74
Commentary
Scientific Medicine, Social Ills, and Child Health RICHARD E. BEHRMAN, MD, Stanford, Califomia
It was the best oftimes, it was the worst oftimes, it was the age of wisdom, it was the age offoolishness, it was the epoch ofbelief, it was the epoch of incredulity, it was the season ofLight, it was the season ofDarkness, it was the spring ofhope, it was the winter ofdespair, we had everything before us, we had nothing before us, . . . A Tale of Two Cities CHARLES DICKENS
D ickens was referring to the last quarter of the 18th century when he wrote these words, but he might just as well have been talking about the last decades of the 20th century. These are, in many ways, the best of times in the biologic sciences as new horizons open with startling rapidity. But if in the future we look back on these times as the halcyon days of biologic science, we must also concede that it is among the worst of times for children in this country. First, more and more children in the United States are realizing less and less oftheir potential for productive and happy lives, and this during an increasingly competitive era. Second, because children are thwarted in reaching their potential, our very social system is threatened. We espouse a political philosophy of equal opportunity, and, indeed, the economic and social stability of our democracy depends on a critical mass of our citizens believing in and realizing their potential. Yet today, for significant numbers of children, the opportunity to fulfill their potential is being compromised by inadequate health care, insufficient parental nurturing, and ineffective education. Poverty is the common thread in the patchwork of services we use to cover these children. Most physicians caring for children do not need to be persuaded about the important relationship between low family income and increased childhood morbidity. But what has this got to do with scientific medicine? Some would say that today's scientifically educated physicians cannot prevent or treat the nation's social ills, that physicians cannot prevent or treat poverty. Others might add that these are certainly issues for all of us as citizens, but hardly the special province of physicians. Research today is more than a full-time job. Providing medical care for those children who come to our offices, community clinics, and hospitals is more than a full-time job. And, of course, teaching responsibilities are added on to these activities. I think this point of view is wrong. Francis Weld Peabody stated it most succinctly: "The secret of the care of the patient is in caring for the patient." I think that scientific physicians and physician scientists have a special responsibility to be informed, to be concerned, and to do something about the
issues of poverty. This responsibility is greater than that shared by all citizens. Why do I say this? Because the relationship between health and poverty, which is a marker for many social ills, invokes two principles that are fundamental to the mission of scientific medicine. One is altruism. The other is an understanding of the intimate interaction between the health of humans and their environment. Not to address these issues as physicians is a renunciation of the Hippocratic oath. Not to address these issues while we care for children and investigate disease is unscientific. The first concept, altruism, is a substantial part of the motivation behind most physicians' choosing a career in medicine. It should be central to medical education and treated explicitly, but most often it is not. I'm not talking about some paternalistic "noblesse oblige" but literally of altruism, the principle of putting the interest of others before self-interest. I'm not going to spend much time on this principle, except to note that it presents a special problem in our time for all who claim to be advocates for children. And this problem arises because of the popularity and acceptance of the "market" philosophy within the health care system, including academic medical centers. The market philosophy argues that medical services are like most other goods and services and therefore should be distributed by market forces differentially to those who can pay for them. This idea denigrates the altruism principle and, because of the dire implications for those who do not receive many needed medical services, conflicts with our basic national commitment to equal opportunity. Health services for the most part are unlike other goods and services distributed in the marketplace because the consequences of not being able to obtain many health services subsequently deprives a person of a fair opportunity to compete for other goods and services in life. Indeed, it may deprive a person of life itself. In addition, if health care is not available, there are substantial untoward effects on society in general and future generations as well as untoward effects on the ill patient. As I mentioned, however, altruism is not the only reason physician scientists and scientific physicians must take primary responsibility for addressing the poverty-related social ills that are so central to most of the health issues and disease problems of children. This responsibility is also inseparable from the scientific mission. It is unscientific to ignore the relationship between disease processes and the social and economic environment of patients. For most human ailments, understanding the interaction between the specific pathobiology of human afflictions and
(Behrman RE: Scientific medicine, social ills, and child health. West J Med 1992 Jul; 157:74-76) From the Center for the Future of Children, The David and Lucile Packard Foundation, Los Altos, and the Departments of Pediatrics, Stanford University School of Medicine,
Stanford, and the University of California, San Francisco, School of Medicine, San Francisco, California. This article is based on the keynote lecture delivered at the meeting of the Society for Pediatric Research and the American Pediatric Society, May 1991. Reprint requests to Richard E. Behrman, MD, The David and Lucile Packard Foundation, 300 Second St, Ste 102, Los Altos, CA 94022.
THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
o *
JULY 1992 JULY
1992
0 *
157
157
o *
1
75
175
the family and community environments in which diseased persons live is central to curing illness and relieving suffering. This is an example of the larger truth that the functioning of a living organism is fundamentally characterized by the interdependency of the organism and its environment at least as much as by its DNA. An appreciation of this interaction makes it unscientific not to address those factors in the external milieu of a child that contribute to illness or to the inability to grow and develop in an optimal way. The mission of medicine is to deal with what Dr Barondess has characterized as "ailing humans in disarray," not merely a narrowly defined abnormality in biology called a disease. To do otherwise would be as unscientific as failing to consider the complexity of genetic, cellular, and systemic factors in the internal milieu of a child that contribute to the enormous variation in the clinical manifestations of a point mutation in the genome. These comments are not intended to deprecate the enormous contribution being made by the systematic application of the inductive experimental approach of attempting to disprove hypotheses in vitro that has been central to advances in molecular biology and physics. Rather, comparable scientific approaches should be applied to investigating the interactions between children and their macro or community environment by those physician scientists with the talent, imagination, and courage to undertake clinical investigation of these issues with the methodologies of epidemiology, biostatistics, decision analysis, and psychology and with the technologies of molecular biology. Understanding and addressing the interaction between the pathobiology of the human organism and the community environment is fundamental to defining the nature of health problems and the ways in which scientific physicians and physician scientists can best fulfill their responsibilities to ailing persons. The problems of AIDS and intrauterine cocaine and alcohol exposure are dramatic contemporary examples of this. But there are many more. The environment of poverty or its consequences, so relevant to these disorders, is also a causative factor or significant determinant of morbidity and mortality in the majority of disorders included in any textbook of pediatrics ranging from inborn errors of metabolism to failure to thrive. Preliminary to deciding how to address this interaction, it is important to understand some of the social anatomy and pathophysiology of poverty in this "worst of times" for children. I'm going to highlight some of what is known about these matters. First, the definition of poverty in this country is based on a few 30-year-old studies determining the average cost of a minimally adequate diet for an adult, estimating that a third of income was spent on food, and inflating these expenditures by the cost-of-living index. Thus, a family of three must have an annual income of less than $10,000 to be considered poor. This Dickensian formula is hard to reconcile with current studies indicating that some low-income families spend more than 70% of their income on housing to avoid homelessness. A broad demographic and social perspective is needed to understand the poverty statistics as they relate to children in the United States. Those younger than 20 now represent less than a third of the population. About 16% of these children are African American. A wave of younger children is now moving through the population. This will peak at ages 5 or 6 in about 1995, to be followed by an adolescent peak in 2005.
