^O00 00o i (X fS S

The First StepA H E A L T H Y S T A R T

"In every childand of/*"year, tm 4,200,Q00 ba

hrate In the lastcKjildren (receive re& fines^or sc! if there is/one rii

i 7who is bom," James Agee wrote, *Wder no matter what circumstances,

what parel>t$, the potentiality ofithe human race isjbom again."' Lastwere born in tJh& United Stated, reproaerrting^he. 7K’»>' ’ »

thirty years.j^yThe quality of health care these hs and years of life will^pfBIotrndly^shape"their

''weiurlshed, phyoically well -proteetod, and it i^the right to a Wealthy start.

the first, ach child muct-

very ^iild can-weiir

cla

GT>6d heall'H~'and good i L'l iu u ^ fu nnarret arc tied tage.thcf and the nation’s firsteducation goal <-.nr, ... fnr thp health professionals and educators te- ) 0,‘~'

—coordinate their efforts. Failure to do so will have a devastating impact on -&Tt educational and economic futur^ -of^tho nation, and^4rros?i^rbriniy-on children. The Business Roundtable, comprised»«f-thc top corporate leaders in till! ualiun, makes thiscompelling claim: "Raising our expectations for educational performance will not produce the needed improvement unless we reduce the banners to learning that are represented by poor student health."3

1 )n

In response to this challenge,fwe propose)a three-pronged s ty tegy^to improve- Lite health -prospects for all children? FlrstT as a long-term Strategy, we call for a comprehensive health education program in every school to educate tomorrow's parents. Second, we propose that the federal nutrition program for women, infants, and children, better known as W1C, be fully funded. Third, to Improve access to basic health care for mothers and babies, we recommend a national network of Ready-to- Leam Clinics that combine health and education.

t *»*£Puling' this naituty, £hild health In this country has undergone a remarkable

transformation. Dreaded diseases^-typhoid fever, diphtheria, tuberculosis, polio—have been largely conquered. ' j^ ( c gntamlnatiofi^ef milk, which once killed thousands of children, is now effectively controlled. Mumps amd measles still threaten ehUdgen, but

15

RTL-HS97.DOC, (PUB,ELB/ds), December 10, 1991

The First StepA H E A L T H Y S T A R T

"In every child who is bom," James Agee wrote, "under no matter what

circumstances, and o f no matter what parents, the potentiality o f the human race is

bom again."' Last year, more than4,200,000 babies were bom in the United States,

the rriMliurt TffriTml lift 11 u i n the last thirty years. The day-to-day physical

nourishment these children receive— the quality o f care they get during the first

months and years of life—will shape profoundly their readiness for school. I f there is

one right that every child can claim, it is the right to have a healthy start.

During the past Century, child health in this country has undergone a

remarkable transformation. Dreaded diseases—typhoid fever, diphtheria,

tuberculosis, polio—have been largely conquered. The contamination o f milk, which

once killed thousands of children, is now effectively controlled. Mumps and measles,

which still threaten children, are! however, no longer widespread epidemics. Today,

the odds of a child in the United States dying from a disease or injury are one half of

what they were in 1950.2

Still, rejoicing should be muted. Despite miraculous medical advances, vast

numbers o f babies in this country are physically deprived in ways that diminish their

quality of life and restrict learning. While no child in America should live a single day\with the pangs o f hunger, it is the nation's shame that nearly half a million children

are malnourished and that twelve million arte hungry some time every months\Infants, whose mothers have not had good health care during pregnancy, are more

are,-«vrtC«Bt, no longer epidemics. Today, the odds of a child in the United States dying from disease or injury are one-half of what they were in 1950.<

Still, rejoicing should be muted. Despite miraculous medical advances, large numbers of babies are physically deprived In ways that diminish their quality of life and restrict their capacity to leam. While no child In America should live a single day with pangs of hunger, it is shameful that nearly half a million children In thir rnitinn are malnourished and that twelve million are hungry some time every month.* Further, studies show that fetal malnutrition affects-eto 10 percent of babies, and w.hl1a some effects _o£ nutrttiomd QiurivatlUTH IlLni Vim icirarolbft.''the damage caused by lack of nourishment during the twelfth to twenty-fourth weeks of gestation, a time critical to brain growth cannot be reversed.*

ability through a decrease in the number of brain neurons.7 Further, when an expectant mother takes Just one dose of drugs, the fetus in the amniotic sac is bathed in drugs for days.8 Fetal exposure to alcohol increases the child's risk of language deficiency and mental retardation. Even before conception, drug-use by the mother or father may tragically damage the unborn child.

Mothers who smoke during pregnancy place their child at risk for low birthweight, asthma, and growth retardations Children of smokers also tend to lag behind their peers in cognitive development and educational achievement and are particularly subject to hyperactivity and inattention (table 1). Further, the effect of smoking is cumulative with children of heavy smokers scoring lower on verbal tests than children of lighter smokers^or nonsmokers.10 As one researcher put it: "At no time does the well­being of one individual so directly depend on the well-being of another.""

