Diabetes in Harlem by Lauren Lancaster Main image

© Lauren Lancaster

The 96th Street divide: why there’s so much diabetes in Harlem (audio)

In East Harlem, four times as many people have diabetes as in the neighbouring Upper East Side. Meera Senthilingam meets the New Yorkers stopping poverty from being a death sentence.


This documentary is also available on the Mosaic podcast through iTunes, RSS, SoundCloud and wherever good podcasts are found.

Whether or not you earn sufficient to afford a place is what really determines where you live – and how healthy you are.

East Harlem: a bite out of the Big Apple

Photographer Lauren Lancaster tours the eateries and eaters of East Harlem.

 

© Lauren Lancaster

A busy junction on 106th street and 3rd Avenue, New York City.

© Lauren Lancaster

Selling snacks on 116th Street.

© Lauren Lancaster

Ellen Simon, a consultant and former Executive Director at the Union Settlement Association, in the garden of the Naturally Occurring Retirement Community Senior Center. “East Harlem is a portal neighbourhood where immigrants come in,” she says. “And one of the things that you see when immigrants from anywhere come up against American fast-food culture, you’re struck by how they abandon their home methods of cooking and things and adopt many of the less wonderful aspects of American cuisine.”

© Lauren Lancaster

A volunteer at the Corsi Senior Center. Here, people with or at risk of diabetes learn how to live healthier lifestyles through a programme called Helping Educate to Eliminate Diabetes (HEED).

© Lauren Lancaster

Preparing for a HEED salad-making demonstration at the Corsi Senior Center. “We provide an opportunity for people to stay in the community, to live healthier and longer lives,” says Maria Alejandro, Director of Senior Services at the Union Settlement. 

© Lauren Lancaster

This salad-making demonstration is one of the activities regulars are required to attend in order to access other amenities in the Corsi Senior Center.

© Lauren Lancaster

A volunteer sits at the front desk at the Corsi Senior Center. “We provide programmes where seniors can go and work with a coach, someone who can help them exercise, be healthy, be strong, be well mentally and socially,” says Maria Alejandro. “We also create programmes where seniors can learn to take care of themselves and cook better for themselves.”

© Lauren Lancaster

Second Avenue near 113th Street. Dr Carol Horowitz says East Harlem is suffering as a “food swamp”. “If you walk around the neighbourhood you’re going to disproportionately find foods that are cheap and unhealthy. And, if you find the healthy foods, they’re expensive and if you don’t have a lot of money you often can’t afford them.”

© Lauren Lancaster

Nancy Cosme, a longtime resident of East Harlem. Like 13 per cent of adults in the neighbourhood, she has diabetes. 

© Lauren Lancaster

Nancy leaving the Corsi building. She lives in apartments above and volunteers at the Corsi Senior Center.

© Lauren Lancaster

Nancy Cosme shopping at her grocery store in Cherry Valley on 115th Street. Food options are limited. One resident says, “All you see are the things we shouldn’t have – the cake, the cookies, the potato chips, the deli. Some of our fruits and vegetables don’t even look like you want to pick it up.”

© Lauren Lancaster

A fruit and vegetable market on 3rd Avenue near 115th Street. Typically associated with wealthier neighbourhoods in some cities, and with fresh produce coming at a premium, the number of markets across New York’s lower-income areas has grown, with more than 60 now located across high-need areas, including East Harlem.

© Lauren Lancaster

Dr Carol Horowitz in her office at Mount Sinai Hospital. She’s working to fight the rising diabetes crisis in East Harlem. “The estimates a few years ago were that, if we didn’t do something, one in two African-American and Latino children born earlier this decade would have diabetes as adults. It would be a majority disease. We are stopping that, and we can see it starting to happen.”

© Lauren Lancaster

Crossing Park Avenue.

© Lauren Lancaster

A doorman stands outside The Monterey, new luxury apartments at 96th Street and 3rd Avenue. Ellen Simon says the stratification in New York is less by colour or language and more by money. “Whether or not you earn sufficient to afford a place is what really determines where you live – and how healthy you are.”

© Lauren Lancaster

A corner store on 106th Street and 3rd Avenue.

© Lauren Lancaster

Michael Shamburger lies on the couch in the apartment he shares with his mother. “I’ve had diabetes for the last 30 years,” he says. “I lost an uncle, a nephew, my grandmother, then me – I have it, my mother has it, my younger brother has it, and my brother under me has it.”

© Lauren Lancaster

Michael lost two toes on his left foot, which had to be amputated due to his diabetes. “I was on vacation in Atlanta, Georgia, and my feet get wet in my shoes. So what I do, like an idiot, I peel the skin off the big toe, just a little piece, and that one little piece developed into gangrene and I lost my toe.”

CC-BY: © Lauren Lancaster

Michael and his mother, Flora, in their apartment. A nurse has just visited to check on Michael’s foot.

© Lauren Lancaster

Michael walks down the hallway of his housing project. He uses a cane and special boots when out and about. “They’re trying to give me a motorised wheelchair,” he says, “Which is really not good for a diabetic, because what happens is we get overweight, because we get lazy, we don’t walk. I’m going to have to use it, because I need to get off my feet, but I like my cane better.” 

© Lauren Lancaster

A mural painted on the wall of Our Lady Queen of Angels School. 

© Lauren Lancaster

Oranges in a vegetable market in East Harlem. 

