Related in Community Gazettes:
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
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
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
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
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
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
"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
"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.
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