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Hurricane Katrina was a natural disaster that covered New Orleans with water and forcefully uncovered that city’s social conditions. Glaring examples of the horrible treatment meted out to the poor, mostly African American survivors have been staring us in the face for the past seven months. Daily, we read or hear about another event in the aftermath of the hurricane that tears to shreds the concept that we live in a “free and equal society.” That the American Dream is a nightmare for millions of people is the result of our economic system and our attitudes about people who are poor. The worst treatment is reserved for poor people of color.
Unfortunately, another natural disaster is unfolding. It is not as dramatic as Katrina, but it is far more dangerous. It is AIDS in poor African American communities and poor communities of color in New York City. Just as the warning signs that a Katrina-like hurricane could happen in New Orleans, the warning signs that New York City’s health “levees” could soon burst have been with us for years. In both cases, the science and technology to ameliorate the disasters have been developed and used around the world, and in both cases, little has been done here at home.
New York City puts poor people of color and poor African Americans starting life at a disadvantage. The current Infant Mortality Rate (deaths of infants under 1 year old per 1,000 live births) tells the story. The overall city rate is 6.1. Overall Puerto Rican rate is 7.5. Overall African American rate is 11.6. The highest rate in the city is in the mostly poor, mostly African American neighborhood of Brownsville, Brooklyn–12.2. The lowest rates are in mostly white, middle-upper class Kips Bay and Yorkville in Manhattan–1.9. Things don’t improve as these children get older.
In a Population Reference Bureau report, The Concentration of Negative Child Outcomes in Low-Income Neighborhoods by Mark Mather and Kerri L. Rivers, dated February 2006, tell us what should be obvious. “Research has shown that children growing up in poor neighborhoods are at higher risk of health problems, teen pregnancy, dropping out of school, and other social and economic problems compared to children living in more affluent communities.” They go on to say:
“There are significant racial and ethnic differences in the proportion of children residing in poor neighborhoods.While about 8 percent of non-Hispanic white children lived in poor neighborhoods in 1999, Asian/Pacific Islander children were nearly twice as likely to live in such neighborhoods (17 percent), and American Indian and Latino children were more than 5 times as likely (45 percent and 42 percent respectively). African American children fared the worst. They were 6 times as likely to live in such neighborhoods (48 percent). Overall there were 5.2 million African American children living in poor neighborhoods in 1999-more than children from any other racial or ethnic group.” The analysis of state-level data suggest “that negative outcomes for children are most highly concentrated in the Mississippi Delta and southwestern United States. New York and Rhode Island also stand out due to high concentrations of negative child outcomes in poor neighborhoods.”
In its 2004 report, “Health Disparities in New York City,” The New York City Department of Health and Mental Hygiene gives us a current picture of the health, or lack of it, in New York City. In their introduction, Dr. Thomas R. Frieden, Health Commissioner, and Dr. Adam M. Karpati, Division of Epidemiology, tell us, “While great gains have occurred in improving overall health and reducing health disparities, the persistence of racial, ethnic, economic, or other social inequalities in health is unacceptable.” Keep in mind when reading these statistics that they show the results of the “great gains” that have been made.
Life expectancy (the average age to which a newborn is expected to live): “In 2001, life expectancy in New York City’s poorest neighborhoods was 8 years shorter than in its wealthiest neighborhoods.” White men live 6 years longer than African American men. White women live 3 years longer than African American women.
Premature death (Death before the age of 75):” The rate of premature death is more than twice as high in poor neighborhoods than in wealthy neighborhoods.”
Except for suicide, the death rates for the following diseases are higher in poor neighborhoods than rich neighborhoods.
Heart disease, Cancer, Influenza and Pneumonia, Diabetes, Stroke, Chronic lower respiratory disease/Emphysema, High blood pressure, Liver disease/Cirrhosis and Kidney disease
Why would anyone think that when AIDS came to town the impact on our poor population would ultimately be any different?
At the beginning of the epidemic, the face of AIDS was, for the most part, a middle-class, gay white male. Now, more than twenty years later, the face has changed color, gender and class. In 1985, only 7 percent of AIDS cases in the U.S. were women. In 2004, the number ballooned to 27 percent, according to the U.S. Center for Disease Control and Prevention. From 2001 to 2004, about 83 percent of women diagnosed with HIV/AIDS were African American or Latina.
The area with the biggest population of African Americans in the U.S. is the borough of Brooklyn, New York. Twenty-one percent of Brooklynites are poor compared to the U.S. average of 12 percent. Brooklyn is also home to two of the poorest neighborhoods in New York City where more than one-third of the residents live in poverty and between 25 and 30 percent have been diagnosed with HIV/AIDS. One-fifth of African American men aged 40-49 are HIV positive. African Americans of all ages are 25 percent of New York City’s population but account for 50 percent of AIDS deaths. African American women have 27 times the AIDS infection rate and 9 times the death rate of white women. African American men die at 6 times the rate of white men.
