Time for Gratitude and Fulfillment

November 23, 2022

The daily swirl of life can make existence seem endlessly routine – same thing over and over. Finding time for daily reflection and thanksgiving is a way to shine the light on the good, the exciting, and the…

HB 2019: Stocking Albuterol in Virginia Schools

The world has spent the last few years grappling with a virus that, at its most acute, denies its host the ability to breathe. Sometimes lost in the sheer scope of the death and destruction wrought by SARS CoV-O-V2 is the terrifying struggle for air faced by those afflicted. There is something uniquely awful about the denial of that which sustains us, and more terrible when we imagine what a child must feel when faced with it. Sadly, such is the case with asthma, which is among the most common chronic diseases to affect children. Managing asthma has two primary components: controlling the disease and ensuring access to rescue medication in the event of an attack. In this year’s General Assembly session, lawmakers tackled the latter of these components with a bill to mandate that all public schools keep undesignated albuterol on-site.  

Child advocates know that 80% of the factors that affect a patient’s health occur outside the care of a doctor. Environmental factors such as where they live, their household’s economic status, the quality of their school, etc. weigh heavily on a child’s opportunities for success. These factors manifest in a number of ways, but the prevalence of asthma offers a glimpse into the equity gap in public health. Asthma disproportionally affects the African American and Hispanic communities not because there is any sort of genetic predisposition to the disease, but because decades of structural inequity have contributed to factors that exacerbate the respiratory condition. Through no fault of their own, children who live near or below the poverty line are far more likely to be exposed to mold, smoke, poor air quality, along with other triggers.  

Addressing those underlying inequities is a long-haul cause; there is not a ready-made solution to unwinding deep-rooted structural inequity in housing policy, though such a solution should be a priority of policy makers. Lack of long-term answers should not prevent us from pursuing acute solutions, however. A small step, but a meaningful one, was contemplated by House Bill 2019 (HB 2019). 

Patroned by Delegate Delores McQuinn (D-Richmond), HB 2019 would require all Pre-K through 12th grade public schools in Virginia to maintain a stock of undesignated (or blanket prescribed) albuterol) on site. Let’s say that a student forgets to pack their rescue inhaler. Let’s say that this child attends school in a building that is more than 40 years old and learns in a dusty classroom. Let’s say that child has an asthma attack and reaches into their backpack only to find their rescue inhaler absent, what then? In the most favorable outcome, mom or dad is able to rush home and grab the inhaler and get it to the school before the asthma attack has gotten out of control. Even here, however, it is painful to imagine the trauma the child experiences during the time that elapses before their ability to breathe is restored.  

It is worth noting that uncontrolled asthma is the leading cause of absenteeism in school aged children. Given the unprecedented potential for learning loss over the last year, addressing that adjacent issue takes on even greater importance. Thus, HB 2019. 

Photo by Peter Idowu on Unsplash

The bill in question builds on legislation from last year and taken in total provides for a standing order to be written by the head of a local health department, gives immunity to school personnel who would administer the medicine, requires schools to stock albuterol, inhalers, and spacers, and provides funds to alleviate the financial burden on school systems for their initial investment.  

This policy is not without complication, however. Schools play an instrumental role in a child’s development, and those who dedicate themselves to the profession of teaching are heroes in their own right, but they have expressed concerns over the scope of their job responsibilities when it comes to the administration of medicine. These are valid concerns, and they were vociferously expressed during the debates over the fate of HB 2019.  

Progress is rarely a straight line. It sometimes demands compromise and it sometimes requires stubbornness and determination. Advocates for the bill opted for the latter, though with a tinge of the former, and ultimatelyultimately, they were successful in the passage of HB 2019. Legislating often involves placing the pros and cons on opposing sides of a scale and making a decision. Often that decision is not easy, and even more often the hardest part of the decision is opting for progress over the status quo. In this case, lawmakers (or, a majority of lawmakers in each chamber of the General Assembly) elected to support the measure and in so doing take a small step toward reducing uncontrolled asthma in children.  

Make no mistake, HB 2019 is not going to solve the pernicious inequity in health outcomes derived from other policy areas like housing and education funding. Further, the COVID-19 pandemic has affected populations differently because of underlying issues that it has exacerbated, not created. Policy makers who do not see these deep inequities are either ignorant of them (a charitable conjecture), or they simply do not prioritize their alleviation. It is the job of child health advocates to ensure that these disparities are not ignored. It is imperative that they be seen for what they are, addressed head on, and resolved so as to ensure every child has the same opportunity for success.  

