If it weren't for the daily drama of the televised war in Iraq, the mysterious flulike illness from Asia known as SARS, for Severe Acute Respiratory Syndrome, would probably be capturing more local interest.
But, aside from a flurry of rumor-fueled panic in Chinatown, which has experienced a dropoff in tourism due to fears about SARS, New Yorkers seem phlegmatic about the risk posed by the new disease. "It sounds like the flu," said Katherine Bruni, 35. "You know, it'll kill the people the flu kills... the very old, the very young, people with compromised immune systems... I'm not that worried about it, personally."
SARS, may, in fact, be worse than the flu - although there have been no deaths among the 148 suspected SARS cases spread over 30 states in the U.S., SARS has so far shown a mortality rate of about four percent elsewhere in the world, as compared to about one percent for common influenza.
According to the World Health Organization, there were 2,671 suspected SARS cases in 19 countries as of April 8, and 103 people have died. China, where the illness emerged about three weeks ago in Guandong Province, has been hardest hit, with 1259 cases and 53 deaths, according to the health organization. Other countries in Southeast Asia, including Hong Kong, Vietnam and Singapore, are also experiencing substantial outbreaks. On March 15, the World Health Organization issued a global travel alert, cautioning that travel to Vietnam or Hong Kong might pose a health risk. It was the first time the U.N. agency had ever issued such a global alert. The U.S. Centers for Disease Control and Prevention have also issued a travel advisory urging people to avoid discretionary visits to Hong Kong, Singapore, Vietnam, and mainland China.
Seven New York City residents have contracted the disease, all while traveling in Asia recently, city health officials report. Ranging from a one-year-old boy to a 91-year-old woman, they all had mild cases and are recovering. So far, there have been no cases of SARS spreading from person to person in New York City.
Rumors of His Death Exaggerated
Chivy Ngo, owner of the Bo Ky restaurant on Bayard St. in Chinatown, notes that he is very much alive and well, despite rumors last week that he and several workers at his restaurant had died of SARS after Ngo supposedly traveled to Asia. Ngo's "death" was falsely reported last week in a mass-circulated e-mail, and business at his restaurant dropped off to nearly nothing for several days, though it has rebounded since the hoax was exposed, according to Robert Weber, a spokesman for the group Asian Americans for Equality. Weber adds that while tourists and visitors appeared to avoid Chinatown out of fear of SARS last week, leading to empty restaurants and deserted street markets, trade seems to be returning to the area now. "But, business-wise, Chinatown really didn't need a SARS scare. After September 11, that was like having a root canal after a heart attack," Weber says. "No one here is spreading SARS. People should come eat here and enjoy what we have to offer."
U.S. Senator Hilary Rodham Clinton, New York City Health Commissioner Thomas Frieden, and New York City Councilmember John Liu held a joint press conference to discuss how $16 million that Senator Clinton secured on behalf of the Centers for Disease Control to help combat SARS will be used. The conference attendees ate at a Chinatown restaurant.
What Is SARS?
The U.S. Centers for Disease Control has said the cause of the disease appears to be a new mutation of the coronavirus, a member of a virus family which also causes some forms of the common cold. Symptoms of the illness include a high fever (over 104 degrees Fahrenheit), cough, and shortness of breath.
There is no cure for SARS at this time, although the CDC is working on an antiviral agent, a vaccine, and a diagnostic test for the illness.
While the disease is clearly contagious, it is not clear exactly how it is spread -- whether it requires personal contact, or can be spread through the air, as through droplets from a sneeze. It is also not clear whether people can be carriers but not show signs of infection themselves.
"Most of what everyone is saying is based on sketchy data, so it's going to be a while before we know what's going on with this disease," says Arthur Rheingold, head of the Division of Epidemiology at U.C.-Berkeley's School of Public Health. "We don't know the primary routes of transmission yet. We don't understand whether people can be carriers without showing symptoms. Investigators are frantically trying to find these things out."
Don't Panic
Jerry Hauer, acting assistant secretary for public health preparedness at the U.S. Department of Health and Human Services, told the Associated Press on April 7 that health officials are baffled as to why U.S. patients have become less sick than those in, say, neighboring Canada, where SARS has killed 10 people and forced thousands of people in Toronto to be quarantined.
"It might be that some of these folks in Canada just got more of the virus, were in closer contact," Hauer told the AP. "Any theory I give you at this point in time would just be a theory."
Hauer also said the spread of the illness may be slowing. ``I think we've started to stabilize in the number of cases. We're not seeing these large jumps every day,'' he said. But "[w]e don't know yet whether ... we're through act one of a two-act play or whether we're just four lines into a three-act play."
President Bush signed an executive order adding SARS to a short list of diseases requiring mandatory quarantine under the Public Health Service Act. But no one in the United States has been quarantined for the illness, and there are no plans to do so at this time, experts testified before a Senate committee on April 7. Although some experts warn that SARS could yet turn out to be a deadly global pandemic, Berkeley's Rheingold says he doubts it could have the kind of lethal potential as, say, the deadly Spanish flu epidemic of 1918, which killed tens of millions worldwide.
"We have better medical care these days, antibiotics for treating secondary infections, better public health systems in place," Rheingold says. "I would expect that even if we find we have an organism of comparable lethality on our hands, we would do much better, mortality-wise."
To avoid contracting SARS, he says, "Don't travel to Asia unless you have to." Otherwise, he says, take the same precautions as you would to avoid the common cold: "Wash your hands a lot." The average person, he believes, has a "vanishingly small risk of catching SARS on the street."
Sue Wilson is a journalist who writes frequently on health and science topics for such outlets as the New York Times, WNET, and UNICEF.
Diabetes rates have doubled in adults in New York City in the last eight years, according to a recent report from the Department of Health (pdf file), which says the disease is now "epidemic" in people of all ages. Eight percent of the population now suffers the condition, which is the sixth leading cause of death in the city. Amongst children, however, the rate may have risen even more sharply, according to physicians who treat the condition in the community.
"The increase has been dramatic," says Dr. Yolaine St. Louis, chief of pediatric endocrinology at Bronx-Lebanon Hospital and a spokesperson for the American Diabetes Association. Nationwide estimates put the rise at between four and tenfold amongst kids.
Diabetes is a condition in which the body stops responding to insulin, a hormone produced by the pancreas which tells cells to remove sugar from the blood for use as energy and for storage. Two forms are most common: type I, which is a genetic condition in which the immune system kills off insulin-producing cells and type II, which is associated with obesity. In type II diabetes, cells become unable to properly respond to insulin. Type II accounts for up to 90 percent of all cases — and is the form that has been increasing.
In fact, type I is also called juvenile diabetes, because it was once believed that Type II never, or only rarely, affected children. Recently, however, the proportion of children with Type II diabetes has skyrocketed.
Says St. Louis, "I have been working in this area for fourteen years. When I first started, about two to ten percent of cases amongst children were type II, now it's 30 to 35 percent."
The epidemic has hit hardest people of color, and those who are poor — populations which greatly overlap in New York. There seem to be both cultural and genetic reasons why African Americans and Latinos are at higher risk for both obesity and diabetes, and there are environmental reasons why in developed countries, the poor are vulnerable.
