In the news recently we have seen the controversial proposal by the City’s Health Department to address the epidemic of obesity by limiting the use of transfats by restaurants and fast food outlets. The city’s health professionals are also working in neighborhoods with high rates of obesity and diabetes to promote the sale of healthy foods. At the same time, city officials are moving to improve the quality of food in school cafeterias. Obesity has reached epidemic proportions in the city, with 43 percent of elementary school children found to be obese or overweight. Health specialists acknowledge that diet and exercise are two key factors related to this epidemic, and they are working seriously on diet.
But what about exercise? Can the city do anything more to increase physical activity? This is a more difficult issue, and not as simple to address. Physical activity is also related to another serious epidemic in the city –- asthma.
Researchers around the nation are beginning to explore ways in which the built environment of the city affects public health, particularly with respect to epidemics like obesity and asthma. They are raising the question of whether public policy can help create a healthier environment through better urban planning and better building and zoning codes. One of the main reasons for instituting building codes and zoning regulations a century ago was to control contagious epidemics like tuberculosis that bred in the dark apartments and alleys in working class neighborhoods. City planning’s mission was to improve public health by creating a set of clear rules for developers that would produce healthy environments.
New York City’s planners oversee a zoning code that regulates what can be done on every piece of property in the city. They are also charged with assessing the environmental impacts of all major new development in the city, and any changes to the city’s zoning code. These are levers that could be used to influence the elements that contribute to epidemics even if they alone won’t cure them.
Eva Hanhardt, coordinator of the Environmental Planning Masters Program at Pratt Institute, is studying new mechanisms for reincorporating health into urban planning regulations. According to Hanhardt, the foundation for zoning and land use regulations is government’s power to act to promote the “general health, safety and welfare.” Why is it, she asks, that “health doesn’t get the same attention as safety and welfare? By neglecting to incorporate public health in the design of land use and zoning policies, these policies have been part of the problem, not part of the solution.”
While obesity isn’t a contagious epidemic (and the same can be said for asthma), it is strongly clustered geographically, which could lend itself to some kind of land use regulation. Obesity cases in New York are concentrated in low-income neighborhoods and in Staten Island. In low-income neighborhoods, they may be associated with high concentrations of fast-food restaurants, limited access to healthy food, and limited access to both public and private recreational opportunities. In Staten Island, they are most likely related to the high dependence on automobile use; Islanders are less likely to walk and use mass transit. Asthma is also concentrated in low-income neighborhoods and related to a host of environmental conditions, including ambient air quality, both indoors and outdoors, access to healthy food, and recreational opportunities.
At the national level, urban planners are applying techniques of “smart growth” –- concentrating new development -– and transit-oriented development to overcome the effects of environmentally damaging sprawl. These strategies are aimed in part at encouraging walkable communities and reducing reliance on the automobile. Public health benefits may include reduced risks of obesity (due to walkability) and asthma (due to cleaner air). New York City, however, is already one of the least auto-dependent cities in the nation, and faces high rates of both obesity and asthma, which are particularly acute among children. This suggests that limited, isolated changes in the physical form of the city may not be enough to deal with these complex epidemics.
One of the arenas health-minded planners are exploring today is access to open space and recreation, especially for children. New York City’s shortcomings in this category make up for its advantages in density and walkability. New York has one of the lowest ratios of park acreage per person in the nation, new parks are rarely built while the population continues to grow, and the parks department budget is under perpetual siege. New York City schools also have chronically limited recreation space and programs, and it is not uncommon to see school playgrounds become parking lots for teachers. And even though large parts of the city are walkable, other parts, including those adjacent to expressways and major avenues, have hazardous walking environments that expose people to large doses of air-borne contaminants and risks to pedestrian safety. A recent study sponsored by Transportation Alternatives showed how residents on high-traffic streets tend to stay home more.
The city’s land use regulations already include minimum requirements for open space. These could be adjusted to encourage more active recreation. The Zoning Resolution restricts the location of sex shops in the city, so it could also limit the location of fast food outlets, keeping them away from schools, as one member of the City Council has already proposed. Zoning can limit large drive-to supermarkets and encourage local markets selling fresh produce. Parking regulations in the zoning code could reduce or eliminate requirements, thereby discouraging auto use. And the city’s zoning could address the existing wide disparities in exposure to environmental risks by restricting the concentration of hazards in neighborhoods where rates of asthma and obesity are highest. These are disproportionately low-income communities with non-white populations, so this is also a question of fairness and social justice. While the principle that no neighborhood should have more than its “fair share” of certain facilities, including polluting ones that have negative health effects, is enshrined in the New York City Charter, it has yet to be applied in land use decision making in a way that addresses current disparities.
