by Tom Farley
The analogy was this: think of smoking as a disease. Among smokers who weren’t “cured,” that disease was fatal about one-third of the time. But the disease was treatable. If doctors spent as little as five or ten minutes counseling their patients to quit smoking, Frieden gleaned from research papers, the patients were 50 percent more likely to quit. Giving smokers nicotine patches, nicotine gum, or other medications increased the quit rate even more. Smokers visited doctors often, but their doctors did a terrible job of treating smoking, asking only about two-thirds of them about their habit, counseling only about one-fifth of them to quit, and treating only 2 percent of them with medications.
Frieden put some numbers into a spreadsheet and did another quick estimate. Close to 200,000 of the city’s million-odd smokers “could quit with better care,” he figured, and if they did, it could save nearly 60,000 lives. All he needed to do, then, was get New York City’s doctors to ask every single patient if he or she smoked and to provide counseling to all the smokers who wanted to quit.
The idea was more than ambitious. Shelley thought it delusional. To most doctors, counseling patients to quit smoking was a waste of precious time. And even if counseling increased quitting by from 4 to 6 percent, the result would still be a 94 percent failure rate. And the health department had little leverage over doctors anyway.
Frieden wasn’t deterred. After all, if the Indian medical system could treat a million people for tuberculosis, why couldn’t the New York City medical system treat a million people for smoking?
He tried to provoke doctors into thinking differently by writing a newsletter to them. At the bottom of the first page he wrote in boldface, “Failure to provide optimal counseling and treatment is failure to meet the standard of care—and could be considered malpractice!”
The state medical society was incensed. “That cannot possibly be what our city health policy is,” its lawyer told the New York Post. Some doctors responded with angry letters and phone calls. Their patients were dealing with lots of health problems, the doctors said, and they were doing the best they could to address them all. Besides, doctors weren’t being paid to counsel smokers.
As Frieden probed for ideas, Donna Shelley had more conflicts with him. “He started with some very weird policy ideas that were not mainstream,” she said. But mostly, she was frustrated by his style of demanding information and making decisions without telling her what he was doing, let alone listening to her advice. After her earlier fights in the department she had considered leaving the agency, and now she quit.
• • •
Gracie Mansion is a Victorian house set in a grassy wooded park overlooking the Hudson, an island of space and tranquility in blaring Manhattan. It is traditionally the mayor’s residence, but Bloomberg passed over it in favor of his Upper East Side townhouse. In May 2002, Tom Frieden hosted a round table meeting at Gracie, with smoking experts from universities, advocacy organizations, and health departments in Massachusetts and California. The location told everyone that the meeting was important and that Frieden had the support of the mayor.
During the months before the round table, Frieden read voraciously about smoking prevention and tested his evolving ideas on various experts, from mainstream thinkers to those on the fringe. Although he said the purpose of the Gracie meeting was to get others’ opinions, by the time he held it, he already had a detailed slide deck on smoking in New York City and what he proposed to do about it.
His proposal had five pieces: taxation, legal action, education, cessation, and evaluation. He celebrated Mayor Bloomberg’s tobacco tax proposal, which was coming up for a vote soon, mentioned expanding the indoor smoking ban to “all workplaces,” said the city might “pursue litigation” against the tobacco companies, suggested he would “educate providers on cessation options,” and promised to track smoking rates with an annual telephone survey.
The experts told Frieden that coaxing doctors to do a better job treating their smoking patients would be an uphill slog. It wasn’t just because of doctors’ “colossal ignorance” but also because the insurance plans didn’t pay them for it. The Massachusetts people touted their tough antismoking television ads. The Californians promoted their new state law prohibiting smoking in bars and restaurants. The group warned Frieden to avoid taking “over the top” steps like banning smoking outdoors in parks.
The health commissioner took one thing from the meeting: “What really came out was smoke-free [policies]. That smoke-free was a wedge issue. You would change social norms, you would get smokers to quit, and you protect nonsmokers.”
