53206 Decimated

October 14, 2016

CHW LogoSome words don’t mean what we think they mean.  Consider the word “decimate,” often used to mean “destroy completely,” as in “Hurricane Matthew decimated entire communities in Haiti.”  Yet decimate literally means to destroy one-tenth; it refers to a Roman military practice of killing one in ten men in a unit to punish mutiny or rebellion.  It has come to have a more global connotation because, well, the loss of one in ten people strikes most of us as pretty catastrophic, nearly inconceivable.  Think of how much worse a greater loss would be.  What if the Romans had killed one in two, or more?

That’s the level of devastation in the northside Milwaukee neighborhood in zip code 53206, one of the poorest areas in the state.  It also has one of the highest incarceration rates in the world.  (Yes, you read that right.)  62% of the men in that neighborhood are incarcerated or under correctional supervision (probation or parole).  The rate for the US as a whole is 2.8%.

Last week Children’s hosted a screening of a moving new documentary called Milwaukee 53206 which portrays the effect of mass incarceration on the people in this neighborhood.  The film does not take a political stance on the issue of mass incarceration.  Specifically, the high incarceration rates among African-American males (the population of 53206 is 97% black) is not portrayed as intentionally racist.  Rather, for a variety of reasons, policies enacted from the 1970s through today have caused the incarceration rate to skyrocket, with a disproportionate impact on African-American communities.  Take the war on drugs.  Currently, more people are arrested for marijuana possession than for all violent crimes combined.  Rates of arrest, prosecution, and sentencing for drugs are higher for blacks than whites despite similar rates of drug use.  In Wisconsin, “truth in sentencing” legislation has resulted in people serving terms far longer than originally intended.  And while over the course of American history the correctional pendulum has swung between emphasis on harsh punishment and meaningful rehabilitation, the system is more punitive than restorative at present, leaving those who have been imprisoned at some point at a long term disadvantage when they are released.  No matter how well intended these policies might have been, the detrimental effects are no less real.

We had the added bonus of a panel discussion featuring three of the individuals in the film after the showing.  What struck me the most after seeing the film was the impact on children.  Dennis Walton, Outreach Coordinator for the Milwaukee Fatherhood Initiative, described a prison class he recently ran.  Among the 50 men in his group, they had 210 children.  210 children who have therefore suffered one of the most devastating adverse childhood events you can imagine, the loss of a parent, with all of the attendant short- and long-term consequences.  Indeed, in 53206, more than half of all children can expect to experience the same loss.  Thanks to mass incarceration, that community is worse than decimated.

Get The Lead Out

September 23, 2016

CHW LogoRemember the game of Clue?  “Colonel Mustard, in the Billiard Room, with the Lead Pipe.”  What if the lead pipe is dangerous even if it’s not being wielded by the vicious colonel?  Since the story about severe lead contamination in Flint, Michigan surfaced, there is growing concern about lead in drinking water.  While lead isn’t actually good for anybody, it’s particularly a concern for children and pregnant women because of the effect of lead on brain development.  How much of a problem is it?

First, some context.  Lead was used for centuries as a material for water pipes (indeed, the word plumbing comes from the Latin plumbum, meaning lead.)  After the mid-1940s this was largely phased out in favor of copper, but through the 1980s lead-based solder continued to be used.  Thus, most homes and buildings built before 1990 have at least the potential for a problem with lead in the water, as do most cities where the water distribution infrastructure is that old.  Like Milwaukee.

Now, for the most part lead likes to stay in the pipe, rather than getting into the water.  It mainly becomes a problem if the water is corrosive, leaching the lead out.  In 1991, the EPA issued the Lead and Copper Rule, pursuant to the Safe Drinking Water Act of 1974.  This rule requires water utilities to control the corrosivity of its water, which is the simplest way to mitigate the problem.  In Flint, the water utility changed its water source to one that was much more corrosive, and failed to add the required treatment agents.  That is what created the crisis there.  (There was a similar problem in Washington DC in the early 2000s due to inadequate corrosion control.)  If the proper procedures are being followed, the risk is considerably reduced throughout the water system.  Water systems in Milwaukee and surrounding communities follow the procedures and meet the requirements for lead levels. (If you have a question about the quality of your water, you can get the annual Consumer Confidence Report for your water utility.)

Another vulnerability is when the pipes are physically disrupted, such as when a segment is damaged or replaced. This disruption can release lead into the water, an effect that is usually transient.  In homes with lead pipes or solder, it is recommended that when repairs are needed, all the piping should be replaced at once.  Since this is very expensive, few homeowners or landlords do that.  So for the most part, lead in water is not a widespread problem in this community, but it can be for an individual home.  Or school.  Or day care.

