Collar pictured with three of her seven children in their Morris Heights apartment.
Laura Collar fidgeted in place outside the fourth-floor courtroom in the Bronx Housing court on a Friday morning in September. The 34-year-old tenant waited to inform her landlord’s lawyer that she’d been granted another 12 days extension before they evict her from the Morris Heights apartment in the West Bronx where she lives with her five children.
A row of piercings protruded from Collars furrowed brow as she thought about what to do next. She had just 12 days to figure out why the New York City Human Resources Administration (HRA) had stopped paying her rent. Twelve days to figure out where she and her children would go if she could not convince the city agency to start paying again.
“HRA approved my case,” Collar said, digging through the mound of paperwork and documents in her tattooed arms that she has accumulated throughout her case. “How am I supposed to make sure they are paying?”
Her apartment is one of those currently subsidized by a city program called the Family Eviction Prevention Supplement (CITYFEPS). The program was created in 2014 to help families in homeless shelters move into permanent housing or low-income families facing eviction avoid becoming homeless.
HRA agrees to pay a substantial portion of the family’s monthly rent — $1,560 in Collar’s case — as long as the family continues to qualify for the program. However, families frequently struggle to find appropriate housing even with this supplement. CITYFEPS is currently being rolled over into the new Family Housing and Eviction Prevention Supplement (CityFHEPS) program, which combines a number of rental subsidy programs into a single program.
The program, designed to keep families off the street, is now the cause of some evictions. When Collar’s landlord filed paperwork to evict her in July, HRA was over $6,000 behind on its share of Collar’s rent. Court records also show that the agency failed to make any payments in August and September.
This wouldn’t be the first time that Collar was evicted from the four-bedroom, three-bath, apartment because of an HRA mix-up. In October last year, she lost the apartment for a month when HRA fell over $16,000 behind on her rent, according to court documents. HRA had been sending checks to the wrong management company, and by the time the agency resolved the issue, Collar’s landlord had moved forward with the eviction.
Having been told that the case should be resolved in a week, Collar and her children moved into her mother’s Staten Island house, where nearly 20 family members shared five bedrooms. It wasn’t until November of that year that the family moved back into their apartment.
“It was traumatic,” Collar said. “We were cramped up in the house and [my children] missed school.”
But, if it’s HRA who failed to pay, why evict Collar? Because landlords have no other option to recuperate their rent, said an attorney who asked that his name not be used to avoid unfavorable treatment from HRA in future cases.
“This court has no jurisdiction on city payments,” explained the attorney, who has 23 years of experience in housing court. Unlike the federal housing voucher system called Section 8, the city does not appear as a third-party on the lease under programs like CITYFEPS, meaning that landlords have no legal recourse against the city.
A tenant can theoretically do everything right, but if HRA makes a mistake or is late to process paperwork, the landlord’s only option is to file for eviction and let the tenant deal with HRA.
The burden of managing her own case makes it impossible for Collar to lead a normal life. She keeps a binder full of documents related to the various programs she relies on, and spends multiple days a week in the HRA office.
Collar folding her children’s clothes.
“I could make a house in there,”Collar said, referring to Bronx Housing Court. “I go every day. I’m not used to this, I never had to depend of welfare before (moving to New York City). It’s just crazy.”
Twelve days after her extension Collar was due back in court. However, she still had no answers from the city.
“I don’t know what is going to happen to me,” Collar said in a phone interview. “ I don’t have proof that (HRA) is going to pay…. They’re trying to put two and two together, but they’re at a standstill.”
Meanwhile, Collar’s case moves on. Her last-ditch attempt to get answers in person from HRA meant she missed her day in court. Normally, Collar would have defaulted and she would have lost her motion. The stay of eviction proceedings would have been lifted and the marshall would have proceeded with the eviction.
However, it was the first day of Rosh Hashana and Collar got lucky. Because of the holiday, the court decided to forgive no-shows and simply pushed her case back another 15 days.
Fifteen days for Collar to find answers. Fifteen days for her to make plans if not.
The tiny waiting room of Dr. Andrea Littleton’s Bronx office was overflowing by the time she arrived in the late morning. Some patients sat in stony determination while others paced impatiently in the hallway — clawed by addiction and anxious for the relief that Littleton could provide. One dozed, slouched in his chair beside the inner door that leads to the claustrophobic medical office where, twice a week, Littleton prescribes buprenorphine to opioid addicted patients.
Littleton has worked for 15 years at Care For The Homeless, a non-profit medical center that provides medicine-assisted treatment for the homeless who suffer from opioid addiction. Medicine-assisted treatment is considered the “gold standard” for opioid use disorder, and the medications used are typically either methadone or buprenorphine (also known as Suboxone).
