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Barred Medicine: Health Care on Rikers Island


photo: WPA nurses care for patients at Rikers
Date unknown. Image courtesy of National Archives and Records Administration / New Deal Network

WPA Nurses assisting patients at Rikers. The original caption read "The New York City institutions have an unusually high proportion of inmates who require such services."

 

For eight months, John, a 56-year-old resident of the Bronx, lived as clandestinely as possible, doing his best to cloak the three scarlet letters symbolically etched on his chest: H-I-V. He avoided prescription lines and ignored cravings for Ensure - considered a clear sign that someone has "the virus."

On Rikers Island, human immunodeficiency virus goes by another name. Whether it's a passing reference to "the monster" or the prying questions including, "You live in the House In Virginia?" John, like the thousands of others who go in and out annually, did everything he could to keep his status a secret. "I found myself trying to conceal it more than take care of it," said John, who declined to give his last name.

Because on this 413-acre island nestled between the Steinway section of Queens and the Bronx, health care was not John's first priority. And in the view of some advocates, providing medical care to prisoners is not one of the city's top priorities either.

Receiving and delivering health care is a balancing act on Rikers. Officials must constantly weigh the relative importance of security, privacy and health as they attempt to care for a population that is not only transient, but is also disproportionately afflicted with mental illness, substance abuse and debilitating illnesses, like HIV.

Clinics on Rikers now are run by a private company whose contract was just renewed for another three years. Though the quality of care has improved since the days when a private hospital ran the clinics, many advocates argue the system still has an attitude of us versus them, of prisoner versus guard and of control versus the powerless -- certainly not conducive to quality care. As the city prepares to likely review the standards that guide health care within the correctional system, decisions made in the months ahead will have an effect on thousands of people who, after leaving Rikers, will return to families and neighborhoods across the city.

A Transient Population

At any one time on Rikers, there are approximately 14,000 inmates, adding up to about 100,000 admissions in a given year. They are not mass murderers, but alleged drunk drivers or drug addicts, among others convicted of misdemeanors, and about 80 percent are being detained prior to trial.

About a quarter are mentally ill, according to the health department, and a third are seen as extremely frail, plagued by severe drug addictions or chronic illnesses.

An average inmate stays 40 days, but the most frequent discharge from Rikers Island is on day one. The population is constantly changing, moving from facility to facility or from imprisonment to freedom.

Rikers has seen its fair share of turmoil. Its health contract has been passed from a nonprofit hospital to a for-profit, private medical center to a private corporation in a little more than a decade. Scrutiny over the island's health care has fluctuated too.

Now overseen by the city's Department of Health and Mental Hygiene, the clinics on Rikers are run by Prison Health Services, a private, for-profit company based in Tennessee. It manages the health and dental care of 10 of the city's 11 jails, nine of which are on Rikers Island. The other is the Manhattan Detention Center. (The Vernon C. Bain Center in the Bronx is not covered by the contract.)

All nine jails on the island have their own clinic, and the whole population is served by one infirmary. Inmates in more serious condition are sent either to Elmhurst Hospital Center or Bellevue Hospital Center.

Barriers to Care

The climate of control and authority that is part of any prison system affects health care. By far the largest complaint about medical care on Rikers, according to former inmates and prisoner advocates, is what they see as the indifference of some corrections officers and employees of Prison Health Services to the inmates' health. Former prisoners, like John, have waited for several hours before seeing anyone at the clinic - a tactic some claim corrections and Prison Health Services's employees use to assert their authority. Prisoners say that those who complain are sent back to their cells. All they can do is wait.

Health department officials said they receive similar complaints and are encouraging Prison Health Services to promote an atmosphere of respect.

"There is concern about the question of respect particularly," said Louise Cohen, deputy commissioner for health care access and improvement at the Department of Health and Mental Hygiene. "It's clearly a problem when you have an adversarial population. People already feel dehumanized. They don't have control over their own lives. They don't have the freedom to move around."

The department, Cohen added, investigates and takes seriously every inmate complaint it receives.

