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Introduction

Socioeconomic conditions are known to be major determinants of health at all stages of life, from pregnancy through childhood and adulthood. “Life-course epidemiology” has added a further dimension to the understanding of the social determinants of health by showing an association between early-life socioeconomic conditions and adult health-related behaviors, morbidity, and mortality. Sensitive and critical periods of development, such as the prenatal period and early childhood, present significant opportunities to influence lifelong health. Yet simply intervening in the health system is insufficient to influence health early in the life course. Community-level approaches to affect key determinants of health are also critical. Many of these issues were raised in the 1995 National Academies report Children’s Health, the Nation’s Wealth: Assessing and Improving Child Health. The present workshop builds upon this earlier report with presentations and examples from the field.

In his welcome address to the workshop participants, John E. Maupin, Jr., of the Morehouse School of Medicine expressed optimism that both the health care delivery system and the health status of children can be improved, and perhaps more importantly, a culture of wellness can be created in communities by educating parents and fostering prevention.

Gary Nelson, of the Healthcare Georgia Foundation, noted that the workshop program was grounded in science, built on partnerships, and focused on results. Nelson said that the workshop holds a special significance for the host city, Atlanta, for the state of Georgia, and for the southeast region, as they know firsthand the effect of the enduring gaps in education, health, income, and opportunity.



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1 Introduction S ocioeconomic conditions are known to be major determinants of health at all stages of life, from pregnancy through childhood and adulthood. “Life-course epidemiology” has added a further dimension to the understanding of the social determinants of health by showing an association between early-life socioeconomic conditions and adult health- related behaviors, morbidity, and mortality. Sensitive and critical periods of development, such as the prenatal period and early childhood, present significant opportunities to influence lifelong health. Yet simply intervening in the health system is insufficient to influence health early in the life course. Community-level approaches to affect key determinants of health are also critical. Many of these issues were raised in the 1995 National Academies report Children’s Health, the Nation’s Wealth: Assessing and Improing Child Health. The present workshop builds upon this earlier report with presentations and examples from the field. In his welcome address to the workshop participants, John E. Maupin, Jr., of the Morehouse School of Medicine expressed optimism that both the health care delivery system and the health status of children can be improved, and perhaps more importantly, a culture of wellness can be cre- ated in communities by educating parents and fostering prevention. Gary Nelson, of the Healthcare Georgia Foundation, noted that the workshop program was grounded in science, built on partnerships, and focused on results. Nelson said that the workshop holds a special sig- nificance for the host city, Atlanta, for the state of Georgia, and for the southeast region, as they know firsthand the effect of the enduring gaps in education, health, income, and opportunity. 

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2 FOCUSING ON CHILDREN’S HEALTH SCOPE OF THE WORKSHOP On January 24, 2008, the Institute of Medicine’s Roundtable on Health Disparities; the Institute of Medicine’s Board on Children, Youth, and Families; the Satcher Health Leadership Institute of the Morehouse School of Medicine; and the Healthcare Georgia Foundation cosponsored a public workshop to discuss in depth the important foundations of adult health that are laid prenatally and early in childhood. Nicole Lurie, chair of the IOM Roundtable, noted that those who study the health care system and those who study social determinants of health do not have many oppor- tunities to interact with one another, either on an academic level or on a community level. As such, the workshop, entitled “Investing in Children’s Health: A Community Approach to Addressing Health Disparities,” was designed to continue to advance the dialogue about health disparities by facilitating discussion among stakeholders in the community, academia, health care, business, policy, and philanthropy. Workshop speakers were asked to do the following: • escribe the evidence linking early childhood life conditions and D adult health. • iscuss the contribution of the early life course to observed racial D and ethnic disparities in health. • ighlight successful models that engage both community factors H and health care to affect life course development. David Satcher, 16th surgeon general of the United States and director of the Satcher Health Leadership Institute, presented the keynote address to the Roundtable, describing investments in children’s health and how policy can affect children’s lives. The foundation for discussion was then set by the presentation of two review papers, one by Bernard Guyer of the Johns Hopkins Bloomberg School of Public Health, analyzing the economics of early childhood interventions, and one by Charles Bruner of the Child Family Policy Center and Edward Schor of the Commonwealth Fund, addressing clinical practice and community building. The practical issues of implementing health policies directed toward children were discussed by Christine Ferguson of the George Washington University Department of Heath Policy and Yvonne Sanders-Butler of Browns Mill Elementary and Magnet School in Georgia. Mildred Thompson of PolicyLink and co-chair of the Roundtable pro- vided the workshop participants with an opportunity to preview a segment of a forthcoming PBS documentary series entitled Unnatural Causes: Is Inequality Making Us Sick?, which explores socioeconomic and racial ineq- uities in health. The segment screened at the workshop, entitled “When the

