Creating an Early Childhood System that Works
The Regional Kindergarten Readiness Collaborative
John A. Kitzhaber, M.D.
May 8, 2018
Portland, Oregon
Thank you for inviting me to participate in this ambitious undertaking. If there is only one thing you take away from our meeting this evening, I hope it will be this: that the single most important responsibility we have as individuals and as a society, is to ensure the success of the next generation; to ensure that all of our children have an equal opportunity to succeed. It was that belief that motivated me to commit most of my adult life to public service; a commitment to equity and opportunity. You would not be here this evening if you did not share in that commitment. We all followed different paths and for different reasons to arrive here together at this time and this place. So, let me start by describing the path that brought me here … a path that began with I was very young.
All of us have childhood memories — some good, some bad—but my fondest childhood memories were the camping trips our family used to take during summer vacation. Led by my father we would sally forth, armed only with an ancient Coleman stove (which I still use) and a huge canvass umbrella tent supported by an elaborate metal infrastructure which could attract lightening from miles away. We camped on the shores of Bear Lake Utah, in the Snowy Range of Wyoming, in Yellowstone National Park and on the Olympic Peninsula of Washington.
As I grew older my father and I left the umbrella tent behind and took our stove to the banks of the great rivers of western Oregon – rivers with names like Santiam, Umpqua and Rogue. It here along these rivers that I first met the salmon in its native habitat and developed my lifelong fascination with it and its life cycle. It was here at a place called Boulder Flats that I first witnessed these scarred and broken creatures, these brave warriors, planting the seeds of tomorrow; fulfilling their responsibility to the future.
Because the life of the salmon is dedicated to the future – to nurturing, sustaining and giving to that which will follow. The salmon I grew to know as a boy were born in the gravel beds of the cold fast-moving streams that tumble down the west slope of the Cascade Mountains. They migrate down these streams to the ocean where they mature and spend their adult lives until some inner voice tell them it is time to come home.
On its final journey this remarkable creature travels thousands of miles, fighting its way upstream — leaping impossible falls and negotiating obstacles – in a single-minded effort to return and spawn in the very gravel where it was born. And even those who never make it home – who die in the effort – give their bodies to the river and to the future; providing the nutrients essential to the survival of the next generation.
I share this story because there is a similar voice calling to us – a voice that reminds us of the responsibility that each generation has to the next; that reminds us that, we too, have the responsibility to nurture, sustain and give to that which will follow; a responsibility that we owe to our children and to the future. We are gathered here this evening in large part because we know that we are failing in that responsibility, because our society has ignored that inner voice and, in so doing, condemns millions of children to lives of poverty, school failure and economic struggle.
As many of you know, over the course of my life I had the opportunity to practice emergency medicine and to serve in public office. For twelve of those years I did these two things simultaneously, which gave me a very interesting perspective on the relationship between public policy and its impact on those it was designed to serve. One of the things I became aware of was a gradual increase in the number of people who came in to seek treatment for medical problems are actually the result of social circumstances we treat the medical problems and then send them back into the same environment that help cause those problems in the first place.
I came to see that much of what we treat in our hospitals and our clinics – and much of what we spend on public safety and in our social support system – represents the symptoms, the aftermath of problems that began first in the family, in the home, in the neighborhood and in the community. And when we look at the history of the highest utilizers our health care system – as well as many of those in our prisons or who are trapped in generational poverty – you find a very interesting correlation: many of them have been exposed to a series of similar traumatic events during their childhood.
As you know, this connection was described in the now well-known study of Adverse Childhood Experience (ACEs). This is not new information. The initial participants in the ACE study were recruited over twenty years ago and yet somehow, we have failed to successfully address this constellation of risk factors and the consequences of that failure continue to be reflected in our public budgets. In Oregon, as in most states, our public resources are increasingly being spent on corrections, health care and the human consequences of neglect, abuse and addiction while our investment in educating our children and building a better economy is decreasing. And the trend is getting worse every year.