This has obvious implications for child abuse, accidents, substance abuse, AIDS, and crime. Perhaps more important, the proportion of children in the population has decreased dramatically, and, overall, this trend continues. Comparing children to adults over 65, we went from a ratio of 10:1 at the turn ofthe century to a ratio of 2 +:1 by 1988. In addition, children of African-American and various Hispanic and Asian backgrounds are making up an increasing proportion of the total. Further, the proportion of households of reproductive-age adults without children has increased significantly in more recent years. It went from 20% in 1960 to 35% in 1986. These changes have an important corollary in our workforce. In 1940 there were 17 workers for each retiree. Now there are two to three workers per retiree, and one of these is likely to come from one of the minority groups just mentioned. There is another major demographic workforce issue related to children and poverty. It relates to the important role of mothers in the workforce outside the home. Women represent a major part of the growth in the workforce. It is projected that more than 60% of the net growth in employment through the turn of the 21st century will be by women. Currently 58% of women with children work outside the home. Since 1978, for all age cohorts of children the proportion of mothers employed outside the home has been increasing. This phenomenon is even more pronounced for single women and particularly white women with younger children. Further, many children no longer live in families with two biologic parents. These changes are the tip of an iceberg of changing family dynamics, of affectionate relationships, of a sense of responsibility and respect, and of changing activities and behavior. The basic values that children acquire, their motivation, their sense of self-esteem and identity, and their personalities will be in large part determined by what goes on in these and other changed family units. A recent national household survey has suggested worrisome correlations with some of these changes. A significantly lower (less than half) incidence of developmental, learning, and behavioral problems was reported by two-biologic-parent families compared with all the other family units such as single parents, parent and stepparent, and so forth. The epidemiology of poverty among today's children and families should be viewed against the background of these demographic changes. Nearly 40% of those living in poverty are now children, although children are less than 30% of our population. African Americans and Hispanics who will make up a large proportion of our future workforce are two to three times more likely than white children to grow up in poverty. Children of single-parent African-American families, which means mostly single-mother families, are at greatest risk of growing up in poverty, which is easy to understand because the average income of all women heads of households, white and black, is less than $17,000 per year, or less than half of that of households headed by men. What is often not appreciated is that two thirds of the children living in poverty are white non-Hispanic children. Further, more than half of poor children live in families where one parent is working in a full-time job most of the time. White two-parent families with one, or more than one, working parent are the fastest-growing group joining the ranks of those who live in poverty and those who are near-
76
COMMENTARY
76~~~~~~~~~~~~~~~~~~~~~~~
poor (defined as those within 200% of the poverty line). These families are working hard but not making it. The distribution of total family income reveals the basic problem. The poorest 20% of families have a tenth the income of the richest 20%. In terms of income per year, over the past decade the wealthiest 20% of families have had an average $9,000 increase in real income and the poorest 40% of families have lost real income. This is not just a matter of a shift in benefit programs away from children in poor and near-poor families, although this has happened. It is more importantly a result of the fall in wages due to the decreased number of manufacturing jobs and increased international business competition. Closely tied to a perpetuation of this problem in the years to come is a mismatch of the skills required for employment and the skills possessed by children entering the workforce. The changes in the infrastructure of the business community in this country have also had a disproportionate effect on the economic well-being of families of children who do not live in poverty. Effective income is dramatically less in such households. The more children there are, the lower the fam-
ily income. Finally, what do these demographic changes and poverty statistics mean for the health of children? The most obvious effect relates to the affordability of health care. Poor people cannot buy health insurance and do not have the jobs that offer it. Medicaid is often inadequate and does not cover many of the poor. Current data on adults indicate a significant correlation between poor health status and inadequate insurance. More limited data on children suggest a similar relationship. About 14% of adults and 17% of children do not have any health insurance. For all ages, the uninsured range from 10% in the non-Hispanic white population to 37% for Mexican Americans, the least-insured group. If we assume that medicaid-insured and partially insured children have inadequate coverage compared to what most of us have for our own children, about 40% of children do not have adequate health insurance. Again, it is important to keep a critical perspective about who is not insured, to investigate why they are uninsured, and to propose interventions that are most likely to improve the situation. The growth of working poor families, those in which one of two parents is working full-time but his or her income is only 25% above the poverty line, doubled in the last decade from 10.7% to 21.8%. When we look at insurance coverage for those two-parent families within 200% of the poverty line ($20,000 income or less for a family of three) where only one parent is working full-time, the change in health insurance coverage over the past decade is striking. The number of these families that became uninsured doubled as the private insurance coverage fell 39%, despite a 30% increase in public insurance. There are, of course, other effects of poverty in addition to the issue of insurance, such as poor nutrition, increased toxic exposures, and a lack of adequate preventive services. These changes in health insurance coverage, in demogra-
