DYING YOUNG : A CRISIS OF TRAGIC DIMENSIONS UNFOLDS EVERY DAY AT THE NATION’S LARGEST CHILDREN’S HOSPITAL

ON THE MORNING AFTER, A WEARY DOCTOR REviews the cases he handled during the midnight shift in the emergency room. Here at Boston Children’s Hospital, the patients are different from the accident victims and middle-aged men with heart attacks one might expect at a less-specialized hospital. After a typical night, 41-year-old Dr. Gary Fleisher counts one sex-abuse victim, one case of malnutrition, an adolescent suicide attempt, a handful of asthmatic “wheezers” and a dehydrated teen-age girl with AIDS. Fleisher, dressed in a wrinkled white coat, takes off his wire-rim glasses, rubs his eyes and scratches his beard. His face is puffy with fatigue.

“You don’t stop to think about it when you deal with the patients, but a lot of what we see every day has a social component. One of the worst examples was this 8-year-old who came in a few weeks ago with a gunshot wound. He had been hit by a stray bullet as he was coming out of a convenience store. It’s that kind of neighborhood. The mother only found out when she heard the kid crying in bed. He said he didn’t want to get in trouble.”

Children with bullet wounds, suicidal teens, malnourished infants--Fleisher calls it “the daily fare” for children’s hospitals across the country. The doctor rocks back in his swivel chair as he talks, and behind him, his own children look down from a picture on a shelf.

On his most recent shift, Fleisher had pumped the stomach of a 14-year-old girl who had swallowed almost everything in the family medicine cabinet, including some shampoo called 9-1-1. The girl told Fleisher she had long been unhappy and isolated at home, but had never discussed her problems with a doctor or counselor. “These visits probably cost $1,000 or more each,” adds Fleisher, “and they all could have been prevented.”

The wounded and the sick Fleisher describes are living examples of a children’s health crisis that has been proclaimed by a succession of blue-ribbon panels and commissions. This crisis is caused not by plagues and disasters but by political choices and by flaws in a medical system that boasts the latest technology but can’t manage to provide vaccines for the poor. America has developed the best medical care in the world, but its children still die at a greater rate than children in 21 other countries.

The largest pediatric hospital in the country, and thus a unique vantage point from which to observe the crisis, Children’s has more than 100 clinics and a staff of 4,000 scattered across an 11-building campus of old, ivy-covered offices and new, neo-Gothic clinical buildings. Patients enter the 350-bed main hospital, in the Fenway area of Boston, through a sun-washed foyer that resembles the lobby of a hotel designed for kids. Soft-sculpture animals guard the door. Water sprays from the mouth of a frog in a fountain filled with wishing pennies. Most of the patients live nearby, but it is not unusual for Saudi sheiks or German industrialists to fly their children here for care.

Because the hospital has the world’s largest pediatric research facility, the latest treatments are always available. Over the years, Children’s has pioneered an unequaled number of medical breakthroughs, from heart surgery to discovery of the polio virus. In the past decade alone, researchers developed a treatment to induce bone growth, created a drug that stops the progress of multiple sclerosis, identified the chromosome responsible for muscular dystrophy and performed the first double lung transplant on a patient with cystic fibrosis.

Yet even here, it’s clear that the American health-care system, designed to provide the most advanced care, often fails in the most basic ways. In America, nine out of every 1,000 children die before age 1, twice the infant mortality rate in Japan. Healthy younger children are threatened by the return of such scourges as measles, mumps and whooping cough. (More than 26,000 measles cases--including 97 deaths--were reported in 1990, compared to just 3,000 cases in 1986.) Thousands of abandoned infants, and those with parents deemed unfit, are hospitalized for months at a time, a stopgap measure that cost 12 hospitals $35 million last year. In adolescence, America’s children face rising rates of mental illness and pregnancy. Adolescent suicide rates have doubled since 1960. The number of teen-agers with AIDS rose 70% during the last two years. And gunshot wounds have become the leading cause of death for 15- to 19-year-old blacks nationwide.

