poverty

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Brain Science, Dangerous? Not So Fast, Says Poverty Expert

Back in June, we wrote about a novel program in Boston that seeks to lift women and their families from poverty, in part by using the latest research in neuroscience. Specifically, the program (developed by the nonprofit Crittenton Women’s Union) takes into account recent studies that reveal how trauma, and poverty, can rewire the brain and potentially undermine executive function.

In an Op-Talk piece in this week’s New York Times headlined “Can Brain Science Be Dangerous?” writer Anna North cites our story, and then goes on to question whether this type of approach might be problematic. In the article, North refers to sociologist Susan Sered:

Dr. Sered…says that applying neuroscience to problems like poverty can sometimes lead to trouble: “Studies showing that trauma and poverty change people’s brains can too easily be read as scientific proof that poor people (albeit through no fault of their own) have inferior brains or that women who have been raped are now brain-damaged.”

She worries that neuroscience could be used to discount people’s experiences: “In settings where medical experts have a monopoly on determining and corroborating claims of abuse, what would happen when a brain scan doesn’t show the expected markers of trauma? Does that make the sufferer into a liar?”

We asked Elisabeth Babock, president and chief executive officer of Crittenten Women’s Union, to respond to the Times piece. Here, lightly edited, is what she wrote:

Moving out of poverty in the U.S. today is an extremely complicated and challenging process. It involves trying to maintain a roof over your head when the minimum wage doesn’t cover the minimum rent; and trying to get a better paying job when almost all those jobs require education beyond high-school and the costs of that education, in both money and time, are well beyond the means of most low-wage workers. It involves trying to care for a family while filling in the gaps in what the minimum wage will buy with increasingly-frayed public supports. It involves a lot of juggling.

We at Crittenton Women’s Union (CWU) understand this process all too well because we work with hundreds of people trying to navigate their way out of poverty every day: homeless families living in our transitional housing and domestic violence shelters, and people who are living on the edge of homelessness, struggling to make ends meet. What we at CWU see is that the stress of this everyday struggle creates an additional set of monumental challenges for those we serve.

Our families often describe themselves as feeling “swamped” by their problems to the point that they can only think about how to deal with the crisis of the moment. And in those moments, they may not have the mental bandwidth to strategize about how to change their current circumstances or help them get ahead.

One of the most valuable things brain science research does for this struggle is that it validates what our families share about the way being in poverty affects them. Instead of saying that stress leaves people “irrevocably debilitated”, or worse still, that people should somehow rise above this crippling stress to “just move on” the science actually suggests something much more important. It calls upon all of us to understand that poverty, trauma, and discrimination are experiences whose cumulative effects impact our health, decision-making, and well-being in tangible and predictable ways, and because of this, we as a society can and must do our best to remediate it. Continue reading

Report Shows Stark Care Disparities, More Amputations Among Black Diabetics

Dartmouth Atlas Project

Dartmouth Atlas Project

Consider this alarming statistic: The rate of diabetes-related amputations is nearly three times higher among blacks compared to other Medicare beneficiaries.

This, according to a new report from the Dartmouth Atlas Project, located at the Dartmouth Institute of Health Care Policy and Clinical Practice. This is the influential consortium that issues eye-popping reports detailing often painfully unfair regional and ethnic variations in medical care. Here are some of the findings from the report, “Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease” released today:

•Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease.

•Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. (Think Mississippi.)

•The amputation rate for black patients is seven times higher in some regions than others

•There is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. In a news conference announcing the report, Marshall Chin, MD, a leading expert on racial and ethnic disparities in health care and a professor at the University of Chicago called these types of diabetes-related amputations “entirely preventable.” “In some ways,” Chin said, “these disparities are hidden unless we look for them.” And here’s more from the Dartmouth news release:

There are significant racial and regional disparities in the care of patients with diabetes. According to a new report from the Dartmouth Atlas Project, blacks are less likely to get routine preventive care than other patients and three times more likely to lose a leg to amputation, a devastating complication of diabetes and circulatory problems…

Amputation rates vary fivefold across U.S. regions among all Medicare patients with diabetes and peripheral artery disease (PAD), the report found. Amputation rates in the rural Southeast, particularly among black patients, are significantly higher than other regions of the country. Furthermore, the amputation rate for black patients is seven times higher in some regions than others and there is an eightfold difference across regions among blacks in the likelihood that they undergo invasive surgery to increase circulation in the lower legs. Continue reading

Can Brain Science Help Lift People Out Of Poverty?

