Economic determinants of child health

By Christina Elston

One of every five kids in the United States is living in poverty and families with children under age 6 are more likely to be poor than those without. In our economic climate, this isn’t news. The connections between poverty and health also have been covered, so how can journalists find fresh angles on the topic?

One way is to look “upstream” at how communities are addressing socioeconomic factors that contribute to health problems.

The situation

At a Health Journalism 2012 panel discussion on the topic, Andrew Racine, M.D., Ph.D., chief of general pediatrics at The Children’s Hospital at Montefiore, compared Putnam County, N.Y. (less than 6 percent of kids living below the Federal Poverty Level) and the Bronx (almost 40 percent of kids living in poverty) to create a snapshot of the situation: 

• infant mortality in the Bronx is 6.2 per thousand vs. 3.8 in Putnam County

• teen birth rate is 48.5 vs. 5.9 per thousand

• premature birth rate is 14 vs. 11.5 per thousand

Children living in poverty endure environmental pollution, limited access to fresh food and few chances for physical activity, and there are fewer educational opportunities open to them – something more highly correlated with health than most other factors.

The standard of care

Rishi Manchanda, M.D., MPH, put a face on the disconnect between modern health care and social issues with the story of “Mrs. M.” of South Los Angeles. After weeks of throbbing headaches, Mrs. M visited her local hospital emergency room – three times – and received two CAT scans, a lumbar puncture, and extensive blood work. When the tests came back normal, she was simply sent home. “For too many people, this is the current standard of care,” Manchanda said.

But this tale has a flip side: Mrs. M. next visited St. John’s Well Child & Family Center, where the staff determined she was living in an area of substandard housing where damp conditions and mold were the norm. Manchanda was able to quickly diagnose allergic rhinitis and migraines, and prescribe medication. But he also brought in a housing case manager to help abate the mold in her home.

Why hadn’t the emergency room doctors asked Mrs. M the questions that helped resolve her health issue? “Where health care meets social determinants, the standard of care must be improved,” said Manchanda, who has founded HealthBegins, a site designed to network doctors on the front lines of these issues.

Policy tools?

Are Medicaid and the Children’s Health Insurance Program (CHIP) improving care for kids in poverty? Kathleen Adams, Ph.D., professor at Emory University’s Rollins School of Public Health and a health economist with the Division of Reproductive Health at the Centers for Disease Control, explained that CHIP kids have better access to care than Medicaid kids, and both groups are more likely to have a usual source of care and well-child visits, see specialists and get the care they need. CHIP is funded through 2015 and states are getting bonuses for enrolling eligible children, but at the national level, Adams points out that the status of reform remains uncertain.

Story ideas and resources

Along with raising awareness of the basic issues, reporting on relevant research and following the progress of Health Policy, where can we look for stories?

The community health center movement: What are health institutions doing to address drivers of illness in the community? “It’s not just about the latest drug and device,” said Manchanda, “but about innovation to go upstream.”

Electronic medical records: Are health providers using these records to improve social screening by incorporating information about issues like housing conditions and food insecurity?

Geomapping: One Los Angeles clinic used this emerging tool to determine that transportation problems were keeping a set of patients with poorly controlled diabetes from coming in for follow-up care. Other potential applications abound.

Physician training: Are doctors learning to address the issues behind their patients’ health problems? “It’s not rocket science,” Manchanda said. “It’s just a matter of re-prioritizing.”

A prevention framework: When covering children’s health problems, don’t forget to ask: “But why?”

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Christina Elston is the health editor of LA Parent and was a 2012 AHCJ-California Health Journalism Fellow.