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."

Yobanna Genao was a 36-year old court reporter earning an impressive salary and raising three children on her own when, in 1997, she contracted a chronic illness that eventually made it impossible to work. She lost her job, her house, her car, her health insurance, and was forced to turn to public assistance. She began thinking of suicide.

This was not the first time in her life Genao had thought of killing herself. Suicidal thinking descended in her late teens, while attending college, after the death of a treasured aunt and the painful break-up of a relationship. Fortunately, a notice on a bulletin board at school about a counseling program caught her eye and she was able to get help. After a few weeks of therapy, the suicidal thoughts left, although it took months for the depression to entirely lift.

Her suicidal thoughts returned at the age of nineteen, when she was living at home with her mother who was herself depressed and threatening to kill herself if her daughter didn't stay with her. This time Genao did not seek help, but escaped the situation by getting married. Today she sees that decision as a symptom of the depression. "It was a bad choice," she said.

The marriage didn't work out. But Genao went back to school, got a better job, was given promotions, bought a house on Long Island for her and her children, and was graced with a positive attitude of just focusing on today, which helped her through the next fifteen years.

But the latest series of losses and financial strains have made for rough going. The depression returned, and so did the thoughts of suicide. "It's like when all the problems start coming at me at the same time I feel powerless, with no way out," she said, "and as I analyze the situation, it seems at times that everybody would be better off without me, especially my children... ."

A social worker referred Genao to a program for depression at the Payne Whitney Clinic. With the help of therapy, medication, and her therapist interceding on her behalf in matters relating to the physical illness (fibromyalgia), she has been able to counter the "naughty voice," as she calls it, that urges her to kill herself, with voices that offer reasons to live. For example, this voice says, her children need her.

Before entering the program at Payne Whitney, Genao says she "looked like a bag lady. My life was a mess." Her daughter had been out of school for five months. Now she is back in school and has won many awards. Her 17-year old son is getting ready to go away to college and Genao has the clarity to be able to help him. Untreated though, "I didn't have the energy to deal with any of that."

"If you can treat the depression, you can prevent suicide," said Sue Matorin, former Director of Social Work, and now Treatment Coordinator for the Affective Disorder Team at the Payne Whitney Clinic of New York Presbyterian Hospital. "I've never seen anybody suicidal who wasn't severely depressed," said Ms. Matorin. "But depression is an illness that can be treated. There is something you can do about it."

Common roadblocks to treatment, however, are the stigma attached to having a mental illness, and the lack of coverage for treatment. People are ashamed to talk about depression or suicidal behaviors, and when they seek professional help, they often find their insurance won't cover mental health treatment in the same way it would a medical ailment.

"If you hear someone has leukemia," said Ms. Matorin, "you make a fund-raiser. But if the family didn't have enough money to treat depression, people are too embarrassed to mention it." Yet mentioning it, talking about it, is a crucial element in getting help. "Suicidal thinking has to do with feelings of hopelessness. If you get people to talk, you create arenas of hope. Different things can be done."

In the last year in which figures are available (1999) from the Chief Medical Examiner, 494 people committed suicide in New York City, with the youngest age group listed as between 10 and 14, and continuing on up to ages 75 and above. These figures are down slightly from the previous year when 524 New Yorkers killed themselves. Men outnumbered women in every age group except 10 to 14, where the girls outnumbered the boys.

Suicide is the eighth leading cause of death in the United States (up from ninth in 1996) and the third leading cause of death for young people ages 15 to 24. More people die of suicide than homicide. In the last fifty years, suicide rates among adolescents have tripled.

To deal with this crisis, Dr. David Satcher, the Surgeon General, recently outlined a national strategy for suicide preventionthat includes:

• improving public awareness about who is at risk for suicide. The people who should know are health care, mental health and substance abuse workers, as well as educators, social workers, correction officers, clergy, divorce lawyers, family lawyers and criminal lawyers -- and the public at large
• implementing more suicide prevention programs in schools, colleges, jails, and the workplace
• reducing the stigma attached to suicidal thinking or depression that often discourages people from seeking help
• evaluating programs and increasing money, support and insurance coverage
• implementing these goals on a voluntary basis in each state by 2005.

