Poverty

Human Rights Day, December 10: Access to Medical Care as a Human Right

I was shocked that I had never read the Universal Declaration of Human Rights (UDHR). Surely I must have learned about it at some point? As I scanned my memory back at world history, US history, and government classes, I couldn’t remember studying it in high school or during my years in university. Certainly it was mentioned at some point. But compared to my familiarity with the Declaration of Independence, the U.S. Constitution, and other historic U.S. documents, somehow the UDHR wasn’t on my radar. I believe that we as pediatricians can help change our culture by familiarizing ourselves with the UDHR and referencing it in our conversations with our family members, friends and those with whom we work.

When I discovered and read the UDHR recently, Article 25 in particular stood out to me. “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.” (emphasis added) 

If achieving these rights outlined in the UDHR, namely access to affordable and accessible medical care as a human right, were part of our culture in the United States, how would conversations about child health, public health insurance, and our culture of health in general, change? Where could our actions as a nation collectively, driven by our legislation and system, go with this sort of culture? More can and ought to be done to use this important declaration as a tool to foster a culture and, ultimately, a society that values equal access to healthcare and public health insurance, especially for the most vulnerable children our country. 

The UDHR was drafted by the United Nations Human Rights Commission in 1948 as an important part of an effort to promote peace and prevent further catastrophe that occurred during World War II. In the preamble of the UDHR, it states “Whereas disregard and contempt for human rights have resulted in barbarous acts which have outraged the conscience of mankind, and the advent of a world in which human beings shall enjoy freedom of speech and belief and freedom from fear and want has been proclaimed as the highest aspiration of the common people,… Now, therefore, The General Assembly, Proclaims this Universal Declaration of Human Rights as a common standard of achievement for all peoples and all nations…” 

Following its preamble, the Declaration outlines thirty articles that outline what are deemed as universal human rights. In studying these rights, I realized that many of the articles align with concepts familiar to most Americans. To the casual American reader, statements such as “Everyone has the right to life, liberty, and the security of person”, “No one shall be subjected to torture or to cruel, inhuman or degrading treatment of punishment” sound familiar.  Rights such as “the right to freedom of thought, conscience and religion” or “the right to freedom of peaceful assembly and association” have their correlates in the U.S. Constitution. Other rights, such as “the right to marry and found a family” may not be canonized in writing, but are indeed part of our common values as Americans. In short, adopting the principles of the UDHR into our identity, culture and belief system does not require the sacrifice of existing values that we all hold dear. Rather, the UDHR adds to those beliefs some concrete and objective ways by which humans can live life to their fullest potential. Because the Declaration was new to me, I spent some time searching through the medical literature for references to this document. On the AAP website, the UDHR was referenced explicitly in only two articles within its database. On PubMed, searching for “Universal Declaration of Human Rights” yielded 229 results. Common topics of articles that cited the UDHR were articles regarding the rights of underserved, migrant or refugee populations, the rights of persons with speech and communication disorders, and, unsurprisingly, the overlap of  medical ethics and human rights. From this brief search, I concluded that while connections between human rights and access to medical care were being made, it has not been prominent within the culture of medicine or even medical humanities. It reaffirmed to me the need for pediatricians and physicians in general to champion the document and reference it more readily.

One article I found in my search, A Culture of Health and Human Rights, elaborated on the importance of human rights as a framework whereon a national culture of focus towards universal health and well-being could be built. Written in 2016 by two Boston University law professors, the article offers the following model:

 “Human rights offers a sustainable conceptual framework that supports the imperative of improving the social determinants; empowers the public to demand positive change; and offers common ground for initiatives, both public and private, that improve population health. Policies that protect and fulfill basic human rights are policies that address the social determinants of health, well-being, and equity. A culture of health can be most effectively deployed to improve population health when linked to a human rights agenda.” 

In tackling the current culture of health that exists in our country, authors Wendy Mariner and George Annas suggest:

“If a culture of health is intended to mean that Americans should prize health as a national social norm, it will be challenging to realize. In our pluralistic, multicultural country, attitudes about health and its causes vary, especially among different socioeconomic groups. While everyone might agree in principle that health, well-being, and equity are desirable, there is less consensus on where health ranks among life goals and values. Empirical observations of what people actually do—actual norms—suggest that there is no universally accepted—or practiced—culture of health in the United States. Many people might view health not as a primary good or an end in itself but as a means to attain other life goals, such as financial security, personal safety, respect in one’s community, and fulfilling relationships with family and friends. Those who are struggling to raise a family on minimum wages or in a violent neighborhood might be too preoccupied with survival to make health a high priority.”

