Promoting Health

I Wonder Why Not a “Child Health Services First” Agenda?

By: Paul H. Dworkin, MD

I was interested to read the recent announcement of Harvard Graduate School of Education Dean James E. Ryan that he will depart Harvard at the end of the academic year to become president of the University of Virginia. Before joining Harvard, he was the Matheson & Morgenthau Distinguished Professor at the University of Virginia Law School, where he founded the school’s Program in Law and Public Service.

My familiarity with Ryan is thanks to Rebecca Beebe, a researcher in our Injury Prevention Center. Noting my penchant for asking questions to stimulate discussion, Rebecca shared with me a copy of Ryan’s book, Wait, What? And Life’s Other Essential Questions, which she received as a gift from her mother. The very brief book, an incredibly quick read, is based on a graduation speech on asking the right questions and living a full life which Ryan delivered to his Harvard students a few years ago.

The author’s message is simple but profound – that true wisdom comes from asking the right questions. Ryan offers five questions that, if asked regularly, can lead to a more rewarding life. Here are Ryan’s questions: Wait, what? I wonder….? Couldn’t we at least…? How can I help? and What truly matters? Ryan illustrates the utility of each question with informative, poignant, and often amusing anecdotes.

Reading Ryan’s book has encouraged me, perhaps to the chagrin of my colleagues, to even further pose questions in my reflection and dialogue. I have found Ryan’s questions to be particularly liberating with respect to challenging basic assumptions. A relevant example is our national focus on health care transformation and the specific assumption that the greatest opportunities accrue from a focus on individuals, primarily adults, with chronic diseases who are high utilizers of care. This seems a reasonable approach, since the greatest opportunity for short-term cost savings logically relates to enhancing efficiency, value, and the experiences of those who account for the largest expenditures.

Emboldened by Ryan’s wisdom, I wonder if, despite the general consensus, we should explore the desirability of focusing first on children and child health services as the impetus for health care transformation. I wonder whether we can marshal support for such an approach, given the acknowledged long-term cost savings of early childhood investments extolled by Nobel laureate economist James Heckman, the near universal coverage and access of young children to health services (notwithstanding such threats to coverage as the failure to extend the Children’s Health Insurance Program), the many evidence-based interventions ready to be brought to scale and impact to promote children’s healthy development, the child health service sector’s recognition of the imperative of engaging other sectors (e.g., early care and education, family support) in comprehensive system building so critical to promoting children’s optimal health, the relatively modest cost of such child health services innovations, and the societal imperative to recognize children as our future. Indeed, I suggest that the answer to such musings is in the affirmative.

Should we therefore agree to advance transformation of our health care system by focusing first on child health services, I wonder about the impact of bringing to scale and sustainability the many critical innovations advanced by Connecticut Children’s Office for Community Child Health. In the spirit of Ryan, couldn’t we at least ensure that all families have ready access to community-based programs and services to address their concerns for their children’s development? That care coordinators from various child- and family-serving sectors work together to ensure that all families have access to beneficial services? That all children with asthma benefit from a model of care that decreases emergency department visits, hospitalizations, and school absences? That all children with mild to moderate developmental or behavioral concerns receive an efficient, timely, and effective assessment? That all families live in homes from which health and safety hazards are removed? That all youth benefit from education that prevents the spread of HIV and sexually transmitted diseases? That all primary care providers expand the care they deliver by embracing guidelines that allow co-management with subspecialists of certain conditions within their practice? That all children and families benefit from critical policy changes that keep Connecticut residents safer? That all child health providers have access to office-based training on new developments in pediatric primary care? That Hartford’s young children benefit from a two-generation approach to obesity prevention and wellness promotion? That all child health providers have support to facilitate the implementation of quality improvement projects in their practices? That education ensures that pediatric trainees become future leaders in the areas of advocacy, community health, and public policy?

My wonder about such advances is not predicated on whether we have the evidence-based innovations to enable such outcomes. In fact, programs of our Office for Community Child Health are currently addressing and advancing such innovations. Rather, I wonder if we have the vision, commitment, and perseverance to demonstrate the efficacy of such a “child first” agenda. Couldn’t we at least try? The ultimate rationale for such effort is informed by the most important of Ryan’s questions, that of What truly matters? The answer is, quite unequivocally, the well-being of our children.

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine.  Learn more »

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