"I see a population in Nassau County as well as in the Bronx," says St. Louis. "Even amongst the kids who are more well-to-do, those with an [African American or Latino] background still have more obesity and diabetes." This could be due to a "thrifty" gene, which tells the body to store large amounts of fat in case of famine. In the past, this gene would have given people a survival advantage because people with the gene could store more food from times of plenty for times of scarcity. Now, of course, it can harm.
Cultural factors — such as a common belief amongst Hispanics that thin children are unhealthy — could also play a part. "Black and Hispanic people don't want to be thin like models and it's positive not to worship thinness, but there's also a healthy limit. We cannot as a community be getting this overweight. It has serious health consequences."
The highest diabetes rate in the city is in East Harlem, where 14.9 percent of adults are affected. The hardest hit ethnic group is Hispanics; 12.2 percent of Latino adults have the condition.
Rising rates amongst children foretell an even greater epidemic in the future, if steps are not taken to fight it. St. Louis says that when she first started practicing in the Bronx, it was rare for her to see a child who weighed 250 pounds. These days, she sees such a new patient monthly, sometimes weekly. "You have to be close to 500 pounds to impress me now," she says, sadly.
So what has changed recently to spur such a shocking increase in obesity and its consequences? Genetics, of course, and many cultural practices, do not change rapidly. But recent research has shown that food portion sizes have grown tremendously in the last decade and that people are becoming less and less active.
Lack of safe streets and play areas reduce opportunities for poor kids to exercise even further. Budget cuts now mean that in many city schools, kids have gym class just once a week. "One kid told me that in his school, some grades have no gym. Grades 3, 5 and 7 have gym-but 2, 4 and 6 don't," says St. Louis, who adds, "If gym class is over-filled, the teacher is probably not making sure that the fat kid in the back is participating."
School lunches, however, are not a big culprit. St. Louis says, "No one is getting fat on school lunch. They all hate it." Also, though the food tends to be fatty, the portion sizes are not overly large and schools have recently added things like skim milk, which help.
"After school, they do all this academic stuff," says St. Louis, "And that's great but there is very little physical activity." St. Louis says that while there are organizations like the Police Athletic League and the Boys and Girls' Club in the Bronx, many parents don't know how to get their children involved and need to be given more information.
For adults, making major lifestyle changes in diet and exercise is difficult. For poor children, there are even more barriers. Fast food is cheap and readily available, while fresh fruit and vegetables are more expensive and harder to find in poor neighborhoods.
Fortunately, with diabetes, small changes can make a big difference, and that is how St. Louis is able to help her patients. "A lot of parents don't realize that going from 300 pounds to 280, that's a big deal. It may make the difference between taking one medication or two and the difference between eye disease later in life or none."
St. Louis doesn't tell a patient, for example, that he has to lose 100 pounds or start exercising every day. Research finds that people told to make such huge changes are usually too daunted to start, and get discouraged. Instead, she praises kids for small steps — walking home from school once a week, losing one pound, or even just stabilizing and not gaining.
Since it is hard to get kids to worry about future consequences, which with diabetes are particularly dire and can include blindness, limb amputation and shortened lifespan, St. Louis focuses on teaching them about how diabetes could hurt them in the near term. If it is not properly controlled, diabetes in children can lead to lifelong short stature, because it hinders development. Also, the disease can dramatically affect school performance because blood sugar problems can cause headaches and difficulty concentrating.
St. Louis runs a support group called Sugar Babes, for kids with diabetes and their families. In it, participants discuss how to make small, manageable changes and what to do when kids are resistant. She mentions making more such groups available, getting more fresh fruits and vegetables into schools and poor communities, improving public safety so that kids can play outside, more gym classes as important steps to fight the epidemic. "All of these are issues that as a city we need to address," she says.
Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.
A number of articles and stories suggest that some people who lived or worked near Ground Zero after the September 11 attacks have developed health problems.
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Commentary/OpinionAir Quality At Ground Zero Breathing the Air Downtown Give Us Back Our Neighborhood Environmental Aftermath More ResourcesGovernment Information EPA Response to September 11 Reports The Environmental Impacts of the World Trade Center Attacks |
Uncertainty Lingers Over 9/11 Air Pollution - Sep 7, 2003
The air in Lower Manhattan after Sept. 11 has swirled back into the news -- what people knew about it, when they knew it and what they said about it. The underlying issue, researchers, doctors and politicians say, remains just as unresolved today as it was back then in the chaotic, emotional days after the attacks: How do you communicate something about which no one has ever had any experience? Was there a standard of confidence about the environmental risks and unknowns that was scientifically or perhaps even morally appropriate under the circumstances? (New York Times)
300,000 Around WTC to be Studied for 20 Years - Sep 6, 2003
Some 300,000 people who lived, worked or were near Ground Zero after Sept. 11, 2001, are being asked to join an official registry to monitor any health effects from the World Trade Center debris plume. (New York Daily News)
EPA Assured Public Before Actual Testing - Aug 28, 2003
In the aftermath of the Sept. 11, 2001, attacks on the World Trade Center, testing to monitor levels of debris dust didn't begin for 10 days - and analysis of the findings didn't become available until October. Months later EPA scientists would conclude that the dust caused lung disease in test animals - ailments that mimicked those reported in people who lived and worked near Ground Zero. (Newsday)
Governor Wants To Know How Dangerous 9/11 Air Really Was - Aug 28, 2003
Six days after a federal report said the White House misled New Yorkers about the air around Ground Zero after Sept. 11, Gov. Pataki said yesterday he wants to know how dangerous it really was. But Pataki stopped short of criticizing President Bush, his fellow Republican, and didn't support a call from Sen. Hillary Clinton (D-N.Y.) and Rep. Jerrold Nadler (D-Manhattan) to reclean area buildings. (New York Daily News)
Residents Angry, but not Surprised at Premature E.P.A. 9/11 Air Reports - Aug 21, 2003
Downtowners expressed outrage but little surprise last week at the news that the White House allegedly influenced statements the Environmental Protection Agency made soon after the collapse of the World Trade Center about air quality in Lower Manhattan. (Downtown Express)
Downtown Moms Question W.T.C.Baby Study Findings - Aug 14, 2003
Despite research showing a possible link between trade center toxins and lower baby birth weight, several downtown mothers who participated in a recent study said last week that the preliminary results did not appear to describe them or their babies. Mount Sinai School of Medicine tracked 182 women who were pregnant and in the vicinity of the World Trade Center on Sept.11, 2001, or within three weeks thereafter. In results released last week, researchers found that women who were exposed to dust from the trade center collapse were twice as likely as a control group to have babies who were slightly small for their gestational age, or for the amount of time they spent in the womb. (Downtown Express)
WTC Health Problems Persist - Aug 11, 2003
Thousands of New Yorkers say they still suffer from the World Trade Center attacks - and they are reaching out to help hot lines in numbers greater than last year, The Post has learned. Callers are seeking assistance for health complaints - ranging from respiratory ailments and pneumonia to acid reflux - that many link to the toxic plume created when the Twin Towers fell, as well as for post-traumatic stress disorder, anxiety and depression. (New York Post)
Feds Launch Long-term WTC Health Studies - Aug 10, 2003
Long-term studies to monitor the health effects of the World Trade Center attacks on New Yorkers are getting under way. A 20-year study conducted by the city Department of Health and the federal Agency for Toxic Substances and Disease Registry will begin in September or soon after to identify patterns of physical and psychological illness attributable to 9/11. (New York Post)
Smoke and Dust at World Trade Center Is Linked to Smaller Babies - Aug 6, 2003
Scientists say they have measured a slight but significant rise in the percentage of small babies born to women who were around the World Trade Center during or after the terror attack compared with babies of a large sample of pregnant women who were elsewhere at the time. The researchers, from the Mount Sinai School of Medicine, proposed that air pollution from the pulverized, smoldering wreckage was the most likely cause of the difference. (New York Times)
Joanne Rosenberg has been a registered nurse at North Shore Hospital in Forest Hills, Queens, for almost 30 years. Her job has always been difficult, but today as she scrambles to tend to more patients, she worries that she is unable to provide the care she would like to give. "Every patient deserves full attention, but it's not realistic," she said. "Sometimes you have to do shortcuts… You don't want to do that, but there's only so much the body can do."
