Ten years ago Jeremiah Taylor walked into a New York City hospital thinking he was going to undergo routine surgery on his lower back. Things did not go as planned.

Hospital staff didn't monitor his blood pressure while he was under anesthesia, and as a result it dipped to dangerously low levels -- so low that his optic nerves died. When he was wheeled out the back door of the hospital and given a month’s prescription for sleeping pills, he was totally blind. His life irreversibly changed. Gone was his privacy; now he would require help to do the things that used to seem so simple.

"I have to ask people I don't know for help getting to the bathroom," he said. "Can anyone really tell me my pain and suffering is worth only $250,000?" asked Taylor.

Taylor finished the legal wrangling over his own incident years ago, but now he has come to Albany to lobby against the recommendation that that non-economic damages in malpractice suits be capped at $250,000.

The caps represent one small part of the package assembled by Gov. Andrew Cuomo's Medicaid design team. The team's recommendations would trim $2.3 billion from Medicaid for the upcoming fiscal year. All these proposals made their way to Cuomo's budget, as well as the Senate's, and are now being debated in the capital. The caps, though, have met staunch opposition from the Assembly, and many expect them to emerge as a deal breaker in this year's budget negotiations.

Tip of the Cap

Hospital organizations like the Medical Society of New York, the Greater Hospital Association of New York and the Healthcare Association of New York State support the cap. These groups say the cost of malpractice insurance is skyrocketing, thanks to multi-million dollar malpractice awards, and make doctors leery of taking on high-risk patients. Further, the increases, they say, will force doctors to leave the state or even their profession. Hospital associations estimate that the caps will save them $700 million a year. They charge that trial lawyers oppose the cap because it would limit what they could earn from a malpractice suit.

Vehemently opposed to the measure in New York are lawyers groups such as the State Bar Association, as well as advocacy groups such as the AARP, Citizen Action and the New York Public Interest Group. They say the cap was proposed largely as a way to get hospital groups to support the rest of Cuomo's Medicaid plan.

"When doctors and hospitals were presented with the question, 'What do you want to sign onto this Medicaid program?’ their holy grail is to be unique from all other members of society -- to be immunized from their mistakes and consequences. When the genie pops out of the bottle and says, 'You get one wish -- not three,' this is exactly what they wished for," said Assemblymember Rory Lancman.

Assemblymember Deborah Glick said the proposal will limit the tools the public has to punish physicians for their negligence. "The way we punish people, the way we correct incorrect behavior in our society is by either sending someone to jail or by financial punishment,"said Glick. "If you take away the financial punishment, the system has no reason to correct itself. Doctors have no reason to be more careful,"she said.

Advocates on both side point to California, which has had a similar cap on non-economic damages in malpractice cases since 1975. The same figure was used: $250,000. Critics point out that by now the number should have been adjusted for inflation and would stand somewhere around $900,000. The number has not been adjusted for inflation in California, and the New York proposal also does not take it into account.

Proponents of the measure say that California's malpractice insurance rates have only risen by half the national average since the law took effect. Yet the number of malpractice cases per doctor in California has remained the same, and in almost half of malpractice cases judges have had to reduce non-economic awards suggested by juries that have wanted to to give plaintiffs greater awards.

Making Hospitals Safer

Lancman says the stakeholders negotiating the Medicaid agreement did not seriously consider other routes of reducing malpractice costs. This, he said, would include working to reduce incidences of malpractice so that there are fewer lawsuits.

Lancman has sponsored a bill called the Medical Malpractice Savings Act to require that the health commissioner establish a set of rules for every hospital to ensure that each one has a comprehensive obstetrics program to reduce malpractice. The Lancman bill was inspired by a "recent report by an obstetrics team at New York Presbyterian Hospital that detailed how it reduced the department’s malpractice payouts by 99 percent.

Bill Ferris of the AARP agrees and blames the omission on the lack of "consumer representation" on the Medicaid redesign team. “There should have been more discussion on how to reduce medical mistakes, not on capping the damages," he said.

Ferris' organization is lobbying against the caps because, according to Ferris, seniors rely on non-economic rewards-- damages for pain and suffering-- to get compensation in malpractice suits. "Seniors are generally unemployed and rely on Medicaid and social security. This would limit rewards for pain and suffering, and economic rewards are generally based on future salary -- seniors don't have that. This does away with how they can be compensated for a medical mistake.

Making a Point

Glick has introduced legislation that would limit hospital administrators' pay to $250,000 a year. Glick said she is trying to make people understand that if $250,000 is enough to cover a life of pain and suffering caused by a hospital error than it should be more than enough for a hospital CEO to make in a year.

"I did this to raise the point that there is another side of the balance sheet -- one that is quite costly," said Glick. "I don't think it will pass, necessarily. ... There are a lot of people who have supported the bill, but hospital administrators are not so happy. I've stepped on some toes there."

Glick said she thinks Cuomo is picking and choosing which “special interests” to back and uses different standards.

"Gov. Cuomo says he doesn’t believe that school districts can't weather these cuts. He doesn't believe that there isn’t waste and corruption in these school districts. Well I don’t believe insurance companies will reduce their rates if this cap goes through. I think they will just take the money and run and find another excuse for why premiums are so high," she said.

With the three major legislative leaders currently in heated negotiations, it is unclear whether the caps will make it through as part of the budget. Cuomo has made it clear that he isn't keen on giving up anything in his budget and has told lawmakers that if a deal is not reached he will push through his budget in extenders.

If a deal is a reached, the caps could be a critical part of making it happen. Majority Leader Dean Skelos has told reporters that he could not support a budget deal that included with a millionaires tax or rent regulations; both of those things are near and dear to Assembly Speaker Sheldon Silver's heart. Silver is a lawyer and tends to be friendly toward trial lawyers. However unions that represent hospital workers also are close to Silver, and the hospital associations warn that if the caps don;t go through they could be forced into layoffs. It may be possible that the caps will be done away with as a concession to the powerful Silver.

At this point it is unclear. But things are much simpler to Taylor, who plans to come to lobby on the issue until there is no more hope. He says he wants others to have the right to sue for an amount that compensates them for having their lives altered by negligence.

"Right now, if I hit you with my car you can sue me, but I can't sue a doctor for more than $250,000? I will fight for other people’s rights to compensation. Why not look at reducing malpractice? Why aren’t doctors subject to tests? I think they sat in a back room and made this deal to take away people’s rights to compensation. It is just un-American."

Photo (cc) Courtney Gross

In an emotionally charged moment, the City Council approved legislation Wednesday to force pro-life crisis pregnancy clinics that do not perform abortions to disclose what services they do and do not provide.

Supporters of the legislation allege these facilities deliberately deceive pregnant women who visit clinics to get medical services. These clinics do not disclose in advertising that they refuse to perform abortions, and staff members wear scrubs even though they have no medical training, the bill's backers say.

"Be proud of what you are and what you do," said Council Speaker Christine Quinn at a rally celebrating the legislation's approval. "I don't understand why anyone would oppose this legislation."

But many do. Opponents of the measure claim forcing clinics to immediately list the services they provide violates their First Amendment rights. Opponents promised to sue the city after the mayor signs the bill, which he is expected to do.

"No city or government agency has ever fined us, sued us or cited us for any violations of law," said Christopher Slattery, the founder and president of EMC Frontline Pregnancy Centers, which has 12 locations in the five boroughs. "The city transit system has accepted our advertising for years. If it is deceptive, why is it accepted?"

The council approved the bill by a vote of 39 to 9 with one abstention.

Right to Disclose?