phy, in the economic circumstances of children, and in family dynamics are major determinants of the environmental side of the interaction between the environment and human biology that defines many of the illnesses of childhood that physicians have a responsibility to care for and investigate. I have presented this synopsis of poverty and closely intertwined social trends because understanding the interaction between the environment of poverty and children is central to fulfilling our responsibility of providing scientific and humane care to sick children, preventing illness, and facilitating growth and development. I hope that out of such understanding will come the will to act to effect strategies that will mitigate these "worst of times." What should we as physicians and as citizens do? It is about time we join the rest of the civilized developed world and guarantee children in every state in this country the legal right to adequate health, social, and educational services and the resources necessary to ensure a healthy transition from childhood to productive adult citizenship, independent of the capacity and will of their parents. Specifically, health insurance for children should be made an entitlement, similar to Medicare, not dependent on whether a child's parents have private or public or no health insurance. Further, because of the important scientifically established relationship between the environment and health during development, health insurance for children should be tailored to the unique developmental requirements of childhood. These include a variety of social and educational services in addition to effective preventive and therapeutic medical services. Society should not attempt to substitute for the nurture and good judgment of responsible parents. Neither should the community abrogate its responsibility to ensure an opportunity for the next generation to achieve its potential solely to protect the autonomy of a family that does not provide such an opportunity. It is easy to rationalize that the social determinants of illness are too complex and beyond our ability to control for us to focus our individual professional attention, resources, and energies on them. I think they are no more complex and beyond our control than the translation of the human genome project into the prevention or treatment of most major genetic illnesses within the same time-frame. To return to Charles Dickens, it is up to us whether this will be the best of times, the worst of times, an age of wisdom, or an age of foolishness. We truly have an opportunity and the responsibility to do a far better thing than we have done up to now as a profession. For the most part, we know what is needed and we know how to do what is needed to make and implement sound public policy. We also have the tools to acquire additional knowledge where it is needed. It is easy to blame others for the lack of will to address the problems, but it is we who must also exercise this will in our medical centers, in our communities, and nationally. It is our professional mandate. Edmund Burke observed more than 200 years ago: "The only thing necessary for the triumph of evil is for good men [and good women] to do nothing." This truth still holds.
Commentary
Scientific Medicine, Social Ills, and Child Health RICHARD E. BEHRMAN, MD, Stanford, Califomia
It was the best oftimes, it was the worst oftimes, it was the age of wisdom, it was the age offoolishness, it was the epoch ofbelief, it was the epoch of incredulity, it was the season ofLight, it was the season ofDarkness, it was the spring ofhope, it was the winter ofdespair, we had everything before us, we had nothing before us, . . . A Tale of Two Cities CHARLES DICKENS
D ickens was referring to the last quarter of the 18th century when he wrote these words, but he might just as well have been talking about the last decades of the 20th century. These are, in many ways, the best of times in the biologic sciences as new horizons open with startling rapidity. But if in the future we look back on these times as the halcyon days of biologic science, we must also concede that it is among the worst of times for children in this country. First, more and more children in the United States are realizing less and less oftheir potential for productive and happy lives, and this during an increasingly competitive era. Second, because children are thwarted in reaching their potential, our very social system is threatened. We espouse a political philosophy of equal opportunity, and, indeed, the economic and social stability of our democracy depends on a critical mass of our citizens believing in and realizing their potential. Yet today, for significant numbers of children, the opportunity to fulfill their potential is being compromised by inadequate health care, insufficient parental nurturing, and ineffective education. Poverty is the common thread in the patchwork of services we use to cover these children. Most physicians caring for children do not need to be persuaded about the important relationship between low family income and increased childhood morbidity. But what has this got to do with scientific medicine? Some would say that today's scientifically educated physicians cannot prevent or treat the nation's social ills, that physicians cannot prevent or treat poverty. Others might add that these are certainly issues for all of us as citizens, but hardly the special province of physicians. Research today is more than a full-time job. Providing medical care for those children who come to our offices, community clinics, and hospitals is more than a full-time job. And, of course, teaching responsibilities are added on to these activities. I think this point of view is wrong. Francis Weld Peabody stated it most succinctly: "The secret of the care of the patient is in caring for the patient." I think that scientific physicians and physician scientists have a special responsibility to be informed, to be concerned, and to do something about the