Mariner and Annas go on to argue that given the plurality of opinions towards health, the best way to improve health culture in our country is to change policy. They astutely note that this endeavor will require decades-long efforts of focused coalitions with unified commitment towards human rights and improving the social determinants of health. 

If culture changes about children’s health can and should start with us as pediatricians, what can we do? More so than ever before, we can amplify our voice on online platforms. Arguably more effective and important are the day-to-day conversations we have with those in our immediate circles. If we individually internalize and embrace those rights that have been declared as universal, we can offer our voice from a place that is grounded in international support and consensus when divisive language about topics like healthcare and immigration arise, or during election seasons. 

Since 1950, December 10th has been dedicated as Human Rights Day and is recognized in many countries. We can use this day, and frankly any other day, to promote access to medical care as a basic human right. Nestled between Thanksgiving and the winter holidays, acknowledging Human Rights Day in our own personal way would lead to conversations about the UDHR.  That will give us opportunities to inform and discuss these principles and how they apply to the children in our communities.

Discussions, especially during the COVID-19 pandemic, have reflected a constant politicization of medical and healthcare issues which need not be political. By addressing the needs of children from a universal human rights framework, we can cast a wider, more inclusive net that catches the attention of those with whom we come in contact. Our efforts can slowly help others, including family, friends and neighbors, embrace health as a part of our culture, and more important, as a human right. As a generation of pediatricians more globally minded than perhaps any generation before, I hope we can help the world embrace the challenge of promoting a “standard of living adequate to the health and well-being” of all children.

David Oleson, MD

References:

Mariner WK, Annas GJ. A Culture Of Health And Human Rights. Health Aff (Millwood). 2016 Nov 1;35(11):1999-2004. doi: 10.1377/hlthaff.2016.0700. PMID: 27834239.

https://www.un.org/en/about-us/universal-declaration-of-human-rights

Literacy in the Time of Coronavirus

Texas is returning to normalcy as restrictions are being eased from the COVID-19 pandemic. Children are still out of school and it remains to be seen when they will return to the classroom environment. The combination of idle time, travel restrictions, and social distancing practices present a significant challenge to parents with restless children at home – as well as an excellent opportunity to promote reading. Pediatricians should use each well-child visit right now to encourage parents to take time to read with their children.

The Council on Early Childhood found approximately two-thirds of children in the United States fail to develop reading proficiency by third grade.1 Reading proficiency by third grade is an important predictor of high school graduation rates, as those who cannot read by that mark are four times more likely to later drop out of high school.1-2 Early reading deficiencies can lead to a lifetime of economic consequences. The Program for International Assessment of Adult Competencies (PIAAC), in a 2016 survey, suggested roughly 1 in 5 U.S. adults do not have basic literary proficiency.3 Low levels of adult literacy and educational level are associated with less economic opportunity, poor health outcomes, and social dependency.1,4

The promotion of reading skills can start in infancy. Parents can read aloud to infants to encourage language development and model reading behavior.1 As infants age, they begin to mimic their parents by turning the pages of books. With picture books toddlers can make inferences from the images before they can read the words on the page. Gradually and with training they may begin to recognize letters and eventually words. Ideally, pediatricians would like our patients to be familiar with the alphabet and recognize their name prior to starting kindergarten. For older children and teenagers, quarantine can be an opportunity to expand their literary horizons. By reading popular novels, classic literature, or books from high school reading lists, students can improve their literacy.

Many resources are available to help parents promote reading. Reach Out and Read Texas has a partnership with many pediatric clinics to provide children with a book at each visit from 6 months to 5 years; their website (see link below) also includes expected reading milestones by age. The Dallas Public Library has Tumble books available for children grades K-12 (see link below) online and additional books are available with a library card (free with proof of residence). Google Play Books has free children’s books available online which are playable on iOS devices.

Donovan Berens, MD

Works Referenced:

  1. High PC, Klass P, Council on Early Childhood. Literacy Promotion: An Essential Component of Primary Care Pediatric Practice. Pediatrics. 2014 August; vol 134 (2): 404-409
  2. Hernandez D. Double Jeopardy: How Third-Grade Reading Skills and Poverty Influence High School Graduation. Annie E. Casey Foundation. 2011 April. https://files.eric.ed.gov/fulltext/ED518818.pdf Date accessed 5/01/2020
  3. Mamedova S, Pawlowski E. Adult Literacy in the United States. National Center for Education Statistics Data Point, U.S. Department of Education. 2019 July. https://nces.ed.gov/pubs2019/2019179.pdf. Date accessed: 5/02/2020
  4. Torpey E. Education pays. Career Outlook, U.S. Bureau of Labor Statistics. 2019 February. https://www.bls.gov/careeroutlook/2019/data-on-display/education_pays.htm?view_full. Date accessed 5/02/2020.