The February 4, 2006 edition of The New York Times tells us [that the Manhattan neighborhood of] “Chelsea with a large population of gay white men continues to have the highest rate of newly diagnosed cases in the city, 153 per 100,000 people in 2004. Central Harlem is close behind with 119 newly diagnosed people for every 100,000. Yet infected people in Chelsea are half as likely to die from the disease.” Is there something different in the biological or genetic makeup of African Americans compared to whites that make them more likely to die from HIV? No. The problem lies with class, racism and our economic system. Health care is just another commodity to be bought and sold. Whoever can afford it gets the best health care. If you can’t afford good health care, good housing and good food, drop dead. As the statistics cited above show, poor people, people of color and women have always been expendable in our society, and nothing much has changed since HIV moved into the ‘hood.
Whether the problem is a hurricane or a disease, the rich have already taken the high ground. The high ground in a hurricane is the area least likely to be flooded if the levees break and where immediate social support will be provided if there is a flood. The high ground in health care is private care. Using the most advanced medicine and the best doctors, all things are tailored to the individual being treated. Social support in the form of housing, nutritional care, psychological counseling, etc. is known to be in place. Everything done is first analyzed for its efficacy.
Poor people and people of color are relegated to the low lands, the places that usually flood. Social support is poor at best and usually nonexistent. People are expected to fend for themselves. If there is no money to escape the flood, tough. If a flood finds the poor in a hospital or nursing home, they have the right to drown. If they survive, our democratic society grants the poor the right to sleep in the muck. The low lands in health care is one size fits no one. Poor people are expected to buy their health care like rich people do, or expect nothing. Nothing is personalized. Little is provided.
In an article I wrote in 2002, I pointed out that New York City’s Health and Hospitals Corporation asked permission to close 27 satellite clinics in poor neighborhoods six months before 9/11, despite the disparity in health care (Body Positive, Vol. 15, No. 4, 2002). Since then “speed-ups” have been added to cutbacks in services across a broad spectrum from medical care to transportation. Doctors in publicly funded clinics are pressured to reduce time spent with their patients. In one major public hospital, seven minutes is the amount of time doctors are “encouraged” to spend. The time spent is not the result of improved time management techniques or careful analysis. Harris Interactive conducted a survey for The Commonwealth Fund called “The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care.” Its purpose was to examine “physicians’ use of quality improvement tools ” The survey found “few physicians have incorporated quality improvement methods into their practices. Only one-third of doctors have been involved in any redesign efforts aimed at improving performance. And just a third have access to any data about the quality of their own clinical performance, while seven of 10 physicians do not feel the public should have access to quality-of-care data.”
People who maintain that the system has failed the poor are wrong. The system is working exactly as it is supposed to work. The poor are to be managed, not helped.
The problem of the AIDS epidemic is not being ignored. In fact, in 2005 Dr. Scott Kellerman was appointed the New York City assistant commissioner of HIV/AIDS by Dr. Thomas R. Frieden, New York City’s Health Commissioner. His assignment from Dr. Frieden: stop the spread of HIV in New York City, a difficult task under the best circumstances. Before Dr. Kellerman came to New York, he worked for ten years at the Center for Disease Control and Prevention, spending the last five years in HIV programs. Unfortunately, Dr. Kellerman came from an administration where 68 percent of sex education funds were spent on the failed policy of abstinence only, so he couldn’t possibly get any insights there on what to do in New York. While the CDC was bungling the AIDS fight-back, the Europeans reduced AIDS deaths by 42 percent between 2000 and 2004. During the same period, the U.S. AIDS death rate declined 19 percent for whites and 7 percent for African Americans. It also decreased among Asians/Pacific Islanders, but increased among Latinos and Native Americans/Alaska Natives. Obviously the Europeans were doing something we were not, despite the fact that we had the same medications.
At a meeting on January 12, 2006 with several of New York City’s oldest and largest AIDS service organizations, Dr. Kellerman promoted an approach to fighting AIDS that largely excludes the needs of the people he is ostensibly trying to help. He asked the ASOs to consider only one aspect of care–keeping clients in primary care. Dr. Kellerman’s approach is often called the “medicalization” of AIDS. It maintains that the context of life is irrelevant because of the absolute efficacy of the medication being used. In Kellerman’s view, the person receiving the care is just a “unit” who needs only to be worked on to be treated effectively. Kellerman asked the ASOs to work like a surgeon who can perform a life-saving liver replacement operation without relying on any understanding of the patient to be successful. He said in essence to take out the bad medication adherence and the bad predatory anti-safe-sex attitudes, and to replace them with good ones. As far as we know, however, there is no behavior organ in the human body that can be replaced by a surgeon. On the other hand, material support, education we call counseling and positive social interaction will bring about a change in irresponsible behavior.
