Mortality rates, mental health conditions, obesity and chronic disease rates are all up significantly in American children. Why are kids in the U.S. so unhealthy?

Guests

Dr. Christopher Forrest, co-author of the recent study Trends in U.S. Children’s Mortality, Chronic Conditions, Obesity, Functional Status, and Symptoms published in the Journal of the American Medical Association. Professor of pediatrics and the director of the Applied Clinical Research Center at the Children’s Hospital of Philadelphia.

Mayor Tim Sandoval, Mayor of Pomona, California.

Dr. Robert Kahn, Vice President of Health Equity Strategy at Cincinnati Children’s Hospital.

Transcript

Part I

MEGHNA CHAKRABARTI: Dr. Christopher Forrest joins us today. He’s a pediatrician and director of the Applied Clinical Research Center at the Children’s Hospital of Philadelphia.

This month, he published a report in the Journal of the American Medical Association. The report analyzed the health of America’s children across 170 different kinds of health indicators. And it compared how healthy kids were in 2007 to how healthy they were much more recently, in 2023.

Forrest’s research team found that across almost all of those indicators — everything from obesity, mental health, chronic diseases, mortality, American children are less healthy now than they were back in 2007. The report calls it a “fundamental decline in the nation’s health.” And Dr. Forrest joins us now.

Welcome to On Point.

DR. CHRISTOPHER FORREST: Thanks for having me.

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CHAKRABARTI: I wonder if you could actually start us off with a story. Put yourself back into the moment that you realized that this dire conclusion about the health of American children was the only conclusion you could reach when all the data came together in this report. I mean, where were you and sort of what was going through your mind at that moment?

FORREST: I was in a little conference room next to my office. And our team was meeting weekly. And each week, we would look at a different health indicator. And that lasted about six months as we went through a variety of health indicators — as you point out, it was 170. It was about halfway through that I kind of realized everything is getting worse.

Not only are kids dying at higher rates in the U.S. than the OECD, but they’re even going through puberty earlier, they’re sleeping less and they have more physical symptoms. I think that’s what really jumped out at me. We knew that anxiety, depression, and loneliness from a variety of reports were on the rise. But we didn’t know that pain disorders, more menstrual symptoms in girls, more abdominal symptoms and so on were also on the rise.

“Not only are kids dying at higher rates in the U.S. … but they’re even going through puberty earlier, they’re sleeping less and they have more physical symptoms.”

And so then we started to put it all together and when we put it up on the whiteboard, we said, “There’s only one conclusion. There’s just a generalized decline in children’s health, and it’s quite alarming.”

CHAKRABARTI: What was the sort of feeling in the room at that moment?

FORREST: I mean, this has been a very hard study to both do and to talk about because behind every number, there are thousands and sometimes millions of children. We see in our mortality statistics that every day, 54 kids are dying in this country, who would not have died if they were in Europe or other high income nations.

So there’s kind of a bittersweet part of this. The sweet part was that we found — like, we uncovered something really important to understand about children’s health, a really important message for the nation. A wake up call for all of us. But the bitterness is that this is happening to our children. This is widespread languishing of children across the nation and and there’s no other way to conclude that there’s a tremendous amount of suffering that’s kind of going hidden and is quiet.

I’d like to think of it now as a quiet epidemic.

CHAKRABARTI: Well, you know, in a sense it may — the study and the data may confirm what a lot of Americans have anecdotally experienced or observed. But I wonder if — and we will dive deeper into the actual health indicators in a moment, Dr. Forrest. But it’s so dire, right? I mean like every, almost every single of 170 health indicators, American kids being less healthy and sometimes far less healthy than they were back in 2007.

As a researcher, was there a moment where you were like, “Hang on?” Whenever data comes out so skewed and all numbers are down across the board, like did you wonder, “Wait, was there something wrong? Was there something amiss in the analysis?”

FORREST: Great team doing this work. We checked things in triplicate, so we were pretty confident of the numbers.

And the other thing, Meghna, is that we wanted to conduct a study that would address prior criticisms of work that has been reporting declines in children’s health. So for example, the CDC reports individual statistics. By individual, I mean individual diseases — obesity rates, anxiety rates, and so on. And sometimes those studies get criticized because they’re limited data sources or just one indicator.

