No one meeting Dr. Joshua Sharfstein would peg him as the guy to take on the drug industry, the medical establishment or federal bureaucrats over issues that threaten children.
He looks younger than his 37 years and has the gentle voice and demeanor of a pediatrician peering into a child's ears and reassuring parents that everything will be OK.
But don't be fooled. Sharfstein has been rocking big boats for years.
No one who has watched him since his early days in medical school would have been surprised to see Baltimore's health commissioner in his recent, high-profile confrontation with the agency that regulates drugs.
On national newscasts and on the front page of The New York Times, he scolded the Food and Drug Administration for failing to slap tighter regulation on over-the-counter cough and cold remedies. Sharfstein laid out evidence that the regulations don't work and that the medications can be dangerous to young children.
Noting the deaths of four Baltimore children who had overdosed on the products in six years, he led more than a dozen medical experts in filing a "citizen's petition" to push the FDA to act.
In an unusually rapid response, a top FDA official promised the agency would review the use of the products in children.
"I enjoy working ... at the juncture of science and the law," Sharfstein said in an interview. "If you can marshal the facts and the legal authority to do something, it really allows you to have a big impact."
He developed a taste for battle while a student at Harvard Medical School, where he rallied classmates to reject free books from pharmaceutical companies. He drew national media attention, challenging drug manufacturers to lower prices instead. He co-wrote a paper criticizing the American Medical Association for political contributions to opponents of its public health priorities.
As a postgraduate, Sharfstein published reports that documented how unsafe housing in Boston threatened kids' health. He also showed that many mentally ill children languished for days in emergency rooms because there were no beds available in psychiatric hospitals, prompting Massachusetts to act.
In Washington, as an advocate for Ralph Nader's Public Citizen, he analyzed data on the warehousing of mentally ill people in jails without charges. He was the voice of Nader's organization on a study of inaccuracies in drug companies' ads.
Most recently, he spent five years tackling health policy issues and government dysfunction as an adviser to Rep. Henry A. Waxman, a California Democrat.
'Working for people'
"He wouldn't accept just a ... brushoff you get from some government agencies," Waxman said. "He wants to be sure government's working for people, especially when it comes to kids."
These experiences sold Sharfstein on a career on the policy side of public health, he said.
"A lot of the time, particularly in pediatrics, you see things that have their causes in the social conditions," he said. "So it's rewarding to be able to engage them at a larger level, too."
It allows him to affect government policies that touch many people at once.
When his predecessor in Baltimore, Dr. Peter L. Beilenson, decided in 2005 to run for Congress, Sharfstein applied for his job. But he told Waxman he didn't expect to get it. He had no experience running an 800-person bureaucracy. And he was young, just 36.
But Beilenson had had no experience running bureaucracies either, and he was 32 when he took the position. And the more Sharfstein spoke to people in Baltimore about the job, he said, the more he wanted it.
The city's selection committee was immediately interested, said one member, Dr. William Blatt- ner, co-founder of the Institute for Human Virology, now a part of the University of Maryland School of Medicine.
"The thing that was apparent from the first meeting with him was his intensity, and the fact that he didn't fit the mold of the traditional commissioner," Blattner said.
"The FDA experience clearly gave him an inside track on how policy is made, and the work with Waxman gave him insights about what buttons to push to make things happen."
Most of the department's funding comes from the federal government.
"He exudes confidence and competence," Blattner continued. "What he says makes sense, and he backs it up with evidence and demands performance."
Sharfstein was no stranger to Baltimore. He and his wife had moved here previously, as she, also a physician, worked at Johns Hopkins and he took the train to Washington every morning.
Though he was raised mostly in Montgomery County, his grandparents were born here. A great-uncle led tuberculosis control efforts in Baltimore in the 1940s.
His father, Dr. Steven S. Sharfstein, is a psychiatrist and president of the Sheppard Pratt Health System in Towson. His mother, Dr. Margaret Sharfstein, is a pediatrician at the University of Maryland, College Park student health center.
Medicine was "always part of the mix" in his home, he said. His sister, Sarah, 30, is in medical school at the University of Maryland.
Even so, Sharfstein once contemplated a career as a political speech writer.
Interest in policy
"I was always interested in policy," he said.
After graduating from Harvard with a bachelor's degree in social studies, he decided to take a year off. His parents told him "all serious doctors need to go right to medical school." But he said he gave them an ultimatum: "Either I take time off, or I don't go to medical school."
He spent the next year in Guatemala and Costa Rica, calling it "the most important" year of his life. "I led a pretty coddled life until that point," he said.
Sharpening his Spanish, he accompanied doctors and health workers as they visited rural shantytowns, examining children and speaking with their parents. "It opened my eyes," Sharfstein said. "I realized I enjoyed working with parents and children. I think that was directly related to why I entered pediatrics."
"I came back for my first year of medical school a much more confident and ... committed person," he said.
Through nine years of medical training, he kept tackling health policy. He was 24 when his paper on AMA political contributions - co-written with his father - was published by the New England Journal of Medicine. Seven more peer-reviewed articles followed.
He volunteered at the FDA, writing and editing portions of the agency's legal argument to regulate tobacco as an addictive drug - a right the U.S. Supreme Court said Congress had not granted.
While working for Waxman, then the ranking Democrat on the House Committee on Government Oversight and Reform, Sharfstein discovered that children who got contact lenses from retailers, just for a change in eye color, were risking blindness and infection. "Because of that we changed the law to require that they be dispensed by a professional," Waxman said.
In Baltimore, Sharfstein has found no dearth of issues to take on during his first 15 months in office.
"The most common advice that I've disregarded is to pick one or two things and just go for them," he said.
From former Mayor Martin O'Malley to Mayor Sheila Dixon and the City Council, he said, "this is a city ... that has high expectations for public health, so what I've tried to do is push things forward in as many directions as possible."
Plenty of issues
He has supported anti-smoking legislation and called attention to the lead in Mexican candy sold here. He addressed crowding in city emergency rooms and closed shelters and shut down restaurants with persistent safety and sanitation violations.
He is keen to expand city-funded training for doctors in the use of buprenorphine ("bupe") to wean addicts off heroin, and enlisting college students to volunteer in family health clinics and drug treatment centers, he said.
He also is expanding Reach Out and Read, a program that provides books to low-income children when they visit a doctor. He said it has been shown to advance their language skills by about 3 to 6 months.
His busiest days may start at 3 a.m. or 4 a.m., answering e-mail from home until 6 a.m. He's in the office by 8:30 a.m. and gets home to his wife and two sons by 7 p.m. or 8 p.m., often with more work to do before bed.
He squeezes in baseball and soccer coaching duties and his reading (Taylor Branch on civil rights and Henning Mankell's Kurt Wallander mysteries).
"My big problem is phone calls," he said. "I have a hard time returning them on time,"
But "I can't complain," he said. "This is a job where I get up every morning and try to make progress on things that are literally killing people."
Dr. Joshua Moses Sharfstein
Baltimore commissioner of health, 2005 to present.
Health policy adviser to Rep. Henry A. Waxman, 2001-2005.
Bachelor of Arts in social studies, Harvard College, summa cum laude, Phi Beta Kappa, 1991.
Doctor of Medicine, Harvard Medical School, 1996.
Combined residency in pediatrics, Children's Hospital Boston and Boston Medical Center, 1996-1999.
Fellowship in general academic pediatrics, Boston University School of Medicine, 1999-2001.
Married to Dr. Yngvild Olsen, medical director of outpatient substance abuse treatment services, Johns Hopkins Hospital; two sons, ages 7 and 9.
Mount Washington neighborhood of Baltimore.