by Tom Farley
“The speed with which a replacement was chosen underscores the importance of the post, as well as the urgency of the H1N1 flu outbreak that Dr. Farley must confront,” wrote the Times, which—thank goodness—called me “an infectious disease specialist.” I had never been so nervous in my life.
PART TWO
10
“All I could think of was, welcome to New York.”
On Monday morning, June 8, 2009, I walked into the corner office at the health department and sat behind what I still thought of as Tom Frieden’s desk. I felt as if I were taking over as manager of the Yankees after they had won the World Series seven years in a row. Even if I won big, it would look like inertia. Still, this would be my chance, an opportunity not only to save lives but also to change the way people fought disease.
That first day I invited a dozen deputies in for a little speech. Like Frieden, I told them, I loved numbers and would be driven by data and scientific evidence. I wanted to go after unhealthy behaviors by addressing the conditions that fostered them. Often that would mean writing new rules, rules that would need approval by the Board of Health, the City Council, or other policy-making bodies. Although Frieden and I had gone through similar training and often thought alike, our personalities were very different. Frieden plays squash, a sport that is frenetic and competitive. I’m a long-distance runner: steady and contemplative. I tried to give my team a sense of how I would be different. I wouldn’t micromanage. In an agency that covered this much territory, I simply couldn’t. I preferred to spend chunks of time in the early days with each deputy, so that they and I would understand each other’s strategy—and then get out of the way. I wouldn’t yell, but they shouldn’t mistake my quiet manner for lack of determination.
I was open about my weaknesses. My management experience in government was limited to a few years running programs in Louisiana’s health department. I hadn’t been chosen for my management skills, I said. Without their help in managing this huge department and navigating the turbulent political seas of City Hall, I told the deputies, I would fail, and so would they.
Later Christina Chang, who initially stayed on as my chief of staff, gave me her first piece of advice: Don’t talk like that. The health department was hierarchical. The staff were accustomed to a leader who was “kind of arrogant”; I would only undercut myself by showing weakness. It was like that in City Hall, too. There, Frieden “was seen sometimes as stubborn and obstinate and kind of a bully,” she said, but that protected the health department. In the mayor’s office, “if you admit weakness in anything, you will get ridden roughshod.”
I considered the obstacles and the opportunities in front of me. I faced a problem in common with every city health director: I would be pressed by the public’s expectations and fears, which would make it difficult to push the actions that save the most lives.
Most city health departments, most of the time, are nearly invisible to the public. They quietly do things that residents take for granted, like inspecting restaurants, catching stray dogs, treating people with tuberculosis, and keeping the drinking water safe. As hidden as the traditional health department programs are, they touch on raw nerves. On any day, any program can explode in the public eye, such as when a popular restaurant is overrun by rats, a well-heeled group catches salmonella, or a kindergarten teacher is diagnosed with drug-resistant tuberculosis. When problems like these erupt, the ensuing outrage can damage the department, the health director, and the mayor.
In my first few months on the job, the H1N1 influenza pandemic seemed poised to roil the city and ruin me. The nation’s public health agencies had long expected a new killer strain of the flu virus to jump from pigs or birds to humans. Health departments had developed their response plans: until a vaccine arrived, doctors would treat the sick with antiviral medications—drugs that were only partially effective—and health directors would try to slow the spread by separating sick people from healthy people. Even if everyone executed those plans well, however, the infection could easily sweep the world and kill tens of millions. The people hit the hardest would be the elderly.
But the new H1N1 influenza strain refused to follow the script. The infection raced through the nation, but it mainly struck children and young adults, most of whom recovered quickly. (Older people escaped probably because they were immune after infection from similar strains many influenza seasons earlier.) Few if anyone in public health had envisioned an influenza pandemic that infected legions of young people but killed very few. We realized only gradually that we had escaped the Big One, but then we didn’t have a useful playbook. We were caught between underreacting and overreacting.
Tom Frieden and I struggled with whether to close schools, which studies suggested could slow an influenza epidemic, buying time while a vaccine was being developed. Shortly before I started, the ill assistant principal had died of the new flu, followed soon afterward by a child in an elementary school. Many parents and teachers panicked and pressed to close the schools. But other parents, seeing most children recover after two days of mild fever, pressed just as hard to keep the schools open; they had to go to work, and sending their children to a babysitter’s home packed with other children hardly seemed safer. At first Frieden had closed a few schools where many children were becoming sick. But as it became clearer that this epidemic of influenza was not particularly deadly, he and then I left the schools open. The new virus retreated in the summer of 2010.
It returned the following winter, but by that time we had a vaccine. The health department shipped the vaccine to doctors throughout the city and set up special vaccine clinics. Initially some people desperately wanted a vaccine that they were unable to get; after dealing with that, we quickly ran into the opposite problem: most people feared a new vaccine more than a now-familiar virus. In the end, the nation discarded millions of unwanted doses of vaccine, and the new H1N1 influenza virus merged into the annual influenza ebb and flow. The much-feared pandemic killed far fewer New Yorkers than influenza did in a typical year. And the New York City health department got through the bizarre episode with its reputation intact.