Americans are clearly ambivalent about taking care of their young. Money is available to provide expensive hospital care for those with serious illnesses. But government makes an inadequate attempt to improve children’s lives before they get sick. A March, 1991, report by the National Commission on Children, which was appointed by the White House and Congress to study the status of America’s young, concluded that because of poverty, many of today’s children will reach adulthood unhealthy, illiterate and unprepared for the workplace. The commission recommended a series of programs and policies widely believed to be essential to help children, but neither Congress nor the President has moved forward on these ideas. Indeed, while both parties made children’s issues part of the 1988 presidential campaign, 1992 finds children conspicuously absent from the national political agenda. And on the state level, governments such as California’s, trying to erase their deficits, are proposing deep cuts in health-care spending, with Gov. Pete Wilson’s plan calling for a 15% reduction in health and welfare programs.

The paradox of America’s struggle to care for poor children implies that they are not worthy of attention until they are sick. A case in point is the measles scandal. It costs $7,000 to provide hospital care for one child with measles, but full vaccination treatment costs just $65. The measles problem is a direct result of a 12-year-long political battle over spending for poor children. Each year, federal funding for immunizations and community health centers has failed to meet the public’s needs. The result has been the return of a disease once on the brink of extinction. Today, a 2-year-old in Mexico City is more likely to be fully immunized than a similar child in the United States.

“The fact is, we have wonderful technology and the expertise to take care of kids who are very sick,” Fleisher says as he prepares to leave the hospital. He works in a windowless office that is strikingly ordered and quiet compared to the chaos that often marks the nearby emergency room. “But we have fallen behind on providing the basics--prevention, education, well-baby care--to all kids,” he says as he riffles a stack of file folders.

Today, more than 8 million children are not covered by health insurance. Many families use costly emergency-room services as they would a private physician because they have no other place to go. Fleisher says many of the 50,000 annual visits to Boston Children’s emergency room are for routine care that could be provided at much lower cost--if the patients had family doctors.

“I think you have to conclude that these are not simply medical problems,” Fleisher says. “You can just walk around and see that we have the very best technology, the highest level of care, but we’re using it to help a lot of patients who shouldn’t be here in the first place.”

AS A GROGGY GARY FLEISHER leaves the hospital, Dr. DeWayne Pursley is just beginning his day in the neonatal intensive-care unit, the first home for children whose very arrival constitutes an emergency. On this morning, a dozen tiny babies occupy the ward--one large room about the size of a tennis court. The patients, who weigh as little as one pound, lie in bassinets illuminated by softly glowing lights.

Most are connected by wires to monitors with red blinking lights. Plastic tubes carry water, sugar and other nutrients into their bodies through their umbilical cords. Some of the babies are connected to ventilators. With all its technology, the unit looks like a nursery out of science fiction. Except for the rhythmic sucking sounds of the respirators, the room is quiet. The light in the room is dimmed to calm the residents of the ward, who look like tiny, wrinkled astronauts, all wired into their glowing spacecraft and dependent on the machines for their survival.

Like similar units across the country, this one is filled with low-birth-weight babies who were born as many as four months premature. Low birth weight is the leading predictor of infant mortality. It is also linked to higher rates of cerebral palsy, mental retardation, autism, blindness, seizure disorders and chronic respiratory problems. After decades of steady decline, the number of low-birth-weight American infants began increasing in the 1980s. In 1989 they constituted 7% of all newborn babies, the highest number since 1978. America now ranks 31st in the number of infants suffering from low birth weight, behind even Egypt and Iran.

New technologies allow doctors to save many of these babies. One of the most important employs a chemical invented at Children’s that imitates the lining of the lungs. Without this substance, premature babies, whose inelastic lungs could not transfer oxygen to their blood, died of respiratory failure. Today, it is common even for “fetal infants” weighing less than 1 1/2 pounds to survive and eventually leave the hospital. Indeed, America leads the world in high-tech medicine and spends more per capita on medical care than any other country.

“But the technology still makes a lousy uterus,” says Pursley, who wears a yellow surgical smock over a blue, button-down shirt and tan pants. He is just under six feet tall with broad shoulders and a strong physical presence, a stark contrast to the tiny patients he treats.

Pursley says he is concerned about preventing low-weight births in the first place, but unfortunately, the trend is moving in the opposite direction. As he starts to explain, Pursley steps outside the unit, away from a young couple in sterile surgical gowns who are gingerly caressing their tiny baby girl. The baby, who looks like a tiny, pink, wizened old man, wears a knit cap and a little diaper.

