The Future of Us: What the Dreams of Children Mean to Twenty-First-Century America

By the mid-1980s the problem of homelessness had evolved from a relatively minor but sad and vexing issue, involving predominantly single adults with mental health or substance abuse issues, to a major social and economic crisis. The number of homeless people spiked to 600,000 by the end of Ronald Reagan’s presidency.1 But the big change by 1986 was the sharp rise in the number of families, as opposed to singles, who were now seeking shelter.² Reagan-era policies had shut down many psychiatric hospitals around the country.³ Their services were supposed to be replaced by an aggressive proliferation of outpatient mental health clinics, but that never happened. In any case, that was not really behind the significant uptick of homeless children in cities like New York. Other forces were driving the crisis for poor families. Jobs were hard to find, especially for African Americans, whose unemployment rate was 2.77 times higher than for whites.⁴ Also during this period, federal support for low-income residential housing construction waned, and there was a concurrent rise in rental rates in the inner cities. Families became homeless for any number of reasons: after fires destroyed their apartments, or because they couldn’t afford the skyrocketing rents, or because they lost their jobs, or to escape domestic violence, for example. But the main culprit was a failing economic and social safety net.

By 1986, thousands of families, including some 10,000 children, were being sheltered throughout the five boroughs under conditions little better than life on the streets.⁵ For the most part, these families were placed in poorly supervised “welfare hotels,” or congregate shelters that were, by design, located far from their original neighborhoods. Once in the shelter system, families struggled to fulfill basic needs like clothing, food, and finding permanent housing. Getting the children to school was often a problem, and finding appropriate health care was close to impossible for many.

And over the course of a year, in addition to the children living in shelters with their families, more than 40,000 children, many like William, the budding paleontologist, would come through the foster care system.⁶ After a temporary stay in a special facility or group home, most of these children were placed with relatives in what the city called “kinship environments.”

But not all of the kids were so fortunate. Several thousand children would never find permanent homes. These were kids without safe or appropriate options, children with physical handicaps or behavioral issues that made finding long-term placement virtually impossible. Such children, once called “nomads” by former New York City mayor David Dinkins, spent their entire childhood going from one shelter to another—from six-bed group homes to residential facilities, from shelters in the city to placements outside the community altogether. Finally, at age eighteen, they were considered discharged from the system. In essence they “aged out,” adrift on the city’s streets.

So it was that summer of 1994 when we were in the mobile clinic, seeing patients from a large shelter for foster kids. As usual, I braced myself for a busy day. There were many children to be seen, mostly between six and fourteen years old. Every one of them was a story of struggle and sadness. They were from broken families, extreme poverty, their parents gone or disabled. They had struggled under conditions of overwhelming adversity, the likes of which were essentially incomprehensible to most of our medical team. More than a few had lost parents to HIV/AIDS. Some of the children were infected themselves.

At some point in the mid-morning, the facility staff brought Clarence, a twelve-year-old African American boy, into the mobile clinic. I greeted the tall, lanky child and shook his hand, asking the worker what the problem was.

“He’s slow,” the man stage-whispered, “and he’s in a special class—and a real behavioral problem.”

I asked for previous medical records and for any more information they might have on Clarence’s medical or family history. Not surprisingly, very little was available—virtually nothing about family background.

We slipped into one of the small exam rooms on the unit. I tried to engage Clarence in small talk; he responded by smiling, wordlessly. His shirt clung tightly to his chest, and his pants hung loosely, a mismatched outfit obviously salvaged from the shelter’s donated clothing. But when he finally spoke, he was virtually incomprehensible. I asked Clarence to sit up on the exam table. When I examined his mouth and throat, I gasped. This boy had essentially no palate. I could see into his nasal cavities through his mouth—the roof was missing entirely. This is a well-known condition called cleft palate—in Clarence’s case, a complete cleft palate.

I stood there for a moment. Clarence, still smiling and sweet, was looking at me. He fidgeted, crinkling the paper that covered the exam table. I asked the nurse to take a look in the child’s mouth. Neither of us could believe it. A twelve-year-old with an untreated cleft palate was unheard of in a modern, developed society. Typically, the condition is recognized at birth and treated surgically starting around four months of age. The consequences of not closing the palate include, among other things, severe delays and impairment of speech. From there, a language-impaired child from an impoverished home in a broken educational system gets labeled. He’s considered severely speech delayed, erroneously considered mentally slow, and placed accordingly in school.