Littleton’s office, situated in Hunts Point in the Bronx, is at perhaps the very heart of New York’s opioid epidemic. In 2018, the overdose deaths per capita in Hunts Point was over 2.5 times the city-wide average, according to a 2019 report from the Department of Health and Mental Hygiene.
Only Staten Island ranks above the Bronx in terms of number of opioid deaths per capita. However, treatment in the two boroughs looks very different.
“Even though both [Staten Island and the Bronx] are epicenters of the opioid epidemic,” said Littleton. “There are far more [buprenorphine] prescriptions being written in Staten Island, but not necessarily more providers.”
A 2018 research report confirms Littleton’s observation: patients in Staten Island receive buprenorphine 3.6 times more frequently than those in the Bronx. Patients in the Bronx are, likewise, 3.2 times more likely to receive methadone. All this while the Bronx has nearly three times as many physicians who are able to prescribe buprenorphine, according to federal data.
“[Buprenorphine] certainly offers more freedom and flexibility,” said Littleton. Some patients refer to methadone treatment as “liquid nails,” she said. “They can’t go anywhere else or have a job or travel even because they have to be there every day.”
Having to show up at the clinic every day to receive treatment is not only a burden on methadone patients. The clinic itself can be stressful. “There is also a lot of stigma,” said Littletone. “People know where [the clinics] are, they don’t feel safe there. And it’s triggering because there might be someone selling right there in the waiting room or right outside the door.”
Finally, the medication itself makes a difference. Buprenorphine lacks some of the negative side-effects that methadone is notorious for. On Buprenorphine, patients “can go about their day feeling normal, they don’t feel high, they don’t feel loopy, they just feel normal,” Littleton added. “Where as a lot of people on methadone feel high, they can’t think clearly, they feel like they can’t maintain their normal activities.”
In 2018, Canadian researchers published guidelines recommending buprenorphine as the preferred first-line treatment for opioid addiction, only switching to methadone for patients who respond poorly to buprenorphine or who express a strong preference.
Salvador, who asked that his last name not be used, is a big man with tired eyes and a tidy grey beard. He is one of those patients who depends on the buprenorphine he gets from Littleton every week.
“When I have these,” he said holding a zip-lock bag containing week’s supply of individually-packaged pills, “I don’t even think about [heroin]. But without them, I have to use.”
But that reliance on Littleton can spell disaster if she is not available.
Salvador had been clean for nearly two months, he said. But, when Littleton had been away the prior week, he hadn’t been able to find another prescriber. Salvador had gone back to heroin to satisfy his cravings.
Salvador had been clean for nearly two months.
“You abandoned me,” Salvador sulked jokingly. But the damage done is no laughing matter.
Now, Salvador will have to endure the unpleasant, and potentially dangerous, process of reinitiating his treatment. Buprenorphine includes naloxone (the active drug in Narcan) which can precipitate withdrawl if patients start treatment too soon after using. Complications from withdrawl, including dizziness and asphyxiation can be severe. He will have to start the first stages of withdrawl from the three baggies of heroin he snorted that morning before he can take his first pill.
Despite the success of buprenorphine, getting access to treatment still remains a problem for many Bronx residents. In February 2019, the New York State Department of Health released new guidelines encouraging SAMHSA-approved doctors to “start prescribing buprenorphine, and if already prescribing to increase the number of patients under care.”
But the question remains, why do these two boroughs, facing the same crisis receive such different modalities of treatment?
From the start, buprenorphine treatment catered to affluent white patients who did not want to be associated with the stigma of receiving treatment at methadone clinics.
“In the case of opioids,” writes Dr. Helena Hansen, Associate Professor of Psychiatry at NYU Langone. “Addiction treatment itself is being selectively pharmaceuticalized in ways that preserve a protected space for White opioid users.”
Buprenorphine was developed in 1966, but failed at catch on until it’s resurgence 30 years later, which, argues Hansen, coincides with the rise of opioid use in white communities. When buprenorphine was legalized as a treatment for opioid addiction, in the 2000 Drug Addiction Treatment Act (DATA 2000), a group of lawmakers who opposed the DATA 2000 bill foresaw that it would “consign ‘hard core’ users to the existing and widely recognized as failed system.”
Sure enough, as the opioid epidemic exploded in in New York City, buprenorphine was increasingly available only to those who could afford private insurance. Between 2009 and 2016, the number of buprenorphine prescriptions on private insurance increased by over 4.5 times, while the number on medicaid fell nearly by half. In 2016, over three-quarters of buprenorphine prescriptions were paid for by private insurance.
