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Harriet S.MeyerMD, Contributing EditorJonathan D.EldredgeMLS, PhD, Journal Review EditorRobertHoganMD, adviser for new media
Those who live and work far from New York City may be tempted to ignore this book, thinking it deals only with the problems of one large metropolitan area with unique circumstances that don't affect the places where most Americans live and work. As the title indicates, this book is an attempt to convince readers otherwise. It takes a very broad view of public health, connecting neglect and withdrawal of services from poor urban communities with epidemics of tuberculosis, AIDS, substance abuse, and violence.
The book begins with several chapters devoted to the policies begun in the 1970s in New York City that closed fire houses in several poor neighborhoods in the South Bronx, Harlem, Manhattan, and Brooklyn. The authors present substantial evidence from memoranda and statements by politicians that the closings were not a mistake or an oversight, but a clearly thought out policy of "benign neglect and planned shrinkage." The Wallaces argue that these policies were a more recent version of urban renewal. The authors assert that officials in New York City looked at planned shrinkage as "a form of triage; it dictated the withdrawal of essential services from sick neighborhoods which were seen as unable to survive or undeserving of survival."
This first part of the book is very interesting reading as it explains how policymakers and the Rand Corporation used overly simplistic models to justify the closing of fire houses. They decided against using global measures of fire service efficacy, such as frequency and severity of fire damage, injuries, and fatalities to civilians and firefighters. Instead they used measures of average response time and average availability of fire companies. The subsequent withdrawal of services based on these flawed calculations led to destruction of large areas of several neighborhoods, and the authors use principles of disease epidemiology to illustrate epidemic spread of fires. They then examine migration from the burned-out areas and show that extreme overcrowding of housing began to be seen in adjacent neighborhoods.
The authors then turn to health problems and devote chapters to tuberculosis (TB), substance abuse, and AIDS. They show how the increased incidence of these problems was related to extreme housing overcrowding in several neighborhoods adjacent to those most affected by the fire control policies. However, they give little attention to other causes of the resurgence of TB that began in the late 1980s. They mention the HIV epidemic in a very short section but do not mention several other contributing factors, such as proliferation of large shelters for the homeless and the crumbling health infrastructure. In fact, they are very critical of traditional medical care and individual prevention as a response to these problems. In the case of TB, they note that the plan for control included decreasing the number of hospital beds but little increase in community public health work such as care contact-tracing, case finding, community participation, and education. They stress the cost and adverse effects of treatment and the dangers of the emergence of drug resistance. They seem not to acknowledge that these treatment measures actually did contribute to control of the TB epidemic in New York in the absence of much improvement in social conditions in the high-incidence areas.
In the third part of the book, the authors attempt to show how the public health problems previously described spread beyond the political boundaries of the city into the suburbs and even to other metropolitan areas, thus affecting public health at the national level. They examine commuting and migration patterns and attempt to relate these to patterns of spread of AIDS, TB, low birth weight, and violent crime. This chapter includes mathematical modeling that is very difficult to follow and understand.
The book has several shortcomings. The difficulty of some of the models used to explain the epidemic spread of fires and diseases is one. In addition, there are a large number of graphs and tables, some of which are very crowded with numbers and not easy to interpret. The authors may carry the argument against medical and traditional public health interventions too far in an attempt to show that only broad social policy changes can correct the problems.
Despite its flaws, A Plague on Your Houses deserves attention for its insights into the connections among urban communities and the ease with which diseases and social problems of the poor and vulnerable can spread into the mainstream and the suburbs. It asks new questions about the determinants of urban decay and public health, and challenges the dominant paradigm of disease causation mostly related to individual choices and lifestyles. Finally, it discusses the possibility of recovery with restoration of municipal services, rebuilding housing, and the re-establishment of community social networks.
Public Health: A Plague on Your Houses: How New York Was Burned Down and National Public Health Crumbled. JAMA. 2000;283(4):538–539. doi:10.1001/jama.283.4.538-JBK0126-2-1
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