So we wanted to use multiple data sources — parents’ assessments, kids’ assessments of their own health, physicians’ assessments, vital statistics like mortality to see what would happen. And when they all triangulated on the same conclusion, we began to scratch our head and say, you know, there’s a bigger story here. It’s just more than just the data that we’re seeing. There’s something happening in the developmental ecosystem of kids. And in some ways we all take responsibility for this because it’s been happening in our backyards.

CHAKRABARTI: Yeah. In our backyards and in our own homes, right?

FORREST: Yeah.

“There’s a tremendous amount of suffering that’s … going hidden and is quiet.”

CHAKRABARTI: Okay. So Dr. Forrest, a little bit later, I wanna see what the differences are between different demographics in the United States. But first, let’s take a look at the sort of the aggregate level conclusions that the report draws.

Those 170 health indicators that we’ve been talking about, we can sort of put them in three buckets, as you’ve done. In terms of mortality or death, disease, and distress.

FORREST: Mm-hmm.

CHAKRABARTI: So you mentioned just mortality rates briefly, a little earlier, that American kids are dying at higher rates than in peer countries?

FORREST: That’s right. We compared the death rates of children from 2007 to 2022 in the United States compared with 18 other high income nations, largely in Europe and also in Asia. And what we found is both for babies — infants — as well as for older kids — kids one to 19 — they were more likely to die. In fact, they were 80% more likely to die. And the causes of death and the reason why we separated the age groups were quite different for the babies versus the older kids.

CHAKRABARTI: Can I just jump in here before we get to the causes? Because statistics are these wily things. When you said they were 80% more likely to die, that sounds terrible, but what does that 80% mean?

FORREST: It means that the death rates were 80% higher in this country compared to European countries. We adjusted for slight differences in age, so that was washed out. So the death, fortunately, in fact, in all nations that are high income today, death rates have been going down for children. But in the 1970s, we began to see a separation between the United States and Europe.

We published an earlier study that showed in the 1960s and 1970s, kids in this country had the same death rates as kids in Europe. They were declining at the same rate. And then towards the end of the 1970s and the early 1980s, began to see the decline in this country slow down. The European decline kept on going. The decline in the U.S. started to separate. So there was decline in both groups, but not as high of a rate in the United States. And that’s led to this 80% increased chances of death, both for babies as well as for older kids.

CHAKRABARTI: Okay. So just again, to be clear, that 80% is the death rate in America — for American children and infants — is 80% higher than the rate in Europe and Asian countries?

FORREST: Yes.

CHAKRABARTI: Okay. And the causes between those two groups in terms of infants and older children or teens, it sounds like they might be different. I mean, what did you see going on in terms of this disparity in infant mortality in the United States? The big driver is babies being born early, so-called prematurity and being born with low birth weight.

The second most common was congenital anomalies or birth defects. And then the third driver was what’s called sudden unexpected infant deaths. That’s the combination of what we used to call crib death or Sudden Infant Death Syndrome, plus accidental strangulation — babies actually dying in the cribs, strangulated by their own beds. That’s very uncommon. But those two have been brought together.

CHAKRABARTI: In terms of the increased number of babies being born prematurely, I mean is part of — in there, I would say there’s potentially some hidden, I’d say not good news, but a positive difference in so far as we did a show a while ago about how more premature babies are actually surviving these days than they were, you know, 10, 20, 30 years ago. But what you’re saying is just the sheer number of babies born extremely prematurely has gone up in this country.

FORREST: Relative to the European and Asian nations.

CHAKRABARTI: Okay. Okay.

FORREST: So there has been a very slight decline over the last 20 years, but babies definitely are more likely to be born early in this country compared to those countries, and that’s the big driver of the differences.

CHAKRABARTI: They’re more likely to be born early in this country. Okay.

FORREST: Yes.

CHAKRABARTI: And what are some of the — I mean, I’m sure there’s probably like 10,000 causes to that, but what are some of the most important ones?

FORREST: Yeah. I like to think of infant health as really a women’s health issue. We know that healthy women, when they get pregnant, become healthy pregnant women. Healthy pregnant women deliver healthy babies. They’re much less likely to deliver babies born prematurely. So you really have to, you know, not talk about so much just prenatal care, but what about women’s health as they enter pregnancy?

We do know that about one in three women are entering pregnancy obese, and they’re at increased risk for diabetes while pregnant and hypertension. Those are not — if not controlled well, those are not good things for the baby’s health. So the combination of spotty access to prenatal care for many women as well as beginning their pregnancies unhealthy themselves, is really, I believe, the major driver.