Both sides dueled in opposing rallies and protests Wednesday. Supporters of the bill, which include Planned Parenthood and NARAL Pro-Choice New York, carried signs reading, "I love pro choice New York." Opponents of the bill, who led a sing along outside of the council's meeting, thrust up posters emblazoned with, "#1 Enemies of the First Amendment." Below the sign had photos of the bill's sponsors.

First introduced in 2010, the bill has attracted an unusual amount of attention despite its small impact. According to council officials, the legislation would only impact about a dozen clinics.

It also comes at a time when Planned Parenthood has come under fire in Washington and could lose hundreds of millions of dollars in federal funding.

Council officials say they are attempting to target clinics that do not provide any medical services, and are not attacking pro-life counseling centers.

Under the legislation, these clinics would have to post a sign disclosing whether they have a licensed medical professional on staff and whether they provide or refer to prenatal care, abortions and emergency contraceptive.

Photo (cc) Courtney Gross

This information would also have to be included in advertising.

Opponents are confident they will never have to post those signs. The courts struck down similar legislation in Baltimore earlier this year, determining it was against the First Amendment. Council officials say their proposal would hold up in court, because it targets a very narrow group of crisis pregnancy clinics.

At the Emigrant Savings Bank Wednesday, the council's temporary home, council members traded barbs and tears -- an exchange that pit the First Amendment against a woman's right to choose.

"Contrary to the speaker's comment this bill is in fact more restrictive than the speech requirements in [the Baltimore bill], and I say that as someone who practiced constitutional law and who is actually admitted to the Supreme Court," said Councilmember Dan Halloran, a Republican of Queens. "This is an unconstitutional infringement. It will be struck down."

Councilmember Melissa Mark-Viverito fired back.

"Our country is continuously being faced with controversial issues, and it is important that we embrace measures that promote choice and democracy versus exclusion and degradation," said Mark-Viverito.

Some council members attempted to change the tone of the debate altogether -- pointing to the city's more than 40 percent abortion rate. They urged the council to focus on education as opposed to a debate on pro-life versus pro-choice.

Help for Liens

The City Council also approved legislation Wednesday, which would provide homeowners who are eligible for tax exemptions assistance with liens.

The measure strikes an appropriate balance between getting scofflaws to pay up and assisting homeowners who can't keep up with their bills, said the legislation's sponsor Al Vann. Under the proposal, homeowners will be given the option to pay off tax liens in installments for eight years with no down payment.

The bill could affect any homeowner in default for property taxes as well as sewer or water payments.

The bill also gives the council the authority to sell liens based on an emergency housing repair program, which targets deadbeat landlords.

Photo by Karen Blumberg

With the Federal Patient Protection and Affordable Care Act -- the full name for "Obamacare" -- set to require that all Americans have health insurance, more people will seek medical care more frequently, health experts predict. The healthcare system is already overburdened, so a key question in New York, as elsewhere, is how can the system take in and treat the people who currently do see medical providers because they don't have the resources?

The Manhattan Institute, a conservative think tank, believes it has the answer. And it could be right in your local Duane-Reade.

The care would come from retail health clinics, for-profit health centers probably located in chain drug stores. These centers would treat people complaining of minor aches and pains, the type of things uninsured people or people who do not have access to primary care now bring to a hospital emergency room. The clinics also would refer patients to specialists if their problems turned out to be serious. The clinics build on some of the services drug stores already provide, such as flu shots and blood pressure testing, and their number has been growing in states such as California, Texas and Georgia.

Storefront Solution?

Manhattan Institute scholar Paul Howard, who once bashed the Obama administration's healthcare overhaul on the pages of conservative websites, has now accepted its existence. The author of the Manhattan Institute report on the clinics, Howard thinks expanding them would help provide care for the 1.2 million New York state residents who will get health insurance under the federal legislation.

"They can offer a terrific access point for busy people," Howard said in an interview. "They often partner to make referrals to a primary care.

The Manhattan Institute study said that when Massachusetts instituted its healthcare law, which is similar in some respects to the federal measure, "expanded coverage led to longer waiting times for physician appointments and a 10 percent increase in emergency room use." Noting that "New York could experience similar problems," the report says an "expansion of retail-clinic utilization in New York could reduce healthcare costs by $350 million between 2011 and 2020 by reducing the number of unnecessary emergency room visits."

Manhattan Institute is not alone in singing the praises of these types of retail clinics. A study commissioned by the Rand Corp. in 2009 showed "no difference in the quality offered to patients visiting retail clinics, physician offices and urgent care centers."

The study's lead doctor, Ateev Mehrotra, a professor at the University of Pittsburgh School of Medicine, told MSNBC at the time: "These findings provide more evidence that retail clinics are an innovative new way of delivering health care. … Retail clinics are more convenient for patients, less costly and provide care that is of equal quality as received in other medical settings."

Changing the Rules

The push to bring these retailers into the state -- there are about 15 so far, according to Howard -- could spark some dissent from health groups. It would require removing the state's legal barrier that prevents for-profit corporations from getting medical licenses. The Manhattan Institute report also calls for getting rid of what it describes as "a costly certificate intended to prove that the health-care provider service will fill a need." This approval, it says, can "take time and often deters new clinics from opening in retail stores in New York."

The report notes that current state law "prohibits retail clinic operators from employing even nurse practitioners and other mid-level practitioners upon whom the cost-savings of the model depends." Currently, these practitioners, nurses who can diagnose ailments and prescribe treatments, need to be under a doctor's supervision. If the state ditches this requirement, retail health clinics could hire nurse practitioners to oversee operations. The institute advocates such a change.

Concerns About Care

But some groups have questions. The New York State Nurses Association, for example, supports the retail centers in theory, but opposes the current state legislation meant to bring more of them into the state.

"There isn't enough information known about how this would operate," said Deborah Elliott, the association's deputy executive director. "It would have to be clearly indicated who would be managing the primary care on these sites."

"It is not a substitute for primary care; it is an adjunct to primary care," Elliot said. "In the long run there could be some very valuable benefits from this."

Judy Wessler, the executive director of the Commission on the Public's Health System, was less than enthused about what Howard is proposing.

"It's as bad going to the emergency room," she said of the clinics. "There's no continuity of care. The person taking care of you doesn't know who you are. It's a very inadequate way of providing care, but it's cheaper than an emergency room."

Politics might be bad for your health. As the state confronts huge budget deficits, Gov.-elect Andrew Cuomo will almost certainly face enormous pressure to slash spending on health care, particularly the Medicaid program for low-income people.

So it may come as a surprise that one expert and key player in state health care policy, Richard Gottfried, who chairs the State Assembly's Health Committee, wants to spend additional money to beef up the state's brain trust.

Gottfried has other goals as well. They include, in his words, "promoting alternatives to nursing home beds and strengthening home care and strengthening primary care to help avoid unnecessary hospitalization," as well as "better integration of health care so that the health-care system can profit by people keeping healthy instead of profiting by increasing volume of procedures." He believes that the federal health-care reform bill, if it survives Republican attempts to repeal it next year, will help the state implement some of these programs.

 

"You get no political support for putting money into central administration. That's about as exciting as a Crisco sandwich, but it is absolutely necessary if we're going to make any kind of progress," Gottfried said. "Has anyone ever marched on Albany saying, 'We need more bureaucrats'? They don't arrive in an ambulance when you're having a heart attack; they're at a desk in Albany, hopefully trying to remake the system."

Hands Off Medicaid

Medicaid -- not bureaucrats -- will almost certainly get the attention when the new governor and legislature take office in January. Medicaid expenditures in the state exceed $50 billion per year, making it tempting target for cuts.