What the pregnant woman eats and drinks is crucial. ______ ______ ___ _______ b e. &.iancy, for example, can permanently impair learning

16

i

on Sch

Table 1

tte Smoking During Pregnancy and Its Impact and Learning Disability by Age Seven

LearningDisability11

No cigarette smoking during pregnancy

One-half pack per day

One pack per day

Two packs per day

More than two packs per day

SchoolFailure^

7%

8

8

9

11

RepeatGrade

6%

7

7

8

10

SpecialClass

1%1

1

1

3

VSource: Education Commission o f the States.

The disturbing news is that approximately forty thousand babies ei»eryyear are bom with serious problems resulting from their mother’s excessive use of alcohol during U pregnancy. About seven thousand of these infants have fetal alcohol syndrome, a severe condition t,h^^results In mental retardation. Another thirty-three thousand

-STrS i firoblems attention span, speech and language, a ^ hyperactivity. Further,marijuana, cocaine, crack, heroin, or amphetamines during pregnEincy.ufirL.Lttr y

aboutjri percent~of newborns every year, 425^000 in 1988^) Cocaine and crack use Hurlpp preftnagrr’ff arp rnngigfpntlv with prprnatiiritv Bower birthwe:smaller head circumference.

'W f/rtt

T T S r ^ i- '. 1 ,

The tragedy is not ordy that so many ngttnnis ynrrth—tomorrow's parents—are shockingly uninformed about how the lifestyle of one generation affects so profoundly the physical well-being of the next.

- bszzUl lb » rr-but that so many of the

17

I

w £ J ‘ ' , « - * - > ^ rYhere- -te „an alarming pattern of substance abuse among young peopleA that is detrimental to their bodies, and later to their babies. Consider, for example, that 91 percent of todays high school seniors have used alcohol, 66 percent have smoked cigarettes, 44 percent have tried marijuana, and 31 percent have experimented with an illicit drug other than marijuana (table 2).>«

Table 2

High School Seniors in the Class of 1989 Who Have Used Various Drugs

Drug type Percent

Alcohol 91%

Cigarettes 66

Marijuana/Hashish 44

Illicit drugs other than marijuana 31

Cocaine 10

Crack 5

Source: National Institute on Drug Abuse. 1991.

A.Beyond alcohol and substance abuse, young people unrnu>wi»fl nrmrtahed i:ii'~physteerily -£u—'-Thai do not get adequate exercise t and are obi pounds Uldiler than their■ ......... |inr|n ° n f 'HWhT'l1'!!1 I < tTH F.rTftmt!ft=Hi n ip r' * In a nationalsurvey of teachers ....... ),lu g n i H more than half of therespondents said that "poor nourishment" among students is a problem at their school. Sixty percent cited "poor health" as a problem.'® One teacher in a midsize city observed: "Every year there seem to be more physical problems at our school that interfere with learning. I know that children who don't eat well or don’t get rest can't do well in school. Yet, that’s exactly what I'm seeing more and more." A kindergarten teacher said: "An increasing number of children who come to school have attention problems that I'm being told relate to poor nutrition and deficiencies in their diet." Another

18

I

teacher told us: 'Today's students take far better care of their stereos than they do their own bodies. And what’s so sad is that later on they'll pass on this abusive behavior to their own children."

This nation simply must fcnii interrupt the cycle of ignorance about physl$well being that tfklmately has such tragic consequences for -mrr children J Today's students neea to know the facts of health, as well as the facts of life^Specifically, we propose that every school district offer a new health course as a requirement for high school graduation, with units of study threaded through the whole curriculum, from kindergarten to grade twelve. "What we need is a national policy," says Ramon Cortinez, superintendent of schools in San Francisco, "one that supports comprehensive school health education."i?

In t£ t proposed new curriculum—called, p^rha^^The Life Cycle"—wellness and prevention would be the-eentrol^ integrating themes. Some units oHstudy- could be taught as separate subjects, oft£r7>thers^woven into history, science, and physical education. As students progress froijn grade to grade, they would i e%rn"to respect the safictily^of their own bodies and^appreciate-^the mystery of birth, the nurturing of lifejM the imperative of death. TEey would begfrJT^ery-earty7*to reflect on what an awesome responsibility it is to bring a new life into the world.

As a capstone unit, we propose that each student participate in an "each-one-teach- one" project, passing along to family and friends what they have learned in school, thus expanding prospects of good health. There isrprecedent for this suggestion. At the turn of the century, a cholera epidemic swept New York City. Thousands of babies died.In response, the public schools, organized a health course for high school girls^to instruct them in the care of babies. After completing their training, the students—called "Little Mothers."—received an "honor badge" and became health teachers in their ogfA homes. They were made to understand that they had a weighty obligation to aid in saving babies’ lives.18 Could todays schogLintroduce a modern-day version of the student health corps that was so effectivewiearfya century ago?