© Lauren Lancaster

A woman eats inside a Dunkin’ Donuts that sits across from a housing development on 3rd Avenue. Says doctor Carol Horowitz, “We’re told to sit in front of the TV, sit in front of your computer, sit in the subway, sit in your car, and while you’re at it have this tasty snack. It’s cheaper, it’s all over the place, we’re advertising it. Go show me an advertisement that says walk and eat broccoli.”

Diabetes in Harlem slideshow slideshow

 

 

 

Full documentary transcript

[Drumming]

Meera Senthilingam: The streets of Harlem, New York…

[Drumming and music]

Meera: A cultural mecca to the north of the island of Manhattan… I’m Meera Senthilingam, here on the streets of East Harlem – a neighbourhood made up of vibrant pockets of culture, namely African-American and Latin American communities with a long history in the area. The latter of which congregate to the east, in Spanish Harlem, known locally as El Barrio.

[Music]

Woman: It was almost like a divide. When you crossed the East Side it became pretty much Spanish Harlem.

[Music]

Meera: Half of the population are of Hispanic origins.

Woman: A lot of the neighbours and the people on the block, we all used to come outside and sit and play Spades. The older men used to play dominoes. Where I live had the Virgin there, you had a lot of people passing by and praying to the Virgin. We used to have block parties. There was so much life.

[Music]

Meera: Aside from its culture, the neighbourhood is well known for its darker undertones.

[Sirens]

Man: In the early Nineties or mid Nineties, we seen a lot of crime coming into the neighbourhood, a lot of gangs, and a shooting was occurring practically every night.

Woman: The community went totally down, meaning it became really rough to live here.

Woman: We’ve had a series of children run over by cars and trucks.

Woman: It was so terrible, you would find needles, condoms, you know, so many different things.

Meera: The environment is in stark contrast to that of people living just a few blocks away. People on the other end of the spectrum, in the Upper East Side, one of the richest communities in New York City.

Ellen Simon: The stratification in New York is less by colour or language, and more by money than anything else. And whether or not you earn sufficient to afford a place is what really determines where you live – and how healthy you are, lord knows, how healthy you are.

Meera: These two polarised communities are separated by just one street.

[Subway announcement]

Carol Horowitz: If I look to the north of 96th Street, I’m in East Harlem. If I turn my back and look to the south of 96th Street, I’m in the Upper East Side – it is one of the healthiest neighbourhoods in all of New York City. There’s no wall, there’s no guard stopping people moving back and forth between these two neighbourhoods, yet they’re as different as two neighbourhoods can possibly be.

Meera: In East Harlem, to the north, an epidemic has brewed and is now storming full speed ahead to capture a community with few defences in place.

Woman: My son is a diabetic, I’m borderline.

Woman: I have diabetes, uncontrollable diabetes.

Woman: My sister has diabetes but I don’t.

Child: My mom has diabetes.

Woman: My sister lives in Tennessee. She also was diagnosed with diabetes, and then I found out. My grandmother died of diabetes, so it runs in the family.

Michael Shamburger: I’ve had diabetes for the last 30 years. I lost an uncle, a nephew, my grandmother, then me – I have it, my mother has it, my younger brother has it, and my brother under me has it.

Woman: My husband died from diabetes complication.

Meera: 13 per cent of adults in East Harlem have diabetes. The condition is manageable, yet in East Harlem, it’s the third leading cause of death. Moving south to the Upper East Side, the situation is the opposite. Rates of diabetes here are lower than the City of New York overall, at just 3 per cent, making it one of the healthiest postcodes in the city.

[Subway announcement]

Ellen: So here we are at the lower edge of East Harlem. If you cross 96th Street, we are on the north-east corner. If you cross to the south-east corner you’ll be on the Upper East Side.

Meera: Ellen Simon.

Ellen: It’s always been the edge of the Upper East Side and the edge of East Harlem.

Carol: It’s the least obese neighbourhood, it has the lowest diabetes rate, it has the lowest diabetes death rate and one of the lowest mortality rates in New York City.

Meera: Carol Horowitz.

Carol: So this is it, my back is to East Harlem, I’m looking at the Upper East Side, and this is what I’m seeing. Now I’m going to spin myself around and I’m going to look at East Harlem, and what do I see in East Harlem? I see, as opposed to a community that’s 6 per cent non-white, I see a community that’s 90 per cent non-white. I see a community that has six times the rate of poverty, nine times the rate of under-education – not graduating high school. A community that more than half of the people think it’s unsafe to live there. Three times the number of people think their health is bad. It is one of the most obese neighbourhoods in New York City. The diabetes death rate is five times that in East Harlem than it is in the Upper East Side. So when you look at East Harlem, it’s not just how much diabetes it has, it’s that if you walk one block south and live there, you’re in the healthiest neighbourhood you can find.

Meera: Diabetes made its entry into East Harlem many years ago, but only recently entered people’s radars – by which point the epidemic had grown to its severest form.

Michael: I lost two of my toes because they got gangrene because my shoe was too high and I didn’t take care of it like I’m taking care of it now.

Ellen: You live north of 96, you’re far more likely to have diabetes, far more likely to suffer negative consequences, such as amputation or blindness or neuropathy, than you are if you live below, because of the quality of the food you’re exposed to, the quality of the healthcare you can get.

