HIV antiretroviral medications fetch a hefty price on the black market, causing poorer Washington Heights residents to sell the drugs that could ward off the worst symptoms of AIDS. (Graphic by Sarah McNaughton.)

Many Washington Heights residents are choosing money over their own health. What once were the miracle drugs that changed an HIV-positive diagnosis from a death sentence into a treatable problem are now among the most desirable medications on the black market.

The trade resembles the usual illegal deals that take place across New York City, but the drugs flow upstream: people with desirable prescriptions sell their medications to buyers, who then either ship the drugs directly to family members abroad or sell it to pharmacists for resales overseas.

Street sales have been particularly noticeable near uptown subway stations for more than six years, according to Dr. Michael Mowatt-Wynn, the president of Precinct 33’s Community Council. Prescription painkillers are prevalent, but the most popular drugs aren’t addictive and don’t produce any kind of high: HIV antiretroviral medications.

Mowatt-Wynn remembers the first time he saw a deal take place.

“I was exiting the subway on the 1 train line, and I always noticed there were young gentlemen just wandering around, scoping out the passengers who were walking up the stairs,” he says. “Others would stop at the first level of the subway, stand with bags in their hands, pull out bottles of drugs, and the young gentlemen would inspect the bottles.”

Drug treatments for HIV dates to the 1990s, and although they remainl expensive, many health clinics and AIDS advocacy groups offer medications at no cost or at sharply reduced prices.

“HIV is no longer a death note,” Mowatt-Wynn says. “It’s a controllable disease someone can live with, like diabetes.”

But that doesn’t mean everyone has access to the medication. The waiting lists for treatment are lengthy. More than 107,000 New Yorkers are living with HIV, and thousands more are unaware they’ve been infected, according to the New York City Department of Health and Mental Hygiene. New York City’s AIDS rate is almost three times the U.S. average, and the infection continues to spread.

And those who do have access to the medication don’t always make healthy choices. Pablo Colón* is the senior HIV counseling and treatment specialist at East Harlem’s Iris House, a service and advocacy program for women, families and communities affected by HIV/AIDS. Colón himself received an HIV diagnosis in 1990, and has witnessed the poorest recipients of HIV medication make the harrowing decision to forgo their physical health in the name of their families’ financial well-being.

“A lot of us are tired, a lot of us are poor,” Colón says. “There are a lot of us who are homeless, a lot of us who have children who are hungry. A lot of us live on the edge. The same reasons that you go out and sell your body is the same reason they sell their medication.”

Although the price depends on the strength of the black market, some HIV medications can fetch around $500 a bottle, Mowatt-Wynn says, an alluring sum to those who are infected but also desperately need money.

“I saw a mother with children in tow, no more than 5 or 6 years old,” Mowatt-Wynn says. “She was selling her HIV medicine, saying she needed to get food for her children. So she was basically selling herself. It’s a form of medical prostitution — that’s what we call it.”

In other countries, HIV medication is expensive and uncommon, making it a lucrative product for the black market. Buyers stand around the more popular uptown subway stations as if it’s a full-time job. From 9  to 5  Monday through Friday, they’re buying prescription medication from people who will use the proceeds to buy food, pay bills or fuel an addiction. Pharmacists then buy and repackage the drugs so they’ll sell for higher prices and ship them to countries with high demand, like the Dominican Republic and Mexico, Colon says.

He also knows people on the other side of the deal — the buyers — who purchase medication in order to send it directly to  infected family members abroad. But people overseas who use medication without a prescription are taking huge risks, he says.

“It’s not only dangerous to buy someone else’s prescription, but you don’t know the effects you’re going to have from those prescriptions,” he says. “Because you and I are on the same medication doesn’t mean we take the same dose.”

Colón remembers when an acquaintance purchased and sent medication to a pregnant HIV-positive family member in the Dominican Republic. She took the medication regularly, but her infected baby only lived a few days. Colón believes the medication actually harmed the woman and baby, and says only a personalized prescription is safe.

The people who stop taking their medication in order to sell it risk even more. Colón says people who do not follow the prescribed regimen can grow resistant to medication and develop serious infections.

As with most black market items, some scam their way into a sale. HIV-negative men and women can obtain medications from corrupt doctors or pharmacists simply to sell on the streets. Many people abuse the system, Colón says.

“It’s unfortunate for those people who really need the medication, who can’t get medication because there’s a waiting list longer than their arms,” he says.

Precinct 33 Commander Brian Mullen told Mowatt-Wynn and the rest of the council during a public safety meeting that the trend of everyday people selling their prescription medications represents one of the precinct’s longest ongoing investigations. The council and precinct have instituted new policies to try to reduce the drug trade, placing cameras on lampposts at the most popular subway stations and stationing patrol officers nearby. It’s a start, Mowatt-Wynn says, but many sales continue right in front of the cameras, and enforcement has been challenging given the precinct’s limited resources.

Colón hasn’t seen much of an improvement from where he’s sitting, either. “What’s out there is real, and it’s a mess,” he says. “And that’s the reason the numbers continue to rise.”

*Pablo Colón died a few days following this interview.

Taeko Frost prepares to test a man for Hepatitis C (Photo by Yumna Mohamed)

A middle-aged man hesitantly enters the CORNER Project syringe exchange program’s office on 176th Street and Wadsworth Avenue in Washington Heights.

“How are you doing today?,” asks Taeko Frost, program director at the CORNER Project, who is in charge of hepatitis C testing. “You OK?” She will be testing him for hepatitis C, a chronic disease affecting the liver.

A lot of information is crammed into these close quarters. The walls are plastered with posters and flyers about hepatitis C: testing, treatment and prevention.

The man, who asked for anonymity, takes a seat and rolls up his sleeve. Taeko explains the risks of sharing needles and cotton when using injected drugs with others and emphasizes the importance of a healthy diet and safe sex, regardless of this blood test’s results.

She gently taps his large, muscular arm for a vein, laughing as he jokes about having none left. She fastens a blue elastic band around his arm; he winces as she inserts the needle.

