by Tom Farley
The victory in Mexico washed back to the United States. In the November 2014 elections, voters in Berkeley, California, passed a referendum for a 1-cent-per-ounce soda tax by a three-to-one margin, despite the soda companies spending some $2.4 million—or $30 per voter—trying to block it. The Berkeley group won with a sophisticated political strategy that preempted the opponents’ attacks, including signing on the NAACP as an early supporter and painting the soda companies as bad guys, even with their organization name: Berkeley vs. Big Soda. Bloomberg donated $650,000 to the tax campaign, and after the win, Howard Wolfson told reporters, “We stand ready to assess and assist other local efforts in the coming election cycle.”
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Mike Bloomberg began his years as mayor wanting to save lives millions at a time—but with no firm ideas about what public health would look like under him. Tom Frieden began his years as health commissioner with a goal to save as many New Yorkers’ lives as possible, but with few firm ideas about how to attack tobacco or other major killers. That willingness to go wherever the data pointed them led both men into uncharted territory.
Often that territory was human behavior. The health department could save more lives by persuading New Yorkers to quit smoking, eat healthier food, and keep physically active than by giving them a cabinet full of medicines. Frieden and Bloomberg went there reluctantly. Frieden had come to the job believing in the life-saving potential of medicine, and Mary Bassett and Lynn Silver had to persuade him to join the fray in food policy. Bloomberg resisted meddling in personal choices but looked to his health commissioners to guide him and was unafraid to take a controversial action when he was convinced that it would save many lives.
The treacherous territory of human behavior was strikingly different from what New Yorkers expected the health department to occupy. When Tom Frieden spoke of obesity as an epidemic or said “trans fat kills,” New Yorkers were puzzled and skeptical. Some viewed the health commissioner less as a savior than as an intrusion.
But human behavior is shaped by the world around us. Many of the behaviors that matter most to health involve consuming manufactured products—like cigarettes or soda—that are sold with aggressive corporate marketing. As Tom Frieden put it, defeating tobacco was much harder than defeating tuberculosis “because tuberculosis bacteria don’t bribe politicians. They don’t rebrand themselves as ‘lite’ bacteria. They don’t hire movie stars to make it look cool to have tuberculosis.” Battles with the corporations were inevitable. There was no way to reduce smoking in New York City without cutting into sales of cigarettes, prompting Philip Morris to fight back. There was no way to slow the obesity epidemic or fight heart disease without changing what New Yorkers ate and tangling with Burger King and Coca-Cola. People leading those corporations, even as they understood the dangers of their products, were obligated to resist because their shareholders demanded larger profits.
Most people view health work as genteel and generous, a gift from a kind-hearted person to those in need. But saving lives in America today means fighting to protect people from the pervasive marketing of cigarettes, junk food, and other unhealthy products. In New York City, those fights were worth it.
While the health department’s clashes were always against companies, the press often framed them as battles against average people. New Yorkers didn’t care about trans fats, but the press wrote that Mayor Bloomberg was taking away their French fries. Most New Yorkers endorsed smoke-free bars, but the press treated the Smoke-Free Air Act as a war on smokers. The press cast the battles as government versus citizen in part because the companies fed them that frame. A majority of New Yorkers initially supported “limiting the size of sugary drinks” sold in restaurants, but after the soda companies’ public relations blitz, a majority opposed the attempt to “ban soda.”
Battles like this required a different sort of health department. The health department of 1900 needed epidemiologists, microbiologists, sanitary engineers, inspectors, nurses, and doctors. The New York City health department of 2010 needed economists, lawyers, policy experts, data scientists, community activists, and specialists in using images and words in the mass media. During the Bloomberg years, Tom Frieden and I saw the New York City Department of Health and Mental Hygiene re-creating itself for this new world.
Many who spoke to me for this book remembered their time at the health department as the highlight of their careers. Beth Kilgore, the media director for the antitobacco program, said, “I felt like we were the luckiest health department in the world because we got to really do things. . . . We’ve saved lives. We’ve done the right thing. We have done it for the right reasons. I mean, who can say that about their job?”
