The Health of Our Cities

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Margaret A. Hamburg
Title: “The Health of Our Cities”
VTR: 6/3/93

I’m Richard Heffner, your host on THE OPEN MIND, and I’ve assured my guest today that in all the 37 years since I began this program, whatever its faults and mine, it has never, ever been accused of prematurely inducing labor.

`Not to worry, told Dr. Margaret Hamburg, who is delightfully very much “with child”, as we used to say, and who surely has a very great deal more on her plate really to worry about as the intrepid Commissioner of Health of the City of New York.

But what could be more important than the children in our lives: their good health and well-being?

And I wonder if in this enormous city – with health problems so enormous, too, problems so much akin to those in America’s other major urban areas — if Commissioner Hamburg has reason to look hopefully to the future … as a public official, rather than as a quite radiant private person. What’s the level of optimism, Commissioner?

Hamburg: Well; I am optimistic, there is no question that we are in the midst of very difficult times that the challenges before us are complex, and they’re pressing. But I think there are … there are some avenues that provide real hope to make a difference, and to make an enduring difference, that will be felt in every person’s lives in this city, and across the nation. One major arena is, I think, of renewed appreciation for the importance of basic, primary care, and prevention. For such a long time our medical system has been so geared towards the acute care hospitals, towards very sophisticated, high technology medicine, towards what are some really remarkable advances in modern medicine that, that are not to be discounted, by any means. We need those kinds of advances in so many areas. But we also need basic, primary care, and we need services that will keep people healthy, rather than putting our emphasis on treating disease once it’s established. So I’m very encouraged, both at the local level, in terms of what we’re doing here … Mayor Dinkins’ new initiative…Communicare … to expand primary care capacity. And what’s happening on the national level. Of course, we still don’t know what the health care reform package the, the President is going to put forward is going to look like. We do know that it’s going to have a heavy emphasis on primary care, and preventive services, and I think that’s going to serve the nation well.

Heffner: Doesn’t that depend, to a very great deal … a very great deal upon what the people who study medicine, who tend to make it their profession, opt for. Is there … are there signs that they are opting for primary care professional involvement?

Hamburg: Well, I think we need to change the culture of medicine to some degree. And that’s been begun, but we need to work on it a lot more. The way you’re currently trained, there is enormous encouragement, if not pressure, to go into … not just a specialty area, like internal medicine or pediatrics, or surgery, but a sub-specialty area … like gastroenterology, or endocrinology, or hematology. And primary care specialties such as, as family practices or pediatrics, or the area that we simply call “primary care”, have not been emphasized much in medical training, particularly in, in cities like New York. But I think that’s changing. I think there’s a new appreciation for the importance of those kinds of roles, and there also are other incentives that are being put in place. Academic institutions are being encouraged in terms of funding streams, to put more emphasis on primary care. We’re seeing more interest in creating loan programs and tuition reimbursement programs that will encourage students to track into primary care specialties, and then they’ll get part of their tuition reimbursed. So, (think that, that those shifts are going to be very important, but it does involve, really, a change in our, our culture of medicine to some degree.

Heffner: That’s such an interesting phrase. What do you mean by “culture of medicine”?

Hamburg: Well, just like in so many other aspects of life, there’s a whole milieu, a social setting, a set of values, and perceptions that associated with medicine, and it’s … it’s something that’s begun as you begin your training in medicine. Really, when you become a pre-med you start to, to become part of the culture of medicine. And it has to do with values that are communicated to you and what you’re taught, and it has to do with the orientation of the health care system, and the health care delivery system. And, we in New York City and in America are in a very unusual position, I think, where we have some of the most sophisticated medicine in the world, some of the best medicine, and you can get some of the finest care … you have seven academic institutions in New York City that are training the best and the brightest, and offering the best possible care. We also have some of the worst possible health statistics that you can imagine in some areas, some communities of this city and across the country, we’re doing worse than many developing nations. You just have to look at, at such indicators as infant mortality, to get a sense that we’re not doing as well by our people across the board, as we have the capacity to do. And so I think part of changing the culture of medicine is also changing our perception of the world in which we operate in recognizing that not only do we serve the patients that we see in the hospital, or that come into your office as a physician, but we also have a responsibility to the communities in which we work, and to make those communities healthier.

