Ramon Mosquea, a 58-year-old heavy set Dominican, looked away nervously and winced as a small needle pricked his finger to draw blood for a glucose reading.
A couple of drops of his blood were inserted in a glucose-monitoring machine. The reading revealed that Mosquea, a cabbie for 20 years, had a blood glucose level of 206 milligrams per deciliter – a level high enough to diagnose him as diabetic.
“Wow!” Mosquea exclaimed when he saw his reading. “It’s never been that high before!” he said in Spanish, promising he’d make an appointment with his doctor as soon as possible.
Taxi drivers like Mosquea are highly susceptible to a number of health problems because of their sedentary lives spent sitting behind the wheel, studies have found. Drivers are often forced to eat on the go, making fast food their easiest option. Few of them get any exercise whatsoever, and often suffer from back, hip and leg pain from sitting in a car all day. This lack of exercise combined with a bad diet has led to high rates of diabetes and high blood pressure among cabbies, according to health experts. Many of them even have kidney problems because they frequently can’t find a place to park when they need to use a bathroom.
A 2001 survey by the New York Taxi Worker’s Alliance found that more than 20 percent of drivers had cardiovascular disease or cancer.
And it is often difficult for taxi drivers to get the health care they need. Another study conducted by the city council in 2009 found that 52 percent of the city’s cabbies are uninsured, twice the rate of the average American.
Drivers often face language and cultural barriers to health care access as well. A 2006 study by a taxi industry consultant found that 91 percent of the city’s taxi drivers were born in another country.
But fortunately for drivers like Mosquea, hospitals and healthcare initiatives across the city are offering an increasing number of free health screening and information programs aimed specifically at taxi drivers.
Mosquea’s glucose test was provided by Lincoln Hospital’s taxi driver outreach program. Maria Ramos, who founded the program, is the daughter of a cab driver who died of a heart attack.
“He never took care of himself,” she said of her father. “Every day he would say his chest hurts, his back hurts.”
Ramos said that demand for the taxi drivers health program has been steadily growing. The program visits taxi bases in the Bronx providing screenings, health information and flu shots. Lately Ramos has been getting requests from taxi bases in Queens and Harlem for the program to provide services there as well.
Part of the reason the program is in such high demand, Ramos said, is because most drivers work 60 to 70 hours per week, and they rarely have the time to go see a doctor. She remembers sometimes her father would come home for only a half an hour of sleep before heading out for another shift. Many taxi drivers also have stress-related problems from the long work hours spent navigating New York City’s hectic traffic.
“Many of them need to see a psychiatrist,” Ramos said.
Rafael Arias, a 62-year-old cabbie who has been driving taxis for 17 years, also received a glucose and blood pressure screening from Lincoln Hospital’s program. He said that a year and a half ago he had to have surgery because of a buildup of blood in his brain. The doctor told Arias that without the surgery he could have had a stroke. Arias said that he felt a great deal of stress from work at the time, and that his stress was partially to blame for his condition.
“If the blood went over here, I’d be dead,” Arias said, pointing to his right temple. “The doctor told me I’m a very lucky guy to be alive.”
Marcelo Villagran, an outreach coordinator at Lincoln Hospital, administered glucose tests for Mosquea, Arias and other drivers at the Prestige Car Service on Webster Avenue in the Bronx on a recent Tuesday. Villagran has been partnering with Maria Ramos to screen drivers for high blood pressure and glucose at taxi bases across the Bronx for four years now as part of the hospital’s taxi driver health outreach program.
That Tuesday Villagran turned the entry hallway of the Prestige Car Service taxi base into a small medical clinic. The drivers lined up to receive their free screenings from Villagran, who also gave out doctor referral forms and information pamphlets in both English and Spanish on diabetes and heart disease. He also gave the drivers $25 gift cards to supermarkets to discourage them from eating fast food, as well as cases of water bottles, telling them to drink water instead of soda.
One of the drivers said that he hadn’t seen a doctor in three years. Many of them said they don’t regularly see a physician, and rely on programs like Lincoln Hospital’s for their health care.
Even Rafael Arias said that he hadn’t seen a doctor since his brain surgery a year and a half ago. But after his blood pressure reading from Villagran was much higher than normal, Arias said he would try to set up an appointment soon to see one.
