摘要：In 1975, New York City experienced a fiscal crisis rooted in long-term political and economic changes in the city. Budget and policy decisions designed to alleviate this fiscal crisis contributed to the subsequent epidemics of tuberculosis, human immunodeficiency virus (HIV) infection, and homicide in New York City. Because these conditions share underlying social determinants, we consider them a syndemic, i.e., all 3 combined to create an excess disease burden on the population. Cuts in services; the dismantling of health, public safety, and social service infrastructures; and the deterioration of living conditions for vulnerable populations contributed to the amplification of these health conditions over 2 decades. We estimate that the costs incurred in controlling these epidemics exceeded $50 billion (in 2004 dollars); in contrast, the overall budgetary saving during the fiscal crisis was $10 billion. This history has implications for public health professionals who must respond to current perceptions of local fiscal crises. IN THE 1980S AND EARLY 1990S, New York City experienced epidemics of tuberculosis (TB), human immunodeficiency virus (HIV) infection, and homicide. Although each of these has unique determinants and each affects people worldwide, in New York City the 3 epidemics played out in a specific geographic, temporal, and political context; affected similar populations; and together contributed to a public health crisis. 1 – 3 HIV infection, TB, and homicide constituted a syndemic that affected New York City from the late 1970s to the mid-1990s. A syndemic has been defined as 2 or more epidemics, with biological determinants and social conditions interacting synergistically, that contribute to an excess burden of disease in a population. 4 , 5 We used journalistic accounts and government reports, as well as recent epidemiological and economic analyses, to examine how budget and policy decisions made in New York City in the 1970s contributed to the increasing incidence of TB, HIV infection, and homicide during the 1980s and 1990s. Municipal, state, and federal policy and budget decisions in the late 1970s and early 1980s determined the severity of the syndemic and contributed to tens of thousands of preventable deaths and illnesses. Ultimately, it cost New York City tens of billions of dollars to deal with the consequences of these budget cuts. We hoped that an examination of this chapter of the city’s history and the longer-term social and economic costs of the policy decisions made in that era would yield lessons that could guide the public health response to future municipal fiscal crises.
