New York City health commissioner Thomas Frieden unveils daring strategies in his quest for a healthier public.
He says he will never forget the moment his cell phone began “ringing off the hook.” Or the panicked voice on the other end of the line: “Dr. Frieden, have you heard the news yet? Is your family all right?”
It happened on a hot, dusty afternoon five years ago, as Dr. Thomas R. Frieden ’82 was clattering along a dirt road in the West Bengal region of eastern India. His white Jeep—marked with the insignia of the World Health Organization—was en route to one of the hundreds of tuberculosis clinics that Frieden had helped establish across the country in the late 1990s.
An international expert on managing epidemics of multidrug-resistant tuberculosis (MDR TB), Frieden, then 40, had spent the previous five years helping to build an immense public health system that was later credited with saving the lives of more than 1 million Indian patients with the disease.
On this particular afternoon, Frieden was visiting a series of clinics along the vast, windswept plain that stretches northwest from Calcutta. There, 80 million people inhabit monsoon-lashed villages and sprawling tea plantations that give the region its distinctive character.
Accompanied by a reporter with the Economist, the former Oberlin summa cum laude philosophy and pre-med student (who describes writing his 200-page honors thesis on Wittgenstein as a “thrilling experience”) was bouncing along a dirt road when his Nokia suddenly came alive.
The caller was an Indian physician whom Frieden had often visited in his campaign to help improve tuberculosis care. With growing disbelief, Frieden struggled to make sense of his colleague’s frantic report about the crash of a jet airliner into a tower at the World Trade Center in New York City. “I couldn’t believe what he was telling me,” Frieden would recall later. “I kept thinking: ‘No, it’s impossible. There must be some mistake.’”
But there was no mistake. Within a few minutes, the dusty Jeep was screeching to a halt beside a paint-peeling, small-town hotel—where the two men jumped out and raced into the lobby in search of a television.
For a few maddening seconds, the TV at the hotel refused to work. But then the screen abruptly lit up. The two travelers watched in horrified amazement as a second passenger jet slammed into the Word Trade Center, triggering a massive fireball that flared across the screen.
The date, of course, was September 11, 2001—and within a few hours of watching the attacks on the World Trade Center, Tom Frieden realized he wanted to go home.
A native New Yorker, the Columbia University-trained physician had always loved his city. After five years of working 12-hour days—often six and seven days a week—to help build the massive TB screening and treatment program with the Indian government, he was convinced that “the work had come to a natural stopping point.” By the fall of 2001, the TB program already covered half of India, and the funding, plans, and expertise were there to cover the rest of the country.
“I remember thinking again and again in the weeks that followed 9/11: ‘Maybe it’s time to go back to New York.’”
Destiny stepped in.
As it turned out, incoming New York Mayor Michael Bloomberg was looking for a new health commissioner, and he’d been hearing some very good things about Tom Frieden, the super-intense and hard-charging public health wunderkind who’d earned praise a few years earlier by stopping a surging New York epidemic of multidrug-resistant TB in its tracks.
As director of New York City’s Bureau of Tuberculosis Control in the mid-’90s, Frieden had implemented a uniquely effective treatment technique that had reduced the city’s drug-resistant tuberculosis by 80 percent. How? By working tirelessly to build a system that allowed public health authorities to ensure quality care for every single TB patient in the city by holding all involved in the effort—from medical school professors to outreach workers to patients—accountable for good patient outcomes.
Mayor Bloomberg, himself a passionate health crusader who had recently donated millions of dollars to strengthen the school of public health that now bears his name at Johns Hopkins, was deeply impressed by Frieden’s track record. Would the youthful doctor be interested in taking on a new public health challenge: becoming the top medical officer in the Big Apple?
It was an offer the relentlessly upbeat Frieden couldn’t refuse, and he was sworn in on January 29, 2002.
His remarkable career as one of the nation’s most proactive, innovative—and sometimes infuriatingly confrontational public health officials—was now underway.
