Mayor Bloomberg’s Public Health Legacy
The Good, the Bad, and the Ugly
By Abdul El-Sayed
Published January 3, 2014
Last week, Mayor Bill de Blasio took office to replace three-term Mayor Michael Bloomberg. Regardless this replacement’s vision for public health in the city, it is hard to imagine a mayor who will make a broader impact. Passionate about public health, Bloomberg is, perhaps, the only mayor of any major city ever to have an eponymous school of public health—that at Johns Hopkins, to which he has donated a total of $1.1 billion over several decades.
Bloomberg’s commitment to public health was certainly strong. But it became clear that the Mayor had a very particular vision for what public health should look like—one that was often narrow-minded and bullheaded.
On the one hand, he rightly understood the importance of leadership to addressing some of society’s most pressing health issues. On the other, his top-down, often paternalistic approach to public health made unnecessary enemies, often out of the very people he was ostensibly trying to help. Even worse, the broader implications of many his social policies, such as stop-and-frisk, will have lasting reverberations on minority health in the city into the future.
Let us take a look at the highlights—and low-lights—of Mayor Bloomberg’s public health legacy.
The Mayor’s leadership on a number of issues, including smoking, obesity, and hypertension, have been laudable. Not only did the Mayor craft policy to address the issues most of his contemporaries were only talking about, but he rightly squared the burden of these policies on industries profiteering at the cost of the public’s health, such as the beverage and restaurant industries.
Among the highlights were the smoking ban in restaurants and workplaces; his efforts to tax sugary beverages; forcing chain restaurants to list calorie information; and restaurant hygiene grading. And his policies pushed public health in the right direction. During his tenure, for example, the smoking rate in the city fell from 22% to 14%, although caution should be taken in fully attributing this decline to the Mayor’s leadership.
Most important, however, is Bloomberg’s legacy as a champion of public health. Displaying the courage to lead on public health issues, he launched them squarely into the public debate in a way that only he could have as the founder and former CEO of a multi-billion dollar mega-corporation with a take-no-prisoners political style. In so doing, he set precedent regarding the potential role a strong leader can have in shaping public health in his constituency.
He also demonstrated how important enacting brave policy could be to shifting public opinion on important health issues. At the outset, for example, his 2003 smoking ban in restaurants and workplaces was widely criticized. A recent New York Times poll however, shows how much things can change, demonstrating an 82% approval rate.
One can only hope his precedent will encourage other leaders to act both on the local and national levels.
Not all of Bloomberg’s initiatives were as good as others, however. At some points, the Mayor’s cult of personality interfered with the broader aims of his public health policies. In that respect, several of his policies were barely, if at all, supported by strong science. Rather, they seemed more focused on a couple of other issues. First, at some points, it seemed that the veracity of the Mayor’s public health policy took a back seat to making a show of public health. This had the consequence of reinforcing incorrect stereotypes about what matters for health and disease. Always a competitor, Bloomberg seemed more interested in sticking it to industries that had opposed him than doing what was right for public health. In creating those enemies, the mayor insured that many of his policies met maximal opposition.
Two examples are illustrative. First, the extension of smoking bans to parks and public places is based on loose, highly controversial data suggesting a link between secondhand smoke and disease risk. What’s more, these studies don’t apply to the types of secondhand smoking that the extension might prevent. Why? Most of the studies demonstrating such health links with secondhand smoke defined secondhand smoke exposure as prolonged and persistent, implying sharing a living space with smokers rather than the passive form of secondhand smoke one might experience while walking by a smoker in a park or at the beach. In that respect, there is little data to support such a wide expansion of the smoking ban. One might argue that the ban was focused on making smoking more difficult for smokers themselves—an explicitly paternalistic justification. Obviously, though, that’s not how the policy was marketed to the public.
The second such example was the soda ban. While the soda ban, itself, was the biggest anti-soda attention grabber during the mayor’s tenure, few people realize that that policy came on the back of a more staid, less flashy push to tax sugar-sweetened beverages in NYC. That effort was ultimately defeated as a result of extensive lobbying by the beverage industry. But the Mayor would not be stopped. In retaliation, he sponsored a more inflammatory, less effective adaptation of the original policy.
