November 2, 2016

A native of Summit, N.J. and a self-described “numbers guy,” Tom Farley majored in mathematics at Haverford College and attended Tulane Medical School where he studied pediatrics. After a CDC training program in epidemiology, he was sold on public health: “We absolutely save more lives in public health than doctors seeing patients do,” he says. Farley worked for the Louisiana Department of Health and as a professor at Tulane for 24 years, then moved on to New York City, where he served as health commissioner under Mayor Michael Bloomberg from 2009 to 2014. He then spent a year writing a book “Saving Gotham: A Billionaire Mayor, Activist Doctors, and the Fight for 8 Million Lives.” Farley was named health commissioner by Philadelphia Mayor Jim Kenney in February 2016. He spoke with DornsifeSPH Magazine about his experiences and plans for improving health in the city.

The jacket blurb on your book says “‘Saving Gotham’ demonstrates how government – local government – can protect citizens and transform health for everyone.” Really?

TF:Yeah – it’s the story of how Mike Bloomberg came in and brought in Tom Frieden who was a very focused public health guy... When he came in, smoking rates in NYC had been about 21.5 percent for over a decade. By the time he left, they were about 15 percent. So you had a big decline in smoking rates and parallel with that there was a big increase in life expectancy: reduction in heart disease mortality and other things that related to smoking so it seemed like it worked. Other things were taking place at the time, but I do think the health department’s activities can take legitimate credit for a good chunk of the health gains that happened in a city of 8 million people.

So you’ve already done Gotham. Philly has always been the forgotten city [between DC and New York]. We boo Santa, we love cheesesteaks, and we’ve got a chip on our shoulder. Why are you here?

Philadelphia is a great city. I’ve always liked Philadelphia. And if you look at its health statistics, they’re the worst of any of the top ten cities. So to me, that’s an opportunity.

A few days after your June commencement address to the Dornsife School of Public Health Class of 2016, Philadelphia City Council passed a soda tax. Were you surprised?

By the time it finally passed we had enough signals that this was going to win, so I wasn’t surprised at the end. Overall, though, it was surprising, because the soda companies hate the idea of a soda tax. They knew that this would be precedent-setting. And so we knew they were going to spend millions to try to stop it – which they did. But the strategy, and the execution of that strategy to gather community support and focus that community support on the benefits of the program really worked.

One of the messages in your commencement remarks was to encourage new graduates to go forth and do big things... and to explain to the public what public health is.

In our society, medicine is really very dominant: When people think health, they think medical care and they raise their children hoping they’re going to grow up to be doctors. I want to change that narrative a little bit. I want people to recognize there’s this other field out there called public health, a different way of approaching health – a much more effective way and cost-effective way of saving lives. I want my son or daughter to grow up to be a public health person, I want the heroes on our television shows to be public health people, rather than surgeons.

What are your top priorities – your challenges – as you begin your work in Philadelphia?

My priorities fall into three broad areas. The first is we have services we provide in the health department that we should continue to provide and to improve. That’s everything from inspecting restaurants to running our health clinics… Secondly, we need to be prepared for new threats. I’m old enough and have been in public health long enough to guarantee you that in the next four or five years, there will be some new threat that will appear on the horizon for Philadelphia. It may be the Zika virus, it may be HIV, whatever – it’ll be something we’re not expecting right now but some new threat and we need to be prepared to handle that.

The third area, though, is really where we save the most lives. That is, I want to create a more health-promoting city. That’s a city that makes it so people are less likely to smoke, more likely to have a healthy diet, to be physically active, less likely to use alcohol or do drugs – that’s for adults. And for children, try to create a city that makes it so that children are more likely to get a good start in life, particularly the first three years of life. Because there’s increasing evidence that what happens in the first three years of life really has lifelong implications for health. So if we want to narrow the health disparity gap, that’s one good way to do it… We’re going to go where we see the biggest opportunities for saving lives, and preventing preventable deaths – even if those are areas where the health department hasn’t traditionally been involved in the past.

I’ll start with the data on what is killing the most people: heart disease and cancer and diabetes. If you think of the risk factors for those – they are smoking, lack of physical activity, alcohol and drugs. So for example, we have a crisis in the city and the country now with prescription opioids. Many people now are going the route of taking heroin and the street drug fentanyl. That is killing roughly eight times as many as gun homicides are killing – a huge public health crisis. We have a partner over in behavioral health which provides drug treatment, and we want to do whatever we can do working with them, to address that crisis - reduce the number of people
who get addicted in the first place, get people into treatment. And for those who are not getting into treatment and are dying of drug overdoses, at least try to prevent them from dying of drug overdoses until we can get them into treatment.

What are the barriers to effective public practice? Philadelphia is among the nation’s poorest cities, where all the social determinants of health are interconnected, in terms of housing and transportation and education and access to jobs that pay a living wage…You can’t gentrify your way out of that, so….?

I think the key determinants of health fall into two categories: There’s behavioral and the environmental determinants, like smoking, the food that’s available in stores, the marketing of unhealthy products. And there are the
social determinants: poverty, housing and education. Sometimes I think people make a mistake by saying, “Well, we can’t make any progress until we make progress on the social determinants,” but I think we can. We know that smoking rates are incredibly high. We know there are many things we can do to reduce smoking rates that will save a lot of lives, whether we solve poverty or not. So yes, we should work on those behavioral and environmental determinants. At the same time, we should also be working on the social determinants, doing what we can – and that’s tougher. It’s definitely much farther afield from where we’re trained in public health, and who we tend to talk to in public health but we might be able to contribute in some way. What can we do to increase the wages of low income people? That is probably the simplest way to reduce poverty. If we can do that, there’s going to be a real health benefit to that. We can participate in that conversation, even if we’re not the ones who are making that change happen.

Four to eight years from now, what would you like to be able to say if you’ve had good success here?

I’d like to be able to say that we’ve made a measurable difference in the health status of the entire city of Philadelphia and a measurable decline in the health disparities in Philadelphia.