During the next few years, while directing a staff of more than 6,000 and a yearly budget exceeding $1.6 billion, Frieden won kudos around the nation for implementing a series of cutting-edge, data-based innovations that are providing major health payoffs for the city’s 8 million residents.
Among them was an ambitious, citywide system for surveying public health, designed to “take the vital signs” of the city. Frieden believes in “finding the answers you need in the data,” and he is committed to the increasingly influential medical-treatment strategy known as “evidence-based medicine” as a tool for solving public health problems. The data collected by his team led to the quick development of a health policy called Take Care New York. It’s the first-ever urban health initiative to broadly measure, and then set, city-specific plans and targets to control infections and chronic health conditions such as high blood pressure, diabetes, high cholesterol, tobacco addiction, alcohol dependency, and risky sexual behavior. “Before you can successfully address a patient’s health needs, you have to understand exactly what those needs are,” he says. “Our program is designed to monitor, track, and hold ourselves accountable for improving health.”
Frieden also led the development of comprehensive “community profiles” for 42 neighborhoods in the five boroughs of New York. Built atop vast collections of patient data, the “profiles” describe each neighborhood and detail its efforts to achieve key health objectives for residents, including having a doctor, being smoke-free, getting HIV tests, monitoring and preventing depression, preventing cancer, and verifying that homes are free of lead and its residents free from violence.
Among Frieden’s more controversial moves was the launching in 2002 of a citywide anti-tobacco initiative that included raising the local tax on cigarettes and prohibiting smoking in virtually all work spaces, including 20,000 bars and restaurants.
Says Frieden, who’s been fiercely vilified by the tobacco industry for his bluntly aggressive attack on cigarettes: “I was once quoted, accurately, as saying that during the years I spent fighting TB, my enemy was a micro-bacterial—tuberculosis—but now it’s an even lower form of life: tobacco executives! An executive from Phillip Morris actually wrote to me and complained, basically, that this was a form of hate speech, and I had to agree. So I no longer use that expression. Now I just stick to the facts and describe tobacco company executives as mass murderers.”
But the campaign is already paying dividends, he says. “There are about 180,000 fewer New Yorkers smoking today than there were in 2000, which means that 180,000 people are now living healthier lives, and something like 60,000 of them will live much longer lives than they would have otherwise.”
And finally, there has been the fierce attack on HIV/AIDS. Frieden’s department expanded and promoted a vigorous program that emphasizes the free distribution of clean syringes for intravenous drug-users and condoms for safe sex. Frieden, who keeps a large bowl of condoms in the reception area outside his office, free for the taking, doesn’t back down when responding to conservative critics of the program. “However well-intentioned policies might be that limit condom use in areas where there’s an HIV epidemic, those policies are killing people. They’re unethical—and they’re killing people.”
... coping with the stresses involved in running the NYC Health Department: “When people ask me if my current job is stressful, I always say: ‘Compared to my five years in India—helping to organize a nationwide TB program where 1,000 people were dying preventable deaths each day from the disease—nothing is stressful.’”
... the performance of the U.S. healthcare system: “We spend almost one out of every six dollars in our entire national economy on healthcare, and yet we often fail to achieve the most simple things required for good health. Example: Only one-third of Americans with high blood pressure have it adequately under control. And less than a tenth of Americans with high cholesterol are controlling it adequately.
“And how about smoking? The data show that only one out of every five smokers who tries to quite gets adequate help from his or her physician. These are people who want to quit—and they don’t get the help they need. It’s hard to spend that much money and do worse than that.”
... Michael Bloomberg’s performance as mayor of New York: I think he’s a terrific political leader, very bold and very courageous. He took a huge amount of political heat for challenging the tobacco companies by proposing a ban on smoking in the city’s bars and restaurants, and for a time it looked like that issue would cost him a second term. But he didn’t back down, and I think that displayed great leadership.”
... his own five-year campaign to help improve TB control in India: “The challenge was enormous—just enormous. But this was an opportunity to have a large impact on health for millions of people. We knew from pretty good data that for every 100 TB patients we treated, at least 18 would have died without our program. The program has now treated more than 5 million people, and at least a million lives have been saved. It’s gratifying when you can help solve problems—but it’s particularly gratifying when the impact is so great.”