I believe that turning this around—ensuring that all of our children have an equal opportunity to succeed—is the single most important domestic challenge we face today. Contrary to what we are being told by our current political leadership, the greatest threat to America is not terrorism, immigration or our trade deficit with China. It is the fact that nearly sixty percent of our children are exposed, at a very early age, to one or more risk factors that can severely and profoundly compromise their ability to succeed. We cannot solve this problem by investing more money in prisons, but only by investing in our communities. And our children cannot be shielded from these risk factors by building a wall; but only by building strong, successful families.
As you know, it is in those early years that we can make the greatest impact on these young lives. It is here where we can most effectively address the racial, ethnic and socioeconomic disparities that often bake in a high likelihood of failure for children from generational poverty, children of color, and English language learners long before they reach school age.
And whether you recognize it or not—and I suspect you do—that is exactly the challenge you are undertaking this evening. The goal of the collaborative you are creating, may be “Kindergarten readiness”—but, in reality, it is much more than that. Why? Because Kindergarten readiness not a cause; it is an outcome, the product of multiple factors and experiences to which that child has been exposed, even before birth. In other words, you cannot be successful in ensuring Kindergarten readiness, unless you are first successful in addressing the underlying risk factors to which children are exposed long before they reach school.
As someone who cares deeply about this work, I commend you on your commitment and would like to offer some thoughts about how we might build the effective early childhood delivery system that has eluded us for so long. Doing so requires addressing four interrelated challenges. First, we must be able to identify at risk children and families in the communities where they live; and to understand the nature of the risks they face. Second, we need objective data to determine those things that can positively alter the life arc of an at-risk child. Third, we need a coordinated, aligned system that can effectively and efficiently deliver those treatments, supports and interventions that we know will help at risk children succeed. Finally, we need the resources necessary to support and sustain these investments over time.
In terms of the meeting the first two challenges—identifying at risk children and families; and understanding those things that can help make them successful—we are fortunate to be in the of developing a longitudinal process database that can be a game-changer for this important work. Housed at the OHSU Center for Evidence-based Policy, this project will match data on every child born in Oregon since 2000, and their known parents, with data from publicly-funded services for those children and families (such as child welfare & foster care, Medicaid services, early childhood investments (such as Head Start), K-12 information, and juvenile corrections.
This is a remarkably rich database, with the oldest cohort now 18 years of age. Since there are around 45,000 children born each year in Oregon, this database now includes more than 800,000 people. (By comparison, the ACE study tracked 17,000). And this is all Oregon data. Without going into great detail, this data provides a critical – and heretofore unavailable – picture of the nature, prevalence and implications of chronic childhood stress and trauma. It will provide us with a risk profile that is highly predictive of future outcomes; allowing us to not only identify at risk children and families; and understand the factors necessary for them to be successful, but also to evaluate the effectiveness of our programs, supports and interventions.
This leaves us with the final two challenges: the need for a coordinated, aligned and delivery system; and the resources necessary to support and sustain these investments over time. The lack of adequate funding is what most people blame for the fact that we are not successfully addressing the ACEs. Certainly, that is part of the problem —but even if we significantly increased the amount of money being spent in this area, we would still fail without a coordinated, integrated delivery system aligned around a common vision and shared goals. So, let’s start with the challenge of funding and then turn to the delivery system.
Given what we know about the relationship between the ACEs and poor physical, mental and behavioral outcomes later in life, it is profoundly logical to invest in preventing these adverse experiences. The problem is a political one. In our society in general, and in our legislative process in particular, we tend to focus on and fund things that are visible, compelling, and immediate. For example, if given a choice between funding prenatal care—or paying to resuscitate a 500-gram infant in the neonatal intensive care unit— the emotional and political imperative always puts money into the hospital rather than into the community.
To policy makers the neonate is highly visible while the thousands of women who lack prenatal care are anonymous and therefore invisible. The challenge, then—staying with this example—becomes one of funding both prenatal care and acute neonatal care at the same time; and for long enough so that the prevention of low birth-weight babies from good prenatal care, reduces the number of infants that end up in the NNICU in the first place. What we are trying to do here is to shift resources out of after the fact crisis interventions—whether that is in mental health, chronic disease, foster care or public safety—and into investments that can prevent the need for those interventions in the first place.