Of course, indoor smoking bans protect nonsmokers from getting lung cancer from secondhand smoke, but they have also had surprising spinoff benefits. In the 1990s, when some hospitals and other employers banned smoking indoors, researchers noticed that smokers weren’t just going outside to smoke. Many were quitting. And nonsmoking employees were deciding that if secondhand smoke was dangerous at work, they didn’t want smokers around them anywhere else. The rules started to make smoking socially unacceptable, which appeared to be driving down smoking rates overall.
The experts left the round table excited that the mayor of New York and his new health commissioner were joining the fight against tobacco. Donna Shelley, who joined the meeting as an outside expert, was stunned at how, after his early oddball ideas, Frieden now grasped the state of the science. “I remember really admiring him,” she said later. “I remember feeling like maybe I shouldn’t have left. Things are going to get really exciting.”
By the end of the meeting, Frieden had a plan that he hoped would save the lives of tens of thousands of New Yorkers. And he knew what dragon he would slay first. He was going to pass a law banning smoking in some 13,000 bars and restaurants, all of whose managers would hate it.
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“I need a one-pager on lives saved.”
Tom Frieden ended many of his lectures with a quote from Dr. Hermann Biggs, a medical officer in the late 1800s and early 1900s who pleaded for New York City to invest in prevention: “Public health is purchasable. Within natural limitations, a community can determine its own death rate.” For over twenty years, Biggs led the health department through its high point in battling infectious diseases. He founded the city’s bacteriology laboratory and was one of the first to test for the bacteria that cause tuberculosis and cholera. He stopped an epidemic of typhus by quarantining immigrants arriving with the disease. In 1897 he persuaded the Board of Health, over fierce resistance by the city’s physicians, to require doctors to report the names of their patients with tuberculosis to the health department. That act enabled Frieden to control tuberculosis almost a century later.
In the 1800s cities were hives of contagion. In those early days of the industrial revolution, people for the first time crowded near factories, packing filthy tenements without plumbing or waste disposal. The lack of running water spread dysentery and cholera, and the poor ventilation spread tuberculosis. Epidemics of yellow fever cropped up as mosquitos thrived in newly cleared, swampy land close to humans.
To prevent those diseases, the city needed to issue orders, particularly for quarantine and sanitation. It was yellow fever that prompted New York City’s Common Council in 1805 to establish a Board of Health with the powers to write those orders. At first, the board consisted of the mayor and a committee of aldermen. During epidemics of cholera and dysentery in the 1830s to 1860s, those elected officials earned a reputation as too corrupt and ineffective to protect the citizens. Quarantining ships hurt business, and as one New Yorker put it, the board was “more afraid of merchants than lying.”
After the Civil War, reformers in New York State took the responsibility for health away from corrupt city politicians and gave it to an appointed Metropolitan Board of Health, requiring at least three of the nine members to be physicians. The new professional board had great power “for the purpose of preserving or protecting life or health, or preventing disease,” and it could call on the city�
�s police or its own inspectors to enforce its orders. Within a few years, the city wrested control of health back from the state, but the board kept its police powers and its professional, appointed structure. To enforce the board’s orders, the city created a permanent health department, run by city’s health commissioner, who also chaired the board.
After Hermann Biggs’s day, the major infectious disease epidemics all but disappeared. Health departments around the country shifted to chasing less-common infectious diseases, first those preventable with vaccines, like diphtheria and whooping cough, and then those curable with antibiotics, like syphilis. To this day, every city health department has a unit to fight outbreaks of infectious diseases, no matter how small. In New York City, outbreaks of salmonella infection from contaminated food happen monthly, the mosquito-borne West Nile virus arrived in 1999, and the biggest infectious outbreak of them all, AIDS, landed in 1979. Those outbreaks can still terrify people and launch the health department into action, as when a single man was diagnosed with Ebola in New York City in 2014. One Friday in 2002, Mayor Bloomberg’s chief of staff Peter Madonia glimpsed that fear. Frieden called to say, “We have somebody with bubonic plague in the hospital.” Madonia said later, “I told him, ‘Tom, nobody’s used those words in five hundred years! What are you talking about!’”