“Drug use is one cause,” Pursley says, once he is in the hallway. Doctors estimate that nearly 20% of babies born in America’s major cities are affected by their mothers’ drug use. Babies born with high levels of drugs in their bodies can suffer permanent nerve and brain damage. While social stereotypes suggest that drug-affected infants are born only to poor, inner-city women, the facts are otherwise. Pursley treats drug-related problems in babies born to middle-class suburban parents as well as those born to poorer urban couples. And he insists that drugs cannot account for the majority of low-birth-weight babies. The chief cause, he says, is poor maternal health and inadequate prenatal care.

“What I’m more concerned with is the fact that of two women who are 12 weeks pregnant, it’s the poor, inner-city mother who has a much higher chance of her baby being born underweight and dying before its first birthday,” he says. Indeed, the 1989 infant mortality rate for black Americans--18 per 1,000--was about twice the rate for whites.

Pursley blames the sudden reversal of progress on cuts in programs aimed at poor mothers. Despite the boom sparked by Reaganomics, funding for maternal and child-health programs was cut by 34% in the 1980s. Migrant health centers lost 38% of their funding, while community health centers for the poor lost 24%. Both kinds of facilities provide prenatal and pediatric care. With the budget cuts, Pursley isn’t surprised that infant mortality remains constant and the number of low-birth-weight babies is increasing. This contrasts with Western Europe and Japan, where all mothers receive comprehensive care, fewer low-birth-weight babies are born, and expensive intensive-care treatment is less common. According to the Children’s Defense Fund, a national advocacy group for children, the difference between America’s rate of infant mortality and Japan’s costs this country an extra $7 billion annually in lost productivity.

Cost has become a serious issue here and in cities such as Los Angeles, where public hospitals have a limited number of units to care for premature babies and poor, uninsured patients may be turned away from private facilities. In those cases, hospitals perform a kind of triage, where babies may be discharged from neonatal intensive-care units ahead of schedule to make room for those in greater need of such care. A single day in a typical neonatal unit costs about $1,000 per child, compared to the average $1,000 total cost for the months of prenatal care leading up to delivery for a typical pregnant woman.

In Boston, where state regulations require that all patients get access to high-tech care in private facilities, Pursley concludes that the system isn’t working. It addresses the symptoms but not the causes of low birth weight. And he says that once children are discharged, having received the world’s best treatment, the system fails again.

“We do follow-up interviews with some of these kids’ families over a number of years,” Pursley explains. “We consider their potential for development, based on the medical condition they were in when they left the NICU (neonatal intensive-care unit), and we compare that with what we observe later on. In middle-class families with medical insurance, which means they get health care, these kids develop so well you can’t tell the difference between them and normal birth-weight babies.” But in cases where infants leave the intensive-care unit for poor homes with inadequate care, children quickly fall behind. “They just aren’t as bright-eyed or healthy,” Pursley laments. “We can’t do anything here to deal with the deficits of these children who fall behind, but someone has to.”

ACROSS THE STREET FROM THE main hospital, in an old seven-story office building, psychologist Edward Tronick sits in a room in the child-development unit that he heads, studying a videotape of a 4-month-old baby, frame by frame.

“Look, there!” he says, stopping the tape and tapping the TV screen with his index finger. An energetic man with bright blue eyes and longish brown hair, Tronick is obviously fascinated by babies. On the screen, the baby in question, a pink-faced little girl in a one-piece stretch sleeper, constricts her arms against her body and clenches her hands into fists. As she moves her head from side to side, her wispy black hair forms a spiky halo.

“This baby is what we call hypertonic. She doesn’t reach out to the environment, doesn’t show curiosity or bravery.” Hypertonic infants may have been born to drug-using mothers, or they may be compromised by malnutrition or another disorder, Tronick says.

In work begun by the pediatrician T. Berry Brazelton, whose behavioral-assessment scale for newborns is used worldwide, the child-development unit tracks the intellectual and physical progress of thousands of children. During the past decade, the researchers have seen increasing numbers of children born with traces of drugs or alcohol in their bodies who are suffering long-term consequences. Whatever the cause, these children are typically overly sensitive to stimuli and difficult to calm. Some suffer seizures or fail to grow at a normal rate. But Tronick’s research has shown that adequate follow-up care can help overcome a bad start.

