Pediatrics and Poverty

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PEDIATRICS Vol. 79 No. 4 April 1987 567

COMMENTARIES

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

Pediatrics

and Poverty

Pediatrics is the branch of medicine whose

pri-mary concern is the protection of our nation’s chil-dren. The guiding principle is to set a course of action that will facilitate their growth and

devel-opment. However, despite our best efforts the

well-being of our pediatric population is at risk. We are

witnessing the reemergence of poverty among

chil-dren and its consequences on life’s basic necessities. This transformation is creating a large and growing number of children who are hungry, homeless, and

uninsured. The data and information that follow

are a composite of material generated by federal and state policymakers. It is information not

typi-cally accessed by the medical community. However,

these adverse changes dictate that we familiarize ourselves with the broader issues facing American children and participate in the policy debate.

POVERTY AND CHILDREN

The Congressional Budget Office has recently

calculated that the poverty rate among children is

at its highest level in 18 years, with 14 million

(22%)

of all children now in poverty. Hispanic children (38%) and black children (47%) now find

themselves living in the environment of

impover-ishment.1 Family composition is a major

determi-nant of poverty in childhood. If the population of poor children is examined, 50% reside in households headed by single women. A black and poor child

has a 75% chance ofcoming from this type of family

arrangement.2 In addition, the poverty rate is

sig-nificantly higher for children than either the elderly

(those older than 65 years) or the nonaged adults

(18 to 64 years) in this country. Can it be that

children who represent only 27% of the population now account for 40% of all Americans living in poverty?

Children in poverty is a reality that must be addressed, and its impact is greater than just the

numbers alone. It is reflected in the health and

well-being of our children and the future of our

nation as a whole.

HUNGER AND MALNUTRITION

Hunger in America has once again become a

cause df concern. It may not be as ubiquitous as in

the Great Depression or even as severe as the early

1960s. However, the US Conference of Mayors

re-cently reported that a majority of cities surveyed

identified food as the “emergency service” most in

demand.3 The Physician Task Force on Hunger

from Harvard University recently released a report

entitled, “Hunger in America: The Growing Epi-demic.” The report estimates that the problem of hunger in the United States is now more widespread and serious than in any time in the last 15 years. Malnutrition was estimated to impact on more than half a million American children.4 The sequelae of

hunger and malnutrition are evident by the increase

of iron deficiency anemia, weakness, fatigue, and

growth failure as problems faced by pediatricians

in the care of children from low-income families.

HOMELESSNESS

The population of people without permanent

homes who are living in cars, tents, and on the streets is on the increase once again. The profile is again changing. Unlike the “skid row” individual of the 1950s and 1960s, the homeless today are a

heterogenous group, including not only the

men-tally ill and substance abusers but families, abused

spouses, and runaway children. The US

Depart-ment of Housing and Urban Development recently completed a study of the homeless. Although

criti-cized for its underestimation of the problem, it did

demonstrate that 14% of the homeless were single women and 21% were family members.5 The

di-lemma of increasing homelessness and the

decreas-ing availability of affordable low-income housing

can only impact in a deleterious manner on the

health and development of children.

UNINSUREDNESS

There are now more than 35 million individuals

at Viet Nam:AAP Sponsored on September 7, 2020 www.aappublications.org/news

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568 PEDIATRICS Vol. 79 No. 4 April 1987 in America who lack any form of health care

insur-ance.6 It seems inconsistent that a nation that

spends more than a billion dollars a day on health

care would have so many families that lack

ade-quate access to care. However, the most shocking

statistic is that 1 1 million of the uninsured are

children. Medicaid, the jointly funded federal-state

program designed to secure the financial access to

health care for low-income persons, now serves less

than 50% of those living in or near poverty. In

addition, in 1983, only 10% of all Medicaid

expend-itures actually went to children from families with

dependent children.