Now you can go back and say, well, why are women unhealthy? And that’s sort of a different kind of set of questions, but that’s really what’s driving the premature rates.

CHAKRABARTI: Okay. And I just wanna briefly mention that for older children, we have issues such as substance abuse and gun violence being drivers of that mortality rate.

FORREST: That’s absolutely true. The number one cause of death for one to 19-year-olds in this country is death by gun. Firearms. These are kids who are dying through firearm-related homicides, firearm-related accidents, as well as firearm-related suicides. Kids in this country are 15 times more likely to die by gun than kids in the comparable countries.

“The number one cause of death for one to 19-year-olds in this country is death by gun.”

Now, the other big cause is motor vehicle accidents. And this is kind of a question mark as to what’s going on with motor vehicle accidents. Probably more time spent on the road driving than kids in Europe.

Part II

CHAKRABARTI: Dr. Forrest, we talked about drivers of mortality rates for children in this country as compared to European kids. Let’s talk about disease and chronic disease. Because this one I don’t know — I just really, I don’t even know what to say. It’s so jaw-dropping.

You found that one in three — so a third — of American kids now has some kind of chronic condition. I mean that’s just huge. How does that compare to, I don’t know, when you were in med school or began your pediatrician’s career?

FORREST: Yeah, that’s a good point. When I started now, a few decades ago, I actually did my training at the Children’s Hospital of Philadelphia because I wanted to train at an institution where I would see kids with chronic conditions in the hospital. So we knew that there were kids time immemorial who had chronic conditions, and there are some children’s hospitals which specialize in the care of those kids.

Out in the primary care practices, we almost never saw a kid with chronic condition. Maybe a child with asthma. But mostly we were focusing on prevention and optimizing healthy development. Since then, there’s been a steady march of at least a perception among pediatrics that kids are getting sicker and sicker, that primary care pediatricians have to take care of more complex kids. That kids are showing up in the hospital sicker.

So part of the motivation for this study was to say, “Hmm, is that intuition that we have that things are actually changing in pediatrics accurate?” And this finding of one in three children in the U.S. having a chronic condition is really, as you point out, it’s jaw-dropping.

“One in three children in the U.S. [have] a chronic condition … it’s jaw-dropping.”

And we also looked at the medical centers. We have data that we aggregate at the Children’s Hospital of Philadelphia across 10 national in scope children’s hospitals. Most children’s hospitals have not only care for their local community, but also they are referral centers. And across these 10 large children’s hospitals, we saw that nearly one in two kids, both in the primary care settings as well as in specialty care settings, had a chronic condition.

That is very different. That’s a very different picture of pediatric care today than just 25 years ago.

CHAKRABARTI: Wow. And again, just to remind folks, this is data across pediatric records for millions of kids, right? It’s not just like a selection from across the country. When we’re talking about chronic conditions though, what are they? Is obesity amongst them?

FORREST: Obesity — we looked at obesity separately actually.

CHAKRABARTI: Okay.

FORREST: So these data, there’s a lot of overlap between obesity and these other conditions. What I mean by that is kids who are obese are also experiencing other medical conditions. What we’re seeing now is teenagers with obesity are experiencing elevated blood pressure, hypertension and Type 2 diabetes.

But the overall way to think about the chronic condition rise is by categorizing the conditions into three buckets. One is sort of the most well-known, which is the neurodevelopmental bucket, which includes attention deficit hyperactivity disorder, autism, and other developmental delays. Those have all been increasing. Mental health — anxiety, depression have been increasing.

But also on the physical side, kids are experiencing more hearing loss. That makes me wonder about those air buds that we all wear that may actually be causing some hearing loss in kids. Of course, we are well aware that kids are more likely to have to wear glasses today. Estimates are that in a few years, one in two kids will have myopia and will need glasses because of all the time they spend indoors on screens as well as looking at things up close.

CHAKRABARTI: Come on! 50% of kids? 50% of kids in a couple years will need glasses?

“Estimates are that in a few years, one in two kids will have myopia and will need glasses.”

FORREST: Yeah. Yes. And then finally, I would say the other sort of striking thing is that even things like cardiac conditions, heart arrhythmias, things like inflammatory bowel disease, inflammation of the intestines, those are on the rise as well. So it’s not as you begin to look across the full spectrum of disease, there’s no single cause.

