By: Elke Weesjes, Ph.D and Lori Peek, Ph.D
In 1987, Irwin Redlener, and singer/songwriter, Paul Simon, founded Children’s Health Fund (CHF) with the goal of providing comprehensive health care to homeless and medically underserved children. Today, under the leadership of Dr. Redlener, Mr. Simon, and Executive Director, Karen Redlener, CHF sustains a national network of 25 programs serving some of America’s most impoverished communities.
This post, the first of a two-part series on CHF, features Alan Shapiro, MD. He is Senior Medical Director of the New York Children’s Health Project and of the South Bronx Health Center and Center for Child Health and Resiliency, both affiliated with CHF and Montefiore Medical Center. Recently, Dr. Shapiro talked to us about the history of Children’s Health Fund, his work in the South Bronx, and how he, after more than two decades of serving some of the most at-risk and marginalized children and families in the nation, is still hopeful and optimistic about the future.
Welfare Hotels and Warehoused FamiliesThe 1980s in New York City were characterized by a significant rise in poverty and an equally dramatic decline in quality of living among the city’s most disenfranchised. Affordable housing options were few, with numerous individuals and families competing for the limited spaces. The result was a substantial increase in homelessness, especially among low-income families with children. Dr. Shapiro described what it was like: “Families were warehoused in large hotels, mostly in midtown Manhattan. They became known as “welfare hotels.” The two largest and most ‘infamous’ ones were the Prince George and the Martinique Hotel. They were just horrendous; housing hundreds of homeless families, with almost no social services and dangerous conditions for children.”
The welfare hotels were not a new phenomenon. Already in the mid 1960s, Ne¬w York City, faced with a desperate shortage of low-cost housing, began locating homeless families on public assistance in hotels. What started as an ostensibly “temporary” emergency-response measure soon became a monstrous problem. In the late 1960s and early 1970s, the number of welfare families housed in hotels throughout the city was increasing at a shocking rate of 10 percent a month.
By 1987—the year Children’s Health Fund was founded—an estimated 10,000 children and 5,000 adults lived in 63 welfare hotels spread across the City. Back then, the hotels charged the government an average of $1,600 to $1,800 a month to house a family of four. A family had to stay for 18 months before becoming eligible to transition to city-owned housing. Many of the residents felt that for that amount of money, they could surely rent something better than a small converted hotel room lined with bunk beds; but to the City, there was a financial rationale behind the large payment and the long wait. New York City government only paid a quarter of the housing bill. The remainder was funded by the State and Federal governments. Long story short, it was cheaper for the City to keep homeless families in hotels than to renovate apartment buildings or single-family homes.
As Dr. Shapiro described, the Martinique was one of the most notorious welfare hotels in New York City. At the height of the problem, 440 families lived in this hotel. Over a thousand residents were children and nearly half of them were five years and younger. The residential rooms were very small. On average, there was one bed for every two occupants of a room. There was no place to play and school-aged children had nowhere to do their homework. There were no kitchens and although most people used them, hotplates were not officially allowed; as such, there was no room for families to cook and serve proper meals. Besides the lack of space, there were significant issues related to hygiene, healthcare access, and safety. The family homelessness problem coincided with the crack epidemic and drugs and sex workers were ubiquitous, especially in the welfare hotels. Consequently, children often had to share their living-space with drug addicts, pimps, and prostitutes.
In the summer of 1987, the city was threatened with a termination of Federal funds to continue subsidizing the hotel bills. Mayor Ed Koch consequently pledged to empty the welfare hotels by July 1990. The most notorious symbol of New York City’s failure to give homeless families safe and decent shelter, the Martinique, was closed first. Over the course of the following few years, all of the other welfare hotels were shut down too.
In 1992, a year after the last welfare hotel closed its doors, there were still thousands of homeless families and around 10,000 homeless children living in New York City shelters. With the shuttering of the hotels, families and children were frequently placed in so-called “congregate shelters.” These facilities, often regarded as the worst solution, were generally converted armories that consisted of a huge room lined with large numbers of cots side by side. Bathrooms were shared by many and privacy was limited. These shelters were designed for homeless single adults but were also used for families with infants and children. It is clear that shutting down the hotels did not end the crisis of family homelessness in New York. On the contrary, the situation had only worsened and CHF clearly had their work cut out for them.