In fact, Cuomo, as the state attorney general, won high-marks for investigating Medicaid abuse; last year the U.S. Health and Human Services Department named his Medicaid fraud unit the best in the country. Although McKnight's Long Term Care News reported that Cuomo has vowed a "fundamental restructuring of Medicaid," details of how he plans handle costs when he takes office remain a mystery. Whatever cuts or reforms he might pursue will likely spark opposition in the Assembly and from unions.

Outgoing Lt. Gov. Richard Ravitch suggested, for example, limiting eligibility, such as denying Medicaid to childless adults. And Albany Republicans earlier this year called for a variety of measures that they say will rein in costs. According to a statement from State Sen. Betty Little's office, a March report recommended, "requiring recipients to choose a primary doctor and a primary pharmacist, similar to managed care plans; allowing elected comptrollers, treasurers or other appointed officials to audit Medicaid claims; and preventing individuals from being forced to go to other counties or states for long-term care."

Gottfried warned that such moves would hamper the overall health-care apparatus in the state.

"You are not just cutting the care for people who are on Medicaid," Gottfried said. "If a nursing home or a hospital has to lay off staff because of Medicaid cuts that affects everyone at the institution, rich and poor alike."

Gottfried supports funding Medicaid through higher taxes on the wealthiest 1 and 2 percent of the state’s population.

Shaun Flynn, the director for governmental affairs at the New York State Nurses Association, agreed that Medicaid cuts hurt across the board.

"You don't see cuts in CEO salaries," he said. "It comes out of direct-care staff, which has a huge impact on how patients receive care in these facilities."

To counter that, the nurses association advocates a mandate on all hospitals to maintain a set patient-to-nurse ratio, similar to the one in California.

"It's something that's been pending in our legislature for some time," Flynn said. "We're hopeful that Cuomo will ask the tough questions that no one else has. What New York hospitals say is, 'We can't do it,' but they can't explain why California can."

To help fund this, the nurses association, which is both a union and a professional organization, supports a tax on sugary beverages along with the Doctor's Council (a Service Employees International Union affiliate), on grounds that it would provide needed revenue for health care and reduce obesity. But some unions like United Food and Commercial Workers Local 1500, whose members work in grocery stores, argue that such a levy is a regressive tax, and the bottling industry managed to scuttle a similar proposal earlier this year.

Is Cuomo Listening?

The transition team that Cuomo has appointed to advise him on these issues consists largely of hospital management representatives. Other than nurses association President Karen Ballard, there are "no voices representing the physician community or community health centers," and "few voices from the health-care policy or academic world, or labor," Gottfried said.

Cuomo broke Democratic Party tradition in his campaign this year by heaping blame for the state’s budget mess on state-worker pensions and pay, resulting in few unions backing the nominee and a half-hearted -- and some say short-sighted -- endorsement from the Working Families Party.

So it wasn’t too much of a surprise when Cuomo failed to initially place a representative of 1199/SEIU, the state's strongest health-care union, on his transition team, although he later brought aboard its president, George Gresham, to smooth relations.

But Flynn believes the inclusion of the nurses association indicates that health-care advocates could get their point across. And that's good news to anyone concerned about the other big health issues in the state, whether it is an infant mortality rate one group has called "disgraceful" or the fact that three major hospitals in New York City have shutteredin the last few years.

"It shows a willingness to listen to people," Flynn said of the Cuomo transition team. "From NYSNA's perspective that's all we're really looking for. We believe the strength of our arguments are enough to win on their own."

The day before Thanksgiving, many New York foodies hustle to pick up heritage turkeys and heirloom vegetables at their local Greenmarket. Meanwhile, food rescue agencies like City Harvest try to persuade the shoppers to donate a bag of produce such as apples, onions or broccoli to food pantries and soup kitchens.

The food pantries trying to help the more than 1 million New Yorkers who cannot afford an adequate supply of food must look to a variety of sources for the food they provide, and much of it originates far from the city. But that could change. A number of programs already try to give poor New Yorkers access to locally grown produce, and several local officials have proposed sweeping efforts that could bring the locavore ethos to low-income homes.

Both Gov.-elect Andrew Cuomo and City Council Speaker Christine Quinn have recently presented plans to get more locally grown food into the city and then to institutions and poor neighborhoods. If implemented, the proposals would bolster grassroots programs that make local food available to people who often have little access to fresh, healthy food, let alone locally produced fruits and vegetables.

City Grown

Several well-established programs already provide poor New Yorkers with Empire apples and root vegetables. The Food Bank for New York City spends up to $500,000 annually on local produce for over 1,000 citywide emergency food programs. The Food Bank's Community Kitchen and Food Pantry of West Harlem runs a Community Supported Agriculture program, where produce comes directly from local farms to consumers, and offers members several plans to pay for it.

In addition, the U.S. Department of Agriculture's Farmers' Market Nutrition Program, established in 1988, gives people enrolled in the Nutrition Program for Women, Infants and Children or in Senior Nutrition Programs coupons that they can use to buy locally produced fruits, vegetables and herbs at participating farmers' markets. All recipients get $20 a year and those in the Women, Infants and Children program get an additional small monthly allotment.

This program encourages people to visit the markets and discover the benefits of eating fresh produce, according to Bob Lewis, who assists the state Department of Agriculture and Markets in farmers’ market development.

Lewis, who co-founded New York's Greenmarket program, said that the city has always worried whether people introduced to farmers' markets by the program could afford to continue to shop there once their coupons ran out. That led Greenmarket to install Electronic Benefits Transfer machines to allow shoppers to use food stamps at the markets.

The Next Steps

Cuomo and Quinn want to take government farm-to-fork initiatives further. In his farm agenda released last month, Cuomo outlined plans to build food-processing facilities and expand urban farmers’ markets. These measures would provide a boost to the state's farmers while providing healthier food to lower-income New Yorkers.

On Monday, Quinn announced the City Council’s own ambitious food policy agenda, called Food Works that addresses all aspects of New York’s food industry, from farming to composting. The plan looks at the way food reaches and then is distributed around the city for solutions to an array of problems.

"For far too long, we’ve ignored a growing crisis in our city and across the nation," Quinn said in her speech. "We’re a city of more than 20,000 restaurants, yet 1.4 million New Yorkers struggle to put food on the table. One out of every four children in New York City is overweight or obese. New York State farmers ... only make half as much per acre as farmers in other parts of the country. Meanwhile, the food system is responsible for nearly 80 percent. of our increased energy use in recent years. "

Both Cuomo and Quinn have stressed the need to update the Hunts Point Terminal Produce Market in the Bronx. The State Department of Agriculture and Markets supports rebuilding the market, constructed in the 1960s, to improve efficiency and food safety and reduce air pollution created by trucks. In particular, the City Council would like to see a large permanent wholesale market at Hunts Points to make it easier for businesses to purchase fruits and vegetables from local producers. The department estimates that rebuilding the market will cost between $300 million and $500 million.

"If we only get one thing in Food Works right, it has to be this,” Quinn said Monday. “How are we going to get healthy food to our neighborhoods if we can’t even get it into our city?” Quinn would like to see train service expanded throughout the state to allow more food to reach the market.

Quinn said that, with more local food in the city, New Yorkers, especially those living in poor neighborhoods, would be better able to buy more local produce. “If we want to have New Yorkers make better choices, we need to give them better options,” she said.

For people living in public housing and using food pantries, those options would include enrolling in a Community Supported Agriculture program. Cuomo said he would ensure that people could pay for their membership in installments and with government assistance benefits. In these programs people pay a set fee for a weekly or monthly basket of fresh seasonable produce direct from a local farm.

Cuomo and Quinn have urged schools, hospitals, nursing homes and corporations to buy more local produce and enroll in a Community Supported Agriculture program. In the past, state farmers have struggled to sell produce to the city’s SchoolFood program because it demands year-round, cheap and easy-to-handle food. Although the department has begin to purchase some locally produced fruits, vegetables and milk, the council report said, "This procurement has, thus far, occurred on an ad hoc basis." The council has said that Councilmember Gale Brewer will introduce a bill to require the city to develop new purchasing guidelines that would encourage it to buy from local farmers.

