by Tom Farley
The phone-booth smoking rooms fooled no one. At another raucous day of hearings, one council member said, “the thing that I think is the most appalling to me is the fraudulence of this compromise. . . . I haven’t met anybody who has read through these regulations and realistically thinks anybody’s going to be able to build a room in their bar.”
The vote the next week was 42 to 7 in favor. New York City would have smoke-free workplaces, including all bars and restaurants, beginning in March 30, 2003.
Years later Christine Quinn said that Gifford Miller had intended to allow the bill to pass all along. “I know Gifford was not going to let it die,” she said. “It was not a burning issue for him, but it was a burning issue for me . . . and he was not going to leave me hanging.” But “he was going to get what he could get for it.” According to Quinn, what Miller got from Bloomberg was a promise not to veto a bill that Miller favored raising the minimum wage for home health care workers.
Michael Bloomberg signed the Smoke-Free Air Act into law on December 30, 2002, nearly a year to the day after he took office. At the ceremony in City Hall, he again cited Frieden’s numbers: “This bill will free more than 400,000 non-smoking New Yorkers from exposure to cancer-causing chemicals and will save more than 11,000 lives in New York City over the life of the law. New York City is the greatest city in the world. . . . And with the passage of this statute, we go a long way toward becoming one of the healthiest cities as well.”
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“I thought, this nutrition stuff is so controversial.”
Mary Bassett is a slender woman with a habit of parking her glasses in the graying curls on top of her head when she looks up from reading. She speaks as calmly and carefully as a diplomat, but her words are strong and often about injustice. When I first met her, she had framed on her office wall a ballot from South Africa’s 1994 election with Nelson Mandela’s name on it and a quote from Dante: “The hottest places in hell are reserved for those who, in a time of great moral crisis, maintain their neutrality.”
Bassett’s father had overcome historic barriers to give Mary the life he couldn’t have himself. Emmett Bassett, an African American, came from a family of subsistence farmers in Virginia. He excelled enough in school to make it to the Tuskegee Institute, studying under George Washington Carver. When he was drafted into the army in World War II, he was assigned to a blacks-only unit. After talking to the northerners he met there, he realized how limited even his college education was, so afterward he went back to school, earning a Ph.D. in biochemistry. He took a job as a professor at a medical school in Newark, settled into the Washington Heights section of Manhattan with his wife, a librarian who was white, and sent his children to a private school with children of investment bankers. It was a great school, and his daughter Mary wasn’t bothered by being one of the few nonwhite children there, but she did resent thinking that, next to her classmates, she was poor. “We were not poor,” she told me emphatically. “I felt we were, but we were not poor.” Her parents were deeply rooted civil rights activists. “As far back as I can remember, we children were carted along to marches and meetings,” she wrote in a short autobiography in a book called Comrades in Health.
At Radcliffe, Mary Bassett volunteered at the Black Panther Free Clinic in Boston, going door to door in the surrounding ghetto to test children for sickle cell disease. After graduating with honors, she came back to New York City for medical school and chose to do her residency at Harlem Hospital. When she finished her training, she was drawn to the African liberation movement, so she headed to Zimbabwe during “the exhilarating post-independence 1980s.” She joined the medical faculty at the University of Zimbabwe in Harare just when AIDS began ravaging that country.
In the university’s hospital, she told “hundreds and hundreds of people that they were HIV-infected.” “There were lots of fairly wrenching human stories,” she remembered years later, including a young guy who was a personal secretary to the president. “I guess by now he’s dead.” She traveled to factories and schools to educate people about AIDS and the risks of having unprotected sex. Thinking back on it, she felt most of her efforts had failed. Because she had no treatment to offer those who were infected, “denial was the most effective response.” That was okay for their psyche, but it did nothing to stop the spread of the virus to others. “Zimbabwe went on to have one of the worst epidemics of the continent,” she told me, because they weren’t fixing the root social problems. “In retrospect, I think we were trying to solve a cholera epidemic by teaching schoolchildren how to wash their hands.”
Bassett had heard of Coke McCord at Harlem Hospital but hadn’t met him. She had a chance one time when she traveled from Zimbabwe to Mozambique. Arriving in Maputo, she went to the hospital and asked in broken Spanish if Dr. McCord was on the grounds. The hospital workers ushered her into an operating suite, where McCord was in full surgeon’s scrubs, plunging his hands into a patient’s open chest to strip off a diseased heart lining. Most surgeons would have been apoplectic to be interrupted by a woman in street clothes while holding a scalpel inches from a beating heart, but McCord acted as calmly as if he were changing a tire. After asking who she was, he told her he was nearly finished and, if she’d wait outside, he’d be happy to chat later.
Many Americans who feel called to do medical work in the world’s poor countries stick it out for a year or two. Mary Bassett’s time in Zimbabwe, interrupted by stints in the United States, stretched to seventeen. But as the AIDS epidemic raged in that country through the 1990s, the political and economic conditions also went into a death spiral. The World Bank and the IMF demanded a “structural adjustment” for Zimbabwe, which forced the government to deregulate prices and spend less on health care.