• • •
All city health directors handle crises like this, and they all manage long-standing programs to try to avoid them. For many city health directors, that is their entire job. But for me, to only maintain those programs and stamp out flare-ups would be to fail. Today the long-standing health programs have very little to do with how healthy we are. Nothing about killing rats or closing a deli serving contaminated potato salad prevents people from catching heart disease, cancer, or diabetes.
Frieden had dealt with that contradiction by redefining the job of the city health director. To him, the job was not about providing services. It was about preventing needless deaths. If people were dying from heart attacks or cancer or diabetes, then that’s where the health department should be.
Prevention is always a tough sell. When people get sick, they demand to be cared for. They want a doctor to write a prescription and tell them it will be all right, and they want a nurse to ease their discomforts. On the other hand, people think only rarely about prevention; when they do, they usually view it as a matter of personal responsibility, not something to demand of others. Health directors in other cities wanted to redirect their agencies to prevent chronic diseases as much Frieden did, but they were straitjacketed by tight budgets, timid mayors, and the curse of expectations. But Frieden had had backing from Mayor Bloomberg to make that radical turn.
His health department couldn’t prevent chronic diseases by itself, though. It had the legal authority to close restaurants and quarantine people, but it had no such weapons to fight smoking, unhealthy eating, or physical inactivity. Reducing those risks had required Frieden to tell New Yorkers what to do. He had pressed bills on City Council members, published instructions for doctors, and posted commands in subway ads for every other New Yorker. Creating those directives required the department to gather and analyze data, writ
e reports, craft recommendations, draft bills, and produce ads, and then use all channels of modern communication to circulate the products. So over the course of seven and a half years, Frieden had transformed the health department, establishing thriving units to do epidemiology, chronic disease prevention, legal analysis, and communications.
For years before I arrived, I had been arguing that chronic diseases are preventable by making healthier choices easier. It’s a simple idea that is difficult to realize. Powerful forces resist the changes that prevent today’s killer diseases. Too often the architects of our day-to-day world are companies marketing unhealthy products, like cigarettes, junk food, and junk beverages. If I wanted to make healthy choices easier, I had to change government rules to protect people from that marketing. And changing the rules inevitably provokes the companies doing the marketing into battle. People in public health have to pick their battles, to find chinks in the armor of strong opponents. Nonetheless, watching Frieden had made it clear to me that saving lives requires fighting.
That makes prevention even tougher to sell to politicians. Championing prevention means taking on political skirmishes that mayors or governors may lose, while few constituents cheer them on. Even if the initiatives succeed in preventing needless deaths, and even if the citizens are grateful for what didn’t happen, the payoff comes well beyond the next election. Politically, public health is more trouble than it’s worth. Because of that, public health officials are usually shut out of power. We attend conferences where we blather on about what should happen but almost never get opportunities to determine what will happen.
Now I had such an opportunity, but I knew it wouldn’t last long. The mayor’s support, his sway with the City Council, and the authority of the Board of Health were a fleeting alignment of stars. I owed it to public health not to squander it.
The stakes were higher even than the lives of eight million New Yorkers. New York is a global megacity and a media hub. Local stories can quickly catapult to become national or international events. When those stories are controversial, people everywhere else notice. By 2009 people around the country and around the world were paying attention to the New York City health department. Before New York City passed its smoke-free air law, only California and a few health-conscious towns in Colorado and Massachusetts had had smoke-free bars. After New York City—and then its suburban counties, and then the state—went smoke-free, similar laws spread across the country. By 2007 cities like Houston, Texas, and Columbus, Ohio, had smoke-free restaurants and bars. By early 2010 smoke-free-air laws were in place in thirty-two states, including the nation’s tobacco capital, North Carolina. The trend was also sweeping Europe. In 2002, after the Irish delegation interrogated Christina Chang about how the New York team had passed its law, groups from other European countries followed, in person or on the phone. Norway and the Netherlands passed comprehensive smoke-free-air laws shortly after Ireland did. Sweden, Italy, and Spain followed. By 2007 Britain and even cigarette-loving France had smoke-free bars.
New York City’s trans fat ban also traveled quickly. As soon as the story hit the press, other cities began calling the health department for help on how to write similar regulations. Within three months of our Board of Health vote, the Philadelphia City Council voted to restrict trans fats. Seattle passed a restaurant ban a few months later; it was followed later that year by suburban counties near New York and Baltimore, and by the entire state of California in 2008. And by the end of 2008, McDonald’s, Burger King, Subway, Starbucks, and several other big chains had announced that they would stop using trans fats in all their restaurants nationwide.
