Keeping Families Together Improves Children’s Health Outcomes, from Borders to Communities

Before joining NICHQ as Chief Health Officer in May 2018, Elizabeth Coté, MD, MPA, spent over a decade working to improve health in vulnerable communities across the world. From rebuilding the health infrastructure of war-torn Iraq to managing the opioid epidemic in a northern Maine community, Coté’s efforts revolved around one central goal: “I want to spend my life working in communities, especially those that are most overlooked, to build health equity and create a more just world.”

Coté’s move to NICHQ reflects her continued commitment to that mission. It also reflects NICHQ’s commitment to the same values that define Coté’s career: working directly with communities to improve population health and health equity so that all children have an equal chance to grow and succeed.

“Every day, children across the country suffer from adverse childhood experiences that will change how their brain develops, shape their futures and threaten their health,” says Coté. “And many of these experiences are preventable. That’s the motivating part. That’s why I joined NICHQ—because NICHQ looks at children’s health in the context of their experiences and the environments they need to thrive.”

"And that’s why I want to talk about the recent crisis at the border. This crisis changed the course of thousands of children's lives, touched many of us, and brought us together as a nation around a fundamental belief that unnecessary separation from parents is incredibly injurious for children, regardless of place, time or circumstance.”

To illustrate her point, Coté takes a step back, to January 14, 2010, two days after one of the most devastating earthquakes in decades struck the country of Haiti, killing over 300,000 victims and leaving millions more homeless. On that day, Coté got off a plane in the Dominican Republic and traveled to devastated Haiti, joining countless other aid workers trying to support the desolated population.

Haiti children
NICHQ Chief Health Officer, Elizabeth Coté, MD, MPA, working to keep a family together during a critical transition in Haiti. 

“It was absolute chaos,” says Coté. “So much destruction. I arrived at a rehabilitation camp as part of the organizing team and I looked around as busloads of the injured arrived and makeshift clinical shelters started taking shape. I asked myself a question I’d learned to trust in chaotic situations in the operating room: ‘what is the most important thing to do right now?’ I had to identify what action I could take at that moment that would minimize future harm and set us up for success down the line.’’

For Coté, that change focused on the Haitian children. After the earthquake, victims were sent to triage centers and then rehabilitation centers that corresponded with their needs. And in this impossibly hectic process, children were getting separated from their families, often undergoing traumatic treatments, even amputations, on their own. As a result, their health was deteriorating. This unintended consequence of the care system, separating children from their primary caregivers, was making them vulnerable to even more atrocious harms—permanent family loss and abduction.

Coté, fellow aid workers and other partners took action, developing a mobile records system to track and manage family care. In addition to treating the individual injury in front of them, they included the family in care, comfort and decisions. It was a small change but a significant one. The UN and UNICEF child protection agencies came on board. Because of that systems change—instituting a record system—more children received treatment alongside their families, the people most invested in their health.  

“Children’s survival and well-being is incredibly dependent on others because they are uniquely vulnerable to stressors in their environment,” says Coté. “But they're also born with the most powerful protective factor: their parents. Taking a long step back from any human turmoil—war, natural disaster, political change, social unrest, disease—shows that keeping children with their caregivers whenever possible is critical for both their immediate survival and long-term health. Keeping them together is the most basic step for doing no harm, the first pledge we make as health caregivers.”

Remembering this principle is how Coté and her team improved the systems in Haiti.  And it’s the same principle that grounds NICHQ’s work optimizing children’s health.

Coté’s story is an invitation for others to pause, take a step back, and ask the same question she asked in Haiti about children’s health in the United States: What is the most important thing we can do right now?

Right now, there are thousands of children who were separated from their families at the border. And in the U.S., millions of children live in poverty and remain uninsured. These seemingly disparate realities are intertwined, says Coté, because the outcomes for the children affected by each would be improved by solutions that acknowledge the power of family-based supports. Solutions that recognize children’s inherent vulnerability and the caregiver’s critical role in protecting and providing for them.

We see this in our improvement work every day. As infants, children gain critical health benefits from continuous skin-to-skin contact with their mothers. During early childhood, when children’s brains are developing at their most rapid rate, caregivers are children’s number one advocate, their first line of developmental support and their biggest defender against adverse experiences. Because of these and many other instances, children’s health cannot be isolated from their families’ health and wellbeing.

“That’s what happened in Haiti eight years ago,” Coté continues. “It’s what happened on our border in Texas. And it’s a central element to NICHQ’s approach to systems improvement: we strive to support the health of families, the health of the caregiver-child dyad, because we know their health is inextricably connected. Supporting family health holistically proves time and time again to be the best thing for children for their short and long-term health outcomes.”  

Coté, who has seen the lasting effects of parent-child separation on the Micmac tribe in rural Maine, knows this firsthand. In the late 19th and 20th century, the children of the Micmac tribe, along with other indigenous groups across the country, were systematically separated from their parents and sent away to schools, purportedly for assimilation purposes. Generations later, Coté witnessed the physical and psychological devastation that lived on in the families she served. The violence of the past invaded the families’ present, through cycles of domestic violence, poverty, untreated mental illness and substance abuse.

“What we do right now will affect generations to come,” says Coté. “It’s why we always need to look at the child’s health in the context of their family’s health. For our borders, that means continuing to support actions that keep children with their caregivers because, without their first protective factor, children’s health is at incredible risk. For our health systems, that means continuing to carry that same principle of family centered-support into all aspects of our work—from helping healthy mothers breastfeed their babies to giving families the tools to support their child’s developmental health.”

If we do this, if we keep families together, we give kids their best chance for a healthy future. And by focusing our efforts on supporting families, we will improve children’s outcomes in communities across our nation.

For questions, please reach out to [email protected]. Interested in hearing more from our leadership? Sign up for NICHQ News and stay informed on new stories, insights and resources. 

Watch the Video

NICHQ President and CEO Scott D. Berns, MD, MPH, FAAP, and Chief Health Officer, Elizabeth Coté, MD, MPA, share why they're committed to improving systems that support parents and caregivers as advocates for and protectors of their children’s health.