In their article, Isett, Laugesen, and Cloud1 attempt to determine the feasibility and potential for success for other public health jurisdictions in adopting what in effect was a top-down approach that characterized public health reforms under the Bloomberg Administration. To answer these questions, they use a "theoretically grounded case study approach" and focus on 3 initiatives: trans fats restrictions, clean bus transportation policies, and a tax on sugar-sweetened beverages. Related to the latter was an effort to limit serving sizes of sugar-sweetened beverages in certain types of establishments.
Nowhere in their articles do the authors characterize the Bloomberg initiatives as top down, except in the "Questions for Further Consideration" section that follows their conclusions. Similarly, they do not comment on the core characteristics that heavily textured the implementation of these and other Bloomberg public health reforms. These included paternalism, taxation, regulation, and a paucity of local community input. In addition, and importantly, the Bloomberg regulatory approach was essentially cost neutral for the city, which in effect eliminated opposition based on budgetary considerations.
The public health reforms launched during the Bloomberg Administration were largely made possible by a confluence of very unusual and favorable circumstances. The first was Mayor Bloomberg himself, who was dedicated to improving the health of the public even before he took office. A business magnate, media entrepreneur, politician, and philanthropist, he had long been interested in improving the human condition. This was clearly demonstrated by his financial gift to Johns Hopkins University School of Hygiene and Public Health, resulting in a name change in 2001 to the Johns Hopkins Bloomberg School of Public Health. None of Bloomberg's 107 predecessors as Mayor of New York City came into office with such a strong commitment to support public health reform. This philosophical commitment, plus his financial and political independence and his popularity with voters, enabled him to face down challenges to this vision.
The second important variable was Bloomberg's successive appointment of 2 very talented and visionary health commissioners, Drs Thomas Frieden and Thomas Farley. The successes of both rested with their ability to imaginatively address chronic disease issues with novel and sustainable innovations, and Bloomberg's strong support for them. Thus, the mayor and his health commissioners were in full agreement on important public health initiatives. This was a very unusual state of affairs in New York City, whose public health history has been generally characterized by states of creative tension between health commissioners advocating reforms and mayors opposing them based on cost and fears of adverse political consequences. Finally, Bloomberg's 12 years in office made possible the initial proposing of reforms that would survive the often long administrative road to full implementation.
Unfortunately, Isett, Laugesen, and Cloud miss the point that the most visionary health commissioner will fail in implementing reforms if he or she does not have the full and complete support of the chief executive. Rather, the authors attribute the public health successes of the Bloomberg Administration to remobilization of the workforce of the Department of Health and Mental Hygiene and knowledge of how authority works. They significantly go astray when they state the following: "While Mayor Bloomberg often gets credit, the real story here was how NYC used all the tools at its disposal such as City Council passed ordinances, health code resolutions through the Board of Health, and administrative rule making."1
The members of the Board of Health are appointed by the mayor and are thus sensitive to his policy positions. Administrative rule making by health commissioners or their subalterns cannot be implemented without mayoral support. Finally, most members of the City Council are well aware of mayoral policy positions that concern the well-being of the public and not generally inclined to oppose them, especially if they are cost neutral.
It is true that reform implementation required restructuring of the Department of Health and Mental Hygiene workforce and collaborations with other city agencies. However, these measures were not determinative to the success of public health reform measures. This success was clearly due to the vision of 2 very talented health commissioners and Bloomberg's strong and unwavering support for them and their ideas.
As Colgrove2(p256) has observed, the Bloomberg Administration often engaged in the use of regulations and law to force through reforms. These reforms were usually open to comment through City Council deliberations and public statements submitted to the Board of Health. Yet, many have argued that these selective modes of opinion expression did not tap into the views of those disadvantaged communities most often affected by such regulatory-based reforms.
The mayoral administration of Bill de Blasio, which began in January 2014, has strongly endorsed the Bloomberg era public health initiatives. However, the mayor and Dr Mary Bassett, Commissioner of Health and Mental Hygiene, have also supported the vital need for community engagement in the conversation concerning such reforms. Since taking office, Dr Bassett has promoted a somewhat different approach from that of her immediate predecessors. This includes focusing on those geographic areas of the city where public health problems exist to excess because of health and health care disparities and engaging all stakeholders in these areas and elsewhere in meaningful and ongoing conversations to embrace reform efforts.
The article by Isett, Laugesen, and Cloud contains a clear exposition of 3 Bloomberg era public health reforms. However, the authors have overlooked some of the crucial variables that made implementation of these reforms successful and which may not be present in other public health jurisdictions. In addition, they largely eliminate from consideration the top-down implementation of many of the Bloomberg era public health reforms. This is a significant oversight, as their article is focused on creating a map for duplicative efforts elsewhere.
Colgrove has cogently noted,
The model of muscular public health that Bloomberg and Frieden advanced has skeptics across the political spectrum: from civil libertarians on the left, fiercely protective of the rights of individual privacy and autonomy, to free-market conservatives on the right, hostile to infringements on commercial and property interests.2(p255)
The combination of a powerful and wealthy mayor forged in the business world and fiercely dedicated to public health reform and philanthropy, talented and visionary health commissioners, and cost-neutral initiatives is what in the final analysis made public health reform so successful during this period. Without these unique features, the simple remobilization of agency workforces and the support of legislative bodies, while important, would not have produced such successful outcomes.
REFERENCES