Gotham Gazette requested figures on the number of complaints received by the health department, including the numbers that were eventually substantiated, since Prison Health Services took over the contract in 2001. The department said it did not track such complaints.

Some inmates who have been behind Rikers' bars said they are subject to intimidation, not health care. Casimiro, whose last name is being withheld, spent 16 years in and out of Rikers Island. He has had 67 arrests, some violent, some drug-related. And time and time again, he said he was treated like an animal.

The 40-year-old former inmate turned group counselor said he had carried other inmates to the clinic, while corrections officers stood by unwilling to call for help. When Casimiro himself visited the clinic, medical charts were often in plain view for any passerby to peruse.

Jason, a 41-year-old Harlem resident who spent eight months on the island in 2000 and whose last name is being withheld, has been HIV positive for more than two decades. He did not disclose his status during the initial mandatory intake procedure for fear of the stigma (All inmates get a medical examination within 24 hours of arriving at Rikers.)

Several days later with a lingering feeling that his body was "shutting down," Jason approached a corrections officer and dislcosed his status. The officer, he said, didn't believe him, claiming he "had no proof."

"They looked at me like I was lying," said Jason. "Their job is to question you."

That attitude, Jason recalled, kept him tight lipped for the rest of his stay on the island, no matter how his body felt.

Given the population at Rikers, some skepticism is justified - but how much? Some medical professionals, including those intimately familiar with the conditions at Rikers, contend the health department and Prison Health Services successfully balance the challenges posed by the population with providing quality health care.

"It's very hard job working out there in extremely challenging circumstances," said Dr. Eric Manheimer, medical director of Bellevue Hospital Center, which houses the men's inpatient prison ward for Rikers. "Generally they (Prison Health Services staff) are qualified... They make good decisions... What we've worked out with the staff over there is a very low threshold to send (inmates) to us."

Some of the prisoners' complaints are beyond the health department's jurisdiction, like those pertaining to corrections officers. The department's role, officials said, is to ensure inmates have access to care and address health issues that may have been ignored for too long, like providing testing for sexually transmitted diseases for all inmates.

According to the department of health, about 5 percent of inmates at Rikers come into the intake process saying they are HIV positive. Another 25 percent, according to the department, submit to a voluntary test that is offered to every inmate. The testing, the department says, is part of the preventive care it attempts to provide on the island. The department has also implemented full discharge plans for HIV positive inmates, and over the last year it has seen 98 percent of them make it to their first appointment outside of Rikers.

"If we can improve the health of those that are incarcerated than we can improve the health of the communities that they come from," Cohen.

Still, admitting to a chronic illness within the confines of Rikers creates another set of obstacles for the prisoner and not just from fellow inmates. Former Rikers inmates say that they have, for example, seen corrections officers insist on wearing rubber gloves when they interact with prisoners who are HIV positive.

Privacy in the Open

Mayor Michael Bloomberg has made public health a hallmark of his administration, and that focus has had an effect on Rikers Island. The health department is creating a network of records accessible throughout all the Rikers facilities so doctors will know a patient's history if they had been previously incarcerated or were being moved from jail to jail. Patients will soon also have the option to disclose past medical records so physicians can get a more well-rounded view of their ailments. Currently, doctors have access only to information on the care patients received on Rikers Island.

Despite these efforts, though, the challenges of providing health care in jail continue to persist to the detriment of inmates, said some advocates. One of the largest concerns for inmates is privacy.

All consultations with medical personnel are supposed to be private. But, inmates said, in a clinic with no walls and diagnoses occurring side by side, confidentiality is impossible. (The health department refused to allow Gotham Gazette to visit a clinic on Rikers, because of privacy issues.)

"There is no confidentiality in jails," said Dale Wilker, a staff attorney at the Prisoners' Rights Project at the Legal Aid Society. "There are standards for it, but guards are right there and overhear. It's something the medical staff must jealously safeguard, but that's difficult in the treatment rooms."

Part of that security is warranted. Rikers clinics are among the few areas on the whole island where inmates from separate units converge in one space. It is there, inmates confirm, that drugs, weapons or other contraband are traded. Because of that, inmates may have reasons for asking to see a doctor that have nothing to do with medicine.

