The Brain Architects Podcast: A New Lens on Poverty – Working Towards Fairness of Place in the United States


In the fall of 2023, we kicked off our three-part Place Matters webinar series with our first installment: “A New Lens on Poverty: Working Towards Fairness of Place in the United States.” The webinar discussion featured the work of Mona Hanna-Attisha, MD, MPH, FAAP, whose research uncovered the water crisis in Flint, H. Luke Shaefer, PhD, co-author of the new book The Injustice of Place: Uncovering the Legacy of Poverty in America, and their groundbreaking new program, RxKids, an innovative effort to address child poverty and improve health equity. This conversation, moderated by our Chief Science Officer, Lindsey Burghardt, MD, MPH, FAAP, has been adapted for the Brain Architects podcast.  


Dr Mona Hanna-Attisha
Mona Hanna-Attisha, MD, MPH, FAAP
Founding Director, Pediatric Public Health Initiative 
H Luke Shaefer
H. Luke Shaefer, PhD
Professor of Public Policy and Director of Policy Solutions, University of Michigan 
Lindsey Burghardt, Chief Science Officer, HCDC
Lindsey C. Burghardt, MD, MPH, FAAP (Moderator)
Chief Science Officer, Center on the Developing Child at Harvard University
Rebecca Hansen
Rebecca Hansen, MFA (Webinar Host)
Director of Communications, Center on the Developing Child at Harvard University
Amelia Johnson
Amelia Johnson (Podcast Host)
Communications Specialist, Center on the Developing Child at Harvard University

Additional Resources


Amelia Johnson: Welcome to The Brain Architects, a podcast from the Center on the Developing Child at Harvard University. I’m Amelia Johnson, the Center’s Communications Specialist. Our Center believes that advances in the science of child development provide a powerful source of new ideas that can improve outcomes for children and their caregivers. By sharing the latest science from the field, we hope to help you make that science actionable and apply it in your work in ways that can increase your impact. 

In October, we kicked off our three-part Place Matters webinar series with our first installment: “A New Lens on Poverty: Working Towards Fairness of Place in the United States.” During the webinar, Dr. Lindsey Burghardt, our Chief Science Officer, moderated a discussion between Dr. Mona Hanna-Attisha, whose research uncovered the water crisis in Flint, and H. Luke Shaefer, co-author of the new book The Injustice of Place: Uncovering the Legacy of Poverty in America. The resulting explores how the qualities of the places where people live are shaped by historic and current policies, which have created deep disadvantage across many communities with important implications for the health and development of the children who live there. We’re happy to share these insights with you all on today’s episode. 

Now, without further ado, here’s Rebecca Hansen, the Center’s Director of Communications, who will set the stage with a brief overview of the webinar series. 

Rebecca Hansen: Alright, hello, everyone. My name is Rebecca Hansen, and I’m the Director of Communications here at the Center on the Developing Child. And I’m very excited to welcome you all to today’s webinar, A New Lens on Poverty: Working Toward Fairness of Place in the United States. This webinar is the first in an ongoing series designed to examine the many ways that a child’s broader environment, including the built and natural environments, as well as the systemic factors that shape those environments, all play a role in shaping early childhood development beginning before birth. In this series, we will explore various environment tool influences from both scientific and community-based perspectives, including strategies to work toward fairness of place and improve existing conditions to allow all children to thrive. I want to thank everyone who submitted questions for our panelists today. We received hundreds of questions, and we will turn to some of those in the second half of the conversation. And with that, I am excited now to hand it over to Dr. Lindsey Burghardt, who is the Chief Science Officer at the Center on the Developing Child and a practicing pediatrician in the community outside of Boston. Lindsey, I will pass it over to you to introduce our panelists and get the conversation started. 

Lindsey Burghardt: Thanks, Rebecca. And thanks to everybody who took time out of their day to join us here. And before I introduce our fantastic panelists, I’m just going to start by giving some context and some background for our conversation, and then we’ll jump right in. And I think we’ll have a great conversation together today. So earlier this year, the National Scientific Council on the Developing Child published their 16th working paper and they called it Place Matters: The Environment We Create Shapes the Foundation of Healthy Development. And that working paper laid out a framework for how the child-caregiver relationship is critically important and just as important as it’s ever been. But in shaping early childhood development. But that relationship doesn’t exist in isolation. And the places where people live affect what they’re exposed to. And that in turn affects maturing biological systems. And those effects can be positive or they can be negative. And that’s what we mean when we say that Place Matters. So the physical environment that surrounds children, their built environment, their natural environment. Both of those are shaped by human actions, including very intentional decisions around policies that shape the environments where kids live and the quality and the conditions in the environment where children live. They’re not evenly or randomly distributed. They’re shaped by and they’re deeply rooted in public policies and social history that we’ll talk about today. So for many families, both these historical roots, as well as present day policies and decisions being made, are resulting in really an uneven distribution of risk and opportunity in neighborhoods and in the places where families are raising young children. So I am thrilled just completely thrilled to introduce two really special guests who are going to talk more about this today and who are really deeply committed to reshaping children’s environments to support their healthy development. Dr. Mona Hanna-Attisha is a fellow pediatrician. She’s an activist and author. Just an amazing person who leads an innovative program called Rx Kids, which aims to address child poverty and health equity. And it does it through unconditional direct cash payments to residents of Flint, Michigan, during pregnancy and throughout the first year of their child’s life. Our other panelists, Dr. Luke Schafer. among many things, is the Hermann Amalie Kohn Professor of Social Justice and Social Policy at the University of Michigan’s Gerald R Ford School of Public Policy and the inaugural Director of Poverty Solutions. And he’s partnering with Mona to launch Rx Kids. Luke has a new book that came out this summer, The Injustice of Place, and it provides what I think is a really sweeping understanding of extreme poverty in the United States. And it puts a new lens on poverty, I think, because of the unique multidimensional measures, Luke, that you used in the book, as well as the way that you engage the communities when you are conducting research for the book. So Mona and Luke, welcome. I’m really excited to have you here.

