Pediatricians just declared war on child poverty.
For generations, a visit to the pediatrician involved the familiar tongue depressor, a stethoscope, and some vaccinations. But if a professional pediatrics organization has anything to do with it, it will soon also involve a new question: "Do you have difficulty making ends meet at the end of the month?" On Wednesday, the American Academy of Pediatrics, which represents 64,000 pediatricians, announced new recommendations to screen for poverty in a bid to reduce its health effects.
The recommendations are the result of a years-long effort on the part of the AAP's Poverty and Child Health Leadership Workgroup, which formed when the academy officially made child poverty a focus of its broader agenda in 2013. In its newly released policy statement and technical report, the group highlights what it calls the "lifelong hardship" faced by kids who grow up in poverty.
Those health effects can be severe: Research shows that among other things, poor children have higher rates of chronic illnesses like diabetes and asthma, lower immunization rates, and a higher chance of dying in infancy. That's not to mention "toxic stress" — heightened physiological responses that activate when children encounter stressful situations. Children in poverty often lack the supportive relationships and structural conditions to regulate that stress response, which can in turn endanger their health for a lifetime.
The AAP's new recommendations encourage pediatricians to screen for poverty-related health risk factors by asking about basic needs, then refer families to resources related to things like nutrition and housing. But it encourages them not to stop there. Rather, the policy statement urges them to participate in programs that help children develop resilience and advocate for public policies that support child health and reduce poverty, like increased health-care access, job training programs and a higher minimum wage.
"We as a country, as a society, chronically underinvest in those aspects of children's’ lives that make them healthy," says Andrew Racine, senior vice president and chief medical officer at Montefiore Medical Center, professor of clinical pediatrics at the Albert Einstein College and chair of the workgroup. Currently, more than one in five children in the United States live below the federal poverty line, which was $24,008 for a family of four in 2014.
But should doctors really hold themselves accountable for the economic well-being of their patients? For a growing number of researchers, the answer is yes. In recent years, health-care providers have increasingly embraced a "medical home" model, which places patients at the center of a system of coordinated care. That focus on the whole person makes social factors—especially ones like poverty that directly impact physical health—hard to ignore.
"We’re asking pediatricians to take on a responsibility that’s much broader than their purview," says Racine. "But we have a responsibility to deal with the world as it is." After all, he says, "We live in a world not necessarily of our own creation, but of our own inheritance."
There are plenty of reasons for pediatricians not to want to engage with child poverty, says Laura Gottlieb, a physician and assistant professor of family and community medicine at the University of California, San Francisco, who researches how health-care workers can address social issues. "I don't have time" and "I don't have the knowledge that I need" are common refrains, she says, as is "If I open that can of worms, I can't close that can of worms." But when physicians do open the conversation, they can make a difference. Last year, researchers from the Boston University School of Medicine and other institutions published results of a randomized trial that showed that when clinicians screen for social determinants like unmet basic needs, their patients received more community resources than controls.
Gottlieb, whose team just closed one of the largest randomized studies of the health-care outcomes of help navigating social resources, says it's an issue pediatricians simply can't afford to ignore. "By ignoring poverty, we're actually undermining all the things we do in the health-care system," she says. But she points out that the statement just puts into words something that pediatricians, who treat millions of patients every year in total, are already doing. "The pediatricians have been out in front for a long time," she says. "It's time for the rest of us to catch up."
"Pediatricians take this upon themselves because it’s the right thing to do," adds Racine. They have a secret weapon in the fight against poverty: patients themselves. Racine points to the resiliency that already exists within kids, families and communities living in poverty—strengths that when, combined with resources and research by pediatricians, give ammunition to pediatricians' war against poverty. Gottlieb agrees. "Patients intuitively understand that all of these issues are connected," she says. "Health is clearly so much more than just medical care delivery."
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