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Gotham Gazette

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Citizens Union

Food Borne Illnesses


Reports of a potentially dangerous E: coli infection among children in a Bronx day care center, coupled with two Yankees players benched by parasitic infestations, seems to have turned the summer into an unplanned Food Borne Illness Awareness Month.

According to estimates by the federal Centers for Disease Control and Prevention (CDC), 76 million Americans get sick each year from food--borne illnesses, more than 300,000 are hospitalized, and 5,000 die.

E:Coli

The city's Department of Health and Mental Hygiene announced in the beginning of July that it is investigating a recent outbreak of E. coli 0157:H7 infection in children who attended the "For Kids Only" day care center in the Bronx. After three children who spent time in the same first-floor room of the center came down with confirmed cases of E. coli 0157:H7, health inspectors visited the site. They are also investigating suspected cases among 18 other children who attended "For Kids Only."

The day care center voluntarily closed during the investigation and has cooperated with the health department. An article in the New York Post reported that For Kids Only passed annual health inspections in March 2004 and April 2003, and quoted parents who praised the center for cleanliness and health consciousness. Toddlers in day care centers, however, are particularly vulnerable to outbreaks of E. coli 0157:H7 and other foodborne pathogens, because they eat the same meals, crowd together, often fail to wash hands after use of the toilet, and frequently wear diapers, which can lead to spread of the bacteria if caretakers fail even occasionally to handle them using precise sanitary procedures.

The health department is also investigating one confirmed case of E. coli 0157:H7 in a local child who does not attend the day care center. All children associated with the outbreak live in the Bronx and range in age from seven months to just over three years.

According to city Health Commissioner Thomas Frieden, all of the affected children "are doing well at this point." As E. coli 0157:H7 outbreaks go, then, this one was relatively benign. The pathogen can cause much more serious health consequences, especially among young children and the elderly. According to the CDC, in three to five percent of cases, a complication called hemolytic uremic syndrome (HUS) can occur several weeks after the initial symptoms (which are themselves debilitating -- severe, bloody diarrhea and painful stomach cramps.) HUS is the most common cause of acute kidney failure in children.

In 1999, there were 18 cases of E. coli 0157:H7 reported among New York City residents. In 2002, only 2 cases -- both in a private home -- were reported, according to the CDC, which collects statistics on foodborne disease outbreaks from state, local and territorial health departments each year.

Some types of E. coli bacteria are normally found in the intestines of humans and coexist harmlessly with their hosts, even performing useful functions. E. coli 0157:H7 is not such a one. Normally found in cattle and similar animals, it typically spreads to humans when they consume food or water contaminated with microscopic amounts of cow feces. Hamburgers have often been implicated in the spread of E. coli 0157:H7 outbreaks, since ground flesh from literally hundreds of different cows may be mixed together in a single hamburger. To paraphrase an old saying, scraps from one sick cow can spoil the whole barrel.

Thorough cooking of meat and pasteurization of beverages like milk will generally kill the bacteria, but are not always performed. In the notorious 1993 E. coli 0157:H7 outbreaks traced to Jack in the Box restaurants in Washington State, the fast-food outlets failed to cook hamburgers infected with the bacteria well enough to kill the pathogen before serving them. About 700 customers fell sick and four died.

Once humans are infected, they can spread the infection to each other through poor sanitary practices, such as inadequate hand-washing after use of the bathroom and/or the handling of diapers.

The health department is asking parents of any children who attend the For Kids Only center to be on the lookout for symptoms of E. coli 0157:H7 infection -- abdominal pain, watery diarrhea that becomes bloody, irritability, and sometimes fever. The department urges parents of children who develop symptoms to immediately contact a physician. It advises parents to consult their own physicians, but they can also call 311 or the New York City Poison Control Center at (212) 764-7667 if they need more information or help finding alternative day care arrangements.

The health department also asks that parents who have children with diarrhea not take their children to daycare. And it has issued an alert to medical care providers requesting that all suspected cases of E. coli 0157:H7 infection be immediately reported to the Department's Bureau of Communicable Diseases by calling the Provider Hotline at 1-866-NYC-DOH1. (E. coli 0157:H7 is one of the so-called "reportable diseases" that the health department tracks in order to identify outbreaks and register them with the national epidemiological surveillance system.

To prevent infection with the bacteria, the city health department makes the following recommendations:

  • Do not eat undercooked hamburger or other ground beef products. Cook all ground beef and hamburger thoroughly. Make sure the cooked meat is brown throughout (not pink), and the juices run clear.
  • Drink only pasteurized milk and milk products.
  • Avoid unpasteurized apple cider.
  • Make sure infected people, especially children, wash their hands carefully with soap after using the toilet to reduce the risk of spreading the disease.
According to the CDC, each year E. coli disease strikes 73,000 people in the United States and kills around 60, mostly children. The elderly and the immune-compromised are also more vulnerable to bad outcomes. Most victims, however, recover without treatment in five to 10 days.

Intestinal Parasites

Meanwhile, pitcher Kevin Brown became the second New York Yankee in short succession to be diagnosed with an intestinal parasite. He has the dubious honor of joining teammate Jason Giambi, who was diagnosed with a parasite a few days earlier, after being sidelined the day before for lackluster performance. Brown had complained of fatigue and the unintentional loss of 15 pounds since the start of the season, while Giambi has suffered from fatigue, vomiting, and flu-like symptoms that have significantly impaired his playing.

Intestinal parasites are contracted from contaminated food or water, and Brown and Giambi are still trying to puzzle out where they might have picked up the bugs. Their teammates were spooked by the second diagnosis of parasites in their midst, but none of the other Yankees are showing symptoms, according to a New York Times report. Parasites can be treated with medication, which typically takes 7 to 10 days, but until the intestinal freeloaders are banished and the players' strength has returned, Brown and Giambi will continue to ride the bench, probably in considerable discomfort.

There were 14 cases of parasitic foodborne illness reported among New York City residents in 2002, the last year for which the CDC has published data. All of those were caused by Cyclospora, a one-celled, microscopic parasite that until the mid-1990s was thought to exist only in developing countries, particularly in tropical climates. In 1996, however, cyclosporiasis broke out in the U.S. and Canada and was eventually traced to contaminated raspberries grown in Guatemala -- underscoring some of the hazards associated with the post-NAFTA mass importation of produce from developing countries, particularly Central America, where parasitic infections are endemic. Anything eaten raw, such as fresh fruits, vegetables, and oysters, can be particularly dodgy unless scrubbed with extreme thoroughness.