Additional Resources:

https://reachoutandreadtexas.org/index.aspx

https://dallaslibrary2.org/services/ebooks/

Building Resiliency

As pediatricians, we often care for children that may have had exposures to neglect, maltreatment, family violence, family separation or extreme poverty. Over time, we see the negative consequences of these experiences on our patients in the form of poor academic success, substance abuse, and medical and mental health problems. These experiences are termed adverse childhood experiences or ACEs and it is estimated that about 60% of the adult population in the United States has experienced at least one ACE. Pediatricians should identify and attempt to prevent ACEs: we can support and coordinate efforts to build resilience in children by understanding the effect of toxic stress and providing early interventions and continuity in care.

The hallmark ACE study conducted in 1998 by the CDC and Kaiser Permanente in California categorized ACEs into three major categories: physical and emotional abuse, neglect and household dysfunction (e.g., parent with mental illness, substance abuse or experiencing separation or divorce). The study showed dramatic associations between ACEs and risky behavior, psychological illnesses, serious illness and even a lower life expectancy in the children.

In a child’s life, experiencing ACEs can lead to toxic stress. Toxic stress occurs when a child stays in a constant state of elevated stress. Often children have a caregiver to give them comfort during normal times of stress. In these cases, the levels of stress hormones will return to baseline. However, when no supportive caregiver can comfort the child, such as in cases of neglect, emotional or physical abuse, the child’s stress hormone level remains high.  This can affect other aspects of a child’s health and development.

The link between adverse childhood experiences and adult health and well-being has been well studied. We know that as the brain develops, more frequently used circuits are strengthened, while those that are not used can eventually fade away in a process called pruning. Stronger circuits are associated with higher-level functioning, improved memory, emotional and behavioral regulation and language. In children exposed to toxic stress, the circuits are weaker and fewer, especially in the areas of the brain dedicated to learning and reasoning. For example, the excessive stress activation shifts mental and physiological resources from long-term development to immediate survival.  This increases the task of vigilance at the expense of focused attention. Ultimately, poor coping habits and mental health problems can develop. We also know that the exposure to stress hormone increases systemic inflammation which contributes to a higher risk of cardiovascular disease and diabetes among other medical problems. Finally, evidence shows that the longer we wait to intervene, the more difficult it is to achieve healthy outcomes.

The concept of resiliency explains why some children overcome stress better than others. As pediatricians, understanding this concept can help us to build stronger individuals. Resiliency is thought to be related to a greater number of positive experiences compared to negative experiences. We know that a very important part of developing resilience is at least one stable and committed relationship with a supportive caregiver. Promoting regular physical exercise, stress-reduction exercises and promoting strong core life skills for both the child and the adult are additional ways pediatricians can promote resiliency.

Trauma-informed care involves prevention, recognition and response to trauma-related experiences. Early identification is an important first step. As pediatricians, we should consider ACEs-based screening questionnaires for every patient to assess the potential need for other services. The next step would be to link these patients with services such as social work, developmental therapies, or mental health support with experience in trauma. This is often the most difficult part in delivering trauma-informed care, so it is important to identify the resources available in the local area.

Finally, to address prevention, we should work with our families to reduce the stress of daily life, such as connecting them to resources like  food pantries or substance abuse programs. We should teach skills to families regarding parenting and safe dating practices. To promote strong relationships with other adult caregivers, we should be know of available after-school and mentoring programs. The overall goal should focus on changing the environment and behaviors in ways that will prevent ACEs from happening in the first place.  

Amisha Patel M.D.

Sources:
Fox  SE, Levitt  P, Nelson  CA  III.  How the timing and quality of early experiences influence the development of brain architecture.  Child Dev. 2010;81(1):28-40.

Felitti  VJ, Anda  RF, Nordenberg  D,  et al.  Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: the Adverse Childhood Experiences (ACE) Study.  Am J Prev Med. 1998;14(4):245-258.

Shonkoff JP. Capitalizing on Advances in Science to Reduce the Health Consequences of Early Childhood Adversity. JAMA Pediatr. 2016;170(10):1003–1007. doi:10.1001/jamapediatrics.2016.1559

Kuehn BM. AAP: Toxic Stress Threatens Kids’ Long-term Health. JAMA. 2014;312(6):585–586. doi:10.1001/jama.2014.8737


Centers for Disease Control and Prevention. Adverse Childhood Experiences (ACE). http://www.cdc.gov.foyer.swmed.edu/violenceprevention/acestudy/index.html. Accessed February 5, 2020.