This requirement not only devastated the clinics but also triggered a much larger unraveling. Robert Mugabe, the nation’s founding father, grabbed total power. He repressed his political opponents, provoked violent takeovers of white-owned farms, engaged in a war in neighboring Congo, and began printing massive amounts of currency, spawning a withering hyperinflation. Bassett’s hospital fell apart, with doctors disappearing to work elsewhere and patients’ families having to pay in cash in advance for everything from medicine to IV tubing. One day a story appeared in the paper that the government was investigating a human rights group for which Bassett was a board member. That was enough. A friend who knew Tom Frieden from “the TB wars” told her that he was going to lead the New York City health department, so she wrote him a letter.
When Bassett first met Frieden in late 2002, during the peak of the smoke-free-air fight, she found him “very cocky.” She knew her résumé was unusual. But she thought Frieden might value her many years working outside the U.S. system, because “it was clear that he had come in with an intent to shake things up.” She was right. He offered her the chance to run the agency’s AIDS program.
Surprisingly, Bassett turned him down. She wanted to work on the diseases that mattered most, and in New York, AIDS wasn’t the biggest killer. She thought back on her time at Harlem Hospital, where “I don’t think I’ve ever seen sicker people.” They were suffering and dying not from infections but from chronic diseases, like heart disease and cancer and kidney failure. “In Zimbabwe I saw very sick people, but usually they had one condition that was life-threatening. But in Harlem the problem list was always eight problems long.”
So despite her limited experience, she asked Frieden if instead she could direct the department’s work to prevent chronic diseases. She was surprised when he agreed, offering her the new job of deputy commissioner for the Division of Health Promotion and Disease Prevention, which he had formed by merging a community health unit with a few other programs, including tobacco. She worried about how well she would tolerate Frieden’s style, but she jumped in anyway.
The biggest health problem the division faced was heart disease. Even if the health department were to erase smoking from New York City, 17,000 New Yorkers would still
die from heart disease each year—more than were killed by all types of cancer combined. Tom Frieden, steeped from childhood in medical care, wanted to prevent heart disease by getting doctors to treat three major risk factors: diabetes, high blood pressure, and high blood cholesterol.
It infuriated him that the American medical care system could perform heart transplants but couldn’t do the simple things that would prevent people from needing them. A slide that he showed in many lectures read, “On ABC’s of health care, USA gets an ‘F.’” Doctors treated effectively only one-third of Americans with high blood pressure (the B in ABC), one-fourth of Americans with diabetes (the A, for the hemoglobin A1C test), and one-tenth of Americans with high blood cholesterol (the C). To Frieden, that meant the health department should coax or shame doctors into providing better preventive care, and that it should push people to go to doctors and take their pills.
Medical treatment of risk factors is known as “secondary prevention.” At the time, though, many in public health were shifting toward “primary prevention,” or helping people avoid diabetes, high blood pressure, and high cholesterol in the first place. The basic idea of primary prevention is simple: people need to eat healthier food—more fruits and vegetables and less salt, sugar, and fat—and exercise more. But making that happen across a whole city of eight million was more than daunting. When doctors try to persuade even one person to behave differently, they usually fail. Public health agencies did what they could with health education and promotion for the whole population, but they barely scratched the surface of the problem.
Mary Bassett had ideas for a third way. She appeared at her first staff meeting waving graphs drawn by the British preventive medicine specialist Geoffrey Rose. The Rose graphs, shaped like bell curves, illustrated a population’s behavior, such as the number of calories people took in. Health educators found people on the risky tail of the curve (the people who ate much more than average) and cajoled them to join the less-risky people in the center (by eating less). It didn’t work very well. The educators reached only a few people, and only a fraction of those could overcome the pressures of life to alter their daily habits. But Rose thought prevention experts should instead shift the entire curve—getting everyone to eat just a little bit less—by changing the everyday world around people. “This is what we’re going to do,” Bassett announced. “We’re going to shift curves.”
She saw traditional health promotion as blaming the victim—lecturing poor people who were adapted to horrible circumstances that they, rather than their circumstances, were the problem. She was determined that “we weren’t going to have a whole health promotion and disease prevention division that was aimed at imploring people to do better.” She wanted to fix the social injustices that made people eat wrong. Among other radical changes, that meant she needed very different types of people working in the division. “I’m proud to say that not a single person that I recruited to the division had a formal background in health promotion.”
When she got into the job, Bassett discovered that the health department was already shifting curves in the way it fought smoking. The cigarette taxes and the Smoke-Free Air Act didn’t entreat people to resist an unhealthy world or scold them if they couldn’t resist. Instead, those policies made healthy choices easier and unhealthy choices harder. She wanted to do the same for eating.
But eating is much more complicated than smoking. To a doctor, smoking is an absolute evil. No one should smoke, ever. That means that tighter regulations on cigarettes, from smoke-free-air laws to high taxes, are always better. But no food is as toxic as tobacco, and everyone has to eat. And there are so many different kinds of problems with Americans’ diet. People don’t eat enough fruits or vegetables. They eat too much saturated fat, too much salt, and too much sugar, and—as is painfully obvious from the obesity epidemic—they consume too many calories.