Carol: One statistic that amazes me is that if you’re a senior citizen living in East Harlem, and compare yourself to a citizen on the Upper East Side – two senior citizens, both have diabetes – you have almost ten times the likelihood of getting your foot amputated if you live in East Harlem than in the Upper East Side. Almost ten times the amputation rate.

Meera: And now, these two women have had enough. And for the past 15 years they’ve been making a stand.

Carol: My name is Carol Horowitz, I am an Associate Professor at Mount Sinai, and a lot of my research is trying to prevent and control diabetes.

Ellen: I’m Ellen Simon, I was the Executive Director at the Union Settlement Association, and I’m a consultant for Union Settlement.

Meera: They’ve been tackling both the medical and social side of the problem. Their journey began with food.

Ellen: Okay, so we basically met around the food festival, someplace between 12 and 14 years ago. Carol had this wonderful grant to get 30-odd restaurants in Harlem to cook dishes in a low-fat, low-salt way, and she had planned to do screenings for diabetes and heart disease, and couldn’t get a location. And I had a location. [Laughs] And together we made food, it was fun.

Carol: What we did is we tried to figure out a way to simultaneously convince restaurants to make healthier versions of their foods, and have people try those healthier versions, and maybe both would say “Hey, this is working out well.”

Meera: The festival took place outside Ellen’s place of work, the Union Settlement, a community association serving East Harlem since 1895.

Ellen: Okay, so we are on 104th Street between 2th and 3th, in front of the headquarters of Union Settlement Association. 12 or 13 years ago, a huge project to prevent diabetes in East Harlem got its start.

Meera: Tickets to the food festival came at a price.

Ellen: It was free but you had to permit – you had to give your name, a contact number, your blood for diabetes screening, and you had to take your blood pressure. And so at the end of it the health screeners from North General handed you a piece of paper that said your blood sugar is – you have diabetes, you don’t, it’s this – the actual number. Many people didn’t know their numbers. That was really a spark that got us interested in doing something much more substantial for health promotion in East Harlem.

Meera: More than a thousand people attended the food fair, and the clinicians involved used this as an opportunity to identify the health needs of the local population. The event stemmed a series of surveys by Horowitz’s team over subsequent years to reveal the true extent of diabetes in East Harlem... And an epidemic was unveiled.

Carol: If you go out to East Harlem and you find people who are overweight or obese, who are at risk of pre-diabetes and diabetes, and you ask who doesn’t think they have diabetes or pre-diabetes (they’ve never been told they have it), and you screen them, only 30 per cent will have normal sugars. We’ve now surveyed thousands of adults in East Harlem. Less than one in three who are overweight have normal sugars. Now we look around, a third of people in our hospital have diabetes, that are admitted to the hospital, have diabetes.

Meera: In the US, normal sugars mean levels below 100 milligrams of glucose per decilitre of blood when fasting. Levels between 100 and 126 mean someone is at risk of pre-diabetes, and levels above 126 mean they have diabetes. The disease is heavily linked with lifestyle factors such as diet and exercise.

Woman: It is very hard trying to be healthy in East Harlem because you don’t have that many supermarkets or stores round here that carry a lot of healthy things.

Woman: All you see are the things we shouldn’t have – the cake, the cookies, the potato chips, the deli. Some of our fruits and vegetables don’t even look like you want to pick it up.

Child: My stepdad he likes to drink syrup because it has a lot of sugar in it.

Woman: I used to like fried chicken, fried pork chops, pernil – which is pork in the oven – French fries, fried eggs. Not healthy at all, and I’m paying for it now.

Ellen: East Harlem is a portal neighbourhood where immigrants come in, and one of the things that you see when immigrants from anywhere come up against what I call American fast-food culture, you’re struck by how they abandon their home methods of cooking and things and adopt many of the less wonderful aspects of American cuisine – McDonald’s, Kentucky Fried Chicken, just to name a few. But the point is that many of them gain weight when they get here, they’re less active, they’re not in the same place or same environment.

Meera: This phenomenon is reflected globally. As more countries urbanise, and people raised on a rural lifestyle find themselves in the city, weight gain and health issues follow suit. By 2050, it’s estimated that two-thirds of the world’s population will be living in cities, bringing greater risks of obesity and diabetes, determined by the options people will have for their food.

[Street sounds]

Ellen: So if you look right here, what are we passing?

Meera: Chinese takeaway.

Ellen: Chinese takeaway. You know, you just don’t see healthy options. I mean, 125th you can get a salad. You come here, you cannot even find a place to get a lunchtime salad. It’s just not offered.

Meera: What would be the food options right now? It’s lunchtime.

Ellen: It’s lunchtime, you can have Chinese takeout, you can have fried chicken, you can have ethnic food – Mexican, or you know, sort of traditional Latino. In fact, that’s probably where we’re going to go now, because that’s the best of the batch around here.

Carol: Look in a community like East Harlem and we know not only is it a little bit of a food desert – that it’s harder to find healthy, affordable foods – but it’s what I call a food swamp, which means if you walk around the neighbourhood you’re going to disproportionately find foods that are cheap and unhealthy. And, if you find the healthy foods, they’re expensive and if you don’t have a lot of money you often can’t afford them. Walk into a store. If you walk into a healthy store what do you walk into?

Meera: Fruit and veg.

Carol: Right, you walk in and you see fruit and veg, and they have spritzers and the lights and it smells so good, right? And you have to walk through that before you get to anything else. You walk in, you’re hungry, you want food, that’s what you buy. Now walk into one of the bodegas with me.