Villagran said that more than 60 percent of the drivers at any given base have high blood pressure, more than twice the rate of average Americans.
“All of the drivers, they drink all soda and beer, they don’t eat healthy, they don’t exercise,” said Jose Hernandez, who manages the Prestige Car Service taxi base.
Hernandez was a driver himself for 17 years, and is diabetic. He said that more than half of the drivers at the base were also diabetic.
“They always sit. I should start an exercise program for these guys,” he joked.
One taxi driver health initiative found an unusual but effective way to get drivers out of their cars and start to exercise. The STEP program conducted by Memorial Sloan-Kettering Center and the South Asian Council for Social Services gave pedometers to taxi drivers like Pritpal Singh, an Indian immigrant who has been driving a cab for four years, and encouraged them to walk more by counting their steps each week.
“Our work is very hard, taxi driving,” Singh, who works 11 hours a day, Monday through Saturday, said. “But if we don’t exercise, then in the future we will have to take lots of medicine.”
Singh said that when he started using the pedometer at the beginning of last year he typically took 2-3,000 steps per day. After a few weeks with the pedometer he was taking more than double that number, and his weekly blood pressure readings showed a significant improvement. Singh said that he and other drivers in the program used to sit and play cards while waiting to pick up customers at the airport, but now they take walks together with their pedometers.
Dr. Francesca Gany, the lead researcher for the STEP program, said that about half of the participants increased their step count significantly. Some even requested pedometers for their friends and family.
For his part, Singh has become a serious ambassador for exercise. After he started using the pedometer, he began doing yoga for a half hour with his family each day after work. He said he always takes the stairs up to his sixth floor apartment, and jokingly chides his children for taking the elevator.
He also said that he tries to convert other drivers to exercising whenever he gets a chance.
“I ask other drivers if they exercise. They always say, â€No.’ I say, â€Why? It is good for your future. Come, let’s go for a walk.’”
On a cold January day, the wind funnels down Creston Avenue in the Morris Heights neighborhood of South Bronx like a river through a canyon. Buildings seem slightly closer to the street here, and the tall towers loom over the narrow street and sidewalk. A couple of teenage girls walk down the street, laughing and shoving each other.
Some new construction gleams incongruently on one side of the street, but most of the other buildings on this block are much older, with a foregone elegance still barely visible in the stonework and tiles.
Yet inside these buildings residents complain of deteriorating living conditions. On a survey tenant after tenant writes of mice and cockroach infestations, peeling paint, broken toilets, inconsistent heat and hot water, and a front door with no lock. “The hallways smell like urine” writes one.
Tenant Johannie Burdier says the building was poorly maintained, dirty, and sometimes simply scary. She tells of a former building manager who, she says, took money from people in exchange for access to sell drugs from inside the building. A resident for seven years, Burdier lives in the building with her aunt and her eleven year old daughter. She says for much of her time there they were lucky if there was heat or hot water in the apartment.
Another resident, who works the night shift, writes that they were frequently robbed in the unlocked building entrance. “Always, always, always, they assault us and take our money and our things in the doorway. Why?” asks the tenant, writing in Spanish, “Why is there no lock on the door or security camera?”
These complaints are more than an inconvenience. Constant anxiety, prolonged exposure to molds, unchecked vermin and inadequate heat and hot water – all these things make people sick. The vast majority of people living in failed buildings are low-income and uninsured. When they get sick, they go to the hospital. And the city is left holding the bill.
A new pilot program, created by housing advocates and healthcare workers, aims to increase awareness of the public health costs resulting from distressed, overleveraged buildings. The program sends healthcare providers and social workers into buildings on the brink of receivership to identify and treat housing-related illnesses. The team hopes to help tenants, compile data on the health outcomes of living in buildings in poor condition, and eventually determine the actual cost to the city.
Dina Levy, Director of Organizing and Policy at the Urban Homesteading Assistance Board, or UHAB, says that what is happening in these buildings is a public health crisis. “It’s an outrageous moral problem, but it’s also a financial problem in whatever geographic space it’s happening in.”
She explains that when banks and owners fail to care for buildings, the costs of that failing often shows up in the medical bills of the people who live in those buildings, and that these tend to be low-income people without healthcare, so that cost is ultimately absorbed by taxpayers and the city. Until now, she says, there has been anecdotal evidence that people in certain buildings are getting sick, but a study would provide the first quantifiable direct connection.
