From Where I Wake

My remarks this afternoon on the recent survey on Americans’ view of children’s health reflect the confluence of three personal vantage points: public health scientist, CityMatCH Chief Executive Officer and Executive Director, and local community leader. It has been eight years since my husband left the Harvard School of Public Health to head Preventive and Societal Medicine at the University of Nebraska Medical Center in Omaha. I went along, begrudgingly, and have since joined its pediatric faculty to lead research and education in community health and child health policy. From within the university, I have been able to grow CityMatCH into a vibrant national organization of urban public health department maternal and child health leaders and programs, and have become very active in community and civic affairs.

Moving from Boston to the Heartland required passage through a series of stages of understanding the views of new neighbors about children, children’s health, and children’s health care. I am in the final stages of grief. I no longer expend outrage at a State Senator’s assertions that no children are without health care in Nebraska because all doctors will see them for free if need be, and that emergency rooms are open 24 hours. I no longer become apoplectic at a business leader’s assertions that persistently high Black infant mortality is inevitable, that these infant deaths are acceptable losses at the hands of unfit teen mothers who conceived to increase their welfare benefits. I have come to appreciate that this Midwestern crossroads is perhaps far more reflective of Americans’ views than the insulated academic havens in which I lived and studied and worked on either coast. I have come to see that Omaha, the 45th largest city in the U.S., is more like most of the 200 U.S. cities over 100,000 in population, and as much an urban community as Chicago and the other handful of cities over one million, albeit at a greatly diminished scale.

From where I wake and shop and worship, the findings reported last December from the 1997 National Survey of Americans’ View on Children’s Health Care ring familiar. Nebraska license plates boast about "The Good Life." KidsCount indicators put this state of 1.6 million folks consistently among the ten best for childhood well-being, and the magnitude of most children’s health problems pale in comparison to other states. Yet there is a palpable unease about just how good that life is becoming. Omaha, the largest city of about 400,000, is seen by most "out state" as a menacing world apart. Its ills of drugs and crime are perceived as seeping into the social groundwater, poisoning the rest of Nebraska’s 77,000 square miles of mostly rural and frontier moral terrain.

Almost all Nebraskans get their news from Omaha or Denver markets. The lead story on Channels 3, 6 or 7 is about gang and drug-related crime or about erupted family violence. "On the CrimeWatch tonight..." announces the anchor. Within the metro area, local opinion survey research conducted in the past three years by various Omaha health, education and human services coalitions working toward a healthier community have put drugs and crime at or near the top of concerns, in general, with teens and young children as the populations of greatest concern. Omaha Goals 2000 report cards published annually in the Omaha World-Herald give less than optimal grades for quality education. Drug prevention and AIDS awareness fliers find their way into elementary and middle school children’s backpacks. Quietly this mid-sized urban community longs for a more innocent time when drive-by shootings were only in bigger cities like Detroit and L.A., when racial tensions were unspoken or dismissed, when summer nights seemed simple and safe, when kids could wear any colored clothes to school without fear.

Omaha has humbled me. I have come to accept that what is factually known about public health and maternal and child health and epidemiology is not readily received - even if known and understood by the community, which often prefers the comfort of perceptions, shaped by how some think things used to be. To be effective in Omaha, Nebraska is to start from where most folks are ready to truly listen about children’s unmet health needs. Omahans believe that they already support children’s issues - just look at the world class zoo and children’s theater and museums. To be invited and empowered to make a true difference for Omaha’s children and families who have not yet reached "the good life," I have become less righteous about scientific truths in public health, and more of a storyteller about the health of the public.

The Survey as "Stories"

This survey is all about stories. It tells us most about the stories ‘average’ American adults - over 18 years old, married, Christian, white, non-Hispanic, middle-aged, politically moderate, working full time, with no children under 18 at home - are hearing and telling about children, children’s health, and children’s health care. Like most stories, their stories have four powerful features. Their stories have the power to attract or repel, like a magnet. Do you ever find yourself in a car full of groceries, pulling into the driveway, with one of Garrison Keilor’s monologues not quite finished? Though the ice cream is melting and dinner needs to be fixed, you just can’t shut it off, not yet. Its magnetism to too strong. Stories also have the power to reflect how we see ourselves, like a mirror. Stories have the power to heal. They make us feel better, like medicine, whether told to us at night’s end, or by our telling them to others. And some special stories have the power to be sung again and again, like a rich hymn, like good music. If we understand the powers of story, we will understand the power of this survey.

Magnet Stories. When asked about their views of the two or three most serious problems facing children in America today, over half of responding adults said drugs and nearly one in four said crime. These dual ills represent the leading edge of what adults fear most. Their fears are fueled largely by the gruesome stories they hear and see in living color each night, stories which are repulsive yet oddly compelling to watch. For some, particularly those who live in inner cities and those of color, the stories reflect the daily experiences of friends and neighbors and co-workers; for most others, the fear is more abstract. For both, it is what sticks most in understanding, readily fed back on the phone to the survey questioner.