Socially, such children may be shunned or ridiculed by peers. Many of these children will develop secondary emotional or behavioral problems, exacerbating an already difficult situation in the classroom. By twelve, the original problems and all of the secondary consequences of a missed medical condition may have already resulted in irreversible problems. What’s painful is that this social and psychological catastrophe may well have been averted by early diagnosis, appropriate care, and a supportive social system. Clarence had none of this.

Over the ensuing weeks, after a lot of digging, our team was able to produce a reasonably clear picture of Clarence’s early medical history. As it turns out, he actually was diagnosed early. In his birth records the examining physician had clearly noted the absent palate. He had even recommended close monitoring and surgical follow-up. The same thing was noted repeatedly by doctors and nurses in various emergency departments that had seen Clarence for acute illnesses over the years. Young Clarence would be taken to the hospital because of high fever, for instance, and get antibiotics for an ear infection. On other occasions he’d be seen for a rash or diarrhea. Each time the doctor would note something about the palate, each time suggesting that follow-up be done.

But it never happened. Among other realities, Clarence wasn’t taken to the emergency room by people who had a long-term, vested interest in him and in what might be a very complicated and expensive surgical intervention. He would be brought to the hospital for evaluation of an acute medical condition by a shelter employee or case worker “on duty.” Most importantly, this boy did not have a regular source of medical care, something pediatricians refer to as a “medical home.” Clarence’s care took place entirely in hospital emergency departments or the occasional random clinic visit. Had he been getting regular care by a medical team that knew him and kept comprehensive medical records, the critical follow-up he needed would likely have occurred.

The fact is that Clarence’s future was placed in enormous jeopardy because he lacked access to appropriate, timely health care in a setting that was committed to his long-term well-being.

At age twelve, now under the care of the Children’s Health Fund teams, he finally began the treatment he should have received as an infant. That was certainly good, but much had been lost that would never be recovered.

Sadly, although we may have hoped to see vast improvements in the social adversities that led to Clarence’s falling through the cracks, that hasn’t been the case. In a 2016 report issued by the Children’s Health Fund, data showed that more than 20 million out of some 73 million young people under the age of eighteen in the United States still lacked timely access to comprehensive health care, even though the number of children without health insurance has dropped significantly.7

How is this explained? It seems that many insured children face barriers of access to health care that have nothing to do with health insurance. These are children who live with their families in severe doctor-shortage communities or places where affordable transportation to get to a doctor is not available.

As for homelessness, many cities have experienced worrisome growth in the number of homeless families and children. In New York City, for instance, the average nightly shelter census of homeless children rose from about 10,000 in 1986 to nearly 24,000 three decades later.8 In other words, more than twenty years after we first met Clarence, it was still possible to have children fall through the cracks of a health care system that simply does not work for millions of vulnerable children.

Thomas and Robert: Emergence!

Spring 1998

I’ve seen my share of children who successfully emerge from serious adversity—and certainly their stories are inevitably inspiring. The problem is that these are exceptional outcomes representing a very small minority of children who have the misfortune of growing up in extreme generational poverty. These are children whose parents and grandparents were poor and, if statistics are predictive, whose next generation of children will remain mired in poverty as well.

Still, it is important to recognize that adversity—even severe and prolonged adversity—does not inevitably determine outcome. Success in spite of (or sometimes because of) coping with huge challenges happens, and that has always been true. Out of war, famine, major disasters, incarceration, discrimination, psychological turmoil, and abuse of all kinds come inspiring examples of emergence. Some individuals who are personally—perhaps even genetically—resilient, gritty, and maybe lucky enough to have somebody who cared about their surviving and thriving can manage to find a pathway to a successful life. Sometimes we recognize them and may call them heroes. Sometimes they thrive, perfectly content, in obscurity.

