Photo (cc) 2008 Department of Environmental Protection

New York City, you have a problem.

Yes, like the thousands of shopaholics or compulsive credit card users, you have racked up some serious debt. And now some advocates want to cut you off.

During the first two terms of the Bloomberg administration, the city's capital budget ballooned from about $24.8 billion to $45.5 billion -- an increase of more than 83 percent. In that same time period the amount of money the city paid in debt service every year increased from $2.4 billion to $5.4 billion. In the mayor's $63.6 billion budget proposal for fiscal year 2011, nearly 9 percent is dedicated to paying off the city's capital debt.

And it doesn't stop there. By fiscal year 2014, the city could be paying about $6.9 billion in debt service.

For years, Mayor Michael Bloomberg has bragged of his commitment to capital investment. He has said he would not abandon the city's infrastructure -- in fact, he would make its renewal one of his top priorities.

Now that those investments have been made, budget experts wonder whether they were the right decisions. The size of this plan has some of them worried.

"What you see in 2010 is record high commitments," said Maria Doulis, a senior research associate at the Citizens Budget Commission, who has called for the mayor to cut back on the capital budget. "They should figure out what their priorities are and adjust accordingly."

The Bloomberg administration has made some strides in the last several years to get its debt service under control -- such as paying off debt with surplus dollars and stretching out the capital budget from four to five years.

But experts wonder whether these actions are enough.

Capital Catastrophe?

Last week, Marc LaVorgna, a Bloomberg spokesperson, said the administration would not turn its back on economic growth. In a struggling economy, city-fueled development helps create jobs. The administration, he added, will not make the same mistakes of the 1970s era New York City -- when streets and economic development deteriorated.

Nonetheless, some members of the administration acknowledge that there is a problem and it needs to be addressed.

On Thursday at the start of the City Council's hearings on the preliminary budget, Councilmember Domenic Recchia, the council's new finance committee chairman, wondered just how big that problem really is.

"Are you requesting we reduce it more, cut the capital plan in half?" asked Recchia.

The city's Budget Director Mark Page responded: He'd take a rain check.

"As a practical matter, I think it's too much to deal with in the next few months," Page said of the city's rising debt. "In the long run, I think the long term cost of debt service as a fixed cost in New York City is a serious problem for us."

The current fiscal year has the largest proposed capital budget commitments in all of Bloomberg's tenure -- projected to top more than $14 billion. Funding is going to resurface 3,700 miles of roadway, at the cost of $689 million, more than $11.2 billion will go to school facilities construction and $646 million for the Newtown Creek Wastewater Treatment Plant.

While debt service is often referred to by the administration as an "uncontrollable cost," it is linked entirely to the size of the capital budget, said Page. If the city cuts the capital budget, then its debt service obligations will also go down.

The record high commitment this year comes despite stretching the budget from four years to five and cutting 27 percent from projects funded with New York City General Obligation and New York City Transitional Finance Authority bonds last year.

While some of the overall increase during the Bloomberg administration has to do with the mayor's priorities and his commitment to updating the city's infrastructure, some of the rise originated outside of City Hall. When the state started matching the city's allocation for school construction, the department's capital allocation effectively doubled, said Doulis. The building boom also caused construction costs to spike, increasing the cost for the city's projects, Doulis added.

Beyond that, she said, the administration substantially increased funding for capital projects for parks, public buildings, hospitals and environmental protection even when adjusted for construction cost increases.

Debt Be Gone

Doulis would like to see the city cut back on capital spending, though she would not detail a specific target.

Those in the construction industry, however, side with Bloomberg.

"Our infrastructure is the circulatory system of what keeps our economy moving and growing and thriving," said Felice Farber, the director for external affairs at the General Contractors Association of New York. "If we're not building it or maintaining it, it's going to cost us more in the long run."

Farber suggested the city commit to completing projects on time instead of cut capital spending. The longer a project is delayed, the more likely the cost of construction could increase, making the entire project more expensive. Nearly two years ago the city and the association agreed to a pilot program that would penalize the city if it were at fault for delaying a project. The city already penalizes contractors if they are at fault for delays.

That program, which was set back when the capital budget was cut last year, just got started in January and covers $5 billion worth of projects, according to the administration. But Farber thinks it will help keep projects on time and on budget.

More than half of the construction trade in the city is supported by city funds right now, Page said last week. With the recession, it's hard to imagine what would happen if the city started cutting capital too.

Photo (cc) h-bomb

City health officials have now rolled out a voluntary program to reduce the salt in foods. This follows the ban on transfats, the requirement that many menus include calorie postings and the removal of junk food and soda from schools. All of these efforts are geared to steering consumers toward healthier choices. But questions remain about how much effect these measures can have on public health problems like obesity and diabetes that are related to the food that people eat.

For example, though preliminary surveys show some people make healthier choices based on calorie postings the findings are inconclusive, and an October 2009 study published in the journal Health Affairs found many fast food restaurant and frozen foods processors underestimate in their posted calories counts. Unhealthy choices -- usually foods that are sweet, salty and relatively cheap – are pervasive, especially in wide swaths of the city known as "food deserts," where fast food prevails, while access to fresh fruits and vegetables is limited. These areas have the highest levels of obesity, diabetes and other food-related diseases, and they tend to be low-income and minority neighborhoods.

To address this, many cities are moving aggressively to shape broad policies on food systems. They are using land use regulations to restrict junk food outlets, and to promote urban agriculture and community gardening. Since access to healthy food varies greatly by neighborhood, many cities are working with the most affected communities on plans and strategies for change. New York City is not there yet. So far, it has not yet expanded its focus to go beyond consumer choice and include access.

