Can New York’s Dr. Frieden Fix What Ails the CDC?

When the H1N1 swine flu reached the United States last month, no one had any idea whether it was going to be mild or a lethal pandemic. It fell to Dr. Thomas Frieden, head of New York City's Department of Health, to sort out the local response. Calmly and methodically, Frieden and his team worked around the clock, seven days a week, trying to size up the new virus, keep the public informed and determine which schools needed to be closed to limit the contagion. Though H1N1 is still spreading—and one assistant principal in New York City just died—many have praised his level-headed approach. "It's difficult to see through the fog of war," says NYC Associate Health Commissioner Geoffrey Cowley. "He walked a fine line between overreacting and not doing enough."
 

Now Frieden is set to become the nation's top doc. On May 15, President Obama appointed him as head of the Centers for Disease Control and Prevention (CDC). Among the issues facing Frieden will be whether or not to develop a vaccine for the new flu. He will be in charge of tracking foodborne infections and conducting research into all the health scourges confronting American society. And he will be in charge of restoring morale at the sprawling bureaucracy. "It's a daunting task. But he's not just someone from the ivory tower," says Dr. Georges Benjamin, executive director of the American Public Health Association (APHA). "He has experience tracking infections in the hood, as they say. Having someone like that orchestrating national policy will be very helpful."
 
At 48, Frieden has created in New York what is arguably the most effective and innovative public-health department in the country. In the process, he has also enraged restaurant owners, drawn fire from religious leaders, driven smokers into the streets and created a whole new category of souvenir: the official New York City condom. But he gets results. His 2002 Smoke-Free Air Act, 2006 ban of trans fat in restaurants and 2007 requirement that chain restaurants post calorie counts on their menus have all inspired similar measures around the country. Though with far less fanfare, he's also spearheaded introduction of electronic health records and dozens of other initiatives against problems like infant mortality, diabetes, HIV/AIDS and colon cancer. The combined effect has been to help bring death rates in the city to new lows. "We used to send out 60,000 death certificates a year," Frieden told NEWSWEEK last year. "Now we're issuing 55,000."
 
Frieden brings passion to a field that few people think of passionately. Public health first seized his imagination during medical school at Columbia University when he read a classic series of articles by Berton Roueché called The Medical Detectives, in which scientific gumshoes unraveled the mysteries behind rare diseases, poisonings and parasites. "I loved clinical practice," says Frieden, who worked among Dominican populations in Manhattan during med school and speaks fluent Spanish. "But in public health, you can impact more than one person at a time. The whole society is your patient."
 
He proved that when he went to work for the CDC in 1990. At the time, tuberculosis was emerging as a threat in New York City, with the caseload tripling between 1978 and 1992. As an epidemic-intelligence-service officer for the CDC, Frieden documented a dramatic increase in multidrug-resistant TB. Under Dr. Margaret Hamburg, then city health commissioner, now Obama's nominee to head the FDA, he set out to contain it. The key was making sure that patients took the complete, six-month course of antibiotics, even after they felt better. But how do you do that, especially when the disease is spreading through places like homeless shelters? He and Hamburg sent outreach workers to patients' homes and offices, not to mention street corners, bridges, subway stations, park benches and crack dens to make sure they were taking their medicines as directed. Over the next two years, infections in the city fell by 20 percent, and multidrug-resistant TB stopped spreading.
 
In 1996, Frieden took the fight against TB overseas as a medical officer for the World Health Organization, on loan from the CDC. That's where he was in 2001, when Mayor-elect Michael Bloomberg began searching for a health commissioner. Bloomberg asked Dr. Alfred Sommer, then dean of public health at Johns Hopkins University, to name the most talented person in the field. "You can't have him," said Sommer. "Tom Frieden is curing tuberculosis in India for the World Health Organization." In five years, he said, Frieden had helped reduce new infections 50 percent in a part of the world known for massive red tape. "Give me his number," Bloomberg replied.
 
Frieden almost rejected the call. In India, he was engaged in important work. It wasn't worth his time to come back for the interview, he said, unless the mayor was willing to tackle smoking or, as he calls it, "legalized drug pushing." It was a bold demand. In the wake of the terrorist attacks on 9/11, the rest of the world was focused on bioterrorism. Frieden recognized the importance of the issue, but said, "Terrorists will never kill as many New Yorkers as smoking." (Terrorists killed nearly 3,000 people on 9/11. Smoking kills 400,000 a year.) The mayor agreed and flew him back for the interviews. Frieden's appointment led to an extraordinary partnership. Bloomberg, who has a school of public health named for him at Johns Hopkins, has strongly backed Frieden's initiatives at a time when, as Sommer puts it, most health commissioners are treading water, just trying to hold together financing for basic services.
 