Mona Hanna-Attisha: Thank you so much for having us. 

Lindsey Burghardt: So the two of you are working in really close collaboration with the community in Flint to address poverty in really actionable ways. And what I’m hoping today and what we talked about before when we prepared for this webinar was really focusing on the innovative approach to solutions that you guys have taken and so that those who are listening can apply anything that resonates in their own contexts. Sound good? Awesome. All right, let’s do it. So first question for Mona. We have some international listeners and some who may not be as familiar with maybe how your really specific engagement in this area got kicked off and your work related to the Flint water crisis and you really helped to shine a spotlight on a key example of how community disadvantage and underinvestment influence exposures that shape children’s developing systems. Can you talk a little bit about how you became involved in the water crisis in Flint, what you learned and kind of where things stand today? Awesome. 

Mona Hanna-Attisha: Thank you for that question and thank you for having us. We’re so excited to be here with all of you, almost 500 people to talk about solutions. And in order for us to really move forward and to make a better world for our kiddos, I think we so often have to start by looking back. So I can share a little bit what happened in Flint and my role. And it’s really it really starts by looking even further back. And I think that’s where kind of Luke is an expert in terms of kind of a history that got us to where we are today in terms of disadvantage. But Flint was at one point like a place of prosperity and opportunity. The birth of the UAW, which is in the news right now, that there’s a historic strike in the 1930s that really put Flint on the map. And autoworkers were demanding prosperity, very similar to what they’re demanding right now. And there was Flint kids striking alongside their parents. And there’s a Flint kid that was holding a sign in the 1930s. It said, give us a chance for better food and a better life. And that advocacy, that resistance that enabled really the beginning of the UAW and the birth of the middle class in America. And that started in Flint. And things happened in the environment and investment and public health and education and community schools and, you know, infrastructure, all this stuff that made Flint a place of prosperity, that translated into improved opportunity and improved health for the people that lived there. The history that followed in Flint is not unique to the communities across the nation. It’s a history of disinvestment. Automation. Globalization. Plants closed. Jobs were lost. Exploitation of workers. Systemic racism that made certain neighborhoods specific to African-Americans because of redlining and blockbusting and chronic disinvestment from, you know, state and federal government, which made Flint kind of this a bleeding city with the loss of population. And really every disparity that you can think of. And even before the water crisis that made growing up in Flint toxic like in so many of our communities, a kid in Flint, you know, their life expectancy is, you know, 15 to 20 years less. And a kid in another part of our county, this is once again not unique to Flint, but the census tract that you grow in the place, the environment, the conditions, the history, the geography, the hierarchy all predict how you end up. Flint was near bankrupt, lost democracy was taken over by emergency management. Like so many cities in our state at that time, anti-democratic law pushed through by our gerrymandered legislature, and that took away democracy, accountability and the decision was made to change our water source. It was from the Great Lakes to Flint River water without proper treatment, and that caused corrosive water to flow through our drinking water infrastructure and that corroded our pipes, which had lead in them for a year and a half. The people of Flint, a predominantly poor minority community, were drinking lead laced water. That’s how I got involved as a practicing pediatrician in Flint to do the research to uncover what was happening to our kids and really since then have been on this path to recovery. But it is an emblematic story of what happens when you live in a place that has been chronically disinvested, that does not prioritize the health and development of our children. Literally, the address of our children predicted whether or not they were going to drink poisoned water. So maybe an extreme example of what happens, a consequence of growing up in a certain place, but once again, not unlike so many communities across this nation. 

Lindsey Burghardt: And, you know, I think for Luke, Flint really represents this example, as Mona articulated so beautifully, of a community that has been disadvantaged in so many ways and the sort of that theme of underinvestment. And Luke, in the book, I was really fascinated when you wrote about this concept and developed this index of deep disadvantage, which is something that I had not heard about before in the context of understanding poverty. So I’m wondering if you can kind of describe the index and share more about how it can deepen our understanding about the circumstances of a community, especially as it pertains to young children. 