“What we have observed is that people are getting sick and don’t have the resources to get adequate medical care,“ she said. “Why are banks and landlords allowed to harm people physically, and why should we be paying the cost of that?”
The project has gone out to buildings four times since Labor Day, and plans to do more outings this year. Members of the Committee of Interns and Residents of SEIU Healthcare, collaborating with the Family Medicine Department at Bronx Lebanon Hospital, the Pediatric Department at Jacobi Medical Center, Urban Homestead Assistance Board (UHAB), and Workforce Housing, created the Doctors’ House Visit Program as part of a larger community outreach program, the Healthy Bronx Initiative.
Tim Foley, Political Director of the Committee of Interns and Residents for SEIU Healthcare, said that the committee was drawn into involvement in the project by its members. “We were getting feedback from members who were frustrated to only be dealing with the effects of illnesses and not the causes. “
The most recent visit was in November, to a building at 2239 and 2241 Creston Avenue in the Bronx. One attending physicians and three resident physicians went to the building, accompanied by a social worker and an administrator with Bronx Lebanon. They visited with residents in twenty-one of the building’s fifty-four apartments.
The team had three specific goals: to help bring relief to tenants suffering health consequences from their building; to gather data for a Bronx-Lebanon study of the correlation between poor housing and chronic health problem; and to give tenants information on their rights regarding the condition of their building.
Levy says that as of July 2011, 2239 Creston had 431 outstanding code violations, while 2241 had 431 violations. The former owners, Victor and Alan Fein, originally bought the Creston buildings along with several others in the Bronx on a loan from Astoria Federal Savings Bank. Three of those projects – including the Creston --have since gone into foreclosure.
A Village Voice article from March 2010 names the brothers as owners of three Bronx properties listed as being among the city’s worst. The article says the Feins have operated since the mid-'90s under various company names including Cherokee Partners and Apache Properties. Workforce Housing Advisors, an affordable housing development firm led by ex-city developers, is working on a public-private financing deal to purchase and renovate the buildings.
Orlando Moronta, the building super, has lived in the building since 1998. He says the Feins barely contacted him in the decade he owned the building. He tells of unscrupulous former building managers who rented out apartments while telling the owner they were vacant, in order to pocket the money, and rented to people engaged in drug activity. Since the building went into foreclosure, Moronta says things have actually improved slightly. He says the number of violations is down and there have been recent mold remediation efforts and lead paint removal.
Tenant Johannie Burdier said she tried avenues to address problems in the building. She tells of taking her complaints directly to the Fein brothers’ office on Bronx Park East, where she says a relative of the brothers would dismiss her complaints and call her a liar. Fein Property Management did not respond to a request for comment, other than to say that relative was no longer working there.
Calling 311 didn’t help either. Burdier the city would investigate and order the brothers to make the repairs, and then when no repairs were made, would send out workers. But she said often the repairs were never made, because the landlord or an employee would always show up and order the city workers off of the premises.
One of the main health effects that doctors point to as resulting from hazardous living conditions is pediatric asthma. Pediatric asthma is particularly an issue in the Bronx, where the rate of death from asthma is nearly three times higher than the national average and hospitalization rates are five times higher, according to a report from the Wagner School at NYU.
While most studies of asthma in the Bronx have focused on traffic, doctors on the visits saw a direct correlation between mold and asthma. Dr. Kerone Thomas, a second year family medicine resident at Bronx-Lebanon who was part of the visit, says living conditions are a major factor in developing childhood asthma.
“Based on the observations we made of mold in the apartments and residents with asthma, there seems to be a strong correlation.” She said in many of the apartments the visiting health workers saw evidence of mold, leaky pipes, and rodents.
While over-leveraged buildings are not the only buildings in poor enough condition to cause housing-related illnesses, they do present a unique situation for the city. Banks and lenders are generally regulated by the federal government and the state, so there is often not a lot that local governments can do to address blighted or neglected buildings in city neighborhoods.
Cities can, through the Housing Preservation Department, enforce building code. The Department is required to identify the worst two hundred buildings in the city for the Alternative Enforcement Program (AEP), which attempts to hold landlords accountable for violations. If a building is found in violation and does not comply with the AEP order to fix the problems, HPD can send out a contractor to make the repairs and bill the owner for the cost. If the owner does not pay, HPD can have a lien placed on the property.