A soda tax is good policy for several reasons that a soda ban is not. First, taxes provide a disincentive to consumption at all levels—among those who drink both big gulps and kiddie sizes alike. This is consistent with what we know about the role of sugar-sweetened beverages in the obesity epidemic. Big gulps don’t cause obesity. Instead, over-consumption of soda, whether in big gulps or in several small glasses per day causes obesity. Second, a tax on soda provides a source of revenue for the government that can be used to pay for the costs that soda drinking bears on society over the long-term—everything from the added wear and tear on subway lines because of obese passengers to the costs of treating diabetic patients in city hospitals.
Rather than continue to maneuver in favor of good public health policy, the mayor retaliated against the beverage industry with the soda ban: a policy with more teeth but less bite. Rather than decrease consumption at all levels, the soda ban focused only on consumption at the extremes. The policy would have had no effect on consumption among those who drank several small servings of soda a day—like children, in whom obesity is most worrying.
Less pressing, but still problematic is that the soda ban reinforced wrongful stereotypes about soda consumption, suggesting that somehow consumption of more than 16 fluid ounces in a serving was more blameworthy than consuming several small servings per day.
In the end, the soda ban was deemed illegal by a state judge and an appellate court, although the New York State Supreme Court has agreed to hear a final appeal regarding the matter in the near future. Assuming the Supreme Court does not overturn the rulings, the beverage industry can count two big wins signaling to others who might follow that soda is untouchable, and hobbling public health efforts focused on big soda for the foreseeable future.
A billionaire Manhattanite, Bloomberg was often accused of favoring Manhattan and the rich, largely white elites who disproportionately call it home. And that is certainly true when it came to public health.
While the Mayor’s explicit public health policy was certainly admirable, his implicit policies were far from it. Since 2002, when his tenure began, New York has seen a considerable demographic shift as the cost of living has outstripped earnings in a way that has largely priced many lower-income New Yorkers out of the city. The disproportionate burden of this has fallen on blacks and Latinos who are being forced out of traditionally ethnic enclaves like Harlem and Washington Heights as a result of rent increases.
Our understanding of the social determinants of health suggests that foundational to human well-being are the ways in which society allocates resources—financial and social—and the relative disparity between those who have these resources and those who do not. In Bloomberg’s New York, the gap between the haves and the have-nots has exploded, with definite implications for public health.
His Stop-and-Frisk is a perfect example. This policy, so egregious that it was deemed unconstitutional by a U.S. district court, specifically targeted young blacks and Latinos, giving police officers the authority to stop and frisk them without probable cause. It created a reality wherein young minorities had no de facto right to privacy and were guilty until proven innocent. And the brutal execution of the policy was even more damaging than its ethical implications. YouTube is teeming with iPhone videos depicting the cruel abuses suffered by victims of stop-and-frisk and the psychological and emotional devastation the policy has wrought on their lives.
Similarly, Bloomberg’s policies regarding homelessness have also largely failed. In December, the New York Times featured a 5-part story about an 11 year-old homeless girl, Dasani, and her family, victims of Bloomberg’s failures. The city was aghast at the harrowing account of Dasani’s struggles.
While the Mayor has argued that Dasani’s story is not the norm in the city, the statistics suggest otherwise. Despite an overall national decline in homeless by 9% since 2007, New York has seen a 13% increase in homelessness over this time period. Homelessness—and that among children—is at a record high.
While at first, stop-and-frisk and homelessness may seem to have little to do with public health, in reality policies like these are ultimately more meaningful than smoking bans, soda taxes, or calorie disclosures. Stop-and-frisk and other anti-poor, anti-minority policies like it reinforce poverty and its trappings, creating the realities wherein poor choices about education, sex, alcohol, drugs, eating and physical activity are made.
Mayor Michael Bloomberg was passionate about public health, no doubt. And there are a number of laudable policies he advocated and pursued that will certainly improve the public health in New York City. At the same time, though, his vision for public health was often narrow-minded, lacking the nuance of thought to appreciate that policy is about more than political battles and moral victories. In the end, though, the most damning aspect of Bloomberg’s public health legacy is that he couldn’t escape his demographic: rich, white, and Manhattanite. And the social policies he pushed forward as such have and will continue to hurt the health of the poor and minorities in the New York for years to come.
Ironically, the Bloomberg School of Public Health at Johns Hopkins offers a number of excellent courses on the social determinants of health. Perhaps it would have been prudent for its namesake to have taken one of them.
Edited by Joshua Brooks.
A previous version of this article failed to mention that the New York State Supreme Court had agreed to hear a final appeal regarding the legality of the soda ban.