NYC's Top Doc on Bloomberg's Aggressive and Often Controversial Health Mandates

Dr. Eric J. Topol Questions Dr. Thomas Farley on His Provocative Approach to Population Health

; Thomas Farley, MD, MPH


December 18, 2013

In This Article

Why Shake the Salt?

Dr. Topol: I wanted to switch to another area that is similar to sugary drinks: salt. There's a raging controversy as to whether there should there be a particular level of sodium intake. What are your thoughts about that?

Dr. Farley: Actually, there is no controversy that we are consuming way too much sodium. People consume about 3400 mg per day, and the question is whether we should we be consuming 2300 or 1500. Both of those are a whole lot less than what we are consuming now. And we also don't consume enough potassium. That combination of too much sodium and low potassium gives us hypertension rates, whereby close to two thirds of people have hypertension by the time they hit their 60s. That is not natural. It isn't necessary.

Dr. Topol: Isn't it too simplistic? Some people are remarkably salt sensitive and will have hypertension. And others are just as remarkably salt resistant. They can have unlimited salt, and it will never affect their blood pressure. Why do we have this kind of population-medicine approach or mentality?

Dr. Farley: There are some people who try to put people in categories like that: You are either salt sensitive or you are not. I'm sure that there is a distribution of this that is continuous. Some people are going to be more salt sensitive than others. As you look across the entire population, if everybody is consuming too much salt, that entire distribution of blood pressure is going to be far higher. In populations that consume much less salt, the entire population distribution is much less. In some isolated primitive tribes, the blood pressures are under 100 systolic. They don't rise with time, and so it's not a given that hypertension is part of the aging process. You could say that we are all suffering from a certain level of chronic sodium intoxication, and so if we all consumed 30% less, we would probably all be far healthier.

Dr. Topol: I don't know about that. My sense is that we don't do enough on the individual level, and if we make assumptions like that then we are basically not accounting for this marked heterogeneity in people.

Dr. Farley: The relationship between blood pressure and heart disease mortality, or mortality in general, is continuous. We don't have evidence of blood pressure being too low. We do have evidence that the average blood pressure in Americans is too high for their health, and so the idea that reducing sodium for the entire food supply is a good thing for the population, to me.

Bloomberg's Role in Public Health

Dr. Topol: In regard to these policies, whether it's the sugary drinks or [salt],[2] how do you coordinate this with the mayor? Do you say, "I think we should do this," and he says, "It sounds like a good idea, Tom?" How do you go about [developing these policies]?

Dr. Farley: The mayor is extremely smart. He understands the concepts of public health and he understands data, so with any big idea I take to him, I lay it out to him the same way I would to you, a physician, or another specialist. I show him the graphs. I show him the biologic evidence, and I'll argue how many lives we think we can save from this. I'll talk about what other expert bodies say on this issue, and he will pick apart all of those and make a very intelligent, reasoned decision. It's rare if ever that a person like me has an opportunity to answer to an elected official with that kind of intellectual power and interest in the subject [of health]. It's great.

Dr. Topol: Did he ever say to you, "You know, Tom, we're embroiled in this whole mess with the legal issues with the sugary drinks. Why did you do this to me? Why did you get me into this?"

Dr. Farley: The mayor is an executive, and he thinks about things when he makes a decision. He doesn't look back. This is the decision I made, and now we are just going to go forward. I think that is the right thing to do.

Dr. Topol: And now he's moving on after 3 terms.

Dr. Farley: He is, but you are going to continue to hear a lot from Mike Bloomberg in the future. There is no question about that.

Dr. Topol: I'm sure of that.

Dr. Farley: He is passionate about public health. He is working at the global level, so his career is far from over.

Dr. Topol: How about you? Will you be staying on in your position, or does that change with the change of mayor?

Dr. Farley: Typically, when the mayor changes, he brings in his own commissioner, so I don't know. I'll certainly continue to work in public health, take a little bit of a breather after this because this is a pretty intense job. But I hope to continue to be involved in the national conversation around what I consider to be the opportunities in public health that we can take right now to prolong life and reduce morbidity.

What's Next?

Dr. Topol: It seems like a lot of our top people in public health have come from this position, whether it's Tom Frieden at the CDC or Margaret Hamburg at the US Food and Drug Administration, or others. It seems like New York City is a precursor to having an impact at a national level.

Dr. Farley: The agency is unique because it's big, as we mentioned, but it's local at the same time. We can see health problems, put in place interventions, and evaluate their impact in a short period of time. We also have regulatory authority, which the CDC doesn't have, so we can do things that no one else can do. We often do them, and then people around the rest of the country look at what we've done and see whether they want to copy us.


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