Meera: A bodega is a grocery store.

Carol: So we’re in a little bodega, just a small store, you look on the outside of it and you’ll see the ads. Let’s look at the ads. We see cigars, beer –

Meera: More beer.

Carol: More beer, more beer, more beer…

Meera: And then soft drinks.

Carol: And Pepsi, Mountain Dew… None of which say diet, they all say regular.

Meera: 33 per cent of adults in East Harlem are classified as obese, a fact easily seen when walking down the busiest streets of the area, such as 116th Street, a central hub in the community.

[Traffic noise]

Meera: Excessive weight gain has resulted in a range of effects on the health of the local community.

Woman: About two months ago I had heart surgery.

Woman: I started to eat like in the restaurants – cuchifrito, alcapurrias, rellenos, which is like fried food. And I was dancing, so I figured I was healthy anyway. But, as you get older, your body chemistry changes.

Woman: There’s issues with health, issues with diabetes, issues with high blood pressure, just in the community in general.

Woman: Well basically, I have diabetes, and I have a few more health issues. That’s imperative that I lose the weight.

Meera: And, of course, diabetes, which can be fatal due to the biological changes that take place inside the body.

Carol: We all need an amount of sugar; sugar is our quick energy, and we need it in our brains so we can think, and we need it for our muscles to move, and for all sorts of things. However, the sugar needs to get from our mouth into our stomach, into our bloodstream, to where it needs to go. When you have diabetes, depending on the kind of diabetes you have, what happens is that your body is unable to process that sugar. Which means you have too much sugar where you don’t need it, and not enough sugar where you do need it. So if you have too much sugar where you don’t need it, and it’s swimming around in your bloodstream, it’s a toxin. If your sugar levels are too high in your blood, that can, for example, impact your vessels and inflame them so you have more heart disease, heart attacks and strokes. It can impact your kidneys so people have more kidney failure, it can impact your nerves so people don’t feel a lot, and that can lead to amputations. It can impact the circulation in your eye, which can cause blindness. And in addition, if you don’t have enough sugar where it needs to go, you end up feeling kind of terrible. People feel tired, they don’t have the same energy they normally do. That’s diabetes in a nutshell.

Meera: And what are some of the typical ways that people get it or have it?

Carol: The vast majority of adults who have diabetes, and now the majority of younger people who have diabetes, have it because they are overweight. And when you’re overweight, your body becomes resistant to the normal mechanisms you have to get the sugar from where it is to where it needs to go, so you end up with too much sugar in the wrong places. Your body becomes resistant to the insulin that you use to drive the sugar from your bloodstream into where it needs to go, so your body doesn’t respond as well to the insulin it has, and it often doesn’t make as much as it needs to. These are major problems.

Meera: If left untreated, the consequences of diabetes are extensive, including blindness and, more commonly in this community, amputation.

Doris Manning: Hi, my name is Doris Manning and I’m 74 years old. My husband died from diabetes complication. He decided that he was going to do his own pedicure, and when he did that his foot got highly infected and it turned into gangrene. And then that was when he lost his first leg… four months later the second one to that. Then he wind up on dialysis because the kidneys went. Then he had a problem with the heart valves. So to see him suffer, that turned my whole lifestyle around.

Meera: Limb amputations are a common site on 116th Street.

Woman: If you stand at 116 and Lexington, you will see so many people with a lot of canes, people in wheelchairs, that it’s amazing.

Meera: Dotted throughout the large crowds are people on crutches or driving mobility scooters to help them stay mobile.

Michael: I lost two toes on my left foot. Also on the right foot.

Meera: This was the case for Michael Shamburger.

Michael: I was on vacation in Atlanta, Georgia, and my feet get wet in my shoes. So you know, you take off your shoe, your feet is white. So what I do, like an idiot, I peel the skin off the big toe, just a little piece, and that one little piece developed into gangrene and I lost my toe. When I came back from Atlanta, Georgia, the toe went from being okay to black and then the whole foot gangrene, and they took half the foot off.

And now they’re trying to give me a motorised wheelchair, which is really not good for a diabetic, because what happens is we get overweight, because we get lazy, we don’t walk. So I’m going to have to use it, because I need to get off my feet, but I like my cane better. I know now that I have to take care of myself a lot better, so I don’t ever end up dying from it.

Meera: And you said you know this now, so I guess – what did you know before, and how did you live before?

Michael: When I was young I hustled like crazy, I made a lot of money on the streets. It was rough at the time, but there was plenty of it. Now you hustle, and making money, you don’t eat right, you run the streets, you drink, you run into girls, you know, it’s a crazy lifestyle. But I learnt a lot from it and I learnt how to survive, you know. And then as I got older I got educated more, did two years of college, and then I just started working after that. And as soon as I started working, I’ve been working the last 30 years.

Working every day, 24 hours a day as a superintendent, it kept me on my feet. I didn’t get enough rest. Food was erratic because I was running all day long, I’m working 24 hours a day, it was like I could never get the sugar low because I worked all the time. So being as I worked like I did, it made it harder for me to take care of it. And I did that 16 years, and then now that I’m retired I’m trying to get better, which took a little surgeries, hospital stays and stuff like that, but now I’m doing a lot better.