With a government estimate of 4 million Americans infected, viral hepatitis C infections are three to five times more common than HIV, according to a 2010 study by the National Institute of Medicine. The study adds that in the next 10 years, about 150,000 people in the United States will die from liver cancer and end-stage liver disease associated with chronic hepatitis B and hepatitis C.  

And more people are infected with Hepatitis C in New York City than anywhere else in the country, says Dawn Kalmar, spokesperson for Vertex Pharmaceuticals, which makes the Hepatitis C medication INCIVEK. She cites the Hepatitis C Index by the National Minority Quality Forum, an organization that studies health care issues among ethnic communities in the United States, which says 150,000 New Yorkers are infected.

Yet many health workers argue that the disease hasn’t gotten the attention necessary to make people more aware of preventing infection. And since it is symptomless, those  infected can spread the virus without realizing it.

Uptown, health professionals also worry that the disease is rising. “Drug use is increasing in Harlem with the increase in poverty,” says Jeffrey Day, a mental health nurse practitioner at Citicare, a Harlem family health clinic.  “More people are turning to drugs – as both dealers and users – when they give up hope of finding jobs and houses, and they are unaware of how easily they can contract and transmit Hepatitis C.”

Many of the people Frost’s organization helps are homeless and disconnected from health care. The Corner Project guides them through the first three steps of Hepatitis C testing: pre-test counseling and a full blood draw sent to a lab, with results in 48 hours.

If patients test negative, they’re told how to prevent infection by using sterile needles, not sharing cotton or cookers or straws (the disease can also be contracted nasally), avoiding unlicensed tattoo and piercing parlors and practicing safe sex. If patients test positive, they are referred to treatment programs.

But routine physical exams don’t usually test for hepatitis C, Kalmar says.

Vertex recently underwrote a guerilla marketing campaign called the “Find HepC” campaign, which consisted of posters, fliers and volunteers talking to people on the streets across the city; its enigmatic blue and yellow slogans featured a large yellow “C” and the words “4 million have it, 3 million don’t know.”

African-Americans and baby boomers are disproportionately impacted. “One in seven African-Americans over 55 are infected,” according to the National Minority Quality Forum’s report.  And
Americans born between 1945 and 1965 are at risk of infection because they grew up in an era of less emphasis on safe sex and the importance of clean needles when injecting drugs or  getting tattoos.

“Approximately 15 percent of people clear hepatitis C on their own during the first few months of infection without treatment,” said Nihar Johnson, project specialist at the city health department’s Office of Viral Hepatitis. “They ‘cure’ themselves.”

After six months of active infection, a person is considered chronically infected, according to Johnson, who added that people can be treated during the chronic phase.  If the viral load drops to undetectable levels and remains undetectable for six months after medical treatments has stopped, that’s called a ‘cure.’

“Certain types of Hepatitis C are easier to ‘cure’ than others,” Johnson said.  People with HIV, African-Americans, Latinos and those with certain other health problems are less easily cured, she added, but with new medications, the cure rate has risen for everyone.

“However, there are many factors involved in treatment success and every case is different,” Johnson said.

Kalmar added that INCIVEK, approved by the FDA in May, could increase cure rates among black Americans.

Despite the Big Yellow C, there aren’t enough awareness campaigns uptown, to reach the people most at risk of contracting and spreading the disease, Frost says.

“The Department of Health just put out a new TV ad to spread awareness, but our participants are not necessarily watching TV,” she said. “It’s not applicable to our population.”

Frost says the health department needs more staff working with community groups to reach people on the streets, actively seeking out drug users and encouraging them to visit testing centers.

“These people feel isolated and stigmatized,” Frost says. “Even if they think they’re at risk, they might not know where to go.”

The invasive nature of testing and treatment for Hepatitis C, involving medications that may have difficult side effects, also deters people, Frost says.

“We are a small program, and do our best to do outreach in Inwood and Hamilton Heights, as do other small drug treatment programs,” she said. “But it’s about being creative, thinking about who is actually at risk and the best way of reaching them.”

Charlie,  who’s 65, is a frequent visitor to the CORNER Project. Tall even when sitting down, he taps his black cane and recounts the dietary concerns his hepatitis C infection raises. Because of the disease’s harsh effects on the liver, patients have to avoid oily and sugary foods, as well as alcohol.

“See, I’m black and I like my fried chicken,” Charlie chuckles. “But because of the oils, it hurts when I eat it.  So I have to have everything broiled and baked, even though fried chicken tastes damn good.” Since his 2001 diagnosis, Charlie, who asked that his last name not be used, has had to make a lot of changes.

”The counselor taught me a lot about eating healthy,” says Charlie. “He told me that once a month he’d splurge on fried chicken, but mostly he advised us to stay away from it.”

For Charlie, the worst thing about living with the disease has been the medication. The treatment affects his mental state, prompting doctors to prescribe an array of additional drugs to deal with its side effects.

“Six pills a day, two shots a week, and then the sleep medication, eating medication and anxiety medication,” Charlie says with a resigned smile.  “I’m walking around with so much medication. I started a pill factory at one time.”

He has discontinued medication, but says, “I’m looking for new meds, something I’d be really interested in if it’s going to cure me.”

While Frost believes that New York has been a leader in HIV prevention and testing, as well as providing special services for those with HIV, the city has not responded as urgently to Hepatitis C.

“I think most people in New York can tell you what HIV is because there is so much education around it and a great emphasis on testing and services,” she says, pointing to the fact that the people most at risk for hepatitis C are drug users, not always considered a priority for health services.

One improvement would be to introduce rapid testing for Hepatitis C, she says, something that appears more likely since last month when OraQuick became the first rapid test to win FDA approval.

“We have a long way to go but I think rapid testing is very important because we’ll be able to use it on the site where people are,” says Frost. It’s less invasive than a blood test and won’t require refrigeration or laboratories. But will take time for free rapid testing to become broadly available.

For now, Charlie is happy to watch what he eats and avoid alcohol. He eventually hopes to give up his other damaging habits too.

“The more I think about me and my liver, the more I think about how much life I have left,” he muses.

“I’ve been doing drugs for over 30 years and I’m not getting anything from it anymore. So I think it’s best to go back away from it all, and go ahead and live my life the best way I can.”

