ABSTRACT. The epidemic of acquired Immunodeficiency syndrome (AIDS) has been concentrated in a few large citles. Thus far, New York City and San Francisco have reported more AIDS cases than any other cities in the world. Together they account for 40% of the total number of cases reported in the United States through the end of 1986.

Both cities have expended an enormous amount of local resources in dealing with the epidemic, although the public policy response has been markedly different in each city. Although historically New York has had three times the AIDS caseload as San Francisco, It has consistently spent less money on public health education and other nonhospital-related health care services. The varied policy responses in each city can be attributed to several factors: differences in the magnitude of the epidemic; the patient mix; the role of risk groups in the political and economic life of each community; the scale of public health care systems, including the number of medical schools; the Impact of local media; and the Institutional roles of the respective health departments.

With the prospect of other cities facing an increasing number of AIDS cases, the New York and San Francisco experiences may prove useful. They indicate that each community's response to AIDS will probably reflect the underlying social, economic, and political characteristics of AIDS victims and the existing structure and organizational roles of traditional health care and community-based service provid

ers.

(NY State J Med 1987; 87:264–272)

From the Department of Health Care Administration, Bernard M. Baruch Col lege/Mount Sinai School of Medicine, City University of New York (Dr Arno). and the School of Health Administration and Policy, Arizona State University (Dr Hughes)

Address correspondence to Dr Arno, Assistant Professor, Department of Health Care Administration, Bernard M. Baruch College/Mount Sinai School of Medicine, 17 Lexington Ave, New York, NY 10010.

This research was supported in part by fellowship grants from the Pew Memorial Trust. Earlier versions of this paper were presented at the Annual Meetings of the American Public Health Association, November 1985, in Washington, DC, and at the International Conference on AIDS in Paris, France, in June 1986.

Forty percent of the AIDS cases reported in the United States through 1986 have occurred in New York City and San Francisco. These two cities account for more cases than any other cities in the world. Yet the ways in which the epidemic has affected these two cities and their policy responses have been quite different. Early reports indicated that the average length of hospital stay for AIDS patients was four times longer in New York, and that services for AIDS patients, ranging from hospital care to housing and counseling, were organized differently in each city.1-4

The concentration of cases in these two cities, coupled with a federal policy preference for shifting responsibility for domestic social problems from the national to the local level, has made the experiences reported here important to an understanding of AIDS in the United States. This paper describes the AIDS epidemic in New York and San Francisco and examines the factors that have contributed to different policy responses in the two cities. This comparison illuminates the problems other cities are likely to face as AIDS continues to spread, and identifies those factors that are important in tailoring local responses to the epidemic.

To investigate the apparent differences between the two cities, we relied on a variety of data sources as well as the organizations that have been involved in coping with the epidemic in New York and San Francisco. We reviewed available published information, including congressional testimony, scientific literature, and newspaper reports, and also unpublished agency minutes and records from involved organizations. Finally, extremely valuable information was provided by numerous public officials, leaders of private AIDS-related organizations, and volunteers from agencies in both cities who discussed the responses to AIDS in their communities.

To place these cities in perspective, it is first useful to describe some of the basic economic and demographic characteristics of each city (Table I). For example, New

Sources, US Department of Commerce. Statistical Abstract of the United States, 1985; US Department of Commerce: 1980 Census of Population, 1983 York is a far larger city, with ten times the number of people as San Francisco. Nearly twice the proportion of New York's population is black or Hispanic. San Francisco is a wealthier city, with a per capita income 26% higher than New York's, and fewer of its residents live in poverty. These general demographic and economic factors are reflected in the AIDS patient groups in each city and have influenced local policy responses to the epidemic.

NEW YORK AND SAN FRANCISCO, DIFFERENCES IN RESPONDING TO AIDS

New York and San Francisco have responded differently to the AIDS epidemic in the amount of money spent, the distribution of these funds among programs, the length of hospital stays of AIDS patients, and the array of services available. Initial policy attention, influenced by the predominant interest in controlling health care costs in this country, was directed at the cost of care for AIDS patients in the two communities.

