Rx for the Future

As a pediatric resident at Johns Hopkins Hospital and an MPH student in the late 1960s, David Paige was frustrated. Iron-deficient infants with stunted growth routinely arrived at the Harriet Lane emergency room-many so sick they required hospitalization. At the time, breastfeeding was rapidly declining in favor of evaporated milk formula, which poor families frequently would dilute with water to make it last. Some mothers gave infants cow's milk, which often led to gastrointestinal blood loss.

The solution pioneered by Paige, MD, MPH '69, and colleagues evolved into the federal Women, Infants and Children (WIC) nutrition program. WIC is the third-largest federal nutritional assistance program (after food stamps and school lunches). Designed to prevent the serious health consequences of malnutrition, it provides nutritious foods, nutrition education and referrals to health care and social services. Today, almost half of all U.S. infants and one-quarter of children aged 1 to 4 participate in the program.

The affable and energetic professor of Population, Family and Reproductive Health recently talked about WIC's origins and impact with Bloomberg School historian Karen Kruse Thomas, PhD.

Power of prevention

In my public health courses, we learned that you prevent disease. You don't wait to treat it. I was really annoyed. I said, "I'm writing prescriptions for everything. Why don't we treat iron deficiency and undernutrition by prescribing appropriate foods?" That was really the dawning of the WIC issue for me. That clinical recognition of the futility in treating case after case.

In the School of Hygiene, I was taking a course on population statistics with Matthew Tayback [ScD '53], an assistant commissioner in the Baltimore City Health Department. Dr. Tayback headed a task force trying to increase enrollment in the federal free school lunch program and asked me, as a student-and this is the greatness of Hopkins-if I would be a working member. It gave me the opportunity to marry the clinical issues and the public health perspective.

The real work

The school lunch program was a good way to assure appropriate nutrition and maximize the educational experience for disadvantaged children, but the negative impact on cognition had already taken place. The real work had to be directed at pregnancy and the early years of life.

To pursue that goal, the school lunch committee led to creating the permanent Maryland Food Committee [now the Maryland Food Bank]. Along with the committee, my colleagues and I tried to think through how to develop a prescriptive approach to early infant feeding and pregnancy. We started to provide iron-fortified formula to newborns at the newborn clinic in Cherry Hill, a poor neighborhood, principally African American. I should say that it wasn't until the 1980s that WIC began to promote breastfeeding.

It was really a mom-and-pop operation, I was doing almost all the work. We started collecting data on heights, weights and blood characteristics and noted a very high percentage of undergrown children, below the third percentile. Of course, a high percentage of low birth weights. The early data on the benefits of supplementing maternal and infant diets gave us courage to try to expand to a larger population.

Expansion

We received a grant from the federal Community Services Administration to launch a statewide voucher program enabling Maryland mothers to purchase formula and nutritious food. My research confirmed that providing fortified formula to infants in low-income families reduced their risk of iron deficiency and undernutrition.

I wanted to demonstrate that the problems we were dealing with at Hopkins weren't specific to Baltimore City, that malnutrition existed anywhere poverty existed. When we submitted the grant, we coined "IFIF" as the acronym for Iron-Fortified Infant Formula Program. Our internal conversation was, "If we get the money, if we can convince the health officers," so everything was if-if, and it seemed like an appropriate acronym.

Resistance

We had considerable resistance from many of the rural counties, where health officers had been disappointed by previous federal programs that came and went. The food vouchers were unfamiliar and untested, and no one knew if the merchants would accept them. Many of the people who most needed the program lived on the Eastern Shore [the poorest, most rural section of Maryland], where resistance from health officers was strongest. Fortunately, as a Hopkins pediatric resident I had traveled throughout the state and down to the Eastern Shore. The health officers finally accepted the IFIF program when I agreed to continue to cover their pediatric clinics once a month.

Going national

CSA liked the IFIF program very much, and they began to spread the word on a national level, that Maryland and Baltimore and Paige and the Maryland Food Committee were the go-to people for nutrition intervention in the community, and that, obviously, they had funded us. It suddenly became bidirectional: Our appeal and our funding unleashed interest on the part of the feds, such as the Food and Nutrition Service in the USDA.

WIC has emerged as an important national program. The School and I can justly revel in its success-we didn't build it alone, but we were important architects for the program.

Long-term impact

WIC has been very successful in lowering the incidence of low birthweight and pre-term birth, which in turn effectively reduces infant mortality and developmental disabilities. Studies by the CDC found that WIC preschoolers show improved weight gain and overall health, as well as a sharp reduction in anemia. At the same time, WIC has been extraordinarily cost-effective. Even reducing one or two nights in the neonatal intensive care unit or an extra day of a woman's hospital stay will more than compensate for the cost of WIC benefits.