In 2010 a law introduced by City Council Speaker Chris Quinn was passed that added asthma to one of the list of violations that made a building eligible for the AEP. The Creston buildings were added to the AEP list in 2010.
While building code enforcement is an important step, some problems with enforcement remain. Though HPD can put a lien on a property, UHAB tenant organizer Dan Desloover says some of those liens are not foreclosable."
"There's no ultimate stick to make building owners do what they should do on these violations.” He says that with so many building violations in the city, some problems slip through the cracks. “Even if things are pretty bad, there are just so many things going on that things get lost."
Identifying housing-related illnesses and applying health code violations to the retinue of charges against a bad landlord may not make much of a difference. Dina Levy points out that for owners unconcerned with breaking the law, the threat of breaking further laws may not carry much weight.
“For those people you need other tools. If you’re willing to be on the wrong side of code violations, are you going to be willing to be on the wrong side of health violations? Probably.” She says from a public policy perspective the goal will have to be to think creatively about enforcement measures beyond violations.
Mitchell Posilkin of the Rent Stabilization Association, New York’s largest real estate industry trade association representing some 25,000 landlords and building agents, worries that adding more regulation will only hurt good landlords who are already struggling to maintain compliance. “There is already an alphabet city of regulations throughout the city.” he said, listing lead paint regulations, building codes and fire codes. “You can always increase the penalties, but most owners do not need the threat of penalties to comply.”
He also had concerns about pinning health problems to building conditions, citing cases where children in New York City buildings with high lead levels in their blood were found to have acquired those levels in their country of origin, not in their New York apartments. Posilkin said the science necessary to identify something like a particular mold as a responsible for an individual’s health issue is not available, and expressed concern that the issue would become “an annuity for trial lawyers.’
“We’re quite dubious. We believe everybody should know their rights, and we believe that landlords should maintain their buildings, but not every ailment in society can or should be attributed to how landlords maintain their buildings.”
Posilkin is concerned that current regulations are making building ownership untenable for many landlords outside of Manhattan. Referencing the recent ban on using #6 heating oil due to its increase in asthma, he said “It’s easy to say that owners should get rid of number six oil but who is going to pay? If you’re owning and managing affordable housing in the South Bronx, where are you going to get that money?”
There are some 80,000 failed housing units up for receivership in New York City. The problem can be partly attributed to outdated policies. After the financial collapse of the seventies and the subsequent abandonment of areas of the city, new housing policy was set in place to spur reinvestment in neighborhoods.
The policy was successful – lots were rehabilitated, and neighborhoods restored. By the nineties, the policies designed to entice banks into investing in these neighborhoods were just icing on an already-sweet cake. Developers and investors, savvy at accessing investment credits, purchased buildings in gentrifying marginalized neighborhoods and converted them to market rate as the neighborhood became wealthier.
By 2005, the success of these gambles means that multi-family apartment buildings with rent restricted units are fetching enormous sums, despite the inability of the rent rolls to pay back the debt. Banks, intending to immediately resell those mortgages in pieces on the secondary market as mortgage-backed securities, didn’t worry too much about their due diligence on the loan.
And then the market collapsed. Building owners suddenly found that even at market rate, rent rolls could not support the mortgage debt. Property taxes and operating costs such as water and sewer continued to increase, and soon investors found themselves sitting on properties worth less than their mortgage. Many stopped putting any more money into what now looked like a bad investment, and the buildings fell into disrepair.
When an owner defaults, the bank holding the mortgage cannot force the owner to reinvest in the building or even pay their debt. All they can do is foreclose on the property. The properties go into receivership. The owner gets to keep the money they made. The bank keeps the profits from the mortgage-backed securities they sold.
In receivership these already neglected buildings deteriorate further. Receivers may do some limited maintenance and upkeep, but do not usually undertake major repairs.
Meanwhile the losers in this game, besides those whose pensions and investments lost money over those securities, are the tenants. Holes in the walls, rats, unsafe electrical wiring, bad heat, flaking paint, all the crumblings of failure compound to create health hazards for the very people those walls should be protecting.