Mobility facilitator Melvin Gray lends Delia Regalado a hand. (Photo: Ines Perez)

Outside a six-story building on West 170th Street, Melvin Gray waits to get buzzed in. Although he’s only been at this job for a few weeks, he swiftly makes his way to a fourth-floor apartment. A stroke 10 years ago left Delia Regaldo, 87, with little mobility, chained to her cane and reliant on the care of others. Today, though, she’s going to see her doctor and Gray will help.  As she holds onto to his arm for support they head out of the building, slowly but steadily, and onto the bus waiting outside.

ARC XVI Fort Washington Inc. launched its Coordinated Older Adult Senior Transportation Service in October to help northern Manhattan seniors stay active and independent. Within the first few weeks, 80 to 100 people had signed up – more than ARC had thought would enroll over months.

“We had not expected this avalanche of need,” said Diana Nobile-Hernandez, chief of transportation at the ARC Senior Center. “It’s amazing.”

Commonly known as COASTS, the program offers free “door-through-door” assisted travel to those over 60, as well as those over 50 with impaired mobility, vision or hearing, throughout Community Districts 9, 10, 11 and 12.  The bus will take them “anywhere” from 110^th Street to 220^th, river to river, Nobile-Hernandez said – “out of their door, across the curb, into the bus.”

“We found, over the years, that people became restricted to staying in their apartment” because they couldn’t get down the stairs, or walk from their buildings to the sidewalk, explained Fern Hertzberg, executive director of the ARC Senior Center and co-chair of the Washington Heights and Inwood Council on Aging.

In a neighborhood where most buildings predate the American with Disabilities Act and are thus exempt from its requirements, many seniors struggle to venture out. A walkup’s flights of stairs pose risks many are unwilling to take.

“There are a lot of things that happen to people when they get older and one of the biggest impacts is mobility,” Nobile-Hernandez explained. “What happens when your body is saying ‘I can’t do it’?”

The great majority of Americans over 50 – around 89 percent – want to stay in their homes as long as they can, according to the AARP Public Policy Institute. In a 2009 study of long-term care, the institute reported that in New York State, Medicaid allows some recipients to choose in-home care instead of a nursing home. Furthermore, it found that, on average, the Medicaid program nationwide can provide home and community-based services to three people for the cost of keeping one resident in a nursing home.

A nursing home offers room and board, supervision, medication and personal and skilled nursing care 24 hours a day. “It’s a medical institution,” Nobile-Hernandez explained. “It’s going to cost more.”

This year New York State placed third in the country in nursing homes costs, with New York City averaging a private pay daily rate of $387, while the average hourly rate for home care was $19, according to the MetLife Mature Market Institute.

The option of aging at home becomes vital for some people, specially those who live on fixed incomes. “Let’s look at an 86-year-old person who has worked 40 years, makes $725 a month on his regular Social Security,” proposed Nobile-Hernandez. “How do they live? They subsist.”

Because it’s free and provides personal assistance with transportation, the COASTS program allows seniors to remain in their homes longer, maintaining their support network of family and friends, while lessening the burden for their caregivers. “It’s like we’re outside home attendants,” said Larry Davies, 43, mobility facilitator at ARC.

Marie Kowalzcky refuses to let appearances give away her age. “I watch my figure,” she told her friend and fellow COASTS rider Ali Bighach. “I’ll watch my figure till I die!”

In neatly-pressed burgundy pants and a beige trench coat, a rhinestone American flag pin glimmering from the lapel, Kowalzcky, a retired hairdresser, was talking about the old days as they rode. “I used to cut my husband’s hair,” Kowalzcky said, with a proud smile.

She worked her magic on many customers until arthritis forced her off her feet. Now, she spends most mornings at the ARC Senior Center, mingling with friends. “I wouldn’t change to any other center because of this program,” she said. “It’s wonderful!”

Public transportation doesn’t always address the mobility barrier, Nobile-Hernandez said, adding that very few Manhattan subway stations are accessible to people with disabilities.

Paratransit services appeared in response to the Rehabilitation Act in 1973 as a more flexible transportation system for the disabled. After the American with Disabilities Act took effect in 1992, the Metropolitan Transit Authority took over the city’s Access-A-Ride program, a transportation alternative for people unable to use bus or subway service, who pay the same cost as public transit.

But it has limitations. “What the Access-A-Ride does is, basically, leave you off at the curb in front of your building,” Hertzberg said. “For many people that’s not sufficient and they need assistance.”

That’s where COASTS comes into play.

All nine buses include wheelchair lifts and are ADA accessible. (Photo: Ines Perez)

While ARC has been offering free transportation services for the elderly in Washington Heights and the Bronx for years, the new program introduces a staff of mobility facilitators – or “mofas” – who meet riders at their homes to help them down the stairs, out of their buildings and onto the bus. “The mobility facilitators are there to assist them physically in a way that has never been done before here, and certainly not for free,” said Nobile-Hernandez.

Members who subscribe to the program ride for no cost, but contributions are welcome. “Everybody helps you, so you want to be able to pay them back in a little way,” Kowalzcky said, even if it’s just with a box of cookies.

Over 150 members have signed up.  “It’s been a hit,” Robinson Hernandez, ARC coordinator of transportation, said in Spanish.

The program is partly funded by a $376,184 grant from the U.S. Federal Transit Administration, plus a local match – the amount the neighborhood had to raise – of $137,958 provided by New York City Council, the Fan Fox & Leslie R. Samuels Foundation Inc. and ARC XVI Fort Washington Inc.

“This was really the first opportunity where the government would give us money to do what we thought was the right thing to do. What a beautiful thing!” Hertzberg said.

“It’s a two-year grant,” said Nobile Hernandez, but “we are going to apply again.”

With a fleet of nine buses, nine drivers and seven mofas on duty from 9 a.m. to 3 p.m., the program services 40 to 50 people a day, Monday through Friday. The most common destination? “The hospital on 168^th Street” and more recently St. Luke’s Hospital, Hernandez said in Spanish, plus several local senior centers.

