Doctors learning how to wield the knife, but not for surgery

The connection between healthy eating and good health is no longer surprising news for most Americans and their physicians. However, even though doctors treat patients struggling with obesity, diabetes, and heart disease, many of them pass through medical school with little knowledge of nutrition. And while your doctor may not be cooking you dinner every night, research has shown that physicians who engage in healthful behaviors are more likely to advise their patients to do the same. In other words, the more your doctor knows about healthy eating and cooking, the better he/she will be prepared to give you advice on how to avoid chronic diseases that are linked with unhealthy food choices such as obesity and diabetes. This idea is catching on. A recent article published in The New York Times chronicles some physicians’ commitment to healthy food and how they use that knowledge to better treat their patients.

Healthy Kitchens, Healthy Lives was founded eight years ago by Dr. David Eisenberg, an associate professor at Harvard Medical School and the Harvard School of Public Health, as a collaboration between the university and The Culinary Institute of America to teach medical professionals how to select, purchase, and prepare healthy foods. The goal is to learn about healthy foods that can reduce disease risk and replace unhealthy habits. Or as one physician attendee of a recent conference said, “I’d love to be put out of work.” Dr. Eisenberg would like to see teaching kitchens in medical schools and hospitals and some physicians are following his lead. One doctor interviewed in the article holds a culinary boot camp in the 2,400 square food kitchen and lecture room built below his medical office. Another physician bought a farm and often runs into her patients when selling eggs at the local farmers’ market.

These efforts are inspiring and depict a shift in the traditional model of how doctors usually treat their patients, i.e. “a pill for every ill” as one doctor put it. But we are still a long way from doctors’ offices being equipped with teaching kitchens or from doctors regularly prescribing healthy food as a way to avoid or manage chronic conditions. Bronx Health REACH has stressed the importance of nutrition and healthy food choices in much of its programming, including the Culinary Initiative in churches and its partnership with New York City public schools, such as the Seeds in the Middle program at P.S. 221 in Crown Heights, Brooklyn and the food access and sustainability curriculum at M.S. 328 in Washington Heights, Manhattan. The Institute for Family Health, Bronx Health REACH’s parent organization, provides WIC (Women, Infant, and Child) services to its patients, which is a special nutrition education service that provides healthy food to mothers and young children. The Institute also employs a number of case workers that seek to coordinate care for the patients and provide them with services outside of the patient-provider relationship. There is a movement underway to integrate nutrition with traditional treatment regimens and it will continue to grow. If that’s the case, we hopefully will see more doctors wielding knives to teach their patients how to chop vegetables rather than using them to conduct surgery.

New York City’s FreshDirect Deal

On February 7^th, Mayor Michael Bloomberg, Governor Andrew Cuomo, and Bronx Borough President Ruben Diaz, Jr. announced a deal that provides FreshDirect with $127.8 million in taxpayer money to subsidize a relocation of FreshDirect’s headquarters from Long Island City to the Harlem Rail Yard on the South Bronx waterfront.  Two days later, the NYC Industrial Development Agency held a hearing on the FreshDirect deal to provide community members with an opportunity to voice their opinions before the deal was voted on. The concerns were many. South Bronx residents raised concerns about the impact on the environment, promised job creation, living wages, acceptance of EBT (food stamps), and the inaccessibility of FreshDirect services to South Bronx residents. A group called ‘South Bronx Unite: Stop FreshDirect’ was formed to speak out against the deal. South Bronx Unite members have created social media outlets (blog, Facebook and Twitter) to get the word out and have started a Change.org petition to stop FreshDirect from building its new headquarters in the South Bronx, and another petition encouraging a boycott of the company.

Many of the concerns that South Bronx Unite has raised include the environmental impact of bringing FreshDirect to the neighborhood, as well as how it will affect residents in the South Bronx. They have asked for an environmental impact statement for the site, noting that bringing FreshDirect to the area would add another 130 trucks per day to the South Bronx (already home to some of the highest asthma rates in the country). The group also says there is no written guarantee that FreshDirect will bring jobs to the area, though the company has said that 30% of the estimated 1000 jobs created in the next 10 years will go to community residents. However, even if the jobs materialize, community residents have argued that the wages are low and the workers will be exempt from any local living wage mandate adopted by the city (nearly 40% of current FreshDirect employees makes less than $25,000 per year). Other concerns center on the clientele that FreshDirect services. Currently, FreshDirect does not deliver to the South Bronx and does not accept food stamps. While the Bronx Borough President put together a Memorandum of Understanding to try and address these concerns, South Bronx Unite has protested that it does not adequately address the issues.  

But concerned residents and community groups are not just protesting, they’re also developing different solutions that would make efficient use of the nearly 100 acres of public waterfront land that FreshDirect will be leasing. Part of this effort entails having the city call for a moratorium on all new development at Harlem River Yards until a new Environmental Impact Assessment is conducted. The city could also consider funding new, innovative projects that make fresh, affordable, healthy food available to New York City residents in a way that provides living wages to its workers and does not add to the environmental burden of the Bronx. 