"We do not inform the Department of Correction law enforcement or the courts about their records," said Cohen. "We do, however, recognize the need for security. All patients need to be in the line of sight of a correction officer at all times."

A History of Neglect

Given the difficulties of providing private health care in the city's jail system, who would take it on?

In the 1990s, the city first awarded the contract to a for-profit entity, St. Barnabas Medical Center. During the three years of St. Barnabas's tenure, accusations surfaced that the hospital denied basic services to inmates to cut down on cost.

When its contract expired in 2000, the city turned to Prison Health Services - the for-profit, private company that holds a virtual monopoly on correctional care throughout the country. Under their care, complaints have received far less attention, but periodically rise to the fore.

Nonetheless, Prison Health Services isn't going anywhere anytime soon. The city recently renewed its contract for another three years for $366 million. It expires in December 2010. When the city first signed the contract with Prison Health in 2000 it was for $254 million over three years.

This nearly 20 percent increase, adjusted for inflation, occurred despite the company's less than favorable reputation throughout the country. It was found to have flawed and even occasionally fatal medical care in New York's upstate prisons. Health officials said no local, nonprofit hospital bid on the contract last year.

Oversight and Accountability

St. Barnabas's contract was set up so the medical center could pocket any extra profits, providing an incentive for it to keep health costs at a minimum. That meant steep reductions in hospital visits and keeping specialists out of the island's locked hallways.

Health department officials say prison health's contract does not resemble its predecessor's, but is based on the cost of care for health policies set up by the city. This way, the department contends, the company has no drive to reduce care to save money.

Oversight and accountability for health care at Rikers rests with the city's Board of Correction. The nine-member board has jurisdiction over every aspect of the correction system, from phone calls to health care.

Three sets of standards guide its work: general provisions covering most aspects of the correctional system from uniforms to telephone calls, mental health standards and the health care standards, which include inpatient and outpatient care and privacy rights.

These rules, said city officials and advocates, govern the ins and outs of the city's jail system. They can protect an inmate from an overbearing corrections officer or an employee disclosing personal medical records to the rest of the population. It is also these regulations that might soon change.

Governing Rikers Health Care

The board embarked on a revision of the city's general standards in 2006. This sparked objections from the advocacy community, which claimed the new rules slashed inmates' rights and gave the Department of Correction an even heavier baton. Advocates claimed their concerns were not adequately heard. Some board members, including Chairwoman Hildy Simmons, refute this claim.

The board approved the new rules late last year. They are currently being reviewed by the city's Law Department.

According to some board members, the health care correctional standards are likely to be next on the agenda. Simmons said it was too early to know whether the board would undertake a full review. She emphasized any review would roll out in three stages: an initial discussion, a formal review and formal action to approve or deny the proposed revisions.

Both the executive director of the Board of Correction Richard Wolf, and Deputy Director Kathy Potler declined to be interviewed for this story.

Paul Vallone sat on the oversight branch since 2002 and voiced concerns over the review process on the general standards. He said he hopes the board will open up the process more this time. "A lot of lessons were learned during that last process that will go and make this process a lot smoother," Vallone said.

Some advocates, many of whom claim that the board has a cozy relationship with the Department of Correction, are skeptical. Jennifer Parish, director of criminal justice advocacy at the Urban Justice Center, said if the board is going to change the mental health standards or health standards it should start by consulting the community and not the Department of Correction.

"It seemed the process was driven by (corrections commissioner) Marty Horn and the Department of Correction saying, 'We want these standards changed and here is the way we want them changed,'" said Parish of the recent review. "That's the cart leading the horse, because the whole role of the Board of Correction is to oversee and monitor the Department of Correction."

Prisoners' advocates saw the last review as having eroded civil liberties by approving monitoring of phone calls and inmates' mail. In light of that, some would rather avoid a review of the health standards entirely. The standards for both mental health and health have not been reviewed since they were promulgated in the 1986 and 1991 respectively.

A Yardstick for Care

While advocates and inmates complain and vehemently criticize the quality of care on Rikers Island, in many respects the city is ahead of the correctional health curve. Most jails require a medical examination within a week of arrival. The city does it in a day.

