For the past 30 years, I have been a part-time practitioner of political medicine, which I define as employing the political process to improve health. Political medicine is different from health policy, a term that repels me. Those involved in health policy are often elitists who like to remain above the fray. They deliberate among themselves and then hand down idealized concepts of what the world should be like. I know of no legislation that ever came about by politicians asking policy makers for guidance. An example is First Lady Clinton's "gang of 400" who labored mightily during the summer of 1993.
Laws and policies come about through the ebb and flow of politics, which involves the exercise of power. If one wants to influence the political process, one has to attain or gain the influence of those who possess power. The currency of power is money and votes. As child advocates, we possess neither. We therefore are left to practice the "politics of the powerless." That does not mean, however, that we are without tools.
Too many child advocates engage in handwringing and self-pity. If we are to practice the politics of the powerless, it behooves us to understand how to be effective, which need not mean crying to each other. It also does not mean proclaiming our moral superiority. Appeating to conscience all the time does not work. Politicians must choose from a variety of causes, many of them as worthy as ours. In the health field, we are competing with issues such as education, housing, jobs, environment, and transportation - all of which are also important. The trick is to give the politicians a way to help our constituents while helping themselves politically.
As an undertalented and overaged jock, I think of politics in terms of sports. Hard hitting and team effort are needed for success. It is imperative to know where the goal line is located. AU too often, we listen for the crowd noise instead of scoring points. Magnitude of effort is confused with outcome. For example, the number of persons attending a meeting, the number of newspaper or television stories, or the number of letters written are important only to the extent that they further a specific objective. Conferences and rallies more often than not provide participants with the illusion that they are "doing something." A more effective use of time would be writing letters or making phone calls to public officials.
PICKING THE RIGHT GOAL
Picking an attainable goal is the most crucial step in advocacy. I like to pick issues where my personal efforts might have some effect. The more narrow and definable the objective, the better the chance of attainment. How to choose? Because much energy needs to be expended, it is therefore important to allocate it on something you care about. A lot of people seek my help with their causes. My standard response is: "I agree that your cause is important, but I've got my own agenda that I am working on." For example, most of my advocacy energy in the past year has been devoted to a small cause, creating a children's playground in a poor Seattle neighborhood to honor the memory of a fellow pediatrician.
I don't spend much time seeking official endorsements of organizations. Prestige matters little. Politicians care about groups who contribute money or whose support or opposition can make or break their reelection chances, which rules out most children's outfits. Some organizations, however, can provide tangible support. The Washington State Medical Association (WSMA) has been extremely supportive of all the public health issues with which I have been involved. The benefit is access to the WSMAJs professional lobbyists. Although I have had more experience in the political area than most physicians, 1 remain an amateur. I always consult professional lobbyists on political strategy
POLITICAL ACTIVITY STEMS FROM CLINICAL PRACTICE
The energy for my political activity has always come from experiences in my clinical practice. In the fall of 1966, in Seattle we had an epidemic of children burned when their pajamas ignited. I was aware of technology that could make children's garments flame resistant, and I brought it to the attention of thenSenator Warren Magnuson, who was Chairman of the Commerce Committee. After the senator and his wife visited some burned children in our hospital, passage of the Flammable Fabric Act Amendments (1967) was assured. I also acquainted the senator with the work of Dr Robert Sehen and his colleagues at Madigan Army Hospital who demonstrated a marked reduction in aspirin poisoning on the military base when childproof containers were used. The result was the Poison Prevention Packaging Act of 1970. My work in helping to fluoridate Seattle's water supply in 1968 came from the frustration of seeing rotten teeth in poor children whose families could not afford dental care. My energy for working in the field of sudden infant death syndrome (SIDS) came from counseling grieving parents who had never heard of the entity and thought themselves responsible for their child's death.1
As with every other subject, effective advocacy is best learned by watching role models. There have been tons of them in pediatrics starting with Abraham Jacobi. I mention just a few whom I admire. None represent organizations; they depend on their own wits and energy.
Gerald Schiebler is a phenomenon. As chairman of the Department of Pediatrics at the University of Florida, he decided that he wanted to learn how state government works. During a sabbatical year, he went to the state capital and served as head of Florida's Crippled Children's Services. He learned his lessons so well that the University of Florida asked him to be their lobbyist in Tallahassee for 3 months every year. His official job was to represent the interests of the university; his unofficial job was to improve health services for children in the state.
Calvin Sia is another lone wolf who is personally responsible for the State of Hawaii having one of the most progressive child health programs in the United States. The upgrading of emergency medical services for children around the country came about because of Cat's friendship with Senator Daniel Inoye. Birt Harvey and Martin Gershman organized Northern California pediatricians into an effective lobbying force. Richard Krugman of Denver and Jay Berkelhamer of Detroit spent a year each as legislative interns with the Senate Finance Committee. Their influence was keenly felt in legislation involving Medicaid and other Social Security programs.
My friend and colleague Ken Feldman is a pediatrician in a Seattle neighborhood health center that serves the poor. He has cared for too many children with tap water scald burns. So Ken, his wife Ann, and a neighborhood health worker went around the community with meat thermometers measuring the temperature of the water coming out of the taps. They found that the majority of homes had water temperatures over 150°. With that data in hand, Feldman started a campaign to lower water heater temperatures as a means of preventing scald burns and conserving energy.2 The Washington Legislature mandated that all new water heaters be preset at 1 25°. Did that body pass the law the first time it came up? No. Feldman went to the legislature twice and lost, but he did not give up. One summer, he went around the state enlisting the help of pediatricians who cared for the children or grandchildren of legislators. The third time around, the law passed. Just recently, Feldman and colleagues repeated the survey and showed that the water temperatures have stayed down, with a concomitant reduction in scald burn injuries.3 That is effective child advocacy. A characteristic that all these political medicine practitioners share is not calling attention to their achievements.