" A f x b v J j t w ( ^ _______________W pjn nnt gngppst a filnglr mrnrniiim fnr all schoMsw Htiwevg^TSne prograrft^esigned byj^e New ^ rk Academy of Medicine^illustrates the^oiyoo ofotudy we have in mind. hi- a cumouium series called "Growing Healthy," elementary school students ace

I

^ntfoducod to such topics as physical and emotiojfal health, family life, and the effects of smoking, drugs, and alcohol. 'For middle-school students,-a coursg~Of study called "Being Healthy" focuses on adolescent growth and development, nutrition, f

/fr, ti* **

developed a

fitness, andiAIDS, as-wpll q c "Family Living" and "Nutrition for Life."'9

Jen called, "Education for Parenting^ heailth curriculun>^-"Leaming About Parenting: Learning To Care,"—tfiet introduces students from kindergarten through grade twelve to the responsibilities and rewards of parenting. The couroe of otud.y is bUJU iTrrnimi n (>iiUi (^sita-^fe^eclassromi^by- parents and their infants, giving students—tomoFr-ow'6— parents—firsthand understanding of on^ of life's greatest challenger:? raising children.^Education for Parenting" has been working with schools across the nation with impressive result Myriam Miedziam, a professor at Columbia University Commented-tm the program^ impacts "Regardless of how much detail these boys and girls remember by the time they become parents . . . the course has imbued them with a deep sense of the importance of parenting. Children get a sense of the reality of parenting, of the sacrifices and demands as well as the joys."20

The -"iirrinilnrn h tailorrrl tn the agr nf ctn<-|pntr nrnl ili.u.lnps. In Llum tho ability to ----- rnrr abintf-wlliH 'I'vmjIp Jn tho eemrcc of the programr, Children are introduced to basic

- ljnHinii-dW(’Ti'miiw»Wtt. fftevobserve' and'record the growth and abilities of an lnfantt ^who vjsitc thoir rliritronnf^Libby Blank, a first grade teacher, has visits from baby

Mark and his mother as part of the program in her class. She says, "Before Mark's visit, we predict what Mark will do. We use a ball and book to experiment and . . . record Mark's interactions. We measure his head circumference and length. The children then write individual, creative stories. Learning becomes more meaningful when its related to personal experiences and feelings. We feel fortunate indeed to be participants."21

StuflPQtn •alrn 1....... il T ' i i l l l iu ILII I I" 11 i " l " ...... piny In-thr 11fn * f th - “ hilii f i " 1! h r -

•apportnnltiffe 4<i> aboerve parent and ililld lllia dilluiis:—^ ey riisr"^ thf*1r n,lf*ctjnn£ and conccmo with the parent as well.—Sludnils often experience pride and joy when "ffieu" C-'Iiild gains a new skill 61 physical growth is meabuiable. Tliey albu leam mure abuul LliKiiibt!lUKb and thatr parents ac they quootion their parents about the-ir pcroenal expei'lLiiCLIT ill Uifuiiuy. Program goals Include having students become~more cautiou

Ecoming- parents, decreasing the incidence of child abuse and neglect and

20

Health education in-the schools , can make a difference. Fot-example', eighteen weeks of health instruction, with subsequent "booster" lessons, oanr according to a -Study

conducted by llit! HanclX oipui'aUuir, produce^a significant decrease in smoking and other drug use. A health education program in South Carolina, was credited with reducing adolescent pregnancies. A Minnesota health project reduced the numbers of students who started smoking. An€T_a study sponsored by The Metropolitan Life Insurance Foundation concluded that the percentage of students using alcohol dropped from 43 to 33 percent after health instruction,* and smoking decreased from 33 to 14 percent (table 3). 'The evidence that health education works is overwhelming," according to a National Health Education Consortium report, 'but national policy is needed."22

Table 3

Students Who Reported They "Often" or "Sometimes" Used Various Substances After One and Three Years of Health Education

After AfterOne Year Three Years

Alcohol

Cigarettes

Drugs

43% 33%

33 14

13 5

S o u r c e : National Health/Education Consortium. The Metropolitan Life Insurance Foundation.

Film 11111 r lnrlml'i nil n i it ifTnTfrnrilth nnri pnnrl rnrrntln f is a long-term strategy*^*, that must get started now. Meanwhile, another crisis—poor nutrition among mothers and babies—also requires mjgeat action. Research clearly ectabhahea that if a pregnant woman does not eat well/her nutritional deficiency can interfere with the fetus' development, increasing the possibility that the baby will be malformed or mentally or

21

1

physically retarded.** Yet, in the United States today, literally hundreds of thousands of expectant mothers Eire not well nourished, and millions of preschool children go day after day without the nutrition they need for good health and effective learning.

