The Urban Health Challenge
by David McGoy
Aug 09, 2004
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Yellow fever presented such a scourge to New York in the early 1800s that as many as one third of all New Yorkers fled the city to escape the deadly outbreaks. At its peak in 1805, a full five percent of those who stayed behind lost their lives to the disease. Victims of this and the other epidemics of the day sought help in the nation's first public hospital -- an estate on the lower East Side called Bellevue -- which itself was plagued with filth and death.
While such lurid events may seem to be a thing of a more ignorant, barbarous past, the truth is, New York continues to face public health crises. Many New Yorkers cannot afford health insurance or adequate health care. Unhealthy conditions afflict many neighborhoods. The threat of epidemic still looms as well, although the specific diseases are different. In the last 30 years, more than 35 new infectious diseases have emerged, and the death rate from infectious diseases in the United States has doubled since 1980.
In a recent essay in Harper's magazine, physician Ronald J. Glasser warned that the scourges of the past did not just go away -- they were defeated by concerted effort -- and it will take a world-wide effort to prevent what he sees as the nearly-inevitable pandemics of the future. "The real weapons of mass destruction," he wrote, "are infectious diseases, such as SARS and influenza."
Mayor Michael Bloomberg has sought to take on those public health challenges he thinks can be addressed within the five boroughs, launching several massive health initiatives:
- A war against smoking
- A campaign to stop so-called preventable deaths, focusing on ten top recommendations for every New Yorker (have a regular doctor; get checked for cancer; get help for depression, etc.)and a half dozen general public health goals (such as increasing by 150,000 the number of New Yorkers 65 and older who get an annual flu shot).
- A survey of the current state of New Yorkers' health and nutrition
- Increased funding to upgrade New York's massive public hospital system (See related story on the renovation of Harlem Hospital )
"Pretending health problems don't exist -- using band-aids where major surgery is more appropriate -- just isn't this administration's style," Bloomberg said in his 2004 state of the city address. "We know what and where the public health issues facing our residents are -- and we're doing something about them."
The mayor's interest is nothing new; he has given so much money to the public health school at his alma mater John Hopkins University in Baltimore (the first such school in the nation) that it is now named after him. But critics suggest that solutions to the health care crisis afflicting New York may simply be beyond the reach of any mayor. Diseases know no borders, and the costs associated with good health are astronomical, which is one reason health could emerge as a major issue in the presidential campaign. To the most alarmed and alarming of public health advocates, the choice that the public and public officials must make sooner or later may come down to a very stark one: debt or death.
CHALLENGES TO URBAN HEALTH
City officials have grappled with improving the general health of residents at least since the 19th century. By the mid 1800s, crowding, garbage and untreated sewage helped spark outbreaks of cholera, typhus and tuberculosis. Infant mortality rates soared, as more than half of those under the age of five died each year. At times, death was so prevalent that youngsters were heard hawking pine boxes on the streets: "Coffins! Coffins of all sizes."
Surgeon and public health pioneer Stephen Smith established the first permanent public health agency in the city, the Metropolitan Board of Health, in 1865. Thanks in part to its efforts, cholera took the lives of "only" 1,137 people in 1866 -- down from 5,071 people in 1849.
Early health department concerns included providing clean drinking water, improving sewage and sanitation systems, and fighting diseases such as typhoid fever and diphtheria. The health department deployed a brigade of "public health police" officers, who sought out sick and dying people and carted them off to isolation wards in hospitals. They also tracked neighbors and families of patients with contagious diseases. Beginning at the turn of the 20th century, the Board of Health turned its attention to infant mortality and became increasingly involved in virtually every aspect of city life, monitoring and regulating highway construction, tenement building, the overall environment.
The results have been tangible. According to a recent Department of Health report, New Yorkers now live an average of 77.6 years - longer than they ever have and longer than the average for Americans overall. At the same time, infant deaths in the city have reached an all-time low.
But huge disparities remain within the city. According to a recent report (in pdf format), people in New York's poorest neighborhoods live an average of eight years less than those in its richest areas. The rate of new AIDS cases among blacks is six times as high as among whites, while Hispanic New Yorkers are twice as likely to have diabetes as white New Yorkers. Other studies found that some immigrant neighborhoods in the city have rates of tuberculosis as much as 20 times higher than the national level (see related story. And despite falling crime rates, murder still claims the lives of many New Yorkers, particularly the young. (See related story.)
"While substantial progress has been made in reducing health disparities, unacceptable health inequities persist," said Health Commissioner Thomas Frieden.
