Not long after he compared tobacco executives unfavorably to tuberculosis bacilli, Dr. Thomas Frieden got a letter from a senior vice president at Philip Morris U.S.A.
“To have the New York City Health Commissioner describe any group of human beings as a ‘low-life form’ is especially inappropriate,” the executive wrote. “Such statements have been used throughout history to justify the worst kind of bigotry.”
Dr. Frieden thought about it. He realized Philip Morris was right.
“Now I stick to, you know, unemotional language,” he told The Observer one recent morning in his sunny office. “I describe them as mass murderers.”
Dr. Frieden, whom Mayor Michael Bloomberg installed to run the city’s Health Department in 2002, has a license to step on toes. That’s because when it comes to telling New Yorkers about their own best interests, Dr. Frieden serves as Mr. Bloomberg’s uncompromising id, pushing the Mayor to follow his instincts. The intensely private doctor and the bon vivant billionaire agree so fundamentally that one top aide to the Mayor described their relationship as “mind-meld.” They share a confidence in their own actions, a sense that-in Mr. Bloomberg’s terms-the most important judgment comes “when I look in the mirror.”
That common ground between the two men is also the ethic of public health, to which Mr. Bloomberg has devoted so much of his personal fortune that the nation’s leading public-health school, at Johns Hopkins University, was recently renamed for him. Public health lacks the glamour of other areas of medicine and philanthropy; it is defined by a bird’s-eye view of society and a scorn for conventional wisdom and political necessity.
Those who take up the field of public health are not always appreciated at the ground level, noted Alfred Sommer, dean of the Bloomberg School of Public Health. “The people they’re helping may not know it and, in fact, may even be irate,” he said of his peers in public health.
There is, of course, another way of looking at the public-health mentality, and seeing in it the autocratic tradition of the temperance leagues and worse. That’s how many bar owners see it.
“Frieden acts as if he’s been appointed by God to save the world from secondhand smoke,” complained Brian Nolan, who heads the United Restaurant and Tavern Owners of New York. Dr. Frieden was the architect of the city’s 2002 bill banning smoking in all workplaces, including bars and restaurants, which has been generally popular despite bitter complaints from smokers, libertarians and bar owners.
Love him or hate him, Dr. Frieden is a rare visionary in an administration made up largely of skilled technocrats. A 43-year- old whose soft, sonorous voice contributes to the impression that he’s 10 years younger, he writes his day’s tasks in a tiny doctor’s scrawl on folded index cards. When he hands over the Health Department to his successor at some future date, he may have changed the city more deeply than any other member of an administration that will be remembered, in large part, for his hard line on smoking.
But before he became the scourge of the tobacco industry, Dr. Frieden made his name convincing sick people to take their medicine. His method was a system called “directly observed treatment,” a classic of public-health methodology whose hands-on paternalism and life-saving potency has made it the global standard for fighting tuberculosis.
Dr. Frieden began using the methods soon after he arrived in New York in 1990 as a young staffer from the Centers for Disease Control. One doctor at Harlem Hospital, Karen Brudney, had been raising the alarm about an epidemic of drug-resistant tuberculosis.
“Tom came to New York to do something else, and he immediately recognized that TB was a hideous problem,” recalled Dr. Brudney, now the director of Columbia Presbyterian’s Infectious Diseases Clinic.
Dr. Frieden was made assistant health commissioner responsible for TB control in 1992. He led a program so ambitious that it sent outreach workers into crack dens to give patients their medicine, and so insistent that a handful of patients were confined to a “TB jail,” a locked ward on Roosevelt Island, until they were cured. Dr. Frieden’s uncompromising style bruised some egos, but his program beat the epidemic, and he became one of the world’s experts on combating tuberculosis. In 1996, he moved to New Delhi, India, to lead a World Health Organization program combating a TB epidemic there. Dr. Frieden said that local doctors had come to see the problem “just like the weather: You can describe it, maybe predict it, but you can’t do anything about it.”
The India program saved, by his estimate, half a million lives.
After the New York and India projects-along with regular publications in journals like the Journal of the American Medical Association and The Lancet -Columbia University’s Mailman School of Public Health tried to lure Dr. Frieden back to New York for a professorship. But Dr. Frieden and his wife had already sold their apartment on East Fifth Street and had no plans to return.
