A conversation with a public health pioneer

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{***Noah***}

Coming up on Harvard Chan: This Week in Health, an in-depth conversation with a pioneer in child and maternal health.

{***Marie McCormick Soundbite***}

(When you look at some of the OECD reports from developed countries, our country routinely ranks somewhere between 27 and 29th on whatever measure of well-being you’re talking about. And it’s not that we have the highest proportion of kids born into poverty. It’s because other countries have figured out how to provide support through a variety of social programs that makes– that limits the effect of that poverty.)

We’ll speak with Marie McCormick about her career, her work to improve health for pre-term babies, and why it’s critical to address poverty’s role in childhood health.

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{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health, I’m Noah Leavitt.

In this week’s episode we’re excited to share an in-depth conversation with a true public health pioneer: Marie McCormick, the Summer and Esther Feldberg Professor, emerita, here at the Harvard Chan School. Over the course of her five-decade career in public health she’s worked on issues ranging from the health of pre-term babies to vaccines to cannabis.

At a recent symposium celebrating McCormick’s career she was hailed as a scholar and a leader with a “steel spine”—and a mentor who has had an indelible impact on so many students.

After seeing and hearing that praise we wanted to sit down with McCormick to learn about her career in public health—as well as her thoughts on where the field of child and maternal health is heading in the future.

McCormick’s impact has been significant.

She began her career as a pediatrician and conducted pioneering research on the outcomes of high-risk infants, especially preterm infants, and the evaluation of programs to improve their health and development.

In recent years, McCormick chaired a high-profile U.S. Institute of Medicine committee that examined claims that childhood immunization with the MMR (measles, mumps, and rubella) vaccine causes autism. The committee found no evidence to support the link and recommended no change in immunization procedures.

McCormick also led a National Academies of Sciences, Engineering, and Medicine committee on the health effects of marijuana and cannabis-derived products.

During our conversation we covered all of that, plus McCormick’s views on the future of child and maternal health, including the need to address poverty’s role in childhood health.

But I began our conversation by asking McCormick to take us back to the beginning of her career and explain why she was first drawn to work with children.

{***Marie McCormick Interview***}

MARIE MCCORMICK: I grew up in Haverhill. And one of the prime jobs, actually, for high school students was to work as a nurse’s aide at the local hospital. And the director of nursing really had created a program that was really quite attractive. And I was assigned to the pediatrics ward. And so that was fine. I enjoyed that work and decided I wanted to be a physician, having had the experience of working in a hospital.

Got to medical school and said, well, you know, let’s not make a hasty decision here. Let’s try some of the other specialties. And rapidly discovered that surgery involved stitching, that my mother tried to teach me, that I didn’t want to learn. And then, internal medicine– you sort of walk into your first 80-year-old stroke and go, oh, now I remember why I liked pediatrics.

Kids are just are marvelous, actually. Even if they’re really deadly ill, they don’t act it until they’re at death’s door. So it was– you went back to feeling that this was really the population I wanted to work with. And there was really nothing in my experience in medical school that changed that, dramatically. I tried to keep an open mind, but I went gravitating back to pediatrics.

So I trained at Hopkins. Did my medical school there. Did my pediatrics there. And then, did something which no one should ever do again, which is did my doctoral degree in public health and my residency at the same time.

And what happened was, there was a program at Hopkins with internal medicine that– people who got their MPH during the same time as their residency. And one of the people had been fostering a group of people interested in pediatrics through medical school. Came in one day, and she said, do you want to be a clinical scholar? And we said, yeah, sure. What’s that? And she said, never mind. I’ll get money.

But it was really, really quite a stressful experience. And the only reason it was possible was, at the time, there was two ways of getting your boards, and this fit into one of those ways. But it really was quite, quite stressful.

On the other hand, I also got my first real thesis advisor. Sam Shapiro, who is an extremely well-known investigator, had done a lot of work on infant mortality. And I was looking at infant mortality in Chile and Argentina. And through that connection, eventually began to work with him on the first very large project I worked on, which was an evaluation of a regionalization program for perinatal care in eight geographic sites in the United States.