Luke Shaefer: I think that the index really tries to pick up on the themes that both of you have already started describing. One is that when we think about something like poverty, it really is often a matter when we’re really thinking about it’s a matter of compounded disadvantage. So in my field, we often think of poverty as a lack of income, not having enough to meet your basic needs. But I think when we all think about it, we think about income. And that’s clearly really important. But we also think about health. and those vast disparities that Mona was describing, you know, huge differences in life expectancy in fairly small levels of geography. And I think we think about social mobility. So we think about the possibility if you grow up or what are your chances of rising to the middle class. And so the index, the first thing the index really did was try to bring income, poverty, income, health and social mobility into conversation with each other. And it turns out we can learn more about a community. We can actually find communities where poverty is very high, but social mobility is also pretty good. Or communities that have longer or shorter life expectancy than we think. And it just really enriches our understanding and I think gets us closer to what we’re talking about. The second thing that the index does is say it tries to shift the focus from the individual to the community. So Mona described like huge, like decade plus long differences in life expectancy and like small geographic spaces and like, how can we how can we explain that the same is true with social mobility. So there are places in the United States where if you grow up poor, you are just as likely as anyone else to rise to the middle class. And then there are places where if you grew up poor, you’re likely to be poor as an adult as well. So how do we understand those geographic differences? So we brought all of those factors together and put them into a Machine Learning technique called principal component analysis. And we’re able to rank all the counties in the United States in the 500 largest cities on a continuum of disadvantage based on income, health and social mobility and it created a map for us and just to reiterate the evidence from this that support is exactly what both of you were saying. Once we had that map, we started comparing it to other maps and we could see like huge parallels. The most stark one was a map of enslavement in the United States from 1860, where we compared our map of deep disadvantage, a concentration of deep disadvantage to a map of the concentration of enslavement from 1860 and could see not just some correlation, but like really just a high level of correlation between the very gradation of those maps. So that really takes the onus off the individual. How can it be an individual’s fault when communities have been bifurcated and divided in these ways, not just for a decade, not just for a few decades, but well over a century? I think we have to start thinking about solutions in a very different way.

Lindsey Burghardt: Thanks for bringing the solutions early. So, Mona, from your experience, like how does this disadvantage, you know, and it’s so deep as you’ve described and kind of through these generations. How does it show up in children’s environment and how does it impact their health? Because, you know, we know that this starts before birth and it can show very early in life and things like low, low birth weight, which Luke talks about in the book, too, is a marker of, you know, disadvantage early in life. So how do you observe that in practice? How is it showing up in your work?   

Mona Hanna-Attisha: Yeah. Lindsey That’s a great question. And as a fellow practicing pediatrician, you know, we see it in our patients, we see it in their bodies and we see it in their blunted potentials. One of my favorite quotes, someone said as a pediatrician, we are the ultimate witnesses to failed social policies. You know, it’s these inaction and policy or certain actions that that make our kids sick. And, you know, and once again, implicate their entire life course. I’m going to share one quick story. The last time I testified before Congress, you always have to tell stories. They don’t listen to science and facts as much as long stories. And I and I told them a story about a patient, a kiddo who and who had seizures and developmental disorders and all these problems because he had drunk, you know, from the leadline in his house during the water crisis. But then I didn’t just talk about the kid. I traced it back to his family history. So his grandparents moved to Flint in the 1950s as part of the Great Migration North. So look at the policy because of Jim Crow racist, you know, laws and lynching and oppression, his family, you know, fled the South and came to Flint like, you know, Chicago, Detroit, all these other places for a chance at equality for them and their children. And they stayed in Flint. The ups and downs and their grandkid, their great grandson, was now sick because of policies not just the acute policy of our water switch, but also these historic policies that have made it hard for people to be healthy. And that’s just an example of how it’s kind of the multigenerational impact. 

Lindsey Burghardt: Yeah, absolutely. And can you talk for those who may not be specifically familiar with exposures like related to water in particular, and like, how does that show up? I mean, can you explain like how that can matter even before birth?  

Mona Hanna-Attisha: Yeah. So important. Yeah. Like most environmental exposures, they often don’t show up acutely. So lead is known as a kind of a silent epidemic. We we don’t see acutely the consequences of lead exposure like like many environmental exposures. Yet we see their manifestations, their, you know, their impact years, if not decades later. So my book is called What the Eyes Don’t See, and it’s because of that we don’t see lead in water. We don’t see a lot of the contaminants in there yet Once again, they manifest later causing things like cognition issues, behavioral problems, early exposure to things like lead and other neurotoxins cause things like hypertension, high blood pressure that’s been linked to, you know, early dementia and gout and kidney disease and a whole slew of lifelong consequences because of an exposure in early childhood. And also, like you said, also prenatally, a lot of these toxins in our water and in our in the rest of our environment also cross the placenta and affect the developing child. So we know that exposure in this kind of critical, you know, prenatal infancy window as these, you know, hazardous kind of life course altering impact. 

Lindsey Burghardt: Yeah, I really appreciate how well you articulated that because I think that’s especially what’s frustrating in practice is that some of these implications and effects of environmental exposures that we see, they are like invisible and they’re delayed. So the implications of being, like you said, exposed to lead in utero or as Luke describes in his book, the implications of being born with a lower birth weight, we tie that I think, sometimes to these very individual actions when really there’s things that are surrounding us and shaping our biological systems from the earliest days of development that are very much not based on individual actions. People’s systems can be shaped for better or for worse by what surrounds them as they’re developing. And so I think I heard you say once, and it has stuck with me on such a deep level. I wish I could prescribe away poverty. And I think that’s one of the times that I knew that you were going to be like a force in this field, is that that connection is so important. And I think that getting that message out about how poverty impacts and how the impacts of things like systemic racism affect not only, you know, how well children do in school, but their health throughout their life, cause it’s so important. So thank you both for being the spokes people that you are and for kind of getting these messages out in the articulate way that you do. And I want to pivot to Luke now and talk about, you know, your team found that some of these places of deepest disadvantage were actually dominated by rural communities. And I think there’s often this counterpoint or kind of counter assumption that poverty can be worse in cities because of things like high cost of living and high concentration of people. And we sometimes, I think, erroneously assume that rural communities might have lower levels of inequality which you actually found is not the case. So can you kind of talk about why these assumptions were wrong and how you kind of found poverty to exist in different contexts and how that played out? 