These are all individually — when you have experts say what’s causing the rates of rise and anxiety, they’ll give you a sort of a mix of things. But that mix of things is gonna be different from obesity, from inflammatory bowel disease, from cardiac arrhythmias.

CHAKRABARTI: Wow. Okay. So then, I mean, you talked about some mental health — deterioration in mental health. That also includes — these are things I think people have heard of and probably even experienced in terms of the lives of children that they know — more anxiety, greater amounts of loneliness, higher reports of depression. You even talked about like fatigue and pain, experience of pain going up in kids.

FORREST: I know. Tat’s really, as I mentioned earlier, I think that was one of the big surprises to me, that things like fatigue, pain, abdominal symptoms, menstrual symptoms for teenage girls, headaches, this sort of physical symptomatology has been increasing.

But Meghna, we know that kids are experiencing an increasing amount of stress. And that stress manifests itself in some kids as anxiety and in some kids as pain. You know, it gets very challenging to kind of pinpoint any one cause, because one cause can produce multiple conditions. And each condition can have multiple causes. And that’s what adds to the complexity of this problem.

CHAKRABARTI: Yeah. Now, you mentioned something earlier, I just want a little bit more detail on that. The rate or the percentage of girls going through puberty earlier, i.e., before the age of 12 has gone up? And gone up by how much?

FORREST: About 20 years ago, 9% of kids in this country, 9% of girls, to be more specific, went through puberty before the age of 12. And that’s increased to 15% over and a steady increase. It wasn’t a big jump, it was a steady increase over the 20 year period.

Which is really quite shocking because now you have nine and 10-year-old girls who’ve had menarche, but they don’t have the psychological maturity to align with their sexual maturity. So that, we know, is one of the drivers of some of the distress that girls experience. And also some of the drivers of early risk behaviors for young girls as well.

CHAKRABARTI: Hmm. Okay. You know, Dr. Forrest, I’m thinking about this in terms of whenever you have a situation. Okay, this is gonna be an awkward metaphor, but you know, say a bunch of people went swimming in a pool and a few days later, a lot of them get really sick. We automatically think, “Well, there was something in the pool. There was literally something in the water.”

In this case, when we have these across the board deteriorations in children’s health, the water, the pool, is our society. I mean, so is it fair to say that politics and policies are actually manifesting themselves in the bodies of American children?

FORREST: I love the pool metaphor. I think that would be fair to say, Meghna, but I think that’s not the full story.

I think that, as you point out, it’s the pool or what we call the developmental ecosystem that’s failing kids. So it’s across the board. It is the policies and the politics at the national level. It’s also the hypergrowth, capitalist political economy that we have that monetizes children’s attention.

And in addition to all that, it’s the neighborhoods and the communities that kids are growing up in. We are starting to see climate disruption affect kids’ health. We actually really don’t know to what degree is our degradation of our environment influencing the increasing rates of chronic disease. It may be an important contributor.

And then finally, we’re talking about families experiencing substantial amount of stress. There really aren’t that many bridges in this country to help families. By bridge I mean helping families move from one phase of life to another — from being a pregnant mom, to being a mom now caring for a young infant. A country that has no guaranteed public support for parental leave. So moms are going back to work at six weeks. And we know those early years are incredibly important for the trajectory of kids’ health.

So as you begin to sort of tick through all these different levels of the developmental ecosystem, which are all interacting, policy and politics are important, but policy and politics will not solve this manifold set of health crises that kids are experiencing.

“Policy and politics will not solve this manifold set of health crises that kids are experiencing.”

CHAKRABARTI: Oh, interesting. I’m gonna put a pin in that because I guess the question is what will solve it? But hang on a second before we get to that though.

So I’m just trying to put a lot of these things together in terms of even just what I’ve observed as a mom myself. You’re talking about declines, overall declines in, you know, maternal health or childcare after birth, and we’re talk also talking about prenatal care, neonatal care, all of these things.

Then there’s also — look, there’s the food system that a lot of American kids are exposed to or able to eat. There’s just the sheer fact of play, right? Unstructured play or being able to play safely outside that seems to have shifted dramatically in the past generation or two.

And then there’s another one I wanna talk to you about. I can’t imagine that these impacts are, are level across the board because a lot of what you’re talking about is related in my estimation to poverty, right?

FORREST: Mm-hmm.

CHAKRABARTI: So are children of low-income families, are they suffering from this decline in their health disproportionately?