Five years ago Lauretta Brennan was a single mom on welfare with a pack-a-day smoking habit, stuck in a “bad” relationship and living in the South Boston projects where she grew up.

Now, she’s still living in the projects with her young son, but the bad boyfriend is gone and Brennan’s got a job as an administrative assistant after receiving a business management degree. And she quit smoking.

Her childhood in the projects was marked by alcoholism and violence all around, Brennan said; “having no adult role model was the norm, being with a man who’s ignorant, that was the norm.”

Lauretta Brennan graduated from Bunker Hill Community College with an Associates Degree in Business Management in June 2013 (Courtesy)

Lauretta Brennan graduated from Bunker Hill Community College with an Associates Degree in Business Management in June 2013 (Courtesy)

But now, thanks to a novel program that uses the latest neuroscience research to help women dig themselves out of poverty, Brennan says: “I don’t want to live off welfare. I want to make money and be around people who work and go to school. In five years, the program got me to think more like an executive — I have goals, I’m an organizer managing my family well. I’m not scared anymore.”

This shift in thinking — from chaotic, stressed-out, oppressed and overwhelmed to purposeful and goal-oriented — may not sound like brain science. But it fits into an emerging body of research that suggests that the stress of living in poverty can profoundly change the brain: it can undermine development and erode important mental processes including executive function, working memory, impulse-control and other cognitive skills.

To fix that damage, the new thinking goes, people must engage in activities and practices that strengthen this diminished functionality and, exploiting the brain’s ability to change (plasticity in neuroscience lingo) re-train themselves to think more critically and strategically.

“Poverty whacks executive function and executive function is precisely what’s needed to move people out of poverty,” says Elisabeth Babcock, chief executive of the nonprofit Crittenton Women’s Union, a Boston-based group that draws on the latest brain research to help families achieve economic success. “What the new brain science says is that the stresses created by living in poverty often work against us, make it harder for our brains to find the best solutions to our problems. This is a part of the reason why poverty is so ‘sticky.'”

In a recent paper, “Using Brain Science To Design New Pathways Out Of Poverty,” Babcock makes the case that living in an impoverished environment “has the capacity to negatively impact the decision-making processes involved in problem-solving, goal-setting and goal attainment.” In other words, this type of stress can “hijack” the brain.

As other researchers, including Jack Shonkoff, director of the Center on the Developing Child at Harvard, have noted, this chronic vise of pressure — to pay the bills, function at work, raise the kids, and simply survive in an atmosphere rife with social bias and harsh living conditions — “places extraordinary demands on cognitive bandwidth.” Babcock writes:

“The prefrontal cortex of the brain — the area of the brain that is associated with any of the analytic processes necessary to solve problems, set goals and optimally execute chosen strategies — works in tandem with the limbic system, which processes and triggers emotional reactions to environmental stimuli…When the limbic brain is overactive and sending out too many powerful signals of desire, stress, or fear, the prefrontal brain can get swamped and the wave of emotion can drown out clear focus and judgement…”

How does this play out in real life? Chuck Carter, senior VP of research at Crittenton Women’s Union, explains:

“One of the things the brain science brings is something of an ‘aha’ in terms of why things are sometimes harder than we expect them to be. When you’re looking at a family that is struggling and making decisions that you don’t really understand, having that research helps you reassess…it adds another perspective. A lot of nonprofit organizations look at the social determinants [of poverty] but not a lot look at the science that says, ‘What else is at play?’