The consequences of this interplay of poverty,

hunger, homelessness, and inadequate health care

are reflected in the health of our children. The

Senate Committee on Labor and Human Resources

held hearings in December 1983 and heard

testi-mony from health professionals from various areas

of the country. These experts reported an

increas-ing incidence of low birth weight and preterm in-fants, failure to thrive, and an increase in infant

mortality.7 A recent report from the US

Depart-ment of Health and Human Services on Black and

Minority Health cited concern about the lack of

progress made in reducing infant mortality for

mi-nority children. In 1983, the mortality rate for black

infants was 20.0 deaths per 1,000 live births as

compared to 10.5 for white infants, a twofold

dif-ference between these ethnic groups.8 In addition,

an analysis requested from US Department of

Health and Human Services by the US House

Committee on Energy and Commerce reported

sig-nificant adverse trends in infant deaths, especially

for minorities, in nine states and the District of

Columbia in 1984.#{176}The Children’s Defense Fund,

long an advocate for children, has estimated that

more children die each year of poverty-related

causes than traffic fatalities and suicides combined,

which is twice the rate of death from heart disease

and cancer.

TRANSFORMATION

OF PUBLIC POLICY

The reason for this grim situation is clearly not

due to a single cause. Rather, it is an interaction of

multiple factors. A significant proportion of the

problem is secondary to the severe recession of the

early 1980s. In the wake of a prolonged recovery,

improvement has not come equally to all sectors of

this society. However, we must also implicate the

recent budgetary reductions which we have

wit-nessed during the last 4 to 5 years. Low-income

benefit programs have been reduced substantially

since 1981. Food stamps have been reduced by 13.8%, child nutrition programs reduced by 28%,

Aid to Families with Dependent Children (AFDC)

reduced by 14%, and housing assistance reduced by

11.4%.b0 In addition, the discretionary health

pro-grams that make up a major portion of the Health

Care Safety Net have been reduced by 36%.’ These

programs include the Maternal-Child Health

Serv-ices Block Grant, the Preventive Health Services

Block Grant, the National Health Service Corps,

the Community and Migrant Health Centers, and

the Indian Health Services. They also include the

National Institutes of Health, the Public Health Services, and the Centers for Disease Control.

Budgetary concerns are now driving and dictat-ing the public policy debate. We are faced with a

national debt that exceeds $2 trillion, and the

fast-est growing segment of our national budget is the interest we must pay on this enormous debt. In

response to this escalating debt, the 99th Congress

passed and the President signed the

Gramm-Rud-man Balanced Budget and Emergency Deficit

Con-trol Act of 1985. This law will again attempt to

balance the budget with additional reductions in

domestic programs.

However, in the effort to address our fiscal

diffi-culties, let us not forget that services for children

are relatively inexpensive and have repeatedly been

shown to be cost-effective. A recent report from the

House of Representatives’ Select Committee on

Children Youth and Families described the

cost-effectiveness of eight federal programs serving

chil-dren from low-income families. The programs

in-cluded the special supplemental food program for

women, infants, and children, prenatal care,

Medi-caid, childhood immunization, preschool education,

compensatory education, education of handicapped

children, and youth employment and training.

These programs not only improved the overall

health and development of children but saved sig-nificant future federal expenditures.’2 As an

exam-ple, it has been estimated that $1 invested in

pre-natal care can generate $3 of savings in the reduced

cost of care for low birth weight infants and as

much as $6 in neonatal intensive care unit

expend-itures.

Investment today in our children will have ben-efits for the future. Continued budgetary reductions will only be counterproductive and entail greater costs for future generations. We, as pediatricians, must continue to advocate and demonstrate for the

needs of this nation’s children. We must not allow

the fiscal difficulties of this country to be alleviated

by the continued impoverishment of our children.

CHARLES N. OBERG, MD, MPH

Department of Pediatrics

Hennepin County Medical Center Minneapolis

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COMMENTARIES 569

REFERENCES

1. Reducing Poverty Among Children. Washington, DC, Congressional Budget Office, May 1985, p 1

2. Children in Poverty, Committee on Ways and Means, US House of Representatives, No. 46-869 0. Government Print-ing Office, May 1985, p 625

3. Hunger in American Cities: Eight Case Studies. Washington, DC, US Conference of Mayors, June 1983

4. Hunger in America: The Growing Epidemic. Physician Task Force on Hunger in America, Harvard University School of Public Health. Middleton, CT, Wesleyan and University