Luke Shaefer: So I think borrowing from Bryan Stevenson I’ll mention that I think we’re best at understanding the problems that we’re most proximate to. And so most scholars and folks who are thinking about poverty are, you know, more clustered in urban areas. And so I myself had been, you know, all of my time that was working in the field in places like Chicago and, you know, in in urban areas in Michigan. And so it’s easier to just see, you know, certain challenges, high cost of living being one of them. Right. We can see sort of how much housing is costing. We can see that public transportation systems maybe don’t work as well as they should. And so we can follow our nose there. In this book, we tried to take a data driven approach to zero in, and we wanted to go to the most disadvantaged places in the country based on income, health and social mobility. And as you mentioned, I when we looked at that top 100 places in the United States, we loaded in every county, in every city. You know, the 500 largest cities gets you down to cities of maybe 50,000 people. It was disproportionately rural. There actually only nine cities in that hundred most disadvantaged places. And in a place like Chicago, it wasn’t even in the 600 most disadvantaged places. And then we went to these places and really got to know a subset of them, the ones that we write about in the book, but also spent time getting to know other communities. And it looked right to us. Right? We felt like this sort of visual audit validated that. So the thing is that like when you are more proximate, the problems, you can understand their downsides, but you also don’t understand some of the signals of those things. So we have a high cost of living in some parts of the United States in urban centers, is often connected to the fact that there are better services in those places. So maybe the health care system doesn’t work as well as it should, but it’s there and people have access to a health care system. Maybe public transportation doesn’t work like it should, but there is some public transportation in the rural communities, which also, you know, I think surprises some folks. Many of these rural communities are predominately communities of Black Americans or Latin Americans, of course, out West and Native American lands. And there might not be any hospital at all or no health care system to speak of. And there certainly is no public transportation. And so there’s cost of living differences, which we’re used to. Thinking of them as a challenge also represent things which are differentiated in terms of private philanthropy. We see, you know, hugely more dollars go into low income Americans in urban centers than in rural areas because that’s where the money is and people like to give to their communities. And then so much of the what’s available, the federal government to work on these community problems is actually driven by contracts or grants. And what does that require? That requires very talented folks who can write those grants, which you often don’t have, in very, very poor rural communities that you might have in an urban community. So once again, I think when we sort of delve deeper, when we really try to understand places and we, you know, we can come away sort of with a deeper understanding of what’s going on, what are the challenges that different communities are facing that that we might not have any connection to at the start?

Lindsey Burghardt: Well, thanks. Luke, let’s shift a little bit and talk about Rx Kids because I think this can feel very overwhelming. And when I heard about Rx Kids and I saw the potential for this solution, I got so excited because here’s a chance for like public policy to really influence child health and development in an incredibly positive way. So this is the first prenatal and infant cash allowance program in the country, is that right? 

Mona Hanna-Attisha:: The first universal one. First universal–okay. All right. 

Lindsey Burghardt: So, Mona, can you talk about how your experience has kind of led you to this program, like how it works? How did you come to Rx Kids? Yeah. 

Mona Hanna-Attisha:: So, so the water crisis happened in Flint, and, you know, we had this population wide exposure to a neurotoxin also just kind of the trauma of the injustice. So we have been working around the clock to mitigate the impact of the water crisis and really promote the health and development of kids. And our work has really kind of focused on that early childhood window. We have two brand new childcare centers, huge expansion of early literacy, Imagination Library, Reach Out and Read nutrition, prescriptions, home visiting programs, trauma informed care, the expanded Medicaid, early intervention. The list goes on and on of the awesome that we have been able to put into place in Flint. But caveat, these are things that should have been there already and these are things that all kids need. They need food, they need education, and they need health care as a basics. But we didn’t have them before and we’re still kind of struggling to maintain them. And a lot of that what we have been able to put in place really relies on families to do more, you know, sign up for this program, go to this class, read to your kids, you know, feed them healthy, come to see me as a clinician. And that’s all good. But it makes me feel guilty like I am. I have been tired of asking the oppressed to do more. We talk about the kind of this concept of resilience, like why should my patients have to be more resilient? Because we as a society fail to build resilient communities. And when you understand what it means to grow up, be born into and grow up in poverty, like Lindsey, you said, I’ve wished so many times the ability to prescribe away poverty, like when I’m holding a little newborn in my hands and doing all the things I’m doing, the vaccines and the growth and development and the back to sleep and feeding and all this up, I wish I could change their zip code so that they do not have to grow up in poverty. And I was kind of sick of shrugging my shoulders and I’m like, Well, hold on, let’s do something. We can do something. We do big, hard things. Let’s do something. So I called Professor Shaefer over here, who is a child poverty expert, helped bring forth the expanded child tax credit for the nation. And I’m like, Do you want to work with me on a child allowance for Flint? He didn’t say no. And, you know, since then, we have been developing this program, which has become Rx Kids. It is a prescription for health, hope and opportunity. And starting in 2024, we will be prescribing every pregnant mom unconditional universal cash allowance and mid pregnancy, and then every baby an unconditional universal monthly cash allowance from birth to 12 months of age. This has never been done before. It’s city-wide scale. It’s launching. I see all the hearts and I’m so excited because now I’m. Sure the loving is hard and. Perfect because this is launching on Valentine’s Day. Because as much as we are trying to alleviate poverty and address economic instability, we are sending a strong message of love. This is how we are supposed to care for each other. This is about loving our moms and babies, seeing them and hearing them and walking alongside them during this really critical mom infant period, which not only is so important developmentally, but turns out to be the most economically vulnerable. Families are the most poor perinatally. So we’re launching in February. We’ve raised a lot of money. We still have about $15 million to raise. So anybody feel free to contact me if you want to give us money or, you know, anybody really rich here wants to support us, go to RxKids.com But we are launching in January and our hope is to do this for five years of moms and babies. And, and maybe I could pivot to Luke and who can tell us more about kind of the science of child allowances globally and domestically, if that’s okay, Lindsey. 