“A child who has a seizure disorder, with good care-taking, will have a very good outcome, eventually having many fewer seizures and becoming, more or less, like other children,” Tronick says. “The same child, with poor care-taking, may never get past the disorder and will always seem different.” The effect of a nurturing environment has been studied in great detail, Tronick adds. “Even neurologists, who take a strong biomedical view, will tell you that the brain of a child with good care-taking is different than one with an inadequate environment. The brain cells themselves are larger, and there are more synapses, or connections.”

Good care-taking involves adequate medical treatment and sensitive nurturing at home. In some cases, impaired children may need special education. Some parents need frequent counseling and education to provide this kind of care. Others are too poor to provide adequate medical care or food or must leave children in substandard day-care for long periods while they try to make a living. The children fall further behind their peers each year, eventually becoming candidates for special education in school, which can cost two or three times as much as regular schooling.

“Quite literally, without intervention and care, their brains get messed up,” Tronick says. However, there are very few programs and institutions that provide the kind of help that Tronick suggests. “In our study, we are referred children from all the area hospitals, and in about a third of the cases we try to make referrals for ongoing support for these families. But there really aren’t enough places to refer these children to, especially if they are from poor families with very few resources.”

Tronick suspects that overall living conditions have a greater effect on developing fetuses and young children than is now known. In cases where drug use is a factor, researchers also frequently find poor prenatal care, malnutrition and exposure to environmental toxins such as lead and cigarette smoke. Lead poisoning, which can be fatal, is a particular problem in older cities where many homes have lead in the paint or pipes. Experts estimate that more than 3 million children have high levels of lead in their blood.

“In general, the cause is the way of life over there,” Tronick says, pointing out the window toward the poor neighborhood flanking the hospital. “In these poor communities the children are more stressed. You can see it in their faces. They don’t have the sparkling eyes and openness of children.”

This apathy is not a medical problem per se, Tronick admits. “It was last seen in the days when there were a lot of children observed in orphanages. We don’t have a name for it, but we sometimes call them ‘care-starved’ children.” Such care-starved children invariably falter in school and, in the worst cases, become unwed teen-age mothers, and teen-age boys who run afoul of the law. “We study these problems and notice the increasing numbers. But of course, there is no system set up to deal with this,” Tronick says with a sigh. “I think it’s for the same reason that we don’t have a name for this problem. We just don’t want to recognize that it exists.”

IT MAY BE EASY TO OVERLOOK THE connection between family stress and children who become welfare dependents or criminals. But in another part of Children’s Hospital, Dr. William Bithoney uses scales and tape measures to show the very real physical effects of poverty and poor medical care.

Bithoney, director of the Malnutrition Clinic, is a Yale Medical School graduate raised in a family of seven children in one of Boston’s toughest neighborhoods, Roxbury. He is a tall, 41-year-old man with a wide, toothy smile, and a tiny teddy bear clipped to his stethoscope. His first patient this day is a 1-year-old named Michael.

As Bithoney enters a small examination room, he discovers a handsome but withdrawn little boy with big brown eyes. Michael is dressed in a red-and-blue-striped shirt and jeans that appear to be a size or two too big. Bithoney weighs him and measures his height and head circumference.

When Bithoney finishes, he uses a special graph to plot Michael’s measurements against the norms for his age. Michael checks in almost five pounds underweight and two inches shorter than a normal, healthy boy his age. But what worries the doctor most is that Michael’s head circumference is in the lowest percentile. Children’s skulls grow along with their brains. A small head indicates slowed brain development, and since a malnourished body will naturally sacrifice weight from every other part of the body first, an undersized skull also indicates prolonged, chronic malnutrition.

In halting Spanish, Bithoney interviews Michael’s mother and father, who are both from Santo Domingo. The father is unemployed and no longer living with Michael’s mother. The mother explains that she and her child survive on $300 per month in welfare payments. She says they are both hungry for about half of each month. When Bithoney asks whether she receives food stamps or assistance from the federal Women and Infant Children nutrition program, she tells him she has never received WIC and was recently dropped from the food stamp rolls.