This vision is similar to solving the problems of the poor African American flood victims in New Orleans by sending them thousands of miles from the flooded areas, as if they, not the flood, were the problem.
The use of “medicine only” to treat disease is not an accident. The English Guardian Weekly, January 13-19, 2006, tells us that in Washington DC, “Drug makers are the biggest lobbyers.” Drug makers have a kennel of 3,000 lobbyists who spent $681 million between 1999 and 2004. Those puppies spent that money on our “impartial representatives” to whom they have access because hundreds of lobbyists are ex-members of Congress and former Federal employees. The $681 million they spent is chump change compared to the billions they anticipate in profits for their efforts. Lobbyists also belong to and finance various committees that help our encumbered incumbent leaders get re-elected. If elected officials or appointed functionaries of those officials take a position that Big Pharma doesn’t like, they may find themselves denied access to the cash-laden feeding trough they rely on.
One of the ways Big Pharma uses lobbying money to get its way is by “helping” to design and fund studies that support its quest for greater profits. In an article about the safety of artificial sweeteners, “The Lowdown on Sweet” by Melanie Warner, the February 12, 2006 edition of The New York Times gives a perfect example of Big Pharma science in action: “In an analysis of 166 articles published in medical journals from 1980 to 1985, Dr. Ralph G. Walton, a professor of psychiatry at Northeastern Ohio Universities College of Medicine found that all 74 studies that were financed by the industry attested to sweetener’s safety. Of the 92 independently funded articles, 84 identified adverse health effects” Is it any wonder that so many people don’t trust the “scientific” explanations of our intrepid health department leadership?
After the need for air, water and food, housing is the most important human need. The National AIDS Housing Coalition says that housing is the lynchpin of the prevention of disease, including HIV. In its 2005 report, Housing Is the Foundation of HIV Prevention and Treatment–Results of the National Housing and HIV/AIDS Research Summit, The Coalition says “Recent studies that examine the relationship of housing status to HIV prevention and care show strong correlations between improved housing status and reduced HIV risk, improved access to medical care, and better health outcomes. Homelessness or unstable housing is directly related to greater HIV risk among vulnerable persons. For persons with HIV, being homeless is a barrier to starting outpatient care, staying in care and starting antiretroviral therapy (ART). For those engaged in HIV care, improved housing status is directly related to higher levels of ART adherence, lowered viral loads and reduced mortality. Indeed, appropriate housing protects individuals from ‘exposure’ to a range of individual and public health threats, including HIV, violence, harmful drug use, and incarceration. Housing protects and stabilizes not only individuals but also their families and communities.”
It is doubtful that the New York City Department of Health or FEMA is unaware of these facts linking housing and disease prevention. We must realize that the goals of the DOH and FEMA are different than our own. When they talk about “health” they mean corporate health–profit. Individual health may be sought after only if it does not interfere with the quest for profit. Corporate and real estate speculators in New Orleans who own the will and the ears of the politicians there, expect to make huge profits on land in the “sick” wards that was once occupied by displaced Katrina survivors. In the March 16-21, 2006 edition of CounterPunch magazine, Bill Quigley tells us that rather than fund reconstruction of the largely African American poor Ninth Ward of New Orleans, FEMA is spending an estimated $60,000 each on trailers because corporate profit is higher on building trailers than on rebuilding homes. The housing situation for poor people with AIDS in New York City is also a catastrophe. There are an estimated 30,000 people with HIV/AIDS living in shelters or primitive housing or on the streets. I’ve visited some of my AIDS clients in Single Room Occupancy hotel rooms infested with roaches or rodents. I’ve been in heatless apartments and apartments without functioning kitchens or refrigerators needed to keep medication from spoiling, where a tenant’s complaint could lead to an illegal eviction. Coalition for the Homeless released its seventh annual “State of the Homeless” report on January 4, 2006. The Executive Director, Mary Brosnahan Sullivan, stated: “This decade is turning out to be the worst decade for homeless New Yorkers since the Great Depression. The number of children in city shelters has risen by more than half since the 1990s, while the population of families in shelters has skyrocketed.”