FORREST: You hit on a number of what I would call sort of the proximate causes, the causes that are easy to see — the food, the activity, sleep, stress, play, a mom’s health. For sure those are drivers. But what underpins it? There’s no question that a society that allows one in seven families to raise kids in poverty is not a society that values children.

“A society that allows one in seven families to raise kids in poverty is not a society that values children.”

And poverty is a driver. It’s not the only driver. You cannot explain the widespread decline in children’s health by poverty alone. But certainly the financial constraints on families today are large. And it’s not just people living in poverty. It’s people trying to manage childcare. It’s people trying to just manage the basic necessities of life. People who you might call middle class are still financially strained.

So there are hotspots. And we’re beginning to uncover those in sort of subsequent research — hotspots of ill health for kids. But I really want to, you know, provide this message that it’s not your neighbors, it’s all of us now are responsible for the decline in children’s health and children are suffering across the board. All SES groups, all race ethnicity groups, both genders.

CHAKRABARTI: You know, you said something really interesting. That a nation that allows one in seven families to live in poverty is not a nation that actually cares about kids. But everyone says they do. Like, literally every group — left, right, center, up, down says, “we’re doing what we’re doing for America’s kids.” I mean, the two things are true at the same time, Dr. Forrest?

FORREST: I think people care about their kids. And I think we have a society that’s focused on our family. We don’t have a society that’s focused on everybody’s family and all kids.

“I think people care about their kids … We don’t have a society that’s focused on everybody’s family and all kids.”

And I think when you see one in seven families living in poverty, you have a political economy that’s producing that. And like in healthcare, we like to say that every system is perfectly designed to get the outcomes that you observe. So we have a perfectly designed system to produce a very high level of poverty. And that’s clearly a driver of some of the findings that we’re seeing. But again, not the only driver.

CHAKRABARTI: You know, it’s interesting to me because there’s all sorts of measures for that that give us an indication about sort of how children really are under incredible amounts of pressure. And one of them, I think, is where their healthcare is coming from.

I was just looking at some numbers about Medicaid and CHIP, the Children’s Health Insurance Program. And CHIP is supposed to capture families who make — I don’t wanna say too much, but their income is higher than the Medicaid thresholds are. But it’s not enough for them to get private health insurance.

But between those two programs — this is from Pew — more than half of the nation’s children get their health insurance through CHIP or Medicaid. Half. More than half.

FORREST: Right.

CHAKRABARTI: I mean, what does that tell you?

FORREST: It tells you number one, we don’t have a universal health insurance system that covers health services for all children. It also says that young families are struggling. They are financially strained. So it’s not just people living in poverty, it’s people who are maybe 200% above the federal poverty line.

I will say this, Meghna, that Medicaid and SCHIP are incredibly important for children’s health. And in pediatrics, there’s just this tendency to sort of ignore a payer. I think that I’ve never seen a child with Medicaid or SCHIP receive different care from kids who have commercial insurance. So once you have insurance, it really doesn’t matter where it comes from. You’re gonna get excellent care in this country.

CHAKRABARTI: Yeah.

FORREST: The issue is those are insurance programs that are designed to take care of people when they’re ill. And a lot of what we’re talking about is antecedent to the illness. How do we prevent the problem so that we don’t need the Medicaid, the SCHIP and the commercial insurance?

CHAKRABARTI: No, point well taken.

I mean, and in this sense, that’s where some strong overlap is with, you know, the Make America Healthy again campaign that’s now being led by the current Secretary of Health and Human Services. I mean, their focus is, to be fair, on those antecedent issues that you said. Like, you know, food, activity, things like that. So do you think that there’s the potential here for cooperation between groups that may not otherwise see eye to eye in other political matters?

FORREST: I really hope so. I think that the MAHA report issued in May and there’ll be a subsequent report on children’s health was incredibly important. It actually, from my view, was the first time that at the secretary level that children’s health was prioritized to such a degree. The diagnosis that children’s health is in decline in that report was spot-on.

But the analysis was very superficial. It’s really limited first-order thinking to blame the decline in children’s health on simple things like food, technology and chemicals in the environment, maybe some over-diagnosis doesn’t get at the root causes that you and I have been talking about. I think they’re important, but they’re not the root causes.

So here’s the opportunity. We have, across the political spectrum, a widespread belief that children’s health is in decline. We have an agreement on the fact that children’s health is in decline. Next step is to figure out how to solve that problem, and I think we can start solving it together.