“I think that, on the ground, it gives us creative ways to think about the work and how we might approach it…Often families are in a lot of crises…and they feel they need to do things ‘right now.’ So, for instance, we’ve got a family, and they’re in a hallway and they’ll have to talk to the case manager ‘right now.’ And we ask whether it’s a true emergency, and if not, can we talk about this the next morning, and not in the hallway. It’s a problem with executive function and poor impulse control, but we can help them slow down and figure out the right time to figure this out and what information do they need. It’s about not responding so impulsively in other parts of their lives. So, in thinking about what to do with money, it can be a question of, ‘Do I buy cigarettes now or save the money for some new furniture when I move?'”

So how do you begin to fix all of this?

I asked Babcock a bit about the science behind her organization’s Mobility Mentoring program, in which low-income — mostly single — mothers apply to get training, professional mentoring, financial and other support for three to five years, in hopes of attaining economic independence.

Here, edited, is our discussion:

RZ: What does the research say about how poverty changes the brain? And how does a “hijacked” brain function compared to a brain not experiencing intense, chronic stress?

EB: Poverty hits what scientists call our executive functioning skills: our ability to problem-solve, set priorities and goals, juggle and multi-task, focus and stick to things. And it does this in at least two very important ways. First, the stress of dealing with new problems every day and never having enough to make ends meet overwhelms our heads and swamps us. It overloads the circuits in our brains and compromises our decision-making in the moment. Continue reading

Poor Get Poorer But Babies Get Healthier, Thanks To Help For Moms

Patricia Wornum,right, is a 'home visitor' with Healthy Families. Every two weeks she check in with Keisha Harrison and her daughter, Cassidy, in their Dorchester home. (Gabrielle Emanuel/WBUR)

Patricia Wornum,right, is a ‘home visitor’ with Healthy Families. Every two weeks she check in with Keisha Harrison and her daughter, Cassidy, in their Dorchester home. (Gabrielle Emanuel/WBUR)

In elephant-print pajamas, 21-month-old Cassidy nuzzles her head into her mother’s lap and then pops up, grabs a ballpoint pen, and starts scribbling. Her squiggles decorate an important piece of paper; it contains a checklist of all the things her mother does for Cassidy, from getting her shots to daily reading aloud.

Cassidy and her mother, Keisha Harrison, are in their Dorchester living room with Patricia Wornum, a “home visitor” with Healthy Families Massachusetts. On the couch, Wornum glances at the decorated checklist and, in her perpetually upbeat manner, asks: “Any papers back from housing?”

Harrison shakes her head. She hasn’t heard anything about her various applications for subsidized public housing. She and Cassidy are staying with her mom — at age 20, she has aged out of a teen shelter — so Harrison is worried they’ve lost their spot on the housing waiting list. Wornum immediately makes a plan to figure out what’s going on. “You got this!” she says.

Wornum and over a hundred other home visitors in Massachusetts are trying to combat a known phenomenon: If you are born to a poor mother, that overwhelmingly raises the chances that you will grow up to be poor. The odds are stacked against you in several ways: Poverty can mean stress and anxiety, poor nutrition and environmental toxins, higher risks of obesity and heart disease. An entire issue of the journal Science on “The Science of Inequality” this month rounded up some of that bad news.

But it also shared what Janet Currie, an economics professor at Princeton, calls a “bright spot” — though inequality has been rising, the health of newborns born into the poorest families has been improving.  TWEET The conclusion: Public policies can make a difference and improve a child’s chance of success. The “Science” article she co-authored looks at which policies are most effective, and found many that work, from early education to family planning services. Home visiting programs like Wornum’s appear to work particularly well.

“You often just hear about how things are getting worse,” Currie says. “The unfortunate consequence of that is that people are left with the impression that nothing works. We wanted to point out that there are programs that work, that they do make a difference.”

What The Statistics Say

Keisha Harrison was in high school when she found out she was pregnant. She remembers it as a clarifying moment.