"Suicide is a preventable problem," said Dr. Satcher at a news conference in May when he announced the plan. "We should make it clear that suicide prevention is everybody's business."

There are populations that have been found to be at special risk for suicide. These include teenagers, especially gay, lesbian, bisexual and transgender teens; the elderly, particularly elderly men; those who have experienced trauma (for example, veterans, and also victims of sexual assault or physical abuse); people with problems of depression, or mood disorders; those with drug or alcohol dependence; people in trouble with the law; those who have made previous suicide attempts; compulsive gamblers; and Native Americans.

One in ten college students considers suicide, according to recent data, and researchers at the Centers for Disease Control and Prevention find that college students have a 50 percent greater chance of suicidal behavior with alcohol or drug dependence. On the plus side, resources to help with depression are generally very good at colleges, if the students in need are steered towards them.

Suicide is the third leading cause of death in prisons, following natural causes and AIDS. The vast majority of these suicides occur among mentally ill prisoners, and over 50 percent within 24 hours of incarceration. Youth suicide in juvenile detention centers and correctional facilities is four times greater than the general population. Promising suicide prevention initiatives have begun in jails and prisons, but continuing suicides among newly committed mentally ill inmates suggests that more needs to be done.

One successful suicide prevention program highlighted by the Surgeon General is the U.S. Air Force program. Alarmed by the finding that one in four deaths of Air Force personnel was the result of suicide, the Air Force set up the program in 1996. An analysis of the suicides showed that the service men and women were more likely to kill themselves following a break-up with a spouse or if they were in trouble with military court. So they started a program to make everyone more aware of suicide warning signs and made it easier to get help. For example, one rule was changed so that Air Force personnel with legal problems can seek psychological counseling without worrying that anything they say can be used against them. In just three years, the Air Force cut its suicide rate by two-thirds. Other branches of the military had no program and their rates remained the same.

A local suicide prevention program, the Suicide Hotline (212-673-3000) run by the Samaritans of New York receives over 100 calls a day, approximately 40,000 calls a year. Executive Director Alan Ross has been on the hotline for ten years now, starting as a volunteer himself. Although the number of daily calls has doubled in that time, the issues behind the calls, the feelings, he says, remain the same. "The issues are pretty universal," said Ross. "They haven't changed with time and they are the same whether you are in New York or Brazil or Sri Lanka: social isolation and feelings of hopelessness."

The main tool used by the all-volunteer staff is active listening, allowing the caller to bring feelings about suicide out into the open, without judgment, which can be a great relief. The Samaritans do not counsel. "It's pure support," said Ross. Occasionally they will make a referral.

Although they have a web page, the hotline does not have on-line access for help. "It's hard enough to run a 24-hour phone hotline" said Ross. But their web page does provide information on warning signs for suicide, and what to do if you or someone you know is feeling suicidal. They also run a program for survivors of suicide.

Ross was very upbeat about the Surgeon General's prevention strategy. "It is significant," said Ross. "It puts suicide on the national agenda. It acknowledges mental health as an issue, and depression as an illness."

The city also has a 24-hour hotline called Lifenet (800/543-3638 or 800 LIFENET) and Lifenet en Espanol (877/298-3373 or 877 AYUDESE) which offers referrals to resources for mental health emergencies, including suicide, and alcohol and substance abuse. And the American Association of Suicidology has a 24-hour National Hopeline (800/SUICIDE).

A suicide prevention program in the city with a different focus is CARES (Children's Attitudes, Responses and Emotions to Suicide), a clinical and research program for children who have had a death in the family from suicide, most often a parent or sibling, but sometimes a grandparent. Developed and run by Dr. Cynthia Pfeffer, author of The Suicidal Child (Guilford Press, New York), CARES helps children, from infancy through late adolescence, understand the illness aspect of suicide, and that they were not purposely abandoned.