So how much should residents of Milwaukee worry about lead in the water?  Toxicologist Dr. Mark Kostic, of the Wisconsin Poison Center, urged a balanced perspective in an interview on WUWM.  He correctly notes that the much bigger concern remains other environmental sources of lead, including paint and soil.

However, for those in older homes who are concerned about the potential for lead in the water, parents can take a number of steps to protect their children.

  • Have their child screened for lead poisoning according to guidelines from the American Academy of Pediatrics. This includes a risk assessment starting at age 6 months, with blood lead testing for children identified as at risk.
  • If a child is found to have elevated lead levels, the public health department should investigate to identify the causes, which should be addressed.
  • For infants being fed formula reconstituted with tap water (a group particularly at risk), consider having home lead water levels tested through the local health department. Alternatively, run cold water (not hot) for 5 minutes before using it to mix with formula.  Filters are available, but these need to be replaced regularly and the cost can add up.  Bottled water is an alternative, but while the risk of lead is lower, it does not provide fluoride which is important for infant dental development.

Natural Healing

August 8, 2016

CHW LogoJust thinking about my upcoming vacation to Acadia National Park, I can feel my stress-induced canker sores melting away.  It’s partly about the time off, and partly about being with family.  Yet there’s something about being in a beautiful natural environment that is especially relaxing.  And healing.  In fact, the health benefits of nature are now sufficiently well understood that in some countries it is becoming common for physicians to prescribe “forest bathing.”

While extended periods in the woods provide even greater benefits – lower blood pressure, decreased levels of stress hormones, higher natural killer cell activity – even a brief stroll can be good for you.  I am grateful to work on a campus that includes green space, including some beautiful woods that used to be part of the county sanitarium.  (Woods that I hope will continue to be preserved in the face of regional development.)  Some days I simply wander over during lunch for a 20-30 minute walk.  It’s amazing how quickly one can forget you are in an urban area, in the midst of a major medical and research center.  And how quickly you can forget the looming deadlines, or the upcoming budget discussions, or the last person who pissed you off.

OK, off to Maine.  For those of you staying home, try the woods across the street.

Kids Deserve The Best

July 25, 2016

CHW LogoSimple.  Declarative.  Forceful.  This isn’t just a fluffy, sentimental, feel-good statement.  This four word sentence is a point of advocacy, a recognition that for too long, and still too often, kids don’t actually get the best. It calls attention to ongoing disparities for kids in health care and other areas of society.  For example, while the overall poverty rate is 14.5%, it’s 22% for children. Only 60% of medications used in both children and adults are approved for and have information on pediatric usage. And payment rates for Medicaid, the primary government insurance for children, are lower than for Medicare, which covers adults.

Few people would disagree with the notion that kids deserve at least as good as adults get.  So why do society’s results fall so short of its ideal?  In many ways, the deck is stacked against children’s issues.  Kids don’t vote.  (And they don’t make campaign contributions.). And because they are basically healthy, while children are 28% of the population, they represent only 13% of all health care spending.  So it makes sense that politicians and policy-makers, and health business leaders, are focused more on adult issues.

Now, saying kids deserve the best doesn’t mean adults don’t, too.  Advocating on behalf of kids to bring them to par doesn’t mean I’m advocating against adults.  I’d love for everyone to have a lower poverty rate, or universal access to medications.  But saying “everyone deserves the best” obscures the message that kids have been missing out.  So with all due respect to my fellow adults, I’ll continue to work to ensure kids get what they deserve.   The Best.

Hit the Trail

July 20, 2016

CHW LogoAs I often do, I had a wonderful run early this morning on the Hank Aaron State Trail!  Extending 12 miles from Lakeshore State Park, just south of Discovery World, to 124th St (the portion west of 94th is unfortunately closed during the Zoo Interchange construction), the HAST provides a vital east-west link in the 117-mile Milwaukee County Oak Leaf Trail system.  While there are many wonderful trails in the Milwaukee area (as described by the Journal Sentinel’s talented outdoor writer Chelsey Lewis), the Hank Aaron is one of my favorites.  Love the combination of seeing the Menominee River, the historic Soldier’s Home, Miller Park, and the now re-industrialized Menominee Valley.  One of the joys of being out on the trail is seeing the vibrant mix of bicycle commuters from Tosa and the east side of Milwaukee (including at least a few Children’s Hospital providers and staff!), along with the predominantly Latino and Hmong families from the near south side neighborhoods through which the trail passes out recreating on the trail, all living out our value of health.

To support that value of health, Children’s Hospital of Wisconsin is a sponsor this year of the annual Friends of Hank Aaron State Trail 5k run, on Saturday, August 6th.  Proceeds from the run support not only trail maintenance and enhancements, but also programming such as the free Bike Adventure Camps for disadvantaged children from the adjacent communities.  It’s a great way for Children’s to partner with other community organizations to provide opportunities for kids in the area to become the healthiest in the nation.