America’s food system, which shapes the American diet, is gigantic and complicated. Food flows from farms and factories into people’s mouths not only through grocery stores but also through corner stores (which New Yorkers call bodegas), restaurants, fast-food joints, school cafeterias, bookstores, snack counters, vending machines, and food banks. Every year the channels grew and diversified. How could one health department alter that deluge of mostly unhealthy food? Even if it was willing to start with one tiny stream, which one would it be?
Coke McCord, who now reported to Mary Bassett, surprised her with a suggestion. He had read Eat, Drink, and Be Healthy by Walter Willett, head of nutrition at the Harvard School of Public Health. “Read this,” he said, passing the book on to her. “Then we can talk about trans fat.”
Trans fats are chemicals that are literally twists on natural oils. No matter what people say, they love the taste of fat. They put butter on bread, pour cream into their coffee, lap up ice cream, and layer nearly everything with cheese. But butterfat is expensive to produce, turns rancid if left at room temperature, and burns too easily when cooked. In 1901 a German chemist showed that if he combined vegetable oil with hydrogen gas and metallic nickel at temperatures approaching one thousand degrees, he could transform it into a semisolid fat. The artificial fat didn’t turn bad if left in a kitchen cabinet, and it didn’t burn as easily.
A few years later Procter and Gamble bought the patent rights to his “partial hydrogenation” process and used it to turn cottonseed oil into a white solid fat that the company sold as “shortening” under the name Crisco. Not long afterward food companies added flavoring and yellow coloring to “partially hydrogenated vegetable oil” and sold it as a butter substitute that they called oleomargarine. By the 1960s, artificial trans fats lurked nearly everywhere in American grocery stores, appearing not just in margarine and frying oils but also in cookies, crackers, pastries, pizza crusts, candy bars, mayonnaise, and peanut butter. For decades, few questioned what trans fats did inside the humans who ate them. The fats predated the Food and Drug Administration (FDA), and when it was founded, the FDA grandfathered trans fats in as “generally recognized as safe.”
But in the 1980s researchers began discovering that trans fats are in fact toxic. First, studies showed that eating them raised blood cholesterol levels even more than consuming the same amount of cholesterol or saturated fat. Then Walter Willett’s research group at Harvard, as well as others, repeatedly found that people who eat more trans fats are more likely to have heart attacks. Eating just 4 grams a day—the amount in a typical order of French fries—increases the risk of coronary heart disease by 23 percent. And Americans on average were eating more trans fats than that every day. Chris Gallin, whose heart attack nearly killed him at age forty-six, loved French fries and ate two slices of pizza every day for lunch. By 1994 Willett’s group estimated that at least 30,000 Americans died every year from heart disease caused by trans fats.
Stalin is reputed to have said that the death of one man is a tragedy but the death of millions is a statistic. No one sees the sad reality of this psychology more than those who work in public health. Teams of doctors and nurses may work around the clock in an ICU to save the life of a single person from a heart attack; anyone who suggests they are wasting their effort is seen as cruel. But for many years, few people paid any attention to the 30,000-deaths-per-year toll from trans fats.
In the early 2000s, under pressure from nutrition activists, the FDA was finally considering a minimal rule that would require food companies to list trans fats on packages’ Nutrition Facts panels. But how many people would flip over a box of crackers to see if they contained trans fats? Also, food at restaurants wasn’t labeled.
With all the city’s nutritional problems, trans fats might seem a strange place for the health department to start. But public health, like politics, is the art of the possible. To McCord, trans fats were a great target because like tobacco (and unlike salt, sugar, or natural saturated fats) they were pure evil—artificial, unnecessary, and killing people by the tens of thousands. McCord argued that the city shoul
d just ban trans fats—they should never have been allowed in food the first place. The team was inspired in mid-2003 when Denmark passed a trans fats ban, the first country to do so.
Bassett and McCord took the idea to the department’s chief lawyer, Wilfredo Lopez. Could the Board of Health ban trans fats? they asked.
The Board of Health hadn’t changed its structure much since the late 1800s, despite many revisions of the New York City Charter. It now had eleven appointed members with expertise in health, five of whom by charter rules were physicians.
Lopez told Mary Bassett no. The Board of Health regulated what happened in restaurant kitchens to avoid bacterial contamination of food. “Historically, we didn’t get into the business of the content of the food,” he told me later. That was the FDA’s job. “As long as it wasn’t poisonous or declared to be a hazardous substance,” he couldn’t see the board banning it.
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Meanwhile Frieden was learning that getting doctors to treat their patients for the disease “smoking” was hard. His newsletter warning doctors about malpractice didn’t seem to change what they did. The city’s Health and Hospitals Corporation should have provided him an opportunity. HHC was a behemoth, a sprawling network of eleven public hospitals and dozens of clinics. Frieden didn’t run it, but he was on the board, so in theory he had influence there.
