"Good afternoon, and thank you, Dr. Gerberding, for that kind introduction. And thank you all for this award as well. I deeply appreciate the honor you've given me.
"Now, as the final speaker at this conference, I have a number of important duties. I'm going to skip the first few, which include reminding you to get your parking validated at the front desk, announcing when the buses for the airport will be leaving, and handing out surveys about who was your favorite speaker.
"Instead, I'm going to go right to the one I think is most important: Telling you this story: The great Supreme Court Justice, Oliver Wendell Holmes discovered, one day, that he had misplaced his ticket while boarding a train. He searched fruitlessly, until the conductor told him it was alright; everyone knew who he was and trusted him. "Young man," Holmes replied, "The question isn't, ‘Where is my ticket?' The question is, ‘Where am I going?'"
"I suggest, after three days of meetings and workshops concerning public health and the law, this is the exact question we need to ask, as well… Where are we going?
"Let me now offer a few ideas about where we're headed—and also about how we can get there. And to do that, we should start with an appreciation of history, a sense of urgency, and, I would argue, a new and comprehensive strategy.
"The history of public health in our nation is truly an inspiring one – a brilliant record of the forward march of science, and a moving tribute to our humanity. Like many older Americans, my early memories include the specter of paralytic childhood polio that stalked our cities, especially during what should have been our carefree summer vacation months. And I also remember the jubilant relief that swept the nation with Dr. Salk's development of the polio vaccine.
"The victory over polio, achieved through massive, virtually unprecedented vaccination programs from coast to coast, was in a profound sense, a triumph of our democratic way of life. It underscores the important subject of this conference. Because vanquishing polio required a full-out social effort. It was a tribute to what a free society is capable of when we mobilize our best scientific minds, marshal public support for public health, and then put the force of law behind these efforts.
"Our history is replete with other examples of the essential role that law in all its forms—regulation, licensing, inspection, tax policy, appropriation, litigation, and enforcement—have played in conquering disease and improving our quality of life.
"But history teaches other lessons as well. As Atlanta's most famous son, Dr. Martin Luther King, Jr., once observed, "Human progress never rolls in on wheels of inevitability." And in the realm of public health, the greatest enemy of progress is complacency.
"Take the example of tuberculosis. By the late 1980s, elected officials and public health authorities in New York City and the U.S. believed, prematurely and wrongly, that TB had been controlled. So they lowered the city's and the nation's guard. Then, when drug-resistant TB re-emerged in the early 1990s, it cost more than $1 billion to care for those who had become ill, and it took a new, concentrated effort to once again bring TB under control.
"So an appreciation of history should inspire not only optimism, but also a sense of urgency and a commitment to tenacity – the kind of urgency and tenacity that we have learned to apply, through hard and sometimes bitter experience, during our now-quarter-century-long struggle with AIDS. Such urgency and tenacity are sorely needed to meet the public health threats of a new era, our era.
"We face two overarching challenges: the threat of chronic and non-communicable diseases and that of health-related disasters. Chronic and non-communicable diseases have now replaced communicable diseases as our society's most pervasive killers. These new threats result from, and are aggravated by, our forbearance, and even social and economic encouragement, of such behavior as tobacco addiction, unhealthy nutrition, and excessively sedentary lifestyles.
"To this list of public health problems, I would add our intolerable inaction in stopping the flood of illegal guns onto our city streets. A century ago, cancer and cardiovascular diseases were the causes of fewer than 10% of deaths in New York City. Today, they account for more than two-thirds of deaths. And across the nation, firearms kill 30,000 people a year.
"All these deadly menaces result from our choices, both as individuals and as a society, to ignore or encourage life-threatening risks. An effective public health strategy must therefore alter that calculus by changing how we live.
"Second, we face threats arising from the possibilities of health-related disaster. AIDS, West Nile virus, SARS, and now avian flu are all reminders of the potential for pandemic disease in a "globalized" world – one that must also contend with the menace of bio-terrorism.
"And because the potential for such disasters, both natural and man-made, now reaches into every community, we all have a responsibility to prepare for and address them.
"We need an aggressive, comprehensive public health strategy focused on both chronic disease and health emergencies. That is the strategy that we have followed in New York City over the past four and a half years. This afternoon, I want to outline some of the principal elements of that strategy, and at the outset, stress two key points about our approach.
"First, we respect science. We base policy not on what we think is true, but what we can prove is true.
"And second, we take seriously our duty to act on what we know. So we rely on the forceful application of law—democratically debated and approved—as the principal instrument of public health policy. Certainly, public information campaigns about health issues are indispensable—and we use them. And there's a good example of that unfolding today, which is World Blood Day.