I’m over in Metro North, and in that whole area over there you have the projects, and obesity is on top of the charts over there, it’s terrible. Everybody’s eating fast foods, nobody’s eating healthy – they eating junk. To me, over the years it’s got worse here in Harlem, I can definitely see that. Because over the years, I’ve been here like 52 years and I never seen it like it is now, it’s rampant. At the clinics, when you go to the hospital, the doctor’s office, it’s ridiculous. Kids have it. It doesn’t discriminate.

Michael: [In background] I really feel like I’m gonna be here forever…

Carol: The problem is that there’s all sorts of influences surrounding us that are pushing us in this direction. The predominant influence in our society right now is to sit down and eat crap. That’s what we’re told to do. Sit in front of the TV, sit in front of your computer, sit in the subway, sit in your car, and while you’re at it have this tasty snack. It’s cheaper, it’s all over the place, we’re advertising it. Go show me an advertisement that says walk and eat broccoli – it’s not out there.

Maria Alejandro: I blame McDonald’s, I blame all of these chain companies that are here forcing people to eat what they serve. And they become rich and we become sick.

Meera: Maria Alejandro is Director of Senior Services at the Union Settlement. She’s worked, and struggled to eat, in the neighbourhood for more than a decade.

Maria: When I started working here 12 years ago, there was not a place where you could buy a banana before you came to work.

Meera: So even if people wanted to access good food they just couldn’t?

Maria: It was not here. You know, there’s not a place where I can buy a banana. I like to have a banana, I like to have oatmeal before I come to my office. Where are those places? If you go downtown, only ten blocks from here, you can buy a banana – four or five bananas for a dollar, right before you enter into any office. Around here you really have to go search for it, and that’s why you see so many children who are big, and you see so many mothers that are even bigger.

I remember when I was growing up that we had one chicken on Sundays on the table, where everybody have to eat from that one chicken. Here, today, you can have a whole chicken. It’s the way that we have taught our population to eat.

[To group] Anybody here have diabetes?

Meera: During their decade-long journey, Simon and Horowitz have brought greater food options to East Harlem and, importantly, helped people with or at risk of diabetes learn how to live healthier lifestyles through their Helping Educate to Eliminate Diabetes project, known as HEED.

Woman to group: Right ladies…

Ellen: The actual HEED project focused on helping people lose weight through their workshop series. Helping them learn to manage, learning portion size, learning label reading, learning the kinds of tools that people need to manage what their food intake is. And even telling them different ways that they can incorporate what doesn’t sound like exercise into their lifestyle that would help them. Getting off a bus a stop earlier to add walking to it, joining a walking group, those kinds of techniques to manage it.

[Sounds of a group meeting]

Maria: We provide an opportunity for people to stay in the community, to live healthier and longer lives. We allow them to exercise and we provide programmes where seniors can go and work with a coach, someone who can help them exercise, be healthy, be strong, be well mentally and socially. And, at the same time, we also create programmes where seniors can learn to take care of themselves and cook better for themselves.

[Sounds of pan cooking]

Woman: And as far as the vegetables – like I’ve ventured out into vegetables, which I never did in my youth. So now I just pick up something I don’t know, and I do have more energy, because my breakfast consists of a vegetable smoothie or a fruit smoothie and that starts my day.

Woman: There’s a lot of people in the community that is diabetes, has diabetes and also hypertensive, but some of them care and some of them don’t. And we have a lot of classes here at the centre on diabetes, so they can help us.

Woman: I was never really taught how important exercise was, and if you don’t use it, you lose it. It becomes harder to do certain things.

Man: I took the healthy eating course. One of the things I learned to do was walk [laughs] instead of taking the bus.

Woman: I’m feeling much better, I don’t get short of breath like I used to when I used to walk. I used to walk about a block and a half and I had to stop. Not no more.

Meera: But truly improving the health of an entire population requires more than awareness and education. Once people know what they should be doing or eating, they need access to make it happen. This led to the growth of the farmers’ market.

[Sounds of farmers’ market]

Child: Ooh, apples!

Meera: Typically associated with wealthier neighbourhoods in some cities, and with fresh produce coming at a premium, the number of markets across New York’s lower-income areas has grown, with more than 60 now located across high-need areas, including East Harlem.

Al: I’m Al from Orangey Produce. We put out a great product, everything you see was either in the ground or on the vine 24 hours ago. Can’t get much fresher.

Meera: Can you tell me a bit about the popularity of the market here, this particular one and what types of people come, what they like to buy?

Al: The majority of the neighbourhood usually comes out but it’s not the greatest day today, so it’s just slow. And then we have limited products now as the year goes down. We only sell what we grow and as you can imagine, in the middle of November there aren’t much growing. [Laughs]

Meera: Have you seen more people come over time?

Al: Well it really depends. This neighbourhood’s kind of cliquey, sometimes a lot of people come and sometimes not. Today it’s a little slow. They usually have the kids out. I love it, the people are great, a little bit of a language barrier but I’m working on that too. [Laughs]

Meera: Importantly, the price of fresh produce at the market has been made affordable.

Alitha Maybank: Hello, my name is Alitha Maybank. I am Assistant Commissioner in the New York City Department of Health, as well as the Founding Director of the Center for Health Equity.

In New York City we actually have one of the largest incentive programmes for farmers’ markets in the country, and it’s called Health Books. And when somebody spends $5, they get $2 more in return to buy more fruits and vegetables at farmers’ markets. And we’ve seen a boom of the farmers’ markets movement across the city and it’s exciting, and here in East Harlem they have a long history of having farmers’ markets, but how do we get more people engaged and knowledgeable that they’re there has always been the challenge.

