New York City is getting healthier, with fewer people smoking, fewer new cases of HIV, even fewer people dying; the city’s death rate recently hit a
historic low. But there is one major health problem that is getting worse in the city -- diabetes. And, New York City Health Commissioner Thomas Frieden said recently,
getting worse much more quickly than anyone could have imagined.”
That is why the Bloomberg administration is taking some unprecedented steps to curb what the mayor calls “a vicious silent killer.”
The highlight of the administration's efforts so far has been the establishment of a
citywide registry (a collection of medical data) to give officials a
better picture of the city’s epidemic. This is the
first attempt by an American city
to track a chronic disease. While the registry will not create a direct
medical benefit to many patients now, health experts are hopeful that
it will serve as the foundation for a comprehensive approach to dealing
with diabetes in New York City.
“If the city’s information system works well and patients’
confidentiality is maintained, the
registry initiative could be a first step towards
other effective -â€“ and no doubt more costly â€“- interventions,” wrote
Robert Steinbrook in the New England Journal of Medicine.
What Is Diabetes?
diabetes is a disease that keeps the body from breaking down sugars
in food correctly. (There is a type 1 diabetes, but it is rare, and
generally when people refer to diabetes they are speaking about type
2). Genetics play a role in whether a person develops diabetes; so does
obesity. Blacks, Latinos, and Asians are both more susceptible to the
disease genetically and, in New York, more likely to be overweight than
whites, so racial minorities and new immigrants suffer
disproportionately from diabetes here, as a recent
series on diabetes in the New York Times made clear.
The disease is chronic and incurable, but it is manageable. Diabetics must watch their
blood sugar levels, and adjust their diets accordingly. If they do not
keep these levels under control, diabetics can lose limbs, or go blind.
Their kidneys fail, and they have heart attacks and strokes.
As America gets fatter, diabetes rates are skyrocketing nationwide,
with serious consequences. The total economic cost of the disease
nationwide in 2002 was $132 billion, with 11 percent of national health
care expenditures dedicated to the disease.
But if diabetes is hitting the entire country hard, New York City is in
the worst shape: A greater percentage of New Yorkers are already
affected by the disease, and the number of new cases here is rising more
quickly than elsewhere. There are about 530,000 documented cases of
diabetes in New York City, and an estimated 265,000 New Yorkers who
have the disease but do not know it. In 2004, 1,734 New Yorkers died of
diabetes, making it the fifth-leading cause of death in the city. But
because many diabetes deaths are attributed to complications and not
the disease itself, the city believes the true toll is much higher.
The City’s Registry
Diabetics regularly monitor their blood sugar with a standard test -- or
at least they should. The health department’s proposed budget this year
includes $2.7 million to fund a registry that will collect and analyze
The program is already underway. In January, city officials began
collecting the results of those blood tests by requiring laboratories that
administer them to report the results. Officials hope to track the
progress of individual patients, and also to get an exact picture of how
diabetes is affecting New York City as a whole.
The city is gathering information across the city, but the initial
effort of the registry is focused on the South Bronx, where diabetes
rates are among the highest in the city. There, the health department will monitor
patients’ progress, contacting them through their doctors if it sees
that their blood sugar levels are persistently high, or that they are
not getting the tests regularly enough. While doctors could probably do
much of this on their own, the city argues that it is better equipped
to handle such large sets of data, and that its efforts will take some
of the burden off individual doctors.
If all goes well in the Bronx, the health department will use that pilot program as
the basis of a citywide effort. By early next year, it will have a
clear view of diabetes in New York City â€“- which populations are most
affected, where they live, how they are being treated. Officials hope
that some idea will emerge from this data about how best to help
diabetics manage their disease.
Medical professionals seem excited about the potential of the registry. Jacqueline Salas-Spiegel of the
Naomi Berrie Diabetes
Center at the Columbia University Medical Center hopes the data from the registry will be used to
identify the ages at which children are most likely to begin developing
diabetes, and which parts of the city they live in. Then, she says, the
city can deploy teams of "roving nutritionists" to their schools,
with the aim of offsetting some of the unhealthy habits that lead to
But others are raising questions about whether this registry invades New
Yorkers’ privacy. “To pass along information like this without the
patient’s even knowing I think is a violation, ” said Councilmember Yvette Clarke, who represents Flatbush, where people die of diabetes at a fifty percent higher rate than in the
city as a whole.
People who don’t want to be contacted about their results can opt out
through 311 or over the Internet, but their information will continue
to be part of the registry. The health department says that it
needs access to all the data if it is going to reach useful
conclusions. Frieden has pointed out that the city has a good track record in managing confidential databases.
Trying To Change Behavior
The challenge with diabetes, say city officials and medical
professionals, is that managing or preventing it requires a change in
behavior. They acknowledge that
collecting comprehensive data and refining the techniques used by
doctors will not solve the problem of diabetes unless the city can use
those tools to convince New Yorkers to adopt the healthier habits that
are the only real way to counter diabetes.
"What we need to do is work to change the [social] environment," said
The city is now establishing outreach campaigns to try to change the behavior of several groups of
veterans, and women who develop diabetes
while they are pregnant, which is called gestational diabetes. While gestational diabetes is temporary, women who develop
it are more likely to end up with chronic diabetes in the future, as
are their children.
Undermining Its Efforts
Critics point to ways that City Hall is undercutting its own efforts:
At a time when
half of children maintain a healthy weight, the city signed a deal
with Snapple giving the beverage company the exclusive right to sell
its sugary juices and iced teas at schools and public buildings.
recently started charging for several recreation
centers in low-income neighborhoods where those at the highest risk
of developing diabetes had been able to exercise for free. While the
city argues that the fees are modest, the Independent Budget Office
recently showed that adding fees to recreation centers elsewhere in the
city has led to
lowered rates of use (in pdf format).
Also, the mayor's proposed budget includes about $9 million less money for child
health clinics run by the Health and Hospitals Corporation; critics
worry these reductions will lead to poorer health care for those who
have relied on them.
These decisions highlight what Salas-Spiegel sees as one of the major
roadblocks to a comprehensive diabetes program. Programs encouraging
exercise and better dieting habits are the only known way to stop the
rise of the disease, and success in the long run would prove to
be cheaper than having to deal with the horrible consequences of the disease -- the amputations, the heart attacks. But it is difficult, she says, to devote the necessary resources now without the promise of immediate payoffs.
"If we prevent all this from happening it would be a tremendous
savings," said Salas-Spiegel. "But would we then be able to transfer those
funds saved to the prevention and education side? That remains to be
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