In the news recently we have seen the controversial proposal by the City’s Health Department to address the epidemic of obesity by limiting the use of transfats by restaurants and fast food outlets. The city’s health professionals are also working in neighborhoods with high rates of obesity and diabetes to promote the sale of healthy foods. At the same time, city officials are moving to improve the quality of food in school cafeterias. Obesity has reached epidemic proportions in the city, with 43 percent of elementary school children found to be obese or overweight. Health specialists acknowledge that diet and exercise are two key factors related to this epidemic, and they are working seriously on diet.

But what about exercise? Can the city do anything more to increase physical activity? This is a more difficult issue, and not as simple to address. Physical activity is also related to another serious epidemic in the city –- asthma.

Researchers around the nation are beginning to explore ways in which the built environment of the city affects public health, particularly with respect to epidemics like obesity and asthma. They are raising the question of whether public policy can help create a healthier environment through better urban planning and better building and zoning codes. One of the main reasons for instituting building codes and zoning regulations a century ago was to control contagious epidemics like tuberculosis that bred in the dark apartments and alleys in working class neighborhoods. City planning’s mission was to improve public health by creating a set of clear rules for developers that would produce healthy environments.

What Can Zoning Do To Promote Health?

New York City’s planners oversee a zoning code that regulates what can be done on every piece of property in the city. They are also charged with assessing the environmental impacts of all major new development in the city, and any changes to the city’s zoning code. These are levers that could be used to influence the elements that contribute to epidemics even if they alone won’t cure them.

Eva Hanhardt, coordinator of the Environmental Planning Masters Program at Pratt Institute, is studying new mechanisms for reincorporating health into urban planning regulations. According to Hanhardt, the foundation for zoning and land use regulations is government’s power to act to promote the “general health, safety and welfare.” Why is it, she asks, that “health doesn’t get the same attention as safety and welfare? By neglecting to incorporate public health in the design of land use and zoning policies, these policies have been part of the problem, not part of the solution.”

While obesity isn’t a contagious epidemic (and the same can be said for asthma), it is strongly clustered geographically, which could lend itself to some kind of land use regulation. Obesity cases in New York are concentrated in low-income neighborhoods and in Staten Island. In low-income neighborhoods, they may be associated with high concentrations of fast-food restaurants, limited access to healthy food, and limited access to both public and private recreational opportunities. In Staten Island, they are most likely related to the high dependence on automobile use; Islanders are less likely to walk and use mass transit. Asthma is also concentrated in low-income neighborhoods and related to a host of environmental conditions, including ambient air quality, both indoors and outdoors, access to healthy food, and recreational opportunities.

Planning the Active City

At the national level, urban planners are applying techniques of “smart growth” –- concentrating new development -– and transit-oriented development to overcome the effects of environmentally damaging sprawl. These strategies are aimed in part at encouraging walkable communities and reducing reliance on the automobile. Public health benefits may include reduced risks of obesity (due to walkability) and asthma (due to cleaner air). New York City, however, is already one of the least auto-dependent cities in the nation, and faces high rates of both obesity and asthma, which are particularly acute among children. This suggests that limited, isolated changes in the physical form of the city may not be enough to deal with these complex epidemics.

One of the arenas health-minded planners are exploring today is access to open space and recreation, especially for children. New York City’s shortcomings in this category make up for its advantages in density and walkability. New York has one of the lowest ratios of park acreage per person in the nation, new parks are rarely built while the population continues to grow, and the parks department budget is under perpetual siege. New York City schools also have chronically limited recreation space and programs, and it is not uncommon to see school playgrounds become parking lots for teachers. And even though large parts of the city are walkable, other parts, including those adjacent to expressways and major avenues, have hazardous walking environments that expose people to large doses of air-borne contaminants and risks to pedestrian safety. A recent study sponsored by Transportation Alternatives showed how residents on high-traffic streets tend to stay home more.

The city’s land use regulations already include minimum requirements for open space. These could be adjusted to encourage more active recreation. The Zoning Resolution restricts the location of sex shops in the city, so it could also limit the location of fast food outlets, keeping them away from schools, as one member of the City Council has already proposed. Zoning can limit large drive-to supermarkets and encourage local markets selling fresh produce. Parking regulations in the zoning code could reduce or eliminate requirements, thereby discouraging auto use. And the city’s zoning could address the existing wide disparities in exposure to environmental risks by restricting the concentration of hazards in neighborhoods where rates of asthma and obesity are highest. These are disproportionately low-income communities with non-white populations, so this is also a question of fairness and social justice. While the principle that no neighborhood should have more than its “fair share” of certain facilities, including polluting ones that have negative health effects, is enshrined in the New York City Charter, it has yet to be applied in land use decision making in a way that addresses current disparities.

According to Eva Hanhardt, however, land use policy “has to do with more than just controlling the physical location of facilities, but should also address the outcomes” by looking at the effect of these facilities on human health. Planners in some cities have suggested requiring “health impact statements” the way environmental impact statements are required for major land use changes. Other cities have established environmental quality goals and targets that individual departments, including transportation and planning, must address. A goal-oriented approach in New York might include targets for reducing traffic, improving access to active recreational facilities, and eliminating the disparate effects of environmental hazards. The first step, however, is for the city’s planners to reestablish a role for themselves in promoting public health.

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. 

In an important victory for immigrant communities in New York City and throughout the state, the New York State Department of Health has adopted regulations setting basic standards for hospitals’ communications with patients who speak limited or no English (or who are hearing- or vision-impaired).

The regulations, which went into effect on September 13, 2006, require all private and public hospitals in New York State to provide skilled interpreters, translate important hospital forms into commonly-used languages, and ensure that patients awaiting care do not face excessive delays because of language issues.

A Life and Death Matter

Millions of New Yorkers stand to benefit from the new rules. One in four New York State residents, and one in two New York City residents, speaks a language other than English at home. In the city, 1.7 million residents—one in four—are not proficient in English.

Hospital communication barriers can lead to serious problems, including misdiagnosis, failure to obtain informed consent, performance of unnecessary medical procedures, illegal delays or denial of care, and severe medical harm. In order to communicate, many patients with limited English are forced to rely on untrained and unskilled interpreters—often a minor child or stranger.

Existing federal, state, and local laws require hospitals to avoid discrimination and provide meaningful access to health care, regardless of a patient’s national origin or the languages he or she speaks. Nonetheless, advocates have documented the widespread failure of hospitals to communicate in the languages commonly spoken in the communities that the hospitals exist to serve.

In one case that was reported in The New York Times, Mr. Chul Sun Moon, a non-English-speaking Korean immigrant, died from head injuries sustained in a soccer game, despite repeated visits to Flushing, Jamaica, and Brookdale Hospitals over the course of a month. Moon never had a chance to discuss his condition or treatment with doctors in a language he could understand. He and his wife relied on strangers and on relatives in Boston, via cell phone, in their struggle to understand what was happening.

In another instance, advocates from the Latin American Integration Center monitoring St. Vincent’s Hospital in Staten Island witnessed emergency room staff using a seven-year-old child to explain to a patient in Spanish that he needed an emergency amputation.

These and many other documented cases of communication barriers led immigrant groups to file civil rights complaints with the state attorney general in 2005 against four hospitals—Flushing, Jamaica, and Brookdale medical centers and St. Vincent’s Hospital on Staten Island. The complaints helped spur the development of the new Health Department regulations, and last month, the four hospitals and the state attorney general’s office announced language assistance agreements that closely track the new regulations.

