The Activist Commissioner

Across Worth Street from Thomas Paine Park in lower Manhattan is a towering building, home to another passionate idealist: Thomas R. Frieden, commissioner of the New York City Department of Health and Mental Hygiene. Since being named commissioner by Mayor Michael R. Bloomberg in January 2002, Frieden has pursued an unapologetically aggressive public health agenda targeting tobacco, HIV and chronic diseases, among other priorities. From his office in Room 331 (with its silver bowl of free condoms), Frieden led Mayor Bloomberg's successful push in 2002 to raise the cigarette tax and eliminate smoking in the workplace. Today, there are nearly 200,000 fewer smokers in the City, which will mean about 60,000 fewer early deaths, according to Frieden, MD, MPH. "He is a very activist commissioner who has a big, ambitious vision for what a city health department can do," says Dean Emeritus Alfred Sommer, MD, MHS '73, who led the search committee that recommended Frieden to Mayor Bloomberg. "It has been a very happy marriage between an activist commissioner who wants the department to lead in critical areas of public health and a mayor willing to do that despite the financial and political costs." Frieden's leadership of the 6,000-employee department and its $1.6 billion budget has had a global impact on the urban health agenda. One example: More than a dozen states and a dozen countries have followed New York City's lead in making workplaces smoke-free.

You're responsible for the health of 8 million people—how do you decide what your priorities should be on a given day?

One of the challenges anywhere in the public sector is keeping a proactive agenda because there are always crises. There's a blackout right now in Queens affecting tens of thousands of people. We're very worried about heat-related problems and food safety. At the same time, we need to move forward with a proactive agenda. We've established a health policy called Take Care New York, which are the 10 things that every New Yorker should do [to protect their health] and that we can make the most difference in. [Editor's note: For more information about Take Care New York, which advocates having a regular doctor, knowing your HIV status, etc., go to: www.nyc.gov/html/doh/html/tcny/index.shtml.]

You're known for a muscular approach to public health—even being accused of wanting to create a "nanny state" or heading up the "sugar police"—how do you balance public health needs with America's individualist, democratic culture?

First off, your right to swing your fist ends at my nose. So for things like secondhand smoke, your right to exhale tobacco smoke ends in somebody else's workplace. You don't have the right to expose them to cancer-causing chemicals. Period. ...Take our diabetes program, which has been somewhat controversial. We're the first place in the country to require laboratory reporting [to the health department] of certain diabetes results—the A1C results that monitor treatment effectiveness over several months. That will allow us to understand where people are not being well treated for diabetes and to help their providers do a better job of treating them. We're in an epidemic of diabetes. Our rate has doubled in the past decade. It's increasing as a cause of death, and we estimate that over 100,000 people with diagnosed diabetes have very poor levels of control of their blood sugar. We need to fix that problem to deal with the current epidemic.

Over the next 20 years what will be the biggest issues in urban health?

Tobacco remains the leading preventable cause of death in this city and globally. We can make a lot more progress than we already have made. Obesity is a serious and rapidly worsening problem. I don't think we have determined what we need to do to change it. Obesity isn't epidemic because of a change in our genetics. It doesn't arise because people have become more gluttonous. We are hardwired to like sweet and salty foods. What's changed is our environment and especially our food environment. The only way we're going to stop this epidemic—and it is an epidemic—is to change our food environment.

What do you mean by "change the food environment"?

Make healthy food cheaper and make lousy food relatively more expensive, particularly sugar-sweetened drinks such as sodas.

So, a tax on sweets?

Or a pricing change. You wouldn't necessarily need to do it with a tax. If you just had a different pricing structure, you could potentially maintain profits of the food industry and change consumption.

You've been quoted as saying, "When anyone dies at an early age from a preventable cause in New York City, it's my fault." Do you really believe that?

I really believe that. There are about 9,000 preventable, premature deaths in New York City each year, and if we did a better job of HIV prevention, cardiovascular disease prevention and treatment, cancer screening, many of them—not all of them—could be prevented.

What special challenges do you face in protecting the health of such a large, international city?

We are a microcosm for the world in many ways. Almost 200 languages are spoken here. If there is a high TB rate in some country, we might see that here sometimes before that gets recognized in the home country. Resistant malaria—we might recognize it here before it's recognized in the home country. We see so much of what's going on globally. At the same time, our immigrant population faces particular challenges in terms of access to health care, and the obesogenic environment of the United States. We found that among immigrants, the longer they live here, the more overweight many of them become. So in some ways, we have a toxic environment.

How do you enjoy working with a mayor who has a school of public health named after him?

Quite frankly, most politicians don't know what public health is. When I met him, I realized that not only does he care about public health, but he really understands it. He fundamentally gets it. That is very exciting. When I've had to go to him with tough issues, whether it's smoke-free workplaces or [when] we expanded syringe exchange programs, he's asked me one question: "Is it going to save lives?" And if the answer is yes, he says, "Do it." It's really regardless of the politics. It's not often in government that you have that kind of opportunity. It's about as close to a golden age of government as you can come these days.

What do you want your legacy to be?

[By the time I leave] we should have established an information system that will allow us to track and improve the health of all New Yorkers. We should have significantly reduced tobacco use and other leading causes of death. We should have made real progress in health disparities in the sickest neighborhoods of New York City. And we should have made progress or set the stage for progress for all of the leading preventable causes of illness and death. Not too ambitious.