However, Mayor Michael Bloomberg has hired a food policy czar and formed a Food Policy Task Force. And City Council Speaker Christine Quinn has said she will roll out a policy agenda for food this spring that will address the question of access in a more comprehensive way. The question now is how far these efforts will take the city toward a more holistic food policy.

From Choice to Access

City food policy has yet to focus on the supply side of the equation -- improving access to healthier foods, especially in the food deserts but also in areas where good choices are available but not affordable.

This theme emerged from the recent New York City Food and Climate Summit, sponsored by Manhattan Borough President Scott Stringer and an array of non-profit healthy food groups. The conclave, which drew hundreds of people from throughout the city, followed an earlier Stringer report on food policy and his 10-point NYC Food Charter: 10 Principles for a Sustainable Food System.

The city already has some of the building blocks in place to expand the supply of healthy foods. The Council on the Environment sponsors 51 green markets, but they tend to be located in areas that already have good access to fresh food. In addition, many are open only once a week, most are seasonal and not all accept food stamps, which 1.1 million New Yorkers rely on to buy food.

The city's http://www.greenthumbnyc.org/Green Thumb program supports over 600 community gardens throughout the city, and many of them supply produce to gardeners. The city’s health department launched healthy bodega and green carts initiatives in neighborhoods where access to healthy foods is particularly limited, but these are limited in scale and have produced mixed results. And the city’s botanic gardens help train people to do their own composting, which can create soil for local gardens.

So far, however, city has not connected the dots to both increase the supply of healthy food and focus on food deserts. In the policy arena, food was noticeably absent from Mayor Michael Bloomberg’s long-term sustainability plan, PlaNYC2030, released on Earth Day 2007.

Meanwhile, the city’s ongoing development efforts have undermined access to better food. For example, the city has been shutting down the Depression-era city markets that were mostly located in working class neighborhoods and could have filled the gap in the food supply. For example, the Bronx Terminal Market was recently converted to a shopping mall and the city has not been able to make places like La Marqueta in East Harlem or the Essex Market on the Lower East Side into major centers for low-cost healthy food let alone multiply that model throughout the city.

While many European cities have preserved their neighborhood public markets, New York has let them slide into disuse and instead encourages large supermarket chains. One of the most dramatic recent examples of the city’s developer-driven policies is the ill-fated city proposal to turn the Kingsbridge Armory in the Bronx into a suburban-style shopping mall with a supermarket that would have driven out of business many well-established local markets.

Planning for Supermarkets

On the surface, it might appear that the city is moving in the right direction with its recent initiative offering tax and zoning incentives to supermarkets that locate in food deserts and older manufacturing areas. But this effort may do more to help supermarket giants find cheap land than it does to improve access to healthy food, as I have previously suggested.

The problems with this initiative are emblematic of the upside-down land use policy regarding food access. The new initiative can pave the way for giant retailers to move into low-income areas that are in transition to upper income communities, helping to push out the very people that are most in need of access, and thus not solving the problem of access. The 100 rezonings completed by the administration, fueled by the real estate bubble, helped pave the way for these changes.

The city’s supermarket program can also push out smaller local retailers, destroying the bodegas instead of helping them to offer healthy food and to become examples of healthy local entrepreneurship. And the zoning changes have made it easier for supermarkets to move into industrial zones, pushing out active industries because they escalate rent levels and cause traffic problems. The supermarkets are allowed to have ample parking, encouraging more driving and energy use at a time the city claims it wants to reduce traffic.

While the chain supermarkets do tend to carry fresh produce, there is nothing in the law that will prevent them the stores from stocking almost all of their shelves with industrially processed food with lots of sugar, salt and other mysterious ingredients. The program offers no incentives or subsidies for green markets, community gardens, consumer cooperatives or other media for healthy food. And it does nothing to expand the production of food in the city.

Urban Agriculture or Asphalt and Concrete?

At first sight, the idea of growing food in New York City might seem absurd. The island of Manhattan is densely populated. Much of the soil throughout the city is contaminated. And even though there were working farms in all five boroughs only a century ago, few New Yorkers have practiced farming.

Yet urban farming occurs throughout the world in cities as densely populated as New York, and it is growing in places where governments help out. According to City Farmer, 40 percent of the population in Vancouver, Canada, a city of 1.6 million, grow food. Vancouver also has 1,000 community gardens and a food policy that encourages the production and distribution of local food, which also reduces transportation and energy costs.

New York City has 52,000 acres of backyard space in New York City that could together provide vegetables for 700,000 people, New School Professor Nevin Cohen, a leading expert on urban agriculture, said at the Food and Climate Summit. There are no city programs to help cultivate them or to systematically promote community efforts.

Just Food, a local non-profit, helps create Community-Supported Agriculture groups that buy directly from local food producers in the region. The city’s zoning regulations are fairly open, permitting agriculture in most residential districts.

While proposals for vertical farming on Manhattan-sized skyscrapers may be literally "pie-in-the-sky," no one in government seems to be looking at the more possible alternatives of farming in the outer boroughs, where some 30 percent of land is public right-of-way, much of it unused or underutilized, and much of it in food deserts. Throughout the city, many parks, schools and other community facilities could host urban farms and composting operations, train a new generation of urban farmers, make healthy food more accessible, and expand the choices for the majority of the population.

In urban Milwaukee, Will Allen created an urban farm that does all of these things and has become a national model. We need to learn from these experiences and then do it here on a large enough scale to make a difference.

This article originally cited the number of neighborhoods where the Green Carts and Healthy Bodega programs exist. That information has now been corrected.

Tom Angotti is Professor of Urban Affairs and Planning at Hunter College, City University of NY, editor of Progressive Planning Magazine, and a member of the Task Force on Community-based Planning.