Doing so requires two things. First, we need to build a new coalition that can elevate the importance of these investments and change the nature of the legislative budget debate—to change the focus from expenditures to investments. Ever since my first legislative session in 1979, the entire budget process has been driven by the appropriation for primary and secondary education: the so-called “K-12 number.” This is the amount we need to continue to fund primary and secondary education at its current level. Once that appropriation has been made, the other budgets—including early childhood—are funded with what is left.
I am suggesting that the first budget to be funded should be an early childhood investment budget, a prevention budget, if you will. And the purpose of this new coalition is to make that happen. I am not saying that K-12 is not important, because it is; it’s incredibly important—but the money we do spend on primary and secondary education would go a lot further (as would the money we spend on community colleges and universities) if all our children arrived at school ready to learn in the first place.
We need to make a stronger case that only through effectively investing in children from birth through age 6 can we reduce much of the cost of remediation in our system of public education. And we need to make a stronger case—not only to advocates for public education—but also to those whose focus on public safety, social services and health care. The only way we can reduce unnecessary expenditures in all of these areas is to increase our investments in children and families.
Finally, the case for increased funding for early childhood will be made much stronger if we can show a direct correlation between the money we spend in this sector and positive outcomes. Unfortunately, we cannot do that today, which brings us back to the challenge of the delivery system.
We know who these at-risk children and families are. We can identify them right down to zip code, neighborhood and often household. And we have well-researched and effective interventions, treatments and supports that could profoundly and positively change the life arc of these children. Yet one of the greatest frustrations and contradictions in American public policy is that we have not done so. We have failed to do so nationally, and we have failed to do so in here Oregon. As Einstein said: The definition of insanity is doing the same thing over and over again, but expecting different results.”
So, what’s the problem? The problem is that we do not have an effective early childhood delivery system. In a way, the problem is right here in this room. Just look around. We have three counties, the Oregon Health Authority, the Department of Human Services, Early Learning Hubs, WIC, Providence Health System, OHSU, Kaiser, Health Share, several school districts, United Way, Social Venture Partners, the Oregon Community Foundation, Help Me Grow Oregon, the Future Generation Collaborative, All Born In, the Children’s Health Alliance, Greater Than, the Portland Children’s Levy and the Children’s Institute. And this is only a fraction of the organizations, institutions and other players involved.
The problem is that we lack an effective delivery system among all these different entities. This is where we are falling down. While we can show positive results from various individual programs, we are not narrowing the achievement gap across the population as a whole. Our problem is a “last mile” problem—actually getting the right services to the right children at the right time. Our problem is that all the multiple efforts to build successful children and families are not leveraged with one another to become greater than the sum of their parts. As someone pointed out, “We are program rich and system poor; we are failing the community one success at a time.”
Last week, I had coffee with Ralph Smith, the Managing Director for the national Campaign for Grade Level Reading, which has now engaged 43 states, 344 communities and 3900 local organizations. And while this effort is showing progress in moving the needle within individual programs, double-digit gaps persist in every state and almost every community. This is due, in large part, to the fragmentation and duplication of efforts, the proliferation of silos and the difficulty of accessing and effectively utilizing data. I think that is exactly what we are facing here and around the state.
In many cases, these diverse entities are dealing with one or two of the risk factors, but not as a constellation and often not customized to the needs of a specific child. And they are certainly not aligned or coordinated; they do not leverage one another, they are far less than the sum of the parts. And without a clear, well defined system we can sometimes break down into a kind of tribalism in which collaboration is sacrificed to a particular program or funding stream; turf issues abound, and organizational survival takes precedent over the larger purpose for which the organizations were created in the first place. We lose adhesiveness and common purpose.
To move beyond this, we need to approach this work as a movement, rather than as a collection of individual organizations. In an organization or program, the mission defines “what you do—for example, providing preschool, nutrition, child care, housing, home visits, etc.—and accountability tends to be first to the organization and organizational sustainability. In a movement, however, the mission defines the ultimate goal that a group of organizations wants to achieve; and accountability is to a cause greater than any one program.