Experts cite a number of explanations for these differences. Poor people, even those who have health insurance, may not have access to the high quality care that richer Americans receive. In an article in the New York Times magazine last year, writer Helen Epstein noted that poor people suffer greater stress, have less opportunities for exercise and live in neighborhoods where liquor, fast food and cigarettes tend to be far more abundant than inexpensive, healthy foods. Some say that the poor may be more likely to indulge in unhealthy behavior, such as intravenous drug use or unprotected sex.
Organizations, such as West Harlem Environmental Action have consistently argued that poorer black and Hispanic communities house polluting facilities, such as treatment plants and bus depots, that threaten the health of neighborhood residents.
The health woes of poorer communities spill out into the city as a whole, boosting health care costs for everyone and leading to the spread of diseases, such as tuberculosis.
Meanwhile, new risks continue to emerge. The last decades have seen new diseases, most notably AIDS. Since 1981, more than 15 percent of all AIDS cases in the United States have been in New York, and the disease has killed over 84,200 people here. As of June 2003, some 57,128 New Yorker were known to have AIDS.
West Nile, which had not been reported previously in the United States, was first diagnosed in this country when it arrived in New York in 1999. That year, it killed four New Yorkers.
Since September 11, 2001 - and the following anthrax scare -- bioterrorism and disaster preparedness have grown as pressing concerns. In mid-July, the Department of Health opened a newly renovated bioterrorism detection facility. After a $16 million upgrade, it can test for a full range of potential biological weapons of mass destruction, including anthrax.
BLOOMBERG'S HEALTH INITIATIVES
In a manner similar to the way he took on education (though generally with less publicity), Bloomberg has tried to focus on health issues.
War on Smoking
No part of the mayor's public health campaign has attracted as much attention or as much controversy as his war on smoking. Bloomberg has maintained that smoking is the number one cause of so-called preventable deaths from lung cancer, asthma and other respiratory ailments. Public health official attribute some 12,000 deaths in New York a year to smoking.
First, Bloomberg increased the tax on a pack of cigarettes from 8 cents to $1.50. Then he banned smoking in all indoor workplaces, including bars and restaurants. In response, the number of smokers in the city dipped by 100,000 between 2002 and 2003, according to a health department survey.
The decline in smoking, Frieden said, will prevent 30,000 premature deaths. And to refute complaints by bar and restaurant owners that the smoking ban would damage their business, the city said that bar and restaurant receipts increased by 8.7 percent in the first year after the smoking ban went into effect in March 2003.
But the war on smoking has its opponents. Some believe that, however unhealthy smoking may be, the mayor's crusade against it infringes on the rights of the individual. And smokers complain they are being unfairly targeted.
Others like Councilmember Tony Avella question whether the initiative is as successful as the administration claims. "I am very skeptical these days of figures that the administration puts out because I suspect they're geared toward supporting their agenda," he said in a Daily News article.
Take Care New York
But smoking is only one cause of preventable deaths. Bloomberg has taken aim at other causes, including undiagnosed health problems and AIDS, in what is considered the city's most comprehensive health policy ever, Take Care New York. The campaign focuses on 10 issues that can improve health:
- 1. Have a regular doctor or other health care provider
- 2. Be tobacco-free
- 3. Keep your heart healthy
- 4. Know your HIV status
- 5. Get help for depression
- 6. Live free of dependence on alcohol and drugs
- 7. Get checked for cancer
- 8. Get the immunizations you need
- 9. Make your home safe and healthy
- 10. Have a healthy baby such as having a primary doctor; being smoke, drug and alcohol free; getting immunized, and getting screened for deadly diseases such as cancer and HIV.
To accomplish its goals, the city sets targets such as increasing the number of women who have mammograms or the number of people over 50 who get checked for colon cancer. But the city has not provided a budget for its plans or precise information on how it hopes to accomplish its goals.
Some may wonder if there is a gap between rhetoric and reality. While the plan seeks to decrease by two thirds the number of children under six with potentially dangerous blood-lead levels, the mayor earlier this year vetoed a bill that proponents said would reduce lead poisoning.
And in an effort to better identify what ails New Yorkers, the city in June began conducting its Health and Nutrition Examination Survey. This effort, which began in June, hearkens back to the days of the door-to-door health police. The Department of Health targets 2,000 randomly selected New Yorkers and pays them $100 each to participate in an interview at home and a physical exam at a public health clinic. Through the survey, the city hopes to determine the prevalence of health problems such as diabetes, high blood pressure and depression among New Yorkers.