“It’s such a powerhouse of a health department,” said Tom Frieden. Winning public health victories with Mayor Bloomberg’s support made its staff “fearless in terms of proposing and trying to get [more] things through.” As Andy Goodman put it, “It was the coming together of the ideas and the political opportunity.” The political opportunity needed ideas, but the ideas needed the political opportunity. Sarah Perl said, “Having done public health under Tom Frieden, at this particular moment in history, is a time that I will look back on in my old age and say ‘You shoulda been there.’”
The reshaping of public health in New York City was contagious. During this period, the New York City Department of Health and Mental Hygiene became the organization that broke news and set a national agenda in public health. Staff from other health departments approached New Yorkers at national meetings to ask, “What’s the next big thing?” New York’s story will likely play out in similar ways elsewhere. I hope so, anyway.
Many of those who led the health department during the Bloomberg years have since taken their ideas to other leadership positions. After leaving New York, Tom Frieden became the nation’s public health leader as director of the CDC. Farzad Mostashari was promoted to national coordinator for health information technology. Amanda Parsons and Susan Kansagra took charge of health promotion for big health care systems. Lynn Silver served as health officer for Sonoma County, California. In 2011 Sonia Angell took over as chief of noncommunicable diseases in the CDC’s Center for Global Health. Mary Bassett, after working on health projects in Africa for the Doris Duke Charitable Foundation for four years, returned as New York City health commissioner under Bloomberg’s successor, Bill de Blasio. When she returned, she brought back Coke McCord as an adviser and Sonia Angell as her deputy commissioner for chronic disease prevention. As of November 2014, most of the others I have featured in this book—including Tom Merrill, Sarah Perl, Beth Kilgore, Maura Kennelly, Christine Curtis, Kevin Schroth, Vicki Grimshaw, and Kelly Christ—continue to work for the New York City health department.
Good ideas in public health are not hard to find. The UN secretary-general is right that the greatest limit to our becoming much healthier is not a lack of ideas or even a lack of money. It is a shortage of leaders who are willing to take action to save lives in the face of determined opposition. As the British medical journal Lancet put it on its cover, “Of all Michael Bloomberg’s legacies to New York, lending his support to the gradual extension of human life may well prove the most meaningful of all.” I hope that other elected officials will follow him.
Back at the United Nations, standing in front of the green marble desk, Mike Bloomberg summed up like this:
First, we’ve learned that changing the social and physical environment is far more effective than changing individual behavior alone. . . .
Second . . . healthy solutions are not necessarily costly solutions. Far from it. New York’s Smoke-Free Air Act, our restrictions on trans fats, and our requirements concerning calorie posting in restaurants cost virtually nothing in public funds to implement. And raising cigarette taxes raises public revenues.
Third, collaboration with the private sector . . . [is] very important. . . .
But fourth and finally, while government action is not sufficient alone, it
is nevertheless absolutely essential. There are powers only governments can exercise, policies only governments can mandate and enforce, and results only governments can achieve. To halt the worldwide epidemic of noncommunicable diseases, governments at all levels must make healthy solutions the default social option.
That is, ultimately, government’s highest duty.
Notes on Sources
The information in this book that didn’t come from my memory came from interviews, health department documents (e-mails, notes from meetings, memoranda, reports, press releases), transcripts of public meetings, and press stories. I have listed the names of the persons I interviewed in my acknowledgments. Below are background and source documents that are publicly available but not easily found.
Chapter 1: “Things are going to get really exciting.”
Tom Frieden spoke about his father and about “the single question that changed my life” in a TEDMED talk in 2012, at https://www.youtube.com/watch?v=rCBXijIXEdY.
Frieden’s tuberculosis control work in New York City in the 1990s is summarized in T. R. Frieden et al., “Tuberculosis in New York City—Turning the Tide,” New England Journal of Medicine 333 (1995): 229–33; and P. I. Fujiwara et al., “Directly Observed Therapy in New York City: History, Implementation, Results, and Challenges,” Clinics in Chest Medicine 18 (1997): 135–48. His work in India is summarized in G. R. Khatri and T. R. Frieden, “Rapid DOTS Expansion in India,” Bulletin of the World Health Organization 80 (2002): 457–63; and G. R. Khatri and T. R. Frieden, “Controlling Tuberculosis in India,” New England Journal of Medicine 347 (2002): 1420–25.