So, how should we proceed? Let me offer a few suggestions for the purpose of stimulating some thought around what the path ahead might look like.
First, you will have to agree on a common metric, which I assume is going to be “Kindergarten readiness.” And you will have to all agree on the definition of this metric and on how to measure. In my view, the definition should not be limited to academic readiness, but should include social, physical and emotional readiness as well. Furthermore, the definition should not come solely form the dominant culture, but should reflect the diversity of our population.
Second, I think there is value in organizing the early childhood delivery model around CCOs and the early leaning hubs in within their geographic areas. This gathering, for example has been convened by five organizations, one of which is Health Share of Oregon, which provides health services to most of those enrolled in the Oregon Health Plan in the tri-county area. Almost all children will be seen in the health care system, long before they ever get to school and over half the births in Oregon each year are to women enrolled in Medicaid.
CCOs might, therefore, be the logical place to do the initial screening for to identify the risk (and protective) factors for children and families that are most highly correlated with poor (or good) outcomes. Using the information from the longitudinal database, CCOs will be able to triage their childhood population to determine the level of screening and/or assessment appropriate for different levels or profiles of risk, the type of community partnerships that will be necessary to address these risk levels, and how to target and measure the impact of community investment dollars.
Third, I would actually implement a largely ignored provision of the legislation that created the Early Learning Division, which required the Division and the Early Learning Hubs—in collaboration with the CCOs, the business community and service providers— to develop, every two years, an “integrated children’s budget.” This budget would show, by program, all the money currently being spent on early childhood development and education. And while not binding, this budget could show how each program intersects with the risk factors and protective factors that we are trying to address.
So, to summarize, I believe we have everything we need to ensure all our children are ready for Kindergarten when they reach school. We have all we need to do what no other state or community has done: put in place a system and the funding to ensure that all of our children have an equal opportunity to succeed. We have an 18-year longitudinal database that will allow up to apply the same kind of risk assessment to our work with children and families that we have been using in the health care system for years. We have the capacity to match individual risk profiles with the targeted investments and interventions needed for success. And through our CCOs and Early Learning Hubs we have the infrastructure around which to build an effective, coordinated system aligned around a common vision and shared goals.
Finally, for the first time, we have the ability to make an objective assessment of the many programs we have designed or put in place in Oregon to help children succeed. And, ironically, the greatest threat to the success of this effort lies in the very database that makes it all possible. Because not only will it help us identify what really matters and what really works, it will also identify what doesn’t’ matter and what doesn’t work. And inevitably there will be situations where the data demonstrates something we’ve been doing for years, or the way we have been doing it—something in which someone is personally or emotionally invested— just doesn’t move the dial.
And here is maybe the most important thing I can say to you this evening. In these situations, we must be willing to overcome our tendency to protect programs rather than solve problems. Nobody wants to lose control or lose funding or have their particular program or organization threatened, or even changed. But unless we are willing to embrace not only a common goal, but also a shared accountability to reach that goal—an accountability that transcends any one program, sector or institution—unless we are willing to do that, this is not going to be much more than an academic exercise. In short, to succeed we must be willing to put outcomes before organizations.
On April 5, 1968—the day after Dr. Martin Luther King was assassinated—Robert Kennedy gave some brief remarks to the City Club of Cleveland. His speech was about the stain of violence in America‑ but at one point he said: “There is another kind of violence, slower but just as deadly, destructive as the shot or the bomb in the night. This is the violence of institutions — indifference, inaction, and decay. This is the violence that afflicts the poor, that poisons relations between men because their skin has different colors. This is a slow destruction of a child by hunger, and schools without books, and homes without heat in the winter.”
The echo of those words reaches out to us this evening across the dusty years of half a century—because, in a real sense, it is the violence of institutions we are gathered here to address; to break down bureaucracies, to transcend partisanship, to move beyond organizations to outcomes; and, in so doing, to fulfill the responsibility we owe to our children, to the next generation and to the future.