"Children who have had a suicide in the family are very high risk for suicide themselves or for psychiatric disorders such as depression and substance abuse," said Dr. Pfeffer "So this is very much a preventative program."

Significantly, Dr. Pfeffer explained, children who survive a suicide are faced not only with the stress and the stigma, but may also be having thoughts of joining the family members who committed suicide.

CARES is part of the Childhood Bereavement Program at Weill Medical College of Cornell University with offices at the Payne Whitney Clinic on East 68th Street (and in Westchester). Dr. Pfeffer also runs a program for adult survivors, and continues her work with children who are themselves suicidal.

Most people who attempt suicide do something to let people know their intentions, but too often these warning signs are ignored by family, friends, coworkers, teachers, and doctors. Warning signs for suicidal thinking include:

• talking about committing suicide
• trouble eating or sleeping
• drastic changes in behavior
• withdrawal from friends and social activities
• loss of interest in hobbies, work, school, etc.
• giving away prized possessions
• previous suicide attempts
• taking unnecessary risks
• recent severe losses
• preoccupation with death and dying
• loss of interest in personal appearance
• increasing use of alcohol or drugs

If someone exhibits these warning signs, talk directly to them about it. Watch for statements like "nobody cares," or "everyone will be better off without me." Ask them if they are thinking of suicide, and if they say yes, ask if they have a plan. Get help from people or agencies specializing in crisis intervention and suicide prevention, such as a community mental health agency, private therapist, school counselor or psychologist, family physician or suicide prevention center.

And if you are feeling suicidal yourself? "Get help immediately," says Yobanna Genao. "Go to the nearest emergency room. Call somebody."

The Stanley Isaacs Neighborhood Center on East 93rd Street brings six lunches a week to homebound elderly residents from East 42nd Street to East 106th Street, with funding from the City's Department for the Aging (DFTA), Citymeals-on-Wheels and private fundraising. It is one of the oldest meals-on-wheels program in the city, started back in 1965 with delivery to eight homebound neighborhood residents. Today, meals are prepared at a catering service in Long Island City, and there are four vans delivering 375 meals Monday to Thursday, and two meals on Friday; the second Friday meal provides a cold Saturday lunch. While their current city contract funds 352 meals a day, the number of homebound elderly requesting meals recently climbed to 375. The Isaacs Center uses private fundraising to provide those additional meals, insuring that no elderly person in their geographic area who is unable to get out or prepare meals will go hungry.

"The homebound population is an absent population," said Beverly Jackson, Director of Senior Services at Isaacs Center." No one knows they are there."

Who are these invisible people? By eligibility requirements, they are over 60 and have a physical or mental disability which prevents them from leaving home or preparing meals. Most are in their late 70s and 80s. Over half are at least 80 years old and ten percent are over 90. Over fifty percent live below the poverty line with an annual income less than $8,240. The majority are women.

It is often the case that Isaacs Center staff members delivering the meals are the only contact a homebound person has with the outside world. In one recent incident, a client didn't respond when driver Joe Colazzo knocked on her door. He kept knocking until he heard a faint voice calling for help. The woman had fallen down and was unable to get up. Joe immediately called for assistance and the client was rushed to the hospital. She is now back home, doing well.

"Food alone won't meet all of people's needs," explained Beverly Jackson. "We want to cure some of the social isolation that many homebound people feel."

In the last year, the Isaacs Center has successfully involved about a third of their homebound clients in conference call activities where they can hear lectures or concerts, be involved in support groups, play bingo or participate in an exercise classÑall over the phone.

Their next initiative is something truly innovative: bringing Web TV to the homebound elderly. With a planning grant from the Isaac H. Tuttle Fund, the Isaacs Center will be providing five of their homebound clients with a keyboard, a Web TV box, and training in use of this equipment. The grant will also cover additional phone expenses incurred. Through this internet access, homebound clients will soon be able to connect with the Isaacs Center, other seniors, and the rest of the world through chat rooms, the web, email, and down the line, with the addition of a Web Cam, virtual home visits.