Part III

CHAKRABARTI: So now the question is what do we do about it? When it’s this entire ecosystem, as Dr. Forrest has been talking about, of American childhood that is not serving those kids well enough?

So let’s go to some solutions. And to that, I’m gonna first go to Pomona, California, where Mayor Tim Sandoval joins us.

Mayor Sandoval, welcome to On Point.

MAYOR TIM SANDOVAL: Meghna, thank you for having me.

CHAKRABARTI: Now I understand — first of all, I just wanna get a little background on you — that you moved to Pomona when you were just nine years old. I’m wondering if you can think back to that time and how was childhood different then than it is now in Pomona? Or, you know, even just in your experience in the city for most of your life, if you’ve seen the kind of differences in health that we’ve been talking about with Dr. Forrest?

SANDOVAL: Yeah, no, thank you. You know, my parents moved to Pomona in 1980. They bought their very first home. And so Pomona really represented opportunity for them because they had been renters their entire lives. And father was a school teacher, mother was a housekeeper.

And I don’t think we fully understood entirely what we were moving into. But it was a time when families were fleeing civil wars in Guatemala and El Salvador and Cambodia and Vietnam and the migration of African Americans from places like L.A. to Pomona. And so I grew up in a very rich, diverse community that I think really helped to sort of shape what I do now. But what I remember is growing up where, you know, my parents put me in programs like Little League Baseball where I had more than one dad who was looking out for me and helping me grow.

And what I see today is I see that there are attempts by parents who are working much harder, housing is more expensive, households consequently are sometimes very unstable, is that they’re trying to do the absolute best that they can to help and to connect their kids to programs in the community. But as I’ve learned, there have been a bit of a shortage of those types of programs that have been critical to our children’s success here in Pomona.

CHAKRABARTI: Okay. So talk to me then a little bit more about what the city has been trying to do in the past decade or so with this Early Childhood Ecosystems Transformation program.

SANDOVAL: Yeah, so for me, you know, I’ve had the privilege of working alongside parents, educators, community leaders, and we have an incredible partner at UCLA called The Center for Healthier Children, Families and Communities. And we’ve undertaken an effort to reimagine what it really means for a city to truly support its children and families.

You know, as clearly stated by Dr. Forrest and I felt like I was a student back in college learning about what’s happening to our young people. And they’re deeply troubling. You know, the rates of child mortality, chronic conditions, and emotional distress.

But in Pomona, we’ve come to see these not just as isolated problems that can somehow be fixed by just providing more or better services, but as signs of a deeper ecosystem breakdown. So we’ve taken a different approach. You know, rather than chasing quick fixes, we’ve brought families, schools, health systems, and city departments together to ask the tough questions.

And what our data has taught us really is it’s turned the light on and allowed us to ask what’s holding our kids back? Where are the bright spots in our neighborhoods where children are doing better than expected? And how can we build a system that that really helps every child thrive? It’s called —

CHAKRABARTI: Can I just jump in here, Mayor?

SANDOVAL: Yeah, please.

CHAKRABARTI: Maybe you’re just getting to it. The EDI, the early development instrument. So from what I understand, it’s that in fact basically, the program looked at Pomona neighborhoods and just almost like, block by block went in and sort of mapped about how kids are doing in various blocks and tried to understand why needs were different in different areas?

SANDOVAL: Yeah, exactly. Basically, it showed where children were struggling. But it also revealed pockets of resilience we hadn’t seen before. So alongside neighborhoods where the indicators showed that kids were struggling, right next to those neighborhoods — right next to that neighborhood, I should say — there were kids who were resilient and doing well.

And there were a couple of key indicators that were very revealing to me as a mayor. One was housing stability and the other one was household stability. And when you think about the impact that rising rents are having on the stress in families, some families having to pick up and leave, but when those families leave, they lose that community network. They lose those relationships that are so critical to their household development.

And so what we noticed in one particular neighborhood is that there were families that had lived there for a very long period and they drew upon each other’s — those relationships they had with neighbors. You know, sometimes you need somebody to care for your child and you may not have the funds to be able to hire a babysitter. You have community members who resided in that particular neighborhood who are helping each other to do those types of things.

