Credit Dan Deitch
A century ago, most local health departments concentrated their efforts on fighting infectious diseases like cholera, polio and tuberculosis. But today, many health departments have a very different focus: cancer, heart disease and Type 2 diabetes, some of America’s leading killers. Fighting these diseases often means promoting changes in lifestyle and behavior, and no health department has done that more aggressively than New York City’s.
Under former Mayor Michael R. Bloomberg, New York’s health commissioners — first Dr. Thomas R. Frieden, and then Dr. Thomas A. Farley — took on smoking, sugary drinks, sodium, trans fats and binge drinking. Those battles weren’t always successful. A state court struck down the city’s controversial soda tax initiative, and critics complained that New York City was becoming a “nanny” state.
But Dr. Farley, who served as New York’s health commissioner from 2009 to 2014, says the city’s efforts helped demonstrate that the key to eradicating lifestyle-related diseases is by changing environments — making bad choices harder and good ones easier. He makes a case for this approach in his latest book, “Saving Gotham: Billionaire Mayor, Activist Doctors, and the Fight for Eight Million Lives,” which shares the behind-the-scenes story of the Bloomberg administration’s radical approach to fighting chronic disease.
Dr. Farley, who later served as the Joan H. Tisch Distinguished Fellow in Public Health at Hunter College and chief executive of the Public Good Projects, is now the health commissioner of Philadelphia, where earlier this month the mayor proposed a soda tax as a way to fund schools, libraries, and parks and recreation centers. Recently we caught up with Dr. Farley to talk about his book, his battles with the beverage industry and how his approach to public health may have influenced other health departments around the world. Here are edited excerpts from our conversation.
Why did you write your latest book, “Saving Gotham”?
I wanted to show that there’s a way to fight disease other than through expensive medical care. In the United States, we spend roughly twice as much per capita for medical care as other high-income countries, and our health statistics are close to last. People naturally assume we’re going to solve this problem through medical care. But it doesn’t fit with those statistics. There’s a different approach — a public health approach — that costs very little. The book tells the story of how with using that public health approach we were able to prevent the leading causes of death and save many lives.
As New York City’s health commissioner you led many public health campaigns. Which had the most impact?
I would say it was our efforts to reduce smoking. During the time of the Bloomberg administration, smoking rates fell by about 25 percent in New York. Since then they’ve fallen by about a third. That’s about 400,000 fewer smokers. And that alone should save thousands if not tens of thousands of lives. At the same time, sugary drink consumption fell by about a third, and heart disease mortality fell by about 40 percent.
Did these efforts ultimately translate into an increase in life expectancy?
Absolutely. During the Bloomberg years, life expectancy at birth in New York City increased by about 3.2 years. During the same period, life expectancy in the U.S. as a whole increased by 1.8 years. So we were fast outpacing the rest of the country, and that increase in life expectancy was bigger than it was in any other big city in America.
Some of your health initiatives created a lot of controversy. Where did you find the most resistance?
There was controversy, but most of the resistance came from industry. In the book, I show how some of the biggest risks today are coming from companies that make, sell and market products that over a lifetime make us sick, like cigarettes and sugary drinks.
When New York City passed the smoke-free air rule that made bars and restaurants smoke free, it was a radical idea. And that idea has now spread across most of the U.S. and almost all of Europe — so much so that it’s almost hard to imagine what it would be like to have smoking in a bar or restaurant. The book shows how those good ideas can quickly spread from one city to others, despite resistance from industry.
The beverage industry says that sugary drink taxes disproportionately hurt the poor economically. How do you respond?
I would say that the poor are disproportionately suffering from obesity and Type 2 diabetes as a consequence of sugary drinks. They drink more sugary drinks now than people who have more money. Because people with lower incomes are more price-sensitive, they will disproportionately benefit from efforts to reduce sugary drink consumption.
The new soda tax proposal in Philadelphia was presented as a way to generate more revenue for the city, rather than as a “sin tax.” Do you think that will make it more appealing to the public?
This is something that is central to the mayor’s agenda, and I think his way of approaching it is terrific. The revenue from the sugary drink tax will go for pre-K, for what they call community schools — which is providing services for children so they can stay in school and learn — and for rebuilding the city’s parks and recreation centers. All of those preferentially benefit people of lower income in Philadelphia. All of those are very popular and will benefit health over the long term. It’s a great way to match up the benefits of the tax revenue with a source of revenue that is also good for health.
You have spent a lot of time fighting the beverage industry. Have you seen any change in their response over the years?
The beverage companies understand that they’re going to have to change the way that they do business. And they are making changes — but they’re not making changes fast enough. They still market very heavily these products that are major contributors to our health problems. In the end, they will move only as fast as we push them.
How did New York’s health initiatives impact the greater public health landscape?
That was another theme I tried to bring out in the book. This is the story of a local health department reinventing itself to take on the biggest health problems of our time. Before the Bloomberg period, most local health departments were seen as organizations that did restaurant inspections and rat control. We showed that local health departments could take on smoking and make a meaningful difference in life expectancy. That model is now being copied by local health departments around the country. And that’s why I think local health departments are where you’re seeing public health innovation right now.
Are there any common misconceptions about the role of public health agencies that you have tried to dispel?
A thing that people often don’t understand and that I hoped to show in the book is that health is political, but not in the way that most people think. If you ask most reporters about the politics of health, they’re going to talk about Obamacare. But as you saw in the book, the fights we faced over health were with the tobacco industry and with the food industry. I hope people read the book just for the story, because it’s a great story, but that in the end they will have learned the great value of public health.