As frightening as infectious disease outbreaks are, by the 1950s chronic diseases like heart disease and cancer were killing many more New Yorkers, so the city’s health leaders had to rethink their mission. “Infectious diseases were largely under control,” wrote Leona Baumgartner, the city’s health commissioner from 1954 to 1962. “The limited goals of the current public health needed stretching.” But because chronic diseases roused little panic, for the remainder of the century health departments received little funding to take them on. Most health departments promoted healthy behavior, usually by distributing pamphlets, but that didn’t do much. In 2002 it fell to Tom Frieden to persuade people that, in this modern era, public health was still purchasable and that he knew how to buy it.
• • •
Even before he came back to New York City, Frieden began pestering people he trusted to join him at the health department. One person dropped into his lap.
When Frieden was a medical student, he had met Colin “Coke” McCord, a chest surgeon who was the father of one of his classmates. By then McCord had spent decades on health projects in destitute areas of the world. When I first spoke to McCord in 2009, he had just returned from Tanzania, where he had been training lay health workers to do cesarean sections. At nearly eighty-one, he reminded me, with his genial manner and warm airy voice, of a left-wing Ronald Reagan. McCord had spent a short time in Vietnam in the 1960s as a civilian providing medical care to the Vietnamese, and according to a colleague, it had “radicalized” him. A few years later he abandoned his surgery practice in New York to run projects in primary medical care in India and then in Bangladesh. In 1980 he moved to Mozambique, where the socialist-inspired government, after defeating its Portuguese colonialists, was building a primary health care system.
He returned to the United States in the mid-1980s, landing at Harlem Hospital. There he quickly published a paper in the New England Journal of Medicine showing that African American men in Harlem had a shorter life expectancy than men in Bangladesh. Once when McCord was “kind of passing through” Nicaragua to see what the Sandinistas were up to, he bumped into Tom Frieden, who asked him to write an article for his newsletter. That led to McCord becoming a mentor to Frieden.
When Frieden took over the health department in 2002, McCord had just retired. With time on his hands, the older man called Frieden to ask if he could help. When Donna Shelley quit, Frieden asked McCord to run the antitobacco program. It was the first of several temporary positions the commissioner would assign to McCord over the next few years, calling him his “utility infielder.” But others recognized that McCord acted more like a sage. Frieden could get lost in the details, but “Coke helped give Tom clarity.”
“I’m good at giving advice on what to do,” McCord told me, “but not so good at doing it.”
Frieden also hired a young assistant, Christina Chang. The daughter of Taiwanese immigrants, Chang at first knew little about public health, but she had the brainpower and, more important, the straight-A-student eagerness for hard work and long hours that Frieden demanded. Even she found his pace tough to handle, though. Already rail thin, “I lost five pounds in the first few weeks just trying to keep up.”
At the time, banning smoking in bars was a radical idea. When Chang heard Frieden’s plan, “I was shocked by the ambition,” she later recalled. “That’s when I thought Tom was really crazy.” In 1995 New York City had prohibited smoking in bigger restaurants but still allowed it in smaller restaurants, in bars, and in restaurants with their own bars. California and some towns in other states had banned smoking in bars, but in the rest of the country, bars existed almost as much for smoking as they did for drinking. But, Chang said, “I thought it wasn’t my job to doubt. It was my job to try to figure out how to convince.”
Frieden gathered his team and asked what arguments they needed to rebut. He intended to bring scientific data to bear on each of them. The first argument was that secondhand smoke was merely a nuisance. In fact, secondhand smoke—a mix of carbon monoxide and fine particles that are proven carcinogens—caused not just lung cancer but also heart attacks. The CDC estimated that secondhand smoke was responsible for 50,000 deaths a year nationally, which translated to more than 1,000 deaths a year in New York City. That was more than the number of city residents who died each year from homicide.
