How last summer’s shocking outbreak of Legionnaires disease in The Bronx was really about neighborhood poverty

Although it’s relatively rare, Legionnaires disease isn’t unheard of in the United States. In fact, the Centers for Disease Control estimates that U.S. hospitals see between eight thousand and eighteen thousand cases every year. Last year, however, the disease made national headlines as an outbreak spread through a New York City neighborhood. That crisis has come to an end but revealed in its wake the vulnerability of an impoverished community and its residents.

The New York City Department of Health began its investigation into an outbreak of Legionnaires on July 20, 2015. The commissioner released a statement that the department was investigating the outbreak, which they identified as taking off early in the month.

“We are concerned about this unusual increase in Legionnaires’ disease cases in the South Bronx,” said Health Commissioner Dr. Mary Bassett in the statement. “We are conducting a swift investigation to determine the source of the outbreak and prevent future cases. I urge anyone with symptoms to seek medical attention right away.”

By July 28th, investigators had narrowed the likely source of the outbreak to cooling towers in the South Bronx and began testing for the bacteria. Two days later, the Opera House Hotel in the South Bronx tested positive for the bacteria and the city ordered disinfection. By August 6th the health commissioner ordered all cooling towers in New York City to be disinfected. And later that week, the New York City Council passed a bill mandating the regular cleaning of cooling towers; with Mayor De Blasio signing signed that bill into law last Monday. Finally, after testing matched a strain of the bacteria found in patients to that found in the cooling towers at Opera House, the hotel was confirmed as the source of the outbreak. The entire crisis spanned thirty-one days. A hundred and twenty-seven South Bronx residents were infected, twelve of whom died.

Legionnaires, a form of pneumonia caused by Legionella bacteria and found most commonly in water systems, is not deadly in most cases. According to the C.D.C., only about 15 percent of the people who become infected die from it. As was the case in The Bronx, the elderly and people with chronic health conditions — especially respiratory conditions — are particularly at risk. According to reports, all of those who died during the outbreak had underlying medical conditions.

More than six hundred people were tested for Legionnaires during last year’s outbreak through the Montefiore Health System, a network of eight hospitals and an extended-care facility in the Bronx.

The emergency room of Montefiore Medical Center on E 210th Street in The Bronx defies the borough’s reputation as blighted. The waiting area is spruce and orderly on a late summer Tuesday afternoon. Patients sit quietly waiting to be seen by a doctor. Nearly every seat in the room is filled, however. Almost all of the 25 or so people waiting are people of color, black and Latino from all over The Bronx. Two are wheelchair-bound; two sit with canes resting nearby and one person next to his walker. A few of the patients are elderly but most are not.

A’Isha Harper is the assistant director of the emergency department for the Bronx-based Montefiore Medical Center. A trained nurse, Harper also processes patients on the emergency room floor at one of the center’s many facilities. She estimates that about half of the patients who come into the ER are there for primary care that they’ve put off due to time constraints or fear of cost. Many, she says, come in on days off from work and while their children are in school, driving peak hours in the middle of the day.

Aside from guiding patients into care, Harper says her job requires her to also identify hurdles they might face to getting well because of their socioeconomic conditions. Chief among the barriers, she says are transportation and housing instability.

“Most people think I’m a social worker, but I’m not,” she says.

Montefiore does have a social work department. It’s headed by Deirdre Sekulic, a medicine social worker who’s been with the hospital for eight years. In her role, Sekulic works hand in hand with Harper to connects patient with the resources they need to get and stay well, including permanent housing. With a caseload of about 20 patients, she says it’s tough, emotional work.

Four of the outbreak cases involved people who lived in The Brook, a South Bronx supportive-housing facility, the exact kind of facility were Sekulic often places Montefiore’s most insecurely-housed patients. One of the four infected at The Brook was among the outbreak’s fatalities. Although none of the Legionnaires patients were her cases, Sekulic says the news was alarming.

“The minute we saw it on the news, of course we were concerned about the residents,” says Sekulic. “You have people who don’t have access to healthcare or who don’t have high health literacy that may be suffering with something and may not have the access to know that it’s actually even going on. They may not have an awareness because they don’t have access to TV, social media. They have no idea and they may be sick and not even know that this is an outbreak that’s affecting the entire neighborhood.”

The Brook opened its doors to residents in 2010. It’s a 190-unit building, nearly two-thirds of which are reserved for “special needs” residents: people who were formerly homeless, who are living with HIV/AIDS or mental illness. The rest of the units house individuals with low incomes. Before The Brook was built, the space it occupies was an empty lot surrounded by decaying buildings. Common Ground, the nonprofit organization that built The Brook, put $43 million and a great deal of care into developing the barren space into a facility that might breathe new life into the neighborhood as well as residents.

The Brook’s design, with its colorful brick and aluminum facade, alone makes it unlike any other building on 148th Street. Beyond aesthetics, the facility has a number of amenities that also set it apart from almost all housing options in the South Bronx. There’s a small fitness center, multi-purpose rooms, terraces and on-site healthcare services. The Brook also has a state-of the art security system to keep the crime of the neighborhood from creeping into the building. Designed for both energy efficiency and safety, there’s a keycard system at the front door that disables electricity in residents’ apartments as they exit the building. It also keeps a record of their comings and goings. In addition, the front door is manned by 24-hour security.

Not all of the dangers of life in the South Bronx are visible to the naked eye, however. The Opera House Hotel sits adjacent to The Brook, separated only by a narrow alleyway. In fact, Opera House’s rooftop — where its cooling tower is located — overlooks The Brook’s ground-level garden and courtyard, the facility’s most popular common area. Experts say contaminated vapor travelled down from that rooftop and found its way into the lungs of South Bronx residents, including residents of The Brook.