Quotes from Michael Bloomberg during the 2001 mayoral campaign come from “Bloomberg Continues Retreat from Campaign Commercial,” New York Times, June 17, 2001; “Bloomberg Raises His Profile and Promises a New Strategy,” New York Times, September 27, 2001; “Being Mike Bloomberg, Without a Script or a Doubt,” New York Times, July 30, 2001; and “Bloomberg Says Education Can Prevent Illness,” New York Times, July 19, 2001.
Health statistics for New York City are published in the health department’s Summary of Vital Statistics series, at http://www.nyc.gov/html/doh/html/data/vs-summary.shtml.
The effects of cigarette taxes on smoking are reviewed in D. P. Hopkins et al., “Reviews of Evidence Regarding Interventions to Reduce Tobacco Use and Exposure to Environmental Tobacco Smoke,” American Journal of Preventive Medicine 20, no. 2, supp. 1 (2001): 16–66. The price-sensitivity of teenagers is summarized in F. J. Chaloupka and Wechsler H. Price, “Tobacco Control Policies, and Smoking Among Young Adults,” Journal of Health Economics 16 (1997): 359–73.
Articles on physician counseling to quit smoking include N. A. Rigotti, “Treatment of Tobacco Use and Dependence,” New England Journal of Medicine 346 (2002): 506–12; and A. N. Thorndike, S. Regan, and N. A. Rigotti, “The Treatment of Smoking by US Physicians During Ambulatory Visits: 1994–2003,” American Journal of Public Health 97 (2007): 1878–83. Figures on cessation counseling also come from Frieden’s summaries of the research and his estimates in 2002.
The risks of secondhand smoke are summarized in the U.S. Surgeon General’s report The Health Consequences of Involuntary Exposure to Tobacco Smoke (Atlanta: Centers for Disease Control and Prevention, 2006), available at http://www.surgeongeneral.gov/library/reports. Research on the effect of indoor smoking bans is summarized in appendix B-2 of Hopkins et al., “Reviews of Evidence Regarding Interventions to Reduce Tobacco Use.” The effect of home smoking bans is described in J. P. Pierce et al., Tobacco Control in California: Who’s Winning the War? An Evaluation of the Tobacco Control Program, 1989–1996 (La Jolla: University of California at San Diego, 1998) and is summarized in R. C. Brownson et al., “Effects of Smoking Restrictions in the Workplace,” Annual Review of Public Health 23 (2002): 333–48.
Chapter 2: “I need a one-pager on lives saved.”
On the history of the New York City health department, see John Duffy, A History of Public Health in New York City, 1625–1866 (New York: Russell Sage Foundation, 1968), and A History of Public Health in New York City, 1866–1966 (New York: Russell Sage Foundation, 1974). A short summary is Protecting Public Health in New York City: 200 Years of Leadership (New York City Department of Health and Mental Hygiene, 2005), available at http://www.nyc.gov/health.
Coke McCord’s article on mortality in Harlem is C. McCord and H. P. Freeman, “Excess Mortality in Harlem,” New England Journal of Medicine 322 (1990): 173–77.
The risks of secondhand smoke in restaurants and bars are discussed in M. Siegel, “Involuntary Smoking in the Restaurant Workplace: A Review of Employee Exposure and Health Effects,” Journal of the American Medical Association 270 (1993): 490–93; and J. P. Leigh, “Occupations, Cigarette Smoking, and Lung Cancer in the Epidemiological Follow-Up to the NHANES I and the California Occupational Mortality Study,” Bulletin of the New York Academy of Medicine 73 (1996): 370–97.
Data on employment and sales in bars and restaurants in California in the late 1990s were obtained from the state’s Employment Development Department and the California Board of Equalization, respectively.
Chapter 3: “I thought, this nutrition stuff is so controversial.”
Mary Bassett’s short autobiography is in M. T. Bassett, “From Harlem to Harare,” in Anne-Emanuelle Birn and Theodore M. Brown, eds., Comrades in Health: U.S. Health Internationalists, Abroad and at Home (New Brunswick, NJ: Rutgers University Press, 2013).
Geoffrey Rose’s curves appear in his book The Strategy of Preventive Medicine (Oxford: Oxford University Press, 1994).