From New York to Peru to the South BronxDr.Shapiro, whose family was from the Bronx and who was raised in the suburbs of New York, graduated from the State University of New York (SUNY) Downstate Medical College in Brooklyn, New York City in 1987. He went on to do his pediatric residency training at Montefiore Medical Center’s Residency Program in Social Medicine—a residency program that focused on underserved populations and health disparities. He finished his pediatric residency training in 1990.
Training in the 1980’s in cities like New York brought young physicians like Dr. Shapiro face to face with some of the most challenging social and medical problems of the second half of the twentieth century. The situation was dire at that time, as Dr. Shapiro recalled: “For the most part, the poor were disproportionately affected by the drug and HIV epidemic. The hospital wards, including pediatrics, were sometimes half filled with patients requiring HIV treatment. As a physician in training it was humbling to be faced with the AIDS epidemic and the co-morbidities associated with it. We were also facing a drug epidemic. The newborn nurseries were filled with infants needing drug detoxification. In retrospect, it was a very shocking time in our history.”
Even though shocking, working in the field with vulnerable children was something he already had experienced before, albeit in a very different context. While still in medical school, Shapiro traveled abroad and worked with a malnutrition program in Lima, Peru. He thought he had found his calling: “I was very interested in international health. I went to Lima for four months and worked in the slums that surround the city. I was exposed to abject poverty of the likes I had never seen. The team I worked with went door-to-door implementing a community based intervention. That is when the career light bulb went on. It was at that point that I knew I wanted to work in a community setting… Or, as they say, ‘in the trenches’.”
Back in New York in the late 1980s, while completing his residency, Shapiro soon realized that the city was not really all that different than an underdeveloped country in terms of the dire need for medical services among the most disadvantaged. During his residency, Dr. Shapiro was again working “in the field,” but this time in New York: “Then, as a resident… I did this incredible elective with the Children’s Health Fund’s New York Children’s Health Project, working on a mobile medical clinic in New York City’s homeless family shelters. I completely loved it and realized then that this was the type of work I was cut out for.”
In addition to his time in Lima and work as a medical resident in New York City, Dr. Shapiro, who comes from a family that had a lot of political consciousness, was also influenced by the Civil Rights movement and felt motivated to seek social change in the face of injustice and inequality: “I was always very much affected by injustice… Obviously, growing up in the ‘60s and ‘70s, you were confronted by the Civil Rights Movement and the racial injustice that movement was responding to… I didn’t want to go into medicine to go into private practice. For me, medicine had endless possibilities for fighting inequality. I was really looking at the disparities in health care in America. That’s what motivated me then, and has continued to keep the fire under me.”
Dr. Shapiro’s personal vision for a more just and equitable future for all children and families aligns closely with the organizational vision of Children’s Health Fund. Fortunately enough, as he was completing his residency, he got a call inviting him to apply for a pediatric position in one of the recently established CHF Mobile Medical Clinics. As he noted: “I was incredibly fortunate they were looking to hire three pediatricians at the time. The timing was perfect! I took the job and I’ve never left.” Now, for over two decades, he has been hard at work and remains committed to the organization that he believes so deeply in and has helped build.
As a pediatrician in one of the CHF’s mobile medical units, Dr. Shapiro and his team began offering high quality medical care, a “medical home,” to children who needed it most. He visited shelters and welfare hotels on a regular basis. Soon families were counting on the big blue clinic on wheels to appear at their shelter to receive health care for their children: “The irony is that these families were only able to be seen in a medical home at their homeless shelter!” The regular appearance of the “big blue bus” dramatized the lack of primary care in the communities where these poor families came from.
The extent of the problem became painfully clear when a major nationwide measles epidemic broke out in 1989-1991. The epidemic primarily involved unvaccinated racial and ethnic minority children who were on average less than five years old and lived in inner city areas. Tens of thousands of people got infected, thousands were hospitalized, and 123 died. To Dr. Shapiro and many others, this outbreak was an eye-opening experience. He was stunned: “I mean, this was in the 1990s, the measles vaccine has been around for how many years? Measles was supposed to have been eradicated in 1987. Yet thousands of children were getting really sick. It said to the public health world and to clinicians, educators, community leaders, and the government, our healthcare system is broken.”