Heffner: Well, question that I frequently put to my quests here on THE OPEN MIND is to ask what basic sense of the nature of human nature informs the work you do. And so, I see that you are somewhat optimistic about the future. But what, what … how do you account for the fact that we are … have not done all that well in as rich a nation as our own in a nation that has a great humanistic tradition …

Hamburg: Um Hmm.

Heffner: Why do you feel any optimism at all, if in this rich nation we aren’t even doing as well in many areas, as you suggest, as some under-developed, and developing countries.

Hamburg: Well, wish I really could give you a good answer. It’s something that has troubled me while I’ve been in the role of Commissioner of Health and, and before that, you know, with the all of the wealth both in terms of knowledge, and resources, that this country has, why is it that there are these huge disparities in terms of health status, in terms of availability of care, and particularly quality care. Why have we allowed that to exist, and I, I can’t give you a good answer, but I do think that we have reached a moment in time where we, as a society, have come to a clear recognition that we can’t only look out for ourselves because the damage that’s being done, and the, the community disruption, the individual disability and illness is impacting on society much more broadly that unless we really address the problems of the poor and the under-served, no one is really going to be able to be comfortable. I think that we can’t turn our back … I think there have been many, many in, in the public sector, in particular, but many throughout both the public and private sector, who have always had that perception, have always been committed to trying to serve the under- served. But I think that there is a broader societal recognition now, particularly in the health arena that if we don’t address the fundamental problems that we have, it’s going to come out of everybody’s pocketbooks and it’s going to come out of everybody’s health security, as well. When you or I have a medical problem that requires emergency treatment, we have to go to the same Emergency Rooms that anybody else does, and if those Emergency Rooms are overcrowded with poor individuals that don’t have access to physicians, that are using the Emergency Room for routine medical care, or individuals who have illnesses that could have been prevented, but because of neglect and inadequate access to care, haven’t gotten timely interventions that could have prevented progressional disease, then, then you’re going to suffer because of their lack of access to disease … just as much … their access to care, excuse me, just as much as, as they’re suffering. So that I think that, that for better or for worse, for pure or less than pure reasons, that there is a broad consensus right now, that we have to really address the issues of health care and health care reform in this country, or else everyone is going to suffer.

Heffner: Well, I … again, I hope that sharing your optimism is, is wise and justified. Your sense of the, of what your mission is as Commissioner of Health in this enormous urban area, I gather goes beyond the question of hospitals and Emergency Rooms, and…

Hamburg: Oh, very much.

Heffner: …and things like that. What, what, what is it? What is your picture?

Hamburg: Well, there … the health department and, and my mission as Health Commissioner is really very broad. We are responsible for a certain array of clinical services, and particularly clinical services that are targeted to those most in need, to under-served populations, poor, indigent populations. But we also have many important functions that, that protect the health of the public in general. We do outreach education and prevention campaigns around a number of issues … AIDS, teenage pregnancy, lead poisoning prevention, a gamut of issues to help people understand what the problems are, and how they, in their communities and in their families can, can take action to prevent problems, or to get the treatment that they need: We do disease surveillance, we track a number of different diseases throughout the city, monitoring them, looking for trends, looking for changes in disease patterns that suggest an emerging problem and then we, we recommend interventions. We collect vital statistics in, in a number of areas. We broadly are responsible for protecting the food and water supply which, of course, benefits every citizen of this city. And when I say “water supply”, it’s from the water your drink to the water you swim in, whether it be beaches or swimming pools, whatever. So these are, these are broad and very comprehensive responsibilities. We have broad responsibilities to protect the public from a range of environmental threats … asbestos, lead, other problems in the environment. So that we really have a lot on our platter. And of course, probably the most visible aspects of what we do has to do with the realm of infectious and communicable disease. And that’s actually how the Health Department was initially started; it was in response to a cholera epidemic some hundred years ago. The problems have changed somewhat, but we still are in an on going battle against infectious diseases in New York City, with a resurgence of tuberculosis probably being the most visible problem at the moment. The AIDS epidemic which emerged, I think, to many people’s surprise as the decade of the eighties began, of course, is another major challenge in this city and across the world. So, so we, we keep busy. (Laughter)

Heffner: Tuberculosis. My assumption was, and I think that of many people of my generation, was … that was a threat from the past

Hamburg: Yes.

Heffner: …forget it. What, what brought it back to the surface. You say one of your responsibilities, or the responsibilities of your department is to track…

Hamburg: Yes.

