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by Corey

Environmental Health in Manhattan Community District 6, New York City

Manhattan Community District 6: Community Assessment

Manhattan Community District 6, located in New York County, New York, covers 1.4 square miles and includes the neighborhoods of Beekman Place, Murray Hill, Gramercy, Stuyvesant Town, Sutton Place, Tudor City, and Turtle Bay. Its boundaries include East 59 Street to the north, East 14 Street to the south, Lexington Avenue to the west extending to Madison Avenue between 34 to 40 Streets, and the East River to the east. According to census data collected in 2016, District 6 has a population of 141,162 with a median age of 35.6 years old. 55% of residents are female and 69% are white. The per capita income is $90,056 with a median household income of $110,401. There are 75,794 households with an average of 1.8 persons per household. 34% of the population is married and 80% have a bachelor’s degree or higher. 22.1% of residents were born outside the U.S., with 48% from Asia. 25.6% of people speak a language other than English at home (U.S. Census Bureau).

The district is home to 44 medical clinics including five major hospitals and about 90% of residents have health insurance. 90% of people reported their own health as good to excellent with an average life expectancy in District 6 of 85.3 years. There are many retail shops and grocery stores, health food stores, and restaurants are easily accessible making access to good quality food convenient.

13% of residents smoke (under the national average) and 93% eat at least one serving of fruits or vegetables per day, similar to residents in Manhattan and NYC as a whole. However only 12% consume one or more 12-ounce sugary drinks per day (best rate in NYC), and 85% reported engaging in physical activity in the previous 30 days. District 6 has the lowest rates in NYC for obesity (only 8% compared to 24% in all of NYC) and diabetes (only 3% compared to 10% in all of NYC). District 6 is just below the NYC average for alcohol and drug-related hospitalizations. They also have the lowest rates of stroke hospitalizations and low rates for avoidable hospitalizations due to adult asthma and adult diabetes. The rate of adult psychiatric hospitalizations, however, is above the overall NYC rate. District 6 ranks the second highest in air pollution in NYC and has the smallest percentage of park space out of all the NYC districts. Similar to most New Yorkers, the leading cause of death in District 6 is cancer and heart disease yet the district’s mortality rate due to diabetes is less than half the citywide average (NYC Health, 2015).

 

The Need to Improve Environmental Health in District 6

The top three pressing issues perceived and identified by Manhattan Community Board 6 are affordable housing, parks, and senior services. Addressing the lack of tree cover and park space has been identified as a health matter by the board (NYC Planning, 2018). It is clear from the statistics that District 6 residents care about their health and engage in behaviors to support that. Avoiding sugary drinks, exercising, and eating well are reflected in their low obesity rate and incidence of diabetes. However, it is concerning that these healthy behaviors are doing little to reduce the cancer rates and cardiovascular disease in their area, which continue to remain an issue for New Yorkers at large. On the HealthyPeople.gov website within the 2020 Topics & Objectives section for Cancer, it mentions that many cancers are preventable by reducing risk factors like use of tobacco products, physical activity and poor nutrition, obesity, and ultraviolet light exposure (ODPHP, 2018). But in Manhattan’s Community District 6, the apparent reduction of these cited risk factors do not appear to be making the difference needed and thus, cannot be the only variables to take into account.

It is difficult to ignore that District 6 is ranked second only to Midtown for air pollution. This could be an often-overlooked connection to cancer and mortalities related to cardiovascular disease. In 2013, the International Agency for Research on Cancer (IARC), part of the World Health Organization (WHO), has classified outdoor air pollution, and specifically particulate matter, as a carcinogen (American Cancer Society, 2013). In NYC, poor air quality is linked to the high volume of automobile traffic and exhaust emissions. NYC is aiming to convert its public bus system to all electric vehicles by 2040. In 2005, they mandated that all diesel-powered vehicles owned by the city be powered by ultra-low sulfur diesel fuel. While NYC has launched initiatives to reduce industrial emissions to lighten the city’s impact on air pollution; this is not capturing the extent of the problem. The influx of cars and trucks from commuters and businesses continue to increase in numbers and automobile traffic is recognized as an issue. The link to health, aside from conditions like asthma and other respiratory diseases, is not commonly highlighted, and pollution is often framed in the context of climate change and geo-environmental impact.

