A Challenge to Child Advocates

251 Brief communication A CHALLENGE TO CHILD ADVOCATES To the editor: The "Children at Risk" conference proceedings [Vol. 2, No. 1 ] highlight a depressing number of problems in achieving even minimally adequate health care for our nation's children. The list of research, programs, and policies (pp. 227-235) needed to achieve that goal is indeed staggering. But that list also reveals a persistent trap in progressive thought that puts better health for children increasingly out of reach—namely, that the problems will disappear when the poor are able to consume more services made available by the federal government. Surely a much more generous federal investment in our children's health is needed. But just as surely, advocates for that federal investment need to reexamine some of their own assumptions about how that money is to be spent. Among these assumptions: 1. Poor people consume health and welfare services; professionals provide them. We could be far more creative in finding ways for low-income people to be providers of services, as Dr. Bean (pp. 147-153) and other contributors to your conference have shown. Typically, when we do find ways to hire low-income people, we give them "aide" jobs (parent aide, home health aide, nurses' aide, child care aide) that usually pay minimum wage, give no benefits, and provide no career ladder. Can't we find ways to reassess the skills required for these jobs (substituting community knowledge for scientific knowledge, for example) so that they can offer more prestige and more pay? A related but different problem is a class bias that excludes low-income people from some home-based jobs, namely foster parenting and the provision of family day care. The shortage of minority foster parents so well documented in your pages can be reduced, for example, by 1) paying people for this strenuous work, and 2) easing licensing standards that make middle-income households the only licensable foster homes. 2. Interdisciplinary teams of professionals, with community input, should assume responsibility for planning comprehensive services. Journal of Health Care for the Poor and Underserved, Vol. 2, No. 2, Fall 1991 252________________________________________________________________ We professionals have a long way to go in learning to involve community residents fully—and equally—in health planning. We in fact have much to lose: it may turn out that community residents do not believe more services are needed, or that the services that are believed to be needed are not the ones we want to provide. For example, to help ease chronic unemployment in Chicago, a colleague developed a comprehensive workplace literacy program including jobs training and literacy funding. But residents involved in the planning process identified very different barriers to employment: housing problems, domestic violence, their children's health problems. The residents' meaning of "comprehensive" was quite different from my colleague's, although, happily, the program design and funding were adjusted accordingly. Similarly, "comprehensive" will often mean "one stop" to a community resident, and this means giving up professional turf. In the program described above, the health care team works "under" the case manager, who is responsible for addressing all of the major employment barriers in a client's life. 3. Community development and health/welfare service provision are separate processes. Funding streams and politics perpetuate this problem, but disciplinary myopia does as well. As suggested above, one step we can take is breaking down the "import-export" nature of the health and social service industry: we import the service providers to a community, we export foster children and troubled youth. Especially in light of the extensive attention given to environmental risk factors, another step is for health and welfare providers to become actively involved in community organizations and community development corporations that seek to build or rebuild communities. Such involvement can be uncomfortable. It means volunteering evenings and weekends, it means being "just" another member of an organization rather than an esteemed expert, and it means politics and sometimes confrontation. Ironically, actively assisting community organizations can also directly benefit health care providers in building grassroots support for some of the recommendations listed in your journal. For example, Saul Alinsky's first community organization, the Back of the Yards Neighborhood Council, became...