New York has a nursing shortage. Last April, 59 city hospitals reported a total of 2,000 vacancies, or nearly 8 percent of their nursing workforce. By 2005, New York State estimates it will have 17,000 fewer nurses than it needs, and that number could double by 2015.
"We are edging closer to a precarious situation," said Kenneth E. Raske, president of the Greater New York Hospital Association. "We must make sure that we have enough nurses to care for future generations." The shortage comes at a time when the demand for nurses is increasing as the baby boom generation ages and requires more medical care. And unlike some of the previous shortages, it could last for many years, if not decades, to come. Fewer young people are choosing careers in nursing, and many nurses are nearing retirement age themselves or just quitting from stress and overwork. Proposed cuts in government spending for health care threaten to make the situation worse.
The shortage in the city is not only taking its toll on nurses and hospitals, but on patient care -- lines at emergency rooms are longer, surgeries are delayed, and even the risk of dying in a hospital may be increasing.
"There is absolutely no question that you cannot have quality care without nurses," said Georgia Persky, vice president of Mount Sinai Hospital in Queens. "Patients need someone constantly, critically looking at them in a unique way that only a nurse can provide."
Nurses generally provide about 80 percent of direct patient care in hospitals. They assess the patient's condition, administer medications and maintain medical records. They look out for symptoms and report them to physicians.
"Nurses are the eyes and ears in a hospital," said Nancy Webber of the New York State Nurses Association. "If they have too many patients to care for they simply can't do that to the extent they should and want to."
Nurses' workloads vary widely. But more than 25 percent of nurses in the state say they do not have time to complete all the tasks involved in caring for patients, and 45 percent say they do not have time to provide a thorough assessment of their patients, according to a 1999 survey conducted by the New York State Nurses Association.
This can put patients' lives in jeopardy. Whenever a patient is added to a nurse's workload, the chance that one of that nurse's patients will die within 30 days of admission increases by 7 percent, researchers at the University of Pennsylvania found.
Some of this results from the strain of an excessive workload. "If you don't get enough rest you may give the wrong medications to the patient. And that's scary," said Pui Ching Mak, who worked at Bellevue Hospital and is now a nursing manager at Visiting Nurse Service of New York. "I had this nurse one time who gave a chemo medication to another patient."
The nursing shortage also forces people to wait for care. "Sometimes we [have] had to reschedule an operation because there was not enough staff," said Freddy Haro, who worked as a medical technician at Memorial Sloan-Kettering Cancer Center for 12 years and recently got his nursing degree.
In nursing homes, where vacancy rates are 10 percent, the shortage of nurses and of nursing assistants, who take care of residents' personal needs, has a particularly dramatic effect.
"Residents in nursing homes often do not have their diapers changed appropriately, or they are not assisted in toilet training, call bells are not responded to promptly, because there is not enough staff," said Randy Blom, a counselor at Friends and Relatives of Institutionalized Aged, an advocacy group.
Nursing has traditionally been a women's profession, but as job opportunities for women have expanded, fewer have chosen nursing careers. According to a survey by the American Association of Colleges of Nursing, over the last five years, the number of graduates from nursing programs declined by an average of 1,030 students each year.
Many are deterred because nursing can be dirty, intense, demanding work -- far different from a job in an office. "When you are a nurse you need to handle dirty stuff - urine, sputum, body fluids. Not everybody wants to do that," said Mak.
Many people do not want to deal with the tension that's prevalent in healthcare facilities." In nursing, there is not much room for you to make a mistake, and when you do make a mistake you pay for it severely," said Vetah Okuomose, a registered nurse who works in a school in Queens. "It's a rewarding profession, but it's a very serious profession."
Caring for a terminally ill patient or seeing a person die is not something everybody can handle. Susan Hertz, a recent graduate of the nursing program at Kingsborough Community College, said, "It's a challenge when someone is in great pain and you can't take that away from them," she said. "We are in a role where we want to make a difference, but if we can't make a difference for somebody, that's tough."
Nurses also complain they do not get the respect they deserve.
"Nurses are often treated horribly by doctors," said Naomi Zauderer, director of New York Professional Nurses Union. "It helps if they are unionized, but without some serious changes in workplace conditions the profession will continue to hemorrhage nurses."
And the pressures are increasing because of managed care. Because patients do not stay in hospitals as long as they once did, those who are left there are there are usually sicker and require more nursing than patients 20 years ago.
Faced with such challenges, many nurses leave the profession. The U.S. Department of Health and Human Services found 19 percent or about 240,000 registered nurses in New York State are not employed, by their own choice. Over the past four years about 8,000 nurses in New York have quit their jobs.
Perhaps the most alarming factor affecting the shortage is that the average retirement age for nurses in New York State is 49, and the average age of a registered nurse in New York is 46.
"In the next five or ten years we all are going to retire," said Diane Mapp, a registered nurse at Long Island College Hospital in Brooklyn, who has been a nurse for 28 years. "I can't see myself at 60 doing this anymore."
Healthcare providers and educators are struggling to come up with strategies to recruit more nurses.
Hospitals in New York generally offer nursing graduates salaries ranging from $48,000 to $55,000. Some provide tuition reimbursement or scholarships. New York Presbyterian Hospital, for example, offers $10,000 in tuition benefits at Columbia Medial Center to nurses who want advanced training. New York University Hospital gives monetary remuneration for nurses who receive certification in specialty areas.
"It's absolutely critical to make nursing a very appealing job, which starts at a threshold level with paying a competitive salary, but [also improving] the job design and the working conditions," said Denise Davin, vice president for Human Resources at Visiting Nurse Service of New York, which employs over 2,000 nurses.
Training programs are also being expanded.