“It’s a good feeling to know that all that service is there,” said Kowalzcky.

Thirteen percent of New York State’s population is over 65. New York’s 85-plus population – the group most likely to need long-term care – will grow 62 percent from 2007 to 2030, according to an AARP study.

At a recent conference hosted by the Washington Heights and Inwood Council on Aging, titled “The Perfect Storm,” participants grappled with how to deal with an aging population in the face of recent health care budget cuts.

“We have to be much more creative,” said Lilliam Barrios-Paoli, commissioner of the New York City Department for the Aging. Like many speakers, she argued that senior services providers now face the challenge of “doing more with less.”

“We need to look at other sources of revenue,” said Aging in America president William Smith, instead of looking to the government. “We need to look for partners.”

“Ready?” Gray asked Regalado as the COASTS bus reached her destination. “Let’s go.” She held his arm once more and headed toward the exit. A couple of steps away, the New York-Presbyterian Hospital’s dental offices awaited.

At 60, Gray is proud to be one of COASTS’ mofas. “I love it,” he said, back on the bus. A self-proclaimed people person, he has enjoyed meeting some unique passengers.

One woman in her 80s who uses a wheelchair always asks to be dropped off last in order to ride longer. “Such a nice lady,” Gray said. “She just wants to get out of the house and see something for a minute.”

A free flu vaccine campaign in Inwood. (photo: Jacqueline Guzman)

On a Thursday morning in November, four nurses covered two tables with gauze, vinyl gloves, syringes and flu vaccine vials in the community center at the Caroline Apartments in Inwood. They made small talk and waited for residents to receive free flu shots, sponsored by the Visiting Nurse Service and local government officials. But only a few people trickled in.

The flu causes about 36,000 annual deaths nationwide, according to the Department of Health and Mental Hygiene—2,000 of which occur in New York City. The elderly are most at risk, accounting for an estimated 85 percent of deaths. So the federal Centers for Disease Control and Prevention recommend vaccination for everyone over 65, and last month, city Health Commissioner Thomas Farley urged all New Yorkers to get flu shots.

Still, a 2008 health department survey says only 34.8 percent of elderly people get vaccinated in Washington Heights and Inwood. Nationally, 69.3 percent of those over 65 were immunized last year, according to the CDC.

Augustin Castellon, 59, was among the few to receive a shot that day. It was his first vaccination; he said he had never felt the need to get one before. “I never get sick, I never get the flu,” he said, “but my sister said, ‘You’re going to be 60 soon’ and thought it would be a good idea.” He added that people his age are often unaware of the vaccine’s benefits, and that superstition prevents them from getting the shot.

“Many people believe, especially the immigrant community think, that they will get more sick,” said Ebenezer Smith, district manager of Community Board 12, who also admitted to never getting a flu shot. Side effects are a common concern among residents.

“I’ve never had a positive effect taking it,” said Tina Riley, referring to the shots, outside New York Presbyterian Hospital where she works in information systems. She’s only been vaccinated twice. “I always end up sick — really on my ass sick,” she said. That’s why she prefers a holistic alternative, taking immune boosters throughout the winter.

The CDC insists that patients cannot get the flu from the flu shot. Minor side effects, like soreness, low-grade fever and aches can occur, but only last a couple of days.

“What people experience after getting the flu shot is the body building up antibodies,” explained Michael Reingold, a registered nurse with Partners in Care, a nonprofit that provides home health care. The vaccine doesn’t guarantee immunity to all strains of the flu, but Reingold believes that everyone should get vaccinated.

Nurses and doctors screen patients before vaccination, making sure patients don’t have severe allergies to medication. If it’s the patient’s first flu shot, he must stay 15 minutes afterwards, as a precaution. But allergic reactions are so rare, said registered nurse Jean Lotz, that they shouldn’t deter people from getting a yearly shot.

Another concern for patients is paying for the shot. Major drugstores offer it, for a fee; a Rite Aid in Inwood charges $28, covered by most insurance plans. “The cost is minimal,” said Charmaine Welch, a registered nurse at the vaccination campaign.

But if cost is an issue, she added, free options are available in Washington Heights and Inwood—like the Caroline Apartments event. The Visiting Nurse Service holds free events throughout the city during flu season. The problem is people don’t know about them. “Community leaders need to be more diligent in getting information out,” said Welch.

Sen. Adriano Espaillat, co-sponsor of the Inwood event, noted that the turnout was lower than in other neighborhoods. At another free vaccine event at St. Peter’s Church in midtown, more than 150 people showed up, said Lotz. Espaillat admitted that local officials have to do a better job of informing residents.

Perry Kramer, 85, a longtime Inwood resident, saw a flu shot flyer posted in the lobby of his building. He received his first vaccination in the Army in 1945, and continues to get one every year. Although the vaccine doesn’t prevent every strain of flu, getting the shot keeps his immune system active, he said. “I believe you have to protect yourself.”

Case numbers of chlamydia in females ages 15 to 24 uptown have been growing since 2006.

With television shows such as “Teen Mom” and “The Secret Life of the American Teenager” bringing the subject of teenage pregnancy to national attention, other unintended consequences of unprotected sex can be relegated to afterthoughts.

“It was just one of those things,” says a Harlem teenager with chlamydia who requested anonymity. “I was drunk and on birth control; I wasn’t really thinking about what else could happen after, so we didn’t use a condom. I got tested a little while after, and it was positive.”

The recent New York City Department of Education mandate to provide sexual education in all public schools seems to have arrived at just the right time. Uptown neighborhoods have seen a surge in recorded cases of sexually transmitted diseases, specifically chlamydia and gonorrhea, the city health department’s latest quarterly report reveals.

Chlamydia and gonorrhea are easily cured with antibiotics, but the majority of those infected show no symptoms; detection occurs only after testing. When left untreated, these diseases can cause permanent damage, including infertility. Unprotected sex also poses the risk of transmitting HIV and AIDS.

Central and East Harlem rank first and second in Manhattan, respectively, in cases of male and female chlamydia and female gonorrhea in 15-to 34-year-olds. Central Harlem’s rates of male chlamydia and gonorrhea for both sexes are the highest in all of New York City.

