Bruce F. Berg's Healing Gotham: New York City’s Public Health Policies for the Twenty-First Century
Reviewed by Erin Wuebker
Healing Gotham: New York City’s Public Health Policies for the Twenty-First Century
By Bruce F. Berg
Johns Hopkins University Press, 2015
312 pg.
The goal of Bruce F. Berg’s Healing Gotham is to explain why particular public policy tools have been used by the city’s government to deal with five different public health problems in the late 20th and early 21st century: lead poisoning, asthma, HIV/AIDS, obesity, and West Nile virus. Berg selected these particular issues not to be comprehensive, but rather to show health concerns that have different etiologies and affect different groups in order to analyze how these factors might impact the city’s approach to dealing with each illness.
Having written previously about New York politics, it makes sense that the city would be his focus for this book as well. But he also makes a compelling argument for his selection. As the largest urban area and an incredibly diverse city, New York has had to deal with a wide variety of public health issues. It has also often been at the forefront of public health historically, leading the nation in terms of developing infrastructure and support for government intervention. As such, New York has often been a model for other cities, demonstrating which “tools” are the most effective or challenging.
In Berg’s introduction, he sets out four factors that he believes have the greatest impact on public health policy decisions in the city: the state of knowledge about the health condition, economic development and the forces promoting it, intergovernmental politics, and diversity. Again, these are elements that shape public health policy across the nation, but sometimes play out uniquely in New York. For example, as one of the most diverse places in the nation, New York has had to grapple with reaching groups who speak different languages and have different ideas and customs related to health and government.[1]
Each chapter covers a different health issue and is organized into clear sections that tackle the etiology and prevalence of each illness, different policies used by New York, and how each of the four factors outlined in the introduction have impacted the approaches used in the city. Berg starts off discussing childhood lead poisoning, an illness that is concentrated among lower income children, who are more likely to live in older, sub-standard housing with leaded paint, and have less access to routine health care. The story Berg paints of the city’s efforts to decrease childhood lead poisoning beginning in the 1950s is one of limited gains over many decades, as the city has tried to increase screening of at-risk children, educate physicians and communities about the illness, and get landlords to address dangerous housing conditions that have exposed children to lead. For this disease, economic interests have had the biggest impact on policy according to Berg. Even as science has shown the dangers of exposure to increasingly lower lead levels, city laws and their enforcement have been limited by opposition from landlords over cost.
Similar to lead poisoning, asthma came onto the city’s radar as the incidence among children rose significantly, especially in the city. Today, more than 10% of New York’s children suffer from asthma and it is the number one cause of hospitalizations among childre. In contrast to lead poisoning, however, this illness is multifactorial — there is no one known cause and we don’t know much about why children develop asthma. Science has tied the condition to indoor and outdoor allergens and irritants like cockroaches, mold, secondhand smoke, and pollution, as well as stress and obesity. City policy has focused on controlling asthma triggers through regulating vehicle and building emissions, which have increased with economic development. Under Mayor Giuliani, the city’s Asthma Initiative also began to support the work of existing community groups in high prevalence areas to prevent asthma hospitalizations via education, training, and access to care. For Berg, the asthma case study is a lesson in why employing a variety of policy tools is necessary.
Berg next tackles HIV/AIDS, arguing that we see the greatest challenge to the public health establishment with the illness by gay advocacy groups, who were broadly middle class and educated. Groups like the Gay Men’s Health Crisis and many others also dove head first into education efforts long before any level of government did, so the city actually borrowed tactics from them like hotlines and condom distribution. One other significant way the pushback from the gay community influenced policy was regarding testing, reporting, and contact tracing, which remained confidential and voluntary.
Berg highlights other groups significantly affected by HIV/AIDS and how the city has worked to reach them with public health interventions, such as controversial needle exchange programs created to decrease transmission among IV drug users. The city also had to factor diversity into its programs and educational materials as heterosexual women, men who have sex with men (but don't identify as gay), and people of color began to account for more new HIV infections. As gay Manhattanites have often been the focus of the story of HIV/AIDS in the US, addressing these other groups is important.