The silver lining of the measles epidemic was that it spawned a movement to improve primary care, including new resources dedicated to improving access to health care, as Dr. Shapiro described: “In 1992, CHF’s flagship program, New York Children’s Health Project, now affiliated with Montefiore Medical Center, was the recipient of a New York State grant to develop a new health center in an underserved area of NYC. In 1993, we opened up a new clinic in the South Bronx. It began as a hybrid site for us. That means the clinic was three storefronts patched together with a mobile unit parked in front. We chose the Hunts Point section of the South Bronx because we knew it was one of the neediest communities in the city. In fact, it lies in the nation’s poorest congressional district.”
Ironically, the brand new clinic, meant to foster health and well-being, was established not far from the site of the infamous 1993 Valentine’s Massacre, which resulted in the slaying of six people, including three teenagers. Although this crime was especially heinous, murder certainly was not unusual in the area. Especially in the 1980s and early 1990s, the South Bronx was notorious for violence, open air drug sales, prostitution, and poverty. Families were torn apart by these and other social ills.
But even during that dark era in the history of the Bronx, Shapiro, ever an optimist, remembered the resiliency of the youth: “One of the things that really impressed me as a pediatrician was the kids I saw, especially the teenagers. The teenagers we saw in the early and mid-90s reminded me of the enfant savage… the wild child. These kids were raised basically without parents. So many of the kids we saw were raising themselves—their parents were struggling to survive, often working more than one job, or there were those that succumbed to HIV and the drug epidemic. The community had really been devastated. I had kids coming to me, the toughest boys you’d ever see, breaking down in my office because they would see their families falling apart. I’ll never forget being at a total loss of words after one such young man told me he would see his mom prostituting.”
As a consequence of the dire circumstances that the children and youth were often faced with, the CHF adjusted some of its policies and procedures. As Dr. Shapiro described: “This was not your typical pediatric practice. We would allow kids hang out in our waiting room just so they could have a safe place to be kids. The memory of the patients I cared for during that time—hundreds of them—have never left me to this day.”
New Challenges and Old Problems
Two decades after the opening of the clinic, the South Bronx has changed markedly. Neighborhoods have stabilized, the crack epidemic has abated, more residents are in stable employment, and there are lower rates of alcohol and drug abuse and disease transmission. Although the South Bronx is in transition, the problems are far from solved. The U.S. Census Bureau reports that over a quarter million people in this area are still living in poverty, affecting a staggering one out of two children. Crime rates are still extraordinarily high compared to the rest of New York and to the United States as a whole.
Following the measles, crack, and AIDS epidemics, a new and substantial public health crisis is currently affecting this already vulnerable area. Obesity is on the rise in the South Bronx, and it has been for years now. Whereas the health center used to have a “Failure to Thrive” clinic for children whose weight or rate of weight gain was significantly below that of other children of similar age and gender, it now has an obesity clinic. Sadly, both of these issues—hunger and obesity—stem from the same root cause: poverty.
To address the obesity crisis, Children’s Health Fund and Montefiore have developed a successful program consisting of group nutritional counseling for weight management, diabetes, and other chronic diseases. There are also one-to-one sessions focusing on dietary and lifestyle modifications. (In the next “Ordinary People Doing Remarkable Things” post, we feature Sandra Arevalo, Administrator of Nutrition Services, who described those activities to us.)
Dr. Shapiro, who is keenly aware of the complex interplay between individuals and their social contexts, talks about what is next: “We are developing innovative programs that will help mitigate the stress that many poor families face. We are trying to change the paradigm of primary care. Instead of one-on-one traditional visits that often last no longer than 15 to 20 minutes, we are moving toward a group primary model of care.” When we asked him for specific examples, he described the pioneering Prenatal and Well Baby groups that they have established: “We have groups of 8-10 pregnant women or parents with their infants, age 0-18 months, participate in a two hour visit. With this amount of time, we feel we can really get at important topics such as healthy eating, parenting, safety, and healthy relationships in a way that the typical visit does not allow for.” The center is also looking to bring in services that address economic and legal needs. Shapiro grew visibly excited as he talked about helping families gain access to “benefits, financial experts, and lawyers on site at the health center. This would help us move to a comprehensive ‘one-stop-shopping’ model that could benefit the families we serve.”
As part of the 2009 American Recovery and Reinvestment Act, the South Bronx Health Center received several rounds of stimulus funds from the Federal government to increase primary care services. With additional support Children’s Health Fund, which matched the stimulus funding, the center was able to double in size. It currently has two buildings in the South Bronx; one for adult’s and women’s health, and another clinic, located just across the street, that is dedicated to pediatric and adolescent care.