One such idea is that of landlord and developer Steve Smith, who has crafted a vision for a regional food campus at Oak Point in the South Bronx. This would provide access to “locally grown, locally raised, locally made” food for South Bronx residents and the larger NYC area.  Paul Lipson, consultant to the project, presented at Bronx Health REACH’s February 2012 Nutrition and Fitness Workgroup meeting about the proposed 130,000 sq ft regional food hub. It would house GrowNYC’s Wholesale Farmers Market and provide the opportunity for store owners and community members to access produce directly. Plans include a kitchen on the second floor and a “wash and chop” facility which would allow everyone – from bodegas to institutions such as the NYC Department of Education Office of SchoolFood – to make more direct use of local produce. Other proposed ideas for the site include having a rooftop hydroponic greenhouse operation serving grocery delivery chains in the New York metro area; an agricultural cooperative aggregating over 60 regional growers and producers; a borough-based brewer of beers and ales (the Bronx Brewery currently brews in Connecticut); a Bronx-based caterer and institutional food service providing meals for charter schools and senior centers; and a produce distributor. South Bronx Unite says that while this whole project would be dependent on subsidies, it would be a tenth of the price of the subsidies the City is planning on giving to FreshDirect. 

Bronx Health REACH will continue to monitor and evaluate efforts to hold the city and FreshDirect accountable to the South Bronx community in which FreshDirect is looking to relocate.

Fighting Childhood Obesity

In recent years, efforts to tackle childhood obesity have engaged everyone from the First Lady of the United States to local bodega owners. The reasoning is sound: today nearly half of the children in New York City are not at a healthy weight and the dearth of healthy options in many communities leave families with few options beyond the many fast food restaurants that crowd city blocks. The bright side is that these troubling statistics have led many organizations to integrate lessons around childhood obesity into their activities, bringing a “stay healthy” message into many different forums. As a recent New York Times article highlighted, the Children’s Museum of Manhattan has taken on this issue and run with it.

EatSleepPlay is a comprehensive, arts and literacy health-based project that uses creative and fun ways to engage children and their parents in the area of nutrition, sleep and active play. It includes a permanent exhibit where children can crawl through a giant digestive system and meet super-powered vegetable heroes called Super Sprowtz that explore the benefits of fruits and vegetables at a giant NYC Green Cart. The initiative reaches outside of the museum walls with an 11 week family health curriculum developed in partnership with the National Institutes of Health. The exhibit has proved popular with schoolchildren and some of the schools that Bronx Health REACH works with on an obesity prevention program have already brought their students to the museum as part of their nutrition education curriculum.

These kinds of efforts meant to engage young people in healthy activities in a somewhat non-traditional way have been sprouting up all over the city. Steve Ritz, a biology and earth science teacher formerly at Discovery High School in the Bronx, started Green Bronx Machine, a so-called “portable science lab” where students plant vertical living walls. (Watch Steve Ritz give a fantastic TEDx talk on YouTube here: http://www.youtube.com/watch?v=lcSL2yN39JM.) Other schools tout healthy bake sales and integrate physical activity into classroom work because students aren’t receiving the recommended amount of physical education. Though more traditional methods, such as organizing sports teams or incorporating nutrition education into the curriculum are critical, the ability to think outside of the box in order to address the obesity epidemic is a crucial part of this movement.

New York Hospitals' Charity Care Isn’t So Charitable

New York State’s Indigent Care Pool (ICP) exists to offset the cost of uncompensated care for uninsured and underinsured patients. Annually, nearly $1.2 billion in Medicaid funds are allocated to 201 hospitals statewide to compensate hospitals for the cost of providing care to people that cannot or will not pay their medical bills. In 2007, the state enacted the Hospital Financial Assistance Law (HFAL) to respond to concerns that hospitals were not properly notifying patients of financial assistance and lacked transparency and accountability for how they using public funds. However, a report issued this month by the Community Service Society found that an overwhelming majority of New York hospitals violate the HFAL and continue to impose barriers to financial assistance.

Bronx Health REACH is a longstanding advocate of providing equitable access to care for uninsured and underinsured patients. Part of this effort involves providing clear financial assistance policies to patients through the hospital’s website and the physician referral line. In 2011, New York State Senator Gustavo Rivera and Assemblyman Nelson Castro introduced legislation that would require patients receive information about financial assistance in these ways, as well as prohibit hospitals from steering patients into different care settings. (To read more about this legislation and segregated care, click here.) The passage of this legislation would be a step forward in ensuring that uninsured and underinsured patients receive the financial aid that they need. However, an overarching concern is that the largest amounts of money are going to the hospitals that provide the least amount of care to needy populations, while the safety net institutions shoulder an increased burden with severely limited funds.

The Community Service Society analyzed state department of health data for all New York hospitals and found that the hospitals that approved the largest amount of financial aid applications generally received a smaller amount of funding. For example, Jacobi Medical Center, a public hospital in the Bronx that treats a large proportion of uninsured patients, received $167 in 2010 for each of the 52,702 financial aid applications it approved in 2008. In comparison, Lenox Hill Hospital, a private hospital on the Upper East Side of Manhattan, approved only 130 applications that year and received $84,469 per application. In this current system, the Indigent Care Pool does not reward safety net institutions, which provide significant financial assistance to needy New Yorkers, as they generally receive a lower amount of funding. The report concludes that the extreme variability in the amount of funding received shows that there is a serious need for change in state policy, as well as increased regulation of how these payments are distributed.

The CSS report contains no end of statistics that detail the non-compliance of New York hospitals under HFAL, as well as the inequitable distribution of resources to safety net hospitals. While these reports are critical in order to shed a light on these practices, they should also be a call to action for communities, organizations, and health care advocates. Enormous amounts of money have been paid to treat indigent patients, yet it’s not reaching the people that need it most. (The New York Times wrote an article on this issue and outlined some patient stories, which you can read here.) Without pressure from the communities that these funds are meant to assist, the hospitals may continue to reap the benefits of state funding without providing the assistance it promises. The $1.2 billion per year needs to go to the people that need it most.