Lindsey Burghardt: Please, yes! 

Luke Shaefer: So in prior work that I had done, I had focused on very, very poor families in the United States. And actually this increase in families without any money. So in the United States, families might have access to food assistance through like food stamps or maybe even work that can provide for that. But what does it mean that they have money to be able to buy toothbrushes or toilet paper or diapers or pay the rent if you’re facing eviction or food? And so as we were thinking about what to do about it being policy scholars and wanting to get to solutions, we also knew that the old casual birth system that we had in this in the United States was a very stigmatized program. It was a program that just made families answer many, many stigmatizing, invasive questions. It has a long history of it being administered in structurally racist ways in the United States. So we wanted to look for a different model. But luckily you don’t have to start from scratch. There is this incredible movement across the world for child allowances or sometimes they’re called child benefits. And the logic starts from a very different place, which is raising kids is expensive and society has a reason to come alongside parents and support parents in that work. And one way to do that that empowers families is to provide cash to pay the utility bill or to buy diapers or buy the crib. And so we’ve seen this over and over again in country after country, provide a small amount of money. Sometimes that’s $250 per kid, maybe $300 per young kid and every time countries adopt this, child poverty plummets and food hardship plummet, and kids do better on so many different metrics. So in the United States, this seemed like pie in the sky a number of years ago, and my colleagues and I started talking about it, but it became a reality in 2021, where we did this through the expanded child tax credit. And families for six months, really received a monthly amount to support their kids in a way that they saw was best. And we saw child poverty fall to an all-time low. Millions of children lifted out of poverty. We saw food hardship fall to an all-time low. We saw improvements, research papers, finding improvements in the mental health of parents. We saw one of the things I thought was most interesting was credit scores actually hit their all-time high. At the end of 2021, the number of Americans with bad credit fell to an all-time low. So, so many markers of financial health and it wasn’t extended. There still is a lot of support in Washington for it, but it did not become a permanent reality. And we just saw new child poverty numbers where child poverty more than doubled. And we have millions and millions of kids back in poverty after having been out of it. But there is still interest. And I think it showed what was possible for as a country that we could follow other countries on this. And so when I got Mona’s call, I couldn’t have imagined a call I would want to have gotten more to try to keep this in the public imagination and be a part of Flint actually leading the nation and saying like, this is how we should care for our families with kids, because we would have loved to done it for every kid of every age. But those numbers got really, really big, really quickly. So as I learned from my pediatrician and new pediatrician colleagues, like how important that first year of life is, and before that, babies brains doubled in size. And so much of what happens in that first year affects the life course. There’s a new paper in the quarterly Journal of Economics that finds an extra thousand dollars during that first year of life, has a substantively increase in earnings like relationship with people’s earnings in their thirties. So we’re talking about decades later and that it pays for itself. So this program is going to be laser focused on that first year of life in that prenatal period. And another thing that I really love about it is linking health care providers. So, you know, there’ll be lots of ways into the program but the primary way is for poor families to, you know, expecting moms to go to their prenatal doctor’s appointment and be prescribed cash along with all of the other advice that they’re receiving. And so we, you know, think and believe that it’s going to deepen the relationship between provider and family. So we’ll have the positive impacts of money that can help with your core expenses that families have, as well as a deepening of relationship with providers. And we hope maybe a re-envisioning of the social contract since this is so different from really any other type of program that we have in the social safety net.

Lindsey Burghardt: I love that and I love that tying it to your prenatal care and your prenatal provider and thinking about that model of a program like Reach Out and Read where parents don’t need to go to another different place and answer another set of questions and make a new relationship. When they already have one that for many they hold dear and as a trusted source of information. So I just think that deepening of that relationship is an incredible part of this program. And I think you talked about this a little bit with some of the effects that maybe we wouldn’t anticipate it with the program. Right. Like credit scores increasing, are there things that you’re thinking about looking at as outcomes that might not necessarily be tied immediately in our conscious, like thinking about implications for parents or children’s mental health in childhood or other kind of downstream implications of not having to feel this kind of burden of poverty.  