What Can Immigrant Patients Expect?

With the new regulations now in effect, hospitals are required to have an effective system in place to communicate with patients who speak little or no English. For the first time, hospitals have clear standards they must meet to ensure that the health and safety of patients will not be compromised by language barriers.

The new rules do not require hospitals to have large teams of interpreters who speak every possible language that is spoken in New York City. Hospitals are afforded great flexibility in using bilingual hospital staff, interpreters, volunteers, and telephone language assistance lines to communicate with patients. Quality matters: Hospitals are responsible for evaluating and ensuring the adequacy of language skills of all staff, volunteers, and contractors who provide communication assistance.

Hospitals are not permitted to use a patient’s family members, friends, or non-hospital personnel as “interpreters,” unless free interpreter services have been explicitly offered to the patient and been declined.

Patients who speak limited or no English should expect the following in every hospital in New York:

• The hospital must offer and provide communication assistance from fully-bilingual staff or skilled interpreters in a language that is understandable to the patient during the entire medical visit. The hospital must ensure appropriate communication when the patient calls to make an appointment, registers for care, and interacts with nurses, doctors, counselors, and non-clinical staff such as the hospital’s financial assistance and insurance enrollers.

• The hospital is responsible for identifying the patient’s preferred language and documenting it in the medical chart. Documenting the preferred language ensures that various departments will be aware of communication assistance needs when coming into contact with the patient, and makes it possible for the hospital to prepare for subsequent medical visits by having the appropriate language assistance services available at the time of the appointment.

• If the hospital fails to communicate with the patient, the patient or the patient’s representative or physician should notify the hospital of the language he or she speaks, and request an interpreter.

• The hospital is permitted to use a variety of methods to provide language assistance services to patients with limited English proficiency. While the new regulations require hospitals to manage a pool of skilled interpreters, it does not specify what form the interpretation should take in any given patient encounter. The hospital’s pool of resources may consist of full- or part-time staff interpreters, and/or bilingual health care and non-clinical staff, and may be supplemented by volunteers and contractors.

• As a backup, hospitals may contract with telephonic language assistance services. Such services may be acceptable when the hospital is interacting with patients who speak languages that the hospital encounters infrequently, or during off-hours in areas of the facility where on-site language assistance resources may be limited.

• The new regulations require hospitals to provide communication assistance to all patients within 20 minutes in inpatient and outpatient settings, and 10 minutes in emergency settings.

• Each hospital must provide key forms in a language the patient understands. Key documents include registration, billing, and consent forms for medical procedures, as well as medication and treatment instructions. Translated documents must be made available in those languages that are spoken by more than one percent of the hospital’s patients or the total hospital service area population. If translated documents are not available, a hospital should provide an interpreter to translate significant documents verbally for the patient at the time of a medical visit.

• Each hospital is required to post signs and distribute written materials notifying patients about the hospital’s free language assistance services, and provide patients and prospective patients with instructions for accessing services. These notices must be distributed in every language spoken by one percent of the hospital’s patients or service area population.

See also: Good Government Speaks Many Languages

Adam Gurvitch is director of health advocacy, and Norman Eng is communications coordinator, with The New York Immigration Coalitioion.  

Twenty-five years ago the first cases of HIV were diagnosed. Within a few short years, children were especially hard hit. A growing number of children lost their parents to AIDS. From 1985 to 1990, according to Tim Ross, a researcher at the Vera Institute of Justice, the number of kids in foster care in New York tripled, from 17,000 to about 50,000.

“The foster care system in New York City faced a double whammy,” said Ross. “There was an epidemic of crack cocaine use that hit women particularly hard, and there was this new disease.”

So many kids were being put in foster care, it was extremely difficult to find placements for kids with HIV, who had contracted the disease from their mothers at birth. There just weren't enough foster parents out there, and a number of potential foster parents feared the disease, refusing to take HIV-positive children into their homes. “Boarder babies” became a term used to describe kids who were literally growing up in hospitals because they couldn't find homes.

Social workers and foster parents struggled to learn how to care for babies and kids infected with this disease that many health officials themselves barely understood. To help pediatricians adjust, New York City's child welfare administration created a special Pediatric AIDS Unit to test kids in care who might be infected and to train the foster parents taking care of children with HIV.

New programs specifically targeting families affected by the virus also started being developed, like Highbridge Woodycrest, a housing program in the Bronx for families affected by AIDS. That program and others like it prevented infected families from being separated.

HIV And Youth Now

Since then, the impact of HIV/AIDS on families has been greatly reduced. Due to medical advances, there are far fewer babies born with HIV. Dr. Anne Lifflander of the Vera Institute estimates that the infection rate among babies born to mothers with HIV has gone from about 25 percent to less than six percent. The number of adults getting HIV has also gone down. Thanks to better treatments, adults with HIV are living longer and more productive lives.

But teens, especially African-American teens like myself, continue to be at a high risk for HIV. In New York City alone, 1, 180 people aged 13 to 24 in March 2003 were known to have HIV. And that is just the teens who were tested. In 2004, more than half of all people in that age group diagnosed with HIV/AIDS were African-American.

Why is HIV continuing to affect so many teens? Some say it is because we teens think we are invincible. According to a survey by the White House Office of National AIDS Policy, close to 90 percent of young Americans do not believe that they are at risk for HIV. This attitude can lead us to have sex without a condom even if we know we should use one. It can also make us not get tested.

For African-American and Afro-Caribbean teens, the typical teenage denial of how HIV could affect her or him is made worse by young men on the down low, a term experts use to describe young black males who have sex with other men while viewing themselves as heterosexual.

Also, black teens in New York City are at high risk for HIV because the neighborhoods where many of us live have high levels of poverty, crime and drug use. Experts say that young people in these conditions are more likely to have what is called survival sex -- sex for money, food, and shelter.

James Bolas, the director at the Empire State Coalition of Youth and Family Services, has worked with homeless and street-involved youth who are HIV-positive for over 18 years. Homeless and runaway youth, Bolas noted, often feel that they only have their sexuality as a means of survival. Bolas estimates that as many as ten percent of young people living on the streets in New York City are HIV positive.

Heterosexual young women in poor neighborhoods are also at risk. All of us teens know many young women involved with men in their 30s. Experts say these young women are less likely to insist on using condoms because they are afraid to lose their boyfriends’ financial support. And if they find out they are HIV positive, they might not tell their partners for fear of violence.

But regardless of our situation, the bottom line is that often, unless we teens know someone who has AIDS or HIV, it is difficult for us to absorb the reality that we could get it. I would know. A month before my 20th birthday, my boyfriend of two months found out he had HIV, and it made me nervous and scared. Luckily, my results came back negative. But I want to learn more about this horrible virus so I can be more informed for my boyfriend and myself.

Jarel Melendez, 20, is a writer for Represent, a magazine published by our partner Youth Communication. Additional reporting by Zaineb Nadeem and Adam Wacholder.  

At each of the City Council's stated meetings, council members introduce bills, most of which will never become laws (for the process by which bills become laws, click here). As a regular feature, Gotham Gazette discusses some of the legislation proposed at each meeting.

17 bills were introduced by the City Council at its most recent stated meeting on September 13, many of which addressed issues related to commuting, tobacco or alcohol abuse.

TRANSPORTATION

Council Member John Liu introduced two transportation bills.