Lynda Sounds Off: Delivery Time Limits

One of the requirements of the City's Department for the Aging funding is that all meals be delivered within two hours. While it is understandable that the city wants to insure that the food is delivered in a timely fashion to remain warm and fresh, and that the nutritional content does not dissipate, this time squeeze often prevents staff members who are making the deliveries from spending even a couple of minutes with each client. "They want to see the client, make sure they are okay," said Beverly Jackson. "And to do this, they'd like to have a little more interaction. So would the clients." But that's frequently not possible within these time constraints.

Someone is violently attacked or pushed in front of a subway train, prompting outrage and alarm about dangerous people on the streets - many of whom, it turns out, sought help for their illness but were turned away. Laws are swiftly passed (Kendra's Law) and funding pours in to fill a portion of the mental health program gaps (Major Mental Health Initiatives); this also makes news, usually with a photo of the Governor.

Smaller headlines emerge about the continuing incarceration of the mentally ill, where 15,000 to 20,000 people with mental illness are estimated to be in the criminal justice system. And there is the item about the mentally ill man, Gideon Busch, shot and killed by police last August. Commissioner Safir defended the officers, saying they acted in accordance with proper procedures. Or the item about the mentally disturbed Queens man, Alan Zelencic, shot and killed by police a few weeks ago. The officers didn't realize he was mentally ill, report say; if they had, they would have waited for the specially trained Emergency Services Unit. At the root of all these headlines is the old story of the deinstitutionalization of the mentally ill without community services to help them. There were 93,000 people in mental institutions in 1954; today there are under 6,000.

Absent from these headlines, though, are the people that go in and out of The Bridge, a day treatment program for the seriously mentally ill on West 108th Street, open 7-days a week, 365 days a year. About 250 people walk into The Bridge each day for activities that include daily living skills, therapeutic groups, creative arts and recreation.

According to Peter Beitchman, Deputy Director for The Bridge, deinstitutionalization was a disaster. "People were given a big bottle of pills and an appointment to go to an outpatient clinic. They were in the hospital for 10 to 30 years, with no independent living skills, and were expected to do well without support. They went into SROs or became homeless and went into shelters. It took the State many years to catch up. It still hasn't caught up."

What people at The Bridge found was most in need was not primarily the medical model of medicine and therapy (although that is certainly included), but the basics such as shelter, housing, income, food, clothing and safety.

"Once you take care of the basic needs," explained Beitchman, "by helping them get a beautiful place to live, a safe place, getting them social security or disability benefits or helping them get on welfare, having them participate in a psychiatric program, making sure they are stable through medication and closely monitored, once these basic needs are met, the next step is rehabilitation."

Rehabilitation doesn't mean a cure. "No one is cured of serious mental illness," says Beitchman. "But the effects and conditions that the mental illness creates can be effectively treated and dealt with." Rehabilitation means people gaining independence, perhaps moving to independent housing or reuniting with family and children. It can mean finding work.

The Bridge came up with the first such vocational training program in the City, again in response to their clients. "They asked us: what else do you have for us," said Beitchman. "We said, what would you like. They said, well, how about work?"

There is a danger that politicians will hear the word "rehabilitation" and think that means people can be taken out of the mental health system. "People with mental illness may not be able to go to full-time jobs or achieve total independence," Beitchman explained. "Some clients can work at a full-time computer job but still live in a 24-hour supervised residence. In that area of their lives, they are not able to function as well. We work with a client to achieve as much independence as possible."

Lynda Sounds Off:

In response to the outrage over violent attacks and the previous budget cuts, Governor Pataki recently allocated $125 million to community mental health programs. One of the flaws of this initiative package, according to Peter Beitchman, is that the majority of money earmarked for residential programs is for unsupervised living. "Yes, it is supportive housing for the mentally ill," says Beitchman. "But the housing is the cheapest and the lion's share of it is virtually unsupervised." Supervised residential housing, such as The Bridge provides in nine locations, has 24-hour staffing and is geared for people just out of the hospital and in need of assistance with living skills, learning to take their medication, and learning to become independent. "These are more expensive," acknowledges Beitchman, "but there are not enough of them. And there are none being developed."

