http://www.nytimes.com/2010/11/07/nyregion/07farley.html?pagewanted=allIT was still dark when Dr. Thomas A. Farley got to Central Park on a cool October morning and started stretching his grasshopperlike legs, blending into the background in black shorts and a T-shirt. He was training for the New York City Marathon, and would not let a sore Achilles’ tendon stop him from a four-mile run.
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Ruby Washington/The New York Times
Dr. Farley stressing the value of exercise — tie and all — in Brownsville, Brooklyn.
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Jennifer S. Altman for The New York Times
After a run in Central Park, Dr. Farley ordered a naked bagel and fruit salad at a Starbucks.
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Ruby Washington/The New York Times
Dr. Farley says the entire cultural landscape must be changed to make bad choices harder and good ones easier, even if the change has to be engineered and legislated.
Dr. Farley, the city’s health commissioner, exercises seven days a week, loves his vegetables and has never smoked a cigarette. He has barely a ripple of fat and has run 15 marathons over the past 34 years, finishing all but the last, in New Orleans in 2008. He had had a fever the day before the race, and decided to stay home. But in the morning, he changed his mind and ran.
“For 19 miles I was O.K.,” Dr. Farley recalled. “At the 22nd mile the course ran right by my house. I rang the bell.” His wife opened the door. He said to her, “I’m done.”
It figures that his risky indulgence is a strong competitive instinct — not cigarettes or sloth.
In his sparsely furnished office in Lower Manhattan, Dr. Farley is Clark Kent, smiling mildly behind his glasses, his plain gray suit hanging on his wiry 6-foot-2 runner’s frame. But in public health, he is fast emerging as Superman, able to reframe public debate in a single op-ed article about whether poor people should be allowed to buy Cokes with food stamps.
He has urged what he calls curve shifting, an overhaul of human behavior toward healthier living. But to do this, he says, the entire cultural landscape must be changed to make bad choices harder and good ones easier, even if it has to be engineered by the government.
The commissioner wants New Yorkers to quit smoking in parks and beaches, take the stairs, cut the salt, lose weight, swear off sugary drinks, have safe sex and drink less alcohol; and he advocates legislation, taxes and industry regulation to help them do it.
Dr. Farley has the mind of a Madison Avenue advertising executive, or a master propagandist, to the dismay of some who think he puts ideological zeal above science. A city advertising campaign, for example, equated drinking sugary soda with adding pounds, without regard for mitigating factors like diet and exercise.
He has accumulated a nettlesome list of opponents: some of those who advocate for food-stamp recipients and the poor; the beverage industry; big tobacco; convenience stores; defenders of free will against the “nanny state”; and a few skeptical scientists who say he is conducting a vast population experiment with no control group.
Asked whether he ever feels like a killjoy, Dr. Farley said, “When I see someone who’s 45 years old with obesity and diabetes and hypertension taking five pills a day and struggling to walk around because of their arthritis from their obesity, that doesn’t seem like a lot of fun to me.”
At 54, he looks like his own ideal, his natural thinness honed by regular running, biking and swimming. “This is what I weighed in college,” he said matter-of-factly. He described himself as having “lucky genes in the era of excess,” but acknowledged that he might not have fared well in the Stone Age. “If I lived in the era of hunter-gatherers,” he said, “I would be the first to go.”
Dr. Farley is elated to have gone from expounding his theories of lifestyle change to little notice as an academic in New Orleans to working for a man, Mayor Michael R. Bloomberg, who has staked his reputation on being to health what former Mayor Rudolph W. Giuliani was to crime. Mr. Bloomberg chose Dr. Farley for the $205,000-a-year job 18 months ago after President Obama elevated the previous commissioner, Dr. Thomas R. Frieden, to direct the Centers for Disease Control and Prevention.
The health commissioner’s job provides a powerful bully pulpit, but it is unclear how far Dr. Farley will be able to advance his agenda during the mayor’s third and last term, since mayors often lose steam toward the end of their tenures. On a radio program in September, Mr. Bloomberg absent-mindedly called Dr. Farley, who was in the studio with him, Tom Frieden, then Tom Friedman (an Op-Ed columnist for The New York Times), then Tom Foley (former speaker of the House?).
“I picked Foley, Tom Foley, because we didn’t have to change the monograms on the towels,” the mayor joked.
“Farley,” the radio host, John Gambling, corrected.
“Farley,” the mayor conceded.
Later, the health commissioner said graciously, “He has more of a head for facts and figures, not so much names.”
DR. FARLEY grew up in Westfield, N.J., the sixth of eight children. His father was a patent lawyer, his mother a full-time parent.