Thomas was twelve and his brother Robert nine when his father lost his job in Kingston, Jamaica, putting himself and the two boys in a precarious economic situation, starting with an eviction notice from their modest one-bedroom apartment. Dad and the boys’ mother had separated a year prior, and she was living in a small spare bedroom of a relative in the Bronx. Her departure had been traumatic for the brothers, and the latest seemingly irresolvable family financial crisis greatly exacerbated the level of stress and anxiety that the family was experiencing. Robert was acting out in school, grades dropping and reports to the principal rising. Thomas refused to go to school at all. Their unemployed father was beside himself, increasingly depressed, unable to manage the boys’ issues while focused on trying to find work. In desperation, a decision was made to send the brothers to New York City in hopes that their mother would care for them, at least until their dad could get his situation stabilized.

This turned out to be more wishful thinking than a viable plan. Not only was their mother living under circumstances that could not accommodate the boys, but when they arrived in New York, they learned that their mother was four months pregnant. Within a week of their arrival, the brothers were placed in the city’s foster care system, assigned to a series of small group home settings. And that’s where I found them.

Thomas was brought to me for a check-up.

“Thomas, I’m Dr. Redlener, and I want to speak with you for a few minutes, do a quick exam, and make sure that you’re healthy. How are you doing?” The boy looked down and said nothing.

“OK if I ask you a few questions?” That at least got a quick shoulder shrug. But clearly this was going to be a challenging conversation. I asked the nurse to push back my next appointment to accommodate what I suspected would be a difficult conversation. Indeed, Thomas had a good deal on his mind, and eventually, bit by bit, over what turned out to be many visits over a six-month period, the story emerged. Besides the details about what his family was going through, it was clear that the young man was deeply worried, not so much about himself but about his brother, who was with him in the group home, about his pregnant mother, and about his father in Jamaica—all of it seemingly on his twelve-year-old shoulders.

Eventually, Thomas and I bonded, and he learned to trust me. We did what we could to address the multiple issues he was worried about, starting with getting his asthma under control. It is worth noting that dealing effectively with this medical issue was straightforward, by the book, and rapidly resolved. But the family challenges, the stress, the academic continuity both boys needed—that’s where the care and support of these boys got really tough.

So, what exactly was my role as a physician? Did it stop with my writing prescriptions for his asthma medications? Hardly. The circumstances that actually influenced Thomas’s well-being were not predominantly medical, not covered in my old textbooks or in the scores of lectures I heard in med school and throughout my training. This situation, like so many that involve children living with multiple adversities, is about health and well-being defined in the broadest sense of those concepts. Doctors need to be sufficiently aware of the entire range of issues affecting their patients, the children who are under their care.

Thomas and Robert got the full range of comprehensive services from the Children’s Health Fund: medical care, case management, psychological counseling, academic support, career advice, and so on. We stayed with these kids as their mom gave birth to their new little sister, as their dad came to New York and found a decent job, and as they got their act together and graduated from high school. We were “there” when the family reunited and moved into a good apartment, finally.

It should be noted that before the boys were bought into the Children’s Health Fund’s network of care, they were getting, at best, random health care for check-ups and a trip to the closest emergency room if they had an acute medical problem. They needed much more. CHF was able to provide substantial attention to the health, psychological, and social issues that were standing in the way of their successful adaptation to their adopted country, the pressures of being in the foster care system, and the academic challenges in their new schools.

Robert went to a community college and landed a great job as a building superintendent. Thomas was accepted to and graduated from a prestigious New York college and went on to finish a nursing program, as well as a master’s degree in social work. As of 2015, he had successfully ventured into writing and publishing children’s books.

Success stories—hard to come by in my work, but always appreciated, always reminding us that almost every child has potential and that success can, indeed, prevail over adversity. But it doesn’t happen on its own. The commitment of supporting adults, the availability of decent schools, and robust social support systems all make a difference.

So, how much credit does the doctor get for a successful child who emerges from a tough environment and actually makes good? That’s not clear, but humility is in order here because many factors will influence the trajectory of a child, including his or her personality, grit, and the presence of a caring adult.