"In New York City, as in many of your home cities, we're sponsoring public events highlighting the essential role that voluntary blood drives play in saving lives. Such efforts are invaluable. But we must also recognize that, alone, public information campaigns are insufficient to the enormous tasks at hand. It's like the way Mark Twain once described his appreciation for the nature of thunderstorms. "Thunder," Twain said, "is good. Thunder is impressive. But lightning does the work."
"In the realm of public health, law really does the work. That has been demonstrated time and again, in areas ranging from mandatory vaccinations to requiring automobile seatbelts and reducing drunk driving to improving workplace safety to providing access to family planning services to fluoridation of water and more.
"Public health succeeds by making healthy choice the default social option. Clearly, there are many matters of personal behavior and personal taste that we have no business regulating. But just as clearly, there are also areas in which we have an obligation to act on what we know—on what incontrovertible facts tell us.
"In outlining what we're doing in New York, I also want to describe what the Federal government has done—and ought to be doing—to meet the dual challenges of chronic disease and health emergencies. Meeting these challenges is not, and must not become, a matter of partisan politics. The health of the American people is at stake. This is an arena in which both Congress and the Executive branch, both Democrats and Republicans, have a duty to rise above "politics as usual," and work together.
"In New York, we've made the control of chronic disease a top public health priority. Our work is intensely information-driven. We've expanded population-based surveillance of chronic diseases in the city. Two years ago, for example, our Health Department conducted the country's first-ever community-based Health and Nutrition Examination Survey. It has provided us with data on the prevalence and control of chronic disease that guide us in directing resources where they're needed most.
"We're also helping underwrite the cost of bringing electronic medical records to primary care doctors in low-income communities. This will not only improve patient care; it will also give us even more vital information—without divulging patient names or other identifying information—about how the health system is doing on the frontlines.
"It's on those frontlines where law is our most potent weapon. And we've brought the force of law to bear on a broad front, including in these three areas: reducing tobacco-related illness; combating diabetes; and ending the violence caused by illegal firearms.
"First, as to tobacco. Not quite four years ago, I introduced our city's pioneering Smoke-Free Air Act, banning smoking in bars and restaurants. Its premise, supported by testimony from a Nobel Prize winner and former head of the National Institutes of Health, Doctor Harold Varmus, was that waiters and bartenders should not be forced to risk their health because of second-hand smoke in order to earn a living.
"We clearly had the facts on our side—and perhaps for that reason, we were met with a massive and well-financed scare campaign predicting doom for our city's tourism and hospitality industry if our efforts succeeded. I remember with particular clarity the dire forecast that prohibiting smoking in bars and restaurants would mean that no one from Italy or Ireland would ever visit New York City again. That has not only proved to be completely wrong; both Italy and Ireland are among more than a dozen nations that have subsequently followed New York City's lead, and banned smoking in public places. So have dozens of cities and states here in the U.S., from New Jersey to Montana.
"The law—in the form of higher cigarette taxes—has played an important role in reducing "first-hand" smoke among New Yorkers as well. Early in our administration we raised the tax per pack by nearly $1.50. This has played an especially strong role in helping to reduce smoking among teenagers, who are particularly sensitive to the price of cigarettes. Data just released show that while smoking among teenagers has increased nationwide over the past two years, it has decreased substantially in New York City.
"And it gives me enormous satisfaction to report that because of all our efforts, today nearly 200,000 fewer New Yorkers smoke than did four years ago – although keeping that trend going is somewhat problematic and shows how important the tenacity I mentioned earlier is. Epidemiology tells us that this will prevent at least 60,000 premature deaths. And replication of these initiatives, nationally and internationally—perhaps accelerated by New York City's example—very likely will have a lifesaving impact many times greater than that.
"We're also making aggressive and innovative use of the law to combat the one chronic disease that's getting worse in our city and in our nation: Diabetes. Beginning this year, we've mounted a wide-ranging attack on diabetes. And such a comprehensive campaign is needed because of the broad range of factors contributing to its alarming spread–and to the fact that, nationally, only about one in three of the now epidemic-level of Americans with diabetes has his or her blood sugar adequately under control.
"That's why we've established the nation's first community-wide diabetes registry—to improve knowledge and treatment for people with diabetes. Today, when New Yorkers get their blood sugar levels tested at any doctor's office, clinic, or hospital in our city, that information goes to our City Health Department. We will soon begin a pilot effort in one part of the Bronx to work with patients, and their doctors, when tests reveal dangerously high blood sugar levels.
"We're matching that with a wide range of legal interventions aimed at curbing the obesity that contributes to diabetes, as well as cardiovascular and other chronic diseases. Those efforts range from regulations mandating better nutrition and exercise programs for youngsters in child care centers to school lunch programs that exceed Federal nutritional standards to other steps we are contemplating to encourage greater physical activity by New Yorkers.
