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Be Well

Should Doctors Screen Children for Poverty?

by Douglas Jutte, MD  

As a practicing pediatrician, I have always asked my patients’ parents plenty of questions. Have you child-proofed your home? Is she getting enough milk and fresh fruits and veggies? Do you have the right sized car seat?

Now, based on new recommendations from the American Academy of Pediatrics (AAP), doctors like myself may be asking, “Do you have difficulty making ends meet?"

The new AAP policy statement recommends that pediatricians screen for poverty and other social determinants of health during doctors’ visits. In the United States, one in five children lives in poverty. Being poor carries serious lifelong health effects, including increased risk of type 2 diabetes, asthma, and obesity. And poverty and its stresses can hardwire the brains of young children, creating long-term consequences.

Learning about patients’ lives beyond clinic walls can help doctors provide better care. But the AAP thinks doctors should go a step further than screening for poverty and linking families to community resources that can help them secure more stable housing or nutritious food. It also recommends that medical professionals advocate for public policies that fight poverty and protect the health of low-income children and their families—such as expanded pre-K, a living wage, or more funding for nutrition programs.

Most exciting to me in my current work with the Build Healthy Places Network are the AAP's specific recommendations that pediatricians as a group “support policy measures that improve community infrastructure, including affordable housing and public spaces” and, as individuals, collaborate directly with community organizations, including those in the community development sector.

I often saw the impacts of poverty on my young patients’ health. One child’s recurrent pneumonia that we just couldn’t kick was due in part to a broken bedroom window the landlord wouldn’t fix. And I could refer patients with complex medical problems to nearby world-class specialists, but they often couldn’t make the appointment as a result of unreliable buses and no access to a car.

As Jack Shonkoff, director of the Center on the Developing Child at Harvard University, explained at our recent Network Commons, “The challenge is you can’t write a prescription for a 10-day dose of eliminating poverty.” And in my own experience, I quickly realized at my very first job—in a low-income community clinic—that over two decades of education and top-notch medical training had not prepared me to handle the real health challenges my patients faced.

Even though I realized that what my patients often needed was a stable home, nutritious food, or better transportation to reach jobs and services, it wasn’t as commonplace to talk about poverty’s role in health and development. And it certainly wasn’t routine to screen for or take on responsibility for referral and follow up of these “non-medical” concerns, let alone be encouraged to reach out directly to community organizations.

But over the last decade, a dialogue about poverty’s health effects has grown within the medical community, and the AAP added “Poverty and Child Health” to its Agenda for Children platform in 2013. Shortly after, the Robert Wood Johnson Foundation Commission to Build a Healthier America issued a report highlighting major strategies to improve America’s health, particularly among young Americans, that extended beyond medical care, further bringing the social determinants of health to light.

Many pediatricians have been ahead of the curve for years. For example, the AAP report highlights the work of the National Center for Medical-Legal Partnerships, an effort founded by pediatrician Barry Zuckerman, that combines free legal services with medical services for low-income families. Pilot research has found that a lawyer’s help for patients fighting unfair evictions or navigating the social safety net can improve child health outcomes and reduce unnecessary emergency room visits.

All the work we do in reforming the health care system won’t have much of an effect if children and families still struggle to meet basic needs or live in neighborhoods unable to support healthy development.

The elephant in the waiting room, of course, is who pays for this. Currently, Medicaid only covers health care costs, reimbursing physicians only for the medical services they provide to a low-income population. But a promising development in South Carolina is tapping the state Medicaid funds to support home visiting, in which a nurse regularly visits a low-income family to help parents ensure their children’s healthy development and reduce later medical expenses. And in an important step, the "pay-for-success" initiative spearheading this novel cross-sector partnership also involves the state’s biggest insurer, Blue Cross Blue Shield.

However, I’d like to see the system go a step further and more routinely provide direct investments for health-improving infrastructure like those we’ve highlighted in our case studies on Stamford Hospital and the Vita Health and Wellness District and Children’s Hospital of Philadelphia’s participation in the new Community Health and Literacy Center.

All the work we do in reforming the health care system won’t have much of an effect if children and families still struggle to meet basic needs or live in neighborhoods unable to support healthy development. Though they are beyond what many doctors were trained for in medical school, the AAP’s recommendations send a clear signal that physicians can take real steps to ensure their patients have a healthy future beyond the clinic walls.

This column is adapted from a post written by Douglas Jutte, MD, for his blog on the Build Healthy Places Network.