CHAKRABARTI: Mm. Okay. And so one more question then. Once you had this better understanding that I think you’ve, in previous interviews you said it kind of turned the lights on in terms of better knowing who was doing well, who wasn’t doing so well. What changes then were you able to make at the city level to improve the lives of kids in places where they needed it the most?

SANDOVAL: Yeah. So one thing I will tell you is that COVID dramatically changed those positive results. And that’s what we know.

But just two areas that are policy related that we recognized that we needed to undertake. One is the rising rents in Pomona was pushing too many of our families out of the community. So the city council through a very laborious process decided to bring a rent stabilization program. So that families and parents from year to year would have an idea of how much their rent would go up each year.

And then the second is, as you may know, access to green space is so critical, particularly with many of our families that are suffering from poverty, live in really concrete jungle apartments and need access to our parks. What we had in the city of Pomona had not raised its park fees since 1989. There were $675 for every new unit built. For perspective, the beautiful city of Pasadena was charging $18,000. So you could well imagine for many, many years we weren’t bringing in necessary funds to help expand our green space. Well, we changed that.

And you obviously, anytime you raise a fee, you have to justify it, and we’re able to do that. And as a consequence, we’re bringing more parks into our system.

CHAKRABARTI: Well, Mayor Tim Sandoval, mayor of Pomona, California, thank you so much for joining us and for giving us an example of what can be done on the city level.

I wanna bring in one more example, so let’s go now to Cincinnati, Ohio. And Dr. Robert Kahn joins us. He’s vice president of health equity strategy at Cincinnati’s Children’s Hospital.

Dr. Kahn, welcome.

DR. ROBERT KAHN: Thanks for having me.

CHAKRABARTI: Okay, so you heard Mayor Sandoval talk about sort of like just on the ground efforts in terms of even just the physical infrastructure of a city. I wanted to ask you about what work is being done in Cincinnati that uses sort of legal assistance to actually help improve the lives of or the health of children in Cincinnati. Can you talk to me about that?

KAHN: Sure. Absolutely. And you know, just to put it in context of Dr. Forrest’s comment, like if we want to work on health and not just healthcare, and every board chair at the hospital has said, you know, that’s our mission. Like, who else do we need to be partnering with to get that done?

And so it’s really, you know, the work of many on this. But you take the average child with asthma who’s living in an urban setting and, you know, a hundred degrees, poor control. And there’s two things a doctor can do at that point, right? He can double the medicine or add to it. Or you could say, “What’s driving that worse asthma?”

And what I found early on — and learned from others in doing this — is there are many partners that are effective in the community, but a health system has to figure out how to work with them. So we partnered early on, starting in 2008, with the Legal Aid Society of Greater Cincinnati. And what we found is, when we studied it, a 35% reduction in overall admissions through this partnership with the Legal Aid Society.

Because they are much more effective at some of the drivers, for example, of asthma. So poor quality housing, mold, cockroaches, so on. A doctor can prescribe or a doctor can turn to someone like a legal aid advocate who can work with the landlord to improve some of those underlying conditions Dr. Forrest talked about.

“A doctor can prescribe or a doctor can turn to … a legal aid advocate who can work with the landlord to improve some of those underlying conditions.”

And at this point, we’re up to over 800 referrals a year to Legal Aid. And that taught me early on that healthcare doesn’t have to do it alone. Healthcare can’t do it alone. But how do we figure out our complementarity? How do we work out the workflows? How do we build a shared vision together?

CHAKRABARTI: Oh, this is so interesting, Dr. Kahn. So the prescription is legal assistance so that the buildings that the kids are living in can actually be improved so that they don’t even, you know, get asthma to begin with. Okay. Now what about also there’s a program called Cradle Cincinnati. Can you talk about that briefly?

KAHN: Yeah. You know, as Chris said early on, these are multi-pronged problems and we needed solutions and approach to solutions for these kinds of wicked challenges.

So we started in one neighborhood and said, let’s come together around reducing that extreme preterm birth, right? And we, we put a precise measure up there that almost everybody could rally around — obstetricians, home visitors, pediatricians, legal aid, community health workers. And came together to figure out what is it we each can contribute to solving the problem? How do we use data not to evaluate but to get better every week? How will we get to a shared set of understanding of the causes?

My partners in that early work went on to create a countywide initiative called Cradle Cincinnati. So what we learned at that neighborhood level — we eliminated extreme preterm birth for three years, it had been one of the highest in the region — they’ve now taken it countywide, Dr. Smith and others, a 35% decline in infant mortality over the last 12 years or so.

