Teddy in blanket
Category: Children's Health, Health Magazine

Title:Children’s health equity through community care

Author: Jane Varner Malhotra
Date Published: November 17, 2021

Answering the call to serve families in need

When Staceyann Smith, MD, MPH (NHS’09), began practicing pediatrics in the Bronx, New York City’s northernmost borough, she knew she was choosing a challenging path. As a daughter of immigrants, she wanted to serve a community with great need. The families she works with face daily hardships that can make even getting to a routine doctor visit difficult.

“We see only a snapshot of how much some families deal with,” she says. “We have to try and support them as best we can.” Many of her patients come from single-parent households, many are struggling immigrant families, and many are living in poverty. They face racial bias on a daily basis, Smith adds, compounding socioeconomic adversity with discrimination that can lead to significant impact on parents’ and children’s physical health.

“We have lots of room to grow in reducing children’s health disparities,” says Smith, pointing to the high rate of COVID-19 in her community during the early months of the pandemic last year. “Look at the people who were dying here during the pandemic—it was minorities. They couldn’t leave the city. They were left with no other options. They had to pay the rent, go into work, and when one person got sick, everyone got sick. So many lost multiple people in their families.”

A New York City native, Smith knew she wanted to practice pediatrics in her home community. Photo: Phil Humnicky
A New York City native, Smith knew she wanted to practice pediatrics in her home community. Photo: Phil Humnicky

Many of her families depend on public transit, so coming in for regular appointments is difficult. Not all parents can take a few hours off work to take their kids to the doctor’s office, and not all offices are open during hours when parents are flexible such as after work or on weekends.

My heart has always been here, and the more I do this work, the more I realize why.

In the United States, three times as many Black infants die before their first birthday as compared to white babies. Startling statistics like high infant and maternal mortality among persons of color are marked in a box and collected as data, reflecting trends both in care and in the social determinants of health for children. But behind every number is a human story, one of people struggling to survive, let alone thrive.

Addressing Systemic Inequities

During her undergraduate years at Georgetown, Smith already knew she wanted to do pediatric medicine. She earned her medical degree and public health degrees at the University of Connecticut, with a focus on urban service. In medical school, she was also exposed to rural health issues through a student-run clinic they held for migrant farm workers. But she grew up in the city, and wanted to help the children there. Today her work at the Montefiore Family Care Center enables her to provide care in an underserved urban neighborhood with a large immigrant population.

“We offer a lot of resources for families,” she notes. Her clinic has an integrated behavioral health team, offering short-term mental health support. They have a nutritionist on staff, as well as a health educator, who serves as a lactation consultant, along with a community health worker and social worker. She also highlights their partnership with a legal aid office. “That’s been really important, in addition to our school health program throughout the Bronx. We offer health education, counseling, sick visits in schools—it’s a partnership to take care of kids through the school system because kids spend so much time there already.”

Their clinic is connected to a community health center, with food pantries, day care, and after school programs. This support for parents and families is all part of a more holistic approach to child wellness, to help address the systemic inequities that people living in poverty face.

Influenced by her childhood in the city, Smith was determined to give back and advocate for children who need the help. “I also wanted children who look like me to see a doctor who looks like them,” says Smith, who is Black. “My heart has always been here, and the more I do this work, the more I realize why.”

Key to her success as a pediatrician working to eliminate health disparities for children is partnering with the community. At Georgetown, Community Pediatrics follows a similar emphasis.

“For nearly three decades, MedStar Georgetown University Hospital Division of Community Pediatrics has provided place-based integrated primary care services to children and families in D.C.’s Wards 4, 5, 6, 7 and 8,” says Janine Rethy, MD, MPH, chief of community pediatrics and assistant professor of pediatrics at Georgetown University School of Medicine. The division currently operates two school-based health centers and a mobile medical clinic that parks at public housing communities chosen based on residents’ expressed interest and need. The clinics offer comprehensive primary care services with integrated mental health, nutrition, legal, and social work services.

“The clinics are designed to minimize barriers to care at every touchpoint—such as financial, transportation, communication access, connection to community partners—and to foster long-term trust,” Rethy explains. Wraparound support services include partnering with D.C.- based nonprofits No Kid Hungry and Power of 10 to address food insecurity by delivering meals and groceries weekly to families.

Partnering with the School of Medicine’s Department of Family Medicine and Division of Child and Adolescent Psychiatry, as well as MedStar Health Research Institute and many community, nonprofit and government partners, Community Pediatrics is helping lead MedStar’s Safe Babies/Safe Moms Program. It’s a five-year $30 million initiative funded by the A. James and Alice B. Clark Foundation’s Parent Child Health Initiative to decrease maternal and infant health disparities in the District through cross-sectional health systems transformation, with a strong emphasis on addressing social determinants of health and structural racism.

Partnering for Success

In addition to Community Pediatrics, Georgetown has a number of centers looking at child health, all emphasizing health equity as part of their work. The Center for Child and Human Development (CCHD) was founded over 50 years ago to improve the quality of life for all children and youth and their families, focusing on those with special needs. Today, driven by Georgetown’s values of social and health justice, the center partners with grassroots efforts in D.C. to transform health systems and support health equity for children in the District.

Children’s health begins before birth, of course, and Black maternal and child health disparities reveal persistent inequities. For example, in D.C., Black women give birth to a preterm or low birth weight baby at nearly twice the rate as their white peers. To help address the gap, CCHD supports maternal health work with local grassroots partners like Mamatoto Village, says Professor Deborah Perry, director of research and evaluation.

“We help elevate their home visiting program called Mothers Rising, which seeks to reduce disparities around breastfeeding and low birth weight. The program is run by Black women doing really innovative care with perinatal health workers, who are a cross between community health workers and doulas.”