Many New Yorkers boast how their tap water is piped into the city from mountain reservoirs yet it’s safety has come under question after the U.S. Environmental Protection Agency (EPA) has identified violations of federal health-based drinking water standards in 2017. Six known cancer-causing contaminants have been found and eight other chemicals associated to increase the risk of cancer have been detected in tap water. Some of these are frequently seen to be associated with agricultural, industrial, and urban runoff, but others like bromodichloromethane and chloroform are due the result of using chlorine and other disinfectants to treat drinking water by government institutions (EWG, 2018). Regular consumption and use of unfiltered contaminated water in food preparation undoubtedly have an impact on cancer rates and overall health. However, this environmental health concern has not been acknowledged by the city and NYC announced in December of 2017 that they received a 10-year waiver to continue delivering unfiltered drinking water from its mountain water supply (NYC.gov, 2017).

If you’ve ever walked around the streets of New York City in the summertime, it would be surprising to not notice the smells of trash and grime of the city. With garbage collection typically, being a curbside event, pedestrians encounter NYC’s waste products on an intimate scale. Also, the need for wide-spread infrastructure maintenance and the constant activity of new construction projects, residents of NYC get exposed to many toxins and chemicals used in the demolition of old structures containing many harmful products. New building materials and furnishings add to the City’s levels of toxic chemicals, and industrial-strength cleaning and disinfection methods add even more. In addition to the toxins one might encounter in the streets, many residential and commercial interiors provide additional exposure to toxins. According to EWG’s Healthy Living: Home Guide (2018), “the air inside our homes is 2 to 5 times more polluted than the air outside”.

 

Solutions to Improve Environmental Health in District 6

Improving air pollution globally and in urban environments is a complex issue and one that is being addressed on all levels of government and within the corporate sector. NYC is continually monitoring levels of fine particulate matter and other air contaminants and trying to advance standards towards a cleaner and healthier city. While asthma and respiratory diseases are sometimes mentioned in the context of discussing air pollution, greater awareness can be placed on the many other health detriments, like cancer and cardiovascular disease, which air pollution can influence. As Manhattan Community Board 6 has recognized, growing the park space in their district should be a priority and will offer a means to help with pollution for their residents. Increasing park space can potentially benefit health in many ways in District 6. As typically mentioned with such initiatives, increased park space can provide residents with more opportunity for exercise and physical fitness. Planting trees has been recognized to offset carbon dioxide levels and remove dust and other pollutants from the air. Trees can also lower temperatures in the summer, provide wildlife habitat, and increase community pride and district appeal (MillionTrees NYC, 2015). Also, by reclaiming land currently allocated for automobile traffic and rezoning transportation routes, adding park space can result in redistributing exposures to pollution in District 6 from cars and trucks. For individuals, as it may be difficult to limit time spent in their own neighborhood, pollution masks are available to wear that can filter dust and small particulate. These type of safety masks are not commonly used in NYC, which underscores the shift in awareness that is necessary to alter people’s understanding of the breadth of health risks associated with regular exposure to harmful air pollution.

Promotion of NYC tap water as “some of the cleanest and best tap water in the world, “ by Mayor de Blasio, and Health Commissioner Dr. Mary T. Basset statement referring to it as “the champagne of tap water,” are not helping to reinforce public perception that concern should be given to the quality of their tap water (NYC.gov, 2017). For now, home filtering systems using carbon filtration, or even better, reverse osmosis, is a good start for all NYC residents to help lower the intake of harmful chemicals and carcinogens identified in the water system.

To improve environmental health in the home and commercial spaces, NYC Department of Buildings could begin by raising environmental standards for all construction projects to adhere to the highest level and require LEED and Energy Star certifications as the minimum benchmark for all city projects. In the home, there is a lot that people can do to reduce their exposure to harmful chemicals. EWG’s Healthy Living: Home Guide (2018), includes many areas that people can make changes to and improve the health in their home. Using air filters and cleaning and replacing them regularly can improve indoor air quality. Adding plants in the home can also help with this. Switching to cleaning products with Green Seal or Ecologo certification can reduce exposure to toxins. Additionally, avoiding furniture and mattresses with stain-guards, flame-retardants, and choosing products using natural latex or low-VOC certified foam can contribute to a healthier home.

