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Special Edition: Title V Technical Assistance MeetingExpand Special Edition: Title V Technical Assistance Meeting
Title V Technical Assistance Meeting

 A Tale of Fences, Ambulances, and MCH Priorities

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Session: General Session, Reflections of a Former Title V Director: Leadership Opportunities in Title V for Advancing Public Health, Oct. 17
Presentation Title: A Fence, An Ambulance, and a River Walk into a Bar…
Presenter: Dr. Michael Warren, Deputy Commissioner for Population Health, former Title V Director, Tennessee Department of Health

When Michael Warren began his career as a pediatrician, he noticed early on the high rate of obesity among his patients and pondered the causes. While he initially considered individual clinical actions, such as a physician not talking with a child about nutrition, Warren also came to see the plethora of home and community factors that can contribute to a child's weight problem but are beyond the clinician's influence. These might include the family's lack of ready access to healthy food, an obese parent who engages in little physical activity with the child, and a lack of physical education at the school.

"It really frustrated me as a clinician – getting the why of conditions like obesity and premature birth," Warren said. Answering these "whys" eventually led him from medical practice to research: "to trade my lab coat for a suit."

It was in one of those suits that the former pediatrician presented a poem about a fence and an ambulance to explore a fundamental challenge in public health care: addressing the immediate health needs of individuals while searching for the root causes of the health problem communitywide in order to achieve broad, lasting change.

In the 1895 poem, A Fence or an Ambulance, Joseph Malins writes of a dangerous cliff that people keep falling off, and the debate among locals about what to do: Erect a fence around the edge of the cliff to prevent falls or put an ambulance in the valley to whisk off the injured. The locals prefer the ambulance because although a fence might be useful, people feel pity for those who slipped off the cliff.

Malins disagrees; his poem points out the flaw in that thinking:

"To rescue the fallen is good, but 'tis best

To prevent other people from falling."

Warren used the poem to deliver the same message in less flowery verse:

"We need fences, but we also need ambulances.

We can't just be clinical. And we can't just focus on prevention."

To adequately provide both, he said, the MCH field needs a public health approach built on the continuous improvement cycle of assessment, policy development, and assurance.

wheel.pngHe cited the perennial MCH challenge of premature birth. Essential functions related to assessment can help inform priorities and guide continuous improvement efforts. Policy actions can include educating consumers and providers, building community coalitions to act, and implementing policies aimed at improving birth outcomes (such as hard-stop policies to reduce early elective deliveries). Finally, the essential functions related to assurance might include the development of systems of care and provision of insurance coverage.

Although it can be difficult to conduct continuous assessment and policy development while dealing with immediate health priorities, Warren urged Title V leaders to tap their advantages: They can show accountability for the funds they spend on addressing health needs; know what their populations want and need; are "natural conveners" who "know how to get things done"; and are not alone as they can tap resources and expertise at such places as the U.S. Maternal and Child Health Bureau and the Association of Maternal & Child Health Programs.

"Ideally," Warren said, "we get to the point where we have more prevention and less treatment."