Home visiting and family values: the powers of conversation, touching, and soap.

• Author: Woodhouse, Barbara Bennett
• Position: Response to article by Martha Minow in this issue, p. 221 - David L. Bazelon Conference in Science, Technology, and Law

Any reader expecting me to quarrel with Professor Martha Minow will be disappointed. In a symposium about science, technology, and the law, how wise and brave of her to talk about the science of helping ordinary mothers and babies.(1) She chooses for her topic neither miracle babies produced in vitro nor monster mothers who must be diagnosed as psychopathic or sociopathic to grab public attention. Her chosen subject is the most low-tech law and science of all - well-baby care, visiting nurses, and human interaction on an intimate scale.

Her chosen context is a type of home-centered, preventive program close to my heart. My favorite example is the civilian "health worker" program in the Brazilian state of Ceara. This impoverished northern region of Brazil cut its infant mortality rate by one-third within four years after initiating a simple program of home visiting that recruited and trained women from the community with a gift for healing, issued them backpacks, bicycles, and baby scales and assigned each woman the task of visiting every home in her territory once each month.(2) "With the `economic miracle,' middle-class infant mortality vanished, but it ha[d] not been eradicated from the shantytowns."(3) The home visitors in Ceara's "Viva Crianza"(4) program are paid the minimum wage, and they travel light. In Ceara, some seven thousand workers visit four million homes once every month, carrying with them basic instruction on sanitation and nutrition, plus a knapsack stocked with soap, scissors, ointments for common ailments, and rehydration formulas for children with intestinal illnesses. "Instead of sick citizens clogging hospitals," explains Ceara's Governor, "we opted for prevention and family visits."(5) Brazil, like many countries, is discovering that centralization and progress are not necessarily synonymous.

Here in Philadelphia, we have our own slightly higher-tech version of the Brazilian "health worker" program. It is called the Maternity Care Coalition (MCC). The brainchild of University of Pennsylvania Law School graduate Harriet Dichter, the MCC operates on a shoestring and survives year to year on scarce grant dollars and inadequate government subsidies.(6) Rather than bicycles, the MCC uses vans called "Mom Mobiles," which take basic maternal and infant health services into poor communities, many of them African-American, East Asian, and Latino.(7) Staffed by nurses and community workers, the Mom Mobiles park on a neighborhood street, broadcasting hit songs and giving out free gifts to make contact with pregnant women who are young, alienated, poorly educated, drug dependent, or simply too confused by a "disjointed tangle of services" to know when and how to access them.(8) The Mom Mobile provides basic health screening such as blood pressure testing, and the workers use their mobile phones to set up clinic appointments for continuing prenatal care. Each woman is offered a community-based mentor who helps her through her pregnancy and first year of parenting.(9) Community groups like MCC have little time and money to spare for self-evaluation. They are too busy dealing with immediate crises, like the epidemic of low birth weights and rising rates of congenital syphilis and HIV infection among the city's newborns. I doubt if the Mom Mobile has been as rigorously evaluated as Professor Minow's social science protocols would demand, with control groups, blind studies, and the like. I am absolutely confident, however, that the program works.

It is said that Mother Theresa once commented that parts of American inner cities rival the Third World for poverty and suffering.(10) I imagine she had in mind places I have seen on my travels in North and West Philadelphia, where small children play nearly naked in trash-strewn lots next to boarded-up and abandoned houses. In spite of their geographical location, many of the mothers and children in the streets of Kensington, Mantua, and Strawberry Mansion live unbridgeable miles, even continents away from Independence Hall. In truth, the infant mortality rate in certain sections of Philadelphia(11) compares to that of many Third World countries.(12)

Philadelphia is not unique. The National Commission on Children reported that one in four children in the United States was born to a woman who lacked early prenatal care, in spite of the fact that overwhelming evidence shows that prenatal care ... reduces the likelihood of low birth weight [and that] positive effects are greatest for those ... at the highest risk of poor birth outcomes: black and some Hispanic women, poor women, very young women, and poorly educated women."(13) The report continues,

[a]s in other areas of human services, it is typically those women who need prenatal care the most who are least likely to receive it. Unfortunately, these are also the women who are most likely to have frail, unhealthy babies, who, in turn, will bear the long-term consequences of poor or inadequate care."

Are the distances between our own domestic first and third worlds unbridgeable? Minow's article asks this same question in another form.

The question Professor Minow poses in her article is deceptively simple - not unlike the bicycles and the Mom Mobiles I described above. If we have reason to believe that home visiting programs work, why don't we fund them? The explanations she offers are far from simple. In fact, they are extraordinarily rich with insights about American society and social history. As those who know my work can guess, I agree wholeheartedly with many of Professor Minow's concerns. I share her ambivalence about the values of privacy.(15) The veil of family privacy, as battered women and abused children know, can exclude not only prying eyes but life-saving interventions.(16) I also share Professor Minow's interest in history - especially in re-examining the insights of Progressives and so-called "child savers."(17) The important contributions of the Progressives, especially their insistence on a public ethic of responsibility for children and their caregivers, have been overshadowed by their well-documented class prejudice and blindness toward other family values, such as respect for the family's religious and cultural integrity, and for the importance of intimate attachments.(18) Learning from history and experience may allow modern family advocates to avoid the cultural blunders and ethnocentrism of the "friendly visitors" who came before them, while recapturing their sense of relationship to their neighbors' children and their commitment to decentralized and personal interaction.

I also agree with Professor Minow about the complex politics of individualism and pluralism.(19) Individualism can be an excuse for failing to offer positive support as well as a spur towards independence and achievement. Especially when dealing with families, often called the basic unit of society and the building blocks of community,(20) there is much to be gained from universalizing and...