"Some people may call that too intrusive. I call it dynamic and effective public health. Because taken together, these measures—employing the force of law—will help us reach our goal of cutting the number of New Yorkers at the highest risk for diabetes complications by 20% over the next two years.
"Clearly, the force of law is also the only effective means of stopping the carnage created by a third great public health menace: illegal firearms. In New York City, we're using every legal tool at our disposal. That includes stronger enforcement, new legislation, and innovative litigation. Some of you may have read about the suit we filed last month against 15 out-of-state gun dealers who we secretly videotaped making illegal sales to our undercover agents.
"Now, at the outset, let me make it clear that New York City is by far the safest big city in the nation. In fact, the most recent national crime survey released by the FBI earlier this week ranked New York City's crime rate 19th from the bottom of the 245 cities with populations of 100,000 people or more. Last year, we bucked a national trend, and continued to reduce the number of murders in our city. And we've driven crime down by more than 22% over the last five years.
"Nevertheless, each year more than 300 New Yorkers are murdered with illegal guns. Year in and year out, illegal firearms account for close to 60% of all homicides in our city.
"New York's battle against illegal firearms is also the nation's. And that's why in recent months more than 60 mayors from across the nation and from both political parties have come together to stop the spread of illegal guns in our cities. It's a coalition that Boston Mayor Thomas Menino has joined me in organizing, and one that I'm happy to say includes another of the nation's best mayors: Shirley Franklin of Atlanta. Because as mayors, our first responsibility is public safety and because we understand that stopping illegal guns has nothing to do with ideology or with the Constitutional right to bear arms.
"We're working together to toughen local penalties for sale and possession of illegal guns, to share "best practices" in enforcement, and also to oppose wrong-headed Federal legislation that would protect gun traffickers and the rogue gun dealers who supply them. In fact, more effective Federal action is needed on a broad range of issues. Our Federal system of government rightly assigns the primary responsibility for public health at the state and local level. We wouldn't have it any other way. But in meeting the challenges of chronic disease and illegal firearms, we also need our partners at the Federal level to step up to the plate. Federal law should make it easier, not harder, to choke off the interstate transport of illegal firearms.
"Federal mandates to reduce industrial and vehicular air pollution would dramatically improve air quality and public health. Federal policy should identify reducing chronic disease as the key objective of our national agriculture, nutrition, and health care financing policies. And we need Federal funding to fight chronic disease on the local level, just as we receive funding for communicable disease control.
"Yet sadly, you should know, we now get virtually no resources from the CDC to address today's leading non-communicable causes of illness and death.
"A more robust Federal effort is also required to address today's second great challenge to public health: preventing disasters of both the natural and man-made varieties. We don't need to Federalize our efforts; but at the local level we do require help that only the Federal government can provide.
"Make no mistake about it, New York City government is more than doing its part in this arena. We take the lessons of 9/11 very seriously. We also remember quite clearly that when seven letters containing anthrax spores were put in our nation's mails during the autumn of 2001, four of them were addressed to locations in New York City.
"We recognize that we are a target for terrorism and also that, as America's most diverse city and as the nation's principal gateway to and from the rest of the world, we are particularly vulnerable to the presence of natural, as well as man-made, health threats.
"So over the last four and a half years, we've created the nation's leading local disaster preparedness infrastructure. New public health policies and protocols are an integral part of that infrastructure. We have, for example, developed a sophisticated bio-surveillance system. It's an electronic tripwire that gives our Health Department more than 60,000 separate data entries daily on hospital emergency department visits, ambulance runs, purchases from pharmacies, and other information. Pieced together, this data could be the first indication of a communicable disease outbreak, or a bio-terror attack.
"We've created a Health Alert Network that gives us the capability of getting critical information—fast—to more than 17,000 health care providers, community volunteers, and first-responders throughout the city.
"We've developed thorough inter-agency plans and protocols for handling natural and man-made disasters, and we regularly test and refine them with training exercises and drills.
"In handling such public health emergencies, clear and well-defined legal authority is all-important. And we are addressing that need. We are, for example, in the midst of thoroughly revising the City Health Code for the first time in nearly 50 years. It will update and clarify the City's authority to, for example, impose quarantines, detain patients, mandate isolation, promote vaccination and treatment, order environmental clean-ups, and institute other measures warranted by a major public health crisis.
"This initiative is being led by someone many of you know very well: Wilfredo Lopez, general counsel to the City Health Department. It will, in fact, be the capstone to a distinguished 25-year career with our city. Naturally, Wilfredo is here – and please join me in thanking him for a quarter-century of devotion to the people of New York City, and leadership in public health law, locally and nationally.