Heffner: …trends. What brought it back to the fore?

Hamburg: Well, there have been a number of factors, and I think that the history of TB, its decline over many, many decades, and now its resurgence is a very important lesson for us to learn from. We, for many years, for decades now, have had the medical knowledge, and the tools in terms of effective antibiotics, to treat and cure tuberculosis. And for many decades we’ve seen the numbers of cases on the decline … a steady decline. But in the decade of, of the eighties, unfortunately a number of factors came together to fuel what is now a true epidemic of tuberculosis. An important factor has been worsening poverty. And tuberculosis has historically been a disease associated with poverty … poor, inadequate living conditions, inadequate nutrition, etc. And we’ve had, of course, pockets of poverty in this city for forever and ever, but the poverty did worsen over the decade of the eighties, and at the same time that, that the poverty was worsening, the economy situation was, was declining for really a large percentage of New York City’s population…

Heffner: Was this reflected to … forgive me for interrupting … in other major urban areas, this concern with tuberculosis?

Hamburg: It is. New York City is clearly the epicenter of tuberculosis problems in this country at this time. We have more absolute number of cases … we represent about 15% of the nation’s caseload, and we also have a more complex picture of disease because we have more individuals with tuberculosis who are also HIV infected, or who have AIDS, who are a( homeless, who also have problems with chronic mental illness, or substance abuse. So, we have a very difficult problem on our hands. But we also do know what needs to be done to, to stem the tide of this epidemic, and that, I think, is the good news. But, getting back to your question of what has fueled the resurgence … in addition to worsening poverty, and worsening conditions, such as homelessness, that, that have enhanced the spread of tuberculosis, that has been compounded by the fact that many of the appropriate facilities for TB control were actually being dismantled at the same time … the resources for tuberculosis control were actually declining, and that was reflective of the caseload declining, but I think what, what was misunderstood, and hopefully we will have learned from this experience in terms of future, was that you don’t pull away the resources until you really have the problem under control. That although the numbers were declining we still had pockets of serious tuberculosis disease and we had conditions that were indicators of potential spread. So that the dismantling of, of many aspects of TB control, because of resource limitations, because of other pressing problems that needed attention. and resources, contributed to the problem we currently face. And then further fueling the epidemic, and this has been a very serious component of the problem here in New York City, is the overlap with the AIDS epidemic. Because tuberculosis is a disease that thrives in individuals whose immune system is suppressed, and so, when you have as many people as we do in this city that are HIV infected, or have AIDS, a disease characterized by immune suppression, then they’re very vulnerable to TB disease. And for someone with a healthy intact immune system, you can be infected with tuberculosis and never develop disease. The probability of developing disease over the course of your lifetime is somewhere between 5% and 10%. But a large percentage of people can be exposed to TB, can actually be infected, but their body will fight it off, it will sort of seal off the TB organism, the way the body will seal off a wound with scab, and you’ll never have a problem, you’ll never be sick, and you can never transmit it to anyone else. But if you’re HIV infected, the problem is compounded and intensified. Instead of having a 5% to 10% probability of developing TB disease from TB infection over the course of your lifetime, it goes to 7% to 10% per year probability of going from infection to, to disease. So, that in a very short period of time, given the number of people with, with HIV that also were exposed to TB, and infected with TB …. we are seeing expression of, you know, many more cases of disease. And that’s a … an area that we really need to target very aggressively, so that we can protect those who are HIV infected from TB infection and TB disease.

Heffner: I’m going to ask you a very unfair question…

Hamburg: Yes.

Heffner: …you’re Commissioner of Health for the City of New York. I’ve lived in New York all of my life … a year or so here, a year or so there … but I’m a New Yorker, somebody says to you, or asks you, “How safe is this benighted city?” Seriously, what’s your answer?

Hamburg: Well, I do get asked that question quite a lot. In terms of risk from TB, or in genera!?

Heffner: In general.

Hamburg: I think that New York City is a place where you have to, to know where you are and, and where you’re going. It is not a safe city to just randomly wander around because there are, this is more in terms of crime then in terms of disease … but clearly there are areas that are safer than others. And it’s, it’s helpful to know. But, you know, the truth is that there are risks everywhere. There are risks in the suburbs, there are risks in urban centers … New York City is a bigger city than many, and has many problems that, that overlap, and, and exacerbate each other. But I don’t think that we are that different from urban centers on the West Coast, in the Mid-west, in the South.

