There’s a great metaphor by medical sociologist Irving Zola: Doctors are always so busy downstream trying to save the patients floating by they never have time to step to the side of the bank and look up at the bridge and see who’s throwing them all in. The challenge [in public health] is that doctors do doctor things, public health folks do public health work, lawyers do their lawyer work. It’s only when you start building bridges that you realize everybody has a common agenda.
The asthma study is an attempt to understand disparities in childhood asthma outcomes. From prior research we know that low-income children are four times more likely to be readmitted [with asthma symptoms]; we know minority children are two to three times more likely to be readmitted. But we really wanted to understand what the underlying factors were, what drove those income- and race-related differences. If we can identify key exposures that are leading to worse health, then we can begin to build collaborative programs to intervene.
We’ve begun to work with the Legal Aid Society of Greater Cincinnati and the Cincinnati Health Department. For Legal Aid we’ve placed a legal advocate in the Pediatric Primary Care Clinic five days a week. About one-third of the cases [that Legal Aid sees there] are around housing conditions, one-third relate to health insurance and benefit issues, and the last third are a basket of education-related and family law issues.
There was one young woman who had been admitted to the pediatric ICU twice in three months. But when she had additional difficulties, the real issues were revealed: The family was being put at risk of eviction and they had lost Medicaid. For a child with such fragile asthma to end up in a homeless shelter and uninsured would have certainly led her back into the ICU, with an outstanding bill in the tens of thousands of dollars. Legal Aid was able to help them get back onto Medicaid and to stabilize the housing. The patient subsequently went on to have six months with no further hospitalizations.
[Another time] we had referred 16 different children [with asthma] to Legal Aid for poor housing; the housing was all owned by a single New York developer. Legal Aid recognized that all these buildings were linked and began to work to get a new roof on two of the buildings. To me it was a perfect example: We were working downstream one by one, [but our] partner said, “Wait a second! You have a sick building, not just a sick patient.” And then suddenly we’re improving the conditions for dozens of children. This notion of recognizing patterns in the community of factors pushing children into poor health and trying to address it at that level just makes tremendous common sense.
Illustration by Scotty ReifsnyderOriginally published in the January 2012 issue.
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