The federal food program^called WIpTwas signed into law in 1972, precisely to meet the nutritional needs of poor wornen//tnfantel an< dyiyiren. Currently nearly five million children cmd low-income womerywho are picgnant ui btutial feeding are being served.24 Milk, cheese, eggs, cereal, and baby formula are distributed monthly through eight thousand service centers across the country.** WIC has proven to be successful in

during thp first trimester of pregnancy, infant m ortal^ and^ unproving

irr^oKiiiaTy rec m FiirthfHy mothers and clHlIIItll wllTT PHTat tfie^greatcst risk, benefits ^the most.zi

But despite WIC’s success, stsrti^ eligible inutlius aiiB Clilk

bringing luw-liiLuiiK. mothers into prenatal care during

and, ■ as a i LibLTlL. ls^ raising birthweightsj^*reducing

they require, and babies.

Surely the time

t%/ M

They fail to receive even the minimum food supplementshas come Jor thio country to gii-----A A ----

— ........ ~~.. - *

Cs Winston Churchill ion orarantee that all mothers

r0 ere iiTno’jane moon Sinn,C^ner investment for any cpmmunity than pj.itting mijk Into babies."26

thereforeTThat WIC be fulfy funded—increased from $2.4 to $4.5 billion.2» moral imperative .y

v>—\jht-we also recommend that the

educational component of WIC be strengthened. When mothers first register for theaIj*program, they are eligible to receive, not just good nutrition, but parenting education,

The problem is that most WIC offices are overburdened and the teaching component is often cursoiy, at best. Still, this is a moment to be seized, and we propose that every WIC office sponsor a "parent seminar series," one that covers all dimensions of school readiness, from physical well-being to moral development. .W

Health education is essential. Good nutrition for mothers is essential. But the greatest (factor in improving the health prospects of children is providing quality prenatal care^gfSrf^***^ The period before birth is critically linked to a child’s capacity to leam. A hesilthy fetusT^ / by the sixth month, has already developed ten billion neurons, nearly the full number v ^ needed for total brain development.30 Pregnant mothers simply must have good medical

22

■ I

T , ^ c ? 5 A '

The Georgia State Health Planning Agency, for example, surveyed the health care

services in its state and found that 92 counties had no obstetrician, 40 counties had no

hospital, and 13 counties had no family physician, (footnote The Atlanta Constitution

attached.) Rural areas in other staes report the same problems.

I

attention, ar&t good nutrition begins in the first trimester. Such care -should be guaranteed, ft W* •

Infants whose mothers have not had §pen are more likely to be physically at-risk^ qpet' intellectually deficient.31 Yet?~one-quarter of all pregnant women in the United States receive belated prenatal care, or none at all.3* Aad^the percentage of women receiving substandard care has been growing.“ Author Lisbeth B. Schorr in commenting on this crisis observed: "The United States is virtually alone among nations—and absolutely alone among Western industrial democracies—in its grudging approach to the provision of maternity care. Government in the United States has . . . never assumed responsibility for assuring that every pregnant woman gets the health care she needs to maximize the chances of a healthy birth.

The most formidable barrier b ilw iu i piCgiicinl. women and good hidltli ia i i is cost, »cpprMaiiy fnr tha pnar Medicaid, authorized by Congress in 1965, provides health coverage for 27.3 million'people. Still, iflS feyciinalid that today more than nine million women of reproductive age have no health insurance of any kind.35 And, although Medicaid coverage has been expanded to include young children, there are 1.5 million under the age of six not covered by- it or**!^ utlmr form of insurance.36 Clearly, universal health insurance of some form is required. .

But even if^health insurance for all Amertcans-^oom r available tomorrow, millions of women and children still woyjd remain medically unserved because the-health 1delivery system, is—so -chaotlc and access to*se£riee shockingly uneven. In rural ■America. for example, where 20 percent of Americans reside, hundreds of health clinics have closed in recent years For many, prenatal care is miles away—or nonexistent.“ K

eda Sharp of the Michigan Department of Health told us that "in many ruralv \ communities in our state mothers may have to travel a hundred miles or more to get prenatal care." Even in our largest cities, health care in the poorest neighborhoods has actually decreased in the past twenty years, leaving many low-income mothers with no place to go.39 This is inexcusable.

Marian Wright Edelman, president of the Children's Defense Fund, states with urgency the challenge: "Children must have their basic needs for health care . . . and nutrition let if they are to be prepared to achieve in school. A child with an undiagnosed vision

prbtalem, or without the means to get glasses once a problem has been diagnosed.

hardly can learn to his potential. A child whose intellectual development is stunted by lead poisoning cannot excel in the classroom. . . . Nor can a hungry child. . . . All of this is common sense. Any parent, any teacher, any doctor, any politician understands these connections. The puzzling thing is why we can't do what we all know makes sense, giving all children the essential and cost-effective early investments they need to prepare them to achieve.""