So he was in his office in New Delhi when an e-mail from Dr. Sommer arrived regarding a job in the Bloomberg administration. When he talked to the Johns Hopkins dean on the telephone, Dr. Frieden made one thing clear: “I told them if the Mayor is willing to take on the tobacco industry I’ll come back, but if he’s not there’s no point.”
This came as something of a surprise to Dr. Sommer. “Tom, did you hear about 9/11?” he thought to ask. “Your top priority isn’t going to be bioterror?” But Dr. Frieden told him that tobacco would “kill more people than bioterror ever will,” Dr. Sommer recalled.
Dr. Frieden prides himself on relying on hard data, and smoking is far and away the leading cause of preventable deaths in the city, associated with 10,000 deaths in New York each year. After wowing a search committee with the fluent Spanish he picked up during stints in Nicaragua in the 1980’s, Dr. Frieden soon sat down with the Mayor-elect.
“He and the Mayor had a mind-meld” on smoking, said Peter Madonia, Mr. Bloomberg’s chief of staff. “Tom laid out why it was an important health initiative, and the Mayor at that point was on board, agreed, and has never wavered.”
That put New York’s retail tobacco industry in much the situation Saddam Hussein found himself in when his bitterest enemies entered the Pentagon in 2001: The ax hadn’t fallen yet, but it was just a matter of time. Since then, Dr. Frieden has overseen a tax hike on cigarettes (stopping 50,000 premature deaths, by his count) and a massive distribution of smoking-cessation patches (11,000 people quit, forestalling 1,700 premature deaths) along with the smoking ban (another 11,000 premature deaths).
What exactly does Dr. Frieden think should be done about tobacco? Asked if it should be legal to sell cigarettes at all, he said, “No,” then demurred: “I don’t think making cigarettes illegal is within the realm of possibility or practicality.”
Anyway, Dr. Frieden is open to compromise. “You know, if [cigarettes] were nicotine-free … and there were no advertising for them, then it’s a free choice,” he mused. But the status quo of massive tobacco-marketing budgets is “legal drug-pushing, and that shouldn’t be legal.”
If the government can’t outlaw cigarettes entirely, Dr. Frieden added, he recently heard another “interesting idea: that the tobacco companies essentially be nationalized, all advertising be stopped, and cigarettes be provided to the people who are addicted and can’t get off.”
It’s enough to give a tobacco executive, even a nonsmoking one, heart failure. And more diplomatic city officials-or those on tighter leashes-might eschew such speculation. But it’s a sign of Dr. Frieden’s influence and Mr. Bloomberg’s hands-off style that the commissioner says exactly what he likes. (“I don’t even try to control him. I just let him say what he thinks,” interjected his spokeswoman, Sandra Mullin, at one point during an interview in his office.)
The thing is, Dr. Frieden’s not trying to make headlines. His smooth, triangular face looked a little pained as he shared his views on smoking. He also seemed puzzled as to why other govern-by-numbers, politics-be-damned initiatives-from saving money by eliminating school nurses to pushing for a needle-exchange program in conservative Queens-have generated such a fuss. Much of the rest of his work has been impolitic in its mildness. Dr. Frieden has been unwilling to launch an expansive crusade against the current hot disease, obesity, for the simple reason that the data won’t support one, he says.
“The sad fact today is that we know that we’re in the midst of a horrible obesity problem, and we don’t know what’s causing it, and we don’t know what to do about it,” he said. Of course, a lack of randomized, controlled studies hasn’t stopped health officials around the country from declaring bold initiatives against obesity in high-profile press conferences.
But it’s his war on smoking for which New Yorkers will judge Dr. Frieden. And he takes solace in the career of an illustrious forgotten predecessor, Hermann Biggs, who built the city’s Health Department at the end of the 19th century. Biggs was a crusader against tuberculosis, and he outlined a program not unlike the therapy that is now standard. His demands for centralization and disclosure made him enemies in the medical establishment, who denounced the “aggressive tyrannies of the Health Board,” according to an article on Biggs which Dr. Frieden published in The Lancet . When criticized for the smoking ban or other, smaller controversies, Dr. Frieden can take solace in the notion that history may judge him as it has Biggs.
“Nobody ever had a rally on the City Hall steps to promote the general good,” he said. “In some ways, public health is inherently unpopular.”