Increasing Support for Public Hospitals
The last decade has been a bit of a roller coaster ride for the New York Health and Hospitals Corp., the largest city public hospital system in the country. For much of his first term, Mayor Rudolph Giuliani sought to make some of the hospitals private and slashed funding. The budget cuts and uncertainty prompted the New York Times to report in 1996 that the hospitals that serve many of New York's poorest and sickest were falling apart.
The courts blocked the privatization effort, but the city hospital corporation continued to cut spending -- shortening patient stays, for example. When Bloomberg became mayor, he sought to modernize and revitalize the system.
This year's budget includes a $200 million subsidy for the Health and Hospitals Corp., which operates 11 acute care hospitals, five long-term care hospitals, six diagnostic and treatment centers, over 20 outpatient clinics, and a health maintenance organization.
"The $200 million subsidy is a wise investment that will allow HHC to continue making necessary management and technological changes that will improve the quality of medical services and save the city money in the long run," said Bloomberg at an April 27 press conference.
The mayor has also committed hundreds of millions of dollars toward capital improvements at the public hospitals. He has provided $225 million for Harlem Hospital Center, $250 million for Jacobi Medical Center, and $91 million for Coney Island Hospital. Even Bellevue Medical Center, marred by crime and low performance, is getting a $178 million facelift.
But critics still question the role of public hospitals. Edmund McMahon, a senior fellow at the conservative Manhattan Institute, has called the huge outlay for the public hospitals wasteful and accused Bloomberg of "falling in love with HHC."
THE HOSPITAL CRUNCH
Even supporters of the corporation question whether the influx of money will merely delay an inevitable crisis. The Independent Budget Office predicts a $600 million deficit for the Health and Hospitals Corp. as early as next year, due to rising costs and the expense of providing services to the uninsured.
"The basic problem is that expenses are growing faster than revenues," said Marleen Zurack, chief financial officer of the Health and Hospitals Corp. "The mayor has been very supportive, but this is a very challenging time for hospitals, public and private. The difference is that private hospitals can reduce or eliminate services that don't make money. Because it is our responsibility to provide services for the uninsured, we don't have that option."
The Health and Hospitals Corp. served 450,000 people without health insurance last year. The cost of servicing the uninsured next year is projected to be $900 million.
The United Hospital Fund recently released a study indicating that it would cost about $1.4 billion a year to enroll some half million New York adults who are eligible for the Medicaid program but not in it. The study urges that action be taken to do this. "Numerous studies have demonstrated that those without health insurance simply don't get the care they need," it says. "The uninsured postpone necessary care and receive less preventive care - and their health suffers.
THE MEDICAID MONSTER
But the insured present a challenge as well. There are currently 2.5 million New Yorkers enrolled in Medicaid, the joint federal-state insurance program to provide health care to low-income people. This will cost the city roughly $4 billion this year. And that number continues to rise.
"I wish that the same way [Bloomberg] committed himself to changing the school system, he would commit himself to Medicaid reform," said City Council Republican Leader James Oddo, a member of the health committee. "Until we tackle the Medicaid monster, we will never have a balanced budget, and we will have to keep making cuts to vital programs. But what will we do once we've cut everything that can possibly be cut and Medicaid costs continue to rise?"
The federal government and the states share Medicaid costs, but New York is one of the few states where local governments must chip in as well. City officials want the state to take on more of the burden.
In addition, Democrats in the State Senate have offered reforms, including a three-year cap on costs, that they say could save New York $27 billion over five years. But no action has been taken.
The federal government, having made sweeping changes to Medicare, the federal health-care program for the elderly, is now turning its attention to Medicaid.
"We're going to try to move toward a comprehensive Medicaid reform bill. I don't underestimate the difficulty of doing that," Representative Heather Wilson, chair of the Republican House Task Force on Medicaid Reform, told American Medical News.
With health care costs soaring -- creating problems for individuals, companies and government -- the issue could be key in this year's election, said Kenneth E. Thorpe, an Emory University professor of health policy. "Health care on the domestic side is likely to be the biggest area of policy difference between these two campaigns," he said.
Democratic presidential nominee John Kerry is pitching a plan that would provide health coverage for an additional 26 million people at an estimated cost of about $653 billion over ten years. He would pay for this by eliminating tax cuts for the wealthy. President George W. Bush's plan, on the other hand, is much less costly and ambitious, providing coverage for an estimated 2.4 million.
But, as the junior senator from New York can attest, truly reforming health care in America presents a difficult -- if not insuperable -- challenge. And so, despite the national crises of rising costs, tens of millions of uninsured Americans, frightening new illnesses and threats of bioterrorism, Bloomberg may have little choice but to rely on his own efforts to make New Yorkers healthier.
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