There is more to child advocacy than legislation. Anyone who serves on a school board gets an automatic pass to heaven. Haîlem Hospital, where Margaret Heagarty is director of pediatrics, probably holds the record for the most number of children treated for bullet wounds. It would be easy to be dispirited in that setting. Instead, Maggie has helped organize the surrounding community to create refurbished playgrounds, art murals, dance classes, and a Little League baseball team. Small finite steps, one foot at a time.
SOME LOBBYING HINTS
If one's going to be involved in child advocacy, infinite patience and persistence are required. A big problem for amateur advocates is that we have to earn a living and care for our families while the "other side" pays their people to be there all the time. When I lobby, I tell politicians that pediatricians are the lowest paid of all specialists and that we are charged with caring for the health and welfare of all children, not just our patients. That impresses them. The following are some lobbying strategies:
* Build coalitions . In embarking on a campaign, try to build as broad a base of support as possible. Always include Democrats and Republicans, business and labor representatives, prosecuting attorneys, and American Civil Liberties Union representatives, etc. Because legislators have to take positions on hundreds of issues, their decisions depend more on the identity of the sponsors than on the merits of the proposal. Legislators worry about incurring the wrath of some pressure group and therefore tend to shy away from bills that emanate from left or right wing fringes. They thus vote for bills that are "ideologically safe." For example, at the federal level, a bill cosponsored by Ted Kennedy and Jesse Helms is a cinch to pass.
Child health advocates tend to gravitate to their political kin (ie, fellow bleeding-heart liberals). Resist the temptation. Knock on everyone's door. Assume that every legislator cares about children. In my state, the most vigorous champion for expanding services for children in foster care was a state senator who considers Jesse Helms a Maoist. (She now occupies a seat in Congress.) At the federal level, Rep Henry Hyde (R-IIl), known best for his staunch pro-life stance, has played a key role in supporting funds for the maternal and child health block grant. Sen Robert Dole has been a champion of the Women, Infants, and Children (WIC) Program.
* Work with the media. Child advocates do not have money and do not control votes. Our "currency" therefore is influencing public opinion. Remember that newspapers and television stations have large news "holes* that they have to fill every day. They tend to like stories about kids. Keep feeding them.
* Constat professional bhbyists for advice. To ease their consciences and support their egos, the pros usually are pleased to help amateurs with a worthy cause. Professional lobbyists can provide advice on strategy, but there is no substitute for a physician sitting down to talk with a legislator. If possible, it is better to see a legislator in his or her home town than in the capítol.
* Do not underestimate legislative staff members. Some folks need the slap on the back or the handshake from the big man himself However, obtaining the interest of the most junior staff person in the office often ensures more lasting results.
* Be brief in phone calls, letters, visits, and in testifying. Legislative hearings are not judicial trials where evidence is impartially considered. They are political forums aimed at achieving some objective, usually the chairman's. Do not be awed - step up and "tell it like it is," but do it briefly. Talk about firsthand experience with individual children and their families. Illustrative examples are better than statistics.
* Carry a good book. Hearings and appointments are invariably late and often canceled. When I get angry about this, I have to remind myself that I am representing kids who have no other voice, and I don't have the luxury of being able to walk away.
* Do not beat politicians over the head with moral TigKteousness. Again, when you are serious about winning, you cannot afford an angry or holier-thanthou attitude. Even if the politician cannot support you on one issue, he or she may be able to help on the next one.
* Submerge your ego. The advocate who needs credit and publicity does his or her client no favor. The politician is the one who has to face the voters, not the advocate. Ghost written speeches, articles, and reports are golden. Keep remembering the objective. Legislative lobbying is not everyone's cup of tea. A sincere and well-reasoned letter can have a powerful effect. Increasingly, the power fulcrum has shifted from the nation's capital, to state capitals, and to local communities; one can usually do more good for children at the local level. City councils, school boards, park departments - they all impact the lives of children. Again, the smaller and more focused the objective, the better its chance of success.
We have to stop moaning and groaning about the fete of kids and instead learn how to be effective advocates. Take the task seriously. Let us not talk to fellow believers all the time. Stay narrow and focused and decide on how to proceed by following the examples of successful role models.
I conclude with three of my favorite quotes:
William Gladstone said, "Indignation without action is froth."
In an address to the French Bishops, Albert Camus said, "You seek a world in which no children starve; I seek a world in which fewer children starve."
And Rabbi Tarfon said in Ethics of the Fathers, "You are not required to complete the work, but neither are you at liberty to abstain from it." (2:21).
1. Bergman AB. The 'Discovery' of Sudden Infam Death Syndrome - Lessons in [he Practice of Political Medicine. New York. NY: Praeser; 1986.
2. Feldman KW, Shaller RT, Feldman JA, et al. Tap water scald bums in children. Rsdiarrfa. 1978:62:1-7.
3. Erdmann TC, Feldman KW, Rivara FP, et al. Tap water burn prevention: the effect of legislation. Pediatrics. 1991;88:572-577.