issues of poverty. This responsibility is greater than that shared by all citizens. Why do I say this? Because the relationship between health and poverty, which is a marker for many social ills, invokes two principles that are fundamental to the mission of scientific medicine. One is altruism. The other is an understanding of the intimate interaction between the health of humans and their environment. Not to address these issues as physicians is a renunciation of the Hippocratic oath. Not to address these issues while we care for children and investigate disease is unscientific. The first concept, altruism, is a substantial part of the motivation behind most physicians' choosing a career in medicine. It should be central to medical education and treated explicitly, but most often it is not. I'm not talking about some paternalistic "noblesse oblige" but literally of altruism, the principle of putting the interest of others before self-interest. I'm not going to spend much time on this principle, except to note that it presents a special problem in our time for all who claim to be advocates for children. And this problem arises because of the popularity and acceptance of the "market" philosophy within the health care system, including academic medical centers. The market philosophy argues that medical services are like most other goods and services and therefore should be distributed by market forces differentially to those who can pay for them. This idea denigrates the altruism principle and, because of the dire implications for those who do not receive many needed medical services, conflicts with our basic national commitment to equal opportunity. Health services for the most part are unlike other goods and services distributed in the marketplace because the consequences of not being able to obtain many health services subsequently deprives a person of a fair opportunity to compete for other goods and services in life. Indeed, it may deprive a person of life itself. In addition, if health care is not available, there are substantial untoward effects on society in general and future generations as well as untoward effects on the ill patient. As I mentioned, however, altruism is not the only reason physician scientists and scientific physicians must take primary responsibility for addressing the poverty-related social ills that are so central to most of the health issues and disease problems of children. This responsibility is also inseparable from the scientific mission. It is unscientific to ignore the relationship between disease processes and the social and economic environment of patients. For most human ailments, understanding the interaction between the specific pathobiology of human afflictions and
(Behrman RE: Scientific medicine, social ills, and child health. West J Med 1992 Jul; 157:74-76) From the Center for the Future of Children, The David and Lucile Packard Foundation, Los Altos, and the Departments of Pediatrics, Stanford University School of Medicine,
Stanford, and the University of California, San Francisco, School of Medicine, San Francisco, California. This article is based on the keynote lecture delivered at the meeting of the Society for Pediatric Research and the American Pediatric Society, May 1991. Reprint requests to Richard E. Behrman, MD, The David and Lucile Packard Foundation, 300 Second St, Ste 102, Los Altos, CA 94022.
THE WESTERN JOURNAL OF MEDICINE
THE
WESTERN
JOURNAL
OF
MEDICINE
o *
JULY 1992 JULY
1992
0 *
157
157
o *
1
75
175
the family and community environments in which diseased persons live is central to curing illness and relieving suffering. This is an example of the larger truth that the functioning of a living organism is fundamentally characterized by the interdependency of the organism and its environment at least as much as by its DNA. An appreciation of this interaction makes it unscientific not to address those factors in the external milieu of a child that contribute to illness or to the inability to grow and develop in an optimal way. The mission of medicine is to deal with what Dr Barondess has characterized as "ailing humans in disarray," not merely a narrowly defined abnormality in biology called a disease. To do otherwise would be as unscientific as failing to consider the complexity of genetic, cellular, and systemic factors in the internal milieu of a child that contribute to the enormous variation in the clinical manifestations of a point mutation in the genome. These comments are not intended to deprecate the enormous contribution being made by the systematic application of the inductive experimental approach of attempting to disprove hypotheses in vitro that has been central to advances in molecular biology and physics. Rather, comparable scientific approaches should be applied to investigating the interactions between children and their macro or community environment by those physician scientists with the talent, imagination, and courage to undertake clinical investigation of these issues with the methodologies of epidemiology, biostatistics, decision analysis, and psychology and with the technologies of molecular biology. Understanding and addressing the interaction between the pathobiology of the human organism and the community environment is fundamental to defining the nature of health problems and the ways in which scientific physicians and physician scientists can best fulfill their responsibilities to ailing persons. The problems of AIDS and intrauterine cocaine and alcohol exposure are dramatic contemporary examples of this. But there are many more. The environment of poverty or its consequences, so relevant to these disorders, is also a causative factor or significant determinant of morbidity and mortality in the majority of disorders included in any textbook of pediatrics ranging from inborn errors of metabolism to failure to thrive. Preliminary to deciding how to address this interaction, it is important to understand some of the social anatomy and pathophysiology of poverty in this "worst of times" for children. I'm going to highlight some of what is known about these matters. First, the definition of poverty in this country is based on a few 30-year-old studies determining the average cost of a minimally adequate diet for an adult, estimating that a third of income was spent on food, and inflating these expenditures by the cost-of-living index. Thus, a family of three must have an annual income of less than $10,000 to be considered poor. This Dickensian formula is hard to reconcile with current studies indicating that some low-income families spend more than 70% of their income on housing to avoid homelessness. A broad demographic and social perspective is needed to understand the poverty statistics as they relate to children in the United States. Those younger than 20 now represent less than a third of the population. About 16% of these children are African American. A wave of younger children is now moving through the population. This will peak at ages 5 or 6 in about 1995, to be followed by an adolescent peak in 2005.