Providing access to basic health care for all new mothers and their children must become a top priority for the nation. The National Governors’ Association, states the case precisely: "If steps are not taken now to build a real health-care system, too many children will continue to come to school unprepared to learn, too many adolescents will continue to face serious but preventable health problems."41 Therefore, we call for a national network of "one-stop11 shopping*’' health and education centers to serve all low- income mothers and children. These centers, called—Ready-to-Leam Clinics—would integrate healthy education, and social services, building on the current system feet malting fficnymarc equiUifclp inAjwirre accessible to all.

Creating a national network of children’s clinics—ones that pull together and extends the existing fragmented system would, at first blush, seem to be a hugely complicated task. But this is something America can do. Let's not forget that we created in this country a network of public schools—eighty-three thousand of them from Bangor, Maine, to Honolulu, Hawaii, serving more than forty-six million children. This was accomplished precisely because tie» citizens of tills country shared the conviction that educating every child was far too important to be left to chance.

Today, no one would tolerate a fragmented, -rule- of public education, -one system in which some children went off to school each morning while others had no place to go.

** A ¥T\ hHow, then, can we tolerate, year after year, a broken system of health care that denies access to millions of jpaf children? After all, health is a^pr-Requisite to education? Clearly, the time has come for America to create a "common" network modeled after the "common" school^. Indeed, the proposed Clinics might well be located at or near a public school since health and education are so closely linked. Further, schools are / found in every neighborhood. They have wide public trust and to have-a nealth -sendee clflseJjv would benefit both institutions. ^ x-t,

Once in place, a Ready-to-Leam Clinic would offer, first, prenatal and maternal care, as well as health services to children up to age five, including regular checkups, routine

24

screening for hearing and vision problems, and testing for lead poisoning, which the American Academy of Pediatricians recently labeled an "epidemic." « Protecting every child against childhood diseases through inoculation is also crucial. It is truly shocking that today, 20 percent of preschool children have not been vaccinated against polio, that the incidence of whooping cough is three times higher than it was a decade ago, and that the reported cases of measles has skyrocketed to more than twenty-six thousand in 19 9 0 .« Surely, this nation can ^nmpHch enmpthinp cirppip -inri w- essential og protect^ every child against contagious Illness^ soriouo dise.asc~or pcrhapo-even death (table 4).

Table 4

Preschool Children Who Have Completed Immunizations

Year DTP**- Measles« Polio*’ -

United States 1985 64.9% 60.8% 55.3%

Belgium" 1987 95.0 90.0 99.0

Denmark 1987 94.0s0 82.0 100.0

Frances 1986 97.0 55.0 97.0

Germany (FRG)* 1987 95.0 50.0 95.0

The Netherlands 1987 96.9 92.8 96.9

Norway 1987 80.0 87.0 80.0

Spain 1986 88.0 83.0 80.0

Switzerland 1986 90-98 60-70 95-98

England and Wales 1987 87.0“ 76.0 87.0

S o u r c e s : Bytchenko, 1988; USPHS, 1989; National Statistics Offices (Denmark. Netherlands, England, and Wales).

^ ^ p ffr - AThe Ready-to-Leam clinic?'would nwS a-o « eng parent education component, serve as a referral center—as—a—special eonoern— strengthen—tink les—between—health—arnT

-cducatioa—working collaboratively with WIC program, and

25

i

rlftftflY tkp/fcurrannHing educational Institutions, such as Head Start and the public schools/ An interagency advisory council might be formed to ensure that the various institutions work together toward common goals.

j i j SHTtnr ^hnnir^thp npfwnrir he <-ranted? We believe foafjstates should take the lead in building -network of Ready to Leam Clinics, just as they have led the way in building a national network of public schools. To begin the process, each state should prepare a county-by-county Maternal and Child Health Master Plan, one that would include:

^ irst, an inventory of the number of low-income mothers and children in the county; second, a description of existing services; third, an analysis of what would be needed to fill the gaps; and fourth, a plan for coordinating all programs for mothers and preschool children in each county—health, education and social services^ln communities where health clinics already exist, services might be expanded. In others, new clinics would be needed. Putting together the comprehensive plans from all fifty states would lay the foundation for a national, rnmt tn rnmt network of Ready-to-Leam Clinics.

)\Several states have begujj^to build a * more- effective healthcare infra atmcttmT. Kentucky, for example, in ito awccping School Reform Act of 1990, authorized a-networlr

M "family service centers" ps be located in school districts where 20 percent of the children participate in the federal school-lunch program^ Hawaii's "Project Healthy Start" has one-stop centers^forj,'chiIdren ana families iit . r taS^ST over the statjp The

women not in the program (J as 14.7 percent^for those in the program, it was 9.6 percent.