Meera: For Simon and Horowitz, this wasn’t quite enough. They worked with the City’s Department of Health to make fresh fruits and vegetables even more accessible, putting them on every street corner on something as simple as a cart. A green cart.

Ellen: Vendors sell produce on the street, it’s called a little mini pushcart, it’s bringing you back to the days of the pushcarts. And what it does is offer relatively low-cost fruits and vegetables to the community, and Union has worked on that and now there are a variety of green carts that you can find. Now it’s more than you were ever able to get before, but it’s not a lot.

Carol: Look over here, here’s a green cart, and here’s a guy with tomatoes and avocados and…

Meera: Bananas…

Carol: Bananas, persimmons. Also figuring out what local people want to eat, right. Not necessarily what me from the suburbs want to eat, but what do people in Harlem want to eat in terms of fruits and vegetables.

Meera: In East Harlem these carts are competing against some unhealthy, but popular, competition.

Carol: You can see we’re walking by right now a place selling hot dogs and fried food.

Meera: I can smell it.

Carol: Wait a minute, here’s another one, more hot dogs, more fried food, soda, Pepsi we’ve got going on here. And what do we have here? A third hot dog truck. Okay.

So the question is, how do you change that ratio? How do you make it so I’m going to see three vegetable carts instead of three fried-food carts? Harder when the weather gets colder. But usually our fruit and vegetable vendors are out here and they’re actually doing better and better. We’ve done some studies with people on the green carts, and they really are being used. We’ve been interviewing people who come to the green carts, and they’re increasingly buying fruits and vegetables. You want people to feel like as they’re walking by, they’re reminded, oh yes that’s what I should be eating. And it’s right here. And most of the green carts here take food stamps, which is food subsidy for folks that don’t have high incomes. So not only are they available, but they’re also affordable. They’re a daily reminder of: have an apple, have a piece of fruit, it’s delicious, it’s fresh, it’s right here, I take food stamps, come on.

Meera: This move towards local food for local people seems to have had an impact.

[Shop sounds]

Carol: Look over here. [To shopkeeper] Buenos. See, we have fruits and vegetables here. So on one side you see some junk food, but look what else you see over here – and you can see how beautiful our neighbourhood is. We see squash, lettuce, peppers, lemons, limes, grapes, apples, right?

[To shopkeeper] How do things like the water and the fruits and vegetables sell as compared to the cookies and candy?

Shopkeeper: The water sells almost more.

Carol: Yeah? The water sells more. Why do you think that is?

Shopkeeper: The people have to drink, you know, not soda, it’s water, water. You know, that good for you.

Carol: You see, it’s a tiny little store and the man’s kind of surrounded. Above his head was gum and candy and cigarettes, and to his left was chips, and to his right was cookies, but right under him, right at eye level, were some fruits and vegetables. You know, nothing is ever going to change completely overnight, but it’s encouraging to hear that water’s selling more than soda. You wouldn’t have heard that I don’t even think four years ago, three years ago.

Meera: Alongside this progression has also been a change in the influences found in the East Harlem community, with the advertising and promotion of fast food starting to decline, albeit slowly.

Carol: So here you see a different kind of store. You can see in here tons of local people sitting further back.

Meera: Hot food being served.

Carol: Hot food being served. And a huge salad bar. And at the front they have another chopped salad area.

Meera: It smells really good in here.

Carol: Yeah, and you can see the kind of lower-fat yoghurts here, and you can see diet soda next to regular soda.

Meera: And small bottles of it.

Carol: Small bottles, smaller portion sizes, yeah. This is a newer kind of store in the neighbourhood. And look outside, remember the place we just saw, what it looked like? We saw beer, beer, beer, beer, beer – here we see a salad, juice, coffee, a sandwich that has some lettuce, tomato sticking out of it.

Meera: And these are very giant posters, taking over half the window.

Carol: Yep. Yep.

Meera: Since 2008, the promotion of healthy food and access to it, including the urban farming of it, has extended to children.

Carol: They take what most people consider a small triangle of land that’s not being used, it’s fenced in. Nobody’s playing, nobody’s doing anything…

Meera: Currently littered with a lot of papers.

Carol: Yeah there’s papers littered, there’s glasses littered, and they will turn this into a community garden. And what that means is that the kids will be getting exercise when they’re gardening in it, people will look out of their windows and, instead of seeing garbage, they’ll see fruits or vegetables growing, and then they’ll pick them and bring them upstairs and have them for dinner. It’s taking an unused litter-strewn yard and making it into an advertisement for fruits and vegetables.

Meera: And one of the originators was Concrete Safaris, an afterschool programme for 7-to-12-year-olds, headed by Mac Levine.

Mac Levine: We started as a garden organisation only, twice a week for two age groups. So gardening is the core of what we do. I see gardening as like a model for social change, right? So if a kid can think from the idea of what does a garden look like, what do I imagine eating, to actually putting that into place, to actually harvesting the crops, to actually helping the next group of kids that they’re with develop the next garden. That to me – that process from the seed, so to speak, of the idea, you know, to the actual food on the table or food into their friend’s hand – is, I think, the core of what we do.

We have all different things growing.