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 INTRODUCTION Bough Breaks,” addressed the disproportionate infant mortality rates and preterm births of African American women. The video and the discussion that followed are discussed in greater detail in Appendix D. Examples of community development approaches in the host city, Atlanta, were discussed by Veda Johnson of Emory University School of Medicine; Marshall Kreuter, Roddie Longino, and Travie Leslie of Georgia State University; and Wayne Giles of the Centers for Disease Control and Prevention (CDC). Finally, the role of the business sector in improving com- munities and fostering health was discussed by Sandra White of WellPoint, Inc., Michelle Courton Brown of Bank of America, and Maureen Kelly of the ING Foundation. KEY THEMES Throughout the day, workshop participants highlighted several recur- ring themes: • ction: The roles of social, racial, and economic determinants of A health are well known. Several participants noted that although continued documentation and analysis of disparities is still needed, what is really needed now is action. The success of model programs shows that disparities in health are not insurmountable. • ircular: Workshop participants discussed the social, environmen- C tal, economic, and genetic influences that affect the health of a child. The health status of the child, in turn, affects total child development and well-being, including education, social develop- ment, economic welfare, and justice. • ommunity involvement: Speakers and workshop participants C alike noted that successful interventions involve the community as a full partner in the process. Identification of health challenges and priority concerns, and the development of intervention strategies suited to a community’s needs and culture, cannot be done without the input of the community members. • oordination: As described by several presenters, there are many C effective strategies in use in communities throughout the coun- try. However, they further stated that there is a need for a more nationally coordinated effort, moving beyond individuals and communities, to systems-level change. Information about success- ful models needs to be disseminated so resources are not wasted through creating same or similar interventions anew from program to program. • ommunication: Workshop participants discussed the need for C better communication in order to foster communication among all

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 FOCUSING ON CHILDREN’S HEALTH people and organizations involved in addressing health disparities, including among and within government agencies. A clear, carefully framed message, with supporting data where possible, is needed to convey the importance of addressing disparities to policy makers and to gain their support of programs. • ustainability: Finally, speakers and workshop attendees repeat- S edly raised the issue of grant funding, philanthropy, and govern- ment programs that provide a limited amount of funding for a finite period of time, often only a few years. A role for sustainable funding sources was described in the workshop as being critical in achieving nationwide, multigenerational success in eliminating health disparities. ORGANIzATION OF THE REPORT The report that follows summarizes the presentations and discussions that occurred during the workshop. Chapter 2 reviews some of the statistics on health disparities and describes the four major determinants of health defined in Healthy Peo- ple 200: access to care, environment, genetics, and behavior. Chapter 3 includes Guyer’s presentation of the paper, “A Systematic Literature Review and Economic Analysis of Intervention in the Preschool Period,” describing the costs and consequences of interventions available to improve the health of children from birth to age 5, including the prenatal and preconception periods. Four areas of preschool child health were reviewed including tobacco exposure, obesity, injury, and mental health. Bruner presented a paper he coauthored with Edward Schor of the Commonwealth Fund, entitled “Clinical Practice and Community Building: Addressing Racial Disparities in Healthy Child Development.” The paper calls for a broad focus on total healthy child development, leading not only to improved child clinical health outcomes, but also improved outcomes including education, social development, and justice. Chapter 4 discusses how the implementation of health policy can not only have far-reaching effects beyond the health of an individual child, touching the overall well-being of families and communities, but also how health policy can go beyond health, influencing education, economic wel- fare, and other aspects of a child’s life. Ferguson spoke about the practical issues of implementing health policy and provided data from several suc- cessful policy programs. Sanders-Butler discussed the innovative health initiative that she has implemented in her school. “Healthy Kids, Smart Kids” supports academics and fights childhood obesity by giving students the information they need to be empowered to make healthy decisions. Chapter 5 highlights three community-based approaches that are mak-

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 INTRODUCTION ing a difference at both the local and national levels and that serve as exam- ples of how individuals and communities can improve the health and lives of children. Johnson spoke about the Whitefoord Community Program she helped to found, which empowers residents of the Whitefoord Elementary School area to improve the health and education of their children. Kreuter and two of his colleagues who are community health workers, Roddie Longino and Travie Leslie, described their Atlanta-based initiative entitled “Accountable Communities: Healthy Together (ACHT).” ACHT is a com- munity-based, participatory research effort funded by the National Center on Minority Health and Health Disparities. Giles provided an update on the progress of the “Racial and Ethnic Approaches to Community Health” (REACH) program. REACH communities are working toward bridging gaps between the health care system and the community; changing their social and physical environments to overcome barriers to good health; implementing strategies that fit their unique social, political, economic and cultural circumstances; and moving beyond individuals to community- and systems-level change. The open discussion that followed focused on budget issues and sustainability. In Chapter 6, representatives from the business sector discussed their interests and investments in health and the role of business in improving communities and children’s lives. White presented the perspective of a major health plan, WellPoint, Inc., an independent Blue Cross/Blue Shield licensee serving Georgia. Courton Brown also discussed a company’s role in improving health in two different communities, the internal community that is the employees, and the external communities where the employees live and where the company does business. Kelly described ING’s initiative to combat childhood obesity by sponsoring school-based running programs. Courton Brown and Kelly both provided perspective on why a non-health care company would invest in health. Chapter 7 includes final comments from members of the Roundtable and the workshop audience. Discussion focused on sustainability of inter- ventions, the link between spirituality and health, education of the next generation of physicians, and need for a social movement to bring everyone together and address health disparities nationally. Workshop chair Nicole Lurie provided closing comments. Further information is provided in several appendixes. In addition to the meeting agenda (Appendix A) and biographical information about the speakers (Appendix B), websites for a number of the resources and model interventions discussed throughout the workshop are included in Appen- dix C, and the discussion of the video presentation Unnatural Causes is included in Appendix D. Appendix E is Bruner and Schor’s commissioned paper.

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