This mother’s struggle is typical of poorer parents who depend on government programs that have not kept up with demand. In the 1980s, as the income of young families declined by 32%, child poverty rose to more than 20% (it’s twice as high in some communities like South Los Angeles), and the demand for food stamps and WIC money increased. By 1991, WIC served only 57% of the poor mothers and young children who qualified for the program. And while food stamp allotments reached an all-time high recently, they still lag behind the actual cost of a good diet. Experts at the Food Research and Action Center estimate that even with WIC and food stamps, 5.5 million children under age 12 suffer from hunger. For some, like Michael, hunger leads to serious medical problems.

After about $400 worth of exams, tests and nutrition counseling, Michael and his parents leave the Children’s Hospital clinic with coupons to buy food at a nearby supermarket, and with appointments for meetings with a social worker and a legal aid attorney who may help them navigate the welfare system. Bithoney prepares to meet the next of six other malnourished children he will examine that day.

“People have trouble believing there’s such a thing as a malnutrition clinic in a major American city,” Bithoney says. “In 1983 we did a study that showed that 15% of poor kids are chronically malnourished. It’s probably higher today. Every day we see kids that are so poorly nourished that it directly affects their general health and development.”At any age, malnutrition lowers the effectiveness of the immune system, making a person susceptible to infectious disease. The effects are worse when hunger strikes the very young. The key period for brain growth is from 6 months after inception to 2 years. “Unfortunately,” Bithoney says, “we hear a lot of poor mothers say that they add water to formula to stretch it, or simply cut back on feedings because they don’t have any money for food. In everyday terms, the damage that is done will mean that a kid whose genetic potential suggests an average-to-high IQ, will instead be below average. They just have smaller brains, and there are fewer synapses.” Such children will learn to speak later than others and, once they do begin to talk, will acquire language at a slower rate. Many will suffer lifelong learning disabilities.

“You can get angry at the parents in these situations, but they both have no more than a fourth-grade education, and I’m not sure getting mad at them will help the kid,” Bithoney adds. “The mother knows that her child is smaller than the others. She already blames herself and is under a lot of stress. What would have probably helped is if somehow we could have spent the $400 that his examination cost on food.”

WHILE SOMETHING AS BASIC AS FOOD COULD HELP MICHAEL OUT OF THE malnutrition clinic, the children admitted to the psychiatric unit at Boston Children’s Hospital are affected by a more complex set of problems. There is convincing evidence that increasing numbers of children suffer serious psychiatric illness. A recent study by the Institute of Medicine found that about 12% of the nation’s children have some diagnosable mental illness. Between 1980 and 1987, the number of people ages 10 to 19 admitted to psychiatric hospitals rose from 126,000 to 180,000 annually. (In the same period, this population group actually declined 11%.) Since 1980, the number of emergency psychiatric cases at Children’s has doubled, to about 35 per month.

“But what’s more interesting is that cases today are more complex, and the families we see are significantly more chaotic,” notes Dr. David DeMaso, who oversees emergency psychiatric admissions at Children’s Hospital. “The No. 1 thing we see are suicide attempts. Usually it’s a kid taking what’s in the medicine cabinet.” Other common problems include eating disorders and behavioral problems such as truancy. In most cases, says DeMaso, these troubled children are under an inordinate amount of stress, often related to family crises such as divorce and unemployment. And while there are programs to help these kids, the ever-changing policies of health insurers make it increasingly difficult to get them the best services.

“It used to be that the first hour would be spent assessing the case. Now you have to ask about insurance within the first few minutes, because that will determine how the case is handled,” DeMaso adds. Because many health maintenance organizations and insurance companies won’t pay for specialized or extended care, a girl with an eating disorder may not be able to go to the best clinic, or a phobic boy will be shut out of the best group therapy. “With the system today, we cannot simply find the best care and send the child. Now it’s a matter of ‘Will they cover it?’ ”

DeMaso grabs a stack of files and quickly finds one to illustrate his point. The charts tell the story of a 12-year-old sexually abused girl who has been bedridden for three months with psychosomatic illnesses. She has lost 10 pounds, complains of pain in every part of her body and has been unable to attend school. Though the doctor who examined her in the emergency room recommended hospitalization, the last note in the file explains that this is impossible, “given her current medical insurance.”