Most jails do not provide drug treatment. The city's methadone clinics have been championed by some prisoners' advocates.

And the health department contends it is not the face of an inmate it sees, but that of a patient.

"We care about correctional health," said Cohen. "We care about our patients, and we think we are doing a good job." But, Cohen agrees, there is always room for improvement.

 

Language Barriers at the Drugstore


When Catalina Martinez of Ridgewood walks into a pharmacy to get a prescription, the task may not be as easy as it seems.

Beyond the long lines and their physician's unintelligible handwriting, Martinez, like thousands of other New Yorkers, faces a seemingly insurmountable wall at their local drugstore: a language barrier.

"When I go to the pharmacy, I see that the bottles are in English and I want to know what it says on the bottles," said Martinez, who was interviewed through a translator. "So many times I leave the pharmacy without knowing what it is saying. That's scary for me."

According to immigrant and health care advocates, the majority of pharmacies, particularly in the outer boroughs, do not provide translation services to their customers. This leaves thousands of New Yorkers with limited proficiency in English to fend for themselves. Labels remain untranslated, so crucial instructions from the pharmacist may be incomprehensible.

Unlike hospitals, which, under state regulations, must provide translators, pharmacies are under no such requirement. That, some city leaders say, may soon change.

Where Regulations Stand

For the hundreds of thousands of New Yorkers who do not know English, the local pharmacy and its rows of bottles with labels reading Zoloft or Ambien can be baffling. With Americans increasingly reliant upon prescriptions, advocates say an inaccurate translation -- or none at all -- can pose a significant danger.

The 2000 Census showed that nearly half of New York City households speak a language other than English, and one out of four New Yorkers do not speak English at all. That leaves 25 percent of the city's population scrounging for health care in their own language or care at a facility offering translation services.

While the state approved regulations in 2006 that set out language requirements for hospitals, pharmacies were overlooked, said some advocates. According to a recent report by the New York Academy of Medicine, two thirds of city pharmacies do not translate prescription labels, despite the fact that 88 percent said they served limited English proficiency patients daily.

A report released late last year by the advocacy groups New York Lawyers for the Public Interest and Make the Road by Walking details nearly a dozen anecdotes from Brooklyn and Queens residents who do not speak English.

Catalina Martinez is one of them. She suffers from gastritis and has a 14-year-old son prone to allergies, forcing her to visit the pharmacy often. A native of Mexico who has lived in Ridgewood for a decade, Martinez sometimes stops strangers on the street, hoping to get her prescriptions translated since the pharmacies she frequents do not provide language assistance. Sometimes, she said, she will not give her son medication for fear of administering it incorrectly.

"Maybe I have to give him this much medicine, sometimes I have to give less," said the 49-year-old. "Sometimes I won't even give it to my son because I won't know how to do it."

Martinez's apprehension is shared by many immigrants, said Nisha Agarwal, a staff attorney with New York Lawyers for the Public Interest. To address this, the lawyers group, along with City Councilmember Eric Gioia and Public Advocate Betsy Gotbaum, is drafting legislation that would require translation services be provided at all city pharmacies.

"Giving New Yorkers access to the information they need starts with simple, common sense steps, like providing translation services and extra medical instruction for those with limited English proficiency who are filling prescriptions," said Gotbaum in a prepared statement. "Our proposed legislation will help break down the barriers many currently face when seeking health care and ensure that no New Yorker is left guessing when it comes to questions about their medication."

Other council members have also expressed support for the measure. "Although I appreciate the efforts already taken by a number of pharmacies to help their customers read their prescription label in a more familiar language, these businesses still have more work to do," said Councilmember Joel Rivera, chair of the Health Committee, in an e-mailed statement. "People should not have to guess how to administer their medicine just because they can't read the directions. Clearly the consequences can be devastating. The translate of drug labels by pharmacies is not only a good idea, it is the right thing to do."

What Advocates Want

Advocates, like Agarwal, believe the city's existing human rights law, which prohibits discrimination based on race or ethnicity in public places, requires pharmacies to translate. So far, though, pharmacists do not interpret the law that way.