Local "one-stop clinics" of the sort we have in mind are found from coast to coast. For years the Robert Wood Johnson Foundation led the way in setting up model progra (EXAMPLE).

-LfJ

program also includes a honje^vigit plan to help parents under stress er-with vulnu atfle -Infants. North Carolina's "Baby Love" program gives basic health care to pregnant women through "maternity care coordinators" who act as ombudsmen, guiding /client^into the system. Results are impressive. Ap. 1988 lln jafB-1! TinrtP^tv

&

26

The Jackson-Hlnds Comprehensive Health Center in Jackson, Mississippi provides primary care services, acute sick-care, screening, and Immunization to aSout four thousand preschoolers every year. The Center provides prenatal care and delivery, a birthing center, and nutrition counseling, as well as referrals to drug and alcohol treatment centers. A satellite health clinic located In a local high school is regarded as a model in community health care. But according to Dr. Aaron Shirley, the clinic's budget has been frozen for the last five years, at the same time that they are "seeing more and more patients in poverty who can pay only 20 to 40 percent of the actual costs, if that much. Poverty Is Increasing, but our funding is staying the same. Also, medical costs are rising. Our equipment is twenty years old, but we don't have enough money to make capital Improvements. We have just enough to keep the door open."*

"TW Cares" a community health center is located in a low-income housing project in Denton, Texas, where mostly single mothers and children live. The program was started two years ago by Texas Woman's University College of Nursing after the public hospital closed, leaving the low-income population with no place to go. Besides its programs aimed at educating families about health and wellness, the center helps patients who come into Its clinic by referring them to providers of the services they need. If a child Is sick they help find a doctor. If cases of abuse or neglect arise, they bring families into appropriate programs run by the police and the department of human services. There is also a dental clinic on-site where last year $30,000-worth of services were donated. TW Cares works intimately with the local school, where one- third of the children are without insurance; and therefore rely on the school nurse for

fund^jW Ready to Loam CUrricsTTFeflrst step woulji-bc to coordinate and make • more efficient existing resourc^^'nteiragmented health services for mothers and children—at the loeal, 3tatc, and iidUuiial l evels—slmuld be brought togetha to 5 eliminat^duplication which wastes so much time and money. In one state, fef-r r n m p l p w p r H s r n v P r p f l t h a t ' » p r p f i in H ln fT h n n l t l . 11 fi \ ^ r-

poor mothers and babies—and nnnr of thi njflni'.Jim ii"Yi li il lln i illim wrrn doin£ We are convinced that Improved coordination ofhealth services would save literally millions of dollars, redirecting resources away from paperwork to people.

J > m tf T * f i l lStill,ynore money be required. Aa-a-firct ctop, we recommend that funding for Community Centers and Migrant Health Centers be expanded. These two federal programs have, for several decades supported clinics for needy clients in underserved

27

RTL-HS85.DOC, (PUB,ELB.SR/kl), November 9. 1991 14

Health Centers should be expandedlfrom the current $530 million to $680

million, with increased proportions. IToday, nearly two thousand of the

federally funded community-based ctnters serve nearly six million clients in

fifty states. The problem is that for eyery ten patients currently served,

another three are on a waiting list.

Coordination of "funding streams” is an idea whose time has come. A

Seattle Health Coalition has a new child health project called "Smart Start" that

will create an agency for child health using a "Child Health Fund" that

integrates money earmarked for children's services from its community health

center, hospitals, school districts, city health department, mental health, and

substance abuse funds, as well as city and state funds, to better target the

health services for children. The purpose of this initiative is "to streamline the

organization and delivery of child health services," according to Michael

Beachler at the Robert Wood Johnson Foundation, which is funding the stert-

rip^administrative and planning costs of the program for the next three years,

"nrvt tn in n i^ o f lr Q p o n d wYg n a .h o n h h h n t tn n r n rn rn n rn n n m n rn

•effectively so they have greater impact.-*' ________________

In Hawaii "Project Healthy Start" combines money from the state, federal

funds for the handicapped, and M

Healthy Start began in 1979 by cr

£temal and Child Health. Hawaii's Project

sating "medical homes"—with one-stop

centers for children and families alt risk. These "homes" identify children and

mothers who are likely to have certain risks during the prenatal period or after

delivery and then provides a home visitors program to the family following the

birth. Home-visits also help parer ts during the formative early years when

families are under stress and infants are most vulnerable. Project Healthy

Start offers referrals, as well, providing information on where to get food and

parenting education.

t -

^ t a t * * V

regions of the country. A «d toaav. neariv twij thousand c*>mpiTheiibTve~ cummimlty- i_based health-efenlcs-serve six million people4a oil fifty states. It has been estimated a !* rthat it all of the eligible people were served, an additional twenty-four hundred centers .^7

. T/-> {vould belieede^-costing about $3.5 billion.“ ^ « r f f - •' k/\ **£35“~~~~~~--------—------------ f p , I 'M-rrT tltCC.