Another longtime community partner of CCHD is Mary’s Center, founded by Georgetown alum Maria Gomez (NHS’77). They offer a program called Centering Pregnancy focusing on prenatal care as a bridge to parenthood. And Community of Hope is a CCHD partner implementing community-based doulas in areas east of the Anacostia River. The center helps these local efforts innovate and thrive by supporting their research and evaluation, supported by the D.C. Department of Health.

Within Georgetown, CCHD supports the Health Justice Alliance (HJA), which is a partnership between the Law and Medical Centers. One cornerstone of this work is the HJA Law Clinic in which a group of 12-14 law students each semester partner with Community Pediatrics and fourth year medical students to help address health inequities through a medical-legal partnership. The HJA has achieved successful outcomes in confronting unsafe housing, environments, and landlord violations that lead to asthma and other health complications.

Rethy has seen the impact firsthand. “In our clinic, almost 25% of our children have asthma, a rate three-fold higher than the national average. Why? These outcomes are the result of decades and decades of structural injustices in all sectors of public life.”

She recalls a 12-year-old patient who has had asthma since he was a toddler. Over the last few years, his symptoms grew worse and required several trips to the emergency room, despite increased medication.

“Then we started doing universal screening for social determinants of health and found out the family had significant mold and rodents in their apartment, and the landlord was not responding to their requests to clean it up,” says Rethy. Community Pediatrics and the Health Justice Alliance partnered with a local organization, Breathe DC, who did a home visit with the family’s permission, and was able to document the environment, provide short-term remediation, and worked with the landlord and D.C. Government to permanently fix the issues. His asthma improved to the point that he no longer needs inhaled steroids to control his asthma and needs only occasional albuterol treatment. His experience made a big impact on Rethy.

Rethy helps train the next generation of physicians at a recent mobile clinic in the District.
Rethy helps train the next generation of physicians at a recent mobile clinic in the District.

“This story inspires and humbles me, because it highlights that our medical training is just one small part of what it takes for child health,” she notes. “We need to create sustainable community-centered models that can see and address root causes. Day to day our team takes this approach one family at a time until the child and family have their needs met.”

Phyllis Magrab, PhD, pediatrics professor and director of CCHD, and Lucile Adams-Campbell, PhD, co-chair the University-Wide Initiative to Reduce Health Disparities, which was launched in 2012 to amplify research, service, and outreach related to health disparities through the development of a campus-wide network and the creation of new opportunities for collaboration and community engagement. Today over 100 faculty are active members of the effort. Magrab says she’s heartened that public awareness around health disparities has grown over the past decade, with more data being collected and innovative solutions being implemented.

When you partner with the community, people are more likely to come to you for help.

Her colleague Perry cites a challenge academics have faced known as the “17-year gap”—the long time that it takes from research to impact, for knowledge about effective interventions generated from randomized controlled trials to be reflected in the care that people get in communities.

“Many of us have gotten impatient with that gap,” says Perry. “We have sought to partner with local organizations to bring interventions more quickly to scale in communities, providing training and technical assistance too.”

Read more in our sidebar A Stark Difference >

A Family Affair

“It’s important to not just look at child health in isolation,” says Perry. “We need to think about it in the context of the family and in the context of community.”

For those working in the field of children’s health, Smith recommends a close relationship with the patients’ community in order to have a positive impact on families.

“When you partner with the community, people are more likely to come to you for help,” she says. “In this last year after George Floyd’s death, you saw people at our hospital standing with each other and supporting each other. We have so much violence going on in the Bronx. When tragedies happen, speaking up and making your voice known in the community can have a positive impact.”

The job of a pediatrician is more than just seeing patients. “As doctors in communities, we’re not just coming to work and going home,” Smith says. “Through mentoring, providing resources, donating diapers, starting a food pantry—it doesn’t have to be a large gesture, but when things happen that impact your community, speak up, do what you can to support the community. Fundraise, donate, present at the school or community center, or offer programs within the parks or places where people gather. Partner with programs that already exist like the Boys and Girls Club or a health program, mentor in health, or collect funds for the pantry.”

For many health care workers, adding more to the to-do list can be overwhelming. For herself, Smith says what is essential is remembering why she went into medicine in the first place.

The clinics are designed to minimize barriers to care at every touchpoint—such as financial, transportation, communication access, connection to community partners—and to foster long-term trust.

“We want to help people and solve their problems, but sometimes we can’t in these overwhelming situations,” Smith says. “Listen to your patients. Families just want to be heard. Listen, be compassionate and gracious, and try not to make assumptions or judgments, because you never know the whole story. Especially in pediatrics. Parents always want to do the best for their children, even though they may not be able to in that moment.”

Read more in our sidebar Insuring Kids Health >

Rethy’s idea of how to be a pediatrician has changed dramatically in the last two decades.

“If you asked me 20 years ago what my pediatric practice would look like, I couldn’t have dreamed this up,” Rethy says. “We are absolutely committed to the principle that every child deserves the chance to be healthy and thrive and we feel privileged to have the trust of our families. So our model of care has evolved, and we will do what it takes to partner with our families and our community colleagues to that end.”

For nearly 30 years, the Kids Mobile Medical Clinic has provided holistic, integrated primary care at designated sites four days a week in Washington, D.C. neighborhoods.
For nearly 30 years, the Kids Mobile Medical Clinic has provided holistic, integrated primary care at designated sites four days a week in Washington, D.C. neighborhoods.

Smith finds hope in the resilience of the children she sees, and in the growing national conversation about social determinants of health, and building health equity.

“A lot of what we see is not new. As we continue to push a little and challenge the biases and health care disparities that we see, I think the resilience in these families will help them. There’s new national awareness about it. It’s being talked about more in the media. COVID-19 highlighted where we still need work, and I have hope we’ll make progress.”

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