Precise estimates of public spending on AIDS programs during the early years of the epidemic are difficult to assess, particularly in New York, where AIDS expenditures were not tracked and programs were split among several city agencies. These figures are therefore less reliable. In addition, figures describing the amount of public money spent on AIDS do not always include the local share of Medicaid funds spent at nonpublic hospitals. Thus, it is important to recognize not only the politically sensitive budget process in which these figures are often used, but that the figures may not be strictly comparable from year to year or from one city to another. Nevertheless, a sense of the magnitude of the resources devoted to AIDS can be ascertained from agency estimates of their own expenditures.

In 1985, the acting president of the New York City Health and Hospitals Corporation (NYCHHC, the municipal hospital system) estimated that $30 million was spent on inpatient health care delivery for AIDS patients in this public hospital system during fiscal year (FY) 1985. During this time, the New York City Department of Health expended an additional $1.1 million on AIDSrelated activities. These consisted mainly of disease surveillance and epidemiologic investigation, health education, and laboratory services. Also in New York, the Human Resources Administration spent $600,000 for social services for persons with AIDS. In total, AIDS expen

ditures of approximately $32 million have been identified for New York during FY 1985, but this fails to include public funds used to subsidize indigent care at private hospitals and a variety of other AIDS-related expenditures.

Expenditures of an estimated $25 million dollars for AIDS-related activities were made in San Francisco during FY 1985. The bulk of these funds ($17 million) was for inpatient care, which was financed primarily through private insurance and the Medi-Cal program. The remaining $8 million was administered by the San Francisco Department of Public Health (SFDPH), more than 90% of which was derived from local taxes. Approximately 17% of these funds went for disease surveillance and epidemiologic investigations, 55% for assessments and medical care, 11% for social support services and housing, and 17% for public education and administrative coordination.8

As the epidemic grew, the expenditure of funds significantly increased in New York. An attempt was made by the New York City Office of Management and Budget to analyze the total amount and distribution of AIDS-related funds during FY 1986. Total spending in New York City was projected to range from $110 million to $148 million. New York City's tax levy support was estimated at approximately 38% of these figures. This included the city's contribution to inpatient medical care provided in municipal and voluntary hospitals, public health education, epidemiologic surveillance, and contracts for social service programs. The remaining balance included all other sources of reimbursement including federal and state funds and private insurers."

This compares to a projected $37 million for total AIDS spending in San Francisco during this time (based on estimates),8.10 Approximately 24% of this sum ($8.8 million) was derived from local tax revenues and was distributed to a similar range of activities as in the previous year. The remaining funds were primarily drawn from private insurers (37%) and the federal and state governments (18% and 13%, respectively).

By estimating the number of living persons with AIDS in each city during FY 1986, we calculated a per capita expenditure per AIDS patient: approximately $22,000 in San Francisco and $36,000 in New York.

A major part of overall costs in both cities is for inpatient care. The average daily cost of care in their municipal hospitals is quite similar, with estimates of $773 per day in San Francisco and $800 per day in New York--less than a 4% difference.9.1 Yet the charges per admission are quite different: $20,320 in New York and $9,024 in San Francisco. As Table II indicates, the key difference in these charges is the number of days spent in the hospital.

The average length of stay for an AIDS patient in New York is more than twice as long as that in San Francisco. TABLE II. Hospitalization of AIDS Patients In Municipal Facilities, 1984: New York City and San Francisco New York City San Francisco

nous (IV) drug users in that city, compared to the predominance of gay men in San Francisco. Female IV drug users and women infected by their sexual partners who are IV drug users represent a much larger proportion of AIDS cases in New York than in San Francisco.

AIDS cases also vary significantly by race and risk group. San Francisco's AIDS patients are more likely to be white, whereas New York's are more likely to be black or Hispanic. This reflects general demographic differences in these cities. Compared to all AIDS patients in the US, patients in San Francisco are much more likely to be homosexuals, whereas patients in New York consist of a larger proportion of IV drug users.

Heavy incidence among IV drug users affects another patient group-children. In New York, where IV drug use and sharing of contaminated needles is more common than in the rest of the country, 79% of children with AIDS were presumably infected during pregnancy by mothers who were either IV drug users themselves or who had been infected by IV drug users.16 The proportion of IV drugrelated AIDS cases among children is likely to rise because of the continued spread of AIDS among drug users and the decline in the number of cases transmitted through contaminated blood and blood products (as a result of improved screening of the nation's blood supply).