Our proposal Is to create a health care system with a more limited target population, ■>serving at least, initially mothers and children under age five. Hence, the cost of getting the proposed Ready-to-Leam clinics up and running would be less specific. Our recommendation is to increase the Community and Migrant Health Centers appropriations by $216 million each year for the next ten years, which would provide the core funding for the national networks of clinics.

We also propose that the Maternal and Child Health Block Grant program be increased from the current level of $530 million to $760 million by 1993. These federal funds are used by states to fund local clinics would be valuable for directing funds to fill in the pieces.

As for staffing, every Ready-to-Leam Clinic should be headed by a health professional—a nurse practitioner, professional midwife, or senior nurse—with a private physician or public health officer providing backup support. Ideally, the Clinic's staff also would include a social worker, a parent educator, and trained volunteers—retirees or college students, for example—to help with parent education, and transportation.Home visits surely should be a central feature of the program and in addition, every clinic should have a hotline service. In Wayne County, Michigan, for example, a mother or father can call a hotline. A counselor on the line tells the caller where to go for help.

To staff its outreach program the Ready-to-Leam Clinics should focus on training parents who in turn will teach other parents what they have learned. A Houston program called "De Madres a Madres"—from mothers to mothers—has launched a vigorous attack on the problem of at-risk pregnancies among Hispanic women. In the barrio where 40 percent do not start prenatal care early enough, or fail to start at all.To meet the need, De Madres a Madres uses women in the neighborhood as volunteers who receive eight hours of intensive training. Currently, fifty women work as bank clerks, waitresses, and school cafeteria staff—serve as volunteers. In two years, these volunteers have contacted three thousand pregnant women, visiting them in their homes, accompanying them to fill out papers, and helping them keep up their spirits.

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The "De Madres a Madres" results are Impressive. Among the clients the program has been able to track, not one has had a low-birthweight baby, and in their next pregnancy most begin prenatal care much earlier. Texas Woman’s University supplied the research and educational resources to begin the program, but training now is done by the veteran volunteers. One woman was asked, 'Why do you do this? You have four children of your own, and it's time and energy away from your own life and family." Her answer: 'Why would I not do this? I care about these women! I care about this community!" This public love was once American life and unless we can rekindle this spirit, neighborhood by neighborhood, America will fall far short of the goal we envision: a society of healthy children.

Recruiting health professionals needed to staff the clinics is a challenge. But here again, the federal government can help. Since 1970, the National Health Service Corps has given scholarships and loans to students, physicians, nurses, and other health care providers—about thirteen thousand doctors, nurses, and other professionals—who agree to work in underseived communities after training.56 Recently, due to budget cuts, the number of National Health Service Corps workers has declined dramatically. At a time when the need is so great, we recommend that nurses and physicians receive full scholarships for training in return for three years of service. We also urge that special priority be given to the recruitment and training of professional midwives and nurse-practitioners who can provide quality maternal and child care.

Improving the health of children is the one dimension of a Ready-to-Leam Campaign where the federal partnership is most apparent. Given budget constraints, we recognize that the program plan outlined above—Head Start, WIC, National Health Corps—will have to be phased in. The important point, however, is to have a plan and a timetable. Above all, let's recognize that giving all children a healthy start is not a cost, but an investment, one that must be started now. 'We absolutely cannot afford to wait until the school bell rings to attend to our children's health," is the way National Health Education Consortium put it. ’We need to start thinking of immunizations, well-child care and health screenings, proper food, and prevention of health problems as being just as important to education as books and pencils and chalkboards and teachers. We need to act swiftly—and we need to act boldly. There is no time to waste."®7

F -H S l 14.DOC/dmo

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NOTES

1. James Agee and Walker Evans, Three Tenant Families: Let Us Now Praise Famous Men (Boston: Houghton Mifflin Company, 1941).

2. l/SA Today, August 2, 1991.

3. "Essential Components of a Successful Education System," The Business Roundtable Education Public Policy Agenda, 2 (date)?

4. Historical Statistics of the United States: Colonial Times to 1970, Part I, U.S. Department of Commerce, 1975, B181-192 and U.S. Children and Their Families: Current Conditions and Recent Trends, 1989 (Washington: U.S. Government Printing Office, 1989), A7.

5. Physicians’ Task Force on Hunger in America, Hunger in America: The Growing Epidemic (Middletown, Connecticut: Wesleyan University Press, 1985), 8-9, 17.

6. Lucille F. Newman and Stephen L. Bukas, Every Child a Learner: Reducing Risks o f Learning Impairment During Pregnancy and Infancy, Education Commission of the States, 1990.