While the city’s $60 million HealingNYC initiative has shown modest success in reducing the number of overdoses city-wide and increasing buprenorphine prescriptions, it hasn’t been enough in the Bronx, where opioid deaths continue to increase.
“It’s supply and demand,” said Dr. Tiffany Lu, Medical Director of the Montefiore Buprenorphine Treatment Network. “The Bronx does not have enough capacity because it historically had the burden of the disease.”
And while money for outreach and education programs are essential, the greatest hurdle in the Bronx is finding physicians like Littleton and Lu who are able and willing to prescribe buprenorphine.
Under DATA 2000, prescribers are required to obtain special wavers to even be allowed to prescribe the treatment.Completing the requirements can be an arduous burden to already-overextended care providers. Doctors are required to attend eight hours of training and clinicians (including nurse practitioners and physicians assistants) are required to take 24 hours of training.
However, once a physician has a waiver to prescribe buprenorphine, they are only allowed to treat 30 patients in their first year. This cap increases to 100 and 275 patients in their second and third year, but the cap still contributes to the shortage of access to buprenorphine prescribers, according to a letter by the New York State Department of Health.
Some physicians question the need for a waiver at all. “[Buprenorphine is] a schedule III drug,” said Littleton. “It’s less addicting substance than opiates, but prescribers are able to provide [opiates] at will without training.”
A bipartisan bill, the Mainstreaming Addiction Treatment Act of 2019, has been introduced to both the House and Senate. The bill would allow physicians to prescribe buprenorphine without a DEA waiver.
Still, even some physicians who interact with opioid-addicted patients may be reticent to start buprenorphine treatment.
Rikin Shah, Chief Resident at St. Barnabas Hospital in the Bronx, is not waivered to prescribe buprenorphine. In the emergency department, where he typically encounters such patients, initiating buprenorphine treatment would require counseling and monitoring, and in a 200-bed room, where other patients require attention, he doesn’t feel that starting new medication is a good idea.
“We may not be able to monitor how they are doing on the medication, whether they need changes in doses, or if they are having any adverse drug/side effects,” Shah wrote in an email. “This is dangerous for our patients.”
Emergency departments are not the appropriate venue for starting addiction treatment, Shah continued, and promoting them as such might lead to an abuse of their resources.
“We need to optimize our resources to taking care of the sickest patients and to those who are at risk of losing their life…. More often than not, although withdrawal symptoms are uncomfortable, they are not life threatening,” Shah’s email continued. “Emergency departments become in a way suboxone/methadone clinics as patients can find coming to the [emergency department] the most convenient way to treat their withdrawals.”
While some physicians may be reticent to provide treatment for medical reasons, their own stigma towards addiction may be just as big a barrier.
Littleton in her Bronx office.
“Lack of knowledge and fear of the unknown are big factors, and the other is stigma,” said Littleton. “People get concerned about [treating] the patient who has an addiction and what that means.”
Some providers worry that treating addiction is like “opening up a Pandora’s Box,” said Littleton. They think “if we talk about [your addiction] we’re going to talk about all that trauma that you had as a child and I don’t have the resources to give you the support to deal with that, I don’t have access to good mental health [services] that I can connect you with… and I can only address so many things in 15 minutes.”
Littleton walks through these traumas with almost every patient she sees. Raymond, who had recently been released from Rikers on drug charges and asked that his last name not be used, told Littleton that he’d been using speedballs (a mixture of heroin and cocaine) since age 11, when his father introduced him to the dangerous cocktail.
Littleton didn’t blink when Raymond said that he’d had a relapse. Like Salvador, he relied on heroin to tide himself over after leaving prison, before coming for treatment. Instead of discharging patients who relapse, punishing “dirty urine” by terminating treatment, Littleton stresses the importance of patience and understanding.
“Many [patients] will have a relapse, and that’s okay,” she said after seeing Raymond out. “Addiction is a spectrum… [and] we do them a disservice by discharging them.”
Once physicians can normalize their understanding of addiction, and see the effect of treatment, those fears and stigmas will fade, Littleton said. “It’s just understanding that… anybody can have opioid use disorder and have perfectly normal lives otherwise.”
Treating opioid addiction is no simple task, and buprenorphine is not a silver bullet, said Lu, the doctor from Montefiore. But, access and supply are the only way to get this life-saving drug into more hands.
“[Being trained to prescribe] buprenorphine is the lowest threshold that anyone can do.” Lu said. “My message to all my colleagues is: please do something, get yourself trained, offer it, because if you don’t offer it you’re basically saying you’re not interested in treating the disease in any way.”