Washington Heights follows with Manhattan’s third highest rate of female chlamydia and gonorrhea, and ranks fourth for cases of male chlamydia and gonorrhea, behind Chelsea.

A majority of these cases affect 15-to 24-year-olds. “New York City has a much higher rate of STD transmission than anywhere else, especially among young people,” says Erica Sackin, a spokeswoman for Planned Parenthood of New York City.

Yet Alwyn Cohall, director of the Harlem Health Promotion Center, points out that sexually transmitted infections represent a national problem. “Every state has an issue and within states there are particular cities and pockets where the concentration of STIs is higher,” he says.

Cohall believes that the prevalence of STDs uptown can be traced to several factors, including social networks. “People tend to have sex with people in a particular area or community or concentration, so if STIs or HIV are introduced into a social network, they continually get reintroduced and retrenched because people keep having sex with each other,” he says. “So the chances of people getting STIs in Northern Manhattan are higher.” He adds, “It’s a relatively small community, and people tend to stay within it.”

Inadequate access to proper health care, substance abuse and poverty also contribute to the high rates. David Bell, a population and family health specialist at Columbia University Mailman School of Public Health and the medical director of the Young Men’s Clinic, says even the reported rates don’t reflect the true pervasiveness of STDs. “There’s an undercount because most people who have STIs are asymptomatic; their infections are silent,” Bell says. “So there are probably a lot more people across the city who have them but don’t know it.”

Bell and Cohall are trying to increase STD testing in the city to curtail this phenomenon. Chlamydia rates across the country have increased in the last decade, according to Bell—and that’s a positive step. “It’s good not necessarily because there’s more chlamydia but because there’s a better nucleic acid amplification test that’s easier to screen and convince women and men to do the testing,” Bell says.

Sackin hopes the mandatory sexual education starting next semester in public schools will also help raise awareness about testing and help curb the numbers. “When teens receive comprehensive, age-appropriate sex education—combined with sex ed services and parent communication—it has been proven to help delay first sexual contact and help them make healthier decisions if and when they do become sexually active,” Sackin says. “Having a large number of our teens not receiving sex ed definitely hasn’t helped.”

Bell and Cohall echo the need for education, but add that it needs to be one step in a process that also includes the city providing proper access to care, teens acting responsibly and everyone getting tested. As Cohall says, “We’re trying to break the cycle of infection and re-infection among the community.”

Obesity data for East and Central Harlem. (Chart by Lina Zeldovich. Data provided by the New York City Department of Health )

Eating carrot cake is not the same as eating carrots, Malika Harrison told a group of Harlem children at the recent Fit for Life Obesity Program’s workshop at the James Varick Community Center. “Carrot cake would have added sugar in it so you’d have to be careful,” she said while her workshop partner held up a laptop showing a heap of vegetables on its screen.

The children discussed the importance of eating veggies of every color. They played a detective game to understand how media influences their food choices. They learned who sponsors advertisements, what messages ads deliver and how to spot information they hide.

While the kids learned about fat and sugar data on products’ labels in the gym, their parents received similar training upstairs. They learned how to find reduced-fat substitutes for cheeses and to balance calories by reducing TV and computer use and exercising more. They also shared lean recipes that use soy substitutes.

“Kids talk more when their parents are not around,” said program coordinator Sara Dennis  of the National Council of Negro Women’s Manhattan Section, which implemented the program with the National Institute of Child Health. Dennis explained that both groups learn the same concepts to understand how to stay fit and healthy as a family.

Uzo Ejogu came to the Fit for Life obesity workshop because her overweight daughter, Malika, gets tired after they take a 30-minute walk together. “We don’t eat fast food at home and we don’t have a TV,” said Ejogu, who wanted to know what else she could do to help Malika lose weight. “I told her she’s big, but she says, ‘No, I’m beautiful.’ But then all her friends are like that. And my husband says we shouldn’t tell her she’s fat because it would hurt her self-esteem.”

Ejogu didn’t bring her daughter to the workshop, but she left with a plan to sign up both of them for Zumba classes.  “It will help me lose weight, too,” she said. “I’m very glad I came. I learned a great deal.”

Cheryl Moody did bring her children, Anthony and Brianna Hatchett. “My doctor told me that my 5-year-old daughter was the same weight as my 6-year-old son,” she said.  “He said he didn’t want her to gain any more weight.” Moody heard about the event from her father who learned about it at his church.

Some parents dropped their children off but didn’t participate. Throughout the afternoon more people trickled in, but the turnout was lower than the organizers expected.

“It’s not an easy subject for many people,” said Dennis. “It means a commitment to making a lifestyle change.”  The National Council of Negro Women had reached out to community centers and churches to spread the word and will continue doing workshops, she said.

Cheryl Moody with her children, Anthony and Brianna Hatchett, at the Fit for Life workshop in Harlem. (Photo by Lina Zeldovich)

The program was motivated, in part, by Michelle Obama’s initiative to reduce obesity in children. Kim Hernandez, a workshop organizer, said that 12.6 million children over 6 are overweight, according to federal data. “Two million of them are African-American,” she said.

According to the National Institute of Child Health, 16 percent of American children are overweight, but the proportion in Harlem is higher. According to a recent neighborhood report from the East and Central Harlem District Public Health Office, 27 percent of public school students are obese and an additional 19 percent are overweight. Nearly 1 in 3 high school students has a weight problem – 14 percent are obese and an additional 18 percent are overweight. So are 6 of 10 adults. Obesity rates are higher in adolescents and adults in Harlem than in the rest of the city, the report says.

More Fit for Life workshops will take place next year, said Dennis.

Campaigners for marriage equality at the SAGE Harlem Health Fair and Pride 2011. (Photo: Christina Da Costa/SAGE)

Rosita Libre de Marulanda shifts in her chair for a few minutes before comfortably folding her hands in her lap. Apart from her long string of pearls and the tiny red flower in her graying hair, she is dressed casually with a large black fanny pack strapped across her T-shirt.