Even if the policy makers recognized that secondhand smoke was dangerous, they might reject a ban since people could just avoid smoke-filled bars. Frieden’s team decided to highlight the injustice for people who didn’t have that option. Waiters, waitresses, and bartenders couldn’t leave when a customer lit up and couldn’t afford to quit working. The team dug through scientific reports for the most powerful words to explain the risk. “Working 8 hours in a bar is equivalent to smoking 16 cigarettes,” they wrote. “Bartenders have higher rates of lung cancer than firefighters and miners.”
The toughest argument to rebut was that a smoke-free law would hurt the restaurant and bar business. Given the opposition that Frieden’s team expected, this was also the most important one. They found numbers showing after California passed its smoke-free laws, sales in restaurants and bars—as well as the number of employees—actually grew faster.
To deflect Mayor Bloomberg’s political advisers, the team produced other kinds of numbers. The nonprofit organizations that Donna Shelley had funded had commissioned a poll that showed that New York City voters liked the idea of smoke-free bars (57 percent) and loved the idea of smoke-free restaurants (84 percent). By two-to-one margins, New Yorkers said if restaurants and bars were smoke-free, they would actually be more likely to go there.
Frieden also wanted to count the number of smoking-related deaths his ban might prevent—or as he saw it, the number of lives it would save. That was the number, ultimately, that mattered most. The department’s epidemiologists told him that there were just too many unknowns to make that kind of estimate. So he did what he did whenever someone gave him an answer he didn’t like; he turned to someone else.
Farzad Mostashari was, like Frieden, a graduate of the CDC’s Epidemic Intelligence Service program. Also like Frieden, he had spent his two EIS years as a disease detective in New York City’s health department. Born in the United States, Mostashari had been raised in Iran, where as a child he witnessed the excitement of the revolution that ousted the shah. Afterward he returned to the United States and graduated magna cum laude from Harvard and Yale Medical School. He was another numbers guy, only more abstract. If posed a question, he tended to stare off into space, rub his hand over his scalp, and restate the question as something much larger. By the time he had the answer, he had invented something new.
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br /> Frieden told him, “I need a one-pager on lives saved” from the smoking ban.
“I had no fucking idea what he was talking about!” Mostashari later remembered. But after thinking about it, he was able to cobble together a mathematical model based on the impact of secondhand smoke on mortality and the difference in death rates between smokers and nonsmokers. Over the lifetimes of people who spent time in smoky places, he estimated, smoke-free air laws would prevent more than 11,000 smoking-related deaths: 4,000 in nonsmokers who would no longer breathe secondhand smoke and 7,000 in smokers who would quit. It was an odd model. Most of the lives wouldn’t be saved for years. And the model counted only people who spent time in smoky workplaces in 2002, not people who would work there in the future. But it was an estimate that Frieden could defend, so he went with it.
The health commissioner then had to persuade Bloomberg’s City Hall lieutenants to let him pitch the idea to the mayor. Those advisers included press officer Ed Skyler, chief of staff Peter Madonia, deputy mayor for economic development Dan Doctoroff, and deputy mayor for operations Mark Shaw. None of them questioned the health benefits. But all were dead opposed.
Ed Skyler was convinced that the public backlash would sink them. When people went to a bar, they expected others to smoke. That’s what you did in a bar. Average New Yorkers would hate the law, so they would flout it, and the city wouldn’t be able to enforce it.
Peter Madonia, who was managing fallout from the post-9/11 budget crisis, thought the timing couldn’t have been worse. “You only have so many political chits in your honeymoon,” he said years later. “Not all of us thought it was a really good idea in the context of a $7 billion dollar deficit where you’re going to raise people’s [property] taxes 18.5 percent, lay off sanitation workers, cut a class of cops, and close six firehouses. . . . And now you’re going to tell people you can’t smoke in a bar. Like, who the fuck needs this now?”