7. Scott R Creel and Jack L. Albright, "Early Experience," Veterinary Clinics of North America—Food Animal Practice, 1987, vol. 3, no. 2, 251-268.

8. Ounce of Prevention Fund, "Education—Does It Make Any Difference When You Start?," 21.

9. Lucille F. Newman and Stephen L. Bukas, Every Child a Learner: Reducing Risks o f Learning Impairment During Pregnancy and Infancy, Education Commission of the States, 1990, 5.

10. Ibid.. 6.

11. "Healthy Brain Development: Precursor To Learning," National Health/Education Consortium, 1991, 1.

12. Learning Disability=normal intelligence (IQ>90) and reading or spelling scores one year or more below grade level.

13. School Failure=repeat grade or enrolled in special class.

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14. The Washington Post November 14, 1991.

15. USA Today, August 7, 1991.

16. The Carnegie Foundation for the Advancement of Teaching.

17. National Health/Education Consortium, Institute for Educational Leadership.

18. Robert H. Bremner, Annual Report 1909 (New York: 1911), 163, 170-171, Children and Youth in America: A Documentary History, Volume II: 1866-1932, Parts Seven and Eight (Cambridge, Massachusetts: Harvard University Press, 1971), 1059-1062.

19. Verbal communication, Fran Kaufman of the New York Academy of Medicine, November 1991.

20. "Education for Parenting."

21. Libby Blank, Presentation to District 8 Principal's Meeting, Anne Frank School, March 15, 1991.

22. National Health Education Consortium, May 1991.

23. Betty Watts Carrington, Ed.D, CNM, 'The Effects of Socioeconomic Factors, Especially Poverty, Malnutrition, Environment and the Medicalization of Pregnancy and Childbirth on Learning Outcomes” (unpublished paper, June 1988),

24. FRAC.

25. "National Evaluation of the Special Supplement Food Program for Women, Infants, and Children (WIC)," The American Journal of Clinical Nutrition, vol. 48, no. 2, August 1988.

26. "Estimated Funding for WIC Applicants," Food Research and Action Center, March 13, 1991.

27. The Department of Agriculture, "The Savings in Medicaid Costs for New Babies and Their Mothers from Prenatal Participation in the WIC Program," addendum.

28. The Oxford Dictionary o f Quotations, 3rd ed. (Oxford.England: Oxford University Press, 1980), 150.

29. Beyond Rhetoric: A New American Agenda for Children and Families, National Commission on Children, 1991, 151.

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30. "Healthy Brain Development: Precursor to Learning," Natural Health/Education Consortium, January, 1991, 2.

31. Lucille F. Newman and Stephen L. Bukas, Every Child a Learner: Reducing Risks o f Learning Impairment During Pregnancy and Infancy, Education Commission of the States, 1990.

32. Su Sheela Singh, Jacqueline Darroch Forrest, and Aida Torres, Prenatal Care in the United States: A State and County Inventory, The Alan Guttmacher Institute, vi.

33. Ibid, vi.

34. Lisbeth B. Schorr, Within Our Reach: Breaking the Cycle o f Disadvantage (New York: Anchor Press, 1988), 68.

35. Children's Defense Fund.

36. National Center for Children in Poverty.

37. "A Healthy America: The Challenge for States," The National Governors' Association, 1991, 25.

38. Ibid., 25.

39. Ibid., 26.

40. Children's Defense Fund, S.O.S. America! A Children's Defense Budget, 1990, 7.

41. "A Healthy America: The Challenge for States," The National Governors’ Association, 1991, 9.

42. The American Academy of Pediatrics to the House Committee on the Environment and Public Works, June 27, 1990.

43. "From the Surgeon General, U.S. Public Health Service," Journal o f the American Medical Association, vol. 265, no. 11, March 20, 1991, 1364.

44. Diphtheria-tetanus-pertussis.

45. U.S. rates are for children ages 1-4; European figures are for children under 3.

46. U.S. rates are for children ages 1-4; European figures are for children under 2.

47. Three doses or more.

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48. U.S. rates are for children ages 1-4; European figures are for children under 1-3.

49. Estimated.

50. Rate is for combined diphtheria, tetanus, and polio immunizations.

51. Estimated.

52. Estimated.

53. Rate is for diphtheria and tetanus; rate for pertussis immunization is 73 percent.

54. Verbal communication, Aaron Shirley, MD, November 1991.

55. "Access, A Date Book, 1991," National Association of Community Health Centers, Inc., 1991, 1.

56. National Commission on Children, Hon. J.D. Rockefeller, III, Chair, Beyond Rhetoric: A New American Agenda for Children and Families (Washington, D.C.: U.S. Government Printing Office, 1991), 46.

57. National Health/Education Consortium, Institute for Educational Leadership.

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