Those patients who are admitted to the psychiatric unit at Children’s are assigned to the Judge Baker Children’s Center, across the street from the main hospital. On the third floor of Baker, a pair of nurses and a psychiatrist tend half a dozen boys and girls in a sunny lounge. Two small boys sit at a big table, rolling toy trucks and building a city out of blocks. In a corner, an adolescent girl slouches in an armchair, reading a book. Other children talk, or visit with parents.

The doctor, Gordon Harper, sidles up to a boy new to the floor, a gangly 13-year-old with a mischievous smile. He greets Harper with a look that is welcoming and wary.

“Why don’t you tell me about school?” the doctor asks.

“I lost my cool at school,” the boy answers, laughing at the rhyme he has made.

“What do you do when you lose your cool?”

“I bleep the bleep word,” he says, cheerfully avoiding profanity with his new doctor.

“How ‘bout we go to your room and talk about it?”

After talking with his patient, Harper takes a break to discuss trends in child psychiatry. He agrees that more children are entering the psychiatric system, but he says that is due, in part, to a heightened awareness of children’s needs. “It’s a major advance that those problems are now identified,” he notes. “The problem comes in getting the kids services they need.” A few hours earlier, Harper had appeared before the special-education director at a local school to plead for special services for one of his patients. “The problem is, they don’t have the money, and they won’t provide services unless you force them to.”

Hospital care and special education are the most expensive ways to provide mental health care and could be reduced by relatively inexpensive alternatives, Harper says. “We don’t often look at it in a medical way. But these kids are caught in a cycle, a way of approaching life, that needs to be interrupted and changed.” Programs such as Head Start, which provides child-care centers for poorer families, reduce the stress in family life and improve the mental health of children, Harper adds. But funding for Head Start has never been adequate to serve all of the eligible families. “Cost-effective prevention begins at a very young age. It’s no mystery. What works is to give the kids a sense that they have a positive, affirming future.”

T. BERRY BRAZELTON HOLDS A LITTLE BLACK BOX UNDER HIS ARM AS HE WAITS in a barren, white hospital hallway outside an examining room. When resident Michael Rich arrives with a young mother and her days-old infant, named Ronique, Brazelton ushers them into the room with the welcoming grace of a maitre’d. Once inside, he sets the box on a table, opens the lid and takes out a rattle, a ball, a little bell and a flashlight: the tools of his trade.

“This is to see how well she responds to a new stimulus,” Brazelton says as he clicks the flashlight on and off. At first the bald-headed little girl shuts her eyes tightly and turns her face away. But she gradually becomes accustomed to the nuisance and responds less. “She’s learning to shut out things she doesn’t like,” Brazelton says. “You’ll really notice that, Mom, when she’s a teen-ager,” he adds with a smile.

Brazelton makes a point of praising the mother so that she feels good about her contact with the medical system. The resident seems infected by Brazelton’s enthusiasm.

“Look how she can hold her head up. That’s amazing for a child this age,” Rich says.

Both doctors encourage Ronique’s mother to follow her instinct for comforting her child. When the exam is over, she takes the fussing baby into her arms and soothes her.

“It’s OK, Ronnie, Mommy’s here. You’re OK. I love you.”

Later, in the hospital’s sprawling lobby, Brazelton explains that he had tried to serve both the mother and child. The child got a full developmental check-up. The mother was taught how capable even a 2-day-old infant can be, and she had a positive experience with a pediatrician.

Regular contact with a caring physician or nurse practitioner is the best way to prevent children’s health problems, he adds. But most health-insurance programs will not pay physicians for the time it takes to engage parents this way. And many people without health insurance cannot afford an ongoing relationship with a doctor. They obtain medical services only when necessary, which would explain the glut of minor children’s ailments--earaches, fevers, influenzas--in hospital emergency rooms.

“We have lost the old idea of primary care,” adds Brazelton, who is a pioneer in the field of child development and a best-selling author of books on parenting. Ideally, Brazelton continues, every American child’s life would begin with prenatal care, followed by regular “well-baby” visits through the early years.