Whatever its shortcomings, though, Quinn used the Department of Education as an example of an institution that has increased its purchase of regional food without increasing procurement costs. "Why can’t every other city agency do the same thing?" she asked.

The speaker wants to keep food production in the city and have producers buy produce from local farmers. She acknowledged that a lot of low-income entrepreneurs who cannot afford to prepare their food in an approved commercial kitchen that complies with the city health department’s regulations. Quinn said the council had helped remedy that issue by building a shared kitchen in East Harlem within La Marqueta.

Finally, Quinn urged producers to minimize packaging and New Yorkers to compost. "We need to stop thinking of food scraps as garbage," she said. The council plans to expand the compost program at Union Square to other farmers markets so that more people will have a place to take their food scraps.

Grassroots Initiatives

While New York politicians drum up support for their initiatives, local leaders have already reshaped their community’s food systems, making seniors in particular not only the recipients, but also the sources of local food.

Through the Healthy Communities Through Healthy Food initiative, seniors work on urban farms, sell food at local farmers' markets and grow food at public housing sites. The program directors said that a large number of older people have been involved in urban agriculture and food for years. Many started gardens in their backyards during the Great Depression or after World War II.

United Community Centers sponsors the East New York Farms! project, which runs two farmers markets that serve East New York, a food desert with one of the city’s highest obesity rates. Project members design gardens with raised beds so that seniors can grow food without straining themselves. They also train seniors to increase the yield of their gardens and to sell more of what they grow at farmers' markets.

Isabella Geriatric Center in Upper Manhattan has organized a senior-run fresh food buyers' club called YUM Food Box that offers regional produce to residents of Inwood and Washington Heights. Only a quarter of food retailers in those neighborhoods sell fresh food, and almost half of residents receive public assistance. Every month the buyer's club distributes about 300 bags of produce, which cost members $20 per share or $10 for a half-share. The club differs from Community Supported Agriculture in that members don't pay upfront for a share, which typically costs several hundred dollars.

Myrtle Avenue in Fort Green and Clinton Hill separates brownstones from the projects and those likely to eat fresh food from those who are less likely to do so. The Myrtle Eats Fresh initiative, led by seniors, tries to level that class disparity by creating farmers' markets, small urban farms on public housing land and fresh-food advocates.

Photo (cc) Norm Walsh

Lee Gary is an intimidating man, towering over most -- if not all -- the people he meets. Sitting in the offices of CASES -- a nonprofit group in Lower Manhattan that assists the formerly incarcerated -- Gary, built like the largest of linebackers, spilled over his black rolling chair, obviously uncomfortable.

He fidgeted. He seemed nervous.

But this was not the most compromising situation he has ever been in.

According to his estimate, Gary has been arrested 30 times in the last eight years, spending a total of a year and a half on Rikers Island -- the 400-acre facility yards from LaGuardia Airport that houses many of the city's accused and convicted criminals. Gary, a 49-year-old Bronx resident who is diagnosed with bipolar disorder, spent half of his time in a mental observation unit there. The rest was clocked in at the prison ward of Bellevue Hospital Center.

"It's horrible," Gary said of Rikers, anxiously rubbing the sides of his legs with his large palms. "You get guys hoarding food. You get guys that want to fight."

"The officers are not there to help you," said Gary. "You'll just sit there to rot."

But Gary had company -- lots of it.

The percentage of Rikers inmates with mental illness has reached its highest level in eight years. While the number of people sent to Rikers Island every year continues to fall -- bucking a national trend-- those that remain, like Gary, keep coming -- often.

In what one expert refers to as a "population distillation," the number of people classified as mentally ill on the island has gone from 25 percent in 2004 to 32 percent today, according to the city Department of Correction. If the trend continues, Rikers Island could resemble the shuttered mental institutions of the 1970s instead of the correctional facility there now.

"Mentally ill inmates are less likely to be released. They are perhaps not as well equipped to manipulate the system. Their cases are more complex," said Martin Horn, the former commissioner of the Department of Correction. "All of those things, make them harder. They are the ones most likely to be there."

Advocates and experts acknowledge the city has taken steps to address the challenges this population presents. But following a decade-long court case over the quality of mental health care, they claim inmates with mental illness continue to fall through the cracks. They say more needs to be done to tackle the treatment, the recidivism rate and the overall number of mentally ill on Rikers -- long term.

These are Rikers' regulars and, for now, they don't appear to be going anywhere.

After Midnight

Circa 1999, it could be 2 a.m. Neon signs might penetrate the pitch-black sky in the middle of Queens Plaza -- a former hotbed of liquor stores, strip clubs and homelessness. Imagine the Rikers Island shuttle bus roaring up, opening its doors and inmates pouring out. Those with mental illness would be among them.

They would have subway fare, but many had nowhere to go.

More than a decade ago, the Urban Justice Center filed a lawsuit, commonly referred to as "Brad H," against the city claiming it failed to provide adequate discharge planning for inmates with mental illness. Advocates and experts contend proper planning for inmates outside of the jail's cement walls will successfully halt the revolving door of incarceration for Rikers' regulars.

Under a settlement reached in 2003, any inmate who stays on the island for more than 24 hours and sees a mental health staffer more than twice must receive a "discharge plan" -- a roadmap to services, housing and hopefully a normal life. When released, inmates must have medication for seven days, leave the island during daylight, be referred to a treatment provider and start the application process for supportive housing or reactivating Medicaid benefits. Inmates are also free to deny these services.

In 2003, the court appointed monitors -- who declined to be interviewed for this story -- to oversee the transition for the next five years.

Because of counter suits, that five-year period was extended until the summer of 2009. The center, which claims the city has not met its discharge planning goals, then asked the court to extend the monitoring for another two years.

In August, the city successfully convinced the courts on appeal that the monitoring period had expired and the Urban Justice Center had no grounds to extend it. The center has appealed to the state's highest court, which will soon decide whether to hear the case.

While the case is on appeal, the monitoring continues at Rikers.

“When people with mental illness are released from city jails today, the services they receive vary widely. Some get real discharge planning, and that’s an improvement from a decade ago -- but too many still do not,” said Jennifer J. Parish, the director of criminal justice advocacy at the Urban Justice Center’s Mental Health Project. “The city has not yet lived up to the commitment they made when they settled the case in 2003.”

Part of the so-called failures at Rikers is communication. There are four city agencies that have some hand in the delivery of health care -- from start to finish -- in addition to a for-profit, private corporation, PHS Correctional Healthcare.

Some say the correctional system itself is the problem -- a jail is not conducive to treatment and its confines aggravate the mentally ill.

Or maybe it's staffing. The department of health, in particular, critics say, has been plagued by high turnover rates. (The department did not provide Gotham Gazette with turnover figures for this story.)

All of this leaves advocates wondering whether inmates with severe mental illness are leaving the island without the proper preparation, reentering society just as unstable as when they left it and destined to return to Rikers.

Left Behind

Marcelene J., according to an affidavit filed with the state Supreme Court, could not get any treatment after leaving Rikers in October 2008. Marcelene, a 23-year-old homeless woman who is diagnosed with bipolar and schizoaffective disorder, was referred to Interfaith Medical Center in Brooklyn upon her release by a Department of Health and Mental Hygiene discharge planner.

When she got to the hospital, she was told she didn't have an appointment. No one knew who she was or that she was coming.

So she left, according to the court filing.