The range of foodborne pathogens is dizzying, and more are being identified all the time, from bacteria to parasites to fungus. Some of the most common bacterial sources of foodborne illness include Salmonella, which now infests chicken eggs, is rapidly developing antibiotic-resistant strains, strikes 1,400,000 Americans annually, and kills 580; the rare but deadly Listeria monocytogenes, which lurks in undercooked meat and sickens only 2,500 Americans per year but kills 500 of them, or 20 percent of its victims; and Campylobacter, which lives on most raw poultry meat and infects 2,500,000 Americans annually, killing 124. Among parasitic organisms, Toxoplasma gondii or toxoplasmosis, which most people associate with cat feces but which can also be contracted by eating raw or undercooked meat, infects 225,000 and kills 750, and is particularly dangerous to the unborn children of pregnant women who become infected. Among the viruses, Norwalk-like viruses (of cruise ship fame) reign as the U.S.'s Deans of Diarrhea, sickening 23,000,000 per year and killing 310. (A case-fatality rate of only 6.7 percent, however, means that Norwalk-like viral infections, while extremely common, are not particularly dangerous to most people.)

The CDC's web page on foodborne illnesses lists a number of simple ways consumers can help protect themselves from these and other pathogens that can turn what should be gustatory pleasures into gastrointestinal nightmares.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Urban Health Challenge


Related in Community Gazettes:

In Harlem, a Neighborhood Institution Expands
(District 9: Harlem)
Treating TB Cases in Jamaica
(District 24: Jamaica)
The Army Comes to East Flatbush
(District 40: Flatbush)
 

Yellow fever presented such a scourge to New York in the early 1800s that as many as one third of all New Yorkers fled the city to escape the deadly outbreaks. At its peak in 1805, a full five percent of those who stayed behind lost their lives to the disease. Victims of this and the other epidemics of the day sought help in the nation's first public hospital -- an estate on the lower East Side called Bellevue -- which itself was plagued with filth and death.

While such lurid events may seem to be a thing of a more ignorant, barbarous past, the truth is, New York continues to face public health crises. Many New Yorkers cannot afford health insurance or adequate health care. Unhealthy conditions afflict many neighborhoods. The threat of epidemic still looms as well, although the specific diseases are different. In the last 30 years, more than 35 new infectious diseases have emerged, and the death rate from infectious diseases in the United States has doubled since 1980.

In a recent essay in Harper's magazine, physician Ronald J. Glasser warned that the scourges of the past did not just go away -- they were defeated by concerted effort -- and it will take a world-wide effort to prevent what he sees as the nearly-inevitable pandemics of the future. "The real weapons of mass destruction," he wrote, "are infectious diseases, such as SARS and influenza."

Mayor Michael Bloomberg has sought to take on those public health challenges he thinks can be addressed within the five boroughs, launching several massive health initiatives:

  • A war against smoking
  • A campaign to stop so-called preventable deaths, focusing on ten top recommendations for every New Yorker (have a regular doctor; get checked for cancer; get help for depression, etc.)and a half dozen general public health goals (such as increasing by 150,000 the number of New Yorkers 65 and older who get an annual flu shot).
  • A survey of the current state of New Yorkers' health and nutrition
  • Increased funding to upgrade New York's massive public hospital system (See related story on the renovation of Harlem Hospital )

 

"Pretending health problems don't exist -- using band-aids where major surgery is more appropriate -- just isn't this administration's style," Bloomberg said in his 2004 state of the city address. "We know what and where the public health issues facing our residents are -- and we're doing something about them."

The mayor's interest is nothing new; he has given so much money to the public health school at his alma mater John Hopkins University in Baltimore (the first such school in the nation) that it is now named after him. But critics suggest that solutions to the health care crisis afflicting New York may simply be beyond the reach of any mayor. Diseases know no borders, and the costs associated with good health are astronomical, which is one reason health could emerge as a major issue in the presidential campaign. To the most alarmed and alarming of public health advocates, the choice that the public and public officials must make sooner or later may come down to a very stark one: debt or death.

CHALLENGES TO URBAN HEALTH

City officials have grappled with improving the general health of residents at least since the 19th century. By the mid 1800s, crowding, garbage and untreated sewage helped spark outbreaks of cholera, typhus and tuberculosis. Infant mortality rates soared, as more than half of those under the age of five died each year. At times, death was so prevalent that youngsters were heard hawking pine boxes on the streets: "Coffins! Coffins of all sizes."

Surgeon and public health pioneer Stephen Smith established the first permanent public health agency in the city, the Metropolitan Board of Health, in 1865. Thanks in part to its efforts, cholera took the lives of "only" 1,137 people in 1866 -- down from 5,071 people in 1849.

Early health department concerns included providing clean drinking water, improving sewage and sanitation systems, and fighting diseases such as typhoid fever and diphtheria. The health department deployed a brigade of "public health police" officers, who sought out sick and dying people and carted them off to isolation wards in hospitals. They also tracked neighbors and families of patients with contagious diseases. Beginning at the turn of the 20th century, the Board of Health turned its attention to infant mortality and became increasingly involved in virtually every aspect of city life, monitoring and regulating highway construction, tenement building, the overall environment.

The results have been tangible. According to a recent Department of Health report, New Yorkers now live an average of 77.6 years - longer than they ever have and longer than the average for Americans overall. At the same time, infant deaths in the city have reached an all-time low.

But huge disparities remain within the city. According to a recent report (in pdf format), people in New York's poorest neighborhoods live an average of eight years less than those in its richest areas. The rate of new AIDS cases among blacks is six times as high as among whites, while Hispanic New Yorkers are twice as likely to have diabetes as white New Yorkers. Other studies found that some immigrant neighborhoods in the city have rates of tuberculosis as much as 20 times higher than the national level (see related story. And despite falling crime rates, murder still claims the lives of many New Yorkers, particularly the young. (See related story.)

"While substantial progress has been made in reducing health disparities, unacceptable health inequities persist," said Health Commissioner Thomas Frieden.

Experts cite a number of explanations for these differences. Poor people, even those who have health insurance, may not have access to the high quality care that richer Americans receive. In an article in the New York Times magazine last year, writer Helen Epstein noted that poor people suffer greater stress, have less opportunities for exercise and live in neighborhoods where liquor, fast food and cigarettes tend to be far more abundant than inexpensive, healthy foods. Some say that the poor may be more likely to indulge in unhealthy behavior, such as intravenous drug use or unprotected sex.

Organizations, such as West Harlem Environmental Action have consistently argued that poorer black and Hispanic communities house polluting facilities, such as treatment plants and bus depots, that threaten the health of neighborhood residents.