 

Header Photo by Santi Verdi on Unsplash

Pediatricians, the Pandemic, Politicization and Polarization

Almost everything about the COVID-19 pandemic has been politicized: mask wearing, school re-opening, vaccination development, social distancing protocols, and many other public health and scientific efforts and recommendations. This politicization undermines public health efforts, science, and public trust. It also creates a polarization that makes dialogue, trust building and any progress forward very challenging. Most critically, this politicization and the ensuing polarization harm the health and well-being of children. While less impacted by morbidity and mortality due to coronavirus, children have borne the brunt of the coronavirus pandemic in a myriad of ways, from watching family members cope with illness, unemployment and other challenges, to social isolation and academic disruption due to school closures. In the spring of 2020, with the coronavirus racing around the globe, most US schools shut down for in-person learning, affecting over 50 million public school students.   

Photo by Deleece Cook on Unsplash

Let’s focus on school reopening. One year later, many communities are still grappling with when and how to send students, teachers and staff safely back to school. What started as two weeks of school closures has evolved into a yearlong debate that has become politicized and polarized. Communities are seeing parents, teachers’ unions, school boards, and school districts plunged into conflict. As spring turns to summer and school districts release plans for the fall, families will need to weigh the risks and benefits of returning to school in-person. And we’re asking families to do it during a time of tremendous conflict and controversy. 

If ever there was a moment for pediatrics, this is it. Pediatrics is part of the solution to politicization and polarization. Our exam rooms and our interactions with families create a space for open dialogue and honest communication. Families face a barrage of information from traditional and social media sources, as well as their friends, family members, and communities. Our exam rooms, our video visits, our phone calls with patients and family members – these are all spaces where we can remove polarization and politicization of issues like return to in-person schooling and apply a family-first focus. Much has been written about what we can do at a policy level, and much controversy remains, but let’s focus on the practice level. 

The conversation with every patient and family about return to in-person school is going to be individual and nuanced. We must provide our patients the space, a safe space, to express their concerns about in-person school and virtual school. We can help families weigh the risks and benefits in their own family, and for each child, of different school options. We can share what we’ve learned about coronavirus and school safety. We can discuss how to best meet each child’s needs, by considering their academics, their nutrition, their physical activity, their socialization. And we can help families figure out what kind of return to school is going to work best for their child – virtual, hybrid, in-person, or even a slow ramp up to an in-person experience. Our visits with patients and families can focus on their unique questions and considerations, not the broader public debate and discord. 

Let’s not let this opportunity pass us by. Families are counting on us to be the safe space focuses on their child, and their family. Let’s make our practices the prescription for politicization and polarization. 

 

Header Photo by Ivan Aleksic on Unsplash

Welcome to the Child Health Advocacy Institute (CHAI) Blog!

Hello, I am Tonya Vidal Kinlow – the Vice President of Community Engagement, Advocacy & Government Affairs at Children’s National Hospital. I welcome you to our CHAI blog and hope that you come back often to learn about the important work we do to help improve the lives of children in DC, our region, and the country. We – me, my staff, colleagues, partners and collaborators – will share our views on matters that impact the health and well-being of children. The views we express are our own and not necessarily that of Children’s National Hospital. In this post, I’ll share my thoughts on what health equity means to me and how the CHAI works to elevate equity for all children and families.

Most Americans are taught and believe the idealized version of our country’s commitment to equality – “that all men (and women) are created equal.” A close review of public policies related to determinants critical to a high-quality life – health care, education, housing, income, employment – sheds light on the structural impediments to equality and equity in our country. The current COVID-19 pandemic aggressively aggravated how a crisis can impact people who have been systemically marginalized. These inequities are built on centuries of policies and established cultural norms, within government and business, that were designed to deprive this country’s people of color of the opportunity for a high-quality life. Achieving equity through policy and systems change must be our top priority if we are ever to achieve the true potential of the American ideal. 

Household income is one of the social determinants that affects many other quality- of-f life factors. Like a snowball rolling downhill, low income often results in lower quality housing, education and health. According to a Pew Research report, the Black-White income gap in the United States has persisted over time. The difference in median household incomes between White and Black Americans has grown from about $23,800 in 1970 to roughly $33,000 in 2018. 1 Making real change in this one area could have a tremendous impact on the lives of so many Americans. One possible policy solution to the income gap is to provide a living wage.  Yet, Congress just rejected a proposal to establish a $15 per hour minimum wage.  