"I was not able to continue my medication because I did not have any place to get ongoing mental health treatment," Marcelene wrote. "I would like to receive psychiatric medication and therapy because I continue to have mood swings and the voices I hear never seem to go away."

Darryl C, according to the court filing, has been bouncing between hospitals, prison and Rikers almost his whole life. A heroin user diagnosed with depression and generalized anxiety disorder, he first received treatment at Rikers in 1990.

During his recent stint there in late January 2009, following an arrest for petit larceny and possession of stolen property, doctors on Rikers refused to treat Darryl, despite his previous medical history, according to the court filing.

He was removed from mental health status the next month.

"I do not want to use heroin again," Darryl wrote. "I want to get help for my mental illness."

According to the most recent monitoring report released in July, many "pivotal monitoring, programmatic and legal issues remain unresolved" in the delivery of discharge planning services. Inmates are misclassified, the report states. Computer files put them in a less severe category of mental illness, while the inmate's physical medical chart may say otherwise. Inmates were not referred to programs that address more serious mental health problems, the report states, and some are still leaving Rikers at night.

The monitors criticize inmates' refusal of treatment, questioning whether discharge planners make an honest effort to convince this difficult and untrusting population to get help.

In response, a spokesperson for the health department said it has been working to increase the accuracy of its electronic records. According to the department, a patient must be "motivated" to receive proper follow-up care. The agency said it is training staff to help engage inmates to get the assistance they need.

Of the 33 areas the monitors evaluate, the city was found "noncompliant" in 10, according to the latest report, which examines a sample of inmates' records. Of those, the city made the appropriate appointment referral only 57 percent of the time. Just 22 percent of the eligible cases received the appropriate referral for supportive housing, according to the report, and 82 percent were sent to the right place for case management. In five areas, results were inconclusive.

Some of the city's figures dispute the monitor's findings and in many cases show it meeting and surpassing its goals. But the reliability of those figures has been repeatedly questioned by the court appointed monitors.

In the areas the health department did acknowledge it failed to meet the court's requirements, staff did perform the relevant tasks, but not within the required timeline, according to the department.

"While it's in appeal, we are complying with the requirements," said Deputy Commissioner Louise Cohen of the Department of Health and Mental Hygiene in response to questions about the lawsuit. "The city is committed and we are certainly committed as an agency to do discharge planning in the best way that we can for the mentally ill."

Should the state Court of Appeals refuse to hear the latest iteration of the litigation or side in favor of the city, Cohen said the city would likely modify its discharge planning process.

The settlement focuses on time restrictions, such as ensuring an inmate referred to the Rikers mental health staff is seen within 72 hours. Cohen said the department would prefer to focus on results. She declined to give specifics on the proposals the department is considering.

"The city would continue to hold itself accountable for discharge planning for those that are mentally ill," said Cohen. "I think it’s a question of what that looks like."

Within Rikers Walls

"Single file, ladies," called Deputy Warden Antonio Cuin down the halls of the Rose M. Singer Center, the women's facility on Rikers Island. Two women in jumpsuits several yards ahead followed the order.

Red and yellow stripes line the floor of the fluorescent-lit corridor. Inmates on either side. Staff in the center.

Asked why the inmates had to walk in a straight line, military-style, Cuin explained: "It's just control. That's what it is."

Later on, Corrections Commissioner Dora Schriro explained further.

"Our primary mandate to focus on is 'Safety Now,'" said Schriro, detailing her new department philosophy. "The statute, at a minimum, expects the Department of Correction to prevent bad things from happening."

Schriro just celebrated a full year on the job. She was previously the head of corrections in Arizona and Missouri and had a brief stint as an advisor on immigration in the Department of Homeland Security.

So, her personal philosophy is still being teased out here on Rikers. Nonetheless, inmates aren't in rehab, although Cuin said they hold daily Alcoholics Anonymous and Narcotics Anonymous meetings and regular group therapy sessions at the women's facility. It's a jail.

Balancing safety with required mental health care can be precarious -- especially when two thirds of the violent incidents that occur at Rikers involve someone classified as mentally ill, said Schriro.

Health care comes second.

"It's only after they have symptoms or behaviors that by the Department of Corrections standards are dangerous," said Dwayne Mayes, executive director of the Howie the Harp program, a peer advocacy group for the mentally ill that contracts with the health department at Rikers. "They are subjective to punitive measures as opposed to health measures."

And some results are mixed.

James, whose first and last name are being withheld due to safety and privacy concerns, has battled schizoaffective and bipolar disorders since 2003, said his mother, Elizabeth, whose middle name only is being used.

But James early this year had been taken off of his medication by a therapist in the Bronx, Elizabeth said. On Mother's Day he was riding the bus when he felt threatened by a female passenger. James found a stray piece of glass, slashed her face and ran away.

He ended up in Rikers' mental health facility -- the Anna M. Kross Center -- in a group dormitory setting, said Elizabeth. Nervous and agitated, he refused to shower, and he was punished for it. When another inmate punched him unprovoked, he ended up in the hole (or solitary confinement), said Elizabeth.

"People who don’t understand people with mental illness, they don’t get it," Elizabeth, who has been communicating with her son and advocates on a daily basis. "We get up and bathe every day. People don’t understand that."

On other occasions, Elizabeth said, her son was so overmedicated he was to the point of drooling. As of Friday, Elizabeth was able to get James his own cell back at the mental health facility and on the right medication. But she and advocates wonder what happens to inmates who don't have someone pushing from the outside.

Moving Forward

No one questions that since 1999 the city has made improvements in how they handle the mentally ill on and off of Rikers Island.

For the past year, Schriro, has been ruminating over population statistics and procedure. In August, she unveiled her first major policy shift as the head of the country's second largest jail system (the first is Los Angeles County).

Photo (cc) reivax. The Bronx barge will relocate to Rikers under the new facilities plan.

She is going to build a new jail and tear down the dilapidated temporary facilities erected during the crack epidemic of the 1980s (facilities that resemble small white spacecraft instead of jails). Hailed by criminal justice advocates, the commissioner is also centralizing the intake procedure, making sure inmates are classified up front. She plans on consolidating staff and some of the mental observation units, streamlining the process. There are now seven separate units spread out throughout the island.

Starting this month, Schriro launched a pilot program to provide corrections officers with additional training on mental health issues. The commissioner says she is approaching correction and health department staff "as a team who together can create a continuum of custody and care that can be carried out not only in the hours and days that our clinical staff is there."

Advocates have called for additional training for a very long time.

The department of health also has almost completed its electronic patient records system on Rikers (now active in several jails). The new system will make sure there is an ongoing record of those with mental health issues on the island.

Should an inmate come back, officials don't have to start off at square one. They can pick up where they left off, said Schriro.

Advocates commend the effort.

"Commissioner Schriro is making really valiant attempts to do something about this," said Joel Copperman, the chief executive officer and president of CASES. "She recognizes the reality that people are coming back to Rikers Island, so what she wants is to understand it, to develop treatment plans."

These represent steps in the right direction, advocates said. But a more seamless transition to society is still necessary to make sure those without advocates or parents by their side can get help too, they add. That means better communication between the agencies overseeing health care and the service providers on the outside. It means getting the proper diagnosis and classification as soon as one enters the system.

Back at CASES, Derrick Neptune, a 36-year-old diagnosed with schizoaffective disorder who has been to Rikers four times, called his treatment off and on the island "helpful."

After spending five years in the shelter system, Neptune now lives in Flatbush in Brooklyn. He attends barber school. He is taking medication and quit smoking marijuana -- the so-called cause of many of his psychotic episodes.

"You learn a lot from being in jail," said Neptune.

So much that he hopes he won't have to go back.