These solutions and practical strategies could be of benefit to all of NYC, not just those in District 6 and Midtown where air pollution is at its worst. Expansion to the existing understanding of environmental health factors on a local, national, and global level will be needed to increase awareness to these issues. Both government agencies and the corporate sector will have to do their part to improve the conditions for environmental health. Individuals, however, do not need to wait for change to come from the top and should be encouraged to take action in their daily lives to set up healthier environments and improve their own health, tat of their loved ones, and their community as a whole.

 

References

American Cancer Society. (2013). World Health Organization: Outdoor air pollution causes cancer. Retrieved from <https://www.cancer.org/latest-news/world-health-orsganization-outdoor-air-pollution-causes-cancer.html>

Environmental Working Group. (2018). EWG’s healthy living: Home guide. Retrieved from <https://www.ewg.org/healthyhomeguide/>

Environmental Working Group (EWG). (2018). New York City system. Retrieved from <https://www.ewg.org/tapwater/system.php?pws=NY7003493#.WzIsyxJKh24>

MillionTrees NYC. (2015). NYC’s Urban Forest. Retrieved from <http://www.milliontreesnyc.org/html/about/forest.shtml>

NYC.gov. (2017). High quality NYC tap water receives new filtration waiver. Retrieved from <https://www1.nyc.gov/office-of-the-mayor/news/779-17/high-quality-nyc-tap-water-receives-new-filtration-waiver>

NYC Health. (2015) Community Health Profiles 2015: Stuyvesant Town and Turtle Bay Community District 6 health profile. Retrieved from <https://www1.nyc.gov/assets/doh/downloads/pdf/data/2015chp-mn6.pdf>

NYC Planning. (2018). Manhattan Community District 6. Retrieved from <https://communityprofiles.planning.nyc.gov/manhattan/6>

U.S. Census Bureau. (2016). American Community Survey 1-year estimates. Retrieved from Census reporter profile page for NYC-Manhattan Community District 6–Murray Hill, Gramercy & Stuyvesant Town PUMA, NY <https://censusreporter.org/profiles/79500US3603808-nyc-manhattan-community-district-6-murray-hill-gramercy-stuyvesant-town-puma-ny/>

U.S. Department of Health and Human Services (ODPHP). (2018). Cancer. Retrieved from <https://www.healthypeople.gov/2020/topics-objectives/topic/cancer>

 

by Corey

A snapshot of acupuncture health policy

In recent years, there has been a growing demand from the public for acupuncture services in the U.S., leading to increased interest and scientific investigation into its effectiveness, safety, and potential uses within the U.S. health care system. The National Center for Complementary and Integrative Health (NCCIH), formerly known as the National Center for Complementary and Alternative Medicine (NCCAM), has funded the most rigorous acupuncture research to date to evaluate its use to ease the pain of chronic conditions such back and neck pain, osteoarthritis, shoulder pain, and headache (Vickers et al, 2012). Findings of this meta-analysis suggest that acupuncture’s effects on chronic pain are clinically significant, supporting the recommendation by NCCIH of referrals for acupuncture as a reasonable treatment option for people with chronic pain (NIH, 2018).

For most doctors practicing within the biomedical paradigm of the heath care system, these findings along with the growing base of evidence for acupuncture’s effectiveness may not be enough to promulgate regular referrals for acupuncture treatment in the context of standard care. However, amidst a growing concern for the widespread misuse of prescription opioids contributing to over 17,000 deaths in 2016 and $504 billion in economic costs (CEA, 2017), many in the health care system are looking to non-pharmacologic alternatives to manage chronic pain. This response to the Opioid Epidemic has drawn interest towards promoting acupuncture and other integrative therapies and inclusion of them in legislation like the Comprehensive Addiction and Recovery Act (CARA), signed into law in 2016, that mandated the Veterans Administration (VA) to expand acupuncture and other integrative health services as well as related research and education.