The health woes of poorer communities spill out into the city as a whole, boosting health care costs for everyone and leading to the spread of diseases, such as tuberculosis.

Meanwhile, new risks continue to emerge. The last decades have seen new diseases, most notably AIDS. Since 1981, more than 15 percent of all AIDS cases in the United States have been in New York, and the disease has killed over 84,200 people here. As of June 2003, some 57,128 New Yorker were known to have AIDS.

West Nile, which had not been reported previously in the United States, was first diagnosed in this country when it arrived in New York in 1999. That year, it killed four New Yorkers.

Since September 11, 2001 - and the following anthrax scare -- bioterrorism and disaster preparedness have grown as pressing concerns. In mid-July, the Department of Health opened a newly renovated bioterrorism detection facility. After a $16 million upgrade, it can test for a full range of potential biological weapons of mass destruction, including anthrax.

BLOOMBERG'S HEALTH INITIATIVES

In a manner similar to the way he took on education (though generally with less publicity), Bloomberg has tried to focus on health issues.

War on Smoking
No part of the mayor's public health campaign has attracted as much attention or as much controversy as his war on smoking. Bloomberg has maintained that smoking is the number one cause of so-called preventable deaths from lung cancer, asthma and other respiratory ailments. Public health official attribute some 12,000 deaths in New York a year to smoking.

First, Bloomberg increased the tax on a pack of cigarettes from 8 cents to $1.50. Then he banned smoking in all indoor workplaces, including bars and restaurants. In response, the number of smokers in the city dipped by 100,000 between 2002 and 2003, according to a health department survey.

The decline in smoking, Frieden said, will prevent 30,000 premature deaths. And to refute complaints by bar and restaurant owners that the smoking ban would damage their business, the city said that bar and restaurant receipts increased by 8.7 percent in the first year after the smoking ban went into effect in March 2003.

But the war on smoking has its opponents. Some believe that, however unhealthy smoking may be, the mayor's crusade against it infringes on the rights of the individual. And smokers complain they are being unfairly targeted.

Others like Councilmember Tony Avella question whether the initiative is as successful as the administration claims. "I am very skeptical these days of figures that the administration puts out because I suspect they're geared toward supporting their agenda," he said in a Daily News article.

Take Care New York
But smoking is only one cause of preventable deaths. Bloomberg has taken aim at other causes, including undiagnosed health problems and AIDS, in what is considered the city's most comprehensive health policy ever, Take Care New York. The campaign focuses on 10 issues that can improve health:

  • 1. Have a regular doctor or other health care provider
  • 2. Be tobacco-free
  • 3. Keep your heart healthy
  • 4. Know your HIV status
  • 5. Get help for depression
  • 6. Live free of dependence on alcohol and drugs
  • 7. Get checked for cancer
  • 8. Get the immunizations you need
  • 9. Make your home safe and healthy
  • 10. Have a healthy baby such as having a primary doctor; being smoke, drug and alcohol free; getting immunized, and getting screened for deadly diseases such as cancer and HIV.

 

To accomplish its goals, the city sets targets such as increasing the number of women who have mammograms or the number of people over 50 who get checked for colon cancer. But the city has not provided a budget for its plans or precise information on how it hopes to accomplish its goals.

Some may wonder if there is a gap between rhetoric and reality. While the plan seeks to decrease by two thirds the number of children under six with potentially dangerous blood-lead levels, the mayor earlier this year vetoed a bill that proponents said would reduce lead poisoning.

And in an effort to better identify what ails New Yorkers, the city in June began conducting its Health and Nutrition Examination Survey. This effort, which began in June, hearkens back to the days of the door-to-door health police. The Department of Health targets 2,000 randomly selected New Yorkers and pays them $100 each to participate in an interview at home and a physical exam at a public health clinic. Through the survey, the city hopes to determine the prevalence of health problems such as diabetes, high blood pressure and depression among New Yorkers.

Increasing Support for Public Hospitals
The last decade has been a bit of a roller coaster ride for the New York Health and Hospitals Corp., the largest city public hospital system in the country. For much of his first term, Mayor Rudolph Giuliani sought to make some of the hospitals private and slashed funding. The budget cuts and uncertainty prompted the New York Times to report in 1996 that the hospitals that serve many of New York's poorest and sickest were falling apart.

The courts blocked the privatization effort, but the city hospital corporation continued to cut spending -- shortening patient stays, for example. When Bloomberg became mayor, he sought to modernize and revitalize the system.

This year's budget includes a $200 million subsidy for the Health and Hospitals Corp., which operates 11 acute care hospitals, five long-term care hospitals, six diagnostic and treatment centers, over 20 outpatient clinics, and a health maintenance organization.

"The $200 million subsidy is a wise investment that will allow HHC to continue making necessary management and technological changes that will improve the quality of medical services and save the city money in the long run," said Bloomberg at an April 27 press conference.

The mayor has also committed hundreds of millions of dollars toward capital improvements at the public hospitals. He has provided $225 million for Harlem Hospital Center, $250 million for Jacobi Medical Center, and $91 million for Coney Island Hospital. Even Bellevue Medical Center, marred by crime and low performance, is getting a $178 million facelift.

But critics still question the role of public hospitals. Edmund McMahon, a senior fellow at the conservative Manhattan Institute, has called the huge outlay for the public hospitals wasteful and accused Bloomberg of "falling in love with HHC."

THE HOSPITAL CRUNCH

Even supporters of the corporation question whether the influx of money will merely delay an inevitable crisis. The Independent Budget Office predicts a $600 million deficit for the Health and Hospitals Corp. as early as next year, due to rising costs and the expense of providing services to the uninsured.

"The basic problem is that expenses are growing faster than revenues," said Marleen Zurack, chief financial officer of the Health and Hospitals Corp. "The mayor has been very supportive, but this is a very challenging time for hospitals, public and private. The difference is that private hospitals can reduce or eliminate services that don't make money. Because it is our responsibility to provide services for the uninsured, we don't have that option."

The Health and Hospitals Corp. served 450,000 people without health insurance last year. The cost of servicing the uninsured next year is projected to be $900 million.

The United Hospital Fund recently released a study indicating that it would cost about $1.4 billion a year to enroll some half million New York adults who are eligible for the Medicaid program but not in it. The study urges that action be taken to do this. "Numerous studies have demonstrated that those without health insurance simply don't get the care they need," it says. "The uninsured postpone necessary care and receive less preventive care - and their health suffers.

THE MEDICAID MONSTER

But the insured present a challenge as well. There are currently 2.5 million New Yorkers enrolled in Medicaid, the joint federal-state insurance program to provide health care to low-income people. This will cost the city roughly $4 billion this year. And that number continues to rise.