Mona Hanna-Attisha: Maybe I’ll talk about some of the wellbeing ones and talk about some of the community measures that we’re excited about. So we’re going to look at wellbeing, so we’re looking at measures of happiness and hope for themselves and their children, looking at the measures of dignity and trust, agency and empowerment. So I’m in addition to, you know, lots of health outcomes and, you know, prematurity and low birth rate, maternal morbidity and mortality, mortality and NICU admissions and well-child visits and health care utilization and postpartum depression. So there’s a lot of health stuff, but through surveys, we’re going to look at these well-being measures, which I’m excited about. And then this is a universal program. So in addition to kind of self-report, we’re going to also be leaning on administrative population level data. So maybe Luke can talk about some of the exciting things that a community level which is really novel for this, for this kind of project that we’re going to look up. 

Luke Shaefer:Yeah, I’m super excited about the sort of deepening of the relationships and seeing, you know, one thing we often see in my field is, well, you know, an organizational start, a new program that they think is really great and nobody will show up in. You know, they’ll think, Oh, we need to market it more. We need to make sure people know about it. Somehow with cash transfers, people show up. It is something that they value. So it’s a way to sort of build that relationship. So I’m excited to see if the cash transfers increases, you know, prenatal visits, does it increase things like nurse home visits after the fact because it’s building the relationship, sort of welcoming us into a conversation. And I’m really excited about child welfare outcomes. So that very first year of life is like a shock. I think it’s the biggest shock in terms of child maltreatment and kids being placed out of home. And so there is a new study out about the Alaska Permanent Fund and what it means to get benefits from that. That’s really a basic income that Alaskan residents have. And so this new paper looks at families that got that during that infant period and sees huge reduction in child welfare reports and out of home placements. Pretty incredible. And there’s yeah, there’s another you know, one thing that people are often interested in is around like alcohol and tobacco or drug use, you know, worrying that maybe folks will use cash in the ways that society deems wrong. And the research has been really interesting on that. So all of the places where we studied that there’s never an increase in substance uses. In some places there’s actually a decrease in those things. So the cash transfers are related to reduced alcohol, and tobacco, for example, maybe as a result of reducing stress, means that families are less likely to feel like they need to rely on substances. And then what we can do with this that we can’t do with any study that, you know, a pilot for a couple hundred is what Mona was alluding to of looking at the community level factors like does this help to rebuild trust in government and just money circulating through the community. So we’re talking about 9 million extra dollars that is going into the hands of Flint residents. And all of the research suggests most, if not all of that is going to be spent locally. And maybe this is going to be a more effective economic development strategy than some of the top down type approaches that we’re more often using.

Mona Hanna-Attisha: The rebuilding of the social contract work, I see this also as a way to restore democracy and more trust and faith in government. And I think we might see that in improved voting rates and civic engagement. So that’s something else that we’re looking at. 

Lindsey Burghardt: So I can imagine that like people who are listening would really like to kind of look into your play book and get an idea of how you’re able to do this. I can’t wait to be able to share some specifics about how you kind of got the program to life. How did you get it written into the state’s budget? So, you know, can you share kind of any tips for people that might be listening and interested in applying this to their own contexts? 

Mona Hanna-Attisha: Absolutely. So from the onset, our intention was to start this in Flint, but really to share this. That’s why we’re so excited to be here today. So this is expensive. So we need about $11 million a year to do this. 9 million are the direct cash transfers. And once again, we want to do this for five birth cohorts, five years of moms of babies. So our goal has been to raise $55 million. We received a very, very generous grant from philanthropy from the CS Mott Foundation, a $15 million match grant very early. Other foundations also came in, a mix of family and local and state and national foundations. But our most exciting funding has come from the state of Michigan, and this is our pathway towards sustainability and scalability. And it has come as a redirection of TANF, which is the Temporary Assistance for Needy Families. This is the cash welfare system, and I’m going to send it back to Luke because he’s an expert here. But this is super exciting. This enables other communities to do this. This is what’s really kind of getting the attention nationally and is the playbook. 

Luke Shaefer: And the United States in 1996, we thought that we reformed welfare to be a work first and time limited cash welfare program. But it turns out what we did was create a very flexible block grant. So this is a chunk of money that’s 16.5 million at the federal level that goes down to states. In Michigan, we get about 750 million of that in this TANF funding. And all the states can choose to use this for cash assistance where they provide a small amount of money to families every single month. And if they do that, they have to do a lot of reporting. There’s lots of requirements. They can actually get into trouble if they don’t do things right. Or if they want to they can not provide cash assistance and use the money for any number of other things as long as they can justify on paper that it fits one of the core purposes of TANF that includes, you know, taking care of kids in their own home, but also things like promoting marriage or reducing out of marriage births. So what states have figured out over time is that they can actually use the money in ways that they were probably already spending otherwise. And so we’ve shifted the money to all sorts of things. Lots of states pay for their child welfare, their foster care system out of it, Lots of, sort of, using the money to deal with administrative costs. And in Michigan is not out of line with where a lot of other states are. Of their 750 million that the federal government spends then and the state puts in another 100 million or so, only about 55 million actually goes to cash assistance to families. So that’s 6% of the total amount to a much bigger chunk goes to things like the child welfare system or in the case of Michigan college scholarships, that mostly go to higher income families because we were short on our college scholarship budget. So Rx Kids what it does is say, let’s bring some of that money back to, you know, what was really the intention of the original program as 6% is not an appropriate amount of this block grant to be spending on cash aid. But let’s do it in a fundamentally different way. Let’s do it with dignity. So, you know, cash welfare programs of TANF always require like an income test, and families have to apply. They have to really prove that they’re not just poor, but they’re really, really poor. In this case, we’re going to use TANF to support families who are low income, but all families are going to be eligible because by making every family in Flint eligible, we actually cut off the stigma that having that income tax can have on families who don’t have enough. Right. We’re no longer saying you get this money because you can’t handle, you know, your own needs. We’re saying raising kids is expensive and society wants to come along and support you in that work. It turns out people that are well above the poverty line, have trouble paying for diapers or trouble paying the rent or paying for child care. So it makes a lot of sense. So we’ve just been so excited to see the level of interest that this has driven from other states. We’re hearing from people in all sorts of other states that want to talk about this. I think in part by focusing on this first year, we sidestep some of the general, you know, the typical questions about, you know, does this become a life cycle? Is this a dependency? Is it going to impact, you know, our work in the long run? We’re talking about really focusing on this first year of life when families are the poorest, when kids are developing at like breakneck speed and using this money in a dignified way, not just to help families meet their basic needs, but also to try to send them a very clear message that you are cared for and we want to be a part of helping you do this job that you think is, you know, the most important thing that you are doing.