At 65, she struggles with loneliness after losing her partner seven years ago and with the challenges of juggling many identities: a lesbian, Latina, mother, grandmother and sister.

“But wait, there’s another very important piece of my identity that I’m forgetting and that is that I’m becoming an elder,” she says. “This is a whole new set of issues.”

An estimated 12,000 to 24,000 elderly people who are gay, lesbian, bisexual or transgendered live in poverty in New York, says Allison Auldridge, a policy associate at SAGE, a non-profit organization that tackles health and other issues in the elderly LGBT community.

“Their health issues are poverty related,” she says. “1 in 5 elderly LGBT in New York don’t have the basic income to meet their needs and are either under-insured or not insured at all.”

Accessing affordable insurance is one of the things the Affordable Care Act, signed by President Barack Obama last year, will address as it rolls out through 2014. In the past, same-sex partners couldn’t benefit from each other’s insurance without paying extra income tax but the new reforms, coupled with the legalization of same-sex marriage in New York, will likely bring change, Auldridge says.

A report released earlier this month by SAGE and the National Academy on an Aging Society highlighted the specific health problems facing the aging LGBT population. The report says lesbian, gay, bisexual and transgender adults over 50 are more susceptible to disability and mental stress, made worse by the fact that they are more likely than their heterosexual counterparts to drink heavily and smoke.

The report adds that lesbian, gay, bisexual and transgender seniors are less likely to see doctors because of the cost and their reluctance to disclose their sexual orientation, which prevents their learning about specific issues that concern them.

“When I go to my health care professional, I’m still a little uncomfortable even though I told her years ago what my sexuality is,” says 67-year-old Carole Robinson. “If I had to change health care providers, I would be in a world of hurt.”

Robinson lives in SAGE’s Naturally Occurring Retirement Community, or NORC, an area whose residents have “aged in place,” thereby forming a neighborhood with a large concentration of elderly gay people.  Spanning from 100^th Street to 150^th Street, it is the largest NORC in Harlem, says Bryan Pacheco, outreach coordinator at SAGE Harlem. SAGE established this branch last year to provide social activities, support groups and education for LGBT seniors of color.

“Harlem is different than other communities such as, say, openly gay Chelsea,” Pecheco says, adding that it’s harder for people to come out in Harlem. “There aren’t many LGBT organizations in Harlem, the older people here are not as open and don’t identify with the terminology.”

Many of these people feel isolated, Pacheco believes, after losing loved ones to AIDS; they grew up in a time when there was less awareness about HIV treatment and prevention.

The Department of Health and Human Services is confident that the Affordable Care Act is a step toward providing better health care and preventative care to the older LGBT population.

“The Affordable Care Act is helping millions of LGBT Americans gain access to preventative care and screenings for free, including for diseases that affect LGBT populations at rates higher than other populations,” says regional director Jaime Torres. “This includes cancer screenings, blood pressure and cholesterol screenings, HIV testing and contraceptives.”

While Auldridge agrees that the Affordable Care Act reflects progress, she says work remains to be done. She feels that data about the LGBT elderly needs to improve and the Department of Health and Human Services must ensure that information about the act reaches the people it affects most.

“I think it does amazing things for the LGBT community, but it could be more explicit in mentioning the LGBT and addressing LGBT definitions of family,” she says.

Torres points out that the elderly LGBT community is no longer governmentally invisible.

“Where once we failed to study LGBT health at all, today researchers engage LGBT populations and are looking to collect data we need to ground our work in science and shape our vision for the future,” he says.

El Hadji Seck sells Diabetes Solution (top-right shelf) from his shop on 116th Street. (Photo by Gabriel Stargardter)

In Le Petit Senegal, Harlem’s main African neighborhood stretching along West 116^th Street, a hybridized approach to health care prevails.

El Hadji Seck, a Senegalese shopkeeper, said he sells three or four rainbow-colored bottles of Diabetes Solution a week. The $25 concoction, a blend of Molinga leaf, aloe vera and oregano oil, isn’t approved by the Food and Drug Administration — or anyone. But Seck, a diagnosed diabetic since 1997, said he took it alongside his prescribed medication to alleviate pain. He extolled the solution’s effects, but added he hadn’t told his physician that he was taking it.

The modern African diaspora in New York began in the early 1980s; according to the non-profit African Services Community, one in 20 New Yorkers today is African-born. A 2009 American Community Survey estimated that 20,819 African-born immigrants lived in Manhattan, but experts believe the true number could be three times that.

Health groups and religious leaders report that Harlem’s pan-African community, a geographically and religiously diverse group, has grown increasingly competent at managing basic health care needs. But those same health groups say it’s still a battle to get Africans to eschew traditional medicines and take preventive steps, like HIV testing and diabetes checkups.

For many, like Seck, a fusion of Western drugs with traditional medicines represents an acceptable compromise. “For some illnesses you have to use our ancestors’ medicine, because sometimes modern medicine can’t cure it,” he said.

If forced to choose, Seck said he would stick to his prescriptions. But he knew of one diabetic customer who had stopped taking prescribed medication in favor of Diabetes Solution. “A lot of diabetic people in my country take leaves and roots, and they lowered their blood sugar, but then they died from something else,” he said. “That’s why I won’t leave my doctor’s medicine.”

Imam Suleimane Konate, who heads the Masjid Aqsa mosque on Frederick Douglass Boulevard, has for years led the charge for a more active approach to health care among his predominantly West African congregation. At the Medina Clinic on West 116^th Street, which he helped found, his image looms on a wall poster advocating HIV testing. Speaking outside the mosque after Sunday evening prayers, his message was equally direct.  “There used to be a fear, but no more,” Konate said.

The fears he spoke of are not uniquely African. For all immigrants, seeking medical assistance can be a daunting task. The undocumented fear deportation. Language barriers and financial anxieties discourage others. Konate acknowledged these issues – “the problem was immigration” – but said they’d been largely resolved. “Our people  have no problem,” he said. “The success is great.”

Such successes are often clear to see. The Senegalese Association in America, for instance, has forged strong ties with local health care providers. “If you go to Citi Care with the association’s membership card, the first visit is free,” said organization president Papa Drame. The organization hosts a walk-in clinic staffed by Harlem Hospital nurses at its 116^th Street office every few months. More than 90 people attended the last session in July.