Ellen: A lot of people here grow their vegetables, grow their own fruits and vegetables. Thomas Jefferson, this public housing project, has a farm where children from concrete safaris do come and farm. And there’s another farm down at 99th Street in another, Washington Houses, a community centre.

Meera: Adults and children are now eating healthier than ever before in East Harlem, but the second challenge remaining is to get them moving, to get their blood flow circulating, their weight shedding, and their blood sugars falling – a further challenge typically associated with life in the city. And in Spanish Harlem one popular strategy has been the provision of exercise classes. [Music] And particularly suited to this area – Zumba classes.

[Music and cheering]

Carol: We started a Zumba class with you guys, people standing on the street, waiting to get in, hoping to get in. We started showing people it’s not just all in the doctor’s office – do stuff in the community.

Meera: This provision of Zumba and exercise classes has been carried on by the city’s administration, and most importantly the classes are free.

Woman: So free fun and a great instructor to get fit, you can’t beat that right?

Woman: It said ‘Shape up New York’ and I’m like, what’s this? And it was a whole schedule and I was like, oh my god, two classes a night, I’m in heaven. [Laughs] I love it.

Woman: I have an illness called multiple sclerosis, so I can’t really run across the floor, but they never pressure me and I can be one spot and work on the wall and they really like let me enjoy this. It’s the best class I’ve done in many years.

Woman: I myself was diagnosed as a pre-diabetic about five years ago, and I completely turned that around and have great glucose levels now. Most recent test about a month ago, and there are no traces of it. And I’m proud, and the doctors attribute that directly to my moving and exercise.

Meera: Leading the programme, known as Shape up NYC, is the city’s department of Parks and Recreation, headed by physical activity coordinator, Kendra Koch.

Kendra Koch: So when Shape Up started, it was exclusively in the neighbourhoods that the Health Department identified as having the highest need. And we’ve kind of continued to keep those neighbourhoods as our targets, and then add on, because the obesity epidemic and the epidemic of physical inactivity really affects the whole city. We do think of Harlem as one of our hub neighbourhoods, but we try to serve as many neighbourhoods as possible because we do want the programme to be convenient for all New Yorkers.

[Zumba class music]

Meera: The impact, though difficult to assess, has been shown to be positive amongst those attending.

Kendra: So these are kind of tough measures to track in just five years. A lot of times, to make a dramatic impact on the obesity epidemic, you’re going to need 10, 15, 20 years, but we know people are exercising more than they did before. We know we’ve been able to offer a lot more classes, thousands of classes every year. People tell us they’re losing weight, we’re in the middle of a big programme of evaluation now. We have surveyed about 700 people so far. We haven’t analysed the data at all, so I can’t really speak to what we’re doing now, but I know the last time we did it about 60 per cent of our people said that they had lost weight, about 70 per cent said that they felt better and had less stress after coming to the programme, and that’s pretty amazing.

Meera: Classes like these, however, can’t appeal to everyone in need of more exercise. And, as mentioned, people always find excuses to stay away. So things are being taken one step further and measures are now being put into place simply to get people walking more, as the benefits are big.

Carol: Do you know, if you have a person with pre-diabetes, so their sugar’s higher than normal but they don’t have diabetes yet, and they increase their physical activity, namely walking, by about 120 minutes a week, they will cut their risk of developing diabetes by half, even if they don’t lose a gram or an ounce. Even if they don’t lose weight, just walking more you can cut your risk of diabetes by half.

Meera: Horowitz and Simon have been pushing for, and seen, changes that dig deeper down into the infrastructure of the city as a whole, changing its design from the roots.

Carol: We also need to change the way things are, we need to design our cities and our streets to be more walkable. There’s bike rentals all throughout New York City, but they haven’t come up north to East Harlem. There’s malls people can walk in – they’re not in East Harlem. If you look at a lot of buildings, they might have safe stairwells, so when you come into your apartment maybe the stairwell begins in the middle of the apartment, and it’s well lit, and it looks good. If you go into the place I’m looking at outside my window, which is a place in East Harlem, which is a high building, which has a very high crime rate, and you walk into the stairwell like we did a few weeks ago, it’s dark, it’s a little scary, it smells like urine, you’re worried you’re going to get hurt in there. So how are we encouraging people to be more active? In a neighbourhood like this people should be able to walk the stairs in their own apartment building.

Meera: The city’s Department of Design and Construction, DDC, have been making this happen.

Lee Altman: We can impact public health and improve health outcomes through the way that we design.

Meera: Lee Altman was formerly active design coordinator for the DDC.

Lee: We did a very good job at designing physical activity outside of our daily lives, everything is dependent on a car, elevator, you sit in front of a computer not moving around a lot, and it’s reversing that a little bit, but also looking forward to see how we can facilitate improved physical and mental health.

Meera: At the core of enabling this is the idea of active design, designing buildings to enable people to move without even really thinking about it.

Joanna Frank: Physical activity was very much linked with the state of infrastructure, so in a neighbourhood that would be the state of the sidewalks, if there was lighting, if they were well-maintained.

Meera: Joanna Frank is the Executive Director of the Centre for Active Design, a not-for-profit organisation that addresses health and social issues such as physical activity through practical design.

Joanna: If there’s graffiti there’s shown to be a big impact, actually more on girls than boys, which is also interesting. But the evidence really led to the fact that people were less likely to walk down streets, less likely to bike if they didn’t feel safe, if the infrastructure wasn’t complete, so you couldn’t get to your destination. Which are pretty obvious now, but really this was not proven, people maybe didn’t think that there was a direct connection between the risk of obesity and chronic disease and where you lived, but now I think we’ve established that’s actually the case.