UPDATE (1/27/2000) - Kensico: "No Brainer"
The Environmental Protection Committee of the City Council passed a resolution on 26 Jan 2000 officially voicing their objection to the proposed expansion of Route 120 aside the Kensico Reservoir. Council member and Committee Chair Stanley Michels dubbed the issue a "no-brainer." Any construction, he concluded, would be a "clear and present danger" to the integrity of the reservoir which supplies 9 million New Yorkers with drinking water each day. Council member CarriĂ–n Jr. pronounced the project "ill-conceived" and "stupid." The resolution calls on Governor Pataki to direct the DOT to abandon the expansion, adopting the 'no-build' scenario in the DOT proposal. The resolution further suggests advancing only those improvements necessary to ensure traffic safety. Chairman Michels, a co-sponsor of the resolution, questioned Governor PatakiĂŞs action, given his generally green leanings and his active role in watershed protection. Response from the Governor yet to be heard...

THE LOWDOWN:

The 1997 Watershed Memorandum of Agreement formalized cooperation between NYC, NYS and US EPA to protect the state's watersheds and drinking water. The Agreement secured $11.5 million from the City and $7.5 million from the State to purchase land in the Croton Watershed (and another $250 million in the Catskill/Delaware watershed, west of the Hudson) As recently as December 22nd, the City purchased a 16 acre tract near the Kensico Reservoir, which will serve as an additional buffer to protect the water supply.

These protective measures could face a serious setback if the NYS Department of Transportation (DOT) has its way. The DOT has proposed widening Route 120, a commuter road with increasing traffic that runs alongside the Kensico Reservoir. Policymakers and environmentalists are concerned with the possible adverse effects on the Reservoir as a result of increased runoff and sedimentation, and loss of wetlands. Serious degradation of the waterĂ…s quality would require a filtration plant, estimated to cost $6 billion dollars to construct, and $150 million annually for operations. Though DOT has expressed willingness to accommodate concerned parties, they have yet to revamp their plan.

THE LAY OF THE LAND:

NYC Water Supply - Valuable background information on the size and breadth of our watershed and water supply system.

Regional Watershed Maps - Click on the boxes for a closer view. Also worth a glance is the DEP's history of the NYC water supply.

WATERSHED PROTECTION:

Unified Watershed Assessment - The Department of Environmental Conservation's assessment of NYS watersheds, a prerequisite for receiving federal monies. The introduction provides a helpful overview of the quality of NYS waters.

Watershed Memorandum of Agreement - Signed in January 1997, this agreement between City, State, the EPA and environmentalists formalizes voluntary partnerships and local protection. Diehards should also look at the final rules and regs for the agreement.

"NYC Signs Purchase Contracts for Lands Near Kensico and New Croton Reservoirs" - Details DEC's acquisition of lands near the Kensico Reservoir as part of the Watershed Land Acquisition Program. Originally slated for development, this environmentally sensitive land will now be preserved as a reservoir buffer.

KENSICO RESERVOIR:

Statement on the Kensico - Dan Klotz, Communications Director at the NY League of Conservation Voters, explains why further development of the 9.9 square miles of the Kensico watershed is fraught with difficulties.

The Comptroller Weighs In - In a December 16 press conference, City Comptroller Alan Hevesi, in conjunction with environmental advocates, denounced the Route 120 plan and vowed to take steps to stop its construction.

Transportation Alternatives - Says that expanding Route 120 is not only bad environmental policy, but bad transportation policy.

Natural Resources Defense Council - In the introduction to a lengthier report, NRDC warns that the Kensico and West Branch reservoirs are especially vulnerable to urban sprawl, and only a comprehensive pollution prevention program can ensure their protection.

The Friends of the Croton Watershed - A coalition of community and environmental groups who oppose the proposed expansion.