Two patient groups remain hospitalized longer than others-IV drug users and children with AIDS. Both groups are concentrated in New York City. There have been 2,570 AIDS cases among IV drug users and 166 cases of pediatric AIDS reported in New York City through 1986. This represents 52% and 40% of the nation's cases in the respective groups. Only 33 IV drugrelated and seven pediatric cases were reported in San Francisco during this time. (The figures for both cities do not include approximately 8-13% of cases among homosexual or bisexual men who also report using IV drugs.)

The municipal hospitals in New York are overwhelmed with IV drug users, a group which comprises 60% of all AIDS patients hospitalized there. These patients are generally indigent, have poor underlying health status, have fewer sources of social support, and are more likely to be homeless than other patient groups. The primary AIDS diagnosis for many IV drug users is Pneumocystis carinii pneumonia (PCP). In general, this opportunistic infection is more debilitating and requires longer and more frequent hospital stays than other AIDS-related conditions, the most common of which is Kaposi's sarcoma, which is often treated on an outpatient basis. In a study of AIDS patients at San Francisco General Hospital (SFGH), the average length of stay for AIDS patients with Kaposi's sarcoma was 7.6 days, compared to 18.1 days for those with PCP. Furthermore, during 1984, Kaposi's sarcoma accounted for 13.3% of the total AIDS admissions at this hospital, as compared to only 3.5% of AIDS admissions in the public hospitals in New York City. All these factors increase the likelihood of a longer hospital stay and an increased direct cost of care for AIDS patients in New York. Hospitalization of children with AIDS has not been a major problem in San Francisco, since there have been so few cases. New York, by contrast, has had to address issues arising from pediatric AIDS, including the unusually long length of stay for these patients. As discussed above,

more than three quarters of the pediatric AIDS patients in New York have parents who are or have been IV drug users. Many of these parents may be ill, and some have died from AIDS. In addition, there is a lack of alternative facilities to care for children outside the hospital, and it has been extremely difficult to place children with AIDS in foster care. Again, this is consistent with the situation confronting adult AIDS patients, who, in New York's tight housing market, also face difficulty in finding available space in nursing homes, and thus are likely to have prolonged hospital stays. A one-day survey conducted in New York's municipal hospitals found nine pediatric AIDS patients awaiting nonhospital placement. All were homeless, and all were candidates for home care. Three of these patients had been on an alternate level of care status (ie, those patients who no longer require acute care hospital services and are ready for placement in nonhospital settings) for 12, 14, and 18 months. Thus, overall, the AIDS epidemic is quite different in New York than in San Francisco. New York is confronted with approximately three times the number of cases, and the patients are more heterogeneous than those in San Francisco with respect to race, age, sex, income, and major risk factors. In effect, the differences in scale and diversity of patients in New York, when compared to San Francisco, present local policy makers with two quite different epidemics of the same disease.

Preexisting Social and Political Structures. The local responses to the epidemic did not occur in a vacuum. They grew out of and were influenced by the social and political structures already existing in each community. Each city's historical development-in size, number, and type of institutions providing health services; methods of payment for health care; and the roles of public agencies--set the stage for what could happen in the epidemic. We differentiate two components in the preexisting social and political structures: one is related to the community and its institutions, especially the structure of health and human service organizations; the other is related to the social and political structures of those persons in the major risk groups.

The scale and complexity of health and human service organizations is far greater in New York than in San Francisco. The difficulties associated with a larger scale in New York range from the simple logistics of epidemiologic case monitoring to the institutional complexities of developing a response in 11 acute care municipal hospitals and over 70 other private and voluntary hospitals scattered unevenly throughout five boroughs. This contrasts with the one city health care facility and 13 other hospitals in San Francisco. In addition, the existence of a single medical school in San Francisco has fostered a relatively unified response to the epidemic, while in New York there is a history of competition in selected areas among the seven medical schools, making a similar response much more difficult.

The cities are similar in having a complex role in the financing of health care for part of their populations. These roles have been illuminated by the AIDS epidemic and the enormous resources needed to cope with it. One of the major differences in the two cities is how local tax monies have been allocated. One report estimated that

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