"I wish that the same way [Bloomberg] committed himself to changing the school system, he would commit himself to Medicaid reform," said City Council Republican Leader James Oddo, a member of the health committee. "Until we tackle the Medicaid monster, we will never have a balanced budget, and we will have to keep making cuts to vital programs. But what will we do once we've cut everything that can possibly be cut and Medicaid costs continue to rise?"

The federal government and the states share Medicaid costs, but New York is one of the few states where local governments must chip in as well. City officials want the state to take on more of the burden.

In addition, Democrats in the State Senate have offered reforms, including a three-year cap on costs, that they say could save New York $27 billion over five years. But no action has been taken.

The federal government, having made sweeping changes to Medicare, the federal health-care program for the elderly, is now turning its attention to Medicaid.

"We're going to try to move toward a comprehensive Medicaid reform bill. I don't underestimate the difficulty of doing that," Representative Heather Wilson, chair of the Republican House Task Force on Medicaid Reform, told American Medical News.

With health care costs soaring -- creating problems for individuals, companies and government -- the issue could be key in this year's election, said Kenneth E. Thorpe, an Emory University professor of health policy. "Health care on the domestic side is likely to be the biggest area of policy difference between these two campaigns," he said.

Democratic presidential nominee John Kerry is pitching a plan that would provide health coverage for an additional 26 million people at an estimated cost of about $653 billion over ten years. He would pay for this by eliminating tax cuts for the wealthy. President George W. Bush's plan, on the other hand, is much less costly and ambitious, providing coverage for an estimated 2.4 million.

But, as the junior senator from New York can attest, truly reforming health care in America presents a difficult -- if not insuperable -- challenge. And so, despite the national crises of rising costs, tens of millions of uninsured Americans, frightening new illnesses and threats of bioterrorism, Bloomberg may have little choice but to rely on his own efforts to make New Yorkers healthier.

Urban Issues: Health Care


URBAN ISSUES - HEALTH CARE

• • • • • • •

George W. Bush

In 2003, President Bush signed into law the most sweeping changes to Medicare since the creation of the program in 1965. As part of the reforms, he added a prescription drug benefit for senior citizens. Health experts are still divided on what these changes will mean for New York City in the long term. For the future, Bush advocates greater patient choices and $117 billion in tax breaks to help the uninsured pay for health care.

Bush also signed legislation that gives access to Health Savings Accounts and provides a tax deduction for premium costs for major medical coverage. He also has a plan to expand or build 1,200 new community health clinics.

Bush proposes reforms to address rising medical malpractice premiums, and supports legislation that allows small businesses to buy better health coverage, tax credits for catastrophic health care coverage premiums, and improving health information technology. (Learn more)

John Kerry

Kerry proposes allowing every American access to the healthcare plan currently offered to federal employees. He would reimburse employee health plans for the most expensive cases. He also plans to spend $72 billion over five years to offer health coverage for low-income people and children. The federal government would pick up the cost of Medicaid coverage for children in exchange for automatic enrollment of all school children eligible for the Children's Health Insurance Program. Kerry also wants to create a Patients’ Bill of Rights that will force health insurance companies to take responsibility for providing medical care and protect patients from misconduct. (Learn more)

• • • • • • •
Back to Urban Issues Main Page
• • • • • • •

GOTHAM GAZETTE’S RELATED ARTICLES


• Urban Agenda: Health Care
• Medicare Reforms and New York City

 

Urban Issues: Poverty


URBAN ISSUES - POVERTY

• • • • • • •

George W. Bush

In 2003, President Bush proposed an extension of the Welfare Reform Act with added requirements. Under the plan, recipients would be required to work 40 hours per week, the average funding for a family on public assistance would be increased, and state and local governments would consolidate food stamps, housing, and education programs. While welfare rolls have decreased drastically in recent years in New York City, there are signs that the poor are not finding jobs or the help they need. Homelessness in New York City is at a record high. The number of single mothers who are unemployed has risen and their average hourly pay has decreased since 2000, according to one report.

To help address poverty, Bush advocates federal funding for local faith-based organizations to help people find jobs, address addictions, and care for children. (Learn more)

John Kerry

Kerry believes that welfare reform has produced some positive results, but that more should be done to give low-income people education, job training, and childcare. He opposes the Bush administration's tougher work requirements for welfare recipients. He wants to build affordable housing to help the homeless.

• • • • • • •
Back to Urban Issues Main Page
• • • • • • •

GOTHAM GAZETTE’S RELATED ARTICLES


• Urban Agenda: Poverty
• Welfare Reform in New York
• Homelessness in New York
• Turning to Faith Based Organizations

 

Andtidepressants and Children


As this month began, a landmark research study and an unusual lawsuit by the state of New York added to the current controversy about whether children and adolescents with depression should be treated with the popular antidepressant medications known as selective serotonin reuptake inhibitors (SSRIs), a class of drugs which includes the best-selling Prozac and Paxil.

On June 1, researchers carrying out a federally funded study at Duke University announced preliminary findings that Prozac works significantly better than talk therapy to combat depression in adolescents, although a combination of the two treatments is the optimum. The early data also suggest that Prozac does not, in fact, raise the risk of suicide in adolescents, and that the benefits of taking it far outweigh the risks if a teen is battling moderate to severe depression.

On June 2, New York State Attorney General Eliot Spitzer filed a consumer-fraud lawsuit against the manufacturer of the antidepressant Paxil, charging that international pharmaceutical giant GlaxoSmithKline deliberately suppressed negative data about Paxil's safety and efficacy when prescribed for depression in children and adolescents.

Specifically, Spitzer's lawsuit alleges that the company suppressed the results of four studies it conducted that failed to demonstrate Paxil's effectiveness against depression in children, and suggested possible increased risk of suicidal thinking and acts. Out of the five studies it conducted, Glaxo released the results only of the one that showed mixed results on efficacy in children and teens, the suit alleges.

As the New York Times story on the lawsuit notes, the suit highlights two particular issues about antidepressants that have recently made headlines and captured medical and public attention. One is the previously mentioned question of whether some antidepressants, specifically some SSRIs, can actually increase suicidal tendencies, especially in children and adolescents. The other is whether, and to what extent, drug companies pick and choose among the data they present to the U.S. Food and Drug Administration when seeking FDA approval for a drug, presenting only those studies that support the drug's efficacy and safety and suppressing any that reach the "wrong" conclusions.

"Doctors should have access to all scientifically sound information so that they can prescribe appropriate medication for their patients," Spitzer said of his lawsuit. "By concealing critically important scientific studies on Paxil, Glaxo impaired doctors' ability to make the appropriate prescribing decision for their patients and may have jeopardized their health and safety."