 

 

(Earlier this month, the Bloomberg administration announced a new initiative aimed at encouraging food processors and restaurants in New York and across the country to cut back on salt in the foods they sell. This one of two commentaries on the move. The other, in support of the plan, appears here.)

Mayor Michael Bloomberg is at it again with his "big government knows better than you and your doctor" attitude. He crusaded to ban smoking in New York City restaurants and bars, forced restaurants into posting calorie counts and promoted high-powered advertising campaigns against sugary drinks. Now, the mayor and his health department czar are demanding 25 percent reductions in the amount of salt in manufactured foods sold in New York City -- even hysterically comparing the popular seasoning with rooting out "deadly asbestos in the classroom."

Since manufacturers would have to change their entire food product line for New York City because of this aggressive assault against salt, Bloomberg's zealous effort will affect food policy for the entire country. Although claiming this is a "voluntary" anti-sodium campaign, his vicious and untrue comparison of salt to deadly asbestos is especially a stab in the back to the city's ethnic cuisine. It will soon affect millions of resident diners as well as tourists who visit New York City for its excellent food offerings.

 

"Say it's not our business?" the mayor grumped at a news conference. "I don't think so," he declared.

In recent years the U.S. Department of Health and Human Services has been asked to run a large-scale trial to determine the impact of salt reduction in the diet upon health outcomes in the general population. Yet this has never occurred. And since there has never been a conclusive scientific trial, what Bloomberg is "making his own business" is essentially his own egomaniacal experiment. He is placing New York City's population into the largest clinical trial ever, using its residents as guinea pigs without their consent.

A Taste for Salt

Bloomberg and his health czar are again pushing a "one size fits all" model for New York City, ignoring that salt has important properties that preserve and stabilize food and, of course, often makes it taste better. Sodium cannot be manufactured in the human body, so all humans need some measure of salt. Isn't it better for Americans to be free to consult their own doctors about their salt intake r than have politicians and nanny state bureaucrats setting arbitrary government rules? What's next in Bloomberg's radical book of "health regulations"? A "bedtime" rule stipulating how long people should get their nightly rest?

By the way, one can conduct an intellectually honest debate over the pros and cons of Bloomberg's health crusades, but there's no argument that the mayor is a hypocrite for often openly indulging in junk food while at the same time attacking everything ranging from salt to sugary drinks. New York Times reporter Michael Barbaro recently listed the mayor's admitted "weaknesses," including burnt bacon, hot dogs, Big Macs, fried chicken, wine, pizza, coffee and his favorite snack of all, Cheez-It's. Think of all the sodium in all that!

New York Magazine's Chris Rovzar has mused that, because of the mayor's love of junk food and awareness of how hard it is to resist, hizzoner likes to set up "hurdles" like calorie counts and trans-fat bans for people who are subject to temptation.

Whatever the mayor's motivation, restaurant owners, chefs and their customers know that salt obviously makes certain foods taste better. Chef David Chang, owner of the Momofuku Noodle Bar, notes that cooks have been using varying degrees of salt with food almost as long as they have been using fire. "You need salt to draw flavor out of food," Chang says. "It is a skill that you teach cooks. For that to be regulated by the government is stupid and foolish."

Noma Dumich, former owner of the Manhattan French restaurant Sel Et Poivre ("Salt and Pepper"), which is now owned by her daughter and son in-law, further underscores that the city government is pursuing a restaurant-killing and job-killing strategy. "I'm very worried about what Bloomberg's campaign will mean to my family and other city restaurants," she says.

Research shows that over the past 30 years the only country that has ever reduced its salt consumption is Finland. Interestingly, though, when comparing cardiovascular performance and increases in longevity in Finland over the last 30 years with the rates in neighboring countries and the U.S., none of which lowered salt consumption, Finland's has had the worst performance of all. Could one therefore conclude that salt reduction doesn't provide any significant health benefits, and may actually lead to diminishing the health of a population?

That's one more reason why the My Food My Choice grassroots organization has emerged to join a growing number of New York City consumers, restaurant owners and food manufacturers in opposing Bloomberg's nutritional fascism. The group is calling for peoples' freedom of health choices, as well as asking the mayor to not treat his constituents as guinea pigs. Bloomberg ought to mull that over while munching on his Cheez-Its.

Orit Sklar is the national spokeswoman of the coalition My Food My Choice, a grassroots coalition of consumers and businesses that promotes the advancement of consumer choice in the marketplace and an environment of economic vitality.

 

 

(Earlier this month, the Bloomberg administration announced a new initiative aimed at encouraging food processors and restaurants in New York and across the country to cut back on salt in the foods they sell. This is the first of two commentaries on the move. Another, opposing the plan, appears here..)

The National Salt Reduction Initiative, a New York City-led partnership of cities, states and national health organizations, has announced its proposed targets for a voluntary reduction of salt (sodium) levels in packaged and restaurant foods. The goal of the initiative is to reduce the salt in packaged and restaurant foods by 25 percent over five years -- an achievement that would reduce the nation’s salt intake by 20 percent and prevent many thousands of premature deaths as well as countless hospitalizations for people with heart and kidney disease. Success would translate into major public health benefits in the U.S.

The sodium in salt is a major contributor to high blood pressure, which causes heart attacks and strokes, the leading causes of preventable death in the U.S. and, arguably, the world. Every year, heart attacks and strokes cause an estimated 23,000 deaths in New York City, more than 800,000 deaths nationwide, and cost Americans billions in health care expenses.