Dr. Kellerman’s boss, Dr. Frieden, said he was looking for a “radical way” to fight AIDS. He wants to change New York State laws so people can be given an HIV test without counseling and without their written consent, ostensibly in order to get into treatment earlier. He is appropriately concerned that in 2004 1,038 people already had AIDS when they were tested for HIV, which usually means they have had the infection for years without treatment. The Body, an online HIV/AIDS magazine, reported on February 2, 2006: “Under current state testing laws, a patient must give written consent to receive an HIV test, and physicians must detail reasons why a patient may not want to consent to testing. Dr. Frieden urged the state to make HIV testing a routine part of medical care; allow verbal instead of written consent to HIV testing; and do away entirely with counseling patients why they may not want testing.” In addition, “Frieden wants state law changed to allow public health officials to consult directly with patients and their doctors.” These consultations would be based on confidential data collected by the state health department from various laboratories.
Almost seven weeks later, on March 21, 2006, Housing Works AIDS Issue Update reported that the bill Commissioner Frieden put before the state legislature was not at all “radical” but far more “reactionary” than the law changes presented on February 2. Frieden wants a poor person to be merely a disconnected object to be “operated” on. A health care worker just has to tell the person that an HIV test is being given. Equally draconian is the requirement that all AIDS service programs, both medical and social, must provide whatever information the health commissioner wants about any person with HIV/AIDS, essentially stripping people of their personal rights and making informants of their caregivers. Logically it follows that refusing the HIV test or refusing to turn over the information demanded will make criminals of the people in the front lines of the fight against AIDS and accelerate the epidemic. It is estimated that in 2005 about 25 percent of HIV-infected people didn’t know they were infected. If they did not practice safe sex, they were unwittingly spreading the epidemic. Frieden’s bill, if enacted, would increase the percentage of unknown infections by driving people away from clinics and ASOs.
In the present political atmosphere, the oppressive tone of the bill is familiar but unacceptable. If the commissioner’s intention were to write a bill to help drive people away from HIV testing and counseling, his suggestions would make more sense. He fails to understand that people want to be helped. They don’t want to be sick or spread AIDS. But they must be helped within the context of their own lives, not in a fantasy world that a spin doctor wants us to believe they live in. HIV carries only 9 genes, but it is heavy with stigma. The stigma against poor people who are HIV positive is real. The pressure of the stigma increases if they are also African American, Latino, women, old, or not conventionally sexually motivated or identified. Charles A. Emlet, in his article Measuring Stigma in Older and Younger Adults with HIV/AIDS: An Analysis of an HIV Stigma Scale and Initial Exploration of Subscales, quoted a 2002 UNAIDS report. “people with HIV/AIDS from racial and ethnic minorities are seen not as individuals living in the contexts of marginalization, but as the cause of their own misfortune.” Since our society will not or cannot protect people from stigmatization, many need to be under cover so they can keep their jobs and stay in their churches. They need to stay under cover so their children can have playmates. They need AIDS service organizations and clinics where they can get food, medication, housing and education about their illness. They need to go to a place where they can be themselves for a while without fear of being “turned in.” Then they can be recruited in the fight against AIDS.
The confidence the NYC DOH has in our hospital’s ability to deal with this sensitive issue stands reality on its head. The largest annual health care quality study is conducted by HealthGrades, whose April 6, 2006 report, HealthGrades patient safety study shows increase in hospital incidents, gaps among state, hospitals, gives a more accurate picture. “Patient safety incidents in American hospitals grew from 1.18 million to 1.24 million among the 40 million hospitalizations covered under the Medicare program, and incidents varied widely from state to state, and among the best and worst hospitals” Minnesota did the best. Louisiana ranked 28th. New York came in 50th, next to last, with New Jersey bringing up the rear. What does this mean? The HealthGrades report gave several examples. Here is one. “Of the 304,702 deaths that occurred among patients who developed one or more patient safety incidents, 250,246 were potentially preventable. Medicare beneficiaries experiencing one or more patient safety incidents had a one-in-four chance of dying during their hospitalization, a rate that is unchanged since HealthGrades’ first study. Can you imagine someone saying “Gee, I can’t wait until my Medicare kicks in next year so I can go to a New York hospital for counseling about managing the complexities of HIV/AIDS”?
What can we do? First, we can stop the Frieden bill. Replace it with anonymous, universal counseling and testing of people who are at risk of catching HIV. Provide food, housing, counseling and health care for all people in New Orleans and New York.
Second, we can work for universal health care independent of corporate interests. We can hire the Europeans to build state-of-the-art “levees” for pathogen and flood control in New York and New Orleans. Get the money by ending the war in Iraq, Afghanistan and around the world. Build a political party independent of the corporate controlled Democratic-Republican cabal.
There is still time before we all drown in AIDS-contaminated water.
EDWIN KRALES is an AIDS Nutritionist and Health Educator who lives and works in New York. He can be reached at firstname.lastname@example.org