The suit, filed in New York State Supreme Court, also stated that an internal Glaxo document from 1998 shows that the company intended to "manage the dissemination of [the] data in order to minimize any potential negative commercial impact."

It alleges that Glaxo misrepresented the drug to its sales representatives who promote Paxil to physicians, as having "remarkable efficacy and safety in the treatment of adolescent depression," despite the company's studies that suggested differently.

Glaxo issued a statement the same day asserting that the company "has acted responsibly in conducting clinical studies in pediatric patients and disseminating data from those studies.... All pediatric studies have been made available to the FDA and regulatory agencies worldwide."

"As for the 1998 memo, it is inconsistent with the facts and does not reflect the company position," the statement continues.

Paxil has been approved by the FDA for the treatment of depression in adults but not in children. The only antidepressant that has been approved to treat depression in children is Prozac, which is made by Eli Lilly & Co.

It is, however, legal for doctors to use their discretion to prescribe medications for uses other than the approved ones, if clinical practice has shown them to be useful. They are especially likely to do so if the medications are similar to ones that are approved for those uses. This widespread practice is called "off-label" prescribing.

U.S. sales of Paxil to treat mood disorders in children and adolescents totaled $55 million in 2002, the lawsuit states. The suit seeks the return of all profits Glaxo has earned as a result of the alleged misconduct.

Meanwhile, according to a New York Times report, the researchers for the Duke University study announced at a psychiatric meeting in Phoenix that the 12-week data showed that a combination of Prozac plus "talk" therapy worked best for depressed teenagers, with 71 percent of these patients responding well to treatment. Prozac alone worked next best, improving depression in 61 percent of the young patients. Talk therapy alone (specifically, cognitive-behavioral therapy, which previous studies have shown to be the most effective type of talk therapy at combating depression) worked only slightly better than a placebo. Only 43 percent of the patients treated with cognitive-behavioral therapy, versus 35 percent of those taking a placebo pill, showed significant improvement. None of the 378 teens aged 12 to 17 committed suicide, although there were six attempts.

The Duke team, whose research is being funded solely by the federal National Institutes of Mental Health with no drug-company involvement, is currently analyzing the data from the rest of the year-long study.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Children and Insecticides


A federal ban on home use of two insecticides has strong benefits to newborns, a new study (In PDF Format) by Columbia University's Center for Children’s Environmental Health. This is the first study to demonstrate the benefits of the ban during pregnancy in human subjects.

The study looked at the impact on fetal growth of chlorpyrifos and diazinon - two insecticides whose use in households was banned by the federal government in 2000. These two insecticides had been among the most commonly used for residential pest control and were available in a wide variety of household sprays and other home insecticides; Chlorpyrifos was the most frequently used residential insecticide in New York City. Both are still widely used in agriculture and continue to be found in the food supply.

The research involved 314 infants of African American and Dominican women in Washington Heights, Central Harlem and the South Bronx. The researchers measured the levels of the two insecticides in blood drawn from the umbilical cords at birth, both before and after the ban, and correlated those levels with the babies' birth weight and length.

Newborns arriving before the ban went into effect in January, 2001, who had insecticide in their blood weighed almost a half a pound less, and were smaller, on average, than those with no detectable levels. After the ban, the combined insecticide exposure levels had been reduced substantially, and there was no discernable effect on fetal growth.

"This study demonstrates the positive effect of the federal ban, which has substantially reduced exposures and benefited human health," said Dr. Robin M. Whyatt, principal author of the study. "The differences in fetal growth seen here are comparable to the differences between babies whose mothers smoke during pregnancy and babies whose mothers don't. The fact that the ban was associated with such an immediate change in birth weight and length provides considerable evidence of cause and effect."

"The results highlight the need to address continuing prenatal exposures to these and other toxic pesticides," said Dr. Frederica P. Perera, Director of the Mailman Center and the study team leader.

This research is part of a broader, multi-year research project, "The Mothers & Children Study In New York City," that was begun in 1998. It examines the health effects of exposure of pregnant women and babies to air pollutants from vehicle exhaust, the commercial burning of fuels, and tobacco smoking, as well as from residential use of pesticides and allergens.

Welfare Sanctions

In 2001, Marleny Acevedo, who was on public assistance, missed an appointment with her caseworker because her eight-month-old son had a fever and she stayed home to take care of him. When she tried to reschedule the appointment, her caseworker told her she would be sanctioned. Her bi-monthly benefits were reduced from $68.50 to $51, and then dropped again. What's more, the city hadn't included her son when it calculated her benefits, so Acevedo was being shorted a total of $174 a month in benefits and food stamps.

Altagracia Galindez, a 44-year-old mother of five, never knew that she was entitled to 25 percent more in public assistance than she was receiving. She didn't even know she was sanctioned until two years later. Several months of subsequent fighting her way through bureaucratic red tape led nowhere.

These women eventually received their full benefits, thanks to Acevedo v. Turner, a class action suit brought against the city's Human Resources Administration that was settled in April. Under the terms of the settlement, people facing sanctions will be notified of their alleged noncompliance and given information on how to challenge sanctions. In addition, the Human Resources Administration is now required to lift sanctions within seven business days of its being notified that a person has complied with the requirements.

Approximately 2,000 women are sanctioned by the city annually because they fail to comply with the child support cooperation requirements. Most of those are for inappropriate reasons, charges Randal Jeffrey, the attorney handled Acevedo's case for the New York Legal Assistance Group, such as missing a single appointment. "The question isn't whether the sanction is legitimate, it's whether they can get it lifted at all," Jeffrey says.

Commissioner Bell resigns from the Administration of Children's Services

William C. Bell, the Commissioner of the Administration for Children's Services, is leaving his post in July to work at a private child welfare agency. Bell, who has headed the agency since December 2001, had helped institute a nationally regarded overhaul of the city's child welfare system.

Bell's record is mixed, say child advocates. Under him the agency tried to keep children in their own homes with the help of services from community organizations. The number of children in foster care has dropped by more than half since 1996, to 22,000. But the average stay in foster care in the city is 49 and a half months, well above the national average of 33 months, and the waitlist for low-income childcare has grown to 43,000.

His replacement has not been announced.