"We have also developed a unique information-sharing protocol among our Health and Police Department and the FBI for investigating incidents which may involve biological agents. Our public health reporting, monitoring, and response system is based on direct reporting to the local authorities who are the first responders. And it has worked well over the years. We had a good example of its effectiveness earlier this year when—through utterly accidental and natural causes—a man in our city contracted respiratory anthrax. I'm happy to report that not only did the response feature superb cooperation between local, state, and Federal authorities; the man involved also recovered completely.
"The system also works in many other incidents, day in and day out. And that illustrates why Federalizing surveillance of and response to such incidents would cause more problems than it would solve. Local authorities must remain the nodal points for communication and response. Change that, and you'll lose valuable familiarity with local conditions and institutions just when that knowledge is needed most.
"Now believe me: In building the City's emergency response infrastructure, support from the Federal government has been enormously valuable, and very much appreciated. That certainly includes the CDC, which has provided New York City with funds that we've used to strengthen our ability to detect and respond to health emergencies. But the Federal government can do far more—by employing the power of the purse—to improve local disaster preparedness, and end the current "disaster du jour" mentality.
"The Federal responses to avian flu, to the shortage of flu vaccine, or to other crises we've faced in recent years, have been episodic and disjointed. They illustrate the lack of the kind of national public health infrastructure, at the Federal, state, and local levels, that our era demands. That infrastructure should include everything from high-level scientific and technical expertise at the national level to a better-trained, better-funded state and local public health capacity. And that is why the current method of allocating Federal
bio-terrorism preparedness funds needs a thorough overhaul.
"The only rational system for apportioning these funds ought to be population density and risk. Unfortunately, those clearly are not the yardsticks that are being used. I really don't know how anyone can justify a distribution of bio-terrorism funds that awards $8.20 per person to North Dakota, when New York City gets less than $3.00 per person. Nor do I understand why Rhode Island, Hawaii, Maine, New Hampshire, Idaho, Kansas, and other small or sparsely populated states merit a higher per capita bio-terrorism funding than New York City does. Nevertheless, that is precisely the preliminary plan for distributing CDC bio-terrorism funds for the next fiscal year.
"Even worse, New York City is 42nd out of 54 states and cities in per capita funding from the Federal Health Resources and Services Administration—funding that goes to hospitals for disaster preparedness. Like the distribution of Homeland Security money, which cut funding to New York City by 40%, this is not just absurd, it's shameful.
"When it comes to bio-terror and preparedness funding, it really is time to put the lid on the Federal pork barrel – because whatever part of the country you live in and are returning to later today pork barrel politics jeopardizes the safety of all our hometowns, all our home states, and of the entire nation we all love. The World Trade Center Health Registry identifies people directly exposed to the dust and fumes created in New York on 9/11. It lists people from all 50 states and more than a dozen countries. When New York City gets hit, the whole country suffers. We really are in this together.
"We can no longer afford to play politics with preparedness – just as we can't permit ideology and wishful thinking to continue to trump science in public health decision-making. And I want to close with a few words about that.
"New York's late Senator Daniel Patrick Moynihan was fond of saying that "You're entitled to your own opinion, but not to your own facts." And nowhere is that more true than in the realm of public health. Because in public health, tailoring policy to fit political preconceptions isn't just ineffective, it's positively dangerous.
"Neither political party is blameless in this respect, nor are advocates on either the left or the right. AIDS policy offers a good illustration. Talk to one set of advocates, and they insist that the answer to stopping the spread of HIV is distributing more condoms and setting up more needle exchange programs. The other side believes just as passionately that the solution to preventing the spread of HIV lies in persuading people that they can't just have sex with whomever they want, whenever they feel like it. The truth is, both sides are right—and we've got to have a political leadership, at every level of government, capable of hearing both sides, accepting what is true in what they say, and acting on it.
"So, let me now answer Justice Holmes's question: Where are we going? And the answer is: It's up to us. We can write our own ticket. The Greeks were on to something when they imagined that we back into the future, our eyes firmly fixed on where we have been, not where we're headed. But our past offers us some guidance, nevertheless. Because the challenges of our day—those posed both by chronic diseases and by natural and manmade disasters—can be conquered in the same way that our predecessors defeated cholera, diphtheria, typhoid, and polio:
"Through the efforts of an informed democracy, not afraid to face the facts and make decisions that put health, not politics, first and capable of fairly and vigorously using the instruments of the law to protect the lives of every member of society. This is the only way we can ensure that our journey into the future will be a long, happy, and healthy one. And, as this conference ends, I wish you the very same now as you go back home to resume your very important business.
"Thank you all very much."