by Tom Farley
For the Gracie Mansion meeting, Bloomberg’s speechwriters had figured that the best way to manage the problem was to spotlight it. “Let me start with a confession,” Bloomberg’s script said. “I love salty foods—really love them. I never eat fries or popcorn without a liberal sprinkling of salt. Despite all of the evidence linking salt to high blood pressure, my health commissioner actually condones this behavior! That’s because the real salt in our diets—some eighty percent of it—comes from prepared foods.”
But that afternoon, Bloomberg did what he usually did—he said whatever came into his head. Cheez-Its, he told the nation’s food industry. That’s what he really loved. If he could, he’d mash up Cheez-Its, put them in a saltshaker, and sprinkle them over his pizza. The Cheez-Its manufacturer applauded.
Frieden laid out the health department’s plan to the companies. Their goal was to cut sodium levels in the entire food supply by 25 percent in five years. They would meet that goal by setting targets for sodium levels in the most important food categories and then ask the companies to commit to meet them. The targets would be “substantive, achievable, gradual, voluntary, and measurable.” Representatives from the World Health Organization then summarized actions on salt that were under way in several European countries, and a woman from the U.K.’s Food Standards Agency showed how they had succeeded.
In response, “the industry was very polite,” said Silver. The representatives admitted that sodium was a problem. But they warned that their customers would reject any food that tasted bad or even tasted just different. “They said they were looking at it, studying ways to do it, but wanted to do it themselves.”
The health department team didn’t want individual companies to work on the problem on their own. That’s what had failed for so many years. The team wanted commitments and open measurement. Frieden asked the executives to send a follow-up letter in which they would “commit to participating in an iterative process by which targets will be created, goals will be set, and progress will be measured.”
Afterward the health department team was ebullient. They didn’t have any commitments in hand, but they had pulled off a crucial first step. The nation’s food giants had shown up to a meeting called by a city health department; they were agreeing on the fundamental problem and what needed to be done about it. “People really took seriously that we were in the mayor’s mansion and that the mayor cared about this,” one staffer said later. Mary Bassett e-mailed me that the meeting had been “pitch perfect. . . . Tom was brilliant as a facilitator [and] the mayor charmingly off message.” And the threat had been heard, Bassett wrote, with just enough “subtle reminders of regulatory potential.”
Afterward Christina Chang and others from the health department went out to a bar to celebrate. With margaritas in glasses rimmed with salt.
• • •
The food companies may have had other reasons for listening to Bloomberg and Frieden. Even though the mayor was nearing the end his second term, it looked like neither he nor his health commissioner was going away.
Earlier that year Bloomberg had finally shut the door on a presidential run. His top political adviser Kevin Sheekey had been agitating for it for years. Bloomberg had the ability to do it his own way, entirely with his own money, like Ross Perot only smarter. Bloomberg had abandoned the Republican Party so he could run as an independent if he wanted to. Sheekey and his staff had researched what it would take to get on the ballot in all fifty states; they had sounded out potential supporters and run polls, while Bloomberg traveled around the country expressing candidatelike opinions on the state of the nation. But in the end, the mayor was too realistic to jump. He told colleagues that a Jewish, pro-choice, pro-gay-marriage, pro-gun-control New Yorker polled at about 10 percent.
Soon afterward, though, Bloomberg’s staff polled New Yorkers about his seeking a third term as mayor. That would require the City Council to pass a law revising the city’s term limits, which the voters had approved. The polls said that while Bloomberg was very popular, New Yorkers strongly opposed him changing that law. Ignoring his advisers, who pleaded with him not to do it, Bloomberg lobbied the City Council to rewrite the law. The Salt Summit occurred less than a week after that vote, which had cleared the way for him to run for a third term. Bloomberg likely would be mayor of New York City for another four years.
The Salt Summit also happened days before the 2008 presidential election, as Democratic candidate Barack Obama was holding a good lead in the polls. Rumors were circulating that an Obama administration might appoint Frieden as director of the CDC or some other prominent federal health job. A smart food company CEO would recognize that it was a good idea to hear what Frieden had to say.
Frieden must have had a federal position on his mind. One day in early 2008, when I was working as his adviser, he had asked me if I wanted to spend a day shadowing him. I turned him down. I was busy, and happily so, working with Mary Bassett and her staff on problems like obesity and high salt levels in food. I liked working behind the scenes while Frieden fought the political battles. Then after I finished my year there, he asked if I could continue to help him part time, and I agreed. We talked on the phone regularly, and I made occasional trips to the city. During one of them, he asked me if I might be interested in becoming the next New York City health commissioner.
His question caught me off guard. I had wanted to direct a city health department, but it had never occurred to me that I might get the chance to run the most prominent one in the nation. I told Frieden that I was excited at the opportunity to make a difference in people’s lives, but I was also scared that I’d screw it up. Making decisions about public health worried me less than being able to do the political maneuvering to make the decisions stick. “I’m an excellent epidemiologist, a so-so manager, and a lousy politician,” I told him. And I put him off.