And as I said, it was the best postdoc I could have ever had. My husband– it was funded by the Robert Wood Johnson Foundation– and he was there at the time. And he assured me at regular intervals that they were paying me as a postdoc.

NOAH LEAVITT: [LAUGHS]

MARIE MCCORMICK: So. But it really was a really marvelous experience, and working with an extremely rigorous but very kind scientist.

NOAH LEAVITT: And so I had wanted to ask– I mean, I was going to ask, at what point did you decide to go from the clinical side to focusing more on the research side? But it sounds like those happened simultaneously, where you were still working on the clinical side but also branching out into research.

MARIE MCCORMICK: I actually went to Hopkins to do research. One of the experiences at the Hale Hospital was there was this small, private residence for severely disabled children. And they would be admitted to the hospital when they got into medical problems. And I just looked at some of these kids and said, we should be able to prevent some of this. And so I really went in with the aim of doing research.

I think to say that the clinical stuff and the research stuff sort of happened simultaneously, actually, isn’t quite correct. In doing this big project on regionalization, I was working with a number of older physicians who had given up clinical practice, and realized that they really were not on top of what the issues were that should be being investigated. And so I determined that I was just going to do enough clinical practice to keep myself honest but not really to try and best– frankly, really being excellent in clinical practice.

When we were training, they talked about the three-legged stool, which was research, clinical practice, and teaching. But by the time I got to my first academic career, you couldn’t do that anymore. You could be really excellent in one thing, pretty good in something else, and the other probably was not going to be your forte. Because the distance between the hospital bed, the research, and the teaching expanded.

So you can talk about people doing molecular biology. That’s not really close to what’s happening to the patient right there. And so this distance meant that you really couldn’t be as integrated as the older cohort of physicians, where they had the patient. And they had the lab right next to the ward and doing some of their research. So that kind of distance meant you really couldn’t quite be as integrative.

As I said at the symposium, the degree that I got was in health services research. And so when I came to consider the outcomes of premature infants, which was part of this regionalization program, I applied a model that was being used in a large experiment on different levels of insurance, which was an operationalization of the WHO definition of health. And in doing so, really discovered that sort of the classic outcomes approach, which was you looked at cerebral palsy and an IQ, really did not do justice to some of the issues that some of these infants had and as they got older.

And saw that taking this broader view actually enabled you to think much more broadly, not only about some of the problems that they had and the interactions of some of those problems, but what would be the impact of interventions, such as early education, such as early intervention that’s out now, other kinds of services that might improve their outcomes, independent of what happened in the NICU. And so that approach allowed me to do some things that initially weren’t as well accepted as they are now. But it really did permit me to begin to investigate some other issues.

The other factor that the regionalization program heralded was that I was involved in the evaluation of a number of programs directed at improving perinatal outcomes, which include the original Healthy Start program, a program in Harlem to increase participation in antenatal and well-child care, and some others. And so there’s both been this direct interest in establishing the outcomes of very premature infants, but also this other part of looking at the evaluation of programs that were designed to improve their outcomes, the Infant Health and Development program being the largest.

NOAH LEAVITT: What you’re saying, if I’m interpreting correctly, is that what you were looking at is not just the treatment that they’re receiving immediately in the hospital after birth, but what can happen when they go home, throughout their early childhood. And so what did you find in terms of the interventions that proved to be most effective for long-term health outcomes?

MARIE MCCORMICK: Sure. The Infant Health and Development program is the largest one of that. That was an eight-site, randomized trial of early educational intervention for preterm, low birth weight infants. And the hypothesis came from the fact that there were really two groups of children who had received early intervention and it appeared to work.

One was poor kids– and healthy poor kids. And that was the largest body of information. But there was also a number of studies that looked at early intervention for children with established disabilities. And that also appeared that early intervention was effective.

The issue with preterm kids is that yes, they have developmental vulnerabilities. I mean, a small percentage will come out of the NICU with significant disability. But most of them are not quite as dramatic as that.

Also, they’re not all poor. They are more likely to be poor because poverty is associated with prematurity. But not all. In fact, I think we had, in this site, the children of a Harvard housemaster. So you had a much more heterogeneous population than previous studies had looked at.

The model that we used was developed by the Frank Porter Graham Center at the University of North Carolina. And it involved weekly home visits during the first year of life with a very established developmental curriculum. And then, the children moved into an educational center for the remaining two years. And that was available five days a week, six hours a day. Parents didn’t have to send their children for that intensity, but they could.

I would also point out, there were a number of people who were very concerned about putting preterm infants into some sort of congregate care situation, because they were also known to be susceptible to infections. And little kids in classrooms spread infections. So there was a very real concern that if you’ve got any developmental outcomes it may be offset by morbidity.

The end of the program, which was three years, the children– and it was deliberately two strata, one 2,000 grams and higher and one 2000 grams and lower– the group 2000 grams and higher had a full standard deviation difference in IQ, which is 16 points, which is, in the psychology literature, a really good effect, as well as diminished behavior problems. The group under 2000 grams, which would have more the developmental neurodisability, had a half standard deviation in IQ in the favor of the intervention and also decrease in behavior problems.

And we actually saw these differences in kids who weighed 1,000 grams at birth, who would be most likely to have developmental problems. So 1,000 grams being two pounds. So it clearly showed the ability to intervene and to change even a group that had a developmental disability.

We followed these kids out to age 18. The differences persisted, actually, in the group 2000 to 2,500 grams without any further intervention. And the interesting thing which has emerged in some of the older studies is that they were less likely, as adolescents, to engage in risky behavior. It’s not clear how that transition occurs, but it does.

The effects did not persist in the smaller birth weight group. And that probably reflects the fact that they probably needed continuing support for there– to be successful. I would note that for a number of the sites, the kids were going back into communities at the height of the crack epidemic. So these may have been very disorganized communities.

So the issue is that there is now a body of literature, which is really quite substantial, that says early intervention works, particularly if it’s a very structured intervention, and may persist into adolescence and adulthood.

NOAH LEAVITT: And so you mentioned, a few minutes ago, that initially, this work– maybe there was some skepticism. But over time, it’s become established. So how, initially, did you react to that skepticism? And how did you see that change over time, where the benefits of this early intervention became more well-established?

MARIE MCCORMICK: Well, the skepticism was about my approach [LAUGHS] to outcomes. I think the issue was that– the skepticism, I think, for the early intervention crowd came from the neonatology crowd. They firmly believed that this was all sort of set in stone by the neonatal complications.

And they were looking at things like ultrasounds and MRI– not that. CAT scans, at that time– and showing there were problems. They– you could see abnormalities in the brain. And so they felt that this would not be an intervention that would work.

I think that, in part, reflects the fact that most of the neonatologists were not really well aware about the fact of the impact of poverty on their graduates, that, in fact, these kids were more likely to be born in poor families. And they were more likely to go home to families that were not well able to sustain them, to support them. So basically, this is a direct line from the literature on poverty, that these children did require more support.

Now, there were, indeed, kids with developmental disabilities and vulnerabilities. And they, too, benefited. But I don’t– because the follow-up literature at that time was really mostly institution-specific, and so you didn’t see the breadth– if you had people from a poor area, you didn’t see what happened to premature infants who came from more affluent area. And so I don’t think the influence of the environment was well-appreciated.

NOAH LEAVITT: Is that idea that influence on both maternal health and child health– is that– it seems like that connection is always growing. Is that true, that we understand more about the influence of environment and those kind of social factors now than we did in the past?

MARIE MCCORMICK: I think that’s true. I– what’s discouraging is our willingness to do anything about them. It’s been very clear for a number of years that one of the– that first of all, we don’t understand prematurity or how to prevent it. But part of it has to be the health of the women coming into pregnancy. So we know this.

But there’s very little willingness– almost none, right now– to really provide women the kind of well-person care that they need to improve their ability to have a healthy pregnancy. That’s not the only reason to do it, of course. But it is one reason to do it. And so I think that one of the issues is that some of these things have been known for a while. But there’s not a great deal of political will to change it.

NOAH LEAVITT: So what do you think it would take to shift that political will? I mean, it’s– I ask the question because it seems like, especially in the last couple of years, there’s been a lot more attention shed on maternal health, especially black women in the US. So it seems like there’s more attention on it now. But as you mentioned, maybe the political will isn’t there to effect change. So what do you think it would take to get to that point?

MARIE MCCORMICK: Well, I think that what you need is probably something like a new progressive era. There were– maternal and child health actually emerged in the late 1800s here, partially in response to the physical condition of young men going into the Civil War, and that they were not particularly healthy. And that actually, unfortunately, has been the stimulus for maternal and child health in many parts of the developed world.

So for example, in France, it was the Franco-Prussian War. For England, it was the Boer war. And so the thing was, we were saying, well, you know, we need healthy young men to be cannon fodder. Sorry. But that was, in part, the stimulus.

Part of it, also, in the United States, particularly in the late 1800s, was these large numbers of immigrants coming in, who were needed as part of the labor force but also were not very well integrated into American society. So the social work movement actually started in Chicago with a wealthy young woman who wanted to help these immigrant populations. And she set up Hull-House, which was a place where they could learn English. They could get basic hygiene education and nutritional education, things of that sort.

And then, the final thing was– looking at this– was the fact of child labor, that when you see the early pictures in the late 1800s of kids running these huge machines and getting chewed up in the process– people began to say, this is not appropriate. These kids are not going to be good citizens because they’re not getting an opportunity to do and learn the kinds of things they need to do.

So I think that some understanding of what forces are influencing outcomes, and particularly poor outcomes, and some sense that there is something to intervene on– that you actually can do something to prevent these outcomes– that realization needs to hit. But it requires resources.

NOAH LEAVITT: You mentioned, a few minutes ago, the difficulty of the research, the clinical, the teaching. And I’d be interested to know– you talk about looking ahead. And I instantly think of the PhD students. You’ve mentioned the students you’re mentoring.

So how, over your career, did you find that balance of staying engaged in the research, keeping yourself focused on the clinical side, but also serving as a mentor to those young students, those future researchers? How did you find that balance to still be able to train the next generation, so to speak?

MARIE MCCORMICK: I think there are two kinds of teaching. One is sort of the formal, didactic stuff. And that’s never been my forte. But working with doctoral students and fellows actually is a joy, because they’re the ones that are challenging you. They’re actually the ones who are teaching you the techniques that you didn’t learn as a doctoral student. But they’re working on your projects. They’re working on projects that are of interest to you, in subjects that are of interest to you.

So that, to me, was never a problem of integration. That was rarely a problem, that they were part of the research endeavor that I was doing, either directly because they’re working on projects that related to what I did, but even indirectly, to projects that were of interest. And it was a learning experience for them to talk to you about what their issues– and the problems and the research that they were doing. So that, I never found a stress.

The didactic teaching– part of it is, I grew up in the era where someone stood in the front of the classroom and lectured. And that’s how I thought you had to teach [LAUGHS]. And so the didactic teaching has been more of a challenge.

NOAH LEAVITT: So can you give an example of that relationship where you’re the teacher, but in some sense, you are learning something from a student? Can you give an example of that in action? Is there a particular memory that stands out from that?

MARIE MCCORMICK: I can think of one, which is a person that I’m currently working with over at the Beth Israel, who did his MPH here, and then decided he needed more skills, and then did a doctoral degree here. He was my doctoral student. But I can tell you right now, I do not understand what he does statistically. And I got it just far enough that I could translate what he said into English for a paper. But he’s just incredible in terms of his ability to think about complex models and how you would begin to understand a whole range of overlapping and evolving kinds of problems.