That caring adult, first of all, must believe that almost anything is possible for the child who is under his or her protective wing. Second, that adult must be committed to doing whatever can be done to mitigate and buffer the conditions that would otherwise blunt aspirations and turn off the dream machine essential to any successful childhood. This assumption of responsibility for protecting a child from the firestorms of a dangerous childhood may be taken consciously by a parent, a physician, a social worker, or any adult in the child’s orbit.

The point is to realize that whoever assumes that role is vital to a child’s ability to escape adversity by serving as a protective buffer for a child awash in challenges, providing consistent support, positive reinforcement, and a reminder that the dreams of childhood can, one day, materialize.

LaTisha, Marine Biologist

Fall 2014

It’s a chilly early November, and I’m sitting in the crowded waiting room of the CHF’s South Bronx Center for Child Health and Resiliency. I had come up to the center for a late afternoon meeting with the clinic’s senior staff, including my wife, Karen, then executive director of Montefiore Medical Center’s community pediatrics program. The agenda was to be a discussion about an upcoming site visit by a major donor looking to get a feel for what exactly we did up here in the South Bronx, a community often considered an urban no-man’s-land by the wealthy Wall Streeter whose usual habitat was Manhattan’s Upper East Side.

We had designed and built the nearly four-year-old health center to be a welcoming and efficiently functioning medical destination for children and their families. A round, sweeping low-rise counter staffed by friendly, smiling registrars was the first thing families saw when they entered the facility. The décor was all about soothing, coordinated pastels; the walls were covered with unique, child-friendly art and bright accent panels.

As I sit in the waiting room, filled with the bustle and buzz of babies, children, and their parents, I’m not thinking about anything particularly profound—just a little zoned out after a long day. To my right are a few couples with an assortment of kids and some young moms tenderly holding babies or reading to toddlers on their laps. Directly across from me, a dad sits smiling at his young child, who is playing with a stuffed animal. Sitting next to him is a teenager, ball cap askew, baggy pants, a Beats headset attached to his phone, eyes lightly closed, and a hoodie—classic adolescent chic for this part of the city.

There’s a young African American girl who catches my eye. She’s adorable, looks about nine or ten, and she’s holding a couple of small toy fish—or that’s what they seem to be. I get up and wander over.

“Nice fish,” I say.

“Well, this one is actually a barracuda,” she says, holding a green plastic toy in her left hand. “And this other one is a tiger shark,” she adds, showing me the other little model.

“Oh yeah,” I respond. “I couldn’t really see them from where I was sitting. Are they the man-eating variety?”

“Well, not the barracuda,” she says assertively, “But you gotta watch out for the shark. Those tigers attack people swimming in the ocean and eat just about anything.”

“Wow! That sounds scary.”

“Yeah. But not as scary as the great whites. Those suckers attack people all the time and they’re huge.”

“Thanks for that. I will definitely try to stay out of their way. By the way, what’s your favorite kind of shark?”

“Me? I like the hammerheads. They look really weird. Ever see one?”

“No. But how do you so much about sharks?”

“From my teacher. She told us about this book. I borrowed it from school—and then my mom got me a video all about sharks.”

“Pretty good. Listen, I’m just curious, what grade are you in?”

“I’m in fourth. My school’s just a few blocks from here.”

“So, who brought you here today?”

“My worker,” the child says matter-of-factly, pointing to a middle-aged woman sitting on the other side of the waiting room.

“Mind if I say hello to her?” I ask.

“No. And my name is LaTisha. What’s yours?”

“I’m Irwin. And by the way, young LaTisha, what do you want to be when you grow up?”

Without a minute of hesitation, this beautiful, engaging, adorable kid who lives and goes to school in one of the most troubled urban communities in America looks up at me and says, with unabashed conviction and clarity, “Well, I’m going to be a marine biologist.”

“I’m not surprised,” I say. “Sounds like a great idea.”

I approach her “worker,” who identifies herself as Gail. Just to establish my credibility, I let her know that I’m the pediatrician who founded the Children’s Health Fund. She’s pleasant enough, and we engage in a little small talk. She doesn’t say, and I don’t ask, why LaTisha is here with her—not her Mom—but she is clearly very familiar with this family.

“So, why is LaTisha here today?” I ask.