Photo byDave Kliman

Timothy Chuang has been in the restaurant business in Flushing for more than 20 years. He said it is hard to do business these days and the city's new sanitation inspection letter grade system is not helping.

The system, approved by the food and community health board in March and effective on July 1, will require food establishments to post letter grades on front windows or entrances easily seen by the public.

This week restaurants that got A's began posting the grades in their windows, and the city launched a website that will present the grades and other information on an establishment's inspection as it becomes available.

Chuang is among the many restaurants owners in Flushing who publicly support the new letter grade system but fear they are at a disadvantage because of preconceptions or misunderstanding about Chinese restaurants. Many are afraid they will get a bad grade, which might deter customers.

The Letter System

Faced with such concerns, the health department said it has made concerted efforts to educate and reach out to restaurant owners in all five boroughs. The agency has held workshops in Chinese, Cantonese, Korean, and Spanish.

"Our inspectors go through extensive training. They are all professionals," said Erin Brady, deputy press secretary at the health department. "They follow very specific protocols, and all restaurants are treated equally."

It is still too early to know how the letter grades will affect the city's 24,000 restaurants and their patrons since it will take more than a year for all the restaurants to get their first report card, according to the health department.

The schedule "depends on each restaurant’s inspection cycle," Brady said. "For example, the ones that were inspected last July are being inspected now."

The letter grade system, similar to the one in Los Angeles, aims to promote sounds sanitary standards for preparing and serving food. According to the health department, the proportion of restaurants in Los Angeles meeting the highest food-safety standards rose from 40 percent to more than 80 percent in seven years, and hospitalizations for food-borne illnesses declined.

"The health department is issuing restaurant letter grades to help consumers make informed choices about where to eat out," said Brady. "Consumer awareness creates a powerful new incentive for restaurants to maintain the highest food safety standards."

At a press conference this week, Mayor Michael Bloomberg said he does not expect to see many low-scoring restaurants. "The best thing that could happen is for everyone to get an A," he said. "That's what we're trying to do and get everyone to that level."

The grades, A, B or C, will correspond to the business's sanitary inspection scores based on a point system, which has been in effect since 2005 and can be viewed on the health department's website. A restaurant will get an A if it receives no more than 13 points for violations, and a B if it gets between 14 and 27 points. A C, the lowest grade given, is assigned if the restaurant gets 28 points or more for violations. The system does not specify how many points will result in the closing of a restaurant. Instead the department will determine that on a case-by-case basis, depending on the severity of the violations.

Some food establishments are not regulated by this new system, including mobile lunch trucks, school cafeterias, soup kitchens and restaurants owned by nonprofit organizations that only serve food to their membership.

Although restaurants getting As, Bs and Cs all are deemed sanitary enough to serve food, the grade determines the frequency of inspection. An A restaurant gets inspected once a year, and a B restaurant gets it every five to seven months. The health department will visit a C restaurant every three to five months.

Too Many Rules?

Some restaurant owners see they system as adding to one the many regulations set by the health department. To Ricky Nacipucha, who owns El Pollito Mexicano restaurant in Park Slope, every inspection means a minimum fine of $200.

"They will look for everything," said Nacipucha, a native of Ecuador. "They give violations for no reason."

If a restaurant is not satisfied with its grade, it can appeal to the health department's administrative tribunal and post a sign that says "Grade Pending."

"I always take pictures when inspectors come so I can fight them in court," said Nacipucha. "At first, I didn't know. But my restaurant friends told me I could appeal. Last time I had seven violations but four were dismissed." He added that he once managed to reduce his fine from $3,800 down to $1,000.

Mario Suvia, a manager at El Pollito Mexicano, added that some inspectors are on a mission to find fault.

"They really want to take points," said Suvia. "They have to find something."

Marilyn Reid, owner of The Islands, a Caribbean restaurant on Washington Avenue in Prospects Heights, said she is confident that her restaurant is clean and her customers are loyal.

"We'll never get a C," said Reid, who came to New York from Jamaica 35 years ago. "Whatever the grade is, it does not reflect the quality of our food."

A search on the health department’s website shows that her restaurant received 20 points of violation when it was inspected in March, which can be converted to a B.

"They are killing me with regulations," added Reid, showing the latest posters on food allergies she said she must post on the wall, which is already covered with various notices from the health department. "I am sure a lot of small business owners will agree with me."

Making It Easier to Swallow

Local community organizations and elected officials have worked with the health department to educate business owners on the new rules. City Councilmember Peter Koo of Flushing, said that business owners must understand and comply with the regulations if they want to conduct business successfully.

"It's not hard to follow the rules," said Koo. "But there are a lot of insensitivities among the inspectors, especially if you don't speak English."

Koo is pushing to form an Asian restaurant alliance and will send his staff members to courses held by the health department so they in turn can help train local restaurant owners and their employees.

In New York City, all restaurant managers must be certified in food protection. A course is available in Chinese, Korean, Spanish and English at the department's health academy. The course lasts 15 hours (three hours a day, Monday through Friday) and costs $114. It also is available online in English, Chinese and Spanish with free access to course material and a $24 fee for the certification exam.

Andrew Rigie, director of operations of New York State Restaurant Association's Greater New York City chapters, said the letter grade is not the most responsible system because the health code is too complex and nuanced for the public to understand what the grades mean.

"A restaurant should either pass or fail the health inspection. You are either sanitary enough to serve the public or you are not," Rigie said.

When asked by reporters, Bloomberg said he would not eat at a favorite restaurant if it got a C. As to one that received a B, he said, "It depends on the food."

Charlie Hauber, a public school teacher from Jackson Heights who frequents Flushing Mall's food court with his family, said the letter grades might influence his decisions only when it comes to a restaurant that he has never visited.

"But if it is a place that I often go to and I see a lot of locals there," said Hauber. "I would still go."

Chris Enright, a tour guide from Park Slope who was enjoying a chicken burrito at El Pollito Mexicano, agreed with Hauber.

"For unfamiliar places, if I have to choose between an A and a B restaurants, I would probably choose the A," said Enright, who had lived in Los Angeles.

"It is hard to run a restaurant. This just adds another stress to them," he said. "But they need to be held to standards."

Larry Tung is a Brooklyn-based journalist and media artist.

Photo byMichael Lehet

New Yorkers know devastation. When the Twin Towers collapsed nine years ago they saw that the blood supplies that might have been desperately needed could dry up in such a calamity. And then there are the disasters outside the five boroughs. When an earthquake rocked Haiti earlier this year, killing hundreds of thousands of people, the Haitian community was struck, too, and New Yorkers lined up to give blood so they could do their share.

Giving blood is one of those selfless acts without which our medical response capabilities would be greatly crippled. In short, it is a public service by citizens. It also is something denied specifically to any man who has had sex with another man.

In the early days of the AIDS epidemic, the federal Food and Drug Administration instituted a ban on gay men with multiple sexual partners donating blood. The agency later expanded that to any male who had slept with a man since 1977.

This federal policy has held fast in the face of changes in our understanding of HIV/AIDS and ability to screen blood. Now, however, movement is building to change the policy.

Leftover From the 1980s

Put simply, the Food and Drug Administration instituted the ban when knowledge of how HIV/AIDS was communicated was not well known, and AIDS was considered predominantly a "gay" disease.

"It's a broad over-classification and an exclusion of an entire group of people," said Nathan Schaefer, the director of public policy for the Gay Men's Health Crisis, a New York City-based organization providing prevention and care services for people affected by HIV/AIDS. "This is really problematic because the nation's blood supply experiences shortages."

While he did not know of any current blood shortage in the city, Schaefer believes New York is vulnerable. The city faced a blood supply drought in 2007 and could encounter a particularly critical situation in the event of another terrorist attack. Given the many gay people in New York, the national policy of not accepting their blood has a disproportionate effect on the country's biggest city.