City University of New York has not been able to accommodate all the applicants to its nursing programs because there are not enough professors. Borough of Manhattan Community College, which has the largest nursing program of all CUNY schools, had to turn down 70 applicants to the nursing program in 2001, the New York Times reported. To address this, CUNY is adding 30 instructors to its nursing programs.
"It's expensive, but we have an obligation to provide work-force training where there is such a great need," CUNY Chancellor Matthew Goldstein has said.
Last year, CUNY created a special program for immigrant nurses with poor language skills who want to get licensed in New York. The 18-month program helps them master English and prepares them to pass the licensing examination. Currently 40 immigrant nurses are enrolled in the program.
The state and federal governments have also taken steps to address the problem.
In January, 2002, Governor George Pataki signed the Health Care Workforce Recruitment and Retention Act, which granted $1.85 billion to hospitals, nursing homes, and other health care facilities. The money would help the facilities recruit and retain workers and increase salaries and would encourage employees to advance in their profession. The current state budget crunch could, however, undermine parts of this program.
The Nurse Reinvestment Act, signed by President Bush last summer, authorized more loans and scholarships to nursing students and offered grants to healthcare providers to help them recruit and keep nurses. The Senate has approved $20 million in new federal funds for the act for the fiscal year 2003.
Training programs, hospitals and colleges are reaching out to the younger generation, trying to encourage them to become nurses. Borough of Manhattan Community College allows high school students to take college credit pre-nursing courses. Kingsborough Community College has been working with several high schools in Brooklyn to raise awareness of the importance of health careers and the need for more people to enter them. "We really need to go into the schools at a very young age, get to the younger population and sort of market nursing, not just for women, but also for men," said Willie Manzano, vice president for Patient Care Services at Columbia Presbyterian Medical Center. Fewer than 6 percent of nurses in New York are men.
Visiting Nurse Service of New York, which faces a 10 percent vacancy rate, is going to the army and the Fire Department to recruit potential nurses. It currently employs five firefighters. Patrick Murpagh, a visiting nurse who is also currently a firefighter, believes this is a good time to try to bring these workers into nursing.
"Both [nursing and firefighting] are service orientated occupations," he said. "After 9/11 there have been a lot of retirements, so I think that [firefighters] will be looking to going into different careers and nursing would be a perfect opportunity for a lot of them."
In the 1980s, many hospitals relied on nurses from abroad to alleviate the problem. But, while some still do this, the tactic is less effective than it once was because many other countries also face a nursing shortage.
To retain nurses, health care providers and lawmakers try to make the job as attractive as possible. That often entails offering flexible hours and bonuses, lowering the nurse-patient ratio and not requiring overtime. Many hospitals offer 12-hour shifts, which some nurses prefer to shorter, more frequent workdays.
New York State Assemblywoman Catherine Nolan and Senator Thomas Morahan have proposed a bill that would prohibit hospitals from requiring a nurse to work more than eight hours a day or 40 hours a week, unless her regular schedule allows for more. The requirement could be suspended during "health care disasters" and publicly declared emergencies.
Hospital management however, argues that some overtime is unavoidable when there is a sudden surge in patients or nurses call out sick. "When we have sick calls, and we can't cover the sick calls with either a per diem nurse or an agency nurse, then we end up asking people to stay. Sometimes they don't do it happily, but we work it out," said Manzano.
Assemblymember Richard Gottfried and State Senator Kemp Hannon have introduced a bill that would require the State Department of Health to establish universal staffing standards for health care facilities, based on the severity of the patient's condition.
Another bill, also introduced by Gottfried, would apply only to nursing homes. It would ensure that in every nursing home during the day shift there are no more than 15 residents for every registered nurse. Many nursing home nurses care for 30 or more residents.
While overworked nurses support the legislation, some health care organizations claim that a universal nurse-patient ratio would only worsen the current situation. "You can't offer some formula and say x number of nurses for x number of patients for this floor," said Monica Mahaffey of the Healthcare Association of the New York State. "The healthcare providers know the . . .needs of the patients, and they should be the ones ensuring that those patients are getting the best care they can." Health care organizations have been lobbying for decreasing the amount of paperwork for nurses. The law requires that nurses maintain records on the evaluation and treatment of each patient. Some nurses at Bellevue Hospital stay an hour and a half extra every day to complete the required records.
"For every hour of patient care, nurses do at least another hour of paperwork," said Mahaffey. "Let's find a way to get them back to the bedside. Let's use the nurses we have to provide direct care and find some other way to take care of these paperwork requirements."
New York will not be able to alleviate the shortage of nurses unless ideas and incentives are backed up by money. And money is in short supply these days.
On January 29, Governor Pataki released a proposed budget imposing more than $1 billion in cuts that would have a great impact on health care providers, their staff and patients.
"When you take a billion dollars out and 60 percent of the cost of a hospital is labor, you run the risk of jeopardizing the workforce supply," Daniel Sisto, president of Healthcare Association of New York State, said on Capital News 9.
The governor also proposed reinstating a tax on hospital revenue. According to the New York Times, that will cost hospitals more than $228 million a year and "could, along with cuts to Medicaid reimbursements of another $317 million, lead to layoffs of hospital workers."
It is unclear whether the governor's proposals will be enacted. But such ideas, along with the $343 million in operating losses that New York health providers experienced in 2001, cuts in federal Medicare funds, and rising costs, do not bode well for the nursing situation.
"The nursing shortage is a scary problem," said Persky. "I would not venture to guess what the future is. It will only be what effort we put into it."
So far, 2003 is proving to be a hot year for health policy developments, both locally and nationally. Here is an update:
Unfortunately, most of the dire budget predictions made here earlier are coming true. The city asked that the state pay an additional $200 million of its Medicaid costs; instead, Governor George Pataki wants the city to pay a greater share of hospital and clinic costs than it does now. In exchange, the state would provide more money for prescription drugs. This shift would benefit many upstate counties, but would hurt the city because 35 percent of city Medicaid payments go to cover inpatient hospital costs while only 15 percent go for drugs. Medicaid is the federal health insurance program that provides coverage for the poor.
The New York Times estimated that the change would cost the city an additional $140 million and wrote in an editorial that the cuts would devastate the city's teaching hospitals, which educate about 15 percent of all doctors in the United States.
The governor also wants to reduce the number of people eligible for Medicaid. He has proposed lowering the maximum income that people can have and still qualify for the program. In the past, this has proved to be counterproductive because many of those kicked off Medicaid remain uninsured. Then, when they turn up in emergency rooms needing treatment, the city is forced to cover 100 percent of the cost. If these people had stayed on Medicaid, the federal government would have paid 50 percent of their treatment costs.
The federal government also has its eye on Medicaid. States, including New York, put many people on Medicaid who do not meet all the federal rules for being in the program. In fact, one third of people currently on Medicaid in the United States fall into this category and receive a full package of benefits. But the Bush administration is proposing that this change - that people who states voluntarily add to the Medicaid program no longer get all benefits.
Under current rules, states must apply for a federal waiver to change eligibility requirements and benefit packages in many cases. With the new system, they would no longer have to do so.
Critics-including some Republicans -say that the Bush proposal looks remarkably similar to a plan vetoed by President Clinton, who said at the time that it would lead to cuts that would be "devastating" for the poor.