New “Public Charge” Rule: How does it affect our patients’ families?

Texas is home to approximately 4.7 million immigrants (an estimated 17% of the state population), including approximately 317,000 immigrant children1. Of these immigrants, approximately 1.7 million are naturalized US citizens, nearly 1 million are eligible to become naturalized US citizens, and nearly 2 million are undocumented immigrants1,2. The number of US-born children in Texas who live with an undocumented family member is reported to be approximately 1 million, with approximately 500,000 children with an undocumented parent1,3. Obtaining permanent residency status is a lengthy process and a source of anxiety for many immigrants. Recent changes to the US Department of Homeland Security (DHS) rules regarding which public benefits count negatively towards obtaining permanent residency may impact these families and children. Pediatric healthcare providers should be prepared to help immigrant families understand how the use of public benefits could impact changing their immigration status.

(more…)

Addressing TB in Pediatric Patients

Cases of tuberculosis (TB), an airborne bacterial disease,  in the US have been steadily decreasing, thanks to improved socioeconomic conditions, focused screening efforts, and thorough follow-up. 9,272 TB cases were found in the US in 2016, down from about 21,210 cases in 1996 [1]. Pediatric TB cases have also been on the decline. In 2016, about 4% of the TB cases were pediatric. However, data from the past several years shows the incident caseload has remained steady [2]. (more…)

Adverse Childhood Experiences

The negative effects of adverse childhood experiences (ACEs) on the health and development of children have been well known in the field of pediatrics for a long time. This topic has recently come back into the public spotlight in the wake of the tragic separation of children from their parents at the southern border of the United States. Given these events, it is important to remind ourselves of the impact of such traumatic events on these children and on the countless other children within the United States who fall victim to similar stressors.

What is an Adverse Childhood Experience?

ACEs can be thought of as anything that causes toxic stress. As described by the Harvard Center on Childhood Development, toxic stress involves experiences of strong, frequent, and/or prolonged adversity that can negatively affect a child’s physical and mental health [1]. These stressful experiences are often worsened by poor social support systems for the child. The Kaiser ACE study looked at 3 types of adverse experience that could lead to toxic stress: abuse (emotional, physical, sexual), neglect, and household challenges (substance abuse, mental illness, violent treatment of partner, parental separation, or member of household sent to prison) [2].

What is the impact of ACEs?

The Kaiser ACE Study looked at surveys of over 17,000 people between 1995 and 1997 that asked questions regarding their childhood experiences, current health status, and behaviors [2]. Almost two-thirds of adults surveyed had at least one ACE, and more than one in five reported three or more ACEs. This study continues today through the Behavioral Risk Factor Surveillance System (BRFSS), which, as of 2014, has the participation of 14 states and the District of Columbia [3]. Most importantly these studies consistently show a dose-response relation between ACEs and negative health and well-being outcomes. This means the more ACEs you had as a child, the more likely you were to have negative outcomes as an adult, such as heart attack, stroke, diabetes, asthma, depression, disability, and unemployment. The Centers for Disease Control and Prevention (CDC) estimates that the lifetime costs associated with child maltreatment are about $124 billion [2].

What can we do to help as pediatricians and as citizens?

The American Academy of Pediatrics recommendations for alleviating childhood stressors focus on 3 major areas: identifying stressors, connecting to community resources, and advocacy [4,5].

As pediatricians, we often have insufficient time to spend with our patients and their families, but, as evidenced above, it is incredibly important that we make the identification of outside stressors an integral part of our social histories. Child safety, substance use, and sexual activity are generally well screened for, but parental health and societal barriers are less common screening questions. Some examples of important questions to include for parents and caregivers are [6]:

  • Food security: Are there times when you don’t have enough food?
  • Income: Do you ever have trouble making ends meet?
  • Housing: Is housing ever a problem for you?
  • Supplemental Child Care: Is your child in Head Start, preschool or other childhood programs? Are you pulled away from caring for your child too much by your job or other responsibilities?
  • Parental Mental Health: Do you take medication for a mental health condition or have you ever been diagnosed with one?

All questions should be posed in a non-judgmental way with an emphasis on the pediatrician’s ability to connect the family with helpful services. In an ideal world, we as pediatricians should be aware of the resources available to our patients’ families, but in reality our attention and time may be stretched too thin to accommodate such constantly-changing information. An incredibly helpful resource for families and pediatricians is 2-1-1. This is a nation-wide service provided by United Way to connect families with local resources such as food pantries, crisis centers, and housing support [7]. Families with identified problems can call 2-1-1 for assistance or www.211.org can be pulled up in the pediatrician’s office for directories of available resources in the area.