America's Salt Habit

Using data derived from the 1988-91 National Health and Nutrition Examination Survey, the average dietary sodium intake for adults in the U.S. is estimated at 3,400 milligrams per day, with similar amounts for all races and ethnic groups. This estimated average, however, does not include discretionary sodium use, such as using salt when cooking or at the table. This discretionary sodium use is estimated to increase the average daily intake by about 15 percent. This means that the average American adult ingests almost 4,000 milligrams of sodium daily, a level that is way above the recommendation of the National Research Council that the average adult American consume no more than 2,400 milligrams of sodium per day.

 

A study using data from over 9,000 overweight American adults in the National Health and Nutrition Survey Epidemiologic Follow-up Study has shown that an increase in daily dietary sodium intake by 2,300 milligrams results in a 32 percent increase in risk for stroke, an 89 percent increase in death from stroke, a 44 present increase in death from coronary heart disease, a 61 percent increase in deaths from all cardiovascular diseases, and a 39 percent increase in death from all causes.

This study did not find a significant association between dietary sodium intake and risk of cardiovascular disease in people who were not overweight . However, since approximately 70 percent of U.S. adults are either overweight or obese -- with that proportion increasing steadily -- the data on risks for overweight people are very relevant to our population.

The statistics bear out what we know medically. High sodium intake increases blood pressure and that in turn increases risk for these blood vessel diseases. Importantly, the large INTERSALT study has shown that lowering sodium intake by 2,300 milligrams a day, from about 3,800 milligrams to about 1,500 milligrams correlates with a 3 to 6 mm Hg reduction in systolic blood pressure. Even a 3 mm Hg reduction for the general U.S. population should result in 11 percent fewer strokes, 7 percent fewer coronary events and 5 percent fewer deaths, reducing the number of heart attacks and strokes by approximately 126,000 a year and deaths by 44,000.

A 1999 statement by the National High Blood Pressure Education Program of the National Heart, Lung, and Blood Institute concluded that a clear causal link between dietary sodium intake and blood pressure exists. The group of scientists also stated that the evidence for this relationship is sufficiently strong to warrant a specific recommendation about reducing dietary salt intake. The American Heart Association and American Medical Association have also called for reducing salt intake.

The Restaurants' Role

As with transfats, which New York City banned in restaurants in 2006, people do not go to restaurants with the express purpose of eating more salt. In the vast majority of cases, most people will not even miss the extra salt.

Millions of Americans live with congestive heart failure and kidney insufficiency. For them, excess sodium intake can result in life-threatening and costly hospitalizations. Despite this, food processors and cooks continue to add unnecessary salt to food, making it more and more difficult to obtain a low-salt meal at most restaurants without considerable effort. Many people with heart or kidney problems cannot experience the enjoyment of eating out because of the relatively high salt content of many restaurant foods.

The New York City-based initiative to reduce salt consumption by working with the food and restaurant industry warrants implementation immediately. Just as restrictions on smoking in public places have led to major health benefits, this initiative should have a similar impact on health without detrimental impacts on the food economy or on the delight people take gain from eating at their favorite restaurants. This is also a very cost-effective approach that is consistent with current efforts taken in Washington and individual states to improve the nation’s health without increasing our national debt.

Robert C. Block, MD, MPH, is a member of the Department of Community and Preventive Medicine and the Department of Medicine, Cardiology Division at the University of Rochester. John Bisognano, MD, PhD, is with the Division of Cardiology, Department of Medicine at the University of Rochester and president of the New York chapter of the American College of Cardiology.

Photo (cc) viewmaker

There’s a type of wind that blows in off the North Shore of Long Island that is not only so sharp and cold it burns your face but also has enough force that if it hits you at the right angle, it can knock the air away from your mouth as you try to inhale. Just after Christmas, as firefighters gathered outside a Suffolk County church for the funeral of retired firefighter James Ryan -- who died from cancer doctors believe was caused by toxins he was exposed to while doing recovery work at Ground Zero -- the burning wind augmented another chilly reality for New York’s Bravest: Ryan was not the first front-line responder to die from a 9/11-related illness, and he will certainly not be the last.

Exactly a week later, many of those same responders gathered by the World Trade Center site to read the names of 9/11 responders and Ground Zero recovery workers who have died from illnesses related to their duty. It was the fourth anniversary of the death a another notable responder, New York Police Department Detective James Zadroga, whose name is attached to a bill in Congress that would establish permanent funding for health treatment and monitoring programs for 9/11 response workers and lower Manhattan residents, students and workers.

The medical centers treating the thousands of 9/11 responders as well as lower Manhattan residents and workers suffering from respiratory ailments and mental illness such as post-traumatic stress disorder survive on annual appropriations funding from Congress. Already a precarious situation, the financial crisis makes things shaker, which is why advocates are intensifying their push for a more reliable funding source.

Show Us the Money

The hold-up -- legislatively speaking -- is in the House Energy Committee. The bill has two parts. The compensation and health component was approved with bipartisan support in the Judiciary Committee on the former aspects terms, but the health subcommittee of the Energy Committee hasn’t voted on it, as its chair, New Jersey Democrat Frank Pallone, is not sure there is enough support for it.

The bill’s supporters -- among them New York Reps. Carolyn Maloney and Jerrold Nadler, both Democrats, and Peter King, a Republican -- say the votes are there.

However, it has been difficult for lawmakers outside the tri-state area to commit to it, since the measure carries an undetermined price tag. "I am more confident than I have ever been, but like anything it's never done until it’s done," Maloney said, noting that the Zadroga Act has the support of House Speaker Nancy Pelosi.