"I don't see how New York would benefit with this kind of arrangement," says James R. Tallon, president of the United Hospital Fund. "New York has a significant Medicaid program, therefore, one has to be skeptical about any standard federal formula. New York probably has more to lose than gain."
The National Governor's Association, which might be expected to enthusiastically support anything that offers Medicaid spending relief (since Medicaid spending makes up approximately 20 percent of most state budgets) did not endorse the proposal but simply thanked the administration for putting Medicaid spending in the spotlight.
The president has put Medicare reform on his agenda as well. During his State of the Union address last month, Bush proposed adding a prescription drug benefit to the program. But to take advantage of the benefit, the elderly would have to enroll in health maintenance organizations. The administration, through its administrator of the Center for Medicaid and Medicare Services, Tom Scully, denied that the program would "force" beneficiaries into HMOs, but few details of the plan have yet been released.
There is some unequivocal good news for Medicare patients and their doctors, however. Scully told a Senate subcommittee on January 30 that the administration did not support actually going through with the 4.4 percent cut in doctor's fees that is scheduled to go into effect on March 1. This will now be considered along with the federal budget. Experts had said that, following a 5.4 percent reduction that went into effect last year, another cut would drive even more doctors out of the program.
And Pataki had some positive news for one group of health care consumers-the seriously mentally ill. After the Times revealed that nursing homes were warehousing mentally ill patients and that many of the group homes serving them provided worse care than the mental institutions they replaced, the governor appointed a commission to look into the problem. Taking its recommendations, Pataki has proposed spending $80 million to create new housing to replace the current system. While Democrats want more, advocates for the mentally ill are pleased to get a substantial increase during a fiscal crisis.
Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.
In late January, New York City will receive 15,000 doses of smallpox vaccine to begin voluntary vaccination of health care workers as part of President Bush's homeland security initiative.
If vaccination of health care workers goes well, other "first responders" like police and firefighters will then be vaccinated, and the shot will be made available in 2004 to members of the general public who want it.
But the vaccination campaign raises many questions. How safe is smallpox vaccination? Do people over 34, who were vaccinated as children, still have protection or do they require booster shots? Should the general public seek vaccination? And how likely it is anyway that smallpox will be used as a biological weapon?
The last question is critical for answering the first. If the chances of an attack are exceedingly low, the risks of vaccination almost certainly outweigh the benefits. The currently existing vaccine, which is basically a variant of the first vaccine ever developed (by Edward Jenner, in 1796, is the most dangerous vaccine still in use. It kills 1-2 people per million and causes life-threatening illness in about 14-52 people per million, according to the federal Centers for Disease Control.
The vaccine uses a live virus, vaccinia, which is a relative of the cowpox virus that Jenner first observed to protect milkmaids from developing the far more deadly smallpox. Most of today's vaccinations use dead or inactivated viruses, so they are far less likely to have serious side effects. Because smallpox vaccination uses a live virus, however, people who are vaccinated can actually infect others with it-- if people who have not been exposed previously touch the vaccination site or otherwise come in contact with fluids from it.
About 1 in 1000 vaccinated people will have a serious, but not life-threatening response, such as a rash which spreads from the vaccination site. Sore arms and fever were common in recent tests of the vaccine conducted to aid the government's decision on widespread vaccination. The tests compared full dose vaccine to diluted versions. This research needed to be conducted because without dilution, there isn't enough existing vaccine to protect the population.
Out of nearly 700 young adults (mainly college students) who volunteered to take the shot, over one third stayed home from school or work for a day and about nine percent developed fevers. Fourteen percent developed rashes which spread beyond the vaccination site. All strengths of the vaccine were effective in this test. There were no deaths.
Today's population, however, is at higher risk from the vaccine than populations that were vaccinated earlier. For example, people with HIV could become seriously ill if they were vaccinated or exposed to virus from vaccinated people. Other people at high risk include people with any form of immune suppression (transplant patients, people on steroids for auto-immune disorders), pregnant women, people with certain skin diseases such as eczema or atopic dermatitis and those who are allergic to certain antibiotics which are contained in the vaccine. Researchers estimate that about 15 percent of the population currently has at least one of these risk factors.
Andrew Stern, the president of the SEIU (the largest national health care workers's union), released a statement in December saying, "The Administration and Congress have protected the wealth of the drug companies who make the vaccine, but not the health of hospital workers and the public. President Bush's smallpox plan will put thousands of Americans at unnecessary risk." SEIU Local 1199 will hold a forum in late January to plan the local union's reponse to the city's vaccination efforts and discuss whether they will recommend vaccination, which is voluntary, to their members.
"We want to make sure all possible risks are weighed, for health care workers, hospital patients and their families," said Dieter Metzger, a spokesperson for the union. Amongst 1199's concerns are the lack of provisions for time off for those who have bad reactions to the vaccine, protection from spread of vaccinia to vulnerable workers and patients, and protection from discrimination for workers who choose not to be vaccinated.
So how dangerous is smallpox itself?. In the past, it killed about one-third of those who were infected. Now, experts think mortality would be lower because many smallpox deaths resulted from bacterial infections which often develop on the "pox" (Note, graphic image) or sores, which cover the bodies of victims. Antibiotics can now easily treat such infections. Also, people can be vaccinated to avoid illness within three to four days of exposure, leaving a window of time for rapid vaccination in event of a terror attack.
And while there is currently no treatment approved for smallpox, a new antiviral drug, cidofovir, has been found to be effective in culture and in mice. Researchers are testing an oral form of this drug; an injectable version is already approved for treatment of a common opportunistic infection of the eyes seen in people with AIDS, called CMV retinitis.
Further, everyone over 34 has been vaccinated at least once. A review of smallpox cases in Europe and Canada in the 20th century found that 52 percent of unvaccinated people died, but only 1.4 percent of cases were fatal for people vaccinated within 10 years and the mortality rate for those vaccinated from 20-50 years prior was 11 percent. A more recent study also suggests on-going protection, showing a strong immune response by cultured cells in people vaccinated between 6 and 35 years ago. Researchers are not sure how generalizable these studies are but the World Health Organization's smallpox fact sheet suggests at least some protection.
The last cases of smallpox to hit New York occurred in 1947. At that time, a businessman visiting from Mexico became ill with the disease and infected 12 other people. Two of them died -- but the city prevented further spread of the illness by vaccinating 6 million people in one month.
Complications from the vaccine killed six people, ironically, more than the disease did.
A country which is at possibly the highest risk for terrorism in the world, Israel, has already vaccinated 17,000 of its soldiers, police and health care workers and plans to vaccinate more. So far, there have been only two serious negative reactions and no deaths. But on Christmas day 2002, Israel announced that it would not vaccinate its entire population, declaring the risk of a smallpox attack to be low.
When the risk of disease is so hard to determine, deciding on use of a risky vaccine is extremely difficult. People over 34 tend to wonder what the big deal is, and why something that all of us received as kids is now seen as so dangerous as to make even clinical trials on children unethical (a recent plan to test the diluted vaccine was stopped by critics). The issue is context. Smallpox was a real threat until 1977, when the World Health Organization declared that it was eradicated. A 30-50 percent chance of death is certainly a greater risk than a 1-2 in a million risk.