Together Frieden and Bloomberg targeted smoking, as promised. They began in 2002 by persuading the city council to boost taxes on cigarettes, pushing prices to $7 a pack, then the highest in the country. Next, over the howls of the restaurant industry, they vastly expanded an existing smoking ban to apply to workplaces, including all restaurants and bars. Doomsday never arrived. Restaurant employment and revenues rose 9 percent in the first year while employment in other retail businesses inched up 1.4 percent.

Frieden continued with a hard-hitting counteradvertising campaign to take the glamour out of cigarettes. One series of graphic ads featured Ronaldo Martinez, 49, who contracted esophageal cancer and now has to breathe through a hole in his throat. With each new initiative, smoking rates in the city dipped lower. Today New York has 350,000 fewer smokers than in 2002. Deaths from smoking are down 11 percent. Most impressive, teen smoking is at half the national rate.
 
Such solid results are exactly what the business-oriented mayor likes to see. And Frieden, who shares his boss's quasi-religious belief in hard evidence, rigorously monitors outcomes. As Bloomberg puts it, "In God we trust. All others, bring data." If a program is working, Frieden expands it. If not, he rethinks it. It's an approach that he will take to his new job. As he wrote in a letter to CDC staffers last week, "Rigorous surveillance and epidemiology are not only our most powerful tools, they also are our ethos and the foundation of our authority."
 
Frieden is not all work and no play, but he comes close. Despite a disarming smile and quick sense of humor, his talk never seems to devolve into banter. He can be short on social graces, sometimes abrasive and often highly impatient. Rather than wait for a limo to plod through traffic jams, he'll speedwalk from the Health Department to city hall, moving at a clip that leaves aides trotting along behind and crowds of pedestrians parting to let him through. At his desk, he's what one aide calls a human throughput machine. He signs off on a stack of papers while answering a reporter's questions. "Did you really read that?" the reporter finally asks, amazed at the pile of papers he's methodically gone through while discoursing on AIDS and TB. Frieden proceeds to summarize the three-page letter he just initialed.

But not everyone is impressed. The restaurant industry lobbied hard against his restrictions on indoor smoking and his 2006 move to ban trans fats from New York City restaurants. Trans fats are chemically altered vegetable oils that extend the shelf life of baked goods and hold up well in deep fryers. Unfortunately, they also foster heart disease by raising LDL (bad) cholesterol and lowering HDL (the good kind). Restaurants said the ban infringed on consumer choice and would harm the taste of products. "Dr. Frieden has a Messiah complex, " charged Rick Berman, head of the Center for Consumer Freedom, a group with industry backing. The New York Post dubbed Frieden's department "the Ministry of Culinary Righteousness." But now that the ban is in place, it's become a non-issue. Restaurants have found substitutes for trans fat, and business doesn't seem to have suffered.

While opponents of his restaurant initiatives charge Frieden with creating a nanny state, religious groups say his condom campaign has encouraged immorality. Cities across the country routinely hand out free condoms. "It's much cheaper than treating sexually transmitted diseases or unwanted pregnancy," says Dr. Benjamin at the APHA. But Frieden has gone to new lengths. He issued a branded New York City condom, with packaging by designer Yves Behar, and launched an advertising campaign urging New Yorkers to "get into it" and get some. Since the first New York City condoms were introduced on Valentine's Day 2007, distribution has soared from 17 million a year to 36 million. This isn't a government-surplus product, but something with cachet, says Frieden. But David Zwiebel of the Orthodox Jewish group Agudath Israel calls the new campaign grossly offensive. And Edward Mechmann, assistant director of the Family Life/Respect Life Office at the Roman Catholic Archdiocese of New York, insists that abstinence is the most effective policy. "The commissioner has no trouble understanding this when it comes to smoking," he says.
 
Despite Frieden's successes, he hasn't come close to solving New York's health problems. Obesity and diabetes are up, as are drug-related deaths. But he's in step with the Obama administration on major health-care goals, including the creation of electronic health records. "Today we don't have a health-care system, but a disease-care system," Frieden says. It's a system that will pay $100,000 to treat a heart attack, but not pennies to prevent one. As Bloomberg says, "I'm not a psychiatrist, but I think I know the clinical term that describes this: it's nuts."
 
At the CDC, Frieden will have major challenges. He won't just be in charge of tracking disease. He will also be helping to steer national policy on health care, trying to improve access, affordability and quality all at once. It's an enormous assignment. Some might call it an impossible case. And perhaps it is. But that's Frieden's specialty.

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