• • •
After the Salt Summit, Frieden got many letters from the food companies, but they didn’t say what he wanted to hear. Nearly all of them wrote that they were already working on salt reduction. One even wrote, “Last December we announced that our sodium reduction efforts have successfully removed nearly three million pounds of salt from American diets annually.” Claims like that, though, were exactly the problem. There was no way to verify them, and despite the impressive numbers, Americans’ intake of sodium appeared to be increasing. The companies’ pledges were frustratingly evasive; one executive wrote that his company was “committed to helping consumers achieve a healthy lifestyle and we look forward to working with you to achieve this goal.”
And with only a few exceptions, the food companies circled their wagons and redirected Frieden to their trade group, the Grocery Manufacturers Association (GMA). The GMA was doing what trade associations are paid to do with proposed government actions: pretend to help while working to neutralize them. Before and after the Gracie Mansion meeting, GMA vice president Bob Earl was on the phone almost daily with health department staff. He questioned the purpose, insisted that the food company CEOs should not attend, and demanded in advance an agenda, a list of invitees, and a list of those agreeing to come. He asked that the health department expand the meetings to include grocery stores, restaurants, delis, and institutional food vendors. He said the process “must also consider other policy issues and initiatives related to labeling, consumer education, and research funding on taste and salt replacements.” Less than a month after the Salt Summit, he announced that his association would hold its own conference to develop its own salt-reduction plan. And at every step, he demanded that the process be slowed down.
The health department was also stirring up another industry. The Salt Institute is an association of companies that sell salt, like Morton and Cargill. (“There’s a lobby for everything,” a congressional staffer once told me.) The “institute” devotes most of its effort to showing that reducing the amount of salt in foods would be dangerous. David McCarron, an adjunct professor at the University of California
at Davis who is paid by the Salt Institute, visited the health department in January 2009 to present his argument. Sodium has a “minimal” effect on blood pressure, he said. People have a sodium “set point,” so that if you cut the amount of sodium in their food, they will just eat more food to compensate and become obese. On the other hand, people who already have severe heart disease can die if you abruptly cut back their sodium intake. He said the issue needed more research, in particular a massive, years-long study in which people are assigned to high- and low-salt diets and the researchers measure which group survives longer.
Lynn Silver called the whole argument “specious.” A study of the kind the Salt Institute proposed would be impractical (who would stick to their diets?) and—many experts would say—unethical, so it would never be done. That, I figured, was why the Salt Institute called for it. The claims of the salt doubters reminded me of decades-long arguments that some prominent, industry-funded scientists made about lead in paint and gasoline. The risks aren’t clear, they said; the studies are flawed. Meanwhile, hundreds of thousands of children were getting brain damage from lead poisoning.
Silver and her team ignored McCarron. But despite the obvious corporate interest behind the Salt Institute’s argument, they had reason to worry. The argument had just enough ring of science to provide cover for food companies that didn’t want to budge.
• • •
Six months after the Salt Summit, Frieden, Silver, Angell and rest of the salt team met at the health department’s headquarters with eight food company representatives. They had come to talk about ketchup. The team had started with ketchup because it looked like the simplest food category, and they needed simplicity because the whole exercise was proving to be very complicated.
The salt team had two tasks: group food items into categories and then choose a sodium target in each category. The United Kingdom had done that, and the salt team hoped to make minor adjustments to the U.K.’s categories and targets. They would group foods that were similar (like sandwich bread and English muffins) but separate foods that were different enough in taste or recipe to have sharply different sodium levels (like doughnuts at 300 mg versus waffles at 570 mg per 100 grams). The salt team didn’t care about specific foods as much as the total sodium sold in a food category. An extremely salty gourmet cracker with a niche market was less dangerous than a moderately salty generic cracker eaten by half the country.
The team’s measure of progress, then, took into account both the sodium levels in each food item and the amount of sales. Having the metric be a “sales-weighted average” would give the food companies many ways to meet a reduction target; they could phase out a high-salt product, introduce a new low-salt product, or cut the salt in continuing products. But it made the calculations complicated and dependent on data on both sodium levels and sales.
Angell gave Christine Curtis the job of building the database to measure that progress. Curtis, a tall, sandy-haired woman, had come to city government as a policy intern a few years earlier. She had a head for numbers and was unflappable, and she soon became the agency’s salt expert. The commercial food database that she built was more complete than any in the nation, and her calculations of sodium levels in food categories were the first that anyone—especially the food companies—had ever seen.
Silver and Angell’s plan was to meet with the dominant manufacturers for each food category to discuss proposed targets, then choose final targets and ask the companies to pledge to meet them. Ketchup seemed like a good starting place because its sodium level was different enough from that of other condiments that Curtis thought it should be in a category all by itself.
A 14-ounce bottle of a leading brand of ketchup contained a little over 1½ teaspoons of salt. A single tablespoon of ketchup that you might put on a hamburger delivered about 10 percent of your sodium budget for an entire day. Curtis now proposed to the ketchup manufacturers targets that would cut the salt in ketchup by one-tenth in 2011 and one-quarter in 2013. Both those proposals were less stringent than the targets already set for ketchup by the U.K.