It took enormous effort by thousands of dedicated doctors, scientists, public health workers, nurses and others around the world to eradicate the smallpox virus, which had long been one of humanity's greatest foes. Smallpox is believed to have killed more people than any other infectious disease, claiming 300 million lives in the 20th century alone.
Communists, capitalists and others across boundaries worked together to ensure the end of the virus, which was then stored only in two sites by the U.S. and the former Soviet Union. Stolen virus from the former Soviet facility, which was less than secure as Soviet rule ended, is believed to be the source for any virus potentially obtained by terrorists.
Unleashing such a threat after such an effort can only be seen as an attack on civilization itself. Let's hope it doesn't happen and that the risk from the vaccine is the greater. But unfortunately, right now, we just don't know.
Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.
"A young fellow in his third year of college had a psychotic break," Judge Matthew D'Emic recounts. The man began hearing voices, which spoke to him through the TV and the radio and convinced him that he was Jesus Christ reborn. He began to act increasingly strange and distant -- and was soon arrested for grabbing a woman's purse. His claims about being the savior irritated his fellow inmates at Riker's Island, and he was brutally beaten while awaiting the disposition of his case.
Typically, in New York City, people such as this man, whom the judge did not name, are at the start of an alternating cycle between incarceration and homelessness in which their underlying mental illness is never adequately addressed. Of the inmates on Riker's Island, as many as 20 percent have a severe mental illness -- and of those who were on psychiatric disability before their arrest, nearly half had been homeless the night before, according to the Urban Justice Center. Around 3,000 severely mentally ill people are incarcerated at Riker's Island on any given day, making it in effect the city's largest psychiatric hospital.
But a new court which began operating in October in Brooklyn hopes to start to change that. The college student whose story D'Emic told is one of the first case to be referred to him.
"He had never been in trouble before," says D'Emic, who has now seen him in court for several months. His father attended his court appearances. "At first, I could see this terrible look on his father's face, like ÔWhat happened?'" says D'Emic. "Now he comes and says that his son is back to his old self." He has re-enrolled in college and is under psychiatric care.
If he completes his period in care under court supervision satisfactorily, the student's case will be dismissed and he will not have a criminal record. The Brooklyn Mental Health Court focuses on serious non-violent crimes committed by the mentally ill. Participants are referred by the District Attorney's office or by other judges. Some violent crimes like burglary can be considered on a case-by-case basis. However, the District Attorney has to approve all participants.
But while these courts sound like a great solution to the problem of the criminalization of the mentally ill, many advocates for those with serious psychiatric problems are skeptical.
Even Judge D'Emic admits that the courts alone can't solve a critical underlying problem, which is a severe shortage of services and residences for those with mental illness. "I do see that there is a problem with not enough services being available," he says, even though only about 30 defendants have already been through his court.
"[These courts] don't do anything to fix the community mental health system, which is in complete shambles in most of the country and that certainly includes New York City," says Heather Barr, staff attorney at the Mental Health Project of the Urban Justice Center.
"I feel like this is more of a band-aid approach," adds Susan Saler, Director of Services for the National Alliance of the Mentally Ill's New York Metro Chapter, though both support measures in general to keep the mentally ill out of the justice system. Both advocates say that if community services were adequately funded and regulated, however, many of the mentally ill would not get arrested in the first place.
A more positive reaction is expressed by Dr. John Goldkamp, a professor of criminal justice at Temple University, and a leading authority on both drug courts and mental health courts. "I think that [these courts] bring an important focus to a long-neglected area," he says. "Good mental health courts are going to play a very important role." Goldkamp says there are now about 20 mental health courts across the country, with others about to be launched. He says that their goal primarily is to keep the mentally ill out of prison
Judge D'Emic is quite clear about that. Using short stays in jail to punish non-compliance with treatment poses a real problem with the seriously mentally ill, that it may not pose with other offenders in alternative sentencing courts.
"Drug treatment courts have the option of putting defendants in jail for a few days for non-compliance," he says. "If I do that, the person could decompensate, he might not get his medications and then I'm worse off than I was before."
As a result, D'Emic must use rewards like fewer court appearances, praise and even lectures to try to motivate those before him. Jail is a last resort. It is not used as a motivator, but simply to protect the public if a defendant becomes dangerous.
Part of the impetus for creating the court, in fact, was the failure of drug courts to help those who were both addicted and mentally ill. Because they were often unable to comply with treatment -- and because many drug treatment centers are not set up to treat serious mental illness -- the addicts with mental illness frequently wound up back in prison.
Since about 50 percent of the severely mentally ill have drug problems and about 50 percent of addicts have additional mental illnesses of varying severity, this is a large group of people who often have contact with the criminal justice system.
Goldkamp says that just as drug courts were started in part because the drug treatment system was failing to help, the same is true of mental health courts. "Thank goodness for the judges who want to face this problem of mental health, just like others wanted to deal with substance abuse. There are all kinds of issues that make this even more complicated and difficult. [These courts] are only there because of the failure of other social service delivery systems," he says.
But many advocates for the mentally ill feel that spending money on mental health courts reduces the pool of money available to improve community treatment. Goldkamp doesn't think this is necessarily so; he says that drug treatment providers initially opposed drug courts using the same reasoning but that the special courts can push providers to offer better and more cost-effective services if they are set up properly.
The New York State Office of Mental Health is spending $465,000 on this court and on training judges to expand it. There will be an outside evaluation once the court has been in operation for six months.
Only time will tell whether these courts will be successful in New YorkÑbut there is no doubt that change is needed. On any given day, there are about 8,000 seriously mentally ill people in New York state's prisons and jails -- and roughly 10,000 seriously mentally ill homeless people on the city's streets.
Maia Szalavitz is author, with Dr. Joseph Volpicelli, of "Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand and Treat Alcohol and Other Drug Problems." She writes frequently on health, science and public policy for the New York Times, New York Magazine, the Village Voice, and other publications.
The nation's looming health care crisis -- 40 million without health insurance, insurance premiums rising, and benefits being reduced -- has made headlines of late. The most startling news is that, in the midst of a recession, health care costs are expected to rise between 13 and 16 percent in the next year. Like many New Yorkers, artists are already beginning to experience changes in their access to health insurance and care.
By some estimates, four of every 10 artists lack health insurance, compared with 14 percent of the total population. This is not because artists are unemployed, however. Like the vast majority of the uninsured, artists tend to lack insurance because they work for employers who do not offer health care; the sporadic, project-based nature of the working artist's career is a major hurdle to health insurance. This is not news to the many actors, musicians, painters, and dancers who keep the day job as much for the benefits as for the steady check.
Complicating this factor, according to a new report from the Future of Music Coalition, is the fact that artists are often considered by insurance companies to be a "risky" population. Whether because of their long hours, frequent travel, repetitive stress disorders, and such job hazards, or because, as the coalition's report suggests, because of an anti-arts bias based on the "hypothesized decadence of art culture," the reality is that it is hard for artists to get access to coverage on their own, even if they could afford the high premiums charged for individuals. In 2002, premiums for the major individual health plans serving New York ranged from $400 to $500 per month for individuals and well over $1000 per month for families.