“It’s her asthma. Mom said she was up all night coughing and was too tired to go to school this morning. She finally perked up, I’m happy to see.”

We talk for a few minutes about LaTisha’s very impressive knowledge about sharks. Gail tells me that the kid is really into the subject, and her mother is very encouraging. I ask if LaTisha’s ever been to an aquarium.

“Almost. A few months ago LaTisha’s mom and a couple of other parents in their building found a way to organize a trip. But when they got there, the place was closed. It was pretty sad,” says Gail.

“I’ll say. Think they’ll reschedule?

“Doubt it. It cost them a lot to get there, and times are pretty tough now.”

I don’t respond.

Gail continues: “That girl is hangin’ in there. But her family is pretty messed up. Her father is in prison, and her younger brother is in a kinship foster home. Worst of all, Mom has a serious addiction issue. And they never have enough food stamps left at the end of the month.” She pauses and looks away. “I’m not really supposed to, but I try to bring them some groceries when I visit.”

I get the picture. The fact that LaTisha’s sole available parent, her mother, is an addict doesn’t bode well for this child with big, lofty aspirations. To begin with, studies have shown that children raised by drug addicts are significantly prone to developing emotional, social, and behavioral adjustment problems. Children of substance-abusing parents are more than twice as likely as their peers to develop a substance-abuse problem of their own.9 Many of these children demonstrate psychological or behavioral problems. And all of these issues can adversely affect school performance. In other words, young LaTisha is at high risk for never being able to realize her own very precious dreams.

I look up at a picture on the waiting room wall. It’s a globe with some smiling children. It says, “The World Is Waiting—Let’s Go!”

I look over at LaTisha, who’s playing with her toy sharks, moving them through the air as if they were riding the ocean waves.

I am thinking that this is a kid who needs to become a marine biologist. For her sake, of course, and also for the world waiting for her to take her place in a society that desperately needs every child to be a success story, to realize aspirations that will lead to a productive, fulfilled life, not slip back into the terrible cycle of poverty and failure that, generation after generation, consumes families like LaTisha’s.

And here I am contemplating all of this in the waiting room of a South Bronx clinic where I met a charming nine-year-old enjoying a short respite from the streets and the stress she has lived with since the day she was born.

Raymond, Graphic Designer

Winter 2015

It’s a bitterly cold mid-January afternoon. I am in the St. John’s Place Family Shelter in Brooklyn, this time in the impoverished Crown Heights community, a neighborhood once notorious for civil unrest involving violent conflicts between the African American and Jewish communities. This shelter was opened in 1990 by New York’s Settlement Housing Fund expressly to provide a civilized option for homeless families who would otherwise find themselves forced into one of the squalid congregate shelters or welfare hotels that proliferated in the city.10

In essence, the unrelenting problem of homelessness among families that prompted us in 1987 to create the Children’s Health Fund, a special comprehensive health services for children in the shelters, had persisted and, sadly, grown substantially by the time I met Raymond in 2015. Unlike Clarence, Raymond was never in the foster system, but his childhood was spent living in extreme economic fragility, housing instability, and long stays in shelters in the metropolitan area.

Estimates suggest that from the mid-1980s through 2016, the number of homeless New York City families increased from approximately 4,000 to more than 14,000. That meant that in the late 1980s, some 10,000 children lived in New York City shelters on any given night, and by 2016 that count had more than doubled to nearly 24,000 children as an average nightly census.¹¹ Even with the help of hardworking city government agencies, newly homeless families simply could not find affordable housing in a city that was otherwise thriving economically and on a mad dash toward maximum gentrification. That left thousands of homeless families with little choice other than “single-room occupancy” (SRO) and decrepit welfare hotels whose owners were repeatedly cited for violating health and housing standards; many of the buildings urgently needed repair for everything from nonworking plumbing, broken elevators, and peeling paint to vermin infestations and broken room locks.

