INSTITUTE OF MEDICINE AS A PROFESSION: Physician Advocacy Conference November 18-19, 2010
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Transcript of INSTITUTE OF MEDICINE AS A PROFESSION: Physician Advocacy Conference November 18-19, 2010
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INSTITUTE OF MEDICINE
AS A PROFESSION:
Physician Advocacy ConferenceNovember 18-19, 2010
Dr. Deborah A. FrankProfessor of Pediatrics, Boston University School of MedicineFounder and Principal Investigator, Children’s HealthWatch
Founder and Director, Grow Clinic for Children, Boston Medical Center
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WE SIT BESIDE THE GIANTS ON WHOSE SHOULDERS WE STAND
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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!
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Children’s HealthWatch
Collect data in five urban, safety-net hospitals
Produce scientific research
that is original and timely
Share evidencewith state and national partners to inform policy choices
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Children’s HealthWatch• 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)
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Why Watch Children Birth to 3?
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Official Poverty Rates by Age Group
22%
18%
14%
0%
5%
10%
15%
20%
25%
Chi ldr en Under Age 6 Chi ldr en Age 6 or Older Adults 18-64
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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)
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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
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Help Connect the Dots
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FOOD INSECURITY, HUNGER, AND MALNUTRITION ARE ALL
– 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 Families with the youngest children are most at risk for food insecurity.most at risk for food insecurity.25.4 percent of households with children 25.4 percent of households with children under six are food insecure in the U.Sunder six are food insecure in the U.S. That translates to 9, 647. 000 American kindergarteners, preschoolers, toddlers, and infants. (USDA data,2009)
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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
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Real Cost of a Healthy Diet
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Can parents afford to purchase healthy food?
$1.33 $2.79880 calories880 calories
Tight budgets limit food choices; cheap calories provide little nutritional value.
Drewnowski 2004
Stop and Shop Price Check Sept 2010
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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
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brain
GROWN UP BRAINS NEED NUTRIENTS TOO
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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
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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
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Housing Insecurity
Household is overcrowded, doubled up with another family and/or has moved twice or
more in the last year
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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
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Economic Hardship
Food Insecurity
Housing Insecurity
Energy Insecurity
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Scoring: Cumulative Hardship Index
• Score of 0, 1, or 2 for each hardship0= Secure1= Moderately insecure2= Severely insecure
• Total possible score of 60= No Hardship1-3= Moderate Hardship4-6= Severe Hardship
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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
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What Do We Mean by Child Wellness?
• Good or excellent health
• No hospitalizations• Not at
developmental risk• Not overweight or
underweight
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Results: Bivariate (N=7,141) Hardship and Wellness
OutcomeOutcome
No No HardshipHardship
(N=2640)(N=2640)
Moderate Moderate Hardship Hardship (N=4075)(N=4075)
Severe Severe Hardship Hardship (N=426)(N=426)
WellnessWellness(p<0.0001)(p<0.0001)
46% 46% (N=1209)(N=1209)
42% 42% (N=1712(N=1712))
35% 35% (N=148)(N=148)
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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
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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
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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
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Can We Fix It?
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Emergency Fixes
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EMERGENCY FOOD NETWORK
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Is That All That Can Be Done?
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Fixing Hunger and Hardship Long-Term is a Political Issue
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Which Programs Promote Healthy Height and Weight?
• WIC• CHILDCARE FEEDING• LIHEAP• HOUSING SUBSIDY
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Which Programs Decrease Poor Health/Hospitalizations?
• WIC• SNAP• LIHEAP• CHILDCARE FEEDING
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Which Programs Decrease Developmental Risk?
• SNAP• WIC• HOUSING SUBSIDIES
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Riding Two Advocacy Horses
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PERINATAL EFFECTS I
• Fetal Hypoxia
• Increased risk spontaneous abortion and still birth
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PERINATAL EFFECTS II
• Low Apgars• Depressed
– Birth Weight– Head Circumference– Length
• ? Congenital Abnormalities
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POSTNATAL EFFECTS
• 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, 2009Buka et. al. Am J Psychiatry 160:1978-84, 2003
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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)
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atlanta meeting
Buying Into Stigma Jeopardizes Mothers and
Children
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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.
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Children’s Share of Domestic Federal Spending
From 1960 to 2008 children’s share of federal domestic spending declined from 20% to 15%
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WHY BOTHER?
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When You Can’t Do Anything Else: Document!
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Thank You!www.childrenshealthwatch.org
88 E. Newton Street | Vose Hall 4th Floor | Boston, MA 02118 | tel: 617.414.6366 | [email protected]