Both New York Lawyers for Public Interest and Make the Road by Walking filed a formal complaint with the state attorney general's office, claiming 16 pharmacies in Queens and Brooklyn routinely failed to translate drug labels or provide instruction to non-English speakers, thus violating their statutory duty. That complaint is pending, said Agarwal.

They hope the legislation currently being drafted will replicate what the state required from hospitals in 2006, making language access a requirement of quality health care. Agarwal said the legislation should be introduced in the coming weeks.

The specific standards for pharmacies would strengthen the current requirements under the human rights law, said Theo Oshiro, the director of health advocacy at Make the Road by Walking.

Oshiro said his group has already seen some success. Pharmacies in Bushwick, for example, stepped up their language education campaigns with signs announcing translation services behind some counters.

"I guess there has been spotty results; there has not been a whole chain setting out clear guidelines," said Oshiro. "We're still looking for that kind of sweeping solution, not only in Bushwick and in Woodside."

City officials spearheading the legislation say the proposal would simply turn an assumed right into an explicit one. Business leaders, however, disagree.

Business Barriers

James Detura owns his own pharmacy in the South Bronx where the population is predominantly Spanish speaking. Detura, who is president of the New York City Pharmacists Society, said a translation mandate would be catastrophic. It is already difficult to find any pharmacist -- due to a nationwide shortage of pharmacists -- let alone a bilingual ones, he said.

For communities that do not have one or two dominant languages, but three, four or even five, it could be next to impossible to meet strict language access guidelines. "What about a pharmacy that is in certain area of New York City when you've got Spanish and Russian?" asked Detura. "What do you do in a case like that? Are you going to have a separate pharmacist for each one?" There are enough pharmacies in the city, especially locally owned businesses that cater to certain communities, that customers who cannot find the services they need at one pharmacy can always find another one a block or two away, he said.

Detura also fears inaccurate translations. He said it may be easy to translate "one pill a day," but more complicated instructions may not be as readily interpreted -- especially if there are no services available for a local pharmacist to double-check a phoned-in translation.

But advocates said there are plenty of accurate resources for a local pharmacist, such as subscriber hotlines that can translate at the click of a dial. Oshiro also said they were not looking to require bilingual pharmacists.

Like Detura, others question whether the legislation would put an unreasonable burden on small, independent pharmacists. In response, Oshiro said the smaller pharmacies already do a better job accommodating immigrant populations' needs.

Instead, advocates argue that it is larger chains, such as Duane Reade and Rite Aid that fail to translate. Even if the big chains have the ability to provide the service (some have telephone translation networks or bilingual staff), they often do not advertise it to their customers.

A Bilingual Call

While many of the details must still be worked out, immigrant and health care advocates said they are keeping both business and health interests in mind. The idea is to save people's lives, or at the very least prevent confusion and sickness.

Convinced she became ill after incorrectly taking medication with a label she couldn't understand, Martinez said she cannot, nor can she give her son, medication with an easy mind.

If pharmacies cannot provide bilingual or trilingual employees, they should at least provide labels in other languages, Martinez said. That way, she added, she and thousands of other New Yorkers can take their medication with confidence.

Breaking Down Barriers to Mental Health Care


Dally Sanchez spent her adolescence getting "treatment" - and the memories still sting: As a traumatized incest survivor, she recalls dealing with a social worker who couldn't talk to her Spanish-speaking mother, being restrained by staff at a youth psychiatric facility and a threadbare education in special-education classes that offered no hope of going to college.

"The reality is that in the mental health system, once you fall in there, you're not a person anymore," said Sanchez, now 27. "Somehow, having a label or having some sort of emotional problem or trauma removes your civil and human rights."

Sanchez's experiences are echoed throughout the city. In classrooms, clinics and emergency rooms, youth are labeled "crazy," "disturbed," "defiant," "loco" - indelibly marking their lives and futures. Among immigrants, people of color and the poor, advocates say, the mental health system is especially prone to misunderstanding and to overlooking youth in crisis. In marginalized neighborhoods, the system's shortcomings are compounded by the challenge of responding to the needs of different ethnic groups. The question of "cultural competency" has emerged as a major flashpoint in the debate over equity in mental health.