“Before I was pregnant I really didn’t think I was going to graduate,” says Harrison. “And then once I got pregnant, I just kicked everything into high gear.” Continue reading

Your Brain On Poverty: Low-Income Childhood Linked To Smaller Brain

Young children living in poverty appear to have smaller brain volumes in critical areas, according to researchers at Washington University School of Medicine. But poverty’s detrimental impact on brain development may be mediated by basic early interventions like compassionate parenting and caregiving, the report says.

(Digital Shotgun/flickr)

(Digital Shotgun/flickr)

Growing up poor is already known to be associated with a higher risk of “poor cognitive outcomes” and school performance, the researchers note. But what’s fairly new here is how outside economic forces play out in the development of a child’s brain. According to the study, published in JAMA Pediatrics Monday:

Poverty was associated with smaller white and cortical gray matter and hippocampal and amygdala volumes. The effects of poverty on hippocampal volume were mediated by caregiving support/hostility on the left and right, as well as stressful life events on the left.

The finding that exposure to poverty in early childhood materially impacts brain development at school age further underscores the importance of attention to the well-established deleterious effects of poverty on child development. Continue reading

Study: Teen Girls Who Exercise Have Lower Risk Of Violent Behavior

A few years back, an acquaintance told me that one of the few mandates he imposed on his daughter was that she play a sport regularly, whether she liked it or not. At the time, I thought it was a bit harsh. But now, with a ‘tween daughter of my own who is happiest curled up on a comfy chair reading, and sometimes needs a nudge to run around, I totally get it.

Girls need to move for so many reasons, among them, mental clarity, physical fitness and confidence, and simply to learn that their own bodies can bring them immense joy. Now, add another benefit to the list: it keeps them out of trouble.

(Rohan Reid/flickr)

(Rohan Reid/flickr)

Researchers from Columbia University in New York report that teenage girls from inner-city neighborhoods who exercised regularly were less likely to carry a gun and engage in violent behavior and activities.

Here are some of the findings, from the Columbia news release:

–Females who exercised more than 10 days in the last month had decreased odds of being in a gang.
–Those who did more than 20 sit-ups in the past four weeks had decreased odds of carrying a weapon or being in a gang.
–Females reporting running more than 20 minutes the last time they ran had decreased odds of carrying a weapon.
–Those who participated in team sports in the past year had decreased odds of carrying a weapon, being in a fight or being in a gang.
Continue reading

Study: Mobile Clinic Saves Money, Improves Health For Low-Income Patients

The Boston “Family Van” is an urban mobile health clinic that travels to some of the city’s poorest, medically underserved communities — Dorchester, Roxbury, East Boston, Hyde Park and Mattapan — caring for patients who have the highest rates of preventable illness, hospitalizations and avoidable emergency department visits. (Not surprisingly, these are also some of the neighborhoods hardest hit by the current flu epidemic.)

A program of Harvard Medical School, The Van is staffed by community health workers, and sometimes by doctors and nurses. Their goal is to bring medical care to the people rather than wait for the people to seek care (which may or may not happen, and if it does, may be dangerously delayed).

A patient treated by staff at Boston's Family Van

A patient, Geralyn Lynch, treated by staff at Boston’s Family Van in Dorchester, Mass. (Photo: Mim Adkins)

A recent study, published in the journal Health Affairs, found that the Family Van — with its neighborhood version of house calls — also saves money by preventing ER visits. Additionally, patients receiving care from The Van staff were able to reduce their blood pressure, researchers report.

The study, by researchers at Harvard Medical School, looked at data from 5,900 patients who made a total of 10,509 visits between 2010 and 2012.

Here’s more from the paper:

“The average reductions in systolic and diastolic blood pressure were associated with a 31.0 percent and a 33.3 percent reduction, respectively, in the relative risk of myocardial infarction. Continue reading

Report: Mass. Among Most Unequal States On Income Gap

Center On Budget and Policy Priorities

Here in Massachusetts we often crow about how great things are — our premier health care and education systems, for instance. But it’s worth noting that not everything is so hot, and some things are pretty miserable. Here’s some evidence: A new report by the Center on Budget and Policy Priorities has found that across all states the gap between the richest and poorest households are wide and growing. The states with the largest gaps: New Mexico, Arizona, California, Georgia, New York, Louisiana, Texas, Massachusetts, Illinois, and Mississippi.

