INSTITUTE
OF MEDICINE
AS
A PROFESSION:
Physician Advocacy Conference
November 18-19, 2010
Dr. Deborah A. Frank
Professor of Pediatrics, Boston University School of Medicine
Founder and Principal Investigator, Children’s HealthWatch
Founder and Director, Grow Clinic for Children, Boston Medical Center
WE SIT BESIDE THE GIANTS ON
WHOSE SHOULDERS WE STAND
How Did I Get Here?
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You were Either Hospital or
Orphanage
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How Did I Get Here?
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Riding Two Advocacy Horses
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Trouble with Women is They Take
Everything Personally!
Children’s HealthWatch
Collect data in
five urban,
safety-net
hospitals
Produce
scientific
research
that is original
and timely
Share evidence
with state and
national partners
to inform policy
choices
Children’s HealthWatch
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Deborah A. Frank, MD (Boston)
Maureen Black, PhD (Baltimore)
John Cook, PhD (Boston)
Mariana Chilton, PhD (Philadelphia)
Carol Berkowitz, MD (Los Angeles)
Patrick Casey, MD, MPH (Little Rock)
Diana Cutts, MD (Minneapolis)
Alan Meyers, MD, MPH (Boston)
Stephanie Ettinger de Cuba, MPH (Boston)
Timothy Heeren, PhD (Boston)
Sharon Coleman MPH (Boston)
Megan Sandel MD (Boston)
Zhaoyan Yang, MS (Boston)
Why Watch Children Birth to 3?
Official Poverty Rates by Age
Group
25%
22%
20%
18%
14%
15%
10%
5%
0%
Chi l dr en Under A ge 6
Chi l dr en A ge 6 or Ol der
A dul t s 18-64
Data Supports Sensitive Period
Hypothesis
Sensitive Period Hypothesis: Insult during brain
growth spurt most likely to be irreversible
Poverty in early childhood has more severe and
lasting effects on later health, cognition, and
behavior than poverty at later ages
(Duncan,Ziol-Guest,Kalil, Child
Development,2010)
Food Insecurity
Limited or uncertain availability of
nutritionally adequate and safe foods
or limited or uncertain ability to
acquire acceptable foods in socially
acceptable ways
Source: USDA
Help Connect the Dots
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FOOD INSECURITY, HUNGER, AND MALNUTRITION
ARE ALL
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Child Health Issues
Adult Health Issues
Mental Health Issues
Educational Issues
Political Issues
Moral Issues
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CHANGES IN FAMILY SURVIVAL
RESOURCES RAPIDLY REFLECTED IN
HEALTH, LEARNING, AND GROWTH OF
YOUNG CHILDREN
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The Problem to Address:
Food Insecurity: Highest Since 1995
Overall, households with
children (<18) had nearly twice
the rate of food insecurity (21.3
percent) as those without
children (11.3 percent).
Families with the youngest children are
most at risk for food insecurity.
25.4 percent of households with children
under six are food insecure in the U.S.
That translates to 9, 647. 000 American
kindergarteners, preschoolers, toddlers,
and infants.
(USDA data,2009)
Puzzle of Poverty and Obesity
• Cyclical food deprivation/overeating
• Need to minimize per calorie cost
• Lack of access to fruits and vegetables in low
income neighborhoods
• Lack of opportunity for safe exercise in low
income neighborhoods
• ? Stress hormones
Real Cost of a Healthy Diet
Can parents afford to purchase healthy food?
$1.33
880 calories
$2.79
880 calories
Stop and Shop
Price Check
Sept 2010
Drewnowski 2004
Tight budgets limit food choices;
cheap calories provide little nutritional value.
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The cheap foods that make adults
fat starve children of absolutely
essential nutrients. Children who
do not receive protein and other
nutrients during early development
are damaged for the rest of their
lives.