The chemistry and history of trans fats are described in W. Shurtleff and A. Aoyagi, “History of Soy Oil Hydrogenation and of Research on the Safety of Hydrogenated Vegetable Oils,” available at http://www.thesoydailyclub.com/SFC/MSPproducts501.asp. The health effects of trans fats are described in Letter Report on Dietary Reference Intakes of Trans Fatty Acids (National Academy of Sciences, Institute of Medicine, 2002), available at http://mem.iom.edu/CMS/5410/13083.aspx. Other articles include D. Mozaffarian et al., “Trans Fatty Acids and Cardiovascular Disease,” New England Journal of Medicine 354 (2006): 1601–13; D. B. Allison et al., “Estimated Intakes of Trans Fatty and Other Fatty Acids in the US Population,” Journal of the American Dietetic Association 99 (1999): 166–74; and W. C. Willett and A. Ascherio, “Trans Fatty Acids: Are the Effects Only Marginal?” American Journal of Public Health 84 (1994): 722–24.
The health department’s nicotine patch distribution program is summarized in N. Miller et al., “Effectiveness of a Large-Scale Distribution Programme of Free Nicotine Patches: A Prospective Evaluation,” Lancet 365 (2005):1849–54.
The telephone survey started by Farzad Mostashari was called the Community Health Survey, and its annual results can be queried through the health department’s EpiQuery tool at https://a816-healthpsi.nyc.gov/epiquery.
Information about the first-year impact of the Smoke-Free Air Act appears in the health department’s The State of Smoke-Free New York City: A One-Year Review, available at http://www.nyc.gov/html/doh/downloads/pdf/smoke/sfaa-2004report.pdf. Revenue from the city’s cigarette tax can be found in the Comprehensive Annual Financial Report of the Comptroller, available at http://comptroller.nyc.gov/reports/comprehensive-annual-financial-reports. The academic article on the Smoke-Free Air Act is C. Chang et al., “The New York City Smoke-Free Air Act: Second-Hand Smoke as a Worker Health and Safety Issue,” American Journal of Industrial Medicine 46 (2004): 188–95, and the article summarizing the early success of smoking program is T. R. Frieden et al., “Adult Tobacco Use Measures After Intensive Tobacco Control Measures,” American Journal of Public Health 95 (2005): 1016–23.
The entire New York City Health Code is available at http://www.nyc.gov/html/doh/html/about/health-code.shtml, and the City Charter at http://www.nyc.gov/html/charter/downloads/pdf/citycharter2004.pdf.
Chapter 4: “We were failing and we didn’t know why, and we had to succeed.”
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The effect of the FTC’s application of the Fairness Doctrine to cigarette advertising is described in K. E. Warner, “The Effects of the Antismoking Campaign on Cigarette Consumption,” American Journal of Public Health 67 (1977): 645–50, and in chapter 12 of National Cancer Institute, The Role of the Media in Promoting and Reducing Tobacco Use, Tobacco Control Monograph no. 19 (Washington, DC: U.S. Department of Health and Human Services, National Institutes of Health, 2008), which also summarizes the evaluations of antismoking campaigns described in the chapter. Many of the antismoking ads that the health department ran beginning in 2006 are on the World Lung Foundation’s website http://www.worldlungfoundation.org. The department’s early ad campaign and the smoking trends after them are summarized in J. A. Ellis et al., “Decline in Smoking Prevalence—New York City, 2002–2006,” Morbidity and Mortality Weekly Report 56 (2007): 604–8.
Results of Quinnipiac University’s polls of mayoral approval are at http://www.quinnipiac.edu/news-and-events/quinnipiac-university-poll/new-york-city.
The Americans for Nonsmokers’ Rights posts data and reports on smoke-free laws at www.no-smoke.org. An early story on smoking bans in Europe is “Antitobacco Trend Has Reached Europe,” New York Times, August 11, 2003.
Much of Tom Frieden’s original proposal for global tobacco control is contained in the slide set How to Prevent 100 Million Deaths from Tobacco, at www.globaltobaccocontrol.org/node/11045, and in T. R. Frieden and M. R. Bloomberg, “How to Prevent 100 Million Deaths from Tobacco,” Lancet 369 (2007): 1758–61. The announcement is summarized in a press release at http://www.tobaccofreekids.org/pressoffice/BloombergRelease.pdf and in “Where There’s Smoke There’s Ire, and the Mayor’s Cash,” New York Times, August 16, 2006.