According to Eva Hanhardt, however, land use policy “has to do with more than just controlling the physical location of facilities, but should also address the outcomes” by looking at the effect of these facilities on human health. Planners in some cities have suggested requiring “health impact statements” the way environmental impact statements are required for major land use changes. Other cities have established environmental quality goals and targets that individual departments, including transportation and planning, must address. A goal-oriented approach in New York might include targets for reducing traffic, improving access to active recreational facilities, and eliminating the disparate effects of environmental hazards. The first step, however, is for the city’s planners to reestablish a role for themselves in promoting public health.
Tom Angotti is Professor of Urban Affairs and Planning at Hunter College, City University of NY, editor of Progressive Planning Magazine, and a member of the Task Force on Community-based Planning.Â
In an important victory for immigrant communities in New York City and throughout the state, the New York State Department of Health has adopted regulations setting basic standards for hospitals’ communications with patients who speak limited or no English (or who are hearing- or vision-impaired).
The regulations, which went into effect on September 13, 2006, require all private and public hospitals in New York State to provide skilled interpreters, translate important hospital forms into commonly-used languages, and ensure that patients awaiting care do not face excessive delays because of language issues.
Millions of New Yorkers stand to benefit from the new rules. One in four New York State residents, and one in two New York City residents, speaks a language other than English at home. In the city, 1.7 million residents—one in four—are not proficient in English.
Hospital communication barriers can lead to serious problems, including misdiagnosis, failure to obtain informed consent, performance of unnecessary medical procedures, illegal delays or denial of care, and severe medical harm. In order to communicate, many patients with limited English are forced to rely on untrained and unskilled interpreters—often a minor child or stranger.
Existing federal, state, and local laws require hospitals to avoid discrimination and provide meaningful access to health care, regardless of a patient’s national origin or the languages he or she speaks. Nonetheless, advocates have documented the widespread failure of hospitals to communicate in the languages commonly spoken in the communities that the hospitals exist to serve.
In one case that was reported in The New York Times, Mr. Chul Sun Moon, a non-English-speaking Korean immigrant, died from head injuries sustained in a soccer game, despite repeated visits to Flushing, Jamaica, and Brookdale Hospitals over the course of a month. Moon never had a chance to discuss his condition or treatment with doctors in a language he could understand. He and his wife relied on strangers and on relatives in Boston, via cell phone, in their struggle to understand what was happening.
In another instance, advocates from the Latin American Integration Center monitoring St. Vincent’s Hospital in Staten Island witnessed emergency room staff using a seven-year-old child to explain to a patient in Spanish that he needed an emergency amputation.
These and many other documented cases of communication barriers led immigrant groups to file civil rights complaints with the state attorney general in 2005 against four hospitals—Flushing, Jamaica, and Brookdale medical centers and St. Vincent’s Hospital on Staten Island. The complaints helped spur the development of the new Health Department regulations, and last month, the four hospitals and the state attorney general’s office announced language assistance agreements that closely track the new regulations.
With the new regulations now in effect, hospitals are required to have an effective system in place to communicate with patients who speak little or no English. For the first time, hospitals have clear standards they must meet to ensure that the health and safety of patients will not be compromised by language barriers.
The new rules do not require hospitals to have large teams of interpreters who speak every possible language that is spoken in New York City. Hospitals are afforded great flexibility in using bilingual hospital staff, interpreters, volunteers, and telephone language assistance lines to communicate with patients. Quality matters: Hospitals are responsible for evaluating and ensuring the adequacy of language skills of all staff, volunteers, and contractors who provide communication assistance.
Hospitals are not permitted to use a patient’s family members, friends, or non-hospital personnel as “interpreters,” unless free interpreter services have been explicitly offered to the patient and been declined.
Patients who speak limited or no English should expect the following in every hospital in New York:
• The hospital must offer and provide communication assistance from fully-bilingual staff or skilled interpreters in a language that is understandable to the patient during the entire medical visit. The hospital must ensure appropriate communication when the patient calls to make an appointment, registers for care, and interacts with nurses, doctors, counselors, and non-clinical staff such as the hospital’s financial assistance and insurance enrollers.
• The hospital is responsible for identifying the patient’s preferred language and documenting it in the medical chart. Documenting the preferred language ensures that various departments will be aware of communication assistance needs when coming into contact with the patient, and makes it possible for the hospital to prepare for subsequent medical visits by having the appropriate language assistance services available at the time of the appointment.
• If the hospital fails to communicate with the patient, the patient or the patient’s representative or physician should notify the hospital of the language he or she speaks, and request an interpreter.
• The hospital is permitted to use a variety of methods to provide language assistance services to patients with limited English proficiency. While the new regulations require hospitals to manage a pool of skilled interpreters, it does not specify what form the interpretation should take in any given patient encounter. The hospital’s pool of resources may consist of full- or part-time staff interpreters, and/or bilingual health care and non-clinical staff, and may be supplemented by volunteers and contractors.