[Sounds of community garden chatter]

Joanna: So for Harlem there’s a lot of great new community gardens, the New York Restoration Project has done some great community gardens up in Harlem, and there’s definitely plazas as well on 125th Street, so creating those small kind of urban spaces. One that we didn’t have an influence on, but that we like, is the Harlem Hospital. It has a great staircase.

[Sounds of walking up stairs]

Joanna: We really want stairs to be enticing, and that’s what design can do. We can make it really kind of intriguing and enticing. So things like natural light, views on a second-storey landing, those kind of things pull people along – you want to take the stairs. Also if it’s the first thing you see when you walk into a building, and you’re only going to the second floor, you’re much more likely to take the stairs.

Meera: In other underserved communities, changes have taken place, in part due to gentrification, a trait in common with the growth of many cities throughout the world.

The arrival of middle- and higher-income communities to live alongside, but not in place of, low-income communities can improve access, resources and services, and therefore health.

But according to Horowitz, Simon and other experts on the area, one key factor is holding East Harlem back.

Ellen: So you’re coming up on James Weldon Johnson Houses, and because of the projects you don’t get a lot of gentrification right here.

Meera: I mean we can see a whole row of projects right now. What really defines them? I mean to me I see tall buildings, essentially, that can therefore house a lot of people.

Ellen: Well what else defines them is that you have to be of modest means to get in, that they take only a quarter of your income. There’s an income ceiling. If everyone in here has to be of modest means then it is basically a low-income neighbourhood without diversity, economic diversity. So here’s another one on the other side.

Carol: One third of East Harlem is low-income public housing. These tall buildings that when I look out my window I see a brick building that’s probably 20 storeys high with a very small green space around it, and there are many, many buildings like that in East Harlem.

Meera: Grouped together.

Carol: And they’re grouped together, so there’s clusters of these buildings.

Ellen: There’s the Washington and Lexington houses, which is a huge project that goes from 97th all the way to 103rd, actually to 104th. It goes from 3rd Avenue to 1st Avenue and across – the Lexington portion goes from 3rd Avenue to Lexington, so you’ve got just huge volumes of people.

Carol: So we’re always going to have low-income folks in East Harlem, and some of the other areas are going to gentrify, which is going to be a problem for some of the undocumented immigrants who may not be able to afford to live here anymore. But I think it is important to have some mixed housing, and the data shows that’s really good for the health of a community.

Ellen: So the project ends here, and look across the street from the project and you will see some of the consequences of gentrification. See those apartments, those are midline renovations, and they’re quite costly for apartments in this neighbourhood. So it pushes out families who are not well-to-do, or who can’t access public housing because they’re somebody who doesn’t have papers, or they perhaps make a bit too much, not enough to afford an apartment there.

Meera: This gentrification has been a naturally occurring aid to the efforts Simon, Horowitz and their army of collaborators have put in over the past decade. The combination of clinical, community, governmental and infrastructural changes that have taken place in East Harlem have been shown to have slowed down the diabetes epidemic.

Ellen: We helped to organise the green cart system and helped to bring, really, fruit pedlars to street corners in underserved neighbourhoods. You now see them everywhere. You get off a train stop, and there is some guy with fresh bananas and grapes and things, at a much lower price than you can get in a supermarket, and for those kind of initiatives, so I think those are to me exemplars of successes. The failures are: there are still tons of people with diabetes, there are still tons of people who are overweight and who aren’t as well, and there’s still tons of unhealthy food being sold. So there are some successes, but there’s more to go.

Carol: Diabetes prevalence has levelled off, obesity prevalence has levelled off, they’re not going up anymore. East Harlem is no longer the worst – we’re not the most this, the most that, and I think you can see in the community there’s a slow shift towards the healthy. Everyone in the community is moving a little bit more towards the healthier – healthier walking, healthier eating, more awareness. When we started this, only 20 per cent of docs knew what pre-diabetes was and screened for it. Now everybody does. So everything is a slow move towards the healthy. Right now, the estimates are – well the estimates a few years ago were that, if we didn’t do something, one in two African-American and Latino children born earlier this decade would have diabetes as adults. It would be a majority disease. We are stopping that, and we can see it starting to happen.

[Music]

Man: I think the people in East Harlem are more conscientious now than say even five years ago about their eating habits.

Child: I usually ate ice cream and stuff like that, but now I don’t really eat ice cream and juice, I just drink milk and water now.

Michael: I do go to a few farmers’ markets, because they do have them come to our neighbourhood now. Before, that never happened, so now they have it more. I guess, with all the demands for people to eat fresh foods, they do come in this area.

Child: Because once I knew – ’cause I never used to look at the back – but once I knew what was inside of those things, I asked the teacher about it, and then he told me, and then that’s when I said to myself, oh, I have to stop eating those types of foods because I could always get sugar diabetes or anything else.

Woman: The neighbourhood is changing and gearing to more healthy because we are changing, because more people are moving into the neighbourhood – it’s a very diverse community now.

[Music]

Meera: I’m Meera Senthilingam, reporting from East Harlem. Music has been by the Arsonist, titled Hot Salsa Trip, and the Marching Cobras. To hear more from East Harlem visit mosaicscience.com.