Major arts unions like the Writer's Guild of America, American Federation of Television and Radio Artists, the American Federation of Musicians, and the American Society of Composers, Authors, and Publishers form a safety net for many artists by offering subsidized group health coverage. However, unions are now feeling the same pressures that are causing employers to pass on more of the costs of health insurance to their employees. (In a Commonwealth Fund/Health Research and Educational Trust survey published last month, the majority of New York State employers said that they plan to pass on more of the costs of health insurance to their employees next year.)
The Screen Actor's Guild has already announced that, starting in January, they will begin to charge enrollees a monthly premium for the first time, either $50 or $65. The benefit plan will also become less generous, charging higher deductibles and copayments and covering fewer services. The change that will affect the most members is that eligibility requirements will be substantially tightened. In 2003, actors will have to earn $20,000 to qualify for one plan or earn $9000 or work 61 days to qualify for another. These changes, the union trustees say, are absolutely necessary to prevent health costs from eating through its assets within the next two years. In May of this year, the guild extended Rule One, which requires that producers dedicate 13.8 percent of actors' salaries for health and pension plans, to all productions worldwide in another effort to shore up the health plan's funding.
Health care is a more pressing issue now because of rising costs, but the arts community has long been advocating for improvements to access to health care for artists. The explosion of HIV/AIDS in the arts community in the 1980s galvanized many to fight for better health care for the dying; now Broadway Cares/Equity Fights AIDS helps those living with the virus. In the mid-1990s, New York-based Actors' Fund won a grant from the National Endowment for the Arts to mount the Artists' Health Insurance Resource Center, a central clearinghouse that educates artists about health insurance options. The online database provides information about group health plans, federal and state public programs, options for the self-employed, and advice on how to get and keep insurance. According to James Brown of the Actors' Fund, the recently redesigned website gets about 650 individual users a day, half of which live in New York City.
Since 2000, the Actors' Fund has also been running the Physician Volunteers for the Arts, which serves the uninsured and underinsured members of the performing arts community. Free clinics staffed by volunteer physicians provide basic health services and referrals for specialized treatment.
Assemblyman Richard Brodsky is sponsoring a bill in the state legislature that would pay for 50 percent of the COBRA premium for up to six months for eligible members of the entertainment industry. COBRA, or the Consolidated Omnibus Budget Reconciliation Act, guarantees employees leaving employer-sponsored coverage the right to buy into that coverage for up to 18 months. While the law provides continuity of care, its premiums -- around $350 for individuals and more than $1000 for families in New York in 2002 -- prove out of reach for many, particularly for those who have recently lost their jobs. Brodsky's bill would subsidize 50 percent of COBRA coverage to qualifying members of the entertainment industry (e.g., screenwriters, actors, musicians, dancers) for up to six months.
Such measures, while crucial, may only be damage control. Increasing problems with access to and continuity of care in the arts community are one more sign that major legislative reform to the health care system is needed.
Martha Hostetter writes for American Theatre magazine.
Some 500,000 people are believed to have developed post-traumatic stress disorder in New York following the fall of the World Trade Center, according to the Journal of the American Medical Association. This rate is nearly three times the national rate per capita. Thousands were directly affected - either having fled the building or the immediate vicinity or having lost a loved one or worked on recovery efforts.
So what are the best ways to cope with the anniversary? Whether you have been severely or moderately affected, experts agree that there are several key considerations to keep in mind in order to reduce stress and maintain optimal mental health. The entire month of September this year will be filled with reminders of the attack, so it is important to pay close attention to how you and those close to you are coping not just on the date itself, but during the weeks surrounding it. As the anniversary approaches, calls to 1-800-LIFENET, the helpline for mental health services which people can call to access Project Liberty, a free counseling and referral service for New Yorkers affected by the attacks, have steadily increased. "We've had a hundred additional calls a week for at least three weeks," statewide director April Naturale said in late August, when there were about 500 calls a week. "And it's climbing every day."
On the anniversary itself, experts say that there is no single best way to spend the day, whether you stay at home or participate in any of the planned ceremonies or events. "Trust your gut," says Dr. Richard Shadick, assistant director of Pace University's Counseling Center. "If you are already feeling very nervous, it might be good to have quiet reflection. But if you are craving information and connection with your community, it makes sense to find a way to participate." Shadick, who witnessed the attack and has provided pro-bono 9/11 therapy throughout the year, agreed to participate in Gotham Gazette's live chats on the day of the anniversary to counsel readers about how to cope. Naturale recommends keeping things "low key, because the emotions themselves may be overwhelming." Small community memorial ceremonies, private rituals like saying prayers or lighting candles, religious services, or just spending time with loved ones and friends can help. "We don't recommend isolating yourself," she adds.
Media attention to the anniversary, in this world capitol of media, will be nonstop and hard to escape entirely. "If you have been traumatized," says Naturale, "We recommend avoiding the images of the planes flying into the towers." For Project Liberty's tips on viewing 9/11 related TV, click here.
Dr. Nancy Smyth, Associate Professor at the University of Buffalo School of Social Work, is an expert on psychological trauma. "We have reason to suspect that the more people watch the images on TV, the more likely they are to have psychological symptoms of post-traumatic stress disorder including anxiety and depression." she says.
Smyth says the research can't determine whether people who are more traumatized are more likely to seek to watch the replays or whether the replays themselves are producing extra stress -- and some experts believe that repeated viewing could lead to desensitization, which might help in some cases. But, Smyth adds, "I have informally collected a lot of anecdotal data and people who have experienced a great deal of sleep disruption report that when they turn off the TV, they feel better."
Smyth advises minimizing exposure to the images of the disaster on television, particularly those which are most gruesome and explicit. She stresses particularly that people should not feel obligated to watch. "Many people felt they had to watch to show that they cared, and felt guilty turning it off. They felt relieved to have permission to stop watching." she says.
New Yorkers seem to be doing more of everything in their attempts to cope: While drinking, smoking and drug use have increased, so have gym memberships. Equinox is reporting a 25 percent increase in profits since 9/11 and New York Health and Racquet Club is also seeing increased demand, according to Crain's New York Business.
Exercise is one thing all the experts agree on as an excellent way of dealing with stress, and the time surrounding the anniversary is no exception. Whatever type of activity appeals to you - from rollerblading, rock climbing and running to dancing, swimming or even just walking -- moving your body can help you feel better.
One reason this is true is because focusing on your physical experience in the moment helps shift attention away from disturbing memories. Smyth cites research showing that traumatic memories seem to be stored in the brain differently from other memories; unlike ordinary recall, traumatic memories seem to involve an actual physical replay of previous events as experienced emotionally through sensations like elevated heart rate and heightened anxiety.
If you can calm those sensations from the past with physical activity now and focus on the current physical activity instead, this can help you overcome them. Therapy for traumatic stress often involves this kind of refocusing -- as well as trying to translate the memories from being disconnected physical and emotional snapshots into a coherent story, like normal memory.