He graduated phi beta kappa from Haverford College in 1977, then received medical and master’s degrees at Tulane University in New Orleans. He is a pediatrician but has never been in private practice; he spent a year in Haiti, then did stints at the C.D.C. and the Louisiana Office of Public Health. For the decade before coming to New York, he was chairman of Tulane’s community health sciences department.
The commissioner and his wife, Alice, a pediatrician who plans to work in community clinics and school health centers, have four daughters, ages 16 to 24, and live on the Upper West Side. After Hurricane Katrina, the family spent a few months living in the house where Dr. Farley grew up, while he shuttled back and forth to Louisiana, working through the C.D.C. on how to rebuild the health system.
His eldest daughter, Emily, a 2008 graduate of Princeton University, joined Teach for America and is teaching high school in New Orleans. Dr. Farley once gave a guest lecture to his daughter’s students, doing hypothetical math problems to find out which foods had made people sick at a church picnic. It did not exactly rivet their attention. “The minute he started talking, I was like, ‘Oh, no. His delivery isn’t strong enough,’ ” Emily Farley told the Princeton Alumni Weekly.
Dr. Farley is more forceful in print. His 2005 book, “Prescription for a Healthy Nation,” which he wrote with Dr. Deborah A. Cohen, senior natural scientist at the Rand Corporation, foreshadowed his hair-shirt approach to public health in New York. In its review, Publishers Weekly characterized the authors as “scolds” and “puritanical,” and predicted that Americans would react to their nostrums the way Emily Farley’s students did: apathetically.
Now that science has beaten back infectious diseases like cholera, influenza and polio, public health is largely reimagining itself to fight chronic diseases like obesity, hypertension and high cholesterol. Dr. Farley, in turn, has made it his mission to foment not the next revolution in drugs, vaccines or germ-fighting, but lifestyle changes that offer New Yorkers the implicit promise of living forever — or at least longer.
Promoting behavior change, Dr. Farley likes to say, is the 21st century’s equivalent of 19th-century advances in sanitation, and “Prescription for a Healthy Nation” heralds that agenda. With characteristic modesty, Dr. Farley insists that the ideas in the book are Dr. Cohen’s and that she came to him because she needed a writer. The book is strikingly agnostic when it comes to doctors, suggesting that medical intervention is overrated, and that even to the degree that it works, too many people trip it up by refusing or neglecting to follow directions.
“Mistakes account for only a minor fraction of the total deaths caused by modern medicine,” Dr. Farley says in the book. “Many more die from medicines or procedures even when medical care is standard practice and the doctors perform flawlessly.”
In a chapter called “Humans Behaving Badly,” Dr. Farley writes admiringly of the reward-and-punishment system of behaviorist theory. “B. F. Skinner would have predicted that health education programs directed at individuals would fail,” he writes. “He would have proposed (he did propose) that if we really want to change how we behave, we must change the environment in which we live.”
IN New York, Dr. Farley has promulgated the behaviorist message. The advertising campaigns his department has run show disgusting or upsetting images — the punishment — and promise better health — the reward — for behavior change.
Under his direction, New York began requiring stores that sold cigarettes to post images of diseased brains, lungs and teeth next to cash registers. Tobacco companies and convenience stores have fought back with a First Amendment lawsuit. In March, the city introduced a television, radio and print campaign, “Reverse the Damage,” which, Mr. Bloomberg said, was “perhaps the hardest hitting antismoking campaign we’ve ever run.” Images of lung cancer and heart disease are followed by positive messages: “20 minutes after you quit smoking, your blood pressure decreases,” and “one year after you quit smoking, your risk of heart attack is cut in half.”
But recent revelations about the health department’s internal debate over its antisoda campaign have underlined complaints that Dr. Farley’s more lifestyle-oriented crusades are based on common-sense bromides that may not withstand strict scientific scrutiny.
The Times reported last month that Dr. Farley, in a series of e-mails, overruled his chief nutritionist and others who had raised concerns about the accuracy of the campaign, “Pouring on the Pounds.” It features a YouTube video of a young man guzzling a glass of soda as goopy fat runs down his chin. The ad warns that drinking a can of soda a day “can make you 10 pounds fatter a year,” without any disclaimer that people gain weight differently.
The health department says that soda is more responsible for the rise in obesity than other sweets, that artificial trans fats are worse than natural saturated fats and that everyone should eat substantially less salt. But there are some critics who say that the statistical evidence that soda is causing the obesity epidemic is weak, and that eliminating trans fats may give people a false sense of virtue when eating other unhealthful foods made with saturated fats, like doughnuts.
Dr. Michael Alderman, editor of the American Journal of Hypertension and a professor at the Albert Einstein College of Medicine, said reducing sodium on the scale that Dr. Farley was recommending could lead to good and bad physiological changes. “It’s an experiment; we don’t know what’s going to happen,” said Dr. Alderman, who is an unpaid adviser to the Salt Institute, a trade group. “Should we do a randomized clinical trial on 10,000 people like we always do? Or should we just impose it on millions of people?”