Advocacy can be taken up by pediatricians and citizens alike. As a new pediatrician, I am already incredibly frustrated by the lack of resources and societal support for my patients and their families. It is so disheartening to see news like the tragic separation of children from their families at the border when the terrible effects of such adverse childhood experiences have been well known for so long. The takeaway message I would like to stress to any readers of this post is that childhood welfare is not partisan. Government funds will not be wasted on this issue, and children will not be made lazy by receiving assistance. Increased childhood welfare could alleviate many causes of ACEs which lead to suffering and wasted human potential on an incredible scale. I implore any readers to find an issue they feel passionately about, and look for ways to help. These may include registering to vote, writing your representatives, supporting child advocacy campaigns on social media, making donations or volunteering for local charities like food banks, shelters, or child care centers. For information on advocacy issue you may visit the websites below for more information.

https://www.aap.org/en-us/advocacy-and-policy/Pages/Advocacy-and-Policy.aspx

https://www.naeyc.org/resources/blog/support-and-advocate

https://www.cwla.org/our-work/advocacy/

http://childwelfaresparc.org/

 

Benjamin Masserano, MD

 

References

[1] https://developingchild.harvard.edu/science/key-concepts/toxic-stress/

[2] https://vetoviolence.cdc.gov/apps/phl/resource_center_infographic.html

[3] https://www.cdc.gov/violenceprevention/acestudy/ace_brfss.html

[4] http://pediatrics.aappublications.org/content/pediatrics/early/2011/12/21/peds.2011-2663.full.pdf

[5] http://pediatrics.aappublications.org/content/128/6/e1680

[6] http://pediatrics.aappublications.org/content/120/3/e734

[7] http://www.211.org/

Food Insecurity and the Pediatrician’s Role in Fighting Hunger

Problem:

In the United States hunger remains a problem with far reaching consequences especially when it affects our youngest members of society. Though many would argue that food is one of our most basic human needs, it is something many United States families at times must go without. (more…)

Lack of Medicaid expansion in Texas continues to impact uninsured

Dr. Rachael Johnston posted a thoughtful piece about a year ago about the impacts of Texas’ refusal to accept additional funding for Medicaid that is available through the Affordable Care Act. This week, on the heels of the opening of a brand-new Parkland Hospital in Dallas, a hospital that provides care for thousands of low-income patients, the Dallas Morning News has published and editorial outlining the impact that this policy decision has had on the state.

Child Trafficking: A Public Health Concern

Human trafficking is not only a global issue, but also a major public health concern within the United States. Studies suggest that up to half of trafficking victims seek medical attention at least once during their trafficking situation. This represents a large, often-missed opportunity for healthcare professionals to intervene. The injustices of human trafficking include forced labor, involuntary servitude, child soldiers, and sex trafficking. Some estimate that over 20 million men, women, and children are victims of human trafficking worldwide. [1] However, the scope of the problem is difficult to quantify, given the covert nature of the crime. The U.S. government no longer includes official estimates in its annual “Trafficking in Persons” reports. In 2004, the Department of Justice estimated that 14,500-17,500 trafficking victims were brought to the U.S. each year. [2] In addition to the victims brought illegally to this country, another 300,000+ youth within the U.S. are thought to be at risk of exploitation. [3]  As many as 80% of trafficking victims are female, and one-third to one-half are minors. [4] Cases of child trafficking have been confirmed in all 50 U.S. states over the last decade. [3]

Here’s what pediatricians can do to help: (more…)

Child Health and Poverty – A Call to Action

It has been well described that poverty is associated with poor health, starting from time in the womb all the way into adulthood. Poor children have higher rates of infant mortality, low birth weight, food insecurity, and unintentional injuries. They also have a higher incidence and worse severity of chronic diseases such as asthma and obesity. As these children grow older, they are at higher risk of poor educational achievement, teen pregnancy, and inability to escape poverty. Finally, most poor children unfortunately grow into poor adults with higher rates of diabetes and cardiovascular disease, depression, substance abuse, and ultimately shorter life expectancy. Lately, a growing body of evidence has shown that toxic stress experienced by developing children fundamentally changes their biology – altering brain development, the immune system, hormones, and metabolism in ways that predispose to illness. As pediatricians, we should understand that addressing the effect of poverty on our patients’ health requires more than seeing families individually in the office. It will require our voices in broader social institutions. (more…)