The first, Intro 429 would give city employees the opportunity to use pre-tax earnings to pay for transportation. The law would also apply to employers with 50 or more employees in the city. Federal law currently requires that these employees are offered the benefit on parking. The new city law would expand the benefits to include costs such as unlimited ride Metrocards.

Liu is also concerned about illegal commuter vans, which were likely responsible for several hit-and-runs in Brooklyn and Queens last year. Intro 430 calls for the city-run commuter vans to be painted orange so that they are identifiable to both commuters and authorities as legitimate city vehicles.

DRINKING AND SMOKING

Studies have shown that smokers who have their first cigarette before the age of 18 have a one in three chance of becoming regular smokers, and young smokers also have a more difficult time when trying to quit, according to the office of Joel Rivera, head of the council's health committee.

Continuing the city’s efforts in recent years to cut down on smoking, Rivera proposed Intro 433, which would outlaw the sale of flavored tobacco products. Activists called for a ban on candy-flavored cigarettes this summer, as part of a campaign to curb teen smoking.

The bill would levy fines up to $2,000 on vendors who made such sales and suspend their cigarette licenses. Rivera previously introduced legislation to raise the age to purchase cigarettes to 21. Both bills will be discussed at a health committee meeting in the first week of October.

At the September 13 meeting, the council also proposed resolutions aimed at increasing control over alcohol consumption.

Councilmember Melinda Katz proposed Resolution 500, which calls upon the State Legislature to create an alcoholic beverage control board run by the city. City communities have argued in a memo to the legislature that the State Liquor Authority “has too few inspectors to properly provide enforcement,” and “issues liquor licenses without community input.” Katz's resolution calls on the state to create a City Liquor Authority with the authority to license and regulate alcoholic beverage businesses and provide “local solutions to problems that most frequently arise in [the city].”

Katz also introduced Resolution 501, which urges the state to ban nightclubs from offering “bottle service”, which requires customers to buy expensive bottles of hard liquor in order to gain access to the club or to exclusive areas. The resolution argues that bottle service adds excessive drinking.

The resolution also called upon the state to tighten laws regarding alcohol consumption in general, but especially by minors.

The big news story on the fifth anniversary of 9/11 seems to be the discovery of the "abandoned heroes" and forgotten victims of the attacks. A New York Post reporter wrote about the "shocking truth": many people had gotten seriously ill from the poisonous dust that the collapse of the Twin Towers spread across lower Manhattan.

While the newly-published statistics may be shocking, the wider truth shouldn't be. None of this is really news. The first newspaper article citing a serious health risk appeared in October 2001. The thousands of people who have gotten sick – no one is sure exactly how many – have been talking about their problems since immediately after the Twin Towers collapse, while medical experts have published a wealth of material pointing to a connection between 9/11 and long-term health problems. But these voices were lost in previous anniversaries, obscured by the public ceremonies mourning those who died in the attacks themselves and the intense focus on the glass-and-steel rebuilding of Ground Zero.

This year, though, is proving to be much different.

In the first week of September, Mt. Sinai Medical Center released a major clinical study of 9/11 rescue workers, providing what Representative Carolyn Maloney described as a "concrete scientific link between the exposure to the toxins of Ground Zero and health problems." Hours later, Mayor Michel Bloomberg announced a wide-ranging plan addressing 9/11 health concerns, and within two days Representative Jerrold Nadler proposed federal legislation calling for free health care coverage for anyone whose health was affected by the attacks.

There are still more questions than answers. The scientific picture is far from complete. There is, for instance, no firm information about the health of people who live or work near Ground Zero. And while there has been the promise of action on all levels of government, it has yet to be seen whether the words will be followed with action.

Skeptics are also withholding their judgment about some of the high- profile pronouncements from government officials that help is on the way.

"You probably won't hear so much on September 12," said Catherine McVay Hughes, a member of lower Manhattan's Community Board One who has long pushed for a better response from all levels of government.

WHAT WE KNOW ABOUT 9/11 HEALTH PROBLEMS

The past several years have been filled with ominous signs for people who worked at Ground Zero, and for those who live and work nearby. The lung capacity of firefighters who worked at Ground Zero decreased an amount equivalent to over a decade's worth of aging in the year following 9/11. People who live downtown have been showing increased respiratory problems, and those with asthma have suffered from more severe symptoms. In the months after 9/11, the babies born at hospitals in lower Manhattan were smaller than average.

Those who worked at Ground Zero or in nearby offices developed a new condition: "World Trade Center cough." Many were forced to cut back on work, or retire. This January, police detective James Zadroga died of respiratory disease, becoming the first person whose death was officially attributed to a problem caused by work at Ground Zero.

Days before the fifth anniversary of 9/11, Mt. Sinai Medical Center published the findings of its monitoring program. Mt. Sinai's study looked at about 10,000 of the 40,000 first responders who worked at Ground Zero. Seventy percent of the Ground Zero workers the center tested between 2002 and 2004 reported respiratory problems while working at the site. Of those, 60 percent have had persistent respiratory problems.

These results are proof, many say, that the dust from 9/11 can be directly linked to serious health problems. Mt. Sinai's study, however, does not tell the whole story. It did not screen for cancer, or psychological problems. And its focus was entirely on rescue workers at Ground Zero – not people who returned to work in offices in lower Manhattan, or those who moved back into apartments nearby.

"The lower Manhattan residents are the forgotten of the forgotten," said Yuichi Tamano of Beyond Ground Zero, a group pushing for recognition of the wider health problems related to 9/11.

The city has established a registry to track the health of 71,000 people who may have been affected by the collapse of the towers. Nearly half of the adults, a group that includes first responders, office workers, and residents of lower Manhattan, have reported sinus or nasal problems. Over half of those who survived the collapse say their respiratory problems are worsening.

This registry is the best attempt to realize the full scope of 9/11-related health problems, but critics say it is not very good. It is based on of people's own assessments of their health, they say, and registry researchers often don't ask relevant questions. Environmental activists, members of the city's congressional delegation, and downtown residents all say that there is a health crisis that extends beyond those who worked at Ground Zero. But the dimensions of that crisis remain cloudy.

GOVERNMENT ACTION AT LAST?

Julian Felipe stood across the street from Ground Zero in early September, pointing out the buildings from which he cleaned dust in the fall of 2001. Like many of the people called upon to clean these offices, Felipe moved here from another country (in his case Mexico). He speaks no English, and does not have health insurance. And, like many of those who worked alongside him, Felipe doesn't do physical work any more. He is too sick.

Felipe speaks quietly, his voice nearly drowned out by the chanting of hundreds of people surrounding him, his fellow participants in a rally for federal action to address their health problems.

"What we want is for the government to listen to us, to see the sicknesses that we have. Those who came to work here didn't know the problems we would have now," he said in Spanish. "If we would have known, we wouldn't have come to work."

Felipe's request – that the government simply acknowledge that there is a 9/11 health problem – is a testament to how little has been done. Now officials say they are planning to make up for lost time.

For his part, Felipe is skeptical. "They have told us before they would help us," he said. "But they have not."

City Hall

New York City officials have been slow to acknowledge that the collapse of the Twin Towers posed a lasting danger to city residents. Then-mayor Rudolph Giuliani encouraged people to return downtown. Mayor Michael Bloomberg has been questioning the idea that sicknesses can be directly linked to 9/11. Bloomberg's arguments seem tied to his reluctance to open the city up to widespread 9/11-related workers compensation claims. The city has been contesting many such claims, and has opposed efforts to extend workers compensation benefits for people who worked at Ground Zero.