In fact, health services abound for those in need, a message emphasized by all health organizations working with the African community. Four years ago, Aka Kakou, 44, a cabdriver from the Ivory Coast, underwent a hernia operation. He was treated and, after qualifying for cheaper care, was  presented with a bill so small he couldn’t remember the exact figure.

He wasn’t intimidated by the process, and while he thought newer immigrants might be, he insisted the road to understanding was short. “If you don’t know, then you get sick, and then you know,” he said.

Such successes can mask persistent problems, however. Immigrants may be unaware of their health options. The African Services Committee is located next to a taxi garage on West 127^th Street, for instance. But despite the prominent sign above its entrance, a colorful silhouette of the African continent, few of the West African taxi drivers assembled below seemed aware of its existence.

As the drivers waited to begin their night shifts, they traded misinformation. Costs constituted a major concern. With many sending money back to their home countries, they feared the impact of a hefty bill. “You go to the hospital and pray for the best,” said Aziz Lee, 40, from Senegal.

For two years, Charles Shorter, executive director of the Ryan/Adair community health center at 565 Manhattan Ave., has tried to combat community ignorance. His organization joined the African Services Committee to better serve the center’s growing number of African patients. Ryan/Adair worked with translators and local religious leaders to offer culturally sensitive care. Some African Muslim men, for example, were unwilling to let their wives be seen alone by a doctor. “It’s been quite slow, but we’ve been building trust and they can see that,” Shorter said.

Stephanie Kaplan from the African Services Committee pointed to a decline in HIV testing among Africans to illustrate the need for persistence. She had noticed a general distrust of doctors among some patients, particularly a resistance to preventive care and a continuing stigma of HIV. “There is a pervasive cultural myth that you don’t go to the doctor until you are ill,” she said.

While Papa Drame emphasized his organization’s efforts in creating health awareness, he looked quizzical when asked about preventive care, reinforcing Kaplan’s concerns. “I don’t know about that,” he said. “Usually they go to the hospital when they feel ill.”

Ryaisa Armelin takes a "Save Half for Later" container to diners at Creole Restaurant. (Photo by Jacqueline Guzman)

Ryaisa Armelin, 18, stands beside the dim-lit bar at Creole Restaurant in East Harlem, wiping down a smooth, granite-colored tabletop as the midday rush dies down. She’s dressed head-to-toe in black; her apron shows a cartoonish figure of a plate and says, “Save Half for Later.” Posters and display cards with the same design, in English and Spanish, decorate walls and tables.

Armelin is between adding up checks and clearing tables, when a group of twentysomethings from the auction house around the corner walks in.

“Four for lunch?” Armelin asks, “I’ll be right there.”

Alana Celii, 25, and her co-workers have a seat while Armelin brings them menus.  After giving them a few minutes, Armelin takes the order and asks if they’d like to have half of the their meal now, and take the rest home.

Creole is one of 15 restaurants that has teamed up with the Mount Sinai School of Medicine’s Communities IMPACT Diabetes Center in a portion-control campaign called “Save Half for Later.” It’s an effort to combat ever-increasing cases of diabetes and obesity in East Harlem. The neighborhood has the highest rates of diabetes in Manhattan, with an estimated 1 in 6 adults living with the disease, according to the center. A contributor to the diabetes rate is obesity, which is also rising for a number of reasons, including the increasing size of food portions in restaurants.

The campaign has even expanded to Central Harlem, where 36 percent of adults were obese in 2009, according to the New York Department of Health and Mental Hygiene. On Wednesday, Sylvia’s Restaurant on Lenox Avenue held a portion-control event, becoming the first Central Harlem restaurant to officially join.

It’s a simple concept — eat less and save money. When dining out, the server asks the customer if he wants to “Save Half for Later.” Before bringing out the meal, the server offers to put half into a reusable plastic container — big enough for an entree and side dish —  that has the campaign’s logo on the lid. Then the diner takes the rest home to have for the next meal or even the next day, just as the name suggests. With “Save Half for Later,” the diner essentially gets two meals for the price of one.

“That’s my favorite part of it – saving your money,” Armelin says. A lot of people don’t have time to cook every day, she adds, “so why not split that in half?” Although servers must kindly offer a container to every customer, the decision to take it is ultimately the customer’s. “Sometimes people say ‘no thanks, I’m fine’ or ‘I’m really hungry today.’”

“It makes sense,” says Celii, who hadn’t heard of the program before. She and the three others have lunch at Creole every couple of weeks, but normally get their meals to go.

“Most people wouldn’t stop themselves midway through a meal,” admits Cory Hooper, 24, including himself. Self-control is difficult, he adds, especially with current portion sizes. Saving money “is a good incentive for people to participate and watch their health,” he says. “I would definitely do it.”

The program was launched last summer. Carolyn Zezima, director of the Food and Health Initiative for the Communities IMPACT Diabetes Center, explains that the group had to first carefully map out all restaurants in the area.

“Our interns pounded the pavement, hitting every restaurant,” Zezima says. The team surveyed and interviewed a number of owners of sit-down, local restaurants with hefty portions. They narrowed it down to those who shared a positive attitude toward healthy eating. Then the team presented the plan and trained the staffs on engaging the community.

“We want to empower the consumer to make decisions about their meals,” says Zezima. The point isn’t to dictate changing their eating habits, but to spread awareness and make healthier choices easier for them.

Although “Save Half for Later” is still in its early stages, restaurants have been receptive to the idea, says Zezima. At Cafe Ollin, Lydia Perez’s only compliant is that the containers are “not convenient for sandwiches.” Since their sandwiches tend to be thickly packed with ingredients, Perez finds fitting even half a sandwich into the container difficult.

Half of the portion is put in a container before enjoying the meal. (Photo by Jacqueline Guzman)

On the other hand, Ramon Duran, owner and operator of El Nuevo Caribeño, has accepted the program into his place wholeheartedly.