Just a few days after I started the job, Lynn Silver e-mailed me with news about restaurant calorie counts. Senator Tom Harkin (D-Iowa) wanted to wrap his bill on mandatory calorie labeling in chain restaurants into President Obama’s health care reform bill. Harkin’s staff had called Silver to make sure the bill wouldn’t interfere with our calorie-labeling rule. After checking, she told them there was no major conflict, and restaurant menu labeling ended up in the Affordable Care Act. The calorie counts will one day go nationwide, too.
• • •
Often new department heads replace the people who report to them. I didn’t have a choice. Within a few weeks of my starting, two deputy commissioners told me they were leaving—they felt burned out, they said, and needed a change—and the chief operating officer followed Tom Frieden to CDC. Even before I arrived, and shortly before Frieden told people that he was leaving, Mary Bassett had quit. “Tom is an enormously dedicated person,” she had told me. “He works heart and soul to accomplish goals. And he gets very involved. His involvement always adds value to everything that we do. . . . But the downside is also that.” Her frustration that Frieden made all the decisions ate at her. Years later she was more direct: “I hated working for Tom.”
To fill in her position running the Division of Health Promotion and Disease Prevention, I promoted Andy Goodman, a mild-mannered pediatrician who had been with the health department for twenty-five years and was then directing the Harlem office. Goodman was another liberal who had traveled to Nicaragua after the 1980s revolution and had even helped Frieden edit his Central America health newsletter. Bassett’s division oversaw the fifteen-hundred-staff Office of School Health; its chief had to have diplomacy in dealing with those staff and with the city’s enormous Department of Education, a diplomacy that I thought Goodman had. Lynn Silver had applied for the position too and felt insulted that I gave it to Goodman. They clashed, and the change set up trouble for me later.
• • •
Several New York City news outlets wanted to interview the new guy. Geoff Cowley, a science writer for Newsweek whom Frieden had hired as the agency’s communications director, and who was himself still learning how to deal with the scrappy City Hall press corps, advised me to do the interviews. They would give me a chance to frame my agenda and might buy me some goodwill with reporters, which I’d need for the battles ahead.
Only gradually did I come to understand the weird symbiotic relationship between news outlets and elected officials, which others seemed to grasp intuitively. It’s not just vanity that compels mayors, governors, and presidents to go to great lengths to look like winners on the evening news. Those elected officials ultimately draw their power from voters, who know their leaders almost entirely by how the press portrays them. Mayors need good coverage. Every day news outlets have the option of showing a mayor solving problems, fighting evil, and caring for people like you and me—or acting petty, defeated, or overbearing. Those news outlets, especially during the Internet era, are fighting for as many readers’ and viewers’ eyeballs as they can get. They need stories every day—the juicier the better.
Unfortunately, juicy stories usually make mayors look bad. The conflicting needs of the press and the mayor led to a daily wrestling match between reporters and the City Hall press office. As Geoff Cowley put it, the press team was always “jockeying to get the kind of coverage you want from people who are basically out to screw you.”
At the health department, we couldn’t avoid getting dragged into this wrestling match. We put out reports on the health problems of New Yorkers that told people and organizations what they should do to avoid them; we believed publishing those reports was a key part of our job. We also proposed ideas to Bloomberg that had built-in opponents. The City Hall press office seemed to groan whenever my staff showed up. Why were we yakking about diabetes or arthritis—problems that Mayor Bloomberg couldn’t fix? Why were we picking fights that the mayor might lose? They tended to consider us as troublemakers. In turn, we considered the press office meddlesome. We understood that the mayor had to spend his political capital wisely, but what better way to spend political capital than to save lives? Or as Lyndon Johnson said when his aides warned him that the civil rights bill would be too controversial, “What the hell’s the presidency for?”
Every day the newspapers set the tone for how the p
ress in general would cover an issue. The television and radio stations usually followed along. That made the City Hall press team particularly obsessed with how the newspapers framed a story. Of the major daily papers, The New York Times and The Wall Street Journal saw themselves mainly as highbrow national papers that dipped into some local stories. There were two local tabloids, the arch-conservative New York Post (a Rupert Murdoch production) and the left-leaning Daily News.
Other than glimpsing headlines like “HEADLESS BODY IN TOPLESS BAR” as I walked by newsstands, I had never read the tabloids, so in the first couple of days I scanned them to learn what they were about. On my first day on the job, the Post informed New Yorkers about a man who had maintained an active membership for a decade in a women-only gym, an ex-con who was suing a prison nurse who had ignored his painful fifty-five-hour erection, and a special rescue team that had rappelled down a cliff in Connecticut to rescue what had turned out to be a mannequin. It was like reading the funny pages, only not as funny.
I was wary of the interviews, so in advance I wrote out talking points and answers to tough questions. Geoff Cowley told me that the press was frustrated that Frieden had been fiercely protective of his private life, so if I could open up about myself, even just a little, I would win some badly needed goodwill.