... his four years as a pre-med and philosophy student at Oberlin: “It was a wonderful place. I did an independent major that was mostly in philosophy, and I took a Shakespeare course with [emeritus professor of English] David Young each semester in my senior year. I met my wife, Barbara Chang, Class of 1982; I got a great education; and I learned how to play squash. What more could you possibly want from a college?”
So how, exactly, did Tom Frieden manage to design and implement such innovative and trend-setting public health problems—and with so much success that other cities in the U.S. and elsewhere are studying his approach?
“I think it was obvious back in the mid-1990s, when he was putting together the TB program from scratch, that Tom was a uniquely gifted and dedicated public health administrator,” says Karen Brudney, assistant professor of medicine in the College of Physicians and Surgeons at Columbia University, who worked on the city’s TB project as a clinician and supervisor. “Tom was persistent, insistent, and compulsive—and he would not tolerate fuzzy thinking. He wanted clarity. But he was also capable of admitting mistakes, and he had a sense of humor.”
“Really, I don’t think people fully realize yet how effective he’s been at improving public health in New York,” she adds. “In my view, attacking the tobacco companies was the most important public health accomplishment in New York City in the past 50 years. Tom was willing to tackle that head-on, and I’m sure there was plenty of ugliness—but you knew he wasn’t going to back down.”
Christina Larkin, the health department’s deputy director of the Brooklyn District, also worked on the anti-TB campaign with Frieden. “He quadrupled the size of the TB Bureau (from 200 employees to around 800) in the space of a year or two,” says Larkin, who served as the project’s outreach director. “He designed a surveillance system that surprised everyone by proving beyond a doubt that the city was in the middle of a TB epidemic, and then he put together a system that kept track of every single patient.”
Describing Frieden—then in his early 30s—as “driven and brilliant, with an incredible passion for public health,” Larkin was amazed by how quickly he took steps to hire new employees, greatly speeding up a process that had taken “months and months” before his arrival. “He brought applicants in on Saturdays to interview, and those who qualified would be offered the job that same afternoon. And then, when they arrived a few days later for their physical exams [another potential bottleneck], they discovered that the doctor who would be giving them their physicals, quickly and efficiently, was none other than … Tom Frieden.”
Ask Frieden to account for his obsession with improving public health, and he will give much of the credit to his cardiologist father, the late Julian Frieden, who enjoyed a dazzling reputation as a gifted clinician.
“I grew up watching him treat patients,” says Frieden. “He was a consummate clinician—a doctor who knew that 80 percent of the diagnosis comes from a carefully taken history. Long before people [in healthcare] began talking about ‘evidence-based medicine’—which is all the rage now—my father was practicing it.”
While Frieden often salutes his father for teaching him about the crucial importance of basing public health strategies on solid medical evidence (“The answers are in the data!”), he also credits his alma mater with helping him develop a “utilitarian view” of medicine in which he seeks relentlessly to find out what works, and then to implement these techniques and track their effectiveness over time.
“I studied a lot of philosophy at Oberlin,” he says with a nostalgic chuckle. “I had my own little cubicle at Mudd library, where I’d write all day long. I worked a lot with [the late] Norman Care and David A. Love [also deceased], and wrote my honors thesis on Wittgenstein’s notion that the meaning of something is its use.
“I also remember thinking a lot about two very different philosophies of life—the ethical philosophy of Kant, with its ‘categorical imperative,’ and the utilitarian philosophy of thinkers such as Jeremy Bentham, which says that the value of an action can be measured by the effect it has on the well-being of the majority.”
Ask Frieden to pick which life-philosophy he prefers—“morally absolute” or “utilitarian”—and you’ll probably come away with a deepened understanding of his motivation as a public-health manager—and as a results-oriented epidemiologist with a bowl of condoms.
“If you ask me which philosophy of life I prefer,” he says with a laugh, “I gotta tell you that ‘The greatest good for the greatest number of people’ still works pretty well for me!”