Earlier this month, the Health and Human Services Advisory Committee on Blood Safety and Availability voted against changing the policy after hearing lengthy testimony on the issue. The panel reportedly said that current research did not yet justify the lifting of the ban. The Red Cross, which runs blood banks, and other group administering donor programs have suggested men wait a year after having sex with another man to donate blood.

Federal policy on giving blood has evolved over the years. In 1990, for example, the Food and Drug Administration banned all Haitians from giving blood on the grounds that because many Haitian transmitted AIDS through heterosexual intercourse, it was more difficult to determine which Haitian were at high risk for AIDS. A few months later, in the wake of protests by Haitian-Americans, the government reversed the policy.

While he doesn't see a change this year, Schaefer believes the push to alter the policy is greater than it has ever been and is bolstered by the fact that, from a cold medical perspective, screening blood donors through a questioning process has become unnecessary.

"The advancement that we've seen in HIV screening and testing technology has been profound," Schaefer said. "They are able to detect HIV in donations of blood within several days."

The Red Cross uses a dozen tests to determine the donor's blood type and to screen for infectious diseases, including AIDS. "Today's technology makes it almost impossible for HIV to slip through, and the total ban puts a huge burden on blood agencies and the blood supply," said Mark Wainberg, author of a study of the policy, in a prepared statement.

A report by Gay Men's Health Crisis issued this year noted that several countries including France, Argentina, Italy and Japan have reversed similar policies and outlines the shortcomings of the current rules.

"Although the current policy purports to be based upon 'behavior-based' deferrals, the questionnaire [given to prospective donors] does not ask particular questions about an individual's sexual or medical history that would be directly relevant in assessing one's risk of being HIV positive. For example, the policy currently fails to take into account the varying level of risk of HIV infection posed by different sexual practices and does not inquire about the nature of a potential donor's prior practices," the report said.

"Similarly, the current questionnaire does not address a potential donor's consistent and proper condom use, universally agreed to be highly effective in preventing HIV transmission through all types of sexual activity, number of sexual partners or frequency of sexual contact with anonymous partners. This means that gay men who always practice safer sex, or who are in monogamous relationships with partners who are HIV negative, are permanently excluded from eligibility to donate bloodm" the report continues.

The Ban's Effects

Barring gay men from giving blood has a measurable effet on the nation's blood supply,according to a recent report by the Williams Institute for Sexual Orientation Law and Public Policy at UCLA School of Law. The study restimated that the policy bans almost 7 million American men from gving blood and that removing it could add 219,000 pints of blood a year, an increase of about 1.4 percent. Restricing donations only from men who have sex with men within the past year would add 90,000 pints.

But the current ban also has broader social consequencesm according to Schaefer.

For one, it stigmatizes gay sex. Think of this way, Schaefer said: A heterosexual man arrives at a blood donation station. Before being hooked up, a screener asks a few questions, including whether he has ever had intercourse with another man. Because a medical professional has inquired about homosexual activity, this man could walk away with the impression that homosexuality should be considered a public health threat.

Schaefer believes New York’s gay community should get actively involved in this issue. “There would be an opportunity for New York to be very helpful here, investment by the gay and lesbian community to really partner with policymakers in the federal government,” he said.

The movement for change has the support of Christine Quinn, the openly gay City Council speaker, as well as U.S. Reps. Jerrold Nadler and Anthony Weiner.

Aside from the message the ban sends and and the fact that excluding gay men -- or even a man who has simply had one sexual encounter with another man since 1977 -- significantly reduces number of potential donors, the issue often comes down to fairness, as gay men believe it robs them of the right to contribute to society like everyone else.

Schaefer said that anger about the current policy has led to straight people on college campuses boycotting blood drives in solidarity with the gay and lesbian community. "This is really problematic, because what this then means is that not only are the gay and bisexual people not donating blood but a number of eligible young people are not donating blood," he said.

Photo (cc) pieter.morlion

Natalie Hunnicutt’s first assignment as a pest control aide for the city, was, she recalls, also her most memorable: crashing a party of dozens of rodents at a Queens supermarket.

“There were rats scurrying left and right and I just thought ‘Oh my goodness,’” the Brooklyn resident said. The pests were leaping over her feet and into a mountain of trash, the result of people using the store’s parking lot as a garbage dump. By the end of the day, Hunnicutt said she and seven of her colleagues removed about 400 bags of garbage from the site.

Hunnicutt continued to clean private and public properties with rodent problems for a little more than two years until the city laid her off in May.

“It hurt,” the 28-year-old said about the pink slip. In her job, she said she was “cleaning up communities and making a difference. I was keeping New York City clean.”

The Department of Health and Mental Hygiene, where Pest Control Services resides, laid off Hunnicutt and 48 of her coworkers. That will save $1.5 million, according to the department. It will leave the department with 41 workers.

Beyond saving money, however, the city says the layoffs are part of a plan to restructure the bureau’s rodent control program. Rather then cleaning lots in response to complaints, the health department has a new project called rodent indexing, which, it says, can control the rat population with fewer workers. Union leaders and some City Council members, though, remain skeptical and warn about a potential vermin crisis in New York.

City Stalwarts

Rodents are preponderant, albeit unwelcome, residents of the city. New York has consistently been named the city most at risk for rodent infestation, according to several reports released over the years by d-Con. The two research scientists who coauthored the 2009 Rodent Risk Report said with New York’s aging infrastructure and high population density, it is no surprise rodents run rampant here.

“The average person does not see much of the infrastructure, some of which are underground,” Bruce Colvin, a rat expert and one of the report’s authors, said. “But rats see it and use that for travel and movement, such as sewers.”

Earlier this week, the health department released a study showing rats either currently infest or could easily inhabit half of the city’s subway lines. As many as 150 rats can live in the walls of a single station’s refuse room, the study found.

Despite that, health department senior research scientist Robert Corrigan told the Board of Health, subways are not the city’s most rodent-infested places. Parks, vacant lots and construction sites are also havens for the pests, he said.

Over the years, experts have offered widely ranging estimates of the number of rats in the city. While some have put the number at one rat per person -- for a total of about 8 million -- others figure there could be as many as almost 100 million rats. Robert Sullivan, the author of Rats: Observations on the History & Habitat of the City's Most Unwanted Inhabitants, has put the figure far lower.

A Plan for the Future?

Whatever the count, most New Yorkers would probably agree that there are too many rats living in their midst. In recent years, the city has tried to stem the number by responding to complaints, often made through the 311 non-emergency hotline. When a rat report is received, Pest Control Services would send out pest-control aides. If they found a problem, property owners could let the aides take care of it for a fee -- shared by the city and the owner.

With rat indexing, however, the health department says it targets rat infestations before a complaint is even made. During an 18-month period in the Bronx – from December 2007 to July 2009 – Pest Control Services inspected 30,000 properties in the borough three times. Combing through neighborhoods block by block, they used hand-held computers and mapping technology to find potential rodent issues.

When they detected a problem, workers gave recommendations to property owners to improve conditions, such as clearing clutter and debris or removing rat enticing garbage. The agency subsequently sent notices to those property owners. If they failed to comply, the agency issued a notice of violation and corrected the issue at the property owner’s expense.

Comparing numbers from the inspectors’ second and third visits, the department said infestations declined in every neighborhood. According to health department numbers, the indexing approach led to an 83 percent decrease in the number of properties with rodents during the Bronx pilot.

Citing its success, the city expanded rodent indexing into Manhattan in January. The health department said further expansion will depend partly on the project’s outcome in Manhattan. The department also said the results of the Bronx pilot program, indicate that the cutbacks in Pest Control Service would not lead to more rat infestations.