Sasha Nyary, formerly on the staff of Life Magazine and the mother of a public school student, edits the newsletter of The Fifth Avenue Committee, a community-based organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Smokers Quitting


One of the most heavily stressed goals in the city's sweeping new public health plan is to help as many New Yorkers as possible quit smoking. It's an instance of the health department getting its priorities right and pursuing enlightened policy. In 2002, the last year for which New Yorkers' causes of death were tabulated, smoking killed more city dwellers (approximately 10,000) than alcohol, suicide, homicide, motor vehicle accidents, illegal drugs, and breast cancer combined. That is, smoking-related illnesses like lung cancer and other forms of cancer, heart disease, and stroke were responsible for nearly one out of six of the deaths in the city, according to Dr. Thomas Frieden, commissioner of the city's Department of Health and Mental Hygiene.

The city's new public health plan, unveiled in April, announced a goal of reducing the percentage of New Yorkers who smoke from 22 percent (in 2002) to 18 percent in 2008; freeing 240,000 individuals from their addiction. If successful, the health department has asserted, this one public health push alone will prevent 80,000 premature deaths among New Yorkers.

It sounded ambitious; but then the health department announced, on May 12, that the number of smokers in New York City had already declined a whopping 11 percent from 2002 to 2003 -- the fastest drop in smoking rates ever recorded anywhere in the nation. In just one year, 100,000 New Yorkers had kicked the habit. This was a decline in the percentage of New Yorkers who smoke from 22 to 19 percent -- making the goal of 18 percent by 2008 seem, if anything, too modest. These new findings come from surveys conducted at the city's behest by the survey unit at Baruch College.

Commissioner Frieden attributes the unprecedented drop to "[t]he increase in the cigarette tax, implementation of the Smoke Free Air Act, our nicotine patch distribution program, and public education about the health risks associated with tobacco." The decline in smoking will prevent 30,000 premature deaths, he said.

The increase in the cigarette tax and the ban on smoking in bars enacted last year undoubtedly played a major role in the decline. The aggressive anti-smoking measures the health department has pursued under Bloomberg, including advertising and the nicotine patch program cited by Frieden, probably account for the rest.

The nicotine patch program, a one-time give-away by the city of six-week supplies of nicotine patches to 35,000 New Yorkers last year, was notably successful, according to a report released by the health department last month. Eleven thousand, or 33 percent, of the participants are now ex-smokers. "The results far exceeded our expectations," Frieden said of the program.

"If you think about everything we did in the New York City Health Department last year, there's no single program that saved anything like this number of lives," he told the New York Daily News.

Most of the smokers who took advantage of the patch offer were black, Latino, or Asian, and/or from low-income neighborhoods. Women and young adults participated at high rates. Roughly 8,500 of the participants were from Brooklyn, 7,500 from Queens, 6,300 from the Bronx, 6,200 from Staten Island, and 5,000 from Manhattan. The city also made follow-up phone calls to participants and provided free counseling to those who wished it, then interviewed the participants after six months to determine the program's success rate.

"Most New Yorkers who smoke want to quit and try to quit each year," said Frieden. "But four of five who tried to quit did so without the benefit of medications or counseling, which we know greatly increase quit rates. Most people who want to quit should receive medications. Doctors should advise their patients to quit and provide medications to virtually all patients who are trying to quit. And families who want to assist their loved ones to quit should encourage them to try medication or counseling. Simply put: Drugs to help people quit smoking work!"

Nicotine patches are estimated to double the likelihood that a smoker trying to quit will succeed.

Although the "patch hotline" was a one-time offer timed to coincide with the enactment of the city's year-old laws prohibiting smoking in bars and restaurants, would-be quitters who lack insurance coverage will still be able to get free stop-smoking aids, including the patch and the stop-smoking drug Xyban, through the New York City Health and Hospitals Corporation's 14 free smoking-cessation clinics, located in Manhattan, the Bronx, Brooklyn, and Queens. Some community clinics and other participating healthcare providers will also offer the services and medications gratis to those who qualify.

Since the city's new health initiative does not have a budget associated with it, it is not clear how much funding will got to the smoking-cessation programs, or if they will be sufficient to reach the ambitious goals set for 2008. If they are anywhere near as successful as the nicotine patch trial, however, they will be a bargain at almost any price: Considering the $2.7 billion in direct medical costs and then the $2.0 billion in lost future earnings, tobacco use costs New York City an estimated $4.7 billion annually.

Aside from the New Yorkers it kills prematurely, the health department estimates smoking has disabled another 240,000 city residents through chronic bronchitis, emphysema, stroke, and heart disease, among other debilitating illnesses. And exposure to second-hand smoke has been demonstrated to contribute to heart disease and cancer beyond a reasonable doubt.

New Yorkers can call the city's help line at 311 for more information about clinics offering stop-smoking aid, including times of operation.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant Children's Illnesses and Access To Health Care


The eight-year-old had had chronic stomach pains for several weeks when his mother came up to Sandra Romain in Cambria Heights asking for help. The mother, undocumented and unable to speak English, had taken her son to the doctor, but left when she heard how high the fee would be. She had been feeding her son a home remedy of a certain Haitian tea, but he was still sick.

Romain, who was passing out flyers about health care for the Haitian Americans United Progress, told the mother that her boy was eligible for free health care. She helped the mother apply for a program known as Child Health Plus B.

Last year, people like Romain helped almost 95,000 immigrant children to sign up for this program, an example of what is called facilitated enrollment. But Governor George Pataki has proposed eliminating $10 million of funding for facilitated enrollment.

The city’s children will be hurt by this.

Undocumented immigrants have few choices for public health insurance in New York. But any immigrant child can enroll in Child Health Plus B, regardless of their status, and this covers many medical costs. Legal immigrants can use the more comprehensive Child Health Plus A, Medicaid or the state’s Family Health Plus.

What The Facilitators Do

The enrollment facilitators have set up shop in about 40 community-based organizations and 12 government agencies around the city. This group of diverse, multi-lingual people demystifies the process, answers questions, and dispels false rumors about the dangers of signing up for health care. They help the applicants fill out and gather the necessary forms, which they then send along to Medicaid or an HMO. Thousands are helped with the renewal process. An estimated 70 percent of adults enrolled in Health Family Plus in New York City came in through these facilitators (in PDF format). Losing this program will result in tens of thousands of immigrant children in New York City being without health insurance.

Why The Facilitators Are Needed

Overall, foreign-born children suffer from more illnesses than native-born children, according to a recent report (in PDF format). The city’s immigrants tend to be poor, especially recent arrivals. A third of children with immigrant parents live in families that have difficulty affording food.

Poor living conditions often lead to big problems for children:

Lead Poisoning

Children born in other countries make up 14 percent of the city’s child population but account for 22 percent of the lead poisoning. Lead poisoning disproportionately affects the Haitian and South Asian immigrant communities. Children born in Haiti are just three percent of the city’s population but account for 27 percent of all foreign-born children with lead poisoning. Children from India, Pakistan and Bangladesh are less than nine percent but account for 23 percent.