After Curtis finished presenting the proposal, the meeting erupted. Bob Earl from GMA wanted to see the entire list of proposed categories, the schedule of meetings, and a description of the steps to create the final targets. A major ketchup manufacturer demanded to know why the health department was picking on ketchup first when ketchup was such a small contributor to sodium intake. Other ketchup manufacturers wanted ketchup grouped with barbecue sauce and salsa. Then they argued that salt in ketchup wasn’t just about taste. It also was a preservative, keeping food safe, and it kept the food stable on the shelf. Did the health department have any technical data on the impact lowering sodium levels in ketchup would have on safety? Representatives of one major manufacturer were “beside themselves,” according to Chang, so much so that a man from a restaurant chain turned to them and said, “Guys, in the end, it’s just ketchup.”
And that was the simplest category. The next, crackers, was much more complicated. Saltines, peanut-butter-filled crackers, flavored snack crackers (like Bloomberg’s Cheez-Its) were in; graham crackers, Melba toast, and hard bread sticks were out. Just five saltine crackers delivered 6 to 9 percent of a daily sodium budget. At the cracker meeting, Curtis proposed cutting the average sodium level by 15 percent by 2011 and another 15 percent by 2013. Both targets would be less stringent than the U.K. targets, and many popular crackers sold in the United States already met them.
The cracker makers raised their own complaints. Snack, butter, and filled crackers couldn’t be lumped together. Sodium was used in crackers not just in the form of salt but also in as baking soda for leavening. Healthier crackers that used whole wheat needed more leavening, which meant more sodium. Salt also was used in crackers for texture, and companies had to alter the amount of salt in a recipe according to how much gluten was in the wheat flour, which changed according to when the wheat had been harvested. The salt sprinkled on top of crackers often fell off and settled to the bottom of the box, so the companies shouldn’t be blamed for it. And they were competing with “private label” manufacturers who weren’t in the conversation.
Between March and July 2009, Silver, Angell, and Curtis held meetings on thirty-two different food categories, squabbling with food companies over breakfast cereal, frozen snacks, potato chips, popcorn, bread and rolls, canned tuna, entrée sauces, soft cheese, hard cheese, canned beans, soups, salad dressing, and salted butter. Making arguments about taste, leavening, and texture, the companies griped that the targets were too aggressive. Even though they had said for decades that they were working on cutting salt levels, the companies complained that New York City was unrealistic in asking them to make changes over two or four years.
The packaged food companies also insisted that they were competing with restaurants. So in January 2009, Frieden and his team held a second Salt Summit for restaurants. Thirteen chains showed up. The restaurant summit spun off its own fractious meetings for categories like hamburgers, cheeseburgers, burritos, cheese pizza, soups, and breaded seafood. Most restaurants hadn’t even begun to think about lowering salt levels. Even beyond the technical problems, “the restaurants were tough,” said Silver. “They were already pissed off at us about calorie labeling.”
None of this was going to be easy.
• • •
In the spring of 2009, after Barack Obama nominated Kathleen Sebelius for secretary of health and human services, Frieden heard that he would be offered the job of director of the CDC. He asked me again if I would replace him in New York City. This time I said yes.
Four days later a public health crisis erupted. The government in Mexico announced it was shutting schools and other public places in Mexico City to stop the spread of what it called a new swine flu virus, which had already killed sixty-one people. On the same day, the New York City health department heard that some seventy-five high school students from Queens who had just returned from a spring break in Ca
ncún were sick with fever. Within two days, the WHO declared a public health emergency over a new strain of influenza virus. If the nearly 10 percent death rate among victims from initial Mexican reports were to hold up, this could be the deadly pandemic that public health experts had been dreading for decades. It would be the job of New York City’s health commissioner to protect the city from the infection. That meant Frieden had to decide whether to quarantine people who were sick, and what advice to give New Yorkers about getting vaccinated, taking antiviral drugs, and the risks of using the subway. Because the city was the first U.S. location hit by the virus, the rest of the nation was watching.
For a week Frieden was the center of a national media frenzy. Then I flew to New York to interview in Gracie Mansion with Mayor Bloomberg and Deputy Mayors Patti Harris and Linda Gibbs. By the time HHS was ready to announce Frieden as CDC director and Bloomberg was ready to name me health commissioner, the H1N1 influenza epidemic had spread from New York to much of the United States and many other countries. The disease seemed to be hitting children especially hard, and Frieden had begun closing schools. While most infected people were recovering, one assistant principal was near death. Suddenly, it mattered to many people who was in charge of health in New York City.
On Monday, May 18, feeling a little like a man headed to the firing squad, I followed Bloomberg and Gibbs to stand behind the podium in City Hall’s Blue Room. The room, named for its cobalt carpeting, walls, and drapes, was outfitted with an ornate chandelier in the center, a platform for video cameras in the back, and a large portrait of Alexander Hamilton at the front. “Tom assumes this vital post at a time when public health is obviously on the front burner,” said the mayor. I looked up from the podium and saw a sea of reporters’ faces and a battery of TV news cameras. I read a few words I had written down. “My goal as the New York City health commissioner,” I said, “will be to continue to make advances against the leading causes of death for New Yorkers today, such as smoking and obesity.”
