The impact of New York City's 1975 fiscal crisis on the tuberculosis, HIV, and homicide syndemic

In 1975, New York City experienced a fiscal crisis rooted in long-term political and economic changes in the city. Budget and policy decisions designed to alleviate this fiscal crisis contributed to the subsequent epidemics of tuberculosis, human immunodeficiency virus (HIV) infection, and homicide in New York City. Because these conditions share underlying social determinants, we consider them a syndemic, i.e., all 3 combined to create an excess disease burden on the population. Cuts in services; the dismantling of health, public safety, and social service infrastructures; and the deterioration of living conditions for vulnerable populations contributed to the amplification of these health conditions over 2 decades. We estimate that the costs incurred in controlling these epidemics exceeded $50 billion (in 2004 dollars); in contrast, the overall budgetary saving during the fiscal crisis was $10 billion. This history has implications for public health professionals who must respond to current perceptions of local fiscal crises.