This has obvious implications for child abuse, accidents, substance abuse, AIDS, and crime. Perhaps more important, the proportion of children in the population has decreased dramatically, and, overall, this trend continues. Comparing children to adults over 65, we went from a ratio of 10:1 at the turn ofthe century to a ratio of 2 +:1 by 1988. In addition, children of African-American and various Hispanic and Asian backgrounds are making up an increasing proportion of the total. Further, the proportion of households of reproductive-age adults without children has increased significantly in more recent years. It went from 20% in 1960 to 35% in 1986. These changes have an important corollary in our workforce. In 1940 there were 17 workers for each retiree. Now there are two to three workers per retiree, and one of these is likely to come from one of the minority groups just mentioned. There is another major demographic workforce issue related to children and poverty. It relates to the important role of mothers in the workforce outside the home. Women represent a major part of the growth in the workforce. It is projected that more than 60% of the net growth in employment through the turn of the 21st century will be by women. Currently 58% of women with children work outside the home. Since 1978, for all age cohorts of children the proportion of mothers employed outside the home has been increasing. This phenomenon is even more pronounced for single women and particularly white women with younger children. Further, many children no longer live in families with two biologic parents. These changes are the tip of an iceberg of changing family dynamics, of affectionate relationships, of a sense of responsibility and respect, and of changing activities and behavior. The basic values that children acquire, their motivation, their sense of self-esteem and identity, and their personalities will be in large part determined by what goes on in these and other changed family units. A recent national household survey has suggested worrisome correlations with some of these changes. A significantly lower (less than half) incidence of developmental, learning, and behavioral problems was reported by two-biologic-parent families compared with all the other family units such as single parents, parent and stepparent, and so forth. The epidemiology of poverty among today's children and families should be viewed against the background of these demographic changes. Nearly 40% of those living in poverty are now children, although children are less than 30% of our population. African Americans and Hispanics who will make up a large proportion of our future workforce are two to three times more likely than white children to grow up in poverty. Children of single-parent African-American families, which means mostly single-mother families, are at greatest risk of growing up in poverty, which is easy to understand because the average income of all women heads of households, white and black, is less than $17,000 per year, or less than half of that of households headed by men. What is often not appreciated is that two thirds of the children living in poverty are white non-Hispanic children. Further, more than half of poor children live in families where one parent is working in a full-time job most of the time. White two-parent families with one, or more than one, working parent are the fastest-growing group joining the ranks of those who live in poverty and those who are near-
76
COMMENTARY
76~~~~~~~~~~~~~~~~~~~~~~~
poor (defined as those within 200% of the poverty line). These families are working hard but not making it. The distribution of total family income reveals the basic problem. The poorest 20% of families have a tenth the income of the richest 20%. In terms of income per year, over the past decade the wealthiest 20% of families have had an average $9,000 increase in real income and the poorest 40% of families have lost real income. This is not just a matter of a shift in benefit programs away from children in poor and near-poor families, although this has happened. It is more importantly a result of the fall in wages due to the decreased number of manufacturing jobs and increased international business competition. Closely tied to a perpetuation of this problem in the years to come is a mismatch of the skills required for employment and the skills possessed by children entering the workforce. The changes in the infrastructure of the business community in this country have also had a disproportionate effect on the economic well-being of families of children who do not live in poverty. Effective income is dramatically less in such households. The more children there are, the lower the fam-