"There's a huge lack of cultural competency all across the board," said Sanchez, who today is YOUTH POWER! program coordinator with Families Together, a statewide mental health advocacy group. "There are huge amounts of people who are not getting the right services and who are being labeled with diagnoses that really aren't fitting."

"It's beyond disparities," she said. "It's called discrimination and racism."

Unmet Needs

In communities with high concentrations of immigrants, people of color and low-income families, youth with mental health needs must negotiate a chronically weak social-service infrastructure. Local service providers strain under tight budgets, most public schools have no comprehensive on-site health clinics, and families lacking health insurance may find psychotherapy financially out of reach.

A 2003 government survey of child outpatient clinics in the Bronx counted about 6,500 youth enrolled in services, mostly for behavioral issues like hyperactivity and anxiety disorders. More than 90 percent were black or Latino, with many from Spanish-speaking households.

According to the survey, the vast majority of the Bronx clinics were unable to meet clients' needs for day treatment. And with a six-week average waiting period, some 60 percent of people referred for services never actually entered treatment, suggesting that many thousands of city children with major mental health needs never make it to a clinic.

On a typical day at the Queens-based Child Center of New York, the multilingual staff of social workers and psychiatrists is stretched paper-thin, ready to field calls for help in Punjabi, Spanish, Haitian Creole, Russian or Cantonese.

"The biggest challenge that we face as practitioners is the waiting list," said assistant project director Reshma Shah. "Each one of us has so much of a caseload. And yet we have more and more of a population that really needs the services."

Language and Cultural Barriers

Immigrant families may struggle just to get help in the right language. In many cases, when bilingual staff members are unavailable, children of immigrants must take on the role of ad-hoc translator.

Cultural barriers, though, can be equally alienating. Adolescent emotional issues may fester silently beneath the social stigma surrounding mental illness.

In A's family, emotional suffering spanned two generations before she reached out for support. The Chinese-American teen, who asked to remain anonymous, wrestled with the scars of her father's suicide for two years until her own persistent sadness became debilitating.

A. initially resisted acknowledging her problems, as she feared she might be "mirroring" her father's actions. But eventually, a guidance counselor and others in her community persuaded her to seek a therapist through the Chinatown-based B. Wang Community Health Center. While she does not consider herself fully "recovered," she said, she has at least begun opening up about problems she previously tried to banish.

"In the Asian community especially," she said, "it is very hard to accept the idea of mental illness, since it is not often talked about."

As teens face alienation within their communities, social distance stretches between them and the people who are supposed to help.

Wanda Greene, a parent advocate with the Mental Health Association of New York City, recalled that her son, as a black youth, needed a clinician he could relate to. But in his early teens, when intervention was most crucial, he never had a therapist he truly felt comfortable with.

"A lot of my son's issues were: 'How can you tell me not to be afraid when you leave your office and you go home, and I have to return to my block?'" she said. "He may see drug deals going down on the corner, he may see gang fights - and that affects you."

Her son, now 26, is still dealing with his emotional problems, serving a long prison sentence that Greene sees as evidence that "the system failed him."

To encourage dialogue on mental health in the city's Latino community, the housing and social-service organization Comunilife is collaborating with state and city officials on a suicide-prevention campaign targeting Latina teens. Young Latinas are at higher risk of attempting suicide than white, Asian or black youth, according to government data.

The initiative, which centers on educational outreach posters, is just one step toward addressing vast, longstanding needs for culturally appropriate treatment programs. Comunilife President Rosa Gil noted that in focus groups used to develop outreach efforts, Latina girls talked about stress tied to community problems, like gang violence and unwanted pregnancy, and voiced fears that clinicians would not be able to understand them.

"The adolescents feel that the current mental health agencies do not help them," Gil said, "because they feel they're going to be blamed for these feelings. They don't believe that they should be on medication. They don't believe that the school system is supporting them. These adolescents feel very isolated."