“It’s a contribution for the people, in order to maintain their health,” said Duran. He operates the restaurant, located on Lexington Avenue, that his father opened more than 20 years ago. He said that customers’ responses have been positive so far.

When they see the program’s poster hanging in the restaurant, they often ask about it. Duran figures that in a given week, all the plastic containers that the program delivers are gone.

“I want to see all my customers as healthy as they can be,” he says. “I want to see people happy and look good. If you look good, you feel good.”

The Communities IMPACT Diabetes Center says that many affected residents are unaware they have diabetes because they have never been tested. The agency is concerned that if nothing is done to educate residents about making healthier food choices, poor eating habits could lead to diabetes in their children. By the time those children grow up, the cases of obesity could increase and the rates for diabetes could even jump to 1 in 2 diabetic adults in East Harlem.

The program is now entering a new phase, Zezima says. Case managers have been assigned to each restaurant and will follow up on their performance and send them more containers as needed. Plans to add more Central Harlem restaurants, like Sylvia’s, are also under way. Lolita’s on West 113^th Street is already training staff on approaching customers. A similar take-out version of “Save Half for Later” would also aim to teach children to make healthier choices at home.

Word of mouth is slowly getting residents to save half their meal. Wednesday’s event at Sylvia’s has drawn instant attention to the center’s effort. Tren’ness Woods-Black, vice president of communications and Sylvia’s granddaughter, tells the press that joining the campaign is “in line with what we do whenever we’re given the opportunity to empower the community and make them healthy.”

“It’s definitely catching on,” said Zezima, “we’re really excited about it.”

Joseph Costa, who works as a construction worker in East Harlem, was getting his daily nicotine fix,  puffing on his Newport cigarette at the corner of 127^th Street and Malcolm X Boulevard.

“I don’t smoke as much as I used to,” said the 32 year-old smoker. “I can’t afford it anymore.”

New data shows that upper Manhattan has fewer smokers than it used to and ranks among the city’s top neighborhoods in smoking reduction, health officials boast. But despite Mayor Michael Bloomberg’s controversial battle against tobacco, many people are still lighting up around Washington Heights and Harlem.

Bloomberg and New York City Health Commissioner Thomas A. Farley announced last month  that citywide smoking rate hit an all-time low last year, with only 14 percent of adults smoking. That means that 450,000 people have kicked the habit throughout the five boroughs since 2002.

The Health Department found in a 2006 survey that among the 17 percent of Inwood and Washington Heights residents who still smoked, more than 75 percent  were trying to quit, compared with 66 percent in the rest of the city.

“The progress didn’t just happen,”  Farley said at a press conference. “It is the result of deliberate steps taken by the mayor and the City Council since 2002.”

The anti-smoking crusade started in 2002 with passage of the controversial Smoke Free Act, which banned smoking in bars and restaurants and, this year, expanded to include parks, beaches and plazas. At the same time, hard-hitting media campaigns have driven thousands to call the city’s 311 line for assistance in quitting smoking. Extensive distribution of free nicotine patches and gum as well rising New York State cigarette taxes have also encouraged smokers to quit.

“I used to love having a cigarette in the park during a picnic or with my coffee,” said Laura Gomez, 28, who has smoked for eight years. “But now, it’s impossible, so I quit,” she said. The ban, which makes it hard to light up anywhere outside her home, has motivated her to stop.

The prohibition on smoking in parks has also proved effective, uptown leaders said.

“People used to smoke more before the ban,” said Elizabeth Lorris Ritter, who sits on Community Board 12’s Parks and Cultural Affairs Committee. Ritter believes the law helps solve both public health and littering problems.

“I’ve done a lot of cleanups on the streets and there were a lot of cigarette butts, but there are so much less now,” she said.

But while official data shows that Central Harlem has seen one of the city’s best reduction results, with an impressive 55 percent decline in adult smoking since 2002, business owners and medical experts took issue.

Although the city’s aggressive tobacco control legislation did build awareness of smoking-related diseases, many uptown residents still struggle with the habit.

“Most people know about the risks, but I have not seen much of a change in the patients,” said Reynold Trowers, chief of the Emergency Department at the Harlem Hospital Center. “I don’t think smoking restrictions apply to the people uptown,” he said.

City data does show variations by uptown neighborhood. The most recent survey the Health Department conducted in 2004 showed that 27 percent of East Harlem residents smoked, compared with 17 percent in Manhattan overall, and only 59 percent of East Harlerm smokers were trying to quit.

Raja M. Flores, a thoracic surgeon specializing in lung cancer at Mount Sinai Hospital in East Harlem, doesn’t see a relation between the statistics and his patients’ condition.

“In my patients, the smoking rate is still the same,” he said. “Most of the patients I see have lung cancer but they smoke anyway.”

Abudullah Ahmed, who works at a bodega on 110^th Street and Park Avenue, says he hasn’t seen a drop in his sales and that Newport cigarettes were still in high demand. “We still sell the same amount, approximately 8 to 10 cartons a month,” he said.  Of the anti-smoking laws, he said, “People make them, people bend them and people break them.”

Locals also debated the city’s report that some of the steepest citywide declines were registered among teenagers, with an 11 percent decline in high school smokers last year. Uptown, some residents argued, young people keep smoking but have stopped buying their own cigarettes.

“These people take their parents’ cigarettes, that is why they see a drop like that,” explained  Flores.

As tobacco taxes have booted the price of a pack to $15 – twice the cost of a decade ago – people have come up with alternative, and sometimes, illegal ways to satisfy their addiction, local business owners say.

Hemya Hamid, who manages the GM Express grocery on Lexington Avenue and 110^th Street, blames taxes and fierce competition for the drop of his sales.

“Other stores are selling the cigarettes cheaper, without the taxes,” he said. “People will not stop buying cigarettes, they will just go to a different store.”

To avoid higher prices, smokers now shop tax-free, and illegally, on the Internet, said Sergio Lopez, manager of the Amsterdam Tobacco Association on Lexington Avenue and 102^nd Street. Lopez doesn’t believe that increased cigarette taxes have led to more people quitting. “They will keep on smoking but will find cheaper ways to get their cigarettes,” he said.