On the last day of this August, city officials changed their tune when they announced that they would send clinical guidelines to doctors citywide about how to diagnose and treat adults exposed to the collapse of the Twin Towers. There have been calls for such guidelines since late 2001, and there has been no small amount of frustration about the years of delay. Critics say that people's health has suffered as a result. But city officials have argued they had to wait until there was scientific evidence linking the dust to specific diseases.

The release of the guidelines, presumably, was acknowledgement that of such evidence. Within days, though, the city backtracked. "I don't believe that you can say specifically a particular problem came from this particular event," he said.

Early this month, Bloomberg presented a broad plan for tracking and treating 9/11-related health cases – despite his doubts that such cases had to do with 9/11. The city will set aside $16 million to the Health and Hospitals Corporation – the agency that runs the city's public hospitals – to develop a specialty World Trade Center clinic providing free care to Manhattan and Brooklyn residents exposed to 9/11 dust. The clinic is scheduled to open in January 2007.

The city's health department will increase World Trade Center health monitoring, putting aside $12.6 million to do so, and is increasing the staff of its WTC Unit from 7 to 20 employees.

The mayor's office is also creating an internal panel to coordinate city responses to 9/11.

Bloomberg says the city can't be asked to shoulder the burden itself, however. He called for state and federal governments to help fund long-term monitoring and treatment programs.

Bloomberg's inconsistency has confused some who are involved in the issue, but they are hoping that his actions speak louder than his words.

"[The mayor] opened the medical clinic that is going to be open not only to the rescue workers but to residents and small business people," said Suzanne Mattei of Sierra Club. "That's a very significant new development because no government entity has done that."

Others describe the plan as a good first step. But because it lasts for only five years, the program will not be sufficient to deal with long-term health problems. No one believes that the city can confront this issue alone.

Albany

New York State's workers compensation program has been one of the only sources of help for people suffering from 9/11-related health problems. But the state's program has been criticized for denying people from benefits. Mattei's says the state has held people filing claims to an "unreasonably difficult burden of proving that their illness was caused by 9/11 pollution – even though they were healthy before the attack and only became ill after their Ground Zero work."

In any case, the time to apply for such benefits had passed. Those with newly emerging problems were ineligible for state aid.

In August, Governor George Pataki addressed these cases, signing a law that allowing Ground Zero workers more leverage in applying for existing workers compensation benefits. Some praised the law for increasing the benefits available. But it was also criticized for putting the financial burden largely on the city. Others saw it as a minor gesture at a time when an increasing amount of evidence showed that the problems are far worse than initially reported. Others complained that it fails to address the health problems of downtown residents.

The recent revelations about the extent of the health problems are likely to push the issue higher on Albany's list of priorities, said State Assembly Speaker Sheldon Silver.

In early September, Silver said that "it's premature" to decide how the health of residents should be approached, but that a response from some combination of city, state, and federal governments should be forthcoming. He suggested basing such an effort on the Mt. Sinai program for rescue workers.

"It's clearly a major priority for the [next] governor," said Silver. When pressed about who would fund such an effort, Silver said that "it should be funded by everybody."

Washington

The federal government has shouldered much of the blame for the failure to confront post 9/11 health problems. The Environmental Protection Agency's assurances that lower Manhattan was safe to breathe despite having evidence to the contrary has been deemed "the big lie", a shocking example of a government unconcerned with the health risks associated with the toxic dust that coated lower Manhattan.

Since then, the federal government's response has been practically nonexistent.

But many say that only the federal government has the resources to respond. The city's congressional delegation has been pushing for a more active approach. To date, its efforts have not been overwhelmingly successful.

Late last year, Washington set aside its first funding for 9/11 treatment programs -- $75 million – but that money has not been released. Representatives Maloney and Vito Fosella pushed for a "Health Czar" to coordinate a federal response. In February, John Howard was appointed to the position, but has since referred to himself as a "czar without a budget." In early September, the Health and Human Services Secretary said he was appointing a task force to further examine Washington's response.

"I welcome this commitment from the secretary, but quite frankly the sick responders of 9/11 don't need another task force or another point person," said Maloney. "They need medical monitoring and treatment."

On September 7, Representative Jerrold Nadler introduced a bill that would extend Medicare benefits to anyone whose health has suffered because of the attacks. Further, he would exempt them from the premiums, deductibles, and co-payments that regular Medicare recipients are responsible for. The bill would also establish a consortium of experts to continue to research 9/11 health conditions for the federal government.

Nadler said that the bill is not likely to be considered before this fall's elections, but he hopes to pick it up when Congress returns to session in January. When it does, its cost will probably prove to be a major issue.

"We don't have a precise cost estimate because we don't know how many people will get sick over the next 40 years," said Nadler. "But off the top of my head I'd say this will cost several billion dollars."

Nadler says the federal government has a moral obligation to right the problems it has created through a response marked by "lies an deceit, and a deliberate decision to not enforce environmental laws." But he says that much of the damage is irrevocable.

"We may see more deaths as a result of the government's inaction than as a result of the attacks themselves," he said.

 

If in 1969, you were a 21-year-old college student in Illinois, and you wanted an abortion, it was an expensive operation -- and an illegal one. Four states had passed laws allowing for some exceptions to the ban, but even in those states, abortions were not readily available. It was not unusual for a young woman to spend her life savings -- and perhaps those of her friends -- to end an unwanted pregnancy.

A year later, New York State passed the nation's first law legalizing abortion without restriction up to the 24th week of pregnancy. It was pioneering legislation, but only a few states would follow. A young woman in Illinois would still need to raise a large amount of money either to travel to New York or to find an illegal abortion.

When the United States Supreme Court overturned state restrictions on abortions with Roe v. Wade in 1973, abortion became legal everywhere for everyone. Over the years, more and more states have passed more and more restrictions, and fewer and fewer clinics operate in the heartland, making abortion difficult to obtain in most places. But New York laws are still among the most liberal.

This fall, with two newly appointed conservative justices in place, the Supreme Court is poised to reconsider Roe v. Wade. Illinois is among the 17 states that will reinstate an abortion ban if Roe is overturned. The U.S. Senate and House recently passed different versions of a bill called the Child Custody Protection Act, which, if reconciled between the two legislative branches, would criminalize the transport of minors across state lines for an abortion by anyone except a parent.

The issue of abortion remains so contentious that when the Food and Drug Administration announced last week its approval of the over-the-counter sale of Plan B - a morning-after contraceptive bill - for women 18 and older, both abortion opponents and supporters took issue. The president of Pharmacists for Life International, Karen Brauer, objected to the availability of the drug. She told WDC Media (a Christian news agency) that Plan B "operates significantly to stop the life of an early human." The National Organization for Women applauded the approval by the FDA but said the pills should be available for minors as well.

Whatever happens nationwide, New York's pioneering laws are likely to remain in effect, no matter how little company they have. Meanwhile, in Illinois and much of the rest of the country, young women will still have to raise the money to go elsewhere to end pregnancies. Often that elsewhere may well be New York.

Views Of The Public, And Public Officials

New York City is likely to remain one of the easiest places in the country to have an abortion. Much of this may be a reflection of the prevailing attitudes here, as demonstrated in the positions of public officials (and candidates).