The facts on disparities in health care, education, housing and employment are no different than the income indicator and are often linked.  People living in poverty or in lower income groups often have poor health, poor housing and poor education. Programs to address system inequities are great, but most only offer temporary solutions.   

Confronting these inequities takes a commitment to change.  Children’s National Hospital made that commitment when it created the Child Health Advocacy Institute (CHAI). More than 30 years ago, Children’s National was the first hospital in the nation to establish a center to champion policies that build better lives for children.   The CHAI achieves its mission through four core operational areas – community engagement, public policy advocacy, data and research, and education.  

Photo by Ponsaksitphotos on Canva

We are starting with the children. They are our priority. The health care system can be complicated and difficult to navigate.  Our community engagement team works strategically with our Children’s National clinical staff and partners in other organizations to improve health literacy. The CHAI team helped to create new systems and processes that improve the coordination of care, making it easier for families to get the quality health care they need. These efforts ensure fundamental health literacy supports, such as making sure families get patient discharge instructions in a language they understand. Additional systems changes establish more high- touch care coordination follow-up, such as, provider to patient calls to address any concerns that the patient might have complying with home care instructions.  

We are focused on eliminating health disparities. Our Data Lab helps us to identify community health needs.  The data drives where we focus our efforts to make change. And, the community consistently ranks mental health care at one of its top needs.  Due to a growing level of socioeconomic inequality among races, African Americans are less likely to have access to mental health care and are more likely to have lesser quality care when they do find it. In one study, of all those who received mental health care, minority populations reported a higher degree of unmet needs and dissatisfaction with the services they were given (12.5% of whites, 25.4% of African Americans, and 22.6% of Hispanics reported poor care). 

Children’s National supported the development of a new system of mental health care.  One that relies on a trusted health care provider – pediatricians.  Child and Adolescent Psychiatry Access Programs (CPAPs) or Pediatric Mental Health Care Access Programs (MAPs) are a recent innovation designed to address the dire child psychiatry workforce shortage by supporting pediatricians and other primary care providers (PCPs) to address their patients’ mental health concerns within the primary care setting. When mental health services are available, families face serious barriers in accessing care, including difficulties with transportation or attending regular appointments and overcoming the stigma often associated with seeking mental health support. In this context, PCPs are often asked to care for children with complex mental health needs without adequate support. MAPs are regional or state-level programs that allow PCPs to access a centralized team of professionals who they can consult about their patients’ mental health needs. MAPs promote health equity by ensuring all children, including those who live in communities with limited resources, have access to high quality mental health care. The CHAI government affairs team advocated for a national expansion of MAPs. President Biden’s COVID supplemental appropriations, the American Rescue Plan, includes $80 million to expand MAPs. 

We are advocating for health equity.  According to the Center’s for Disease Control (CDC), infant mortality is the death of an infant before his or her first birthday.  CDC’s data shows that Black children are more than twice as likely to die before their first birthday than White children (10.8 deaths per 1000 live births for Black infants and 4.6 for White). Birth defects is one of the leading causes of infant mortality and early detection is a way to save an infant’s life.  The Children’s National Government Affairs team was an early leader in efforts to require birthing hospitals to conduct newborn screening that would detect birth defects. This life saving public policy is now law in all 50 states. There is also a federal law that defines the birth defects that all American infants must be screened for.  While newborn screening is only one strategy used to reduce infant mortality, it creates equitable access for all children regardless of race and ability to pay. 

We are training the next generation of pediatric health care providers to care for the whole child. The CHAI team understands that excellent clinical care is only a small part of what it takes to keep a child healthy.  We want our young doctors to also understand this.  Social factors, such as housing, education and access to quality food, also make a difference in health outcomes for children.  The CHAI advocacy education team developed a national model for socially accountable, interprofessional advocacy education, that will result in a skilled workforce driven to advocate for child health equity and systemic change. Trainees learn about food insecurity during a day long interactive session at the Capital Area Food Bank.  Their experiential learning also includes strategies for helping families resolve this need. 

Eliminating inequity across all social systems will take determination to untangle systemic bias in public policy that have been entrenched for centuries.  At Children’s National, the focus is squarely on making a difference in the lives of children.  We are guided by our community; use data and research to focus our efforts; and advocate for public policy and systems change. Children are only a small part of the U.S. population, but they are our future.  The Child Health Advocacy Institute, through policy and systems change, will champion polices that improve the quality of life and create equity for all children. 

Header photo by Ponsaksitphotos on Canva

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