Photo by Geoffrey Cowley

Just months after the terrorist attacks on the World Trade Center, Dr. Thomas Frieden arrived in New York from India, where he was helping to fight tuberculosis, to interview for the job of New York City health commissioner. When asked what his top priority would be if he got the job, Frieden startled interviewers by proclaiming, “Tobacco.” With fears widespread about America’s vulnerability to biological terrorism—especially in the aftermath of the anthrax letters, which killed five people not long after 9/11—one interviewee asked: “Tom, have you heard of 9/11?” Frieden answered: “Bioterrorists are not going to kill more New Yorkers than tobacco is.”

Frieden was right, more than a decade ago, that the effects of smoking killed far more people than bio-terrorism (or Ebola, for that matter). But his response was troubling nonetheless because of the way Frieden conflated use of tobacco—a legal substance whose ill effects are well known to those who choose to use it—with the death that terrorists (or highly infectious diseases) might rain down on innocent people. Frieden’s retort said much about the evolution of public-health medicine over the decades into a field more concerned with the choices people make than with the scourge of infectious diseases. His answer also helped clarify how Frieden himself would eventually operate as New York City health commissioner. His tenure was marked by a series of health crusades aimed at so-called “lifestyle diseases” based on dubious evidence.

Frieden is now perhaps the most visible example of the transformation of the field of public health—for better or for worse. Until recently, that arena owed a great debt to the English epidemiologist John Snow, who correctly deduced that the London cholera epidemic of 1854 was caused by contaminated water from the Broad Street pump. Shutting down the pump not only stemmed the tide of the epidemic, but also convinced public officials to undertake construction of sewage and clean-water systems that would effectively end the spread of water-borne epidemics. Encouraged by a series of discoveries of the germ basis of many devastating diseases, researchers in the nineteenth and early twentieth centuries made other rapid advancements in public health, including the development of vaccines against some of humanity’s deadliest diseases and techniques such as the pasteurization of milk to stem bacterial contaminations. Through these advances, industrialized nations like the United States have completely eliminated such once-deadly diseases as smallpox, diphtheria, and polio, vastly cutting childhood mortality rates and increasing lifespans.

But as the impact of communicable diseases has lessened, public-health medicine—which concerns itself with community-wide solutions to health problems—began to look more intensely at treating and preventing conditions that don’t originate with germs. The focus of researchers and doctors turned especially to conditions thought to underlie cardiovascular disease. But unlike battles against germs, isolating the key cause of such problems has proved elusive, because multiple factors—from genetics to diet to personal habits, like smoking—are all potentially contribute.

Advocates like Frieden have plunged ahead anyway, sometimes proposing simplistic solutions to complex problems, often without much data to back up their claims. As New York City’s health commissioner, Frieden engineered a law requiring food chains to post calorie counts on menus, though there was no evidence that the availability of such information has any effect on eating habits. Frieden also led a campaign to cut salt consumption despite studies that had shown, in fact, that some individuals fared poorly on a salt-restricted diet. Frieden’s campaign led one world-renown hypertension expert to proclaim that New York was attempting to engineer a giant uncontrolled experiment. As time passed, Frieden’s practice of recommending sometimes outrageous solutions to health problems based on few facts grew more disconcerting. In 2007, he even proposed a campaign to persuade uncircumcised adult men in New York to get circumcised to reduce their risk to HIV; a study in Africa had concluded that the practice helped lower infections there. But Frieden’s proposal was widely derided and quickly dismissed because of the vast differences between the two populations and the preliminary nature of the research.

Given his specialty in infectious diseases, Frieden would have seemed well- prepared to deal with the swine flu outbreak that hit New York in the spring of 2009. And indeed, in the days after the first reports of actual cases here, Frieden seemed to inspire confidence, at least at the New York Times. In an early profile of Frieden that seemed more like a chapter out of Lives of the Saints, a Times reporter noted the doctor’s “passionate rectitude” and described him as a “boyish figure in the dark suit,” who announced daily updates on the flu “in the meticulous, benevolent tones of the trusted family doctor.” The problem was that at this point, just four days after the first reported local cases, Frieden hadn’t accomplished much beyond reading the daily tally.

The situation quickly spun out of control. The city kept open schools where students had contracted the swine flu, and it spread rapidly among kids and staff. One victim, a 55-year-old assistant principal at a hard-hit Queens school, slipped into critical condition and died in mid-May. The victim’s wife criticized the city for underestimating the severity of the outbreak, and some of the school’s staffers told the press that they had pushed the city to close it for a week. But “nobody listened. We had kids dropping like flies,” a school official told the New York Post. Even the Times weighted in with the troubling headline, NO GUIDANCE ON HOW TO REIN IN THE FLU. City officials defended their decisions, saying that they had deferred to the CDC’s guidelines on when to close a school after an outbreak, but Mayor Bloomberg told the Times, “There’s no right answer.” In an accompanying story, the Times said that the outbreak tested “Bloomberg’s political skills” but said nothing about the role of the point man on the issue, the health commissioner it had so effusively praised a few weeks earlier. The city eventually estimated that somewhere between 750,000 and 1 million New Yorkers caught the swine flu; 54 people died from it.

Meantime, however, President Obama had already selected Frieden to run the CDC, though he had yet to depart New York. Nothing about his handling of the swine flu epidemic kept him from getting the federal job. A Times story on the appointment quoted a public-health expert calling Frieden a “transformational” figure, a clear reference to his crusades in Gotham. Frieden had been a leading candidate for the CDC job, in part because his agenda seemed to dovetail with the Obama administration’s notions of where public health should go, as reflected by Michelle Obama’s controversial efforts to reshape school lunch programs. The day after Frieden’s appointment, newspapers in New York featured headlines like OUTRAGE OVER RESPONSE TO FLU. Yet no one in Washington seemed troubled.

One of Frieden’s tasks at the CDC was the reorganization and revitalization of the agency. (Stories had characterized it as demoralized, thanks to supposedly unpopular appointments made during the Bush years.) But under Frieden’s leadership, the CDC has underestimated the Ebola virus’s ability to infect those who come in contact with it and ineffectively communicated to health-care workers the proper protocols for dealing with sick patients. The agency told Amber Vinson, a Dallas nurse who had cared for Ebola patient Thomas Duncan, that it was okay to board a plane with a low-grade fever; Frieden later said that Vinson, who is now being treated for Ebola, never should have done so. When President Obama told Africans in a video message that they couldn’t get Ebola from sitting next to someone on a bus, Frieden was asked to clarify. His response only confused matters further: “If you’re a member of the traveling public and are healthy, should you be worried that you might have gotten it by sitting next to someone? And the answer is no. Second, if you are sick and you may have Ebola, should you get on a bus? And the answer to that is also no. You might become ill, you might have a problem that exposes someone around you.” Under fire, President Obama has appointed an “Ebola czar” to coordinate the government’s response: Ron Klain, a lawyer and political operative with zero experience in infectious diseases.

The mainstream press has seemed mystified by Frieden’s performance. In large part that’s because of the Times-supported fiction that Frieden led an effective campaign against the swine flu in New York. In August, NBC News even described Frieden as “the face of the American public health system . . . trying to calm nerves . . . doing it with the cold, procedural focus of a scientific investigator.” But the truth is that by appointing Frieden, the Obama administration got exactly what it wanted, and there’s nothing baffling about his failures.


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