comment 1

Special Messengers: Physician-Advocates

Do you remember the last time your insurance denied payment for a visit or procedure you had or your gym double charged you for your membership fee? What did you do? Did you sit back and say — “Well, they must know better than me — I’ll just accept their decision.” Or, did you call up and say, “Excuse me, but I believe there has been an error and I’d like you to fix it.” My guess is, you did the latter. What you did was advocate for yourself.

Advocacy is “the act or process of supporting a cause or proposal; the act or process of advocating something.” Advocacy can happen at a wide variety of levels and in a wide variety of forms. It includes everything from the sort of self-advocacy above, to a parent meeting with a teacher to devise a plan for a child struggling in school, to a phone call to your congressional representatives’ offices to let them know that you really care about a given issue — the environment, health care, education — and that you are paying attention to whether they vote in a manner that is in line with those views.

Physicians can play a very special role in advocacy. Society offers physicians a great deal of respect and deference, which can be a tool for making real change, for truly making the world a better place. A physician can talk about what they see in their clinical time and the impact that social or other problems and policies have on their own patients, giving extra credence and weight to a discussion of scientific evidence. When a physician weighs in on issues, particularly those that are not strictly health care focused, like housing, the environment or education, people listen. This special or unusual messenger status is a powerful tool and must be responsibly used. Partnering with other non-clinical professionals can make the work of advocacy on the one hand, less intimidating and, on the other hand, much more effective.

This kind of partnership is the cornerstone of the work I do as the research and policy director of Children’s HealthWatch. We are an interdisciplinary, non-partisan research and policy network of pediatricians and public health researchers, child health and policy experts. Our mission is to improve the health of young children by informing policies that address and alleviate economic hardship. We collect data in urban medical centers in five cities by conducting interviews with caregivers of very young children. Our goal is to produce research on relevant policy issues of the day that then help to provide the foundation for evidence-based policy — this is a form of legislative advocacy. Our work has covered the gamut from housing to health care to food assistance programs.

Every five years, Congress reauthorizes the Child Nutrition and WIC Reauthorization Act, known as CNR, which governs all the nation’s child-related nutrition programs from school breakfasts and lunches, after-school snacks and meals, meals in child care, to food assistance for very young children under the age of five. This legislation sets funding levels and all the rules and regulations that guide these programs, including eligibility. These reauthorization periods provide the opportunity for people connected to the issues at all levels to provide their recommendations about how to improve the relevant programs. Input from physicians is especially helpful during these periods.

Knowing that Congress would be considering CNR during the summer and fall of 2015, we began last year to think about what we could study that would be useful for the expected debates about changes to the programs. An issue that had arisen over and over among our clinician-investigators’ patients was that children from low-income households can only receive benefits from WIC, the Special Supplemental Nutrition Program for Women, Infants and Children, up to their fifth birthday. For many children, there is then a quick transition into the school setting and eligibility for school meals. However, for some children, their birthdate falls after the date cut-off for entry into kindergarten. These children have to wait, sometimes up to a year, to be eligible for kindergarten, and therefore, also for eligibility for the nutrition support provided by school meals. For families struggling to afford enough food due to economic constraints, food insecure families, this wait can mean a period of deprivation for the child — causing them to miss out on key nutrition in a critical period of their growth and development.

Therefore, led by our principal investigator, pediatrician Dr. Diana Becker Cutts, we undertook research using data from our families in Minnesota and found that compared to children who discontinued their participation in WIC, children who stayed consistently connected to WIC had lower rates of obesity and being overweight and higher rates of being judged as a “well” child. Based on these findings, one of our recommendations was to extend WIC to age six to catch the children falling in this gap between programs.

Over the years, we have developed relationships via phone calls, emails and in-person meetings with members of Congress and their staff interested in the issues we study. Our team shared the WIC findings with the office of Representative Rosa DeLauro, a Democratic representative from Connecticut, and she and her staff immediately saw that this was a policy problem they could help to solve. They were thrilled to back up their policy proposal with science as well as a pediatrician who could speak from clinical experience about the importance of both WIC and fixing the age gap. They also reached out to other organizations, like the National WIC Association, to ensure that this bill was a useful course of action. With that, the Wise Investment in Our Children Act was born and filed as legislation for consideration in CNR. Congresswoman DeLauro issued a press release quoting Dr. Cutts:

WIC hits a research-based, cost-effective, proven home run for my youngest patients. At first base, it begins with enhancing prenatal nutrition before birth, at second base it increases access to healthy nutrition for infants and kids, at third base is WIC’s on-going nutrition education and guidance for parents. Ensuring that young children receive these essential supports until age six without a gap, as the Wise Investment in our Children Act would do, would help bring kids into home base with the healthy start in life they need and deserve.

Congress has been in tumult for some time, but especially in the last few weeks. So, unfortunately it seems that this will not be the year in which WIC is extended up to age six; in fact, it is unclear if CNR will get passed at all this year. However, the process of filing and promoting the bill with a strong, research-based and physician-backed message, brought a lot of attention to the issue, which will make it easier to promote at the next opportunity.  We hope to use this momentum to propel the policy forward in the future.

Your voice as future physicians is a valuable one. Think about the issues that drive you and use your voice to make change happen at the local, state or federal level. Don’t be discouraged if change does not happen right away — much like introducing vegetables to children; sometimes a bill has to be offered several times before it passes!

Stephanie Ettinger de Cuba Stephanie Ettinger de Cuba (1 Posts)

Guest Writer

Stephanie Ettinger de Cuba is the Research and Policy Director for Children’s HealthWatch, a non-partisan pediatric research and policy network focused on improving the health and development of young children by informing policies that address and alleviate economic hardships, like hunger, trouble keeping the heat or lights on, or unstable housing. In this role, she oversees the network’s data collection, research and preparation of publications. She has co-authored more than 65 research and policy publications on a variety of subjects from food to housing to health care. She collaborates extensively with policymakers and advocacy organizations to disseminate Children’s HealthWatch original research. Prior to joining Children’s HealthWatch, Ms. Ettinger de Cuba worked at Project Bread – the Walk for Hunger, a statewide anti-hunger organization in Massachusetts. There, she focused on SNAP (formerly food stamps) policy and outreach and was the evaluator and interim project director for USDA grants to develop and pilot Massachusetts’ first SNAP website and online application. Ms. Ettinger de Cuba previously worked for the Agricultural Health Study at the University of Iowa, College of Public Health and served as a Peace Corps Volunteer in Bolivia focused on small-scale agriculture and nutrition and hygiene education. Ms. Ettinger de Cuba received her BA from the University of Michigan and her MPH in International Health from Boston University School of Public Health, where she is also currently a doctoral candidate in Health Services Research.

  • Katherine Joyce

    Fantastic piece – I hope today’s med students are inspired to do this kind of advocacy in the future so groups like CHW can continue the fight for kids!