ily income. Finally, what do these demographic changes and poverty statistics mean for the health of children? The most obvious effect relates to the affordability of health care. Poor people cannot buy health insurance and do not have the jobs that offer it. Medicaid is often inadequate and does not cover many of the poor. Current data on adults indicate a significant correlation between poor health status and inadequate insurance. More limited data on children suggest a similar relationship. About 14% of adults and 17% of children do not have any health insurance. For all ages, the uninsured range from 10% in the non-Hispanic white population to 37% for Mexican Americans, the least-insured group. If we assume that medicaid-insured and partially insured children have inadequate coverage compared to what most of us have for our own children, about 40% of children do not have adequate health insurance. Again, it is important to keep a critical perspective about who is not insured, to investigate why they are uninsured, and to propose interventions that are most likely to improve the situation. The growth of working poor families, those in which one of two parents is working full-time but his or her income is only 25% above the poverty line, doubled in the last decade from 10.7% to 21.8%. When we look at insurance coverage for those two-parent families within 200% of the poverty line ($20,000 income or less for a family of three) where only one parent is working full-time, the change in health insurance coverage over the past decade is striking. The number of these families that became uninsured doubled as the private insurance coverage fell 39%, despite a 30% increase in public insurance. There are, of course, other effects of poverty in addition to the issue of insurance, such as poor nutrition, increased toxic exposures, and a lack of adequate preventive services. These changes in health insurance coverage, in demogra-
phy, in the economic circumstances of children, and in family dynamics are major determinants of the environmental side of the interaction between the environment and human biology that defines many of the illnesses of childhood that physicians have a responsibility to care for and investigate. I have presented this synopsis of poverty and closely intertwined social trends because understanding the interaction between the environment of poverty and children is central to fulfilling our responsibility of providing scientific and humane care to sick children, preventing illness, and facilitating growth and development. I hope that out of such understanding will come the will to act to effect strategies that will mitigate these "worst of times." What should we as physicians and as citizens do? It is about time we join the rest of the civilized developed world and guarantee children in every state in this country the legal right to adequate health, social, and educational services and the resources necessary to ensure a healthy transition from childhood to productive adult citizenship, independent of the capacity and will of their parents. Specifically, health insurance for children should be made an entitlement, similar to Medicare, not dependent on whether a child's parents have private or public or no health insurance. Further, because of the important scientifically established relationship between the environment and health during development, health insurance for children should be tailored to the unique developmental requirements of childhood. These include a variety of social and educational services in addition to effective preventive and therapeutic medical services. Society should not attempt to substitute for the nurture and good judgment of responsible parents. Neither should the community abrogate its responsibility to ensure an opportunity for the next generation to achieve its potential solely to protect the autonomy of a family that does not provide such an opportunity. It is easy to rationalize that the social determinants of illness are too complex and beyond our ability to control for us to focus our individual professional attention, resources, and energies on them. I think they are no more complex and beyond our control than the translation of the human genome project into the prevention or treatment of most major genetic illnesses within the same time-frame. To return to Charles Dickens, it is up to us whether this will be the best of times, the worst of times, an age of wisdom, or an age of foolishness. We truly have an opportunity and the responsibility to do a far better thing than we have done up to now as a profession. For the most part, we know what is needed and we know how to do what is needed to make and implement sound public policy. We also have the tools to acquire additional knowledge where it is needed. It is easy to blame others for the lack of will to address the problems, but it is we who must also exercise this will in our medical centers, in our communities, and nationally. It is our professional mandate. Edmund Burke observed more than 200 years ago: "The only thing necessary for the triumph of evil is for good men [and good women] to do nothing." This truth still holds.
![[Social medicine and public health].](/assets/img/hold.png)