Press, 1985

5. A Report to the Secretary on Homeless and Emergency Shel-ter. US Department of Housing and Urban Development, Office of Policy Development and Research, No. 35-941. Government Printing Office, 1983

6. Current Population Reports, P-70-83-4, Economic Charac-teristics of Households in the United States: Fourth Quarter 1983, Table E. Washington, DC, US Bureau of the Census,

1985

7. Going Hungry in America. Report to the Committee on Labor and Human Resources, US Senate, Dec 22, 1983

8. Report of the Secretary’s Task Force on Black and Minority Health, US Department of Health and Human Services. Government Printing Office, August 1985, p 171

9. Report from the Department of Health and Human Services on Infant Mortality for the Committee on Energy and Com-merce, US House of Representatives. Government Printing

Office, April 1985

10. End Results: The Impact of Federal Policies Since 1980 on Low Income Americans. Washington, DC, Center on Budget and Policy Priorities, September 1984

11. Alternatives for the 1980s, No. 17: Health Care: How to Improve It and Pay For It. Washington, DC, Center for National Policy, April 1985, p 59

12. Opportunities for Success: Cost-Effective Programs for Chil-dren. Staff Report of the House Select Committee on Chil-dren, Youth, and Families. Government Printing Office, Aug

14, 1985

Need

for Large

Sample

Sizes

in Randomized

Trials

Prevention is an area of relevance and concern

to all health professionals, in particular,

pediatri-cians. This concept encompasses primary

preven-tion of disease (such as diphtheria, pertussis, teta-nus, and poliomyelitis) among healthy individuals

as well as secondary prevention or the reduction in

risks of complications, recurrences, or mortality

among those already affected. It is unlikely that a

new measure will have as dramatic an effect as did the poliomyelitis vaccine, a prevention measure, which reduced the incidence of paralytic disease in

the vaccinated group more than 50% compared with

children given placebo. Analogously, virtually none

of the new therapeutic measures of promise is likely

to have as clear-cut an effect as did penicillin, which decreased mortality from pneumococcal pneumonia

approximately sixfold (from about 95% to 15%).

For the vast majority of interventions, the most plausible effects will be small to moderate in size, on the order of a 10% to 30% difference.1

Despite the relatively small size of the likely effects, for common outcomes or diseases such re-ductions in risk of development or recurrence would have a major impact upon the health of the general public. The problem is that such small but clinically worthwhile effects are difficult to detect reliably.2 Simple clinical observation is often useful to gen-erate research questions, but because it is usually based on the experience of a series of cases without

an appropriate comparison group, it is not possible

to test hypotheses with such data. Observational

analytic studies can be used to test hypotheses but

are limited by the fact that the magnitude of their

inherent biases, as well as uncontrolled baseline differences in patient or disease characteristics (confounding), may easily be as large as the postu-lated effect of any agent or procedure. Thus, an

intervention study or clinical trial is the most

pow-erful tool available to detect reliably such small to

moderate effects and can provide the strongest and

most direct evidence to judge whether an associa-tion is one of cause and effect. If, first, the

treat-ments are allocated at random and, second, the

sample size is sufficiently large, a clinical trial can provide a degree of assurance about the validity of findings that is simply not possible with any other

epidemiologic design option.3

With respect to the first of these, randomization

is the preferred method of treatment allocation in

any clinical trial because it has the unique

advan-tage that the study groups that are formed will be,

on average, comparable with respect to all variables

except for the intervention being tested. This is

especially important because baseline characteris-tics that differ between the treatment groups and also affect the risk of developing the outcome would confound the relationship between exposure and

outcome. With randomization, not only will all

recognized confounding variables be equally

distrib-uted but so will all potential confounders that are

unknown or unsuspected by the investigator be-cause of limitations of biologic knowledge at the

time the trial is initiated. The known confounders

could be controlled for in the design or analysis of

studies, whether observational or intervention. In

contrast, the only possible way to achieve control of the influence of unknown confounders is through randomization. The fact that randomization works

“on average” implies that the larger the sample size,

the more successful the randomization process will

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1987;79;567

Pediatrics

CHARLES N. OBERG