Have adult perceptions changed in ten years? The leading edge of fear remains drugs; the breakdown in home life and poor quality education remain near the edge. The leading edge of violence in 1986 was child and sexual abuse. It has become crime a decade later, but violence, nonetheless. The edges of our fears are shaped by the stories of our times. Our fears drive much of what we see as important problems facing ourselves and our children. Our fears have not changed dramatically since 1986.

More recent stories about uninsured children and the new Title XXI legislation have been far less magnetic: almost two thirds have no recollection of hearing about children’s problems getting health care or the new government program to provide health insurance to children without insurance. Maybe it was too soon to expect adults to be attracted. This story was not yet newsworthy in most states and communities as of last Fall; less than a third of parents of children with and without health insurance recalled reading or seeing news about the State Child Health Insurance Program enacted just last August.

An alternative interpretation is that "uninsured children" is at best an abstract menace that does not viscerally engage most adults’ emotions the way that drug abuse and crime chill the heart. True, more than a third surveyed said they knew of a family with uninsured children, and that not having child health insurance is a serious challenge for those families to get emergency, dental, routine and complex medical care for those children. Uninsurance is simply not a direct threat. It does not penetrate like an arrow of fear.

Mirror Stories. The most powerful stories are those in which we see some of ourselves reflected. Sometimes when we look in the mirror, we see things as they truly are; other times, as we would like them to be. American adults surveyed are clearly optimistic about the future of children. Contrary to widely published objective comparative morbidity and mortality data, American adults clearly perceive American children as healthier than children in industrialized nations, and as being better or much better off than 10 years ago in getting the health care they need. This is like the thin man’s obese reflection in the mirrors of the Fun House. Adults see a truer reflection of themselves and their neighbors when asked about parenting; most see children as being worse or much worse off in getting the care and attention they need from their parents than ten years ago. American adults do not see themselves reflected at all - or do not choose to recognize themselves - in the mirrors of welfare or food stamps or public housing; less than half see these as very important government programs. Instead, immunizations, social security, and Medicare are in their views, all highly important. Their children get shots, their parents need Medicare and Social Security, as will they.

Medicine Stories. What American adults are telling us about what they say they want for children makes us feel better, like nighttime medicine, like a good bedtime story. They say that health care and health insurance are rights of children. While parents are seen as primarily responsible for assuring these rights, they say that government plays an important second role. They say that they are willing to pay higher taxes to assure that uninsured children get financial access to the health care they need. They value and are willing to support key government programs for children - prenatal care, special education, Head Start, immunizations, and community clinics. This bedtime story has a limit in an era of limited resources and hard choices. Assuming a fixed pot of money to help both the old and young, they will opt to support programs for the elderly.

Adults are clearly wary of the stories told by those groups they do not fully trust. They do not want the cures for the ills of children’s health care policy offered by those with greatest control over the new State Child Health Insurance Program and managed care, including governors and insurers. They are reluctant to be healed by well-meaning strangers - from famous foundations to local public health officials. They are most likely to follow the piper of the Red Cross. A good story is best told by a trusted storyteller.

Music Stories.Did you ever you find yourself humming a melody in your head over and over? This happens to me when I have been exposed to memorable musical refrains or have been trapped in an elevator full of Muzak. Repeatedly, American adults have been told certain stories about children’s health in recent years. Some of these stories are "news"; others are part of intentional public awareness campaigns in print, TV and radio. When adults without recent experience with children and adolescents in their own lives are asked about two or three most important health problems facing children in America today, they are likely to drum up familiar old tunes about the childhood maladies they recall or the illnesses they faced - infections, whooping cough, cancer. Or they hum a tune about the bad guys they have been hearing about - AIDS and tobacco. Adults are not singing compelling melodies to their policy makers about children’s health care. This may be because they do not find the music compelling, or that they just don’t know the words. Advocacy is best fueled by personal fears and clear hopes; neither appear to be in great supply among American adults around children’s health care.

We have been gathered today to find ways to increase public concern for children’s health. I believe that in the Omaha’s of the country, there is great concern for children, their own children. Perhaps we all need to be a bit less righteous about the scientific truths about what we have defined as wrong. We must find a way to connect our story to their stories. If uninsurance does not attract passion, if poor access to preventive and primary care is not something recognized in the mirror, we must learn to tell the story another way that does attract and reflect the experiences of American adults.

Great Storytellers

Last, we must be - or find - better storytellers. A great storyteller knows the difference between a good story and a great story. A great storyteller feels compelled to tell her stories. That all of America’s children are not achieving their best childhood outcomes, with purpose, with conscience is a great story that bears repeating again and again. A great storyteller discovers the true meaning of the story each time she tells it. Our passion, our belief, our rediscovery of truth about what is needed for all of America’s children to be their healthiest must ring clear with each telling.

Our challenge is to harness the four powers of "story" as Americans like to hear them. We can tell stories about children’s health that attract the public’s ear and heart. We must tell stories in a way that reflects their concerns. We will tell stories that help, that give hope, that have the power to heal. And these stories will be sung for generations. With magnets, mirrors, medicine and music - we will mobilize a nation on behalf of all its children. That is precisely what this meeting is about.

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