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Unintended Consequences

I have had the privilege of serving as a pediatrician for nearly twenty years, and have encountered dozens of children and families who have deeply impacted me. Their stories fuel my drive to transform systems to those that truly produce, sustain and enable health. Cris’ is one of those stories.

Cris* is a 13-month-old adorable child who is the third of four siblings all younger than 6 years. I first met Cris and his mother Tanya* when they came for a follow-up appointment for lead re-check. Cris’ mother had brought him to the office the previous month to obtain a physical exam and immunizations so that he could attend child care. My colleague performed a complete physical examination including a lead screen, which revealed a significantly elevated blood lead level at 38 µg/dL (while there is no “safe” level of lead, tests are normalized to <5 micrograms/deciliter). My partner took all the appropriate next steps including notifying our local public health lead poisoning prevention program, who sent a public health nurse to Cris’ home to assess risks of lead exposure, and to educate Tanya about ways to reduce his lead exposure. Cris’ mother was instructed to return to our clinic in a month for a lead re-check to see if his levels were decreasing.

When I met with Cris’ mom, I saw a quiet, young woman in her work uniform. Her affect was flat and she would not make eye contact with me. After many attempts at obtaining a history in which I received monosyllabic responses, I scooted up to Tanya, knee-to-knee, and gently asked her what had happened. She shared that the public health nurse had come by her apartment to talk about ways to clean the blinds and to wipe down surfaces so the lead paint peeling from the walls wouldn’t be as much of a risk to Cris and his siblings. However, the nurse also noticed other hazards in Tanya’s rental property that she reported to her colleagues in neighborhood services. When staff from the department of neighborhood services inspected Tanya and Cris’ apartment, they found several serious health and safety violations, for which the landlord was cited. Their landlord, in return, evicted Tanya, Cris and his siblings.

This mother – who was doing everything in her power to ensure her children had what they needed – did everything she was supposed to do. The pediatricians did everything they were supposed to do. As did the public health nurse and neighborhood services staff. Why then, were four young children now also experiencing homelessness, in addition to the other challenges of environmental hazards, stress and poverty?

Aside from the obvious challenge of chronic, pervasive and predatory eviction practices in Milwaukee, Cris’ story is reflective of multiple systems – health care, public health, social and community services among others – that have evolved over time in ways that create unintended consequences. Health is an outcome that is influenced by physical, emotional, social and economic environments, in addition to our genetics and health related behaviors. Thus, many institutions play a role in supporting health – health care, public health, education, public safety, economic development, and others. Yet these institutions typically operate in silos, with unique objectives, separate funding streams and different measures of success. Often, as a result, children and families like Cris’ experience unacceptable outcomes despite the best of intentions.

This isn’t “falling through the cracks” – it’s having the floor violently yanked out from under you and leaving you spinning. Rootless. And often, hopeless. But it doesn’t have to be this way.

I can imagine a world in which the many systems that support health are intentionally linked and organized around the child and family. In this system, Cris would still be screened for lead exposure as well as for other non-clinical influences on health outcomes. A finding of elevated lead would still prompt a referral to public health, and the public health staff would be incorporated as part of Cris’ care team. The finding of an unsafe living environment would still be referred to neighborhood services, however would also automatically trigger inclusion of legal aid services into the care team because the clinician, public health, neighborhood services and Tanya – who has been actively engaged in identifying her goals for Cris and her family’s health and well-being – collectively understand the risk of eviction and are proactively working to ensure Cris and his family are able to live in stable, safe housing.

While not yet a reality, this certainly isn’t fantasy. It is achievable through system alignment around a shared goal of improving child health and well-being. Research has shown that there is no better investment than ensuring children have a strong, healthy start to life. Yet, there are far too many families with experiences like Cris’. We can and must do better.

Genesis Health Consulting has experience facilitating systems change across multiple sectors – including designing measures that are relevant to diverse stakeholders – to sustainably improve the health of communities in which children live, learn, play and grow. For more information, contact us.

*The names of my patient and his parent were changed to preserve privacy.

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