The bill has had a complicated history among the various groups who support long-term federal funding. The main city police union -- the Patrolmen’s Benevolent Association -- has opposed the bill’s current language because it does not specifically mention certain cancers. They have feared this means that members who develop those cancers would not be covered. Other police and first-response unions believed it is more important to pass the bill now and tweak conditions -- such as adding the cancers -- later.

Resident and worker groups such as Beyond Ground Zero have had similar reservations and also noted that the bill covered residents, students and workers only from Houston street to South Ferry in Manhattan. They believe that the coverage area should extend at least to 14th Street, of not higher.

Even if the activists can push the measure through the House, the Senate will be another story. If the health-care reform bill is any indication, the Senate is far more averse to government funding for health-care than the House. And the senator who had been credited with pushing for much of the current temporary funding, Hillary Clinton, is now secretary of state.

At the ceremony on the anniversary of Zadroga’s death, John Feal -- who heads a 9/11 responders group called the Feal Good Foundation-- showed his technique for passing the bill as soon as possible by displaying his chief weapon: a piece of Whole Foods pork.

"That’s how we get votes right? We give someone in Washington some pork," he said, citing the recent drive to pass the health-care reform bill by offering funding provisions geared to specific states. "So what I’m going to do is mail every member of Congress one these pieces of pork, and I'm going to put a 9/11 responder’s name on it."

Death and Glory

Meanwhile, the 9/11 first responders, their families and supporters face other issues as well.

Ryan’s funeral, at first glance, looked like the typically ornate send-off the city's fire department is famous for: the Emerald Society’s rendition of "Amazing Grace" and a salute by columns of uniformed members. But it wasn’t an official Fire Department event with eulogies from the mayor and commissioner. Those events are reserved for firefighters who die on or as a result of injuries sustained on their shift. Those who die years later don’t count, and 9/11 responder families take this as a snub.

Fire Department officials responded that while members who die long after 9/11 don’t get the official "line of duty" funeral, Ryan and many others did retire with a disability pension, meaning they get three fourths of their average annual salary for their last three years on the job, as opposed to half the salary, which is the standard benefit. In addition, they said, Ryan's family was virtually guaranteed a full death benefit.

But for many first responder advocates, including the heads of unions and fraternal groups, the pomp and circumstance matters. They have voiced their protests for people, such Paramedic Deborah Reeve, a dead Ground Zero worker whose death was designated an "administrative line of duty death." One activist joked that this sounded like she died from a paper cut.

There is a split between how the police and fire departments handle this kind of death in terms of memorials. Police officers like Zadroga, have their names displayed on the police department's memorial wall in lower Manhattan, along with cops who died on their shift, such as officers shot and killed by assailants. Ryan’s name, though, will not be affixed to the Fire Department's memorial wall at its downtown Brooklyn headquarters, along with the 343 FDNY members perished as the towers collapsed.

Mayor Michael Bloomberg has the power to set a single standard for honoring uniformed responders who die in the line of duty. But he has said he won’t. "I think each agency has to make its own policies," he said at a recent press conference. "There are great traditions that go back a long ways in both these departments."

Uniformed Firefighters Association president Steve Cassidy said that after Ryan’s funeral, much of the media coverage treated his as a line-of-duty death -- more than had been the case for another responder who had died before him. This, Cassidy said, gives him hope that pressure has increased not only on Washington to enact the Zadroga bill but also for the city to give further honors to responders like Ryan.

"A sense of change is in the air," he said.

Ari Paul is a reporter for The Chief-Leader, a weekly newspaper covering city government and the civil service, and a correspondent for Free Speech Radio News. Due to a computer error that deleted key words, this article originally incorrectly identified Rep. Pallone and Rep. Maloney. The error has been fixed.

Photo (cc) ttfnrob

Enrique Chavez, a native of Lima, Peru, was excited about the prospect of joining his father and sister in the United States in 1991 when his father, a Green Card holder at the time, sponsored him for immigration. However, that dream quickly vanished when he was tested positive for HIV during the medical exam required for prospective Green Card applicants. The officers at the U.S. embassy told him that result made him ineligible for immigration to the United States.

"The doctor told me I had one year to live," said Chavez, calling the diagnosis a social as well as a medical one. "I went into depression." His job at a trading company was not renewed because his boss found out he was HIV positive, and a neighbor threw rocks at his house. His family was extremely supportive, but it took him another 12 years before he finally immigrated to the United States.

On Oct. 30, President Barack Obama made a major announcement that should help prevent similar stories in the future. He removed a 22-year-old ban on travel and immigration to the United States by individuals with HIV or AIDS. Calling the ban "a decision rooted in fear rather than fact," Obama also reauthorized the Ryan White Comprehensive AIDS Resources Emergency Act, which funds the largest program in the country to provide care and support for people living with HIV or AIDS.

"We lead the world when it comes to helping stem the AIDS pandemic -- yet we are one of only a dozen countries that still bar people from HIV from entering our own country," the president said. "If we want to be the global leader in combating HIV/AIDS, we need to act like it.”

Many applauded the announcement, saying it finally ends the discrimination.

"HIV or AIDS is just another disease like diabetes," said Chavez. "It transmits, but it is not contagious."

Shut Out

After the diagnosis and the loss of his job, Chavez, still in Peru, started volunteering at the local AIDS organization, Via Libre, which eventually offered him a staff position. Miraculously, he continued to live without any HIV medication because it was not available. But seeing many people suffering helplessly, his dedication to HIV/AIDS advocacy work grew stronger.

"I watched my friends die," he said. "Sometimes three or four died in one night. I need to work hard to make sure they have medicine and better quality of life."