And again, addressing some of the core issues Chris raised: How do we ensure healthy women can have healthy pregnancies and a healthy first year of life? So better access to trusted prenatal care, smoking cessation, community-based movements that emphasize women’s health and agency.

CHAKRABARTI: What advice would you have for other cities that are considering trying to start similar programs?

KAHN: Yeah. So, you know, so to me it would be pretty easy to be dispirited and overwhelmed by the data. But I actually wake up energized every day that there are proven methods to overcome some of these wicked problems, right?

So to me, getting the folks in a room, and I sort of think of it as a three or a four step process. Like, can we get to a shared vision and purpose? Can we have an established good data and an unassailable goal? You know, can we get the right people in the room, including parents and youth to figure out what it is that needs to change, just as the mayor was talking about?

And then instead of strategic planning for two years and everyone’s afraid to take a step and all the best people leave the room, what are the proven methods to start testing and kind of fail forward? And what I find is that energizes donors, it energizes foundations because instead of having kind of a thousand points of light and we never get to where we want to get to, they see sort of a coherent way of solving the problem.

“Instead of strategic planning for two years … what are the proven methods to start testing and kind of fail forward?”

CHAKRABARTI: Hmm. Well, Dr. Robert Kahn, vice president of health equity strategy at Cincinnati Children’s Hospital. Thank you so much for joining us.

KAHN: My pleasure.

CHAKRABARTI: Okay, so Dr. Forrest, I wanna wrap up with you here. We’ve just got a couple of minutes left.

I am quite inspired by the two examples that we just heard from about what can be done on the ground locally, in places across the country. It’s not easy. I’m not gonna just pretend that they can just flip a switch and change the outcomes for American children, but things can be done. There is room for hope and action there.

But I also wanna balance that against the national picture here. Because I’m gonna offer this, that I think part of the problem is we have a cultural sickness in this country. We keep saying America’s the greatest nation on earth. That’s maybe true in a lot of areas. But here’s one where it’s undeniably false that we are the greatest nation on earth. I don’t actually know if culturally and politically as a nation, and I’m looking at our nation’s leaders now, are ready to accept the truth of your report.

Because if they did, it would mean doing things like not cutting Medicaid. It would mean doing things like not cutting the child tax credit. It would mean doing things that put more money and resources to people who don’t vote because they’re under the age of 18. I don’t know if we have a cultural pill to solve that disease.

FORREST: You are identifying what we might call the root causes of all this. And I think you’re absolutely right to focus on the cultural system that we have in this country. It doesn’t value children. You pointed out that the children don’t have a voice. And so children rely on the agency of adults to help them overcome some of these challenges.

But just think about this, Meghna, the exceptionalism of the United States is largely based on the economic growth of this country, and the GDP is that indicator that we seem to be following with a microscope. What if we actually refocus the GDP to the gross developmental potential? And for every political policy that we implemented, we evaluated its impact on the economy, but we also evaluated on its impact on children’s ability to develop into flourishing adults?

And I focus on children here, not to the exclusion of the rest of the nation, but to point out that children are the foundation. Children are a hundred percent of future adults. And children are the canaries in the coal mine. So if we can improve the world the way Mayor Sandoval has been trying to improve Pomona for young kids, it actually will improve the world, or improve Pomona, for everybody.

I think the second issue that you’re pointing out is that there are some political decisions that have been made very recently that’s going to lead to more suffering. I think there’s no question about that. The declines that we are showing are alarming. The kids are suffering. And now is not the time to pull away the healthcare or the social supports that they need.

“The kids are suffering. And now is not the time to pull away the healthcare or the social supports that they need.”

And then finally, I’d love to see our society become much more child-centric, focused on what’s good for kids, and think about how we can create neighborhoods where kids can flourish.

CHAKRABARTI: Yeah. Well, even though I just was profoundly cynical a second ago, I’ll also say that I do believe that people care about children, but now we have to just act on that care.

FORREST: Yes.

CHAKRABARTI: So, Dr. Christopher Forrest, it’s been such a pleasure speaking with you. Thank you for your team’s report and thank you for joining us today.

FORREST: It was a pleasure being here. Thanks.

The first draft of this transcript was created by Descript, an AI transcription tool. An On Point producer then thoroughly reviewed, corrected, and reformatted the transcript before publication. The use of this AI tool creates the capacity to provide these transcripts.