Mona Hanna-Attisha: I can just add you have Luke and I, but this this work, like all good work is done, has been done in a humble partnership with our community. And that we have a group of moms and dads and kids that have been really driving this work and where this kind of originated and that that’s part of Flint’s story. If you remember Flint’s a story that lost democracy so central to our recovery and our path forward is the role of participatory democracy and self-determination. So from the logo design to how much money to our Valentine’s Day party and who’s going to perform it, maybe Beyonce, maybe so all of this has been driven by our parents, by moms and dads in this work, which I think is, you know, which is kind of central to all public health work and working communities. 

Lindsey Burghardt: And that’s amazing. It’s actually the perfect segue to our questions. We got over 100 questions from the webinar registrants from all around the world. And one of my favorites, because I’ve heard you talk about this is really how you were incorporating that lived experience and community perspective in the in your work. And I just think to hear you talking about bringing back like the joy and the dignity and centering those in this process just I think is amazing. And we’re going to jump into a couple of questions. We have a few minutes here to just hear from what our registrants wanted to know more about. And there are several questions that kind of got into the education and early education space and thinking about applying, Luke, like what you kind of learned on the road about schools in the education context, to think about how we can think about solutions to funding to support these places, you know, schools and early childhood centers to address issues related to poverty and kind of what strategies and recommendations would you both give school districts to help center the importance of place? Sorry, there’s a couple questions in one.  

Luke Shaefer:Actually I’ve just been writing about this, so the very first thing that I mentioned is it’s worth it to look at the history of places and figure out why schools are so unequal. So one of the favorite parts for me of my book is a passage about segregation as academies that cropped up in a lot of the communities that we’ve studied over time where, when Brown v Board came down, communities were able to ignore it for a while, and then finally they weren’t. And they had to integrate public schools and the research is very powerful that integrating public schools had a huge positive impact for Black American schoolchildren and no negative impact for white schoolchildren. But communities going in the opposite direction and the segregation academy sometimes pulled over like all of the resources from the public schools and basically replicated in many ways the system we had before. So looking at that history, I think is really critical. I think it can help us understand like what are the solutions that would actually work, how could they be circumvented? So what do you do with that? One strategy that I have actually become very interested in is just raising the pay of starting teachers. So this has a really nice evidence base around. We just we paid teachers who do incredibly hard work almost nothing. And so, you know, to keep that up–again, it’s not just the money and being able to survive, but it’s the signal that we send to people who want to go into the teaching profession about how we value it. So the evidence is sort of in that first few years of teaching: if we could raise those salaries, we would attract more people, we would keep them for longer. And if you can have mandates across systems that, like everybody is raising their teacher salaries, it’ll impact the poorest schools the most.

Mona Hanna-Attisha: But we need to raise early childcare teacher salaries even more. They are paid so little. And if we respect the science that we all understand that this is the most critical time in a child’s life, we know these are brain builders We need to be paying them Ph.D. level salaries. I mean, it just it needs to follow the science and they are absolutely undervalued. So, I mean, that would be one of my recommendations. But also really thinking about the education system a lot earlier, you know, why is a school, you know, grade K-12? Well, why doesn’t it start at age three or, you know, age one? So really respecting the science and thinking about the importance of the–prioritize the importance of early education. 

Lindsey Burghardt: Yeah, I couldn’t agree more. And I think, you know, Luke, you mentioned that there’s like economic perspective now looking at kind of the cost benefit analysis, even like focusing on young children very early when they need it most. And I think to us as pediatricians and for people who are deeply immersed in this work, it just makes total sense. But I, I hope that we can continue to build the kind of arguments for what really feels like science that our grandmothers told us that makes the most sense: if you take care of young kids when they’re very small, you can get them off to a good start and sometimes better to get it right the first time, I think, although it’s never too late, of course. 

Mona Hanna-Attisha: So I know you have a bazillion questions, but I’m going to I can’t not share my favorite quote, so  

Luke Shaefer:I know you’re going to.

