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Nicholas Freudenberg, DrPH, Marianne Fahs, PhD, Sandro Galea, MD, DrPH and Andrew Greenberg, MS

Nicholas Freudenberg and Marianne Fahs are with the Program in Urban Public Health, Hunter College, City University of New York, New York, NY. At the time of writing, Sandro Galea was with the Center for Urban Epidemiological Studies, New York Academy of Medicine, New York, NY. Andrew Greenberg is with the PhD Program in Sociology, City University of New York Graduate Center, New York, NY.

Correspondence: Requests for reprints should be sent to Nicholas Freudenberg, DrPH, Program in Urban Public Health, Hunter College, City University of New York, 425 E 25th St, New York, NY 10010 (e-mail: nfreuden{at}hunter.cuny.edu).

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.

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