The homeless program still exists and has actually grown over the years. Again, when the New York Children’s Health Project first began in 1987, there were approximately 5,000 families and 10,000 children living in shelters across the city. Today, that number has doubled to 10,000 families and about 20,000 children without homes. As a consequence, the program, and Dr. Shapiro, are busier than ever.
A Beacon of Hope
The figures on poverty and homelessness and obesity—and the list goes on—would likely discourage most people. But Dr. Shapiro is more motivated than ever. Even after years of working with underprivileged children and adults, he stays positive and never experienced the feeling of wanting to give up: “As a pediatrician, I feel like I am a born optimist. Seeing just one child grow up and be successful is all it takes. And I have been lucky enough to see many, many children, facing incredible hurdles, grow up to be teachers, nurses, bankers, and even doctors. In fact, one of my former patients recently graduated medical school and is now doing his residency here in the Bronx. My dream is that I will be able to hire him to work with us—that will be full circle!” After taking a breath, he continued to describe what keeps him so hopeful: “In the clinic, every time I see a child or family, whether they are doing well or have lost everything and are living in a shelter or on the street, it gives me motivation to keep making change. I have tons of kids who are doing really amazing things, they are great parents, they are working in school, they’ve gone to college… So it’s not all doom and gloom you know.”
Dr. Shapiro is also driven by the realization that the children and youth whom he serves are just as capable as any other young people; they just often need more support: “You know, these kids have such great potential, and given the chance, they can reach the same goals and dreams as more fortunate children. What really drives me is knowing that children growing up in poverty are not given the same chance as those who don’t. Enormous human potential is wasted if these kids are not given the chance to reach their full potential. One of our jobs is to be able to identify that potential and help them get to where they need to get to.”
Above and beyond his own personal passion and drive, another reason that Dr. Shapiro and his colleagues at the center have been so successful is that they have been committed over the long-term to the children and families of the South Bronx. Dr. Shapiro noted that people often ask him: “How could you have been here so long?” And he replies: “You know, when I came into this community, I said I wasn’t going to leave. I have been given incredible opportunities to follow my dream. It is also a very unique opportunity to watch a community evolve and literally rise from the ashes. There is a long way to go, however, so I will probably stay around for many years to come.”
When compared to other publicly and privately insured population groups across the country, patients at Dr. Shapiro’s offices actually have better than average health outcomes. He proudly shared: “When we look at our own statistics, our health outcomes are not only better than the city, in general, but they’re also better than other children around the country or adults around the country… If we can have better outcomes when serving the poorest populations in the country, other programs could do it too. That is amazing progress. I say to myself, Wow, we are a beacon, and we could be replicated.”
Giving and Getting Involved
We were inspired learning more from Dr. Shapiro about all the great work that he and his team are doing in the South Bronx. If you, too, are interested in learning more about Children’s Health Fund and about how you can contribute or otherwise get involved, please visit http://www.childrenshealthfund.org/.—————————————————————————————————
 William Friedman and Robert Anson: “Welfare: Hotels without Hope.” Time Magazine, January 04, 1971.
 Lydia Chavez. “Welfare Hotel Children: Tomorrow’s Poor.” New York Times. July 16, 1987.
 Josh Barbanel. “As a Hotel is Emptied, The Poor Move On. New York Times, December 27, 1988.
 Roy Grant. 1993. “No Place to Call Home.” In Working Together with Children and Families: Case Studies in Early Intervention, edited by P.J. McWilliam and D. Bailey. Baltimore: Paul H. Brookes Publishing. Accessed on April 23, 2013, http://www.cmiproject.net/Stories/no_place_tocall_home.htm
 Alan R. Hinman, Walter A. Orenstein, and Anne Schuchat. 2011. “Vaccine-Preventable Diseases, Immunizations, and MMWR—1961-2011.” Morbidity and Mortality Weekly Report. Atlanta, GA: Centers for Disease Control and Prevention. Accessed on April 23, 2013, http://www.cdc.gov/mmwr/preview/mmwrhtml/su6004a9.htm.
 Roy Grant, Delaney Gracy, and Irwin Redlener. 2012. Still in Peril: The Continuing Impact of Poverty and Policy on America’s Most Vulnerable Children. A Children’s Health Fund White Paper. New York: Children’s Health Fund.
 We are grateful for Andrea Braxmeier, Manager of Media Relations for the Children’s Health Fund, for providing the photographs featured in this article and for her additional feedback.