Fewer Workers, More Rats?

Fitz Reid, president of Local 768, a union of health workers, questions that reasoning. He said rat indexing is not proactive, as the city describes it, but “a passive thing [that] does not respond to the people.” He said with fewer workers less attention would be paid to services such as baiting and cleaning.

The department contends it will continue to answer complaints about rats, conduct inspections, perform exterminations and issue violations.

City Council members also have their doubts. Although he commended the department for being proactive with the indexing program, Councilmember James Vacca said he is not convinced the program will work since the health department has yet to give council members information on the impact of laying off pest control workers. Knowing New York’s history with rodents, “I don’t want to cut programs that keep [rats] at bay,” Vacca said.

Councilmember Peter Vallone said even in lean times, services such as pest control should not experience cutbacks.

“I’m glad [the health department is] using technology against an age-old problem, and perhaps that will allow for things to be done more efficiently in the future,” Vallone said. But he wants the health department to remember that “pest control is one of the things government needs to do that the citizens can’t do for themselves. That’s a quality of life issue that we need to provide necessary funding for.”

Funding Issues

In theory, said Colvin, proactive approaches such as indexing are the most effective means to control rat infestations. But, he said, other cities that tried such preventative measures find it difficult to secure funds to sustain the effort.

That, he said, is because attention to pest control increases when there is a visible problem. That attention translates to political, and therefore, financial, support for extermination and prevention projects. In New York for example, it took rats overrunning a Taco Bell in Greenwich Village to lead to stricter restaurant inspections.

“There’s a myth that if we’re seeing rats, we don’t have to invest in rat control programs,” Colvin said, “That’s a fallacy that’s gotten cities into trouble. … Rat populations can rebound quickly within six months if risk factors are not continually targeted.”

If Colvin’s reasoning applies here, the health department could find it difficult to get steady funding for rodent indexing in the future. The department said it did not have the cost of the rat indexing program available.

From her experiences as a pest control aide, Hunnicutt said she also is skeptical about how well rat indexing will do.

"It's a given," she said, that reducing the workforce will make the siutation worse "because there's not an efficient amount of workers to get the job done. The work will always grow."

Hunnicutt said she has kept in contact with some of the other laid-off workers. Some of them have moved on, she said, while others are still coping with the job loss. But she said she rebounded pretty quickly. She applied for, and was offered and accepted, a janitorial position at the department of health.

Her first day, June 14, went well, she said, adding “I don’t have to deal with rats!”

Jim Henderson

Harlem Hospital is one of 11 hospitals run by the city's Health and Hospitals Corp.

With almost every city agency, the key word this spring has been "cut." Mayor Michael Bloomberg's executive budget calls for operational cuts and layoffs across the board to deal with the yawning budget gap, and the reductions could get worse depending on what kind of budget the state adopts.

One of the very few to see a substantial increase is the Health and Hospitals Corp. In announcing the massive cuts throughout the city on May 5, Bloomberg said he would give the HHC $350 million in order to help it close its $1 billion shortfall. The budget also includes $310 million in capital spending for the agency.

Yet , despite this increase for next fiscal year, the HHC has instituted $300-million budget containment plan for the next four years. Explaining the seeming paradox in a briefing on May 11, HHC President Alan D. Aviles said, "The protracted economic downturn, a substantial loss of federal funding, increasing numbers of uninsured patients, sky-rocketing fringe benefit costs and $240 million in cuts to our Medicaid reimbursements, have created a perfect storm that has saddled HHC with a projected $1.2 billion budget shortfall."

Aviles promised that the four-year downsizing plan was intended to cause the least pain possible. No hospital would be closed, and job cuts would focus on people with administrative titles rather than on caregivers. Some 3,700 jobs will be cut through a mixture of layoffs and attrition.

But Judy Wessler, the director of the Commission on the Public's Health system, a labor-community health advocacy group, said that there will be pain for the public, especially under a plan to close five child health clinics and one dental clinic.

"We are adamantly opposed to that," she said, even though HHC said it selected facilities that are under-utilized. "Any community-based primary care or dental care service are needed and should not be cut."

Shuttering these sites, the HHC said, would save $39 million over four years.

The HHC has a total budget of about $6.7 billion and operates a number of health facilities, including 11 hospitals and more than 80 community clinics.

Path to Privatization

The reorganization, Wessler noted, calls for contracting out some of the agency's management operations to private, which some might say makes more sense for a quasi-government operation like HHC than a mayoral agency.

But Wessler said that many city plans for privatization have been costly and ineffective. IN particular, she cites the CityTime palm scan time-keeping system for city workers, where consultants have charged the city hundreds of thousands of dollars each, helping to send costs to 10 times the original projections.

"Number one, there's not a cost savings and number two, it doesn't do what it's supposed to do," she said. "I think that as a rule privatization does not work."

The HHC, however, said it would save $141 million over four years.

More to Come?

The realignment plan may not mean the end of the HHC cuts. Should the state adopt a budget incorporating many of the cuts proposed by Gov. David Paterson, "it could still be very bad," Wessler said.

And then there's the federal government's commitments, such as the medical assistance payments many low-income people may receive through Supplemental Security Income.

"If, for any reason, these additional supplemental federal Medicaid funds do not materialize, we would be left with a deficit amounting to several hundred million dollars and that would lead to further, deeper and much more devastating cuts," Aviles said.

He recalled that the last time the system was in such straits 15 years ago public hospitals were up for sale. The courts blocked that action but it served as the impetus for an overall revamp of the system, which Aviles said has been largely positive.

Enter ObamaCare

Unlike the operational reductions on tap for other city agencies, the hospitals corporation's cost-containment plan is set for four years. Outside factors could improve the situation by then.

Part of what is draining HHC resources is the cost of uninsured patients entering and receiving care in the system. According to the agency, it serves 450,000 uninsured New Yorkers a year, The overhaul of the health-care system that President Barack Obama signed this year, which will provide millions of uninsured Americans health coverage, could very well ease that burden.

Others see possible hope in Paterson's proposed tax on soda and other sugary beverages. Wessler and Barry Liebowitz, president of the Doctors Council, which represents HHC doctors, think such a tax would not only push New Yorkers toward healthier eating and drinking habits but also would provide another revenue stream for public health.

The proposal though, has run into stiff opposition from the beverage industry, from The The Teamsters, which represents workers in the beverage industry, and from United Food and Commercial Workers Local 1500, which charges it would place a burden on poorer, urban consumers.

Picking Up the Slack

The proposed cuts come at a particularly critical times for the city's public hospitals and clinics. The backdrop for all of this is the closing of St. Vincent’s Hospital. "With the closure of St. Vincent's Hospital, the last vestige of a formerly vast Catholic healthcare system in the city, the viability of our public system, as the primary healthcare safety net for the most vulnerable among us, is all the more critical," Aviles said.

As a Catholic hospital, St. Vincent's turned away no one, making it more like public facility. Because of that, the HHC will have to pick up more of the slack in lower Manhattan than private hospitals. "The private sector has been less than good about taking care of people who are uninsured," Wessler said. "The public hospitals are going to have to continue their very important role."

Further, she noted, plans for Lenox Hill to operate a facility in lower Manhattan offered little consolation. "Lenox Hill has their own financial problems," she said.

Wessler said she heard reports that emergency rooms at Beth Israel and Bellevue have begun to overflow as a result of the closing, which many people in lower Manhattan feared would happen. But Patrick Bahnken, who as president of District Council 37 Local 2507represents city paramedics and emergency medical technicians, said that the 13 Fire Department ambulance tours that replaced the St. Vincent's tours, have not been overburdened yet.

"They're doing a hell of a job," he said of his members.