Like asthma, obesity became a major public health issue as prevalence jumped in the 1990s. In 2012, 60% of New Yorkers were overweight and 40% of school children. Economic development has had in important impact on increasing obesity rates overall as it is shaped by increased sedentary work and leisure time due to computers and television, a growing food industry, and changes in eating habits. Low income households and communities are most at risk for obesity, as it is also linked to food deserts, food insecurity, and characteristics of the built environment that discourage physical activity (higher crime rates, few parks, and environmental hazards).
Also similar to asthma, this constellation of causes have led the city to employ a variety of approaches to try and decrease rates among adults and children. People will likely be most familiar with the controversial calorie posting law and attempts to ban the sale of large sodas, which combine regulation and education. New York City has also enacted many programs to encourage bodegas (neighborhood corner stores) to carry healthier foods, assist vendors to set up Green Carts to sell fruits and vegetables in areas with fewer healthy food options, and create incentives for building grocery stores in neighborhoods lacking them.
The final chapter details approaches to contain West Nile Virus, which first appeared in North America in New York in 1999. Very different from the other illnesses addressed, the virus affected a small amount of people, but its mortality rate and its novelty to Americans led to serious concern. Also dissimilar to most of the other public health issues, it is not tied to economic development and it is not shaped by race, class, or other social identities. During the initial outbreak (sixty hospitalized, seven died) in the summer of 1999, the city sprayed insecticide widely to kill mosquitoes, the vectors of the virus. While there was some opposition to the health hazards posed by these chemicals, the city adjusted its spraying policies and increased education in the summer of 2000 and gained significant support and participation from residents to curb the mosquito population. For me, this was the least interesting of the chapters, as there were few challenges for the city dealing with the virus and so the path to policy seemed more straightforward. Although, it served perhaps as a foil for the other illnesses.
While his overall analysis — that demographics, economics, and politics shape policy as much as knowledge about a public health issue — will not be new to scholars of public health, Berg’s book is an incredibly detailed study of policy in New York that takes a comparative approach less often seen. As he also convincingly argues, there are elements that are unique about the experience of New York, but its story is also likely applicable to other cities in the United States. The book also takes time to introduce foundational knowledge about public health. As a result, it will be of use to specialists and those less familiar with public health or New York, adaptable to both undergraduate and graduate courses.
While Berg’s broad approach comparing policy regarding six different illnesses in the city is useful, it also has some limitations. For example, there is not a lot of space to address how policies may play out differently in the five boroughs and neighborhoods, with their varied politics, ethnic and racial diversity, community organizations, income levels, and more. While Berg is able to address this briefly in some sections, such as Harlem’s community efforts to curb asthma or the city’s focus on food deserts in East and Central Harlem, the South Bronx, and North and Central Brooklyn, overall he is looking at the city as a whole.
The book also doesn’t include many people or grassroots organizations in its analysis. Berg’s analysis mostly looks at public health from the top down, so mayors or health commissioners are the few people singled out. Those looking for information on how communities have shaped public health policy will find some examples, but that is not really the focus of Berg’s approach. I felt this limited his discussion of lead poisoning in particular where he asserts there was not much controversy over the illness’ concentration not just among low-income communities but specifically those of color. As other scholars have shown, the moderate steps the city takes to amend lead-paint laws and increase screening and education come in the wake of work and activism by medical professionals working within “lead belt” communities, parents of lead poisoned children, and civil rights groups.[2] In spite of these few limitations, Healing Gotham is an ambitious book that is an important contribution to our understanding of New York and public health.
Erin Wuebker is a U.S. historian of public health, visual culture, and the history of women, gender, and sexuality. She teaches at Queens College and works at the Museum of the City of New York and Brooklyn Historical Society.
[1] Berg also sets out two political science theories he is using to analyze public health policy—rational model and market failure, and urban political theory. Coming from history I didn’t find these that helpful, but they may be to scholars in that field. Bruce F. Berg, Healing Gotham: New York City’s Public Health Policies for the Twenty-First Century (Johns Hopkins University Press, 2015), 12-18. He also comes back to them in his conclusion.
[2] See for example, Christian Warren, Brush with Death: A Social History of Lead Poisoning (Johns Hopkins University Press, 2001).