procedures carried out could be extended to the
whole gamut of basic health services to which
all citizens are entitled" (2).
New York's fiscal crisis has pushed
underlying tensions to the point of
open conflict. The crisis in the City's
budget and the scramble to cut
spending and programs has created
what a former City Health Commis-
sioner calls a lifeboat mentality'
This kind of health care delivery model is one
that approaches the provision of services from the
perspective of need. Most other health care pro-
viders, including hospitals, approach the ques-
tion from the perspective of demand. Ideological-
ly, this latter orientation leads to "marketing"
services to "consumers" who can "purchase"
them if their "effective demand" is improved.
But the health problems faced by large, urban,
often low-income populations have proved stub-
bornly immune to this market approach. High
infant and maternal mortality rates, for example,
rooted in poor nutrition, substandard educational
levels and poor housing, have remained alarmingly
high despite all the onslaughts of market medicine.
Meanwhile, market providers seldom undertake
the kinds of programs that could seriously attack
such problems-nutritional and prenatal coun-
seling, birth control programs, and an aggressive
outreach to find pockets of high risk-because
they represent a "poor return" in either direct
reimbursements or potential new inpatients.
For many, the only viable solution to the cur-
rent conflict is an expansion of the public health
model of service delivery. However, New York
seems firmly headed in the opposite direction-
toward strengthening the market model. In recent
years, in New York City, those services delivered
on the basis of need have been cut first and deep-
est and this trend seems likely to continue in the
coming months.
In the pages that follow, the extent of these
cuts and the rationale for them will be explored.
The reader will note persistent references to cut-
8 ting "fat" and to reducing services that were
previously "underutilized" or "available else-
where." The question remains whether such
explanations miss the mark entirely. In the words
of one veteran professional in the Department, "I
really worry whether anyone realizes what is lost
by turning away from the concept of treating
health as a public problem, and health care as a
public service?"
The Role of District Health Services
In November, 1974, as New York City entered
a severe fiscal crisis, the City's Department of
Health began a period of unprecedented reduc-
tions in its budget, services, and personnel.
From 1974-1977, the Department's tax levy
budget was reduced by 20%, from $50 million to
$40 million. Its staff size was reduced by 28%,
from 6,000 to 4,300. A hiring freeze, imposed in
1975 and 1976 on all city agencies, made it
impossible to replace key professional staff.
Over this period, the Department cut programs its
policymakers classified as "life-enhancing" (rather
than "life-saving"), programs such as dental,
school and child health, audiometric and eye
testing, chest clinics, public health social work,
education, and nutrition.
These reductions took place despite a con-
tinuing need for the services by New York City's
poor. In 1974, approximately 938,000 of the
City's total population of 7.8 million were on
welfare. For them, for the City's working poor,
and for the City's estimated one million illegal
aliens, the Department of Health was a primary
source of free health care.
The DOH has a long history of providing direct
personal health services, free of charge, to the
City's poor. As immigrant groups streamed in-
to New York, the DOH responded, sometimes
from fear, sometimes compassion, with a number
of public health innovations, many generally re-
cognized as "firsts" for a municipal health de-
partment.
In the early 1900s, the Department began to
offer a wide range of free personal services through
its District Health Services program. These neigh-
borhood-based Health Centers were seen at that
time as the answer to the special out-of-hospital
health problems of the urban poor, chiefly infec-
tious diseases and infant malnutrition. In January
of 1915 the City's first Health District was es-
tablished on the Lower East Side of Manhattan.
This experimental health center quickly proved