"If you find yourself coming across images that are upsetting or intrusive, take time to sit down and write out what you feel and then go do something soothing." says Smyth. Both writing and talking with others can help people make sense of the traumatic experience and integrate it into normal memory. If you have intrusive memories, trying to put them out of your mind without giving them this kind of context tends only to produce more flashbacks and increased symptoms.
It's kind of like those thought experiments where people are told not to think of a certain subject, for example, white cats, say experts. Trying not to do so almost always fills your head with thoughts of pale felines; similarly, trying to suppress memories of an event that has upset you often calls up more of them until you can make sense of it and it no longer stands out so much.
Both Smyth and Naturale emphasize doing something that is meaningful to you personally to mark the anniversary, whether it be as short as observing a moment of silence, or whether you want to attend a memorial or plan a get-together with people close to you.
Finally, if you feel you need help, don't be afraid to seek it. Smyth says that the time to seek help is when talking to friends or taking other self-support measures aren't working and you continually feel low or have flashbacks. Project Liberty's hotline offers access to free, licensed mental health care services through 1-800-LIFENET, and the hotline can be accessed 24/7.
Tanya Keys never noticed the four smiling babies dressed in furry angel wings. Yet these spokesbabies are part of a multi-million dollar advertising campaign out to enroll city kids into Child Health Plus, the state insurance program that offers coverage to all children under 18. The free or low cost program came as a total surprise to Keys, a mother of six. She did not learn about it until she went to the Riverside Child Health Clinic last year with her children.
"I didn't know about Child Health Plus or that we could even get health insurance," said Keys, revisiting the West 100th Street clinic for check-ups for Davon, 10, and Shanice, 7.
The word is not getting out about Child Health Plus. Although there are 735,000 New York City children currently enrolled in the insurance plan, an additional 370,000 kids remain uninsured. Many parents are equating the program with welfare and do not believe their children are entitled to coverage. Others, particularly immigrants and working parents, are afraid or ashamed of public programs.
The number of American children without health insurance has increased steadily in the last decade, totaling about 11 million in 1999, the latest date when statistics are available. In an effort to reduce these numbers, Congress passed the State Children's Health Insurance Program in 1997. Billions of dollars were made available to states for the sole purpose of insuring children.
With an annual budget of over $250 million, New York State launched Child Health Plus. Child Health Plus is actually a dual program that joins Children's Medicaid (now called Child Health Plus A) with the new Plan B, primarily for children from better off families; a family of four is eligible if it earns up to about $41,000 a year.
Child Health Plus has a lot going for it. Both plans offer emergency, preventive and routine physical and dental care, and prescription drugs, at no charge, or premiums of no more than $15 a month per child. Families with incomes above the cutoff can also buy into the program at slightly higher rates. And with life around the poverty line routinely accompanied by depression, substance abuse, and eating disorders, mental health is an important part of the program. Child Health Plus A, however, offers additional Medicaid benefits, while Child Health Plus B operates more like a private insurance program through a range of sponsoring insurance providers.
Against this backdrop of differences stands the program's single biggest barrier: lack of information. "A lot of parents know about Medicaid and that it pays for everything," said Ruth Santana, a social worker with the Morris Heights Health Center in the Bronx. "But very few working families that don't have insurance know that Child Health Plus is a good option for them."
According to a recent report, "Addressing the Barriers to Covering Kids", funded by the Robert Wood Johnson Foundation, the nation's largest health care foundation, many parents are like Tanya Keys and are unaware of Child Health Plus. "Because they work, earn a living, probably pay taxes, and equate government programs with welfare only, they tune out messages promoting State Child Health Insurance Programs," the report found.
A number of community roundtables sponsored by the New York Academy of Medicine found that children eligible for Child Health Plus aren't signing up because families aren't getting adequate information from sources they rely on. "The information is not out there, it's not in the places parents need to be," said one participant. Moreover, trusted messengers such as clinicians, schools and community groups are often just as confused as parents about the program and eligibility of children from working families.
According to the New York Academy of Medicine, this ignorance is creating a host of false impressions and unfounded fears. Medicaid still carries the stigma of dependency and charity, despite the de- linking of welfare from Medicaid in the 1996 federal welfare laws. And all too many parents think Child Health Plus is Medicaid. "My suspicion is they lump the two together and question its value," said Santana.
But behind the surplus of confusion and inconvenience, lies a sharp reality: most uninsured children come from families in which the parents are themselves uninsured. In New York City, more than 70 percent of the uninsured have an employed adult in the family but still have no coverage. "The fact that parents are delaying care for their uninsured kids because of financial worries is tragic," said Dr. Risa Lavizzo-Mourey of the Robert Wood Johnson Foundation. This fall Child Health Plus is scheduled to expand into Family Health Plus, and allow some parents to enroll with their children.
The city has started to address some of these barriers. Mayor Rudy Giuliani announced a back-to-school enrollment drive with the popular children's clothing stores Modells, Cookies and Sears. So far, 1,000 children have signed up for Child Health Plus through this partnership. Under a plan unveiled this spring by the mayor, schools that successfully enroll uninsured students will receive bonuses ranging from $25,000 to $50,000. Dr. Diane Stump from the Riverside Health Clinic said she has seen information about Child Health Plus on the new school enrollment forms. These initiatives are part of the larger HealthStat program, which targets uninsured New Yorkers who are eligible for Child Health Plus, Medicaid or Family Health Plus. HealthStat initiatives have enrolled more than 151,000 adults and children since it began in 2000.
But signing kids up for insurance does not necessarily guarantee they'll use it. There are a number of other obstacles, such as lengthy Medicaid interviews, Child Health Plus re-enrollment procedures, immigrant fears about deportation, limitations on providers and inconvenient office hours. Medical treatment for many children is limited to the school nurse or emergency room. In a study reported by the American Academy of Pediatrics, researchers found that, "Simply extending health insurance coverage to low-income children is not enough to ensure access to care."
"It's time we encourage eligible New Yorkers to take advantage of existing coverage programs," said Mark Green, the public advocate, in a August speech. "My proposal rests not on making a new bureaucracy, but instead on making the most of existing programs." Like Green, the other candidates have suggested building greater awareness through aggressive advertising, simplified enrollment and more extensive outreach with churches, and community groups in low-income neighborhoods. "It's the city's responsibility to guarantee access, remove barriers, and make the process family- friendly," said Judy Farrell, a policy analyst for Bronx Borough President Fernando Ferrer.
Peter Vallone, the City Council speaker, has proposed that the city pick up all premiums on Child Health Plus B, which would cost the city an additional $147 million. "It's a way to get to those for whom the premium would be a factor," said Vallone spokesman Mattis Goldman. Green, Ferrer and Alan G. Hevesi, the city comptroller, have been critical of this plan. "Why should the city pay if state and federal already pay for those who need it," said Farrell. Moreover, Ruth Santana, the Bronx social worker, said that many parents want to pay premiums. "Parents want insurance for their children," said Santana. "But they also want to maintain dignity."