As part of our sponsorship, we have a limited number of complimentary entries for the run.  If you are interested in joining, please contact Robin Pitts.

Wait For It…

July 15, 2016

CHW LogoSeveral years ago, we had an exchange student from Norway who needed to see a specialist periodically to have a cyst drained.  The day before a big school dance, she told me she needed to go get it taken care of before the dance.  As in, that afternoon!  I explained to her that in the US you can’t simply see a subspecialist to get a non-emergency procedure done at a moment’s notice.  We have these things called appointments.  And you have to make them.  In advance.

Was this just a cultural difference in expectations based on better medical care access in Scandinavia?  (It turns out you can’t just waltz into the ENT office same day in Norway, either.)  Or was it typical Millennial insistence on instant gratification?  Either way, she asked if maybe she could find someone else to do it.  I then explained that her doctor was one of the best, and no, we weren’t going to find just anyone, who might not do as good a job – quality is worth waiting for.

A lot of us in health care tend to rationalize this way.  Quality is most important; convenience is just a frill.  We feel pretty good if our time to next appointment is “only” a week or two.  Yet I routinely get requests from people inside the system who have to wait that long for a family member to see if there is anything that can be done to get them in sooner.  I heard a colleague at another hospital talk about how nearly every day she helps friends and “important donors” get quicker access.  Not only does this create a two-tiered system of easy access for those with connections while regular folks have to wait, it belies the assertion that convenience isn’t important.  Timeliness is one of the six domains of quality espoused by the Institute of Medicine. And while we tend to associate such impatience with the Millennial generation, it appears to be pretty important to the Boomers whom my colleague keeps listed on her phone.

Data from a Healthgrades survey in 2014 suggest that in choosing a physician or hospital, convenient location and hours were cited as factors far more often (56-62%) than outcomes (22-30%).  While this may be accelerating, this has been true for some time: a 2000 study from University of Nebraska of factors used in choosing a primary care physician found that wait time for an appointment was as important as whether she/he had any malpractice history, and more important than factors such as the doctor’s training or years of experience.

To the extent that the prioritization of convenience is a bigger issue for the Millennial generation, then those of us in pediatric health care need to be especially ready to address this, as the Millennials are the parents of our patients.  And they aren’t willing to wait for what they want.


June 17, 2016

CHW LogoThe first time I saw a TV ad for a prescription medication (direct-to-consumer advertising was made legal in 1985), I was appalled.  Not only because of the long list of potential side effects – which as I recall included both flatulence and death) – but the whole concept that companies would try to market something as complex as a drug the same way they would treat floor wax or breakfast cereal.   Health care is not a consumer good!

Well, it’s become clear that health care is, in fact, a consumer good, and those of us who provide health care need to accept that and understand how consumers make decisions about it.  Even when we grudgingly admit that people may be doing some “shopping” for their medical care, we tend to think that health care is still very different.  In some ways that is certainly true.  For example, measuring and reporting on quality is far more challenging in health care.  And there is considerably less ability for consumers to get information on medical cost than for almost any other product or service.  But as a 2015 McKinsey study showed, the factors used by consumers to rate health care and non-health care companies are nearly identical: the top 4 were (in order) customer service, “delivering on expectations,” convenience, and “offering great value.”

It may be that these other factors are merely proxies for actual quality measures.  As noted in a Deloitte report:

Quality tends to be defined with professionals in mind. In lieu of understanding clinical quality, consumers may substitute cost, convenience, and customer experience for quality. Consumers may well equate quality with cost, assuming a direct relationship between the two.

Certainly, health providers like to think that when it comes to picking a doctor or hospital, quality is most important and trumps everything else.  But maybe not so much.  Another McKinsey study found that although patients stated that clinical outcome was most important to them, experience was actually more highly correlated with willingness to choose that provider again.  And cost is increasingly a factor.  In a 2015 survey by FAIR Health, 48% of all respondents indicated they always or usually considered cost when selecting a doctor.  And despite a widespread belief that cost is no barrier when it comes to health care for children, it actually appears to be more important for the generation with kids.  In this survey, cost was more often cited as a key factor for those age 18-44 (58%), those with children (56%), and women (53%).

We can wish away consumerism (and TV ads).  Or we can deal with it.  That doesn’t mean sacrificing quality.  We need to maintain our commitment to the best and safest care.  At the same time, we also need to address families’ real concerns about cost, convenience, and experience.  It starts with one element of our service promise: “I will strive to understand what matters most to you.”  If we don’t know what consumers value, we can’t provide it, or help them navigate the choices they must make.

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