In 1996, Chavez started to take medication through a program run by Aid for AIDS, a New York-based organization that provides services to people living with HIV or AIDS in Latin America and the Caribbean as well as immigrants from the region. It is called the HIV Medicine Recycling Program, which provides unused medication to patients in Latin America. The organization also runs other programs, including AIDS treatment access, immigrant program, children’s program, and prevention program among other things.

In 1998, Aid for AIDS established a branch office in Lima and hired Chavez. As he gained prominence in the HIV advocacy world in Latin America, his missed his father and sisters in the United States. In 2003, after a one-month trip to the United States on a one-year double-entry visa with a special HIV waiver, Aid for AIDS asked him to relocate to New York to serve as its director of advocacy. But his HIV status came up again as a problem. This time, he sought political asylum.

No Easy Asylum

"In my case, I had to prove I was persecuted because of my sexual orientation and my activism," said Chavez. "In addition, I had to prove that there was no medication available to treat HIV in my country."

Chavez is one of the few lucky ones. Obtaining legal status through seeking asylum is not an easy task and it requires a lot of supportive material, according to Vishal Trivedi, project manager of the Immigration Project at Gay Men’s Health Crisis, which provides direct legal representation as well as consultation.

"You have to submit the application within a year of your entry," Trivedi said. "The basis of asylum is either past persecution or a well-founded fear of future persecution. You can argue that because I am HIV positive, I was a target of persecution or it is likely I will become a target. … I would be beaten, tortured or killed and there is no government protection."

"The burden of proof is on the applicant," said Trivedi, adding that proof can include documents such as State Department reports, reports by Human Rights Watch, newspaper articles, scholarly study and eyewitness testimonies.

For Eric Wong the obstacles proved too great. A native of Hong Kong, he came to New York in 1998 as an international student and tested HIV positive in 2000.

"I cannot seek asylum because I am not persecuted in Hong Kong, and there is medicine available," said Wong, who used a false name to protect his privacy. "But everybody has preferences in terms of where to live. This is where I feel most comfortable."

After graduation, Wong worked for a company on a H-1B work visa for six years until the visa expired. When the company offered to sponsor him for a Green Card, he declined, fearing that the medical exam required for the application would reveal his HIV status. He later switched to a different employer and obtained another temporary work visa under a different classification.

Obama’s announcement brought him hope.

"It was huge," said Wong. "I was in tears. Who would’ve thought? It is like part of my dream came true. Now I realized that I actually have an opportunity, even though it is very slim."

To Wong, immigration is a race with time. His current job is not permanent and will most likely end next year. So the Obama announcement could provide a reprieve. Now that his HIV status is no longer a roadblock, he can try to obtain a work visa other than H-1B.

Wong wants to get an O Visa, which is granted to people with extraordinary abilities. His lawyer said this would be difficult. Another alternative is to get married. But being gay, he cannot marry his longtime partner in New York and does not want a paper marriage. Wong does plan to enter the diversity visa lottery, which allows citizens from countries with low immigration to the United States to enter to win a Green Card.

Chilling Effect

The entry ban, introduced during the peak of the AIDS pandemic, was written into immigration law in 1993. It included mandatory HIV-testing as part of the medical exam.

The rule has had a long-lasting effect on Wong, who is paranoid about traveling. "Every time I left the country, I had to flush all my pills down the toilet on the way back before I got off the plane," said Wong. "What happens if they check my luggage and find all those pills? I was afraid to travel. Everything was in limbo."

In addition to the stress and anxiety, the cost of HIV medicine is also prohibitive. Wong pays $1,000 a month for his health maintenance organization because his employer does not provide health benefits.

"But I am lucky to have a job and could afford the medicine," said Wong, who prefers to pay for his own treatment rather than to seek help from HIV organizations. "My insurance is expensive but it doesn’t have many restrictions. My immigration problem is stressing me out already, so I just want to make sure I have a good health insurance."

Image from the cdc.gov

Syphilis is caused by the spirochetal bacterium Treponema pallidum.

The solution is not simple, and the cause is even more complex. That's what experts and advocates say about the reemergence of syphilis in New York City and across the country. The number of cases among both men and woman and in all ethnic groups has risen, but the disease hits some parts of the population more severely than others.

In an effort to combat syphilis and other sexually transmitted diseases, the city health department handed out a record number of free condoms this year. Government and private groups have launched public education campaigns, and free testing clinics exist around the city. Still, as the numbers continue to rise, advocates think the city and health organization must design campaigns more closely tailored to the group hardest hit by the increase in the infection: men of color who have sex with men.

The Disease's Targets

In 2000, the national syphilis rate fell to its lowest point since 1941. But it has increased annually since then; New York City cases nearly doubled to 282 in 2001, according to the Centers for Disease Control and Prevention. This year 1,079 cases were reported, up 12 percent from last year. City health department data shows that the highest concentration of syphilis is in Chelsea.

Men who have sex with men account for 87 percent of cases, with the disease most prevalent among African-Americans. Well over half the victims are HIV positive.

"The connection between HIV and syphilis is really disturbing," said Sean Cahill, managing director of public policy, research and community health at Gay Men’s Health Crisis in Manhattan.

Syphilitic sores facilitate transmission and contraction of HIV/AIDS. And the same is true the other way around -- anything that weakens the immune system makes people more vulnerable to other infections.

This bacterial infection spreads through skin-to-skin contact. Congenital syphilis is passed from a mother to her child during childbirth. According to the website of the New York City Department of Health and Mental Hygiene, antibiotics can cure syphilis, but the chances of curing the infection becomes more difficult the longer someone waits to get treated. The most infectious stages of the disease are primary and secondary syphilis. These stages are also the easiest to treat.