Asthma

Similarly, communities with high immigrant populations where the primary language is not English have extremely high rates of asthma. Haitians in Jamaica and Flatbush, and Dominicans and Latinos in Bushwick have very high rates of asthma. East Harlem, which is primarily Spanish-speaking, has the highest rates in the city. Rat and roach infestations, mold and dust mites are all linked to asthma.

Pesticides

Pesticides both legal and illegal are big problem for New York’s immigrant children. Children absorb more pesticides than adults because of their proximity to the ground and their still-developing bodies and brains. Pesticides have been shown to lead to lower birth rates and learning and behavioral problems. The insect and rodent infestations often present in poor housing means a higher use of pesticides, which have higher rates of use in New York City than in upstate agriculture. Illegal pesticides imported from China and the Dominican are widely sold in immigrant neighborhoods.

Obesity

Obesity is a particular problem for Hispanic children, who have by far the highest rate of pediatric obesity in the city. Almost one-third of Hispanic children between the ages of six and eleven are obese, compared with 16 percent of white children and 23 percent of black children. Diabetes, high blood pressure, and asthma can result from obesity, which usually follows children into their adulthoods, and increases the chances they will have obese children.

Immigrant parents are often working long hours and can’t monitor their children’s eating habits well. Low-income families can’t afford organized sports programs and poor neighborhoods often have poor or no playgrounds and parks, so children spend their time watching TV or playing video games. Culturally, many immigrant families come from countries with significant food shortages, so they urge food on their children as a way to show love.

Sasha Nyary, formerly on the staff of Life Magazine and the mother of a public school student, edits the newsletter of The Fifth Avenue Committee, a community-based organization.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

“Take Care New York” New Health Program; Old Diseases


The New York City health department has announced the most detailed and comprehensive health policy ever developed for the city. Called "Take Care New York," the ambitious, four-year plan sets goals and activities in 10 health areas the department believes will have the most impact on improving the health of New Yorkers. The 10 areas were chosen because they address the leading causes of illness and death in the city considered preventable (such as heart disease, smoking, excessive drinking, and cancer) - what city health commissioner Dr. Thomas R. Frieden called "our most important and winnable health battles." The city claims that successful implementation of the new policy will save thousands of New Yorkers' lives and prevent hundreds of thousands of illnesses each year.

The program makes 10 top recommendations to New Yorkers to improve their health:

1. Have a regular doctor or other health care provider
2. Be tobacco-free
3. Keep your heart healthy
4. Know your HIV status
5. Get help for depression
6. Live free of dependence on alcohol and drugs
7. Get checked for cancer
8. Get the immunizations you need
9. Make your home safe and healthy
10. Have a healthy baby

Some of the targets for 2008 the city says it plans to hit include:

• Reducing the number of adult smokers by 240,000, preventing 80,000 premature deaths;
• Decreasing the number of HIV/AIDS-related deaths by 42 percent, preventing more than 700 deaths every year;
• Increasing by 200,000 the number of New Yorkers 50 and older who are screened for colon cancer, preventing at least 200 colon cancer deaths per year;
• increasing the percentage of women 40 and older who receive regular mammograms from 77 percent to 85 percent;
• A two-thirds decrease in the number of children under six with potentially dangerous blood-lead levels caused by environmental lead hazards; and
• Increasing by 150,000 the number of New Yorkers 65 and older who get an annual flu shot, resulting in 1,000 fewer deaths during flu season each year.

There will obviously be price tags for many of the plans mentioned, such as the city's printing and distributing many more informational brochures and expanding or creating programs such as testing for AIDS, giving away condoms, creating an Internet registry of children's immunization histories, and providing smokers with free nicotine patches to help them quit. The city has not yet given out an estimate of the total cost of the program or details on how it will be funded.

This huge public health undertaking is the most ambitious that New York, even with its long history of pioneering public health programs, has ever attempted, and a broader and more aggressive program than any other city's in America.

One can view a booklet laying out the basics of the recommendations in at the city health department's web site; or download it as a PDF file. Those interested in the health department's formal, 64-page policy paper, which sets forth the goals, recommendations, benchmarks, rationales for focusing on the areas it does, current leading causes of preventable deaths and illnesses among New Yorkers, and funding and progress-evaluation issues, can alsodownload it as a PDF file from the department's web site.)

Increases in Syphilis and Tuberculosis

Both syphilis and tuberculosis, infectious diseases against which the city had made great headway in past decades, are on the rise. Although curable with antibiotics, both diseases are quite dangerous if left untreated; and both are contagious, although infection is preventable. New York seemed to be achieving a clear victory over the sexually-transmitted disease syphilis in the late 1980's and the 1990's, with cases dropping from a high of 5,000 cases in 1988 to just 82 in 1998. A bacterial rather than a viral infection, syphilis can, after all, be cured with a single shot of penicillin if caught in its early stages. However, an alarming resurgence of the disease has taken place in New York in the past few years. Shockingly, there was a nearly threefold increase in cases just between 2000 and 2002. The figures for 2003 show the increase has continued, although at a slightly slower pace: a 22 percent increase between 2002 and 2003. New York City's total rate of the disease in 2002 was 5.4 cases per 100,000 persons, or more than twice the national rate. This disparity may well be because the new epidemic is primarily affecting gay and bisexual men (and white men living in Manhattan). More than 95 percent of reported cases in recent years have been among men; in a 2002 study, 80 percent of them reported male sex partners.

What is most alarming is that having syphilis increases the chances that one will get HIV -- by up to five-fold, according to Dr. Susan Blank, the city's Assistant Commissioner for Sexually Transmitted Disease Control. Meanwhile, syphilis also makes a person with HIV much more infectious to their sexual partner(s), presumably because in its early stages syphilis often causes painless open sores, mainly on or in the genitalia or anus, but also known to occur on the lips, inside the mouth, as a rash on the hands, or indeed on any skin exposed during sex. Their painlessness may cause them to go unnoticed by the infected person. Having HIV also makes it more likely that one will get syphilis. According to Blank, when the city conducted interviews of syphilis patients at city STD (sexually transmitted disease) clinics, the men with syphilis who also knew their HIV status reported a more than 50 percent rate of HIV. Indeed, a 2002 study conducted by the health department along with the U.S. Centers for Disease Control and another research group found that having HIV was the number one risk factor for getting syphilis.

