The Long View
December 2, 2009 |  by Rich Shea

Bernard Guyer believes that to improve the health of American children, the health care system needs to start early — before those children have been conceived.

Half an hour after it was scheduled to begin, a September meeting of the East Baltimore Early Child Development Working Group gets under way. A dozen of the group’s members—representing Johns Hopkins University, the mayor’s office, and various community organizations—nosh Danish and sip coffee as Margaret Williams, director of the Maryland Family Network, reports on available grant money. “As for the state,” she says, “it’s a short report.” In a couple of weeks, the Maryland Legislature will approve a budget that, like those of other financially strapped states, cuts funding across the board. “The department most hurt is the health department,” she adds. “I mean, it’s just tragic.” Seeing as the recently established working group is supposed to help provide East Baltimore residents with family, child, and health care services, this is not good news.

Regardless, the members discuss the best ways to map out a strategy tailored to the target population. Toward the end of the meeting, taking place in a fourth-floor conference room in the Johns Hopkins Bloomberg School of Public Health building, Janie McCullough, an assistant deputy mayor, makes a striking suggestion: To best serve the health of East Baltimore children, reach out to families before women get pregnant. The quality of a child’s life, she says, is dependent upon the health and education of both the mother and the father. “You have to address all those things. If we think in that fashion, we’re thinking about families. It has to be pre-conception on through.”

What McCullough is talking about is known in public health as “life-course orientation.” It’s the idea that health care professionals should consider a person’s entire life course and, in the case of children, intervene not just when a child becomes ill but even before he or she is born. Knowing the medical histories and dietary and lifestyle habits of a child’s parents, for example, as well as the home and community environments into which the baby will be born, helps service providers apply those interventions that might reduce, if not eliminate, the need for much more expensive services later in life. If, for example, a mother-to-be can be taught how to quit smoking and eat healthy, her child will be much less likely to suffer from hypertension, obesity, and heart disease as an adult. Life-course orientation shifts the health care focus from doctor’s offices and hospitals to home and community.

One of the idea’s biggest proponents, in attendance at this meeting as a member of the East Baltimore group, is Bernard Guyer, a professor of children’s health in the Bloomberg School. He’s a renowned expert on immunization, a member of the Institute of Medicine at the National Academy of Sciences, and has chaired the department now known as Population, Family, and Reproductive Health in the Bloomberg School. But he’s happy to let McCullough bring up the idea. These days, at 66, he says he prefers to play the role of the “gray-haired guy with the gray beard” who, with expertise and research data in tow, can serve more as a team player than a leader—preferably at the local level.

“The whole idea is that what happens early in life makes a big impact on what happens later in life,” says Guyer, in a later conversation in his office. “Most of what goes on around adult chronic disease in health care is contemporary.” If you’re diagnosed with diabetes, for example, doctors ask about your present habits—smoking, drinking, diet, exercise. “They don’t say, ‘What was your birth weight when you were born?’ or ask about your mother’s diet when you were in utero, or your growth patterns in early life.” Treatment, which often includes expensive medicines, caters to the patient after he or she has contracted a disease, which, Guyer says, “costs society a huge amount of money.” True prevention demands a life-course approach, “looking, early on, at what influences the risk of diabetes or hypertension in fetal life and in early life. We need to start putting our resources there.”

Last May, a study conducted by a Guyer-led Hopkins research team was published in the journal Academic Pediatrics. “Early Childhood Health Promotion and Its Life Course Health Consequences” concluded that preventing health problems in preschool children born in the United States could save up to $100 billion in future health care costs. But the study, funded in part by the Partnership for America’s Economic Success—a nonprofit group of economists, business leaders, and advocates—offered more than a bottom-line assessment of health promotion.

Guyer and company reviewed 10 years’ worth of literature on four child health problems: tobacco exposure, mental health, unintentional injury, and obesity. Looking at the causes of each, and the effects on children ages 0 to 5, they discovered that “one-third to one-half of each U.S. birth cohort children”—1.3 to 2 million children per year—“are affected by one or more of the four health issues,” as the report states.

Substantial progress in prevention has been made in two areas, tobacco exposure and unintentional injury, due largely to public awareness and policy changes—smoking bans, for example, and the mandatory use of seatbelts. But there’s room for improvement. Unintentional injury is the leading cause of death and disabilities among 1- to 19-year-olds, and half a million babies are born annually to mothers who smoked during pregnancy. The cost of childhood illnesses caused by parental smoking alone is estimated at $7.9 billion a year, according to the Hopkins study.

Obesity is a bigger problem, in part because there are few interventions aimed at what’s considered a relatively new phenomenon. The Hopkins team discovered that, in the past 30 years, “the obesity rate nearly tripled among preschool children, from 5 percent to 14 percent,” making preschool children five times more likely than others to be overweight at age 12. In addition, “an estimated 50 percent to 80 percent of obese children and adolescents stay overweight in adulthood,” with health consequences ranging from diabetes to impaired mobility to hypertension. The costs, both direct and indirect: $184 billion per year.

Although it’s been called an epidemic, obesity doesn’t share the same history as, say, tobacco, revealed as cancerous decades ago and the subject of numerous lawsuits since. The Hopkins team lists a few root causes—increased caloric intake, decreased physical activity, aggressive junk-food marketing—and Guyer thinks that the media’s conflicting reports on causes, including so-called obesity genes, are “rubbish.” “We have the same genes we had 30 million years ago, and we weren’t obese then,” he says. “It’s simple. The more you eat, the fatter you get. The less energy you use, the fatter you get.”

Which brings us to a teachable moment, a specialty for Guyer, who’s won excellence-in-teaching awards from both Harvard and Hopkins. One tenet of life-course orientation is that there are multiple determinants of health. In “The Embarrassment of Riches,” an article published in the Maternal and Child Health Journal in 2001, Guyer wrote that the forces that shape the health of a population are not just medical but social, environmental, economic, political, and cultural as well. So, when it comes to obesity, he says, “I think, ‘What are the lives of children like?’ If a child lives here in East Baltimore, she might be in an apartment where there’s not a decent cooking facility—a hot plate, maybe, and no good refrigeration—and no stores where her family can buy decent fruit or vegetables. Instead, the best food you get down at the Eastern Market is fried chicken. It’s absolutely delicious, and it’s cheap. You can buy it in quantities that kids and their families really fill up on.

“And then you combine that with an environment where it’s dangerous to go out on the street. There are no play environments, and there are drug dealers and guns and cars zooming by on one-way streets. You’ve created the perfect environment where you can get these rapid changes in how obese the population is.”