Dr. Margaret Chan WHO
GROWN UP BRAINS NEED NUTRIENTS
TOO
brain
Help Connect the Dots
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Energy Insecurity and the Heat or
Eat Dilemma
Limited or uncertain access to home
heating or electricity
Moderately energy insecure:
received a letter threatening
utility shut-off in the last year
Severely energy insecure: actual
utility shut-off, at least one day
with no energy for heating or
cooling, or have used a cooking
stove as a heating source in the
last year
Effects of Energy Insecurity
Compared with infants and toddlers in
households that were energy secure, those in
households with just moderate energy
insecurity were:
• More than twice as likely to live in a food-insecure
household
• 79% more likely to be child food insecure
• 34% more likely to be reported in fair or poor health
• 22% more likely to have been hospitalized since birth
Housing Insecurity
Household is overcrowded, doubled up with
another family and/or has moved twice or
more in the last year
Effects of Housing Insecurity
Compared to children in families that are stably
housed, children in families who are housing
insecure are more likely to be:
• Food Insecure
• In poor health
• At risk for developmental delays
Economic
Hardship
Housing Insecurity
Food Insecurity
Energy Insecurity
Scoring: Cumulative Hardship Index
• Score of 0, 1, or 2 for each hardship
0= Secure
1= Moderately insecure
2= Severely insecure
• Total possible score of 6
0= No Hardship
1-3= Moderate Hardship
4-6= Severe Hardship
Majority of Families Experience
Hardship (N=7,141)
• 37% (N=2,640) No hardship
• 57% (N=4,075) Moderate hardship
• 6% (N=426) Severe hardship
• Increasing scores on the cumulative hardship
index, indicating worsening material conditions
What Do We Mean by Child
Wellness?
• Good or excellent
health
• No hospitalizations
• Not at
developmental risk
• Not overweight or
underweight
Results: Bivariate (N=7,141)
Hardship and Wellness
Outcome
No
Moderate Severe
Hardship Hardship Hardship
(N=2640) (N=4075) (N=426)
Wellness
46%
42%
35%
(N=1209) (N=1712) (N=148)
(p<0.0001)
Multivariate Logistic Regression I
Children with severe vs. no hardship
had AOR
0.66 (95% CI 0.52, 0.84, p=.001)
of “wellness” after controlling for
covariates
Multivariate Logistic Regression II
Children with severe vs. moderate
hardship had AOR
0.74 (95% CI =0.59, 0.93, p=.01)
of “wellness” after controlling for
covariates
Multivariate Logistic Regression III
Children with moderate vs. no hardship
had AOR
0. 89 (95% CI =0. 80,0.99, p=.01)
of “wellness” after controlling for
covariates
Can We Fix It?
Emergency Fixes
EMERGENCY FOOD NETWORK
Is That All That Can Be Done?
Fixing Hunger and Hardship
Long-Term is a
Political Issue
Which Programs Promote Healthy
Height and Weight?
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WIC
CHILDCARE FEEDING
LIHEAP
HOUSING SUBSIDY
Which Programs Decrease Poor
Health/Hospitalizations?
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WIC
SNAP
LIHEAP
CHILDCARE FEEDING
Which Programs Decrease
Developmental Risk?
• SNAP
• WIC
• HOUSING SUBSIDIES
Riding Two Advocacy Horses
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PERINATAL EFFECTS I
• Fetal Hypoxia
• Increased risk spontaneous abortion
and still birth
PERINATAL EFFECTS II
• Low Apgars
• Depressed
– Birth Weight
– Head Circumference
– Length
• ? Congenital Abnormalities
POSTNATAL EFFECTS
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Increased risk SIDS
Attention Deficits
Lower IQ
Increased risk exposed child will grow up to be
adult addict
• Sleep problems
Stone et. al. Behav Sleep Med 7:196-207, 2009
Buka et. al. Am J Psychiatry 160:1978-84, 2003
South Carolina Judges Speak
• “Now this little baby is born with crack, when he is
seven year old, they have an attention span that
long. They can’t run. They just run around in class
like a little rat. Not just black ones. White ones too.”
(State v. Collins Pickens County 1991)
• “Sick and tired of these girls having these bastard
babies on crack cocaine.” (State v. Crawley 1994)
Buying Into Stigma
Jeopardizes Mothers and
Children
atlanta meeting
FERGUSON V CITY OF CHARLESTON
• Health professionals selectively screened
urine of medically indigent obstetric for
cocaine
• Reported positive results to police
• Pregnant and post-partum women (all but
one African American) arrested for possession
of an illegal drug, delivery of drugs to a minor,
or child abuse
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FERGUSON VS CITY OF
CHARLESTON
SUPREME COURT RULED POLICY
UNCONSTITUTIONAL 6-3 IN MARCH 2001
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BUT NOW THERE ARE 40 NEW
PROSECUTIONS IN ALABAMA
ALONE
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Prevalence of Food Insecurity in the United States, 1999–2008.
Seligman HK, Schillinger D. N Engl J Med 2010;363:6-9.
Children’s Share of Domestic
Federal Spending
From 1960 to 2008 children’s share of federal
domestic spending declined from 20% to 15%
WHY BOTHER?
When You Can’t Do Anything Else:
Document!
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Thank You!
www.childrenshealthwatch.org
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