According to a statement on the group’s website, the 2000’s were a “lost decade” for low and middle-income households:

“Prolonged growth in income inequality undermines the basic American belief that hard work should pay off,” said Elizabeth McNichol, co-author of the report and senior fellow at the Center. “Anyone who contributes to the nation’s economic growth should reap the benefits of that growth. But for decades now, those benefits have been skewed in favor of the wealthiest members of society.”

The long-standing trend of growing income inequality continued between the late 1990s and the mid-2000s.

Incomes fell by close to 6 percent among the bottom fifth of households, on average, while rising by 8.6 percent among the top fifth, during this period. Incomes grew even faster — 14 percent — among the top 5 percent of households. For the middle fifth of households, incomes grew by just 1.2 percent.

In 45 states and the District of Columbia, gaps between the richest and the poorest households widened during this period and narrowed in none. Average incomes grew more quickly among the top fifth of households than among the bottom fifth in most states.

“For low- and middle-income families, the 2000s were a lost decade of falling incomes and economic insecurity,” said Doug Hall, co-author of the report and Director of the Economic Analysis and Research Network (EARN) at the Economic Policy Institute.

“That’s not only harmful to these families, but it also threatens our future economic growth.”

How does this relate to health care? Quite directly, says Nancy Turnbull, Senior Lecturer on Health Policy and Associate Dean for Educational Programs at the Harvard School of Public Health: Continue reading

Essay: Patient’s Death Highlights Medicine’s Promise, Failure

(bogelo/flickr)

By Jonathan Adler, Ph.D.
Guest Contributor

A new class of doctors entered the world this spring: medical school graduates, who will join the legions of caretakers we turn to for insight and comfort and rescue. Among the most elite of this new group of caretakers are those who graduated from Harvard Medical School in May. Their graduation speaker was Dr. Donald Berwick, the former Administrator of the Centers for Medicare and Medicaid Services. His speech, reprinted in a recent issue of the Journal of the American Medical Association, eloquently highlighted both the “glory of biomedical care” and its blind side. Dr. Berwick dedicated his address “To Isaiah,” as he told the story of one of his patients from many years ago whose life and death touched him and stands as a call to action for what the medical profession ought to be about.

Dr. Berwick met Isaiah when he was 15 years old, a rough kid from a rough neighborhood, living with his mother, his brothers, and his mother’s ten foster children in a third-floor walk-up in Roxbury. Isaiah had a bad case of leukemia and a worse case of despair. As Dr. Berwick put it, in the sanctity of his clinic at Children’s Hospital, “the glory of biomedical care came to Isaiah’s service” and over time Isaiah was cured of leukemia. But years later, Isaiah was found convulsing on a street corner, brain dead as the result of uncontrolled diabetes. He never came out of this state and died two years later, at age 39. As Dr. Berwick said, “Isaiah, my patient. Cured of leukemia. Killed by hopelessness.”

Dr. Berwick gleans two lessons from the sad story of Isaiah. First and foremost, doctors must vociferously attend to their patients’ illnesses, no matter who their patients are. And second, that doctors must also seek to cure the injustice that Dr. Berwick believes was the true cause of Isaiah’s death. Continue reading

What If Our Health Care System Kept Us Healthy?

Rebecca Onie is the cofounder of Health Leads, the Boston nonprofit that helps doctors “prescribe” basic necessities (housing, food, heat in winter) to low-income patients, in addition to just medications.

In her recent TEDMed talk, she asks some radical question: What if our health care system actually kept us healthy? What if doctors could truly prescribe solutions, not just drugs? What if ER waiting rooms around the country weren’t just places to watch the clock and read old copies of Good Housekeeping, but rather, were transformed into service-oriented, patient-centered hubs where, in a brutal New England winter, a family could go and a volunteer could help that family get the heat turned back on? Listen to Rebecca’s talk and get inspired: