We often hear about the harmful effects of poverty on health, particularly the health of children. But we hear less about the decisive role health plays in triggering, or exacerbating, poverty.
When a member of a struggling family falls ill, it means a loss of income, potentially major costs, and much stress and fear. That’s more than a family living on the margins can withstand — even if they are lucky enough to have insurance. These so-called “health shocks” happen everywhere, but they are particularly devastating for people in the developing world, especially those who inhabit overcrowded slums – the mega-shantytowns with poor sanitation, untreated water, damp, smoky houses, and few public services that are home to a third of the world’s city dwellers.
That’s why it’s worth paying attention to the work of an organization called the Associação Saúde Criança (ASC), based in Rio de Janeiro, which helps poor, urban families with seriously ill children. A recentstudy conducted by three researchers from Georgetown University found that the organization produced surprisingly strong results — including an 85 percent decrease in hospitalizations and a 92 percentincrease in household income — results sustained years after the program stopped working with the families (pdf).
“These are already very poor families and we would expect these health shocks to send them down to a place where the family just can’t recover,” explained Jennifer Tobin, assistant professor at Georgetown, who co-authored the study, with James Habyarimanaand Daniel Ortega Nieto. “Not only are these families doing better when they leave Saúde Criança than before the child’s illness, but 3 to 5 years later they’re doing even better.”
The Associação Saúde Criança (or children’s health association) was founded in 1991 by Vera Cordeiro, a physician working out of Hospital da Lagoa, a large public hospital in Rio de Janeiro. Cordeiro had grown weary of seeing children caught in a cycle of “hospitalization, re-hospitalization, and death.” Lagoa served families from the poorest areas in and around the city, including Rio’s North Zone, the Baixada Fluminense, and Rocinha, one of the largest slums in Latin America.
Children would arrive in the pediatric unit with respiratory diseases, parasites, blood diseases, serious congenital illnesses, cancer, sickle cell anemia — and, after receiving treatment, they would be discharged back into the same dismal conditions that triggered or worsened the illnesses. Predictably, the kids would return, each time sicker.
Cordeiro saw that what was needed was a bridge connecting the hospital to the home, something that could provide families with a range of supports so they could learn to manage their children’s illnesses more successfully — and, ideally, keep them out of the hospital. She saw that it made no sense to conceive of medical care as something that takes place exclusively within the confines of a hospital. If you were serious about providing effective treatment, she said, you had to address the real causes of many diseases: the social conditions behind them. (The same applies in the United States; see this Fixes column about Health Leads.)
Cordeiro saw that parents (mainly mothers, since the most vulnerable families are usually those where the father is not in the household) needed to learn about nutrition and hygiene. It was essential to improve living conditions: if a child was sleeping on a damp earthen floor under a leaky roof, or breathing in smoke every day, she would remain prey to pneumonia or asthma attacks. If a mother had to stay home alone to care for a child who was too ill to attend school, that meant she would be unable to work and afford decent food or clothing. She might also be depressed. If her days were spent lurching from one health crisis to another, she would have little opportunity to think about how to meet the requirements for government benefits or develop job skills to move ahead.
All these things were connected; all of them were vital for children’s health. But there was no system to address them together. So Cordeiro took a leap; she quit the hospital and established ASC.
Over the past two decades, she and her colleagues have developed a remarkable social technology: a standard methodology that consistently helps highly vulnerable families stabilize themselves.
It works like this: Hospitals refer vulnerable families with sick children directly to Saúde Criança, and they work intensively with families for two years on average. The ASC network currently enlists 1,000 volunteers who help mothers develop customized action plans. (It’s impressive to see. I have visited the program in Rio de Janeiro numerous times. I reported on it in a book published 10 years ago.)
Volunteers are taught to listen well, asking things like: Does your house have running water? Do you have beds? What skills do you have? What do your children eat? The approach is about breaking down complex problems into manageable steps. Once the situation is assessed, mothers define specific goals in five areas — health, education, housing, income and citizenship — they sign a compact, and come in for consultations two or three times a month. This gives them time to develop their problem-solving muscles. They interact with other mothers who have made progress against similar problems. (The management consulting firm McKinsey & Company provided 5,000 hours in pro bono consulting to refine this system and develop data-tracking for monitoring and evaluation.)
ASC assists families with food and medicine, vocational training, housing assistance, legal support, psychological counseling, health lectures and lots of emotional support — but it’s all focused on helping mothers to advance step by step toward their own goals. “The most important thing is that it’s not us doing the work,” explains Cristiana Velloso, the organization’s chief operating officer. “The families are doing it. We’re a channel to help them believe and understand that they can do it.”
Over the years, the approach has spread to 23 locations in seven Brazilian states and been adopted by the government of Belo Horizonte, one of Brazil’s largest cities. Thousands of families have been helped. ASC has won numerous awards.
But the thing that always weighed most heavily on Cordeiro was the question: How do families fare after the organization’s support ends? “I had a lot of fear in my heart,” Cordeiro said. “We’ve been working very hard with families for 22 years. We knew from a study in 2006 that we brought down hospitalizations by 60 percent [while working with families], but we didn’t know how sustainable the results were.”
Many social organizations hope that they are achieving long-term results, but they don’t know. For an organization like ASC, collecting data after families “graduate” is difficult. Families in slums tend to move frequently and can be hard to track down. And, ideally, to know if a program is working you would want to do a randomized controlled study. In this case, researchers would have had to randomly assign some families to a control group, but they were unwilling to deprive sick children of assistance for the sake of the study.
Cordeiro kept urging researchers to find a way, offering unrestricted access to ASC’s data. “Vera was very keen to have the study done,” said Tobin. “That’s unusual. When we talk to N.G.O.’s, they’re usually not that interested in finding out what the impact of their program is. I think deep down they’re worried about what it’s going to say. Vera wanted to do whatever it was going to take to find out about the impact.”
What the researchers did was construct a “synthetic” control group. They searched across Rio de Janeiro for hospitals serving a demographic similar to Lagoa’s, and selected Hospital Jesus. Then they randomly selected children from the hospital and matched them with hundreds of families from ASC based on age, illness and demographic factors, and had surveyors go door to door conducting interviews with 300 families. It wasn’t a perfect solution, but it provided a solid basis for comparison.
Most important, the study shed light on how ASC was helping families gain a foothold. For example, they found that school enrollment for the children who had been hospitalized at the start of the program increased from 9 percent at the time of entry to 92 percent at the time of the study. This meant mothers could work. And, indeed, they did. Employment increased significantly. With more resources, the rate of housing ownership doubled — which led to improved living conditions, which protect health gains. All these things add to a sense of control. As Cordeiro put it: “There is a huge difference between people who are in misery and people who are in poverty. After we help them they are still poor, but they have dignity.”
ASC is now establishing a training center to spread its methodology to other organizations, companies and government agencies. The city of Belo Horizonte plans to serve 3,000 families over the next two years. “The big advantage of ASC’s model is the integrated approach,” explained Marcelo Alves Mourão, deputy secretary of social services for the city. “The innovation is bringing together health, education, housing and other goals into a single family plan.” He added that it was a big challenge to integrate government services.
The ASC program is particularly valuable in helping extremely poor people gain access to major government programs that have behavior requirements. “Countries like Brazil and Mexico have instituted big conditional cash transfer programs like Bolsa Família and Oportunidades to help people deal with poverty,” explained James Habyarimana, one of the researchers. “But when families experience deep health shocks, they are often unable to take advantage of them.”
One of the researchers, Daniel Ortega Nieto, conducted a series of focus groups with ASC and control group families and found a big difference in the “overall sense of confidence” among ASC families about how to manage health problems. When the control group families were asked what they would do in the event of a new hospitalization, they said things to the effect that they would pray and hope for help from God. The ASC families said things like: “In case of a new hospitalization, now I have a profession and can sustain my family.” Their answers reflected greater knowledge about illnesses, more awareness about options and resources, and more confidence that they could cope with problems.
“I think the study supports the idea that any intervention that aims to address deep poverty has to be multifaceted,” adds Habyarimana. “This is an approach that could certainly be useful in large parts of Latin America, Africa or Asia — wherever urban poverty tends to be quite deep.”
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David Bornstein is the author of “How to Change the World,” which has been published in 20 languages, and “The Price of a Dream: The Story of the Grameen Bank,” and is co-author of “Social Entrepreneurship: What Everyone Needs to Know.” He is a co-founder of theSolutions Journalism Network, which supports rigorous reporting about responses to social problems.
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