Welfare Reform: Are Kids Paying With Their Health?

Susan Phillips
March 7, 2005

Since the welfare reform legislation of 1996, the number of people on welfare has declined by 50 percent, a decline that has continued despite a weakening economy and increases in poverty over the past three years.

For those who have found stable employment and moved to economic self-sufficiency, this is good news. But for many, their departure from the rolls has been caused instead by sanctions that cut benefits to individuals who fail to meet program requirements.

Learn how researchers define and measure food insecurity using a survey developed by the U.S. Department of Agriculture.

What has that meant for the children of sanctioned families? According to a long-term national study carried out by a network of pediatricians and child health researchers, these children are 50 percent more likely to suffer from what researchers and the federal government call "food insecurity," which means quite simply not being able to count on having enough to eat every day.

Such food insecurity, in turn, can cause a wide range of health and developmental problems.

Read Dr. Frank's testimony.

Dr. Deborah Frank, a pediatric researcher with Boston University's School of Medicine, testified before Congress in February 2005 about the findings. She's the founder and director of the Grow clinic at Boston Medical Center which treats undernourished and malnourished infants and young children.

CFK: What sparked your interest in finding out more about the health of children in families sanctioned off welfare rolls?

Dr. Frank: In my work at the clinic, I was starting to get perturbed. We were seeing more children with malnutrition, and it seemed like we could trace the malnutrition to stresses placed on families by social policies.

But I'm not only a doctor, I'm a scientist too, and I knew that our observations weren't enough to establish a link. So I reached out to colleagues across the country, and I said, 'We have to start an active surveillance to see what is happening to babies in this population.' No national group was doing it.

Read the C-SNAP report and other publications.

So we pulled together C-SNAP (Children's Sentinel Nutrition Assessment Program). In 1998 we started monitoring these impoverished kids coming in to hospitals across the country, weighing them, interviewing their parents about food security and access to support programs, including welfare. We found this very clear relationship: welfare sanctions were associated with a greater likelihood of food insecurity, and in families with babies, a greater likelihood that the babies would be sick enough to be hospitalized.

That's pretty alarming, that there's something out there that is increasing the chances children will be sick. I know from my other work that it is not just physical illness, but that learning and brain development are affected by malnutrition.

CFK: Can you explain some of the specific connections between hunger and developmental problems in very young children?

Dr. Frank: The first thing that happens, long before you can see that they are underweight, they are less active, less exploratory, less interactive. They try to conserve their calories, their body heat. They sleep more, they may be more irritable, they don't learn as much from the social or inanimate environment. By the time they are actually underweight, many opportunities for learning have been missed.

And it's hard to see outside the doctor's office. Facial fat is the last to go, a malnourished child can still have big rosy cheeks. And as an observer, you won't know how old they are, a four year-old might look like a two-year-old.

So unless you measure and weigh, and have an age, you just don't know how underweight a child is.

CFK: Any specific examples of how hunger can get in the way of healthy development?

Dr. Frank: Last week in the clinic, I saw a baby with a hole in her heart, a one-year-old. The heart doctor said, "This kid just isn't growing," and couldn't figure out why.

Well, we asked the family—and it turned out they didn't always have enough food. Well, duh—a heart baby has extra calorie needs! But she wasn't getting any extra calories.

Malnutrition, under-nutrition, are part of an insidious process that is corroding children's health and future abilities.

It's a vicious cycle. Any kid loses weight if they are sick. The moment a kid in a reasonably resourced family recovers, they just eat double portions and regain what they've lost. A child in a food insecure household who loses weight can't do that. He or she becomes more susceptible to a new infection and illness, and then loses more weight. It's called the infection-malnutrition cycle. And it can lead to more hospitalizations, as our surveys showed.

CFK: Why are they hospitalized?

Dr. Frank: Mostly for stomach and gastro-intestinal infections. Pneumonia, diarrhea.

CFK: Why did you take on the combined research/advocacy role you have adopted with C-SNAP?

Dr. Frank: How else can we know what is happening? The thing is, little babies are almost invisible to everybody except their families and their doctors. They're not in school, they're not on the radar screen. A lot of the evaluations of welfare reform explicitly excluded families with children under the age of two from the research base.

CFK: What's your recommendation for policy makers?

Dr. Frank: Take a hard look at the sanctions system. In Pennsylvania, they've done some work on a sanctions-avoidance system. Before imposing sanctions and cutting people off, someone had to go and do a full evaluation of the family, and figure out why they were failing to comply, and try to help them get into compliance.

But most states don't do that. If you ask parents why they were sanctioned, they'll often say something like, "My caseworker doesn't like me." They really have no idea. If the goal of sanctions is to change behavior, then you need to make sure people understand why they are being sanctioned, and give them a chance to behave in a way that avoids sanctions.

I can't give a kid a shot without asking a parent a two-page list of questions, and reading a list of possible results and side effects. Yet we can remove a whole family's livelihood without taking that kind of care.

CFK: Not many pediatric practitioners have taken on the role of advocate, testifying before Congress as you have done, etc. Why is that?

Dr. Frank: I'm fortunate, I'm not a full time clinician, I have the time to do this. If you are in a clinic all day every day, you don't have time to brush your teeth, let alone advocate. Doctors need time, training, and encouragement from non-physicians and other physicians.

For somebody who lives outside the Beltway the whole hearing process is beyond weird, very odd. Unless someone has coached you, it is just terrifying.

Clinicians need time and support to do this kind of work. It's certainly not that they don't care. There is real agony among clinicians about what is being done to children.

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