Laws concerning abortion are state-wide. The state-wide candidates for office who are widely given the best chance for winning in this year's election make a point of displaying their pro-choice credentials. On Democratic gubernatorial candidate Eliot Spitzer's Web site, he lists his endorsement by NARAL, the pro-choice group and reprints his speech to them.

Besides supporting New York's liberal abortion laws, he promises that if Roe v. Wade is overturned by the Supreme Court, he will review state laws and strengthen any that the court decision will throw into jeopardy. He also supports easy access to emergency contraception and the right to late-term abortion.

Despite Hillary Clinton's statements in a January speech about teen celibacy, prayer, and the "tragic choice" that abortion represents, her campaign Web site proclaims a solidly pro-choice position, though she does repeat that abortion should be "safe, legal and rare."

It is more difficult to find the views towards abortion of the Republican candidates for these offices; abortion is not mentioned on their Web sites, no matter what their position. But in a debate on August 9th between the two Republican candidates for U.S. Senate, John Spencer said he would restrict abortion except to save the life of the mother, while his opponent, Kathleen Troia McFarland , a former Reagan official, said she supports abortion rights.

The Republican candidate for governor, John Faso, has worked to restrict abortion when he served in the state assembly. His positions are outlined not on his own Web site but by a Westchester County pro-choice group.

It is worth noting that Faso is reportedly the first anti-abortion candidate for governor in either party in more than 25 years.

No matter who becomes governor, though, measures to restrict abortion in the state are unlikely. The State Assembly remains solidly pro-choice. "The Assembly has been at the forefront of protecting and ensuring women's rights in New York State," says Eileen Larrabee, spokeswoman for Assembly Speaker Sheldon Silver. "Obviously it's something we need to continue to push to ensure those rights are not chipped away." The Assembly Speaker's staunch pro-choice stand frustrates Lori Hougens of the New York State Right to Life Committee. "New Yorkers support a ban on partial birth abortions and are in favor of parental involvement legislation, which would make sure parents know that their underage daughters are having an abortion," she wrote in Gotham Gazette. "But in the Assembly, Speaker Silver will not allow a vote on the floor for legislation banning partial birth abortions or requiring parental notification."

The State Senate is more conservative, but the abortion issue doesn't come up there, says Mary Alice Carr of NARAL Pro-Choice New York. Without Assembly support, a bill would not reach the governor's desk, so passing restrictions would be pointless. "A lot of legislators," says Carr, "don't want to deal with the issue."

One Out Of Every Ten Abortions

Despite restrictions and a dearth of clinics in most states, abortion remains a common experience across the country. One out of three American women has had an abortion by age 45, reports the Guttmacher Institute, which tracks abortion laws and statistics. The majority of women who get abortion already have children (61 percent) and are poor (57 percent). Women of color make up most of those who get abortions: While 41 percent are white, 32 percent are black, 20 percent are Hispanic and 7 percent are other minority races.

But New York Magazine has called New York City "The Abortion Capital of America." Women come here for the procedure. "New York City has the least amount of practical barriers," explains Carr of NARAL Pro-Choice New York. One out of every 10 abortions in the nation is performed in New York State - 120,000 abortions performed in New York State in 2003, according to the New York State Department of Health. Seventy percent of those are performed in the city, where there are 34 major clinics.

Medical training

Unlike other parts of the country, if you go through a residency in obstetrics/gynecology in New York City, you'll learn how to perform abortions. That's because Mayor Michael Bloomberg, shortly after taking office in 2002, ordered city hospitals to include such training. There's a similar requirement in the California university system, but nowhere else.

It might seem obvious that someone going into obstetrics and gynecology would learn how to perform an abortion, if only for emergencies (such as completing a miscarriage). In fact, the accrediting agency for graduate medical education has required such training since 1995, says Lois Backus, director of Medical Students for Choice, a national organization promoting reproductive and abortion education for physicians in training. Despite those regulations, only 12 percent of the OB/GYN residency programs train first first-trimester abortions. Only 7 percent train for second-trimester abortions.

Backus says that her organization is particularly interested in making sure medical students, not just specialists, receive education on family planning and abortion. "No more than two-thirds [of medical schools] provide any required medical education on abortion," she says. And those schools often focus "only on the ethical issues" not on clinical practice.

Most hospitals across the country do not provide abortion services, so medical students would have no opportunity to learn about the procedure firsthand. That effectively blocks training for medical students.

For medical students "New York City is actually fairly good and largely due to Mayor Bloomberg," says Backus. Unlike most other places, "there is hospital-based abortion and family planning, that students gain access to as they go through medical training. In most of the rest of the country, that clinical care is not provided in hospitals where students receive most of their training."

Another barrier for medical students involves an "opt-out" clause for hospitals. In 43 states, hospitals may refuse to participate in abortion services. In New York State, they cannot. "For example, with a religious hospital, if a woman comes in and is miscarrying and needs an induced abortion to complete the miscarriage, the hospital can't refuse to provide those services in New York," says Rebecca Wind of the Guttmacher Institute. "In most other states, they can." In those states, the woman would be transported to a facility that would do it.

That is not a rare scenario, says fourth-year Mount Sinai medical student Erika Levi. She's the regional coordinator of Medical Students for Choice. "I've seen many women coming in with a miscarriage who need a D and C [dilation and curettage-a surgical abortion]," she says. "It happens often enough to be an issue."

She thinks that she and most medical students in New York City receive a good education in reproductive issues including abortion. Because most of the hospitals do offer abortions services of some kind, students also learn about the procedure-and the women who undergo it-firsthand. In other parts of the country Levi says it is different. If the procedure is mentioned at all, it is in a pejorative manner.

Protesters

Vocal and sometimes violent protesters in many parts of the country make abortion more difficult for young women and sometimes dangerous for providers. From time to time, New York City has had its share of demonstrators, especially at the Margaret Sanger Center in Manhattan. That clinic sees some 11,000 abortions a year.

Carr of NARAL credits the tough enforcement by state Attorney General Eliot Spitzer and by Manhattan D.A. Robert Morgenthau. Strict enforcement of laws protecting clinics and their personnel has helped maintain safety. The possibility of violence is not just paranoia. Abortion clinics have been subject to bombings and staff have been shot. The Attorney General's Reproductive Rights Unit aims to keep clinic violence and intimidation at bay. "Peoples' safety is at risk," says Carr. "Laws are only as good as the people that enforce them."

Crossing State Lines

At present, most of the states near New York City also have liberal abortion laws, and facilities are available. However, nearby Pennsylvania and Rhode Island require parental consent for minors. Thirty-four states have parental consent laws, and 24 mandate a waiting period between initial consultation and the procedure. Second-trimester abortions are also more available and less expensive in New York City than elsewhere.

For some minors, the barriers to abortion may soon be insurmountable. If federal legislation called the Child Custody Protection Act becomes law, girls who don't want to consult their parents who come from Rhode Island, Pennsylvania and other parental consent states will not be able to do so accompanied or aided by an adult (unless the adult wants to chance prosecution).

If Roe v. Wade is overturned, 17 states plan to put into place highly restrictive measures that will affect all women, not just minors. Of those, only Delaware is near New York, so the impact might not be the same as it was when New York stood alone with abortion on demand as it did in 1970. Before Roe v. Wade, women from out of state accounted for 61 percent of abortions, according to New York Magazine.

"We would anticipate a situation that we saw pre-Roe v. Wade," says Carr of NARAL: "a haven for women across the country. New York would be taking on the burden of a lot of other states that outlaw abortion."