To try to break this deadly, spiraling dance between the two diseases, the city has extended the hours of its 10 free, confidential STD clinics, which are located in all five boroughs. (Click on the link for clinic locations, hours, and other information). Even aside from the grim HIV-syphilis synergy, it is crucial that those who have syphilis learn that they are infected, because the disease is easy to treat in early stages with antibiotics, but if left untreated can gradually play havoc with various organ systems, including the brain, cause serious health damage, and end in death. Many times syphilis presents few symptoms, at least initially, so a blood test is a good idea.

The city and gay men's health groups are continuing educational outreach efforts to the male gay and bisexual population. The health department is also developing programs to further educate health-care providers about the disease. Syphilis can be spread by vaginal, anal, or oral sex, or by kissing if there are sores in the mouth.

Meanwhile, the city also released preliminary data in March that cases of tuberculosis in New York had increased five percent from 2002 to 2003. While not large, it is the first increase in a decade mostly marked by reliable decreases in the TB rates. (New York City's TB rate remains three times higher than the national average, however.)

According to city health commissioner Dr. Thomas R. Frieden, the increase is part of the current global TB epidemic. Sixty-seven percent of diagnosed cases were among foreign-born New Yorkers, whom city officials say might well have been infected in other countries. Another 8 percent were among homeless people. Frieden urged New Yorkers to get screenings and treatment at city hospitals and clinics. The city provides free, confidential treatment for TB at its 11 "chest centers" around the five boroughs.

Left untreated, TB can ravage a patient's lungs and other organs. On a more optimistic note, the cases of tuberculosis resistant to treatment with multiple drugs continued a decade of decrease. There were 21 in 2003 compared to 27 in 2002, contributing to a total decrease of more than 95 percent since 1992. These multi-drug-resistant cases of TB can take three to four times as long to treat as conventional TB. The rest of the world apparently has not been so lucky; a recent New York Times article cited a World Health Organization survey estimating there may be as many as 300,000 new cases of drug-resistant tuberculosis a year in the world, particularly in underdeveloped countries. The Times article noted that drug-resistant cases are more common in moderately poor countries where patients receive inadequate treatment (a course of treatment for TB in the U.S. is lengthy, with patients required to take various pills for six months or more, often under direct supervision to make sure they don't stop too soon or skip days, which might allow the growth of drug-resistant bacteria).

One can acquire tuberculosis by breathing in bacteria in air that is contaminated by someone with active, untreated tuberculosis in the lungs. Luckily, it is rather hard to catch, requiring "prolonged, direct contact" with an infected person, according to the health department. It cannot be spread by sharing utensils, or casual contact.

Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Homeless Children and Asthma


Sarah Baez, a homeless mother of two, was waiting for the city to find a shelter for her family at the notorious Emergency Assistance Unit in the South Bronx earlier this month, but even when the temperature dipped into the 40s, she preferred standing on the sidewalk across the street from the crowded, noisy intake facility.

“The place is too dirty for my son, and the security guards are always yelling at people,” she said. “My son starts crying as soon as we go in there. I have to calm him down or he can have an attack.”

She is talking about an asthma attack. Her two-year-old, Nathaniel, has been hospitalized with asthma and needs frequent treatments with albuterol, a medication that dilates constricted bronchial tubes.

Nathaniel has plenty of company. Fully half of the homeless children entering New York City family shelters show some symptoms of asthma, according to the authors of a study published this month. Four in ten reported serious, persistent asthma attacks; and a third of those children have never been diagnosed with the disease by a physician. By contrast, about one in 18 children have asthma in the United States as a whole, according to the Centers for Disease Control.

This was not the only alarming report about asthma in New York. Another new study, published in the Journal of Allergy and Clinical Immunology, of 205 children with asthma who lived near the World Trade Center, according to Newsday, "says their condition was worsened by the 9/11 attack, seeing the doctor more often and taking more medication the year after the attack than the year before."

Medical experts have known for a long time that New York City has the worst asthma rate in the country, and that asthma is the childhood disease of the poor. The chronic lung ailment is triggered by environmental agents that occur most often in the poorest neighborhoods, such as dust, industrial pollutants and roach droppings. Once poor children get asthma, their condition suffers from such aggravating factors as persistent psychological stress, and limited access to health care. And the poor children who suffer the most, the new study found, are those who are homeless.

“We knew there were very high asthma rates in some of the city’s poorest neighborhoods,” said Dr. Irwin Redlener, one of the eight authors affiliated with Columbia University and Montefiore Medical Center in the Bronx. “But we were taken aback by the high rates we found.”

The 15-month study, which spent years wending its way through the peer review process before finally appearing in Archives of Pediatrics and Adolescent Medicine this month, began in 1998. Researchers struck an agreement with the city to screen children entering three family shelters, one each in Brooklyn, Queens and the Bronx. The city allowed the scientists to add a questionnaire to the standard medical intake interview, if the researchers would agree not to identify the homeless shelters used in the study.

Parents of 740 children were interviewed; for nearly 13 percent of the children, parents described symptoms in their children consistent with serious persistent asthma, but said that their children had never been diagnosed with the disease

“The study confirms what we know,” said James Anderson, from the Department of Homeless Services. “Homeless children come from communities with the highest risks of asthma, and most come from the most vulnerable families in those communities.”

The researchers have continued collecting data since the formal study ended in 1999. Redlener, who also heads the Children's Health Project, said that a few children may be getting better treatment. But he also points out that the number of children in the shelter system has nearly doubled to about 16,000.

For many such children, the very process of entering the homeless system can trigger asthma attacks. Sarah Baez, her boyfriend, and their two children spent two weeks shuttling between the emergency unit and a variety of shelters and motels for one-night stays. Often, she says, they return too early to get a full night’s sleep or too late to get her daughter to school on time.

“If they wanted to help cut down on asthma attacks, one thing that the city could do immediately is to cease the practice of overnight shelter placements,” said Patrick Markee of the Coalition for the Homeless. The coalition filed suit against the city four years ago, asking for increased services for asthmatic children, the same year that WE ACT, the West Harlem advocacy group, filed a federal complaint against the city for locating diesel bus garages in poor neighborhoods.

The city introduced a policy last fall of trying to place homeless families in shelters near the neighborhood where they once lived, in part to help them stay connected with familiar schools and medical providers. In these shelters, health care educators, such as Shelly Moore of Care for the Homeless, help them learn to manage the triggers in their home environment, and help connect them to medical providers.

“Community placement sounds good,” Moore says. “But the families are telling us a different story. They say the city is pressuring them to take the first apartment that becomes available, even if it has roach infestation or carpeting, which is very inappropriate for children with asthma.”

Ron Feemster has written for The New York Times, City Limits, and National Public Radio.



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