Heffner: There’s no place to hide.

Hamburg: Well, life is increasingly complicated, I think. But, you know, again, I think that one has to try to open your mind (laughter) and be as informed as you can be about, you know, what the risks are and how to protect yourself from risks, and that has to do with your own personal health, has to do with, you know, safety in terms of, of crime and a range of other issues as well, but we’re not passive passengers in the world.

Heffner: And I, I know that you believe that to become safer passengers there is a lot that we can do ourselves. I know you feel that way about smoking, you feel that way about protective devices for children, whether it’s screens on windows, and auto safety and seat belts, and things like that. And it’s strange that we as a people, even in that area, don’t do all that well.

Hamburg: That’s true.

Heffner: But you know, it was so many years ago, it was three decades ago that I attended a conference at which the discussion was “what are our great problems in the future”. We had licked infectious diseases.

Hamburg: Yes.

Heffner: That was just a matter of a mopping up operation … now we had to deal with old age, we had to deal with how long can you live in a healthy environment.

Hamburg: Mm Hmm.

Heffner: Do you think given the complexities of our lives, and I don’t just mean in this city, but talking to people in many urban areas in this country, do you think we have the determination plus resolution to spend the money, our money, that will put us back in a situation in which we can look more comfortably at extending life, but not worry so much about it taken … being taken from us in the midst.

Hamburg: Well, I think the sad fact is that it’s going to cost us a lot more today than it would have cost us a few decades ago if we had made the, the commitments and invested the resources wisely at an earlier time. Tuberculosis is one example, but in the health arena there are many others where we’re struggling to combat problems that really are treatable and preventable, but we simply did not commit sufficient resources to manage the problems well at an earlier time, and now we’re paying the price both in economic terms and, you know, more tragically, in terms of human lives and human potential. But I, you know, I think again we are at a, at a critical crossroads where I think the handwriting is on the wall. If we want this to be a city that we want to live in, a city that, that really supports the health and quality life of its citizen, then, then there are some fundamental areas that we need to address. And I think some of the things we’ve been talking about already fall into that category. The need to, to build as I think the Mayor has shown on leadership more primary care for New York City citizens. That will make a difference in people’s lives. That will help to keep people healthy, to promote health and prevent disease, rather than treating disease when it’s already entrenched and when it’s a little bit too late. Or sometimes, sadly, a lot too late.

Heffner: Addressing ourselves to cities afar … far a field from where we are today in New York, to the other major urban areas in, in this country. Seriously, just between the two of us, how sanguine are you that we’re going to meet that challenge. You describe it exceedingly well. You say if some decades ago we had addressed ourselves to these problems, we wouldn’t be suffering quite so much from them. What’s your best, honest guess as to what we’re going to do?

Hamburg: Well, I think that we’re already on track in terms of turning some of these problems around, in terms of putting in place the programs and services that are necessary. We’ve only begun to take important steps in critical area, but I think that what we’re seeing in terms of this renewed emphasis on, on primary care … a, a real sense of the importance of health that hasn’t really been on the political agenda, or the public agenda in, in the way that it is now for a long, long time.

Heffner: Let me ask one question, as we have one minute left … has AIDS been a sufficiently frightening scourge to have moved us onto the next rung of the ladder in terms of doing what we have to do.

Hamburg: Well, I think AIDS has been a sobering lesson that has taught us that we cannot be complacent. I learned in medical school just as you were reporting from that Conference that infectious diseases were really not the future of medicine … that chronic disease was. Well, AIDS has told us we have to always be alert to an emerging problem, a new disease, a new syndrome, a new set of issues that we may not have fully anticipated. But we, we have to have in place a core set of programs and services so that we can respond swiftly and so that we can protect the health of the public.

Heffner: Dr. Margaret Hamburg, Commissioner of Health in the City of New York, thank you so much for joining me today on THE OPEN MIND. I hope your optimism pays off, and that you have a wonderful, healthy baby.

Hamburg: Well, thank you very much.

Heffner: And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you’d like to share your thoughts about our program today, please write THE OPEN MIND, P. 0. Box 7977, FDR Station, New York, New York 10150. For transcripts, send $2:00 in check or money order. Meanwhile, as an old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Thomas and Theresa Mullarkey Foundation; The New York Times Company Foundation; and, from the corporate community, Mutual of America.