Such care is available in Japan, Germany and a host of other countries that provide health care for all children while maintaining competitive national economies. It can also be found at the Martha Eliot Health Center, a clinic run by Children’s Hospital in the midst of an old, sprawling public housing project called Bromley Heath.

On a late afternoon, the center’s first-floor waiting room is full of parents and children. Adolescents wait for counseling and care in their own special clinic on the second floor. Women receive gynecological exams in another special clinic. And a handful of single mothers wait to see the nutritionist in the WIC office. Almost every health-care need, including dentistry, can be taken care of here. The clinic can submit for reimbursement when patients are insured and it offers free care to those who are not.

Neighborhood-based clinics are regarded as the most effective way to provide care to those who need it most. They are, like Head Start, one of the successes that were part of the much-criticized War on Poverty mounted in the 1960s. Nevertheless, Washington pulled back from this approach in the 1980s, and the health of the nation’s children suffered. Some cities and states have tried to fill the gap. New York City plans to open 20 such centers in the coming year. In Los Angeles, where there are four pilot health clinics in the city school system, school officials are contemplating starting health clinics using outside grant money. But in the meantime, many low-income people go without.

At the Martha Eliot clinic, the staff includes young students from Harvard Medical School and veterans from Children’s Hospital such as Dr. Louis Fazen. Fazen says that in Zimbabwe, where he has spent much of his time working abroad, the medical system may do a better job of providing primary care. He says he sees many of the same problems in both places: malnutrition, inadequate immunizations, untreated illness and injuries due to accidents or violence.

“There are still gaps in the United States, even in communities that have a place like Martha Eliot,” says Fazen, a silver-haired 48-year-old. “People may get a free office visit, but they don’t tell us that they can’t afford the prescription. That happened last week. I diagnosed a strep throat, but the mother didn’t buy the child the medicine because she couldn’t afford it. The child wound up in the emergency room a week later to be treated for the infection and dehydration.” Clinic doctors say parents often delay non-emergency care because they have lost their health insurance. The delay may avert a minor expense but opens the door to a major illness.

But even with the obvious holes in the safety net, the clinic makes a difference in the lives of poor families in Bromley Heath. Deborah Robeson’s 3-year-old son, Moe, an insulin-dependent diabetic with a seizure disorder and severe, chronic asthma, is one such person. Like hundreds of thousands of children, Moe was denied Social Security disability payments under a new interpretation of rules adopted by the Reagan and Bush administrations.

But because the Martha Eliot center offers free care, Moe has received the attention of some of Children’s Hospital’s most qualified doctors. At the same time, the clinic staff has shown his mother how to use the Medicaid system, WIC and other programs to pay for medication and the special diet her son needs. They have taught her how to administer insulin, how to draw blood for tests and how to manage her son’s asthma medication. So far, the teamwork has kept the cost of Moe’s care down while he has grown healthy and strong.

“Moe has had 120 doctor appointments, and he’s only 3,” recalls Deborah Robeson, an energetic, matter-of-fact woman. “But I haven’t had to take him to the hospital all the time and deal with that. They take very good care of him right here at Martha Eliot, but we’ve still got problems. I can’t feed him the right way, completely, and still give all I should to my other children. And it’s very rough living here. You see the kids, little kids, hanging out all night. And you don’t know when something bad is going to happen and your child might be in the way.”

Robeson is attending community college in hopes of one day getting a job with health benefits and a salary that’s sufficient for her to live in a safer community. In the meantime, she struggles to hold on to the benefits from the various programs that help provide basic care for Moe and her two other children. She worries that Moe may have to leave the specialists at Children’s Hospital when Massachusetts phases in a new “managed care” health-care plan for the poor aimed at lowering costs.

She is grateful for the help she has received, but discouraged by a system that requires her to surmount endless hurdles to maintain her son’s health.

“Living around here makes you see the world as it really is--hard. I didn’t choose to be on welfare, and neither did my kids. Nobody chooses welfare. But when you think about how much they put you through, just so you can help your kids survive, it makes you wonder what has happened to the United States. They say we have to compete with all the other countries. But how can we do that when we make it so hard on even children? I don’t know for sure, but I just bet the Japanese help their kids better than this.”