In fact, the VA has championed integrative health delivery on a national level through the creation of the Integrative Health Coordinating Center, a branch of the Office of Patient Centered Care and Cultural Transformation (OPCC&CT). The VA offers acupuncture or other integrative services in 93 percent of its nation-wide centers that treat more than six million veterans annually (Reddy, 2018). In addition, the VA’s 2018 policy to establish an occupational qualification standard for employment positions of state-licensed acupuncturists within the VA Health Administration further recognizes the advanced professional education, training, and experience of state-licensed acupuncturists and distinguishes their knowledge and skills from that of a certified acupuncturist physician with less acupuncture-specific training (NCCAOM, 2018). This status for licensed-acupuncturists to be acknowledged by a government standard (GS) rating of GS 9-12 helps to lend credibility to the profession of acupuncture and its perception in the national health care arena.

Similarly in 2018, acupuncturists earned a distinct Standard Occupational Code (SOC) by the Bureau of Labor and now have their own federally recognized labor category based on data that confirmed growth within their profession (NCCAOM, 2018). These developments in understanding on a government-level will undoubtedly help to advance the acupuncture profession as it continues to establish itself as a mainstay in standard medical care and make its way into future public policy initiatives.

Preserving the integrity of the profession of acupuncture by its licensed members has long been a priority within the community as most biomedical physicians are also permitted to practice acupuncture within the scope of their medical practices with little to no additional related training. Only three states (Hawaii, Montana, New Mexico) require that physicians obtain acupuncture licenses by completing an accredited program and two states (Vermont and Rhode Island) decreased their requirements over the past two decades, allowing physicians to deliver acupuncture within their scope of practice where in the past this was prohibited. State regulations for training and competency have been focused on safety, recognizing contraindications and complications, and observing the procedures of clean-needle technique (Lin & Tung, 2017). Licensed acupuncturists, who provide acupuncture according to East Asian medical theories of diagnosis and treatment, often criticize the lack of this holistic basis of understanding by certified acupuncture physicians and cite it as a key motivation in preserving the extent of their scope. Further investigation into the differences in outcomes by the two approaches to acupuncture is necessary to address the associated strengths and weaknesses.

Similar issues regarding preserving scope of practice and safety have recently come into question with regard to the use of acupuncture techniques by practitioners other than acupuncturists, specifically physical therapists, who are using a procedure called intramuscular manual therapy, commonly called “dry needling.” This physical therapy service involves the insertion needles into trigger-points of muscles and is sometimes being sought after in lieu of services by licensed acupuncturists because of its access through insurance coverage of physical therapy and rehabilitative services. State regulations in California, Utah, New York, Idaho, Hawaii, and Florida do not allow dry needling in their states because it involves puncturing the skin (Kinetacore, 2018). The American Academy of Physical Medicine and Rehabilitation (AAPMR) recognizes the risks associated with dry needing, such as bruising, hematoma, pneumothorax, nerve injury, vascular injury, and infection. Despite the legality of physical therapists being able to utilize this controversial procedure in most states, The AAPMR maintains their position that dry needling “should only be performed by practitioners with standard training and familiarity with routine use of needles in their practice, such as licensed acupuncturists or licensed medical physicians” (NCCAOM, 2012).

With the potential of future legislation providing greater access of acupuncture to a vast number of Americans, it is clear that may factors and stakeholders will be taken into consideration when crafting related policies and regulations. Licensed acupuncturists may continue to practice a form of the medicine most true to its origins and traditions but they also may need to share in the delivery of acupuncture with other health care providers to meet growing demand. Their role in shaping what that ultimately becomes will be a critical part in establishing the competencies required to maximize the impact that acupuncture can have within the wider landscape of America’s evolving health care system.

 

References

Kinetacore. (2018). Scope of practice. Retrieved from: <https://www.kinetacore.com/about/scope-of-practice/>

Lin K., Tung C. (2017). The regulation of the practice of acupuncture by physicians in the United States. Medical Acupuncture, 2017, 29(3):121-127. http://doi.org/10.1089/acu.2017.1235

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). (2012). AAPM&R policy on dry needling. Retrieved from: <http://www.nccaom.org/resource-center/press/press-releases/aapmr-policy-on-dry-needling/>

National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). (2018). Acupuncturists now included in the Veterans Health Administration. Retrieved from: <http://www.nccaom.org/blog/2018/03/01/acupuncturists-in-va/>

National Institutes of Health (NIH). (2018) Acupuncture: In depth. Retrieved from:<https://nccih.nih.gov/health/acupuncture/introduction>

Reddy B. (2018). A model for integrative health in the U.S.. Acupuncture Today, 2018, 19(6):1526-7784

The Council of Economic Advisers (CEA). (2017). The Underestimated cost of the Opioid Crisis. Washington, DC: U.S. Government Printing Office.