He said that other inadequately tested interventions, like postmenopausal hormone therapy and low-fat diets, had backfired, adding, “There’s almost a law in this world, when you do things without solid scientific evidence, there are unintended consequences.”
Safe sex has been another of Dr. Farley’s obsessions; in 2002, he caused a splash with a Washington Monthly article describing, in graphic detail, his $8 visit to a gay bathhouse as a scientific voyeur. (Headline: “Cruise Control: Bathhouses are reigniting the AIDS crisis. It’s time to shut them down.”) Some gay rights advocates in New York feared he would try to shut down the city’s few remaining bathhouses, but Dr. Farley said recently that he had crossed the issue off his agenda.
“The Internet is now the biggest meeting place for men who have sex with men,” he said.
Behind the glitzy ad campaigns is a health department filled with unsung but highly credentialed data-driven researchers, who each year compile a survey of New Yorkers’ habits and attitudes. At a recent staff meeting, Dr. Farley and five senior employees worked to winnow a list of 242 proposed questions to 151.
Dr. Farley favored topics like blood pressure and diabetes, but was cool to a series of questions on emergency preparedness: whether people had packed a go-bag and set up a meeting place with their children. Looking at questions about alcohol and drug use, he vetoed a suggestion to change the words of a question from “wine coolers” to “alcopops” and expressed doubts that anyone would admit to stealing narcotic prescriptions. The injury experts wanted to ask about gun ownership, but others doubted people would tell the truth.
“It would be nice if we had firearms, don’t you think?” Dr. Farley said.
“I knew he was going to say that!” exclaimed Dr. Carolyn Greene, a deputy commissioner.
On a query about whether people read the nutrition facts on grocery labels, he said, “Just ask about sodium.”
Dr. Farley was fascinated by noise, interested in whether people had hired exterminators to get rid of bedbugs and bored by inquiries about drinking filtered, bottled, tap or seltzer water. “If we had to kill off some questions, I’d kill both water questions,” he said.
WHEN Dr. Farley first heard Mr. Bloomberg speak, in 2006, he said, he immediately recognized “a kindred spirit.” So he e-mailed Dr. Frieden, complimenting the work being done in New York. This led to a post as an adviser to the city health department from 2007 to 2008, for which he earned $161,000.
So it was with a rhetorical wink that Mr. Bloomberg announced the next year that he was appointing Dr. Farley after a nationwide search.
In the first seven years of the Bloomberg administration, Dr. Frieden laid the foundation for Dr. Farley’s behavior-change mantra. New York banned smoking in bars and restaurants and barred trans fats from restaurants. It required chain restaurants to post calorie counts and began negotiating with food companies to voluntarily limit salt in packaged food.
When Dr. Farley took over, he set his sights on weight loss. After lobbying Albany for a soda tax, which failed, the commissioner last month advanced his highest-profile initiative yet. In an essay in The Times, he revealed that the Bloomberg administration wanted federal permission to stop poor New Yorkers from using food stamps for soda and other sugary drinks.
Usually, it is conservative and corporate voices that go after Dr. Farley. This time, traditional liberals accused him of stigmatizing poor people.
“To say that low-income people are uniquely irresponsible, ignoring the Paris Hiltons of the world — I find the message offensive and counterproductive,” complained Joel Berg, executive director of the New York City Coalition Against Hunger.
Mr. Berg said he was not “in any way, shape or form pro-soda,” but added, “I’m used to fighting with conservatives, and it’s particularly heartbreaking on this issue that I’m fighting with people who should be natural allies.”
Though the federal government will most likely reject the proposal, Dr. Farley said he was happy to have sparked a national debate.
DR. FARLEY began running in high school, on the cross-country team, and “basically never stopped,” he said, despite injuries that have forced him to take months, even a year, off; he heads out to the park most mornings at 6. “I would rather have orthopedic problems than cardiology problems,” he said.
He eats parsimoniously (and, he said, “very rarely” indulges in a soda). After the four-mile run the other day, he ordered a naked bagel and fruit salad at a Starbucks, nothing to wash it down.
“I completely understand” the urge to eat junk food, Dr. Farley said. If someone puts something he should not eat in front of him, he said, he has to push it away or he will eat it.
He ran his first marathon in Philadelphia in 1976. His fastest was a decade later, in Paris: 2:59:40. He expects to finish the race on Sunday — his third in New York — in 3:15.
On the training run, he tolerated a reporter’s slower pace for a while, but when given permission to go ahead, he grinned and bounded away. The sunrise beckoned over the reservoir, and it would have been easy to stop and enjoy it, but suddenly, it seemed wrong. Dr. Farley’s drive was infectious.
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