For a few months before he entered medical school, Thomas Frieden lived in Stanton, Tennessee, a small, rural area so poor that few residents had telephones. Sent by the Appalachian Student Health Coalition, a community outreach program led by volunteers, Frieden rode his bicycle for five days to the predominantly black town.

Frieden's job was to find out why a community health center in Stanton was underutilized. With little idea of how to design a survey, he came up with a brute-force scheme: using census maps, he selected 500 households at random and, over the next two months, visited each one. He then tabulated the results on an adding machine, using up an entire case of paper.

What he found was deceptively simple: people weren't using the clinic because most didn't know it existed. Many of those who knew didn't realize that it had a sliding fee scale, or that it would send a van to pick them up. “The people who knew were the ones who didn't need to know, who were more mobile, who could go to Memphis for their cure,” Frieden recalls.

The lessons Frieden learned then still stand him in good stead. When he arrived in 2002 to become New York City's health commissioner, he immediately launched a series of surveys to find the most pressing health concerns in the city. “If you can't measure it, you can't manage it,” he says.

Once again, the results were clear: people were dying of smoking-related illnesses and chronic ailments such as diabetes and cancer, and not from the infectious diseases that health departments have traditionally tackled. “We had nobody in the department working on cancer, diabetes and heart disease—zero, zero,” Frieden says.

There's a poem, 'the grave's a fine and private place.' I understand privacy concerns, but society has a moral imperative to try to provide care.

With his characteristic directness, Frieden set out to change things. He established centers in the three parts of the city with the worst health outcome. In March 2003, he banned smoking in public places in the city—which he says has resulted in 200,000 fewer smokers. And in January, he launched a controversial scheme to begin monitoring the blood sugar levels of diabetics. But he has also retained a focus on infectious diseases, distributing greater numbers of clean syringes and condoms, and advocating for HIV tests to become a part of routine medical care.

“Frieden has a much broader perspective than any public health official I've ever encountered,” says Neil Calman, president and chief executive officer of The Institute for Urban Family Health, a network of community-based health centers. “He is willing to take on unpopular opinions to promote issues that he thinks are in the public's interest.”

This is Frieden's second stint in the city's health department. His first was in the early 1990s, when the city was in the grip of a grim tuberculosis (TB) epidemic. HIV-positive individuals, immigrants, prison guards and healthcare workers were all falling victim. Hospitals spent millions of dollars on infection control, but with no follow up, most people didn't complete their treatment regimens. There were laws in place to detain people who didn't adhere to their treatment, but they were not enforced.

It was not uncommon to see people infected with TB smoking and chatting with HIV-positive individuals in the waiting room, recalls Chris Larkin, who was then on the city's TB team. “Frieden came and cleaned all that up, he cleaned it all up,” she says.

In May 1992, at just 32, Frieden became director of the TB program. Over the next few months, staff collected data from every laboratory in the city. They encouraged those infected to go to clinics. If that failed, they went to the homes of those infected, or into crack dens and homeless shelters. They detained and treated a small number of people who refused to adhere to treatment. Hospitals began reporting information on numbers of drug-sensitive and drug-resistant TB.

The rigorous city-wide surveys documented a massive increase in drug-resistant TB and convinced the government to put in the resources needed to control the epidemic. Within a year, rates of TB began to come down, faster than anyone had anticipated, eventually plummeting by 80%.

A less forceful leader might have squandered the resources, says Larkin. “It's very difficult to say no to him. He gives you tremendous hope and vision that what you're working for is not a waste of time—that it will make a difference.”

In 1996, Frieden left for India and spent nearly six years helping control TB there. But after the events of 11 September, Frieden was asked to come back as New York City's health commissioner. “I was born in New York, went to medical school here, did my health training here, and so I felt a pull to come back,” he says. But first, he downloaded health statistics for the city and found that smoking was the biggest killer. He didn't accept the position until the mayor, Michael Bloomberg, had assured him that he would fully back him on what was sure to be an ugly political fight.

Frieden won that battle, but several other schemes—including the one on diabetes and another on HIV testing—have also been controversial.

With more than 100,000 HIV-positive people, New York is the epicenter of the AIDS epidemic in the US. Testing for HIV requires a separate written form of consent, which Frieden says is a huge barrier and allows people to unknowingly engage in risky behavior and infect others. He is advocating for laws to require only oral consent, and to be able to track people on treatment as with other infectious diseases. Under his plan, doctors would offer a test for HIV along with routine tests for cholesterol and diabetes.

But the plan steamrolls over concerns of privacy and stigma, critics say.

“An HIV test is not like a cholesterol test or even for another sexually transmitted infection,” says Marjorie J. Hill, interim executive director of the advocacy group Gay Men's Health Crisis. “HIV has very significant life consequences if a person is positive and a person needs to understand that before they get tested,” Hill says.

“This isn't about public health. This is more about public corralling,” adds Terri Smith-Caronia, director of New York City public policy for Housing Works, an HIV/AIDS advocacy group.

The advocacy groups will go head to head with Frieden in a series of public meetings on the topic, but some experts on the state's AIDS advisory council are already convinced. Frieden says when so many people are getting infected and dying, it is the government's job to step in and help.

“There's a poem, 'the grave's a fine and private place,'” he says. “I understand privacy concerns, but you also have to recognize that society has a moral imperative to try to provide care.”