanding reams of data about their programs: what did they do, why did they do it, what population were they trying to reach, who did they actually reach, and how did they know if they were successful? The e-mails “sent shock waves through the agency,” an assistant in the commissioner’s office recalled. “People had never been asked this kind of question. . . . They had no idea what their population . . . served was. They didn’t have numerators, they didn’t have denominators, they didn’t even think in numerators and denominators. . . . I think people started to quake.”
The new health commissioner wouldn’t waste his time with “process”—about who did what. Shortly after he arrived, the agency staff briefed Frieden about one unit that was disorganized enough to be in trouble with a federal regulatory agency. “It was a mess managerially,” he told me. “It was bad.” A staff member in the commissioner’s office proposed a solution: hire a consultant to do a “process analysis,” then set up a Continuing Quality Improvement program. Frieden had an entirely different take. The problem with the unit was the man running it, who had kept all the files himself and then couldn’t keep track of them. So Frieden fired him.
He wanted numbers that measured what mattered. Just as he returned to New York City, Frieden had visited his father, who was now in a nursing home, dying. He described the visit in a talk at a health conference. “And in the very last conversation I ever had with him, before he faded, I said ‘Dad, I’m going to be health commissioner for New York City.’ He was happy to hear that. I said, ‘Dad, I want to be the best health commissioner.’ And he said, in the last words he ever spoke to me, ‘How would you know?’” It was why Tom Frieden saw his job as saving as many lives as he could. And why he had to count them.
But Frieden was more than just “outcome-oriented.” He was, in Donna Shelley’s words, “incapable of process.” He wasn’t deliberately rude; he was just too impatient to be polite or to explain himself. He would demand, decide, and act, without communicating with the people he needed to carry out his orders. Shelley remembers an early meeting in his office with officials from the American Cancer Society. Ten minutes into the meeting Frieden, apparently feeling the conversation wasn’t worth his time, just stood up from the head of the conference table, walked to his desk, and started working on some papers. Shelley said later, “I looked at these people and I thought, ‘Oh my god, this is so rude!’” Sure, the meeting was going nowhere, but “we all learn early on as children that we have to engage in some kind of process with people.” She thought, “I don’t know anybody who acts like that.”
• • •
By taking on smoking, Tom Frieden had certainly chosen the right target. He soon refined his initial back-of-the-envelope estimate of the number of New Yorkers killed by smoking to “more than 12,000 adults a year”—more than AIDS, alcohol, suicide, and homicide combined. Half of these smoking-related deaths happened in people under sixty-five. Chris Gallin, who survived his heart attack, was nearly one of them. And people who died from smoking didn’t just drop dead—they suffered and lingered from it, paralyzed by stroke, breathless from emphysema, or in pain from cancer. The medical costs associated with smoking ran to more than $4 billion a year in New York City alone—costs that everyone ended up paying through taxes and health insurance premiums.
Coming in, Commissioner Frieden made sure that everyone, both inside and outside the health department, knew exactly how determined he was to combat smoking. “For the last ten-plus years, my enemy was the tuberculosis bacteria,” he told reporters in his first press interviews, “but now my enemy is a really low-life form, tobacco executives.”
But what exactly was Frieden going to do? People’s reasons for smoking defied all logic. Nearly forty years after the first surgeon general’s report, everyone—everyone—knew that it could kill you, yet one in five adults in New York City still smoked. Every year the small fraction who quit or died were replaced by teenagers taking their first puffs. Kids tried c
igarettes to look grown-up and cool and became hooked before they knew it, then struggled to break the habit the rest of their lives. In the decade before Frieden arrived, smoking rates in New York City had not budged.
Before the new health commissioner could figure out his antismoking strategy, Mayor Bloomberg began his. In Frieden’s third week on the job, the mayor announced his budget for the year. To fill a $4.8 billion budget gap opened by the city’s post-9/11 economic slowdown, he proposed to cut funding for most city agencies, including shrinking the police force and closing care centers for the elderly, in addition to raising some fees and taxes. A key piece of the budget package was a leap in the city’s cigarette tax from 8 cents to $1.50, which would make it the nation’s highest and raise the price of a pack from a little more than $5.00 to nearly $7.00. The city needed the money, but Bloomberg was sold on the health benefit, telling reporters, “The numbers are clear, you raise taxes, the kids smoke less.”
Bloomberg was right. Economists had repeatedly shown that even though tobacco was an addictive drug, when the price went up, people bought fewer cigarettes, smoked less, and quit more. Later Frieden, playing catch-up, used these studies to estimate that Bloomberg’s $1.42 tax increase would cut smoking rates in teens by 15 percent and prompt 70,000 adult smokers to quit.
In the health department, Donna Shelley had her own plan to combat smoking. In the years before Frieden arrived, she had visited the top tobacco control programs in the country and consulted experts. She favored a tax increase, among other ideas. She wanted to testify in favor of a cigarette tax, but Giuliani’s people had muzzled her. With the best ideas forbidden, she was paying nonprofits to organize teenagers against smoking, under the label “youth empowerment.” When she first saw the energy and political power that Frieden and Bloomberg brought to smoking, she was in awe. “Oh my god, this is going to get easy,” she thought. But instead, she quickly found herself frustrated. Frieden wasn’t about to follow her strategy. He had his own ideas. Among them, he wanted to treat smoking as he had treated TB.
