Book Review: Saving Gotham

Heart disease, stroke, diabetes, and cancer. These are the enemies of the modern-day public health crusader. In Saving Gotham, former New York City Health Commissioner Dr. Thomas Farley recounts the groundbreaking work of the Department of Health and Mental Hygiene to tackle just these foes.

Saving Gotham takes the reader through the makings of progressive public health policy initiatives in New York City during the tenure of Mayor Michael Bloomberg. The story centers on the leadership of Bloomberg’s health commissioners, starting with Dr. Thomas Frieden and followed by Farley himself, who took over the post after Frieden was appointed Director of the CDC. Moving away from the traditional realms of city health departments – infections, food contamination, and sanitation – the Department’s measures were aimed at the non-communicable diseases responsible for the vast majority of deaths of New Yorkers. The leadership built sometimes-controversial policies to combat the behaviors responsible for these diseases. As Farley writes, “public health succeeds by making the healthy choice the default social option.” Clearly an admirer of Bloomberg, Farley describes the mayor as committed to public health and unafraid to propose laws based on data, not political favors or public opinion. When presented with contentious ideas, Bloomberg’s response was simply, “will this save lives?”

The way Farley tells it, this work is not for the faint of heart. The book’s subtitle characterizes their mission as “the fight for eight million lives,” and the feeling of going to battle persists throughout the book as Farley details policy initiatives to combat smoking, trans fats, salt, and soda. The central theme of the efforts is that human behavior is shaped by the world around us, which is filled with aggressive marketers, special interests, and companies out to make a profit. Farley has long argued for the role of large-scale government initiatives to fight back against these forces, whether through regulatory actions or public health messaging. As he recently asserted in JAMA Internal Medicine, large companies would not engage in mass marketing if it were not effective, and by the same logic, mass media campaigns should be used to spread messages that change attitudes and behaviors to promote public health. Yet the enemy remains fierce. In the book, Frieden is quoted as saying that defeating tobacco and food products was much harder than defeating tuberculosis “because tuberculosis bacteria don’t bribe politicians. They don’t rebrand themselves as ‘lite’ bacteria. They don’t have movie stars to make it look cool to have tuberculosis.”

Saveing Gotham is written in two parts. The first half focuses on Frieden, starting with his early career working on tuberculosis through his tenure as the New York City health commissioner. He is portrayed as a tireless visionary. Frieden estimated that smoking, one of his signature issues, was responsible for 20% of the deaths in New York City. He aimed a multi-pronged attack on cigarettes, most famously championing the ban on smoking in restaurants and bars. He also targeted obesity with measures requiring calorie counts on menus, healthier school lunches, banning trans fats, and more, as well as other issues such as decreasing sodium content in foods.

The second half of the book recounts Farley’s time as commissioner. He carries Frieden’s torch, continuing to fight smoking and improve nutrition. This part of the book is more personal, with Farley sharing his anxieties about starting as commissioner and his frustrations over failures like the striking down of a law limiting portion sizes for sugar-sweetened beverages. However, Farley is strong in his convictions and makes bold assertions about the flaws in our health and policy systems and the challenges faced by public health leadership.

The strength of the book lies in its insider access. The pace can feel breathless, at times jumping from issue to issue in a way that is occasionally confusing but also conveys a sense of excitement and urgency. We learn about the fascinating inner workings of city policy, such as the political drama behind the failure of the soda tax, negotiations with the food and restaurant industry over sodium content, or the court challenges to the portion cap on soda. We also learn interesting nuggets about the people involved, like Mayor Bloomberg’s love of salt (“he salts his bacon”).

Farley is not afraid to speak his mind, and the book includes a heavy dose of his views on policy. Farley is scathing when it comes to industry and critical of a number of groups for being resistant to change or pandering to special interests, including everyone from the FDA, to Congress, to the NAACP to New York City doctors. Where Saving Gotham sometimes falls short is in its relatively uncritical view of the policies of Bloomberg and the Department of Health. Farley is reflective, but mainly about the failings of the system and ways in which he could have done more. Although much of the legislation enacted during this period was data-driven, not all of it is backed by flawless science. Some policies, such as calorie counts on menus, have not born out to meaningfully change behavior, but Farley glosses over that information with a quick dismissal. Farley’s tone sometimes feels paternalistic, not dissimilar from the critiques of Bloomberg when he was mayor.

Regardless of your politics, Farley does a good job of highlighting the impressive impact of public health interventions. It is striking to be reminded that incremental change on an individual level can lead to massive change to a population. Farley effectively incorporates data into the narrative to make the argument that in public health, numbers matter, and that a change in a few percentage points for something like smoking can mean that tens of thousands of people actually quit.

For me, Saving Gotham drives home both the importance and the challenges in enacting policy to influence peoples’ behavior. Farley has written a passionate and engaging account about the tenacity of Frieden, Bloomberg, and his team as well as the battles that lie ahead. In the end, the book is optimistic, and the fight for eight million lives is one that is slowly being won.

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