So the example was– one example is that premature infants are known to have lung problems or breathing problems later on, particularly something that looks like asthma. They’re also known to have behavior problems. And so the question comes, which comes first? Is it the breathing problems, and because you have these problems, you can’t quite control yourself? Or do they co-evolve because there’s some underlying mechanism? And it’s a very complex modeling procedure to do that. And he is able to do that.

Another student, however– it was quite different– was a eating disorders thesis that was under the aegis of actually someone who left the school and then someone over in adolescent health. But I certainly learned a lot from her about what the dimensions of eating disorders– it wasn’t just the anorexia nervosa that I grew up with– but all of the issues of bulimia, the issues of inappropriate dieting, what those meant for in terms of self esteem, and what some of the interventions are. And she actually did a very nice meta-analysis of that. And so that, for me, was learning a topic that I didn’t know.

NOAH LEAVITT: Well, and it seems like in this field, there’s a lot of adaptation required over time, whether it’s the interventions are changing, or even if it’s just the statistical methods are constantly changing, it seems like.

MARIE MCCORMICK: I think there’s also– if you’re a senior faculty member– there’s a little bit of the what I call free range grazing, that you look over a number of journals. And sitting in some of these thesis presentations and things of that sort, you’re exposed to a very broad array of both topics and methods. And so when someone comes to you with a problem, you can say, oh, you know, that’s over here. And that was part of being a doctoral degree.

There were kinds of research that I never did and never wanted to do. But I’d say, you know, I had lectures in that. And here are the references. And so that you could get someone get started, because you had this sense of where in the spectrum of topics they fit.

NOAH LEAVITT: That was a good segue because you talk about broad array. And I know, over time– and I’ve talked with you about these in the past– you’ve branched out. You’ve served on several of these scientific advisory committees. I know one was one looking at the MMR vaccine and autism, finding no link. So with regard to vaccines, what drew you to that work in particular?

MARIE MCCORMICK: Sheer, bloody naivete.

NOAH LEAVITT: [LAUGHS]

MARIE MCCORMICK: I’m not kidding. And actually, I thank our dear former dean Harvey Fineberg for that, because he was president of the IOM at that time. And the issue was that the CDC and– particularly the CDC– was confronting a whole array of assertions of vaccine complications.

And the Institute of Medicine– or now, the National Academy of Medicine– had a history of examining adverse vaccine events. And so, but this was a long list. I remember going into the first meeting, and there must have been like this.

And so the question is, how could you put together a committee that would address that and address it credibly? And so the committee had very interesting characteristics for being on the committee. One is, you could have done no vaccine research. You could have made no policy statements about vaccines. You could have had no funding from CDC, like, in the past five years.

And as our critics said, they don’t know anything about vaccines. But the issues that were being discussed really required more an understanding of epidemiology and some of the basic immunology of vaccines, and less more about the actual components of the vaccine. And so, basically, the committee was supposed to do nine reports in three years, which is unbelievably fast for the National Academies. And we didn’t know, actually, more than one report ahead, what we were actually going to look at.

So the first one was MMR and autism. The second one was thimerosal, the mercury preservative, and neurodevelopmental disorder. But that’s all that we knew when we went into this. And so we then went through a variety of these. We looked at that. We looked at the relationship of vaccines and sudden infant death. We looked at the relation of vaccines, particularly the hepatitis vaccines, and demyelinating disorders.

And the staff was able to bunch these complications so that we could address them very efficiently. So we actually did eight reports. And we were so efficient, we did seven reports and then had a break. And then the National Vaccine Compensation Program was supposed to look at autism and vaccines again– or it– in one summer. And they called us together again to review the data on vaccines and autism before this. They actually didn’t get around to it for another two years.