Troubled Teens, Troubled Neighborhoods

Mental health advocates point to social and economic hardships that breed instability. For teens living in tough environments, treatment involves addressing not only physiological problems like chemical imbalances, but also the psychological affects of growing up in troubled circumstances.

Howard Raiten, director of mental health with the social-service agency AsociaciĂłn Comunal de Dominicanos Progresistas (Community Association of Progressive Dominicans), said that while mainstream clinicians tend to prioritize medication, mental health issues may be "rooted more in environmental situations than in biology," though biological factors can play a contributing role.

Raiten pointed to a corrosive, ingrained sense of hopelessness in the low-income immigrant neighborhoods his organization serves. "For years and years," he said, "people in these communities have not gotten recognition. They haven't been affirmed. They've been, and still are, very much invisible."

Shah said the social dislocation of immigration itself can push some people over the edge. "You lose your natural support system once you come into this country," she said. "So we have had cases where there might not have been depression or anything like that before. But once they move here - and due to inadequate social-support structure and services - the symptoms really come out."

Missed Opportunities

The shortage of mental health resources in some communities means that many youth do not get help until a crisis hits. That can lead to inappropriate care or even deeper problems.

"If you don't get them the right services, they start consuming the wrong services," said Greg Greicius, vice president of educational initiatives with Turnaround for Children, a group that helps public schools develop preventative mental health programs. "So they wind up accessing special-education services, they wind up going out of schools in an ambulance for a behavioral crisis and get seen in a hospital. This is often the worst way to try to get a child mental health support."

In New York's special-education system, Black and Latino youth are overrepresented, with blacks more likely than whites to be labeled "emotionally disturbed." Generally, students of color with disabilities are disproportionately placed in more isolated settings than their white peers, spending less than 40 percent of their school time in a regular classroom.

Black and Latino youth are also more prone to winding up in residential treatment facilities, housed under detention-type conditions, far removed from their communities.

Family Healing

Ethnic disparities in mental health, along with a growing recognition of cultural issues in treatment, have spawned alternative approaches that integrate psychological health with community identity.

Ruchika Bajaj, health policy coordinator at the Coalition for Asian American Children and Families, a pan-Asian children's rights group, said traditional psychiatric treatment can overlook the importance of family and culture in addressing adolescent mental health issues.

"The Western model targets individual youth, with family involvement being supplementary treatment," she said. "But for Asian American youth, this 'one size fits all' treatment model is not effective, because family dynamics and culture play an important role within Asian families. Effective treatment must incorporate cultural aspects as well as the family."

At the Child Center in Queens, for example, family members participate directly in a youth's treatment sessions. This fosters emotional communication within the household and helps build an intimate support network for the young person.

Comunilife, which serves low-income black and Latino communities, is developing a youth program offering regular psychiatric care along with holistic initiatives like peer-support networks, tutoring and arts enrichment programs. The project aims to engage the whole family - for instance, peer groups for fathers provide both concrete social supports, like job assistance, as well as a space to talk.

The Department of Health and Mental Hygiene has tried to target underserved youth through the Coordinated Children's Services Initiative. Backed by a six-year federal grant, the program has linked hundreds of families to teams of community representatives and social-service providers. Together, they create community-based, "wraparound" treatment plans that keep families intact during the recovery process.

Beyond enhancing services, some advocates look toward systemic reforms that can tackle the social factors driving psychological issues. In Sanchez's view, promoting mental health is not about clinics or hotlines, but more fundamentally, improving lives and communities.

"We need to build communities and communities' ability to take care of themselves," she said, by strengthening schools, social-service groups, and other community institutions.

That grassroots approach has resonance in Sanchez's own recovery. The turning point came when her "wraparound team" introduced her to a local peer-support group. After years of medication, institutionalization and counseling, what helped most was simply connecting with other youth going through similar struggles.

"Traditionally, historically, naturally - peer support is what helps people," she said. "Having the support from your family, from your friends, from your neighbors, from your community, helps people get over things and heal - in any culture, in any community."

Michelle Chen is a freelance reporter in Manhattan and a native New Yorker.  



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