Vickers A.J., Cronin A.M., Maschino A.C., Lewith G., Macpherson H., Foster N.E., Sherman K.J., Witt C.M., Linde K. (2012). Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Archives of Internal Medicine, 2012 Oct 22; 172(19):1444-53. http://doi.org/10.1001/archinternmed.2012.3654

by Corey

The Affordable Care Act and Acupuncture

The Affordable Care Act (ACA) attempted to create wider access to health care services for patients in America and reframed some of the guidelines that insurance companies and other payers must oblige when evaluating coverage of services by acupuncturists and other alternative medical providers. Section 2706 of the ACA, also known as “Nondiscrimination in Health Care,” aimed to create professional parity for state-licensed providers like acupuncturists who render services within their legal scope of practice. By mandating coverage of these services and eligibility for reimbursement for treatment of health conditions covered in an insurance plan, state-licensed heath care professionals can no longer be excluded from insurance plans on the basis of their profession.  Section 2706, however, does not create parity in terms of reimbursement rates, which creates a loophole for insurers that concerns many acupuncturists. Also, in states where professional licensing of some alternative medical providers is not in place, coverage may still be denied for services that may be covered elsewhere. It is clear that the nondiscrimination provision is a start to addressing egalitarian recognition for some alternative health care professionals, but there is still much to address to ensure interpretation of this provision is not tailored to the needs of insurers instead of to patients and related providers. Section 3502 of the ACA, also was an attempt to legitimize acupuncture and other alternative medical services through its mention of establishing interdisciplinary community heath teams that may include licensed professionals offering complementary and alternative medicine (CAM), a.k.a. complementary integrative health (CIH). This language opened the discussion of inclusion of CIH services in essential health benefits but, again, more attention will be needed to see implementation of CIH as a mainstay in the common delivery of health care in America. Regardless, these provisions do favor the recognition and use of acupuncture and other services, which have been historically marginalized in the insurance marketplace. This is surely a positive start to mainstream integration.

by Corey

Acupuncture for Heroes and Seniors Act of 2017

The Acupuncture for Heroes and Seniors Act of 2017, if passed, would expand the treatment of veterans, U.S. Armed Forces military personnel, and their dependents to include acupuncture services for many health concerns without the need for a referral. The significance of this bill on a national level is that it would provide a new baseline for standards of care that recognize acupuncture as an essential benefits for the populations mentioned in addition to those who receive Medicare. Also, by including licensed acupuncturists with medical doctors certified in acupuncture as “qualified” providers, this bill elevates the reputation of our profession on the national stage, lending credibility and perceived value to the training that licensed acupuncturists receive by the public and other established medical professionals.

By creating an overarching recognition of the merits of our profession in federally funded health care, this has the potential to affect legislation on a state level, especially in states where laws for the practice of acupuncture are not clearly defined or lacking. A nationally accepted bill may force change in these states to advance the status of licensed acupuncturists to be accepted as respected medical practitioners. In states where acupuncture laws are more progressive, this bill could be helpful to protect and expand our scope of practice as acupuncture services become more of a mainstay in the current system.

To date, the development of acupuncture in the military has affected my practice in an indirect way as it has helped to provide a reputable source of acceptance that filters into the mainstream media and perception of acupuncture by the conventional medical institution. I live in Manhattan, right around the block from the local VA hospital and have volunteered there for several years. Even so, I have not had the opportunity to treat veterans with acupuncture. In the past, I’ve spoken to the head of the acupuncture department there who mentioned that there is a long waitlist to receive acupuncture for pain management yet they do not refer out to licensed acupuncturists, despite the demand and positive treatment outcomes recorded. Recent developments with the VA Mission Act of 2018 may be enough on it’s own to increase acupuncture services offered by licensed acupuncturists to veterans, however, the passing of the Acupuncture for Heroes and Seniors Act of 2017 will place a focus specifically on acupuncture and will open up a clearer path for me and fellow licensed acupuncturists to participate in treating veterans.