But that already happens to some extent. Abortion is now legal across the country "in theory, not in practice," says Carr. Some 87 percent of counties across the nation have no abortion provider, according to the Guttmacher Institute. It's particularly hard for low-income women and those who do not speak English. "Roe does not exist in practice for a lot of women in this country," says Carr.

The restrictions elsewhere already bring young women to New York for abortions. The Sanger clinic has reportedly seen an uptick of 21 percent more out-of-state women seeking abortions.

Paying for Abortion

For low-income women in New York, state Medicaid covers abortion services, because the Hyde Amendment, passed in 1976, restricts Federal Medicaid funding for abortion except in the cases of life endangerment, rape or incest.

Minors in New York can be covered by Medicaid. Some clinics offer sliding scales, so teens who can't afford the full fee (about $350 in the first trimester), can still obtain an abortion.

Whether the easy access to abortion in New York is a good thing is a matter of individual opinion. For the time being,, the procedure will remain easily accessible and affordable to the women in the city.

LINKS:

A Pro Choice Agenda for New York City by Andrew Stern
January 27, 2003
Andrew Stern is political director of National Abortion & Reproductive Rights Action League of New York State.

The Pro-Life Agenda by Lori Hougens
January 27, 2003
Lori Hougens is spokesperson for the New York State Right to Life Committee.

Planned Parenthood of NYC
 

Every year since 1993, Assemblyman Richard Gottfried has introduced a bill that would give the families of incapacitated patients the legal right to make their medical decisions for them, and every year the measure has been neglected in Albany's end-of-session rush. This year was no exception.

The Family Health Care Decision Act is not as controversial as the bill that would that would have forced employers to give workers health insurance (which didn't make it to a vote after months of high-profile campaigning). It doesn't pack the financial punch of cuts to nursing homes or hospitals ($490 million of which were restored on the last day of the legislative session). But its fourteenth consecutive failure will have tragic implications for a number of New Yorkers, say health care advocates, the state bar association, and others who have been pushing for its passage for the last decade and a half.

A mixture of indifference and culture-war politicking, they say, means that New York continues to deny its residents a right shared by most other Americans.

A LACK OF LEGAL RIGHTS

In New York, the family members of incapacitated patients are explicitly denied the right to make medical decisions for them.

This stems from a 25-year old court decision involving two patients with terminal conditions. One had specifically asked not to be kept alive if he fell into a permanent vegetative state; the courts ruled that the hospital should take him off a respirator. But it decided the other way in the case of a man with severe mental retardation and bladder cancer who complained of painful blood transfusions. His mother asked doctors to stop the transfusions -- which were expected to keep him alive for a matter of months -- but they refused. The state Court of Appeals ruled that such action could only be taken if the patient himself made a "competent request" (which the man could not make because of his mental condition).

This standard continues to exist today, even as most states now have laws specifically granting families the legal authority to make major medical decisions for loved ones. Aside from New York, Missouri is the only other state with such an explicit restriction.

In reality, the law does not always matter; doctors generally consult with patients’ families about treatment. But it is in the most difficult situations –those that involve a decision about whether to continue someone's life – when the restriction becomes an issue.

“It's only in the worse cases when things are really going wrong when people realize they really have no authority,” said Jack Freed, a physician working to change the state's policy. Patients have been left in legal limbo in such situtations, he says, because no one has the authority to stop sometimes painful and futile treatment.

There is a consensus among experts in the medical field that the best way for individuals to avoid this problem is to complete a health care proxy – a form officially designating someone else to make one's medical decisions – before they get ill.

But only 10 percent to 25 percent of New Yorkers have health care proxies today. After the Terry Schiavo case, there was a push to get more people to sign the forms, but it quickly died down. Experts believe that the numbers will not get much higher.

"I think you reach a point where those people who are going to do it have, and those who aren't going to do it are never going to," said Carol Levine, head of the Families and Health Care Project at the United Hospital Fund.

THE FAMILY HEALTH CARE DECISIONS ACT

The Family Health Care Decisions Act would set up a framework for determining who should make medical decisions when people cannot make their own. With the guidance of a physician, decisions would be made based on what family members believe a patient would want.

Allowing family members to stop a patient's life-sustaining treatment has the potential to be controversial – it was at the heart of the ugly Schiavo battle last year. But over 30 states have passed such laws. In New York, there is little opposition to idea at the core of the bill.

"What has happened to this legislation is that other issues – unrelated issues – have become attached to it," said Mark Alcott, head of the New York State Bar Association, which had made the bill a legislative priority this year.

These issues include two of the country's more intractable controversies: abortion and the legal status of domestic partnerships.

Gay rights groups are urging lawmakers to give domestics partners equal weight with spouses in the law, putting them first in line to make decisions. But while there was some debate over this language, the major point of contention for the past several years has related to the health of fetuses.

The New York State Catholic Conference has no stance on the domestic partnership language but insists that there be a guarantee that the health of a fetus be considered when making decisions made for pregnant patients.

Some advocates of the bill went along with this, arguing that it made no practical difference. "Obviously people would take it into consideration," said Freed. "It has no real practical effect."

As a result, the Catholic Conference dropped its previous opposition.

But earlier this month, Deborah Glick and several other members of the State Assembly decided to make an issue of the domestic partnership and fetus language. They convinced the assembly to pass a bill with the pregnancy language removed, over the Catholic Conference's renewed opposition.

"We had come off that position of opposition and had no position, until the bill was amended," said Dennis Poust of the Catholic Conference after the assembly passed its bill. "What they have done is effectively kill any chance of this bill passing."

The State Senate bill included the pregnancy considerations, meaning the two would have had to have been reconciled if they passed. But the Senate never touched the bill, and the legislative session ended without it becoming law, once again. Neither Gottfried nor James Seward – the Senate bill's sponsor – returned calls for comment. But if history is any guide then they will start pushing for the act again in January.

 

Nearly every person in Massachusetts will have health insurance by next July, officials there claimed recently, thanks to a plan that combines government action with responsibilities for employers and individuals. Maryland is toting its plan to force large employers to provide insurance (actually, the law applies only to Wal-Mart), and the former governor of Oregon believes that his state should abolish Medicaid and Medicare, replacing them with a public health plan that all state residents are eligible for.

State governments have always played a role in providing health insurance. But experts say there is increasing energy coming from state officials, largely because there is so little of it in Washington.

In New York State, almost 3 million people lack health insurance -- six out of ten of those live in New York City. The uninsured have less access to health care, and, consequently, poorer health, than those with insurance. In addition, the large uninsured population also places financial burden on both the governments and private hospitals that serve them.

Unlike some places elsewhere in the country, New York State officials are not hard at work on a magic bullet for universal health care coverage. A bill is advancing through the legislature, however, that would require large employers to insure their workers. The bill's supporters are optimistic its chances, but they also acknowledge that at best it is only a small piece in the puzzle. So as they develop state policy here, officials and health experts have been watching more ambitious plans elsewhere.

A PIECE IN THE PUZZLE?

Across the country, state legislators are considering bills that would penalize employers who don't provide health insurance. Such a law already exists in New York City. The law's scope is fairly limited, but is currently in court because Mayor Michael Bloomberg has challenged its legality.

New York State's more ambitious attempt at an employer requirement is called the Fair Share for Health Care bill. This bill would require all businesses with more than 100 employees to pay $3 per hour per employee for health insurance, an amount based on the estimate of how much it costs actually to insure someone.