A Web of Risks

Experts point to a number of factors that have contributed to the resurgence in syphilis. One is what health experts call "risky sexual behavior," including having unprotected sex and having multiple partners. The 2009 Mayor's Management Report, for example, attributes the rise in the disease "primarily to increases in risky behavior among men who have sex with men." One factor here is substance abuse.

Jose Gonzalez is the founder and president of TRI Center, which offers rehabilitation services in Manhattan, Brooklyn and the Bronx. Gonzalez said there was a "high correlation between sexually acting out and the drug use." He added that education about how to avoid HIV and sexually transmitted diseases can be part of some people's treatment plans. Engaging in high-risk sexual behavior and other compulsive behavior is "just one of the medical aspects of the disease" of addiction, Gonzalez said. He said health clinics should ensure that clients who test positive for STDs are asked about their substance habits to see if they need more comprehensive care.

At the Lesbian, Gay, Bisexual and Transgender Community Center, substance abuse treatment focuses on the clients' particular vulnerabilities. "We’re looking at the areas we would call 'disconnections,'" said Carrie Davis, the director of adult services who also directs the center's CARE Wellness and Recovery programs for substance abuse treatment and prevention.

Social stigmatization can cause these "disconnections" or "isolations," as can particularly difficult transitions in people's lives, like coming out to family members. Hard times can lead to substance abuse and other risky behavior, which could play a factor in the spread of sexually transmitted diseases.

"From an overall prevention standpoint, I think it's really critical that we de-stigmatize LGBT identities," said Davis.

Unprotected sex also has to do with inadequate or absent sex education for young people, said Cahill from Gay Men’s Health Crisis.

While condom use has increased around the city, Cahill said not everyone uses them properly. For example, some people may use lotions that render the condom ineffective. Susan Blank, assistant commission for the city's Bureau of STD Control, said people reported not using a condom during oral sex, when syphilis also can be transmitted.

But risky behavior cannot explain the racial disparity incidence in sexually transmitted diseases. In 2006, non-Hispanic blacks of all ages had the highest rates of chlamydia, gonorrhea and syphilis of any group nationwide, according to the Centers for Disease Control. But national and New York City studies show that gay and bisexual African-American men do not participate in behaviors deemed "risky" at a higher rate than white men who have sex with men.

A New York City report produced as part of the National HIV Behavioral Surveillance Study found that white men who have sex with men "had the lowest HIV prevalence, yet higher rates of many HIV risk factors." For example, binge drinking and alcohol use during sex were more common among whites.

New York City is one of 25 sites participating in the national study, which began in 2004 and focuses on at-risk populations.

Patrick Wilson, an assistant professor and researcher at the Mailman School of Public Health at Columbia, is among those studying why African-American men have higher rates of syphilis than white men. He says a key factor is an individual's "sexual network," such as the number and profile of partners.

In addition, Wilson has found, there is a kind of vicious circle at work here: The prevalence of syphilis and other sexually transmitted diseases among African-Americans produces high rates of HIV and vice versa. Also, Wilson has looked at the characteristics of the sex partners and has found evidence that young African-American men tend to have older partners. Older partners, by virtue of their age, are more likely to have syphilis themselves and more likely to have sex with men of the same race/ethnicity, said Wilson.

Getting Treatment

And then there is access to health care.

"Access to treatment and health care is a huge issue," said Wilson, Dealing with that, he said, is "not an easy step to take but it is a step that we can take."

A 2007 report by the city health department in 2007 found that " Hispanics, men, younger adults, people with low income, and residents of the South Bronx, South Brooklyn, and West Queens are more likely than others to lack insurance and a regular provider." It determined that 25 percent of Hispanics, 21 percent of Asians/Pacific Islanders, 16 percent of blacks and 11 percent of whites in New York City were uninsured in 2005.

The study also compared data on testing for HIV, finding that "among those with two or more sex partners in the past year, those without a regular provider are less likely to have been tested recently." Delaying treatment increases the severity of the virus and likelihood that the infected person will pass it on, whether it's HIV or syphilis.

The Latino Commission on AIDS, based in Manhattan, has tried to create a space geared specifically toward Latinos. The commission’s director of health policy, Oscar LĂłpez, pointed to their MPowerment Project as particularly successful and effective.

"The focus is building community and addressing the feelings of isolation that many experience,” said LĂłpez, who explained that many of the members only speak Spanish and are separated from their families. While the commission only offers HIV testing, the experiences of its members indicate many avoid other types of testing or care. LĂłpez said many of the men he works with have a "mistrust of the system" or worry about deportation, so they either do not seek medical attention.

The city tries to encourage these men to overcome their fears. Its Bureau of STD Control operates 10 free and confidential testing clinics: three in Manhattan (although one in Central Harlem is closed for renovations), three in Brooklyn, two in Queens, and one each in the Bronx and Staten Island.

Blank said that staff doesn't ask for immigration papers before testing a patient. LĂłpez agreed that he had never heard of such a case in New York City, but that undocumented immigrants had been picked up in other states and these stories can act as a deterrent.

Fighting the Disease

The current resurgence in syphilis is surprising but not completely unexpected due to the many factors working together to spread the disease, said Wilson. He believes the trend will reverse but only with a lot of work.

"It really depends on our prevention and our treatment efforts and how robust those efforts end up being," Wilson said. And those efforts have to correspond with the actual trends and the reasons for those trends. According to Wilson, doing that also requires support from all levels of government and funding to bolster efforts already in existence.

On a state level, the New York State Department of Health, AIDS Institute and Center for Community Health, and Health Research, Inc. accepted grant applications last month for organizations working with gay men and men of color who have sex with men.

