Successful Health Programs for the Poor and Underserved

271 Guest editorial SUCCESSFUL HEALTH PROGRAMS FOR THE POOR AND UNDERSERVED LISBETH B. SCHORR Lecturer in Social Medicine Harvard University 3113 WoodleyRoad, N.W. Washington, D.C. 20008 If the nation is το address successfully the medical needs of the poor and underserved, fundamental changes are required. We need changes not only to expand access to care, but changes in how primary health care is organized and paid for, changes in how professionals are trained, and changes in what we consider an appropriate range of primary care services. The work that has led me to these conclusions began with a hypothesis that we knew a lot more about successful programs than we were acting on, and culminated in my book, Within Our Reach.1 To test my hypothesis, I looked at programs—in the fields of health, mental health, education, and social services —which have succeeded in changing long-term outcomes among disadvantaged children and their families. I took three damaging outcomes that occur in adolescence—school-age childbearing, school dropout, and delinquency—and examined the risk factors that have been identified through longitudinal research as implicated in these outcomes. I found a handful that, on the basis of theoretical understanding, seemed likely candidates for reduction or prevention through outside intervention . This approach led me to focus on the period from pregnancy through elementary school as the most auspicious and economical time to intervene. The youngsters who become pregnant or delinquent or who drop out have already been in trouble for many years, and many of the troubles that surface in adolescence can be predicted from poor school performance and truancy as early as third or fourth grade. We also know that trouble in elementary school correlates with a number of antecedent risk factors, including low weight at birth; untreated childhood health problems; lack of language, reasoning, and coping skills at school entry; failure to develop trusting relationships with Journal of Health Care for the Poor and Underserved, Vol. 1, No. 3, Winter 1990 272_______________Successful Health Programs reliable and protective adults early in life, as a result of abuse, neglect, or an environment of pervasive chaos; or being born unwanted or to a teenage mother. The important news about these risk factors is that each of them has been successfully attacked through interventions we know how to provide. The popular notion that "nothing works" is in fact a canard, a myth that cannot be maintained in the face of the research and experience now at hand. • There are comprehensive prenatal care and nutrition programs that have reduced the proportion of low birth weight babies.1"4 • There are intensive family support, nurse home-visiting, and child care programs that have resulted in lower rates of child abuse, fewer children removed from home, and fewer mothers dependent on welfare.1,5"8 • There are high-quality preschool programs that followed their threeand four-year-old participants into adulthood and found fewer dropouts, fewer delinquents, fewer teenage mothers, and fewer youngsters without jobs.1,9-12 • There are elementary schools that were able to so change their educational climate that whole populations of children who had been failing began to succeed.11314 • There are school-based health clinics that have reduced the rate of teenage childbearing;1'15-17 there are family planning programs that have reduced the number of unintended births.1 The successes of these interventions are of enormous importance despite the fact that many of the most successful programs operate in special—and sometimes idiosyncratic—circumstances. The successes show that something can be done to address social problems previously considered intractable. They refute the contention that families in the so-called underclass are beyond the reach of organized services. They show that when high-risk populations get the best of services rather than the worst, life trajectories change. The good news, then, is not only that there are programs that work, but that we now also know a lot about how and why they work. As I analyzed the information I had collected to discern common patterns, five basic elements emerged. Elements of successful programs First, successful programs are comprehensive and intensive. They take responsibility for providing ready access to...