Supporters of the legislation argue that some large employers rely on public health insurance programs for their employees, instead of providing health insurance themselves. This is both a drain on taxpayers and an unfair advantage over those employers who do provide health insurance. Advocates for such laws nationwide say that the momentum for employer requirements is already putting pressure on large companies like Wal-Mart to reassess providing health insurance for their employees.

But critics say that it distorts the labor market. In other states employers have found loopholes, or have cut back on the amount of business they do, argues Regina Herzlinger of the Heritage Foundation.

The legislature is planning hearings on the bill for May. Even if it passes, though, its supporters say there will hardly be a reprieve. This bill is intended to keep employers from exploiting Medicaid, said Richard Gottfried, its primary sponsor in the assembly; it "is not meant to be a solution to the uninsured."

A MODEL FOR UNIVERSAL HEALTH CARE?

Massachusetts became the center of attention in April when it announced a plan that it claimed will provide near-universal health coverage for its citizens by the middle of next year. Everyone from the state's Republican governor to the New York Times' editorial page heralded the plan as a possible model for other states.

Democratic gubernatorial candidate Eliot Spitzer recently indicated his "great interest" in the plan, and Republican candidate William Weld (himself once governor of Massachusetts) said it could be a "brilliant political achievement."

Not everyone believes that the plan will work for Massachusetts. Even if it does, say others, there is no guarantee it would work in New York, which has a greater percentage of uninsured workers and a larger population in general.

But there is no question the plan is being watched carefully.

"The project is both novel and ambitious," said Alex Navarro of the Working Families Party, which is working on the Fair Share for Health Care bill and is dubious of the potential of the Massachusetts plan. "Those are qualities that get people's attention."

Massachusetts has patched together a mixture of action by individuals, employers, and the state government to form its plan.

Everyone in Massachusetts must find a way to get health insurance by July 1, 2007 – supporters compare the requirement to the one that says drivers must have auto insurance. Using information from tax returns, the state will determine who does not have health insurance, and fine them.

The success of this approach will rely on whether people actually buy insurance – and that means helping those who have not been able afford it in the past. The state will subsidize health insurance for those whose incomes are less than triple the poverty rate. Massachusetts also plans to expand Medicaid, the government health insurance program for low-income people.

Employers who do not contribute to the health insurance costs of their workers must pay a $295 annual fee for every employee.

The political success of this approach is that it has managed to be all things to all people. The government and business contributions appeal to liberals; the stress on personal responsibility and consumer choice pleases conservatives.

"All Massachusetts citizens will have health insurance," wrote Massachusetts Governor Matt Romney in the Wall Street Journal. "It's a goal Democrats and Republicans share, and it has been achieved by a bipartisan effort."

But everyone didn't really agree on everything.

Romney toted the plan's "market reforms". But he called the portion that required employers to contribute to health insurance "unnecessary and probably counterproductive", and vetoed it. The legislature is expected to override this move.

Meanwhile, critics questioned the market's ability to solve health care problems. Unless there are enormous subsidies, they say, decent health coverage will remain unaffordable for those with low incomes who don't qualify for Medicaid. Some have also described the employer's role as simply symbolic.

"It's hard to imagine that they're going to be able to provide high quality care to everyone with the money they intend to spend," said Mary O'Brien of the New York chapter of the Physicians for a National Health Plan, a group that has referred to the plan as a "cruel hoax."

 

New York City is getting healthier, with fewer people smoking, fewer new cases of HIV, even fewer people dying; the city’s death rate recently hit a historic low. But there is one major health problem that is getting worse in the city -- diabetes. And, New York City Health Commissioner Thomas Frieden said recently, “it’s getting worse much more quickly than anyone could have imagined.”

That is why the Bloomberg administration is taking some unprecedented steps to curb what the mayor calls “a vicious silent killer.”

The highlight of the administration's efforts so far has been the establishment of a citywide registry (a collection of medical data) to give officials a better picture of the city’s epidemic. This is the first attempt by an American city to track a chronic disease. While the registry will not create a direct medical benefit to many patients now, health experts are hopeful that it will serve as the foundation for a comprehensive approach to dealing with diabetes in New York City.

“If the city’s information system works well and patients’ confidentiality is maintained, the registry initiative could be a first step towards other effective -– and no doubt more costly –- interventions,” wrote Robert Steinbrook in the New England Journal of Medicine.

What Is Diabetes?

Type 2 diabetes is a disease that keeps the body from breaking down sugars in food correctly. (There is a type 1 diabetes, but it is rare, and generally when people refer to diabetes they are speaking about type 2). Genetics play a role in whether a person develops diabetes; so does obesity. Blacks, Latinos, and Asians are both more susceptible to the disease genetically and, in New York, more likely to be overweight than whites, so racial minorities and new immigrants suffer disproportionately from diabetes here, as a recent series on diabetes in the New York Times made clear.

The disease is chronic and incurable, but it is manageable. Diabetics must watch their blood sugar levels, and adjust their diets accordingly. If they do not keep these levels under control, diabetics can lose limbs, or go blind. Their kidneys fail, and they have heart attacks and strokes.

As America gets fatter, diabetes rates are skyrocketing nationwide, with serious consequences. The total economic cost of the disease nationwide in 2002 was $132 billion, with 11 percent of national health care expenditures dedicated to the disease.

But if diabetes is hitting the entire country hard, New York City is in the worst shape: A greater percentage of New Yorkers are already affected by the disease, and the number of new cases here is rising more quickly than elsewhere. There are about 530,000 documented cases of diabetes in New York City, and an estimated 265,000 New Yorkers who have the disease but do not know it. In 2004, 1,734 New Yorkers died of diabetes, making it the fifth-leading cause of death in the city. But because many diabetes deaths are attributed to complications and not the disease itself, the city believes the true toll is much higher.

The City’s Registry

Diabetics regularly monitor their blood sugar with a standard test -- or at least they should. The health department’s proposed budget this year includes $2.7 million to fund a registry that will collect and analyze this data.

The program is already underway. In January, city officials began collecting the results of those blood tests by requiring laboratories that administer them to report the results. Officials hope to track the progress of individual patients, and also to get an exact picture of how diabetes is affecting New York City as a whole.

The city is gathering information across the city, but the initial effort of the registry is focused on the South Bronx, where diabetes rates are among the highest in the city. There, the health department will monitor patients’ progress, contacting them through their doctors if it sees that their blood sugar levels are persistently high, or that they are not getting the tests regularly enough. While doctors could probably do much of this on their own, the city argues that it is better equipped to handle such large sets of data, and that its efforts will take some of the burden off individual doctors.

If all goes well in the Bronx, the health department will use that pilot program as the basis of a citywide effort. By early next year, it will have a clear view of diabetes in New York City –- which populations are most affected, where they live, how they are being treated. Officials hope that some idea will emerge from this data about how best to help diabetics manage their disease.

Medical professionals seem excited about the potential of the registry. Jacqueline Salas-Spiegel of the Naomi Berrie Diabetes Center at the Columbia University Medical Center hopes the data from the registry will be used to identify the ages at which children are most likely to begin developing diabetes, and which parts of the city they live in. Then, she says, the city can deploy teams of "roving nutritionists" to their schools, with the aim of offsetting some of the unhealthy habits that lead to diabetes.

But others are raising questions about whether this registry invades New Yorkers’ privacy. “To pass along information like this without the patient’s even knowing I think is a violation, ” said Councilmember Yvette Clarke, who represents Flatbush, where people die of diabetes at a fifty percent higher rate than in the city as a whole.

