The original mission of Boston City Hospital, now Boston Medical Center (BMC), was to provide medical care for all children and adults regardless of race, ethnicity, or insurance status. Today all Massachusetts children and most adults have health insurance, but the majority of children seen at BMC are from low-income and minority families and suffer disproportionately from low birth weight, asthma, learning disabilities, and poor nutrition.

Recognizing that such challenges matter not only to the children and their parents but to the cost of health care and the future of Boston, BMC's Department of Pediatrics has expanded its mission to meet the needs of the whole child and the whole family. Our experience indicates that the best way to help low-income children is to help their parents, and the best way to reach parents is through their children.

Early Learning

BMC pediatric patients frequently suffer learning problems that are associated with other issues later on, including dropping out of school, early drug and alcohol use, and teenage pregnancy.

Although reading to young children is considered the best way to promote school readiness, BMC pediatricians discovered that many low-income parents were not doing so. In most cases, parents explained that they grew up in countries without children's books or without a tradition of reading aloud and thus did not have books in their home. Additionally, many lived in areas with no children's bookstores. Some considered books too expensive.

Among the most successful efforts of the BMC's Department of Pediatrics is the Reach Out and Read (ROR) Program, which underscores the importance of education to children's well-being. Starting in 1989, doctors began giving young children books at each pediatric visit from six months to five years, explaining to parents the importance of reading aloud to children.

Published studies showing ROR as an effective strategy corroborated what physicians already knew from seeing the joy in parents' and children's faces when they received and shared a book.[1] Hillary Clinton, Laura Bush, and the late Senator Ted Kennedy helped obtain federal funding to scale up the program nationally. Today, ROR has about 5,500 clinical sites serving nearly 25 percent of low-income children in the United States.

Basic Needs

Children get sick not just because of germs. Social problems, poor housing, and other nonmedical issues play a significant role. Wheezing in asthma is associated with mold, mites, and similar triggers in homes. Children also may suffer from inadequate food, lead poisoning, utility shutoffs, child abuse, or domestic violence-problems that may cause failure to thrive. It makes little sense to prescribe an antibiotic or an immunization if the real problem is that the family has to choose between food and heat. BMC programs developed and implemented during the past 20 years are therefore designed to protect health by ensuring that basic needs are met.

Yes, there are laws and regulations to address the negative health impact of hunger, insufficient income, unsafe housing, and disability, but the laws are not always followed. When families do not receive the protections the laws are meant to provide, and health suffers, those upstream causes of illness are best addressed with legal strategies.

Thus in 1993, the Family Advocacy Program, now call the Medical-Legal Partnership, made lawyers part of the health-care team to tackle violations of the laws and regulations designed to protect health. The collaboration of lawyers and doctors, a novel idea at the time, has since spread to more than 220 sites nationwide.

Fortunately, legal strategies are not always needed. The first manifestation of HealthLeads (formerly Project Health), which I started with Harvard sophomore Rebecca Onie in 1997, was a card table set up outside the doors of the pediatric outpatient clinic. At the card table, patients could talk to trained staff and receive information connecting them with community-based resources.

HealthLeads continues today. First, doctors identify underlying nonlegal social and environmental causes of health problems, such as lack of food, heat, or safety. Then trained college volunteers fill "prescriptions" by working with the patient to secure the needed resources. Chosen through a competitive application process, the college volunteers participate in reflection sessions and work on developing their understanding of the social determinants of health. The student opportunity has produced a pipeline of physicians with the insight to transform health care for low-income families. Currently, HealthLeads operates in 22 sites in six U.S. cities.

Nutrition

Ensuring that low-income children have adequate nutrition is a longstanding challenge. BMC Pediatrics opened the first hospital-based preventive-care food pantry in 2003. It provides families in need with two bags of groceries prescribed by their doctor, and it conducts eligibility screening to assist individuals who need to apply for food stamps. In addition, food pantry nutritionists hold cooking classes.[2]

Consider another improvement. In the mid-1990s, most babies at BMC were missing out on the nutritional benefit that breastfeeding provides. By promoting the notion of babies rooming in with mothers and by educating doctors, nurses, and staff about strategies to make breastfeeding successful, Barbara Philipp, MD, led an effort to get more mothers breastfeeding their newborns. The hospital also refused free supplies of formula from manufacturers. In the first four years, the breastfeeding initiation rate rose to 87 percent. Last year it was at 94 percent.