Most of these facilities could have and should have been torn down to make room for new construction of apartment buildings or small business venues. But the city urgently needed a place to warehouse thousands of homeless singles and families who had little likelihood of finding affordable permanent housing. With a combination of funds from the city and the federal government, private owners of these emergency shelters kept these decrepit facilities intact. In effect, they were a virtual gold mine for the owners, who exploited the city’s desperation—and the availability of emergency shelter dollars—charging from $1,500 to sometimes as much as $3,000 per room per month to “house” a homeless family. And it was full occupancy 365 days a year! But New York City was committed to finding shelter for the homeless, even if more than $100 million would eventually be spent to keep people, including families and children, off the streets.

Hearing statistics about homelessness is not enough to appreciate the actual impact on the families caught up in the destructive morass of prolonged displacement under highly adverse conditions. One of the mass shelters housed up to a thousand people, including families with kids and homeless singles with drug, alcohol, and criminal histories, for periods that averaged eighteen months or more.

Think about that. Terrified, poor, and out of options, single parents with babies, toddlers, and school-age children in tow would be spending more than a year in shelters intermingled with adult drug addicts and people with serious mental health problems.

And in the privately owned welfare hotels, a common bathroom could be shared by many people, some of whom might be prostitutes or drug dealers. Access to school, hot meals, or health care for children was severely impaired. To this day, no one has been able to fully measure the long-term effects of homelessness on many of the children who lived through these very tough years. That is not to say that none of the children enduring these conditions got through unscathed. In fact, many kids proved to be surprisingly resilient to the stress around them, often buffered by a strong parent or other adult figure who was able to protect them from the ubiquitous psychological and sometimes physical trauma of urban homelessness.

But in general, for the majority of children trapped in the shelters and the welfare hotels, childhood was a living hell.

By 2000, the small nugget of good news in the “management” of homeless families was the elimination of placements in the large, dehumanizing congregate shelters and the so-called welfare hotels that had been so prevalent in the late 1980s and early 1990s. These worst of the worst shelters were in part replaced by so-called Tier II shelters, some of which provide clean facilities, a working kitchen, and a private bathroom. Unfortunately, with the recent dramatic growth of the homeless population, many families with children continue to be placed in terrible public housing facilities in some of the city’s most treacherous neighborhoods.

That said, St. John’s Place, and other facilities like it, were expressly designed as antidotes to the welfare hotels. St. John’s provides clean, furnished apartments with private baths and kitchens in a secure building. It isn’t fancy by any stretch, but it is a relatively safe place for children. A flourishing garden tended by the residents provides fresh vegetables and a source of pride.

Raymond, a sweet-faced fifteen-year-old boy, born some four years after we started Children’s Health Fund in 1987, sits down across from me at a table in the shelter director’s office, staring anxiously at the floor. This young man is part of the latest generation of lost and struggling kids, and I am still waiting for some kind of revolution, a wake-up call that would lead to the elimination of homelessness and poverty that is still grinding down the dreams of more than 16 million children in America.

There is no eye contact for the first minutes of our conversation. Raymond is clearly small for his age; his pant legs are bunched up at his ankles, and the sleeves of his zippered fleece flap loosely on his arms. But what strikes me is the huge shoulder bag—worn, stained, strapped across the boy’s chest, jammed full of what, I have no idea.

I greet Raymond and introduce myself. He nods, eyes fixed on the empty table.

Raymond unstraps the shoulder bag from his chest and clutches it in his arms. I ask him a few questions. “How long have you been living in the shelter? Where do you go to school? Who lives with you?” His replies are polite, but soft, almost muted. He says, “About five weeks” and “In Brooklyn” and “I live with my mom and stepfather. And my sister.” Still no eye contact.

I explain that I want to talk about his life and his future. Raymond glances at his bag.

“What’s in there?” I ask. “I’m dying of curiosity.”

Like William, the boy who aspired to be a paleontologist, Raymond suddenly raises his head and looks right at me, with a big smile spread across his face. He actually startles me.

“It’s my art work,” he says. “I always have it with me.”

“I’d love to see your work, if I may.”

From the worn, dirty shoulder bag, Raymond pulls out dozens of portfolio books, carefully spreading them on the table.

What I see is dazzling. On page after page, in book after book, are hundreds of stunning images of characters, still-life drawings of fruit and flowers, science fiction–like industrial designs, logos he has created for real or imagined companies or products, sketches of people and scenes. There is a beautiful pencil drawing of an art teacher who inspired and encouraged him, even as a fourth grader. Raymond clearly has tremendous talent.