The Hunts Point peninsula sticks out of the South Bronx mainland like a thumb. Defined by the East River to the south and the Bronx River to the north, this maze of scrap yards and warehouses is severed from the rest of the Bronx by the Bruckner Expressway.
However, hidden among the twisted metal and industrial rubble, behind a long concrete wall, is the largest food market in the world. Entry is $3 and all are welcome, but few apart from the industrious obsessives who run the market ever come. Even they are increasingly rare.
Mike Karan arrived at 6 p.m., four hours before the market officially opened. He followed his nightly ritual, weaving through the market’s 1 million square feet of warehouses, loading docks, and sales rooms, inspecting each seller’s inventory. A 30-year veteran buyer, Karan moved fast for a man pushing 50.
“There is no walking,” Karan shouted between breaths. “No eating. No sleeping. No rest.”
The market is organized into four long parallel rows of warehouses. Inside, tidy towers of produce line the walls. Boxes of Ecuadorian plantains from Ecuador sit across from bins of Texas watermelons from Texas. Over $2 billion worth of fruits and vegetables pass through the gates every year, according to the market’s website, feeding over 22 million people in a 50-mile radius around the market.1 However, all of the action happens in the middle of the night.
At midnight, Karan crouched in a frigid box car, examining blackberries. He investigated each row of boxes, peering into each plastic container with his iPhone flashlight, and tasting as he went. The plump berries were still reddish and tart. Some were touched by mold (a “gift” in market lingo). “The best are $32 a box, these are $12,” he explained, and at that price, a deal too good to pass up. Karan scribbled “SOLD” on a paper attached to the boxes and hurried on.
As Karan snaked through the warehouse, squeezing, peeling, smelling, tasting every item along the way, he created a mental inventory of the night’s offerings. Plump sweet-O pluots (a plum/apricot hybrid) from California with speckled yellow skin looked delicious but were too sour. Mandarin oranges from Peru peeled easily, but didn’t have a sticker. “Customers want to see a sticker,” Karan said.
Outside on the loading docks, the hot air carried the sour smell of composting produce. Errant tomatoes and apples, the casualties of hurried transport, lay crushed into the concrete. Workers in reflective vests, hauling pallets stacked with onions and cucumbers, weaved between one another on the narrow walkway. A novice might stay pressed up against the wall for fear of joining the tomatoes crushed underfoot. Karan walked down the middle of the dock, allowing the traffic to make way for him.
After making his selection from each seller, Karan headed for the sales office to complete his purchase. The entire process generally takes around eight hours, often keeping Karan at the market past 2 a.m.
Each of the market’s 35 sellers has at least one glass-enclosed sales office stationed along the loading dock. Rows of salesmen (they are all men) sit behind raised counters, punching orders into the computers in front of them and cracking wise to anyone within earshot.
“This is what I call jack-off hour,” a salesman named Joey Mush grinned through his walrus mustache. “Because all the customers are jack-offs.” A menagerie of gold charms, jumbled together on a single chain around his neck, jangled as he laughed at his own joke.
Mush is not his real last name. He doesn’t like people to know his real last name. And he’s particular about the pronunciation: “Not ‘moosh,’” he instructed, “mush, like mushroom.” The pronunciation make sense since Mush is the resident mushroom specialist at A&J Produce, one of the largest sellers in the market.
Mush has been at the market for over 40 years, first working with his father, then running his own business, before coming to work at A&J Produce. Like Karan, Mush is a total obsessive. His mind is constantly churning through data. Recently, Trump’s tariffs on Chinese imports had caused a shortage of peeled garlic. This week, the price of broccoli had spiked during the gap between the Canadian and Californian growing season.
The camaraderie and teasing between salesmen and buyers like Mush and Karan belies the gravity of their relationships. A single transaction can total thousands of dollars.Trust and reputation mean everything to these men.
But, just as necessary as characters like Mush and Karan are, they are also quickly becoming an anachronism.
These days, over 60% of orders that A&J Produce receives are placed over the phone for delivery, according to co-owner John Tramutola, Jr. These tele-buyers rely on Tramutola and his team to ensure quality, instead of visiting the market to inspect the goods in person. “Those days are over,” Tramutola said. “Nowadays everyone wants to stay in bed.”
And as the current salesmen age out of the industry, it isn’t clear who will replace them. “This isn’t a job for the young,” said Anthony G, a salesman at AJ Trucco, another larger seller in the market. “What young person is going to spend all night here?”
Whoever comes next, they will have to be just as obsessed and just as tough. “This is my life,” Mush said, reflecting on his career, before adding with a chuckle, “and I lament every night.”