The city also has made efforts to collaborate with community-based organizations to combat the spread of syphilis. The Syphilis Advisory Group, formed as a direct response to the flare up in 2002, according to an email from the health department press office, is a coalition of the health department, the New York State AIDS Institute and community-based organizations that work with gays and lesbians. The group aims "to improve the quality of internet-based HIV and STD prevention, as well as partner notification services."

The Internet could play an increasing role in this, according to Wilson. Companies have created anonymous online notification systems to allow people to inform past sex partners if they are at risk of infection and encourage them to get tested.

Davis also would like to see advocacy and information at commercial sex venues, where adults to pay to engage in sexual activity on site. This, he said, could keep the parties from going "underground."

The advisory group is looking into this too with the Commercial Sex Venues Workgroup. With the help of the health department, the group plans to "establish new community partners (e.g., owners of sex clubs) to raise syphilis awareness in these venues, increase condom usage, and encourage regular STD screening."

Gay Men’s Health Crisis currently provides testing at three commercial sex locations in the city, said Cahill.

In the past, the city had tried to shut down such establishments. Cahill said he did not see a push for closures recently. But these are fights that date back to the early years of the AIDS epidemic and government closures of bathhouses in an effort to stem the rising crisis.

With the AIDS crisis, there was a tendency to blame the victims. With syphilis, Wilson and others said it is important not to do that.

"There’s not a sound bite that can really explain how this happens," he said. Dwelling on that, he said, could only end up “maligning” affected communities.

Instead, Wilson said, efforts should remain focused on targeting the numerous facets of the disease: "We’ve still got a firefight going on. It’s not at all over."

Photo (cc) uberzombie

Ambulances wait outside Columbia University Medical Center

The financial stakes of federal health care reform are high. I am a strong believer that we need to rethink the way we provide health insurance for all Americans. However, I also feel strongly that the health care reform legislation currently under consideration in the United States Senate can and must be made better for the residents of New York State.

As New Yorkers, we should be proud of our state’s trailblazing leadership in developing important public programs like Medicaid, Family Health Plus and Child Health Plus. By broadening eligibility for these programs, we have dramatically reduced the ranks of uninsured. Unfortunately, under the bill approved by the Senate Finance Committee last month, New York and nearly 10 other so-called leader states will be fiscally punished for their efforts.

The Senate bill would provide new federal money only for states whose eligibility for public coverage programs currently falls below the new federal minimum -- an outcome that the New York state health department estimates will result in an additional $900 million in annual costs for New York State. In this area, the House bill is better and rewards all states -- regardless of previous coverage levels -- for expanding public insurance coverage.

Penalizing High-Cost States

The Senate Finance bill also could better address the needs of high cost of living states, like New York. This bill provides insurance premium subsidies based on the federal poverty level, which does not recognize the high cost of living -- and of health insurance -- in New York State. The value of the proposed insurance premium subsidies will not go very far in New York’s high-cost health insurance market.

A new affordability exemption, included in recognition of the unfair burden that high health insurance premiums might place on lower-income families, would allow many New Yorkers to opt out of the insurance mandate. Some estimates indicate that as many as 500,000 New Yorkers might accept this exemption and remain uninsured. While nearly 2 million would still get coverage, I believe that we can, and must, offer better subsidies to reflect the realities of high cost states such as New York.

Protecting New York's Protections

New York has some of the strongest consumer protections in the nation. Our state has guaranteed open enrollment and renewal and significant limitations are placed on insurers regarding exclusions for pre-existing conditions. We are the only state in the country that has a pure community rating model, meaning that health insurance rates are the same for everyone, regardless of age or health status. This protects our most vulnerable residents and ensures that the cost of illness and disability is shared fairly across our state.

New York also has strong external review and appeals protections, which encourage expeditious resolution of claims disputes. The Senate Finance bill would curb the worst insurance abuses and provide new national protections that would act as a national floor, but not a ceiling for insurance regulation. But insurers still will be able to charge higher prices for older people and people who smoke. New York will maintain its superior rules, though some are concerned that the existence of a federal floor will create pressure on New York to loosen its laws.

Several other provisions of the Senate Finance bill raise red flags for New York State. Its version of health care reform would change one of the ways that we reimburse hospitals that care for people who do not have insurance. This would devastate New York City’s public hospital system, the Health and Hospitals Corp., for which these payments are a critical source of funding.

A new small business tax credit, meant to help small businesses because their cost of insurance is higher than for larger companies, is pegged to wage rates. Hence, New York’s high cost of living and relatively high wages would leave many small businesses ineligible for federal help.

Finally, a tax on high-cost insurance plans, intended to discourage people from buying more health insurance than they need, will harm many New Yorkers more than people in other states. The high cost of health care in the state has led to insurance premiums that are correspondingly high and the relatively high rate of unionization in our state has led to more generous benefits packages for New York workers. As a result, New Yorkers will likely pay considerably higher taxes on their health care.

Looking Out for Our Interests

So where does this leave New York? The good news is that there is still time to improve the Senate bill -- first in the melding with the Senate Health, Education, Labor and Pensions bill, and second when the House bill and the Senate bill are crafted together in conference. In addition, none of the provisions of health care reform begin immediately, which provides New York State an opportunity to think through our plans.

It would be wise for our state to put together a team that includes representation from the executive and legislative branches, as well as relevant stakeholders, to generate, discuss and vet ideas and plans. Bringing providers, consumers, health plans providers and insurers together increases the likelihood of getting it right, and of being sure that key issues are not overlooked. National health reform presents a huge challenge for New York State. It will take all our best efforts to get it right at the federal level and make it right for New York.

Thomas K. Duane, a Democrat, represents 29th Senate District on Manhattan's West Side and parts of the East Side and chairs the Standing Committee on Health.