Mona Hanna-Attisha: So, we’re launching on Valentine’s Day, remember, because this is about love, and it’s Black History Month. And it’s also Frederick Douglas’s, self-proclaimed birthday. And he his quote about prevention is my favorite quote and really kind of what I live by. And he has said: It is easier to build strong children than to repair broken men. And that is the work that we are all doing every day. It is building strong children, our health care system, our education system, our criminal justice system, you name the system. It’s reactive. We fail to prevent we fail to invest in our kids and we go on and Band-Aid and pay the consequences. So it is easier to build strong children than to repair a broken man. 

Lindsey Burghardt: Yeah, it’s beautiful and I think to your point, we can hold up each of these systems and look at how they are considering or not considering very young children’s welfare and their impact on the youngest citizens. And I don’t think that we do that in a universal enough way. And thinking about bringing in folks to the table in zoning and urban planning and environmental protection who do not consider themselves early childhood advocates or people whose work influences early childhood, when in fact it has a profound influence on children and families. And I think you both are just doing such important work and connecting the dots. And you know, the last question that I’ll raise that came from audience that I loved, and I swear it was not planted: if science is so clear about how exposures like pesticides in lead and water affect brain development, you know, how have these things become so partisan in their communications? And how do you address that in your work to achieve the kind of mindset shift that allowed you to get something like Rx Kids off the ground? Like, how do we kind of approach these conversations to demonstrate to a variety of audiences what science tells us about supporting young kids? 

Mona Hanna-Attisha: There’s a lot in there, and I’m just going to, you know, I think we have to keep sharing the science. And as we’ve done a little bit today, we have to continue sharing the stories about why this is important. I think very often we share a lot of bad news and we share we catastrophize, especially with all the issues facing children and climate change. And, you know, the list goes on–gun violence. And I think like you have done today, I think it’s important to share the solutions and to share kind of the community driven, you know, hope and the practical way that we can do this. We are at a place right now, this science denial place, not by accident. And we have to look at the history. Special interests and corporations have made it be this way. They have purposefully weakened regulations, disinvested in public health. Everybody, you know, go read about one of my heroes, Harvard’s first woman, professor Alice Hamilton, who fought against these industries and, you know, against the lead industry and General Motors and all these special interests and was silenced. And that really kind of set forth this paradigm that we work with today that has allowed for the unchecked use of so many bad things that hurt kids because the upper hand is always industry and corporations and profits and it’s not kids. So we have to learn that history and then we have to kind of, you know, keep electing people who understand that and respect that and will fight for kids.  

Lindsey Burghardt: Beautifully said. So closing thoughts from the two of you. So if you had to give advice for listeners, people who want to pursue public policy changes like what the two of you have worked so hard for in their own communities, what advice would you give? 

Luke Shaefer:I guess I would encourage people to start with listening. You know, I have found that my book that we talked some about today, all of the chapters were not things that I really expected to write about going in. But as we got to know communities, we really started to talk to families that drove our research agenda. That really drives the agenda of my research center here. And so we have to be willing to look at things like in our book, we have a chapter on government corruption, we have a chapter on community violence, and then tie it to the history and really be mindful that the challenges that face us today did not appear out of thin air. And if we really understand where they came from, we can do better at figuring out where to move forward and then come to positive, concrete solutions and celebrate them when things happen. You know, positive change can happen in the incredible distance that we’ve come on lead pipes being replaced all over the country is really remarkable. And so we have to understand our challenges and celebrate solutions.

Lindsey Burghardt: Love it. Mona? 

Mona Hanna-Attisha: I would just say you make all kinds of friends, those of us who live in who do this work often hang out with folks that are very similar to us. And I never thought I’d hang out with a social scientist policy guy to be able to do this. But we need to make all kinds of different friends. The tent of folks that care about kids is broad, and I think if that tent– as big as we can make that tent–the more likely that we will be able to achieve the outcomes that we hope to see. 

Lindsey Burghardt: I love it. Every time I talk to the two of you, I feel so inspired and buoyed to go out and think about this more. And you gave me so much to think about and reflect on and consider in our work at the Center. We partner with other organizations as well but everybody who’s listening feels the same way is that thank you so much for making the time, for being here, for being the advocates that you are for young children, for all the work you’re doing in Flint and beyond. 

Mona Hanna-Attisha: Thank you for having us. 

Lindsey Burghardt: So I’m going to turn it right back over to Rebecca Hansen from the Center to close us out.  

Rebecca Hansen: Alright, Thank you, Lindsey. And thank you again to our panelists for a really wonderful conversation. As Lindsey said, this has given us so much to think about and great ideas to apply to our work, and we’re really grateful for your willingness to share your expertise with our community. And lastly, I just want to say that there is so much more to come in this webinar series. We are working to bring more conversations like this one to you in the coming months. we’ll be sharing more about the next webinars in our series, including a conversation examining the impact of racism on child development. So please stay tuned on our social media channels and subscribe to our newsletter so you can stay up to date on additional activity in the series. So thank you again to you, all of you, for coming and I hope you have a great day.

Amelia Johnson: The Brain Architects is a product of the Center on the Developing Child at Harvard University. You can find us at developingchild.harvard.edu, where we will post any resources that were discussed in this episode. The next webinar in our three-part Place Matters webinar series is on December 11th at 12pm EST—stay tuned to our social channels for more details. You can find us on Twitter @HarvardCenter, Facebook at Center Developing Child, and Instagram @DevelopingChildHarvard. Our music is Brain Power by Mela Collective.

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