Questions remain about what the appropriate policy response should be. Using health code to go after negligent owners seems likely to encounter many of the problems that using building code does. Without harsher enforcement, those already on the wrong side of the law seem likely to stay there.
In addition, the levels of government most affected are not the ones with the most regulatory power. While it is cities and local governments that pay for the health-care costs of low-income renters suffering building-related problems, they have very little power over the banks and lending companies that are underwriting mortgages.
Levy says while she isn’t sure what the policy answer is, she hopes that providing more information on the cost burden of these buildings will help summon the political will necessary to address the issue. She says the effort to raise awareness of the relationship between failed buildings and heath is an important first step. “Once that’s established then there are all kinds of openings for trying to figure out what is the right policy solution to address that.”
Meanwhile Burdier is still looking for a way to move out. Her bathroom ceiling is leaking, and she says she’s been threatened with eviction because checks collected by the management company were never turned over to the new receiver. “It’s unbelievable,” she says. “I wish I could move.”
Update: An earlier version of this story incorrectly stated that HPD liens are not enforceable. Liens placed by HPD through the Emergency Repair Program and the Alternative Enforcement Program are forecloseable as long as they total $1,000 or more and accrued after January 1, 2006.
In Brooklyn’s PS 321 in Park Slope, it is second-grade lunch period and the adjoining lunchrooms are a controlled cacophony of happily eating kids. Children carefully balance trays from the cafeteria to the long white lunch tables. On those trays a small apple wobbles beside a grilled cheese sandwich, a serving of salad and some mixed cooked vegetables.
The cafeteria has a water cooler and twin water fountains, as well as crate full of small cardboard cartons of milk. On one wall display the word “Yum” hangs below photos of smiling students eating fruits and vegetables. The school, which serves over 1,400 kids in pre-K through 5th grade, incorporates a “healthy choices month” into their classroom learning. They also uses students to talk to other students about what is and isn’t good in their lunches, and works with school food staff to incorporate those findings into meal planning.
Despite the success of efforts like those at 321, school officials and health advocates still face many obstacles to getting children to eat better. Even the best school lunch program can falter in the face of all the junk food options available on city streets and in the disdain of notoriously picky eaters. And, as the recent vote by Congress to consider pizza a vegetable makes clear, institutional obstacles remain as well.
Assistant Principal Ryan Bourke says PS321 works to teach students the importance of healthy eating. In an organic garden in the school yard, kids learn about growing vegetables, and occasionally parents come harvest those crops into salads for students to sample. While the majority of students bring their food from home, Bourke says he believes that to be changing, especially when certain foods are offered. “Pizza day they love,” he said, smiling. “Chicken they love.”
In October, Manhattan’s P.S. 75 on the Upper West Side became the first school in New York City to receive a HealthierUS School Award. The school added more fruits, vegetables and whole grains to kids’ lunch, and also installed a water cooler, earning them a bronze award. The school’s website offers “snack guidelines” for parents, to guide them in the sorts of foods they send their child to school with. The guidelines encourage parents to send kids to school with a refillable water bottle, and discourage things like store-bought muffins and fruit roll ups.
While not all schools have the resources to provide students with these sorts of experiences, citywide regulations on school food are among the strictest in the country. Regulations like the 2009 ban on most bake sales also place limits on what can be sold in school vending machines and stores.
Yet even the healthiest of school options cannot negate the options available after school. A recent study from researchers at Columbia University’s Mailman School of Public Health looked at the availability of junk food sold near public schools in the city, using data on school locations from 2006-2007. The abstract gives a lot of insight into why healthy school lunches are only one step toward maintaining healthy children.
The researchers found that 92.9% of students had a small grocery store within 400 meters of their school; these stores typically carry fewer healthy food options than larger grocery stores. In addition, 70.6% had a pizzeria within 400 meters, 48.9 % were that close to a convenience store, 43.2% were within 400 m. of a national chain fast-food restaurant, such as McDonald’s or Burger King, and 33.9% were within 400 m. of a local fast-food chain restaurant.
Even in affluent Park Slope, where students who go off campus are more likely to purchase healthy foods like sushi than a McDonalds hamburger, schools hope to encourage more eating of school food. PS 321 has recently been engaging in an effort to destigmatize school lunches and eating in the cafeteria. They are working to find healthy foods that kids like, and limiting the number of days that older students are allowed to eat lunch off campus.
