Growing the business of caring:

T. Berry Brazelton

on healthcare

by Joe Flower


This article appeared in the Healthcare Forum Journal, November-December 1992, Vol. 35, #6.

International Copyright 1992 Joe Flower All Rights Reserved


He's a sweet man, but he can be scathing: "Our health care system is out of control. It's just not serving anybody. Doctors hate it. Patients hate it. Nobody's getting what they need."

Somebody's dream of a grandpa with the sure hands, the calming voice, the smile you could put away for rainy days, he says, "What the hell, we pay a hundred thousand dollars for intensive care for a premature baby that we could have salvaged with pre-natal healthcare. What kind of a system have we got? We have an absolutely thoughtless, patched-up, Band-aid system."

If you wanted to give out a prize for America's best-loved pediatrician, the contest would come down to three older men: Benjamin Spock, C. Everett Koop, and T. Berry Brazelton, professor of pediatrics at Harvard Medical School and chief of the Child Development Unit at Boston Children's Hospital. When Brazelton looks at the practice of healthcare, he uses the eye of a man who has spent his life studying the development of children. He sees growth and life stages, not pathology. He doesn't see "cases," or even individual patients, he sees families, growing together.

He has turned this point of view into serious medical tools, including the widely-used Brazelton Neonatal Behavioral Assessment Scale, and into a great range of scholarly publications. At the same time he has popularized it in a syndicated newspaper column, in Family Circle (where he is a contributing editor), on National Public Radio, on the "What Every Baby Knows" series on the Lifetime cable channel, and in a series of books such as Working and Caring, To Listen To A Child, and On Becoming A Family - all geared at helping parents understand what their children are going through, helping them see the growth and see how they can help.

The day I caught up with him was perhaps a little more hectic than the rest: he was about to go to the war. The head of UNICEF had asked him to come along to trudge the streets of Sarajevo and Zagreb, to see what they could do to save the children. "And if we can focus the world's attention on the children," he says, "maybe it will help stop the war. Maybe. It's worth a try."

But we talked for a while despite the press of time. He had some thoughts about healthcare. His eye is an unusual but powerful one. It might help us in the business of caring if we spent some time looking through that lens.

It was focused at the moment on France, a nation with one of the lowest infant mortality rates in the world. How do they do it? "They give every pregnant mother a bonus equivalent to one thousand dollars if she will come in for four pre-natal visits."

But how could we afford to pay for that kind of thing - pre-natal visits, screenings, immunizations, check-ups, basic family medicine?

"We can't afford not to. It costs us and the vendors four to ten times as much to deal with the same issues when they show up in the emergency room."

Surely you can't get the vendors to go for that.

"We did it at Children's. We demanded that Blue Cross/Blue Shield and other vendors pay for preventive care for high-risk people in our clinic, and they're doing it."

They bought the cost argument?

"No, they wouldn't listen that. But they would listen to the fact that we were going to turn away from them if they didn't do it. You just have to hold out for it. HMOs have a lot of power today. They ought to be demanding that the insurance system pay for pre-natal and preventive care, screenings and inoculations."

He calls this early screening, preventive care, and on-going relationship with the family "front-end loading," and he feels the need for it powerfully. The American Academy of Pediatrics, an organization that had given him its highest award, recently called and asked him to help them with their outreach for immunization. He refused.

According to Brazleton, "The people that aren't getting their children immunized have two good reasons. One is that it costs too much. Charging people $125 for a shot and then blaming people because they can't get it just illustrates the absurdity of our present healthcare. The other reason is that they really don't trust the medical system. Unless the pediatricians of America are going to make an effort to reach out and give people the kind of trust that lets them feel that somebody cares about them, it isn't worth getting them in for one shot. They will take a screaming baby home and never come back.

"If, on the other hand, every time they walked in your door you said, 'Hey, what a beautiful baby! Look how that baby looks in your face and smiles, and look how you look back at her,' and began right from the start to help the parent see the responses the child makes, and the stages the child is going through - nobody would ever miss another appointment."

Making that connection of trust would not only help the children, he feels, it could be a powerful marketing tool. "You can use prenatal visits, inoculations, and screenings as a way to reach out to people, to let them know that you're participating with them in the job they're trying to do for their kids. I know it's competitive out there. If healthcare people used child development as their hook, they would be flooded with families. It doesn't need to be done by a pediatrician, or by a doctor, or even by a nurse. You could have one psychologist in each center who could sensitize the professionals around them. Everybody would focus on the family and the child's development. I know it worked at our hospital - it raised the whole atmosphere of the program.

"We need to change our medical system from a pathological model of looking for defects to one in which we look for people's strength. We could do it so easily, but none of us, in medicine at least, are trained that way. We are trained to look for problems. Change your model, and people will recognize it right away. They'll change their whole attitude toward you.

"In my area, looking for developmental processes in the child is just like talking a parent's language. Parents of any class and any ethnicity fall flat on their faces if you help them see the stages the child is going through, encourage them to participate in those stages, and talk with them about how the child does it.

"The cost isn't a big factor. It doesn't take time, it takes attitude. Everybody blames the cost and the time. They're really just afraid that if they get too close, people might ask them questions. If you ask people to, and you trust them, they'll come with a set of questions written out. You can answer them in five minutes, and they're out of there just as quickly as they would be if you were fending off their questions all the time.

"We have to work with the parents, including working parents. That may mean having shifts of doctors and nurses for clinics after normal work hours. I think it would pay off, and I know that working parents would be grateful. It may mean providing the health care at the site of the workplace. It may mean doing immunizations at the daycare centers at the end of the day when everyone is coming to collect their babies. It may mean mobilizing the healthcare people to leave their offices and hospitals.

"Unless we start paying for early prevention and intervention efforts, and reaching out to parents with them, we are never going to be able to afford our medical system. People are so hungry. They recognize when you are looking for what they're trying to do with their kid. Any medical person that joins them in their effort is going to reap the reward. And it is so easy to do."

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