People who don’t want to be contacted about their results can opt out through 311 or over the Internet, but their information will continue to be part of the registry. The health department says that it needs access to all the data if it is going to reach useful conclusions. Frieden has pointed out that the city has a good track record in managing confidential databases.

Trying To Change Behavior

The challenge with diabetes, say city officials and medical professionals, is that managing or preventing it requires a change in behavior. They acknowledge that collecting comprehensive data and refining the techniques used by doctors will not solve the problem of diabetes unless the city can use those tools to convince New Yorkers to adopt the healthier habits that are the only real way to counter diabetes.

"What we need to do is work to change the [social] environment," said Frieden.

The city is now establishing outreach campaigns to try to change the behavior of several groups of diabetics, including veterans, and women who develop diabetes while they are pregnant, which is called gestational diabetes. While gestational diabetes is temporary, women who develop it are more likely to end up with chronic diabetes in the future, as are their children.

Undermining Its Efforts

Critics point to ways that City Hall is undercutting its own efforts:

At a time when less than half of children maintain a healthy weight, the city signed a deal with Snapple giving the beverage company the exclusive right to sell its sugary juices and iced teas at schools and public buildings.

The city recently started charging for several recreation centers in low-income neighborhoods where those at the highest risk of developing diabetes had been able to exercise for free. While the city argues that the fees are modest, the Independent Budget Office recently showed that adding fees to recreation centers elsewhere in the city has led to lowered rates of use (in pdf format).

Also, the mayor's proposed budget includes about $9 million less money for child health clinics run by the Health and Hospitals Corporation; critics worry these reductions will lead to poorer health care for those who have relied on them.

These decisions highlight what Salas-Spiegel sees as one of the major roadblocks to a comprehensive diabetes program. Programs encouraging exercise and better dieting habits are the only known way to stop the rise of the disease, and success in the long run would prove to be cheaper than having to deal with the horrible consequences of the disease -- the amputations, the heart attacks. But it is difficult, she says, to devote the necessary resources now without the promise of immediate payoffs.

"If we prevent all this from happening it would be a tremendous savings," said Salas-Spiegel. "But would we then be able to transfer those funds saved to the prevention and education side? That remains to be seen."

Each day, over 250 people visit the emergency room at Woodhull Medical Center in Brooklyn. And each day the hospital loses more than $75,000 treating them -- adding up to more than $27 million a year. If Governor George Pataki and President George W. Bush have their way with the state and federal budgets, Woodhull will be losing even more -- and it and other New York hospitals might be sent over the edge.

Pataki's proposed budget for New York State, released in January, contains sharp cuts for Medicaid. New York's program is the country's largest, and Pataki argues that costs must be brought under control. His proposals to do so, however, will cost New York City hospitals $341 million next year, according to the Healthcare Association of New York State, a trade association for health care providers. The loss for Woodhull alone could be $15 million (on top of the $27 million.) The association says these costs would be devastating to a struggling industry in which eight hospitals already have been forced to close in the city since 2003.

Pataki's plans are not the only thing worrying health care advocates, though, nor is Medicaid the only concern. Decisions about New York City's public health insurance programs are made at the state and federal levels (the city, while it does foot a portion of the bill, has essentially no say over how these programs are run; its own budget will not really affect them.) So it was another blow when President George Bush laid out his budget for the forthcoming fiscal year earlier this month: he called for significantly reduced funding for Medicare, the country's other major public health insurance program.

"This year our concern is the governor's budget in relationship with the president's budget," said William Van Slyke of the Healthcare Association of New York State. "It's a one-two punch to hospitals."

THE STATE BUDGET

When he presented his budget, Governor George Pataki proclaimed his dedication to health care: "[New York] must continue to invest in a health care system that is second to none," he said. "And as part of that endeavor, we have to redouble our efforts to control the growth of Medicaid spending." At an annual cost of $44.5 billion, New York's Medicaid program is the single most expensive item in the state's budget. Unlike other states, New York's Medicaid program also affects local governments, which Albany asks to share the costs. When Mayor Bloomberg complains of uncontrollable items in the city's budget, Medicaid ranks high on the list.

The governor wants to continue a program he started last year that caps the amount local governments contribute to Medicaid. He estimates that this will save New York City $750 million this year alone.

Shifting costs from local to state government, however, does nothing to address the overall cost of Medicaid. For that, Pataki hopes to cut down on widespread fraud by setting up an independent office where 600 people will work full time investigating it. While establishing this office will cost $15 million, Pataki thinks it will end up saving the state money.

The governor's budget also includes $1.3 billion in cuts to Medicaid, and health care advocates are particularly concerned with his plan to change the way that hospitals are reimbursed for providing care to patients in the program.

For years, hospitals have argued that they are losing money each time a Medicaid patient shows up in the emergency room, because it costs more to treat him or her than the hospital is paid to do so. At Woodhull, for instance, the average cost of an emergency room visit is $411. But the maximum reimbursement the hospital can get for a Medicaid patient is only $95. The governor's budget would make the problem even worse, say health care advocates.

The Healthcare Association of New York State estimates that hospitals in the state will lose $431 million if the proposed budget is approved. New York City, which has a disproportionate amount of Medicaid patients, will be hit hardest: the city's hospitals will have to absorb 80 percent of the statewide losses.

This comes at a time when hospitals are already struggling. "Statewide, they have lost money for targeted investments in emergency room, outpatient, and long term care services," he told state lawmakers earlier this month.

A state commission is already looking at how to address the poor financial performance of the industry, and will almost surely recommend closing hospitals at the end of the year.

More cuts could cause some hospitals to cut back on services or shut down entirely.

THE FEDERAL BUDGET

President Bush seems even more concerned about the cost of public health care programs than Pataki. His budget calls Medicare and Medicaid (along with Social Security) "the greatest threat to our fiscal health over the long term."

The proposed federal budget mixes spending cuts with tax incentives that Bush hopes will help lead the country towards a more market-based health care system.

The president's budget proposes $36 billion in savings to Medicare. Joshua Bolton, his budget director, was careful to say that these savings will not be cuts but a "reduction in the rate of growth." Still, the impact on New York City hospitals is slated to be $356 million over the next five years, according to the Healthcare Association of New York State.

This budget also hints at a more fundamental shift in the way the government helps provide health insurance by including tax incentives for health savings accounts. The White House estimates that these incentives will cost the federal government $59 billion over the next five years. But by allowing people to put money away tax-free to pay for health care, the Bush administration argues, health savings accounts will eventually lower overall health spending by encouraging people to make smarter decisions about seeking health care. Critics, however, believe that these savings come by encouraging people to skip necessary health care.

NOW THE NEGOTIATIONS BEGIN

"If both these budgets were enacted as proposed," said Van Slyke of the Healthcare Association of New York State, "we would absolutely lose more hospitals. There is no doubt about it."

Of course, the chances that either budget will be enacted as proposed are slim. The governor and the president have made their opening volleys; they will now spend the next several months negotiating with lawmakers about which provisions stay and which are removed.

At both the federal and state levels, it doesn’t seem as if reductions in health care costs will be easily approved. Pataki's proposals are similar to those he has made in recent years, which the state legislature has regularly rejected. Further, many are saying that the president will also have a hard time trying to get Congress to agree to reduce spending on popular programs. It is, after all, an election year.