January 28, 2014
My Dear Colleague Jeff Bergstrom:
The interaction you had with the couple in the restaurant in June 2013 was fascinating, scary and probably an honest summary of some of the mis-information and the biased thinking that dominates segments of this country. I have been told that it is difficult to reason someone out of something that they have not been reasoned into. This may be one of those conversations. But I wonder where the ideas about children in foster care came from? It is hard to imagine abuse and neglect being targeted at children - particularly when you have some of your own. My parents would do anything to improve the status of their children, and I would do the same for mine. They say that fruit does not fall far from the tree. I believe this - and I count on it.
At one time I served as Deputy Health Director for the County of San Diego (1980-96). Dr. David Chadwick was the physician-leader in the Department of Social Services for foster care and Clinical Director of Center for Child Protection at Children's Hospital. He was responsible for the medical care aspects of the foster care system until he retired in 1996. I was running a pilot project for dissemination of the first electronic medical record system developed by the National Center for Health Services Research, which began in 1981. It was called COSTAR. Had we been successful, I would have partnered with Dr. Chadwick and built an electronic Health Passport, a multi-site health summary that had previously been crafted in paper. It is only within the last two years that I became aware of the potential impact of Adverse Childhood Experiences (ACE) on young people - and how these experiences evolve into adulthood. When we look at adult chronic disease mortality by ethnicity (even when we control for income), we find significant gaps in health status – (both class and race).
Might it be that poverty sets the stage for the sadness, the depression, the hostility, the joblessness, the incarceration, the broken families - all of which are fuel for ACE. Do the same ACE issues arise in families which are not close to the poverty line. It seems to me that if this work has been examined and various solutions exist, there might be an opportunity to spring into action. If this work has not been pursued, maybe we can integrate what we know and what we now believe into a model that will provide mentoring to parents (and to family support groups) to provide gradual transition into tighter, more supportive, more accountable social structures. What kinds of conversations (or site visits or pilot projects) do we need to foster with our children, to bring a more focused perspective into their reality? Maybe the world has already changed and they need to craft their own solutions. What I do know is this – as an African American man, I felt dismayed and ashamed when it was clear that I belonged in the back of the bus. And if reading and study and academic performance would empower me to inch my way to the front of the bus - this was the price that I should pay - and I did pay. So now we are examining diabetes, looking for mechanisms we can craft to stimulate behavior change that will help close the health status gap. This means steps related to medication management, monitoring blood sugar levels, stimulating exercise of one kind or another, and promoting fruits and vegetables over chips and salsa. But where is the prevention agenda going to take us – and how can we craft messages that will not be ignored. This is what cultural competency means!!
These are difficult times. Anyone who has a model worthy of analysis or insight should write me at the email address: simmstech@cox.net. I would appreciate any suggestions you (all) may have. This is our turn to conduct research, but research driven by the events we see on the ground. We conducted “house call” site visits into barber shops and churches last year to screen for high blood pressure and diabetes, as part of the Men's Health Project (San Diego Black Health Associates, Inc. - www.sdbha.org). Many consumers welcomed our presence, particularly as we had made arrangements for immediate follow-up and further testing and then treatment. We did NOT EXPECT reluctance and non-cooperation from a sub-group who preferred that we should go away. The clinical trials we are now trying to design get to the crux of grace, self-confidence, resilience, mental clarity and recognizing your own personal rhythm.
Anyway, there are opportunities for new reimbursement models and the health care system will soon be more inclined to compensate with incentives for healthy outcomes. This shift away from fee-for-service is a natural outcome of a health plan written by insurance companies.
This change in provider payments MAY also stimulate the opportunity for us to introduce another vector - the importance of ACE on health and wellness.
Be well.
Paul B. Simms, MPH, Visiting Scholar
Claremont Graduate University