But it was, for me, a pediatrician– what’s to hate about vaccines? It was a real learning experience about the vehemence, the various constituencies that got involved. I know one was on mesothelioma. And the constituency was the asbestos lawyers who wanted anything other than asbestos to cause mesothelioma.

NOAH LEAVITT: And I know a couple of years ago, you– maybe more naivete– you took on cannabis with a different scientific advisory committee. When you– would taking on these– I guess you could call them controversial topics– I imagine– did you ever face any backlash personally for your findings? And then, how did you deal with that, especially someone who’s a pediatrician? And you’re someone who obviously widely advocates for vaccines.

MARIE MCCORMICK: I jokingly say, I discovered two advantages from the univer– or two services that the university offers, that are not in the faculty handbook prominently. One is, they will receive your subpoenas. And secondly, the university police have a very well-worked-out protocol for handling threatening email.

There was– and in fact, actually, after our last meeting, which was on vaccines and autism, we actually had to– all the committee had to stay in one hotel and take a bus to the building. The building was shifted from the usual Institute of Medicine building to the regular National Academies building, because one, the bus could put people off under the building. And two, the committee could leave the conference room without going through the audience. And they beefed up all of the security, of course, and basically called the school here to say, be careful.

And I was interviewing a young woman who was applying for a job in the medical school. And she came over, and she said, wow. She said, the security here is really tough. I said, let me explain that.

[LAUGHTER]

And then she said, oh, maybe that’s why they weren’t so interested that I was seeing another faculty member. So yeah. I mean, clearly, there were threats.

The confidential sessions from our committee were subpoenaed and then leaked to the anti-vaccine people. And of course, they would cherry pick the quotes that they wanted to hear. And so yes. That’s true.

And you were personally threatened as well as having some demeaning photos of yourself being circulated. But I think the issue is that you’re much more protected here than, let’s say, the public health official, who really has to have thick skin. Because there’s so much of a blanket around the university.

And the Institute of Medicine, itself, is very used to handling this kind of stuff. They actually would prefer the subpoenas go to them, because they know how to do it. They’ve got a court that understands what they do.

And so it’s a much more protected position than being a public health professional, which– or, for example, the pediatrician in California that got the law passed that got rid of personal belief exemptions. I mean, that’s tough sledding.

NOAH LEAVITT: And so is part of the reason why you and other researchers take these kinds of things on is to– I don’t know if the– to provide some sort of cover for those people who are working one-on-one with people?

MARIE MCCORMICK: No. I think the reason for doing it with the National Academies is that it offers an opportunity to provide a synthesis of the science that can be used in public policy. The Academies aren’t, themselves, very good at generating that kind of communication.

But basically, they are very good at providing these kinds of syntheses that are credible. I mean, I was always sort of amazed that I’d pick up something and you’d see, the court in Virginia threw this case out, of autism and vaccines, because the Institute of Medicine had spoken. And so there’s an enormous amount of credibility, in part because the process is so rigorous.

Once the funders fund the program, they have no control over what the committee says. The staff negotiate between them. But the funders never have any control over what the committee says. And then the committee– it’s– the report, itself, has to go through at least 15 outside reviewers that the committee does not know– and respond to every one of those comments that come back. So it’s a very rigorous process in terms of– and with, I might add, extremely expert staff who really know the topic– and so it’s a very rigorous process.

There’s a whole series of efforts to make sure, not that there’s no conflict of interest, but that you are willing– despite what you come into the project– but to change your mind if you hear different evidence. And so there is what’s called a conflict and bias session at the beginning of every committee, where people talk about what their prior experience is with the topic, what things they may think about.

So when we were talking about autism, I said, both my brother’s children have autism. So I have some firsthand experience with it. So there is that confidential section where the people on the committee learn what the other committee members think about things. So there is a very strong process by which the integrity of the summaries is maintained.

NOAH LEAVITT: That’s such an interesting model. And I’m guessing IOM– how regularly do they convene these kind of committees? And then, are there any issues, going forward, that you think warrant this kind of treatment, where there’s a particularly contentious issue, or there’s just this need to synthesize all of the research in a particular area?