Jenniabell Moore, 51, is one of the residents of The Brook who contracted Legionnaires. She says she’d never even heard of the disease when she began coming down with the symptoms. After checking herself into nearby Montefiore hospital, she was diagnosed.

Moore says she used to enjoy relaxing in the courtyard at The Brook but doesn’t anymore.

“They say we got it from the water next door, so I barely leave my apartment,” she says. “I only go outside to go to the store.” As an extra precaution, Moore says she’s been boiling her drinking water.

What happened to residents of The Brook illustrates just how dangerous it can be to simply live in an area of concentrated poverty. Indeed, while the quality of life created at The Brook is arguably better than that of other facilities in the area — in particular for the population it houses — just existing in the South Bronx comes with its own risk factors.

Diana Hernández is a professor of sociomedical sciences at Columbia’s Mailman School of Public Health. She grew up in the South Bronx and in her work examines the impact of social and environmental determinants on the wellbeing of vulnerable populations focusing much of her work in her old neighborhood. Hernandez says that the rate of poverty in the South Bronx cannot be untangled from its residents’ vulnerability to public health crises like this summer’s outbreak of Legionnaires.

“Several risk factors are linked to Legionnaire’s disease including neighborhood poverty level,” she says.

According to the Hernandez, other risk factors include disproportionate rates of chronic health conditions such as diabetes, asthma, COPD and smoking prevalence — all present in the South Bronx.

“So, there are many vulnerabilities that made this outbreak more egregious for South Bronx residents,” she adds.

Overall, living in poverty is associated with a variety of chronic health issues including depression, asthma, obesity, diabetes, high blood pressure and heart disease. Some of the difference is, of course, explained through poor health habits, but environmental factors like poor air quality, lack of access to healthy foods, and safe spaces to exercise also play a role. Nearly 40 percent of people in New York’s 15th congressional district, which includes the South Bronx, live below the federal poverty line, according to the U.S. Census Bureau.

“Unfortunately, this is definitely part of the reason the recent outbreak in the Bronx affected and took the lives of so many people — a large number of our population is affected by chronic diseases like asthma and diabetes. As a result, our community was particularly vulnerable to the disease,” said Congressman José E. Serrano, who represents the 15th district. “As we take the necessary measures to prevent future outbreaks, this is a factor that must be taken into consideration. We must prevent Legionnaires’ disease not only by eliminating the bacteria from the air ducts in public and private spaces, but also by continuing to work on strengthening the health and economic conditions of residents in the South Bronx so they are better able to withstand this and other diseases.”

A report issued earlier this month by The Century Foundation found that, while the poverty rate has remained relatively constant in recent years, the number of people living in high-poverty neighborhoods — census tracts where the federal poverty rate was 40 percent or more — has nearly doubled since 2000, rising from 7.2 million to 13.8 million. There are more Americans living in neighborhood of concentrated poverty neighborhoods today than at any other time in recorded history. Paul Jargowsky, the researcher who composed the report, says living in concentrated poverty has profound negative effects on outcomes of residents.

“Poverty can be bad enough when you have your own individual poverty,” he says, “but then when you layer that on top of living in an extremely poor place with all kinds of problems — failing schools, crime and violence — I think that it makes it so much harder to escape the effects of poverty and to access opportunities.”

City officials identified the bacteria in twenty poorly maintained rooftop cooling systems. The buildings with contaminated cooling towers include a hotel, a hospital, a nursing home, a high school, a post office and one Bronx housing-court office. On Monday, New York City Mayor Bill De Blasio signed a bill into law requiring building owners to register their cooling towers with the city, to inspect them quarterly and to report and disinfect towers where dangerous levels of Legionella bacteria are found. But prior to De Blasio’s emergency law, government guidelines only recommend that cooling towers be cleaned and disinfected at least twice a year; there had been no legal requirements to do so. Cooling towers were often operated without regular maintenance.

Getting a fast, sweeping response to an outbreak like Legionnaires’ disease, Jargowsky says, is usually much harder and much less common in poor communities when issues don’t make national headlines.

“They don’t have the resources and often they don’t have the time to be engaged because they might be working two or three part-time job and might be taking multiple buses to get to those jobs and can’t take a day off to go to a city hall meeting because they could be fired,” says Jargowsky. “Their lives are difficult enough that they can’t out in the extra time to track down those kind of conditions and report them and deal with the bureaucracies to get things cleaned up.”

Beyond troubleshooting dangerous conditions in areas of concentrated poverty, Jargowsky proposes a more lasting solution: breaking up clusters of poverty. Such an effort would require fundamentally reshaping the way neighborhoods are planned and built in America. In the report for The Century Foundation, he writes:

“First, federal and state governments must begin to control suburban development so that new housing construction is in line with metropolitan population growth, and second, every city and town in a metropolitan area should be required to ensure that the new housing built reflects the income distribution of the metropolitan area as a whole.”

Another solution, one perhaps just as revolutionary, is being attempted by Diana Hernandez. After leaving the city to study in rural New York at Cornell University and living in for some time in Manhattan, Hernandez returned to her old neighborhood to live. With enough resources to have other options, she says her decision to live in an area of concentrated poverty is not one she takes lightly.

“I don’t have children but I’m of childbearing age and one of the things I know for a fact is that low birth weight in babies and also infant mortality are huge issues in my neighborhood, and some of that has been shown to be driven by environmental causes,” Hernandez says. “I definitely am concerned about that, but then I feel like if not me then who…Many of the people in the same position as me, who have been equally upwardly mobile have gone…Part of the solution is planning to stay and using our platforms to raise awareness about these issues,” she says.

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