• As a backup, hospitals may contract with telephonic language assistance services. Such services may be acceptable when the hospital is interacting with patients who speak languages that the hospital encounters infrequently, or during off-hours in areas of the facility where on-site language assistance resources may be limited.
• The new regulations require hospitals to provide communication assistance to all patients within 20 minutes in inpatient and outpatient settings, and 10 minutes in emergency settings.
• Each hospital must provide key forms in a language the patient understands. Key documents include registration, billing, and consent forms for medical procedures, as well as medication and treatment instructions. Translated documents must be made available in those languages that are spoken by more than one percent of the hospital’s patients or the total hospital service area population. If translated documents are not available, a hospital should provide an interpreter to translate significant documents verbally for the patient at the time of a medical visit.
• Each hospital is required to post signs and distribute written materials notifying patients about the hospital’s free language assistance services, and provide patients and prospective patients with instructions for accessing services. These notices must be distributed in every language spoken by one percent of the hospital’s patients or service area population.
See also: Good Government Speaks Many Languages
Adam Gurvitch is director of health advocacy, and Norman Eng is communications coordinator, with The New York Immigration Coalitioion. Â
Twenty-five years ago the first cases of HIV were diagnosed. Within a few short years, children were especially hard hit. A growing number of children lost their parents to AIDS. From 1985 to 1990, according to Tim Ross, a researcher at the Vera Institute of Justice, the number of kids in foster care in New York tripled, from 17,000 to about 50,000.
“The foster care system in New York City faced a double whammy,” said Ross. “There was an epidemic of crack cocaine use that hit women particularly hard, and there was this new disease.”
So many kids were being put in foster care, it was extremely difficult to find placements for kids with HIV, who had contracted the disease from their mothers at birth. There just weren't enough foster parents out there, and a number of potential foster parents feared the disease, refusing to take HIV-positive children into their homes. “Boarder babies” became a term used to describe kids who were literally growing up in hospitals because they couldn't find homes.
Social workers and foster parents struggled to learn how to care for babies and kids infected with this disease that many health officials themselves barely understood. To help pediatricians adjust, New York City's child welfare administration created a special Pediatric AIDS Unit to test kids in care who might be infected and to train the foster parents taking care of children with HIV.
New programs specifically targeting families affected by the virus also started being developed, like Highbridge Woodycrest, a housing program in the Bronx for families affected by AIDS. That program and others like it prevented infected families from being separated.
Since then, the impact of HIV/AIDS on families has been greatly reduced. Due to medical advances, there are far fewer babies born with HIV. Dr. Anne Lifflander of the Vera Institute estimates that the infection rate among babies born to mothers with HIV has gone from about 25 percent to less than six percent. The number of adults getting HIV has also gone down. Thanks to better treatments, adults with HIV are living longer and more productive lives.
But teens, especially African-American teens like myself, continue to be at a high risk for HIV. In New York City alone, 1, 180 people aged 13 to 24 in March 2003 were known to have HIV. And that is just the teens who were tested. In 2004, more than half of all people in that age group diagnosed with HIV/AIDS were African-American.
Why is HIV continuing to affect so many teens? Some say it is because we teens think we are invincible. According to a survey by the White House Office of National AIDS Policy, close to 90 percent of young Americans do not believe that they are at risk for HIV. This attitude can lead us to have sex without a condom even if we know we should use one. It can also make us not get tested.
For African-American and Afro-Caribbean teens, the typical teenage denial of how HIV could affect her or him is made worse by young men on the down low, a term experts use to describe young black males who have sex with other men while viewing themselves as heterosexual.
Also, black teens in New York City are at high risk for HIV because the neighborhoods where many of us live have high levels of poverty, crime and drug use. Experts say that young people in these conditions are more likely to have what is called survival sex -- sex for money, food, and shelter.
James Bolas, the director at the Empire State Coalition of Youth and Family Services, has worked with homeless and street-involved youth who are HIV-positive for over 18 years. Homeless and runaway youth, Bolas noted, often feel that they only have their sexuality as a means of survival. Bolas estimates that as many as ten percent of young people living on the streets in New York City are HIV positive.
Heterosexual young women in poor neighborhoods are also at risk. All of us teens know many young women involved with men in their 30s. Experts say these young women are less likely to insist on using condoms because they are afraid to lose their boyfriends’ financial support. And if they find out they are HIV positive, they might not tell their partners for fear of violence.
But regardless of our situation, the bottom line is that often, unless we teens know someone who has AIDS or HIV, it is difficult for us to absorb the reality that we could get it. I would know. A month before my 20th birthday, my boyfriend of two months found out he had HIV, and it made me nervous and scared. Luckily, my results came back negative. But I want to learn more about this horrible virus so I can be more informed for my boyfriend and myself.
Jarel Melendez, 20, is a writer for Represent, a magazine published by our partner Youth Communication. Additional reporting by Zaineb Nadeem and Adam Wacholder. Â