MARIE MCCORMICK: The staff, themselves, can see an area that they think should be dealt with. And they can apply and try and get money to do that. One recent one– not an uncontroversial one– was on the health effects of abortion. And that was sort of staff-generated. They wanted that report out there.

But also the controversial issues can be– like the health effects of cannabis was actually generated by several states who were facing either, like Massachusetts, a new recreational use or a medical care use. Plus, the FDA and NIDA– the National Institutes of Drug Abuse– wanted some summary of this material. And then, particularly, the states wanted it, because they were going to be confronted with developing regulation. And so they wanted to have something on which to base reasonable regulation of access to cannabis products. And so I think there are a variety of pressures that can emerge.

One that was an ongoing one was controversies about the health effects in veterans of exposure to foliates in Vietnam. And there were a whole series of committees that dealt with various aspects of that. Another was the health effects of veterans who were exposed to whatever was going on in the Iraq war, between the fumes from the burning fuel tanks, the massive immunizations they received, and so forth. And so there can be ongoing issues that are addressed by a number of committees.

And there are funding agencies that can say, can you look at this? There are also very strict limits about how much any one funding agent can support an individual committee. So for example, let’s say, Procter and Gamble want you to look at something. They cannot support– they have to support less than 50%. And other funding has to be obtained.

NOAH LEAVITT: Interesting.

MARIE MCCORMICK: So again, there’s very real effort to keep things really rigorous and uncontaminated.

NOAH LEAVITT: That’s so fascinating. So just a last question– I think we’ve done a lot of looking back in this interview. A few minutes ago, we have looked forward. But I did want to end with, for you, both personally or from a research perspective, what do you see are the most pressing issues for maternal and child health in the decades ahead? I think both in the US and abroad, what are some of the things that you’ll be watching closely in the years ahead, that you’re interested in?

MARIE MCCORMICK: I think we’ve touched on these. And that is particularly the devastating effects of poverty. When you look at some of the OECD reports from developed countries– so I’m not talking about Zambia. I’m talking about developed countries– our country routinely ranks somewhere between 27 and 29th on whatever measure of well-being you’re talking about.

And it’s not that we have the highest proportion of kids born into poverty. It’s because other countries have figured out how to provide support through a variety of social programs that makes– that limits the effect of that poverty. And so France has a very extensive network of creches for young families to bring their children to, access to medical care.

In Massachusetts, it doesn’t hit you so hard. But when you get south of the Mason-Dixon line, these kinds of access issues, the kind of quality of care that you’re getting are very, very real. And the disparities between someplace like Massachusetts, which is probably closer to France, and Mississippi are just devastating.

And these are young kids. They didn’t start out asking to be born poor. And they didn’t ask to be put in rotten schools. And you’re basically denying them the opportunity to be really functional and good citizens. And so it’s really how one approaches the issue of vulnerable families.

NOAH LEAVITT: And is there anything that gives you hope in that area, that you’ve seen developing, that would give you hope that there may be progress in that area?

MARIE MCCORMICK: I think that some of the issues– for example, some of the provisions of the Affordable Care Act, such as– which are now being eroded– but just making sure that well-woman care is paid for and contraceptives are paid for. Those kinds of things show that there is some realization out there that there is a need for these kinds of services.

I think the issue about early educational intervention is becoming much more pressing. And I know Jack Shonkoff argues this very eloquently from his Center on the Developing Child. So I think those issues are coming through.

What is happening, I think, is happening much more at a local or a state level. It’s not happening nationally. And so those states that are predisposed to do this will do it. And those states that aren’t, won’t. And again, this widening inequality of resources available to young families is just unbelievable.

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That was my conversation with Marie McCormick. If you’d like to learn more about her work, we’ll have some additional links on our website, hsph.me/thisweekinhealth.

That’s all for this week’s episode. A reminder that you can always find us on iTunes, Soundcloud, Stitcher, and Spotify.