In December 1999, BMC became the first hospital in Massachusetts and 22nd in the country to achieve Baby Friendly status, a title conferred by the World Health Organization and UNICEF to hospitals that meet high standards for promoting breastfeeding. In 2002, the assistant secretary of health at the Department of Health and Human Services picked BMC as the best-practice model for the nation.

Freedom from Violence

A published study of BMC patients demonstrated that 10 percent of children under age six had witnessed a knifing or shooting the previous year, and 18 percent witnessed moderate violence.[3] Although pediatricians were able to treat the medical problems associated with exposure to violence, the emotional trauma necessitated other therapeutic measures. An effort to educate teachers, doctors, and nurses in posttraumatic stress disorder was also necessary.

The Child Witness to Violence Project (CWVP) opened its doors in 1992. In addition to counseling affected children, the program trains frontline professionals, police, and family court officials to recognize the signs children show when they have witnessed violence. Police officers have become the biggest sources of referrals and support. Meanwhile, the Good Grief Program, one of the first such in the nation, provides education to school officials, teachers, and others to help children cope with the death-violent or otherwise- of classmates, relatives, and neighbors.

Ongoing

One innovation in the testing phase is patient navigators, who help parents get services for a child diagnosed with autism. Other efforts include: help to prevent depression among low-income mothers; use of visual media to explain diseases and treatment if a parent has low health literacy; helping sexually active adolescents get contraceptives by offering them in the Emergency Department; establishing a bWell Center, a resource center next to the clinic to connect families to libraries, schools, exercise activities, and health information and mobilizing a network of "mothers' special friends," who are available by phone to provide a safety valve and help prevent parental stress and child abuse.

Advocacy

Boston Medical Center pediatricians have also played important roles in a number of policy issues, including expanding health insurance to children in Massachusetts in the late 1990s, promoting expanded funding for the federal Women, Infants, and Children program and food stamps, providing prescriptions to all patients to reduce use of sugary beverages, keeping children from falling out of windows, and testifying in favor of housing subsidies (because subsidies are correlated with better child health).[4] Additionally, Children's Health Watch provides information to public officials and policymakers nationwide on how nutrition and public policy changes affect low-income children.

Financial Concerns

Lack of money prevents many parents from buying small necessities that other families take for granted. So BMC's Barbara Philipp, MD, and Robert Vinci, MD, established the Kids Fund in 1984 to provide assistance. Whereas charitable contributions are usual in pediatric departments to support research and other academic activities, the Kids Fund focuses on providing items such as coats, special formulas, summer camp, eyeglasses, breast pumps, and the like.

By extending the boundaries of traditional health care to address socioeconomic determinants of health, well-being, and educational success, BMC Pediatrics is providing whole-child and whole-family care to the neediest in the community and helping to prevent later problems and cost for the education and health sectors. Growing numbers of health-care sites beyond Boston have endorsed and adopted the programs.

Barry Zuckerman, MD, is the former chair of pediatrics at the Boston University School of Medicine's Boston Medical Center. Contact him at Barry.Zuckerman@bmc.org.

Endnotes

[1] B. Zuckerman, "Promoting Early Literacy in Pediatric Practice: Twenty Years of Reach Out and Read," Pediatrics 124, no. 6 (December 2009): 1660-1665. [Back to story]

[2] In 2011, more than 80,000 patients and family members received food. In 2012, the food pantry won the James W. Varnum National Quality Health Care Award. [Back to story]

[3] L. Taylor, B. Zuckerman, V. Harik, and B. McAlister-Groves, "Witnessing Violence by Young Children and Their Mothers," Journal of Developmental & Behavioral Pediatrics 15 (1994): 120-123. [Back to story]

[4] A. Meyers, D. Rubin, M. Napoleone, and K. Nichols, "Public Housing Subsidies May Improve Poor Children's Nutrition," American Journal of Public Health 83, no. 1 (1993): 115. [Back to story]