Offering food that kids like is a big part of steering students away from the fast-food. While some schools seem to do that quite well, others have been less successful. At the Young Women’s Leadership School in Astoria, students have created a blog about the quality of the food, and while many of their comments seem to express normal kid pickiness, a look through the posted photos is instructive.
Removing sodas from school may not have the hoped-for effects on children’s health either. In a nationwide study published in The Archives of Pediatrics and Adolescent Medicine, researchers found that in schools which banned soda but allowed other sugary drinks, students just consumed more sugary drinks. More alarmingly, in states that banned all sugary drinks in schools, students’ overall consumption of sugary drinks still remained constant –the kids just upped their intake elsewhere.
Then there is the issue of pizza as a vegetable. This month Congress blocked an effort by the Agriculture Department to create stricter guidelines to ensure that schools served fruits and vegetables. Currently schools are able to claim credit for serving a vegetable even for the watered-down tomato paste present on a slice of pizza. The New York Times reports that food companies including ConAgra, Coca-Cola and frozen pizza-maker Schwan praised the decision as reasonable.
Here in New York, Amie Hamlin is not pleased by the decision. “The whole point” says Hamlin, frustration audible in her voice, “is to have more nutrient-rich vegetables that are low-calorie.” Blocking it, she says, was “really dumb.”
Hamlin is the Executive Director of The New York Coalition for Healthy School Food (NYCHSF),a statewide nonprofit that advocates for healthier plant-based school lunches and increased school nutrition education. In New York City, NYCHSF partners with others to bring whole-food healthy recipes into 17 NYC public schools, twice a week. Her organization provides recipes that use ingredients that schools already have access to, and trains staff in how to prepare them. They also provide a “Wellness Wakeup” program, giving principals short bits of nutritional information to be read over school intercoms in the mornings.
Not every school in New York City has a cafeteria, and not every cafeteria has cooking facilities. Hamlin estimates that in NYC’s 1500 schools there are about 1200 cafeterias, due to colocation of multiple schools in a single building. Of those, some are only equipped for reheating and serving.
Still, Hamlin says, the demand for healthy food in schools is strong. While her organization only serves 17 schools, there are 48 more on the waiting list. Hamlin says NYCHSF is constrained by a lack of funds and volunteers. “We need more people power to do it,” she says, adding that volunteers with NYCHSF also go into school lunchrooms with the raw ingredients of the meal, to allow students to touch and see and smell the foods. The organization plans to collect data regarding how much of their food is consumed or thrown away.
Income-eligible in New York City public schools are entitled to eat lunch for free or at a reduced rate of twenty-five cents, other students pay $1.50. That price may increase next year due to a provision in the federal Child Nutrition Bill that mandates that the price of school lunches better reflect the cost of preparing the meals. Those higher prices may pose a challenge for families ineligible for the reduced rate but still struggling financially. DOE spokeswoman Marge Feinberg said it is “too soon to know” whether New York City students will have to pay more next year, but pointed out that it costs the Department $2.60 on average to produce a meal.
DOE would not permit an interview with the Steven O'Brian, the Director of Food and Food Support, but sent a statement saying New York Schools are “ahead of the curve when it comes to making school food more nutritious” and citing their efforts to eliminate trans fats and reduce sodium, fat and calories. “The Department serves over 820,000 meals a day and purchase a large volume of goods each year. For example, we purchase 15 million apples a year, 400,000 pounds of chopped Romaine lettuce and 4,000 pounds of cucumbers, 99,000 pounds of broccoli florets, to name a few. “
Still, the Department has no way to track what gets eaten and what gets thrown away. The reticence of the Department to speak to the press may be due to recent criticisms brought on after a school food internal website with nutritional value for the food was accidentally made public. The site was quickly removed and the link now brings up a message that the file or directory is not found, leading some critics to wonder why the DOE would not release nutritional information to parents.
Back at PS321, kids are finishing lunch and squirming onto their jackets in anticipation of the playground. Patient lunch aides help locate hats and zip zippers. Several second graders hop up and don badges designating them as Healthy Kids Café Student Representatives. One representative, a tall pretty girl with bright plastic beads in her braids, circles the room, seeking out the kids with school lunches and asking them how they liked the food. One after another after another, the students give her a thumbs-up and a smile.