By Michael D. Warren, MD, MPH, FAAP
MCH Director, Tennessee Department of Health and AMCHP President of the Board of Directors
I remember as a pediatric resident participating in a poverty simulation sponsored by a local university here in Nashville. Before I attended, I can recall thinking, "I know about poverty. I take care of lots of kids and families who are poor." Turns out I had no idea what being poor was like. At all.
The simulation was fascinating. I was given a dossier and assumed a character for the hour-long exercise. The hour was divided into four 15-minute blocks, each representing a week. During that time, I had to complete various tasks: "work" in my factory job for eight minutes to represent full-time employment, pay a series of bills, complete routine errands, etc. As we were given the instructions for the simulation, I thought to myself, "I'm smart. I can figure this out and get all these things accomplished."
Yet as the game started and the "weeks" passed by, I realized that despite my best efforts, I couldn't "get ahead" in the game. It took me longer than others to cash my paycheck because I didn't have an account at the bank near my house, so I had to use a check-into-cash establishment that charged me a significant fee. Because of delays at the check-into-cash establishment, I couldn't make it to pay my electric bilI before the first "week" ended. When the second "week" started, I had to report to work (you can't be late!), and by the time I was able to get to the electric utility, my electric service had been shut off and I had to pay not only my bill, but also a re-connect fee. I also didn't ask for a receipt when I paid my cable bill in cash, and when my cable was subsequently shut off, I had no way to prove I had, in fact, paid my bill. Despite my best intentions, working hard, and knowing all the "right" things to do, I still couldn't get ahead.
This simulation caused me to reflect seriously on the social determinants of health and how they should influence the way that I cared for patients. I learned, as much as one can in an hour simulation, just how hard it is to be poor. It had previously been easy to subscribe to the "pull-yourself-up-by-the-bootstraps" mentality. I had done things like refuse to see a family if they were more than 30 minutes late (after all, our clinic did have a 30-minute "rule") – nevermind the fact that they may have had difficulties navigating public transportation (or even our hospital's parking garage). And I had taken the "you should just make better choices" stance far too many times without understanding (or asking) why people made certain choices. As it turns out, if you're poor and your baby formula is running out and you can choose to either pay your rent or buy your formula, watering down the baby's formula might be a perfectly rational choice.
As we think about how we can improve the health and well-being of all children and families, we must think about social determinants. No discussion of health equity, disparity elimination, or optimal health for all can be complete without a realistic conversation on factors like poverty, education, the built environment, and social supports and how those factors influence the health of a population. As maternal and child health (MCH) leaders, we have an opportunity to not only highlight the disparities in health outcomes by a variety of stratifiers like race or income or educational attainment, but also to think about how we can engage partners in reducing or eliminating those disparities.
Before we know it, Title V agencies will be heading into the next round of five-year needs assessments. These assessments provide an excellent opportunity to deliberately explore the health of the MCH population in its entirety, to critically examine the outcomes for various parts of the population, and to identify strategies for bridging the gap where disparities exist.
Thank you for all that you and your teams do every day to help assure that every child and family in our country has the best chance for achieving their optimal health and well-being.