There is no stopping him now. Words tumble out. Raymond explains that he first became interested in drawing when he was seven, and he has saved every piece of artwork since then.

“See this?” he says, opening one book. “I think this was the first drawing I ever did.” He points out an exquisitely detailed pencil drawing of a cartoon character. Then his fingers move to a drawing on the opposite page. “And here,” he says, “is an updated version I did last year.”

It’s a beautiful color rendition of the same image, more sophisticated and clearly done with a far more mature technique.

After going through almost everything, he says, “Hey, do you want to see some of my computer-designed work?”

“Hell, yes!” I reply.

Raymond pulls a flash drive out his pocket and grins. “It’s all here. I’ll email it to you.”

“Great,” I respond. “You have a computer?”

He shakes his head, grin fading. “I do. But it’s old and not really working. I try to use the computer room at school.”

“Raymond,” I say, leaning toward him. “Your work is just beautiful. Tell me what you want to do after you graduate from high school.”

“I want to go to art school and learn graphic design,” he says immediately, his brown eyes once again fixed down at the table. “I would be so happy if I could do that for the rest of my life.”

No doubt, I think. “Can you make this happen?”

“Sure,” he says, beginning to put his work back into his bag. “Why not?”

“Of course you will,” I say with as much assurance as I can muster. But I know better.

As with many precariously situated families, Raymond’s family’s fall into homelessness had been steep, fast, and persistent. Years earlier, the family was doing okay, with income sufficient for just making ends meet. Then his stepdad was injured on the job, and it was downhill from there. They ended up in the shelter system and, as with so many others, breaking out was not so easy.

Because his living situation, essentially shelter to shelter, was always changing, the shy teenager avoided making friends, rarely speaking with classmates. Everything was always in flux, but he found peace and stability in his artwork. And with tremendous effort, he managed to pass all of his courses, regularly winning praise from teachers for his wonderful drawings.

Through some inexplicable force of will, Raymond’s parents were still chasing the dream of a better life, somewhere. Anywhere. But in the middle of a tough Northeast winter, they ended up in a homeless shelter deep in the heart of Brooklyn.

Raymond and his sister have asthma. This is the most prevalent pediatric chronic illness, being diagnosed in 8.6 percent of all children,12 and found in an astounding 33 percent of homeless children in New York City.¹³ In any case, recurrent wheezing and poorly controlled asthma were taking a toll on Raymond and his family. They usually, but not always, had medicine and inhaler pumps to treat the symptoms when it was just too difficult to breathe or impossible to sleep through the coughing spasms. Like many other homeless kids, they had the prescriptions for their breathing meds written in crowded, dingy exam rooms of the public hospital closest to whatever shelter they happened to be in.

I couldn’t know for sure, but it is likely that some combination of changing weather, the stress of constant displacement from one shelter to another, and his parents struggling to sustain some semblance of a normal life triggered the asthma attacks. And as they became increasingly frequent, he missed many days of school.

Raymond also tells me he has “some kind of eye problem.”

“Like what, exactly?”

“Sometimes, when I’m reading, my vision gets blurry and I can’t see the letters,” he explains.

“What do you do? Have you seen a doctor for this?”

“Not really,” Raymond says. “I usually just blink a few times and it seems to get better.”

I make a mental note and the next day arrange for him to see one of the eye doctors who work with our primary care teams.

The family has been living in St. John’s for just a few weeks. The director has big plans for more improvements, including a computer room. But it isn’t there yet, and Raymond has only his shoulder bag to carry his personal art gallery, his life story, and the dreams he is determined to hang onto despite unforeseeable challenges.

I stare at Raymond, trying to absorb what he has said, the whole of it—the love of art, the traumas, the uncontrolled asthma, the deprivations, and, especially, the extraordinary barriers that stand between him and a fulfilled life, free of poverty, working at a job he would love.

The painful reality is that millions of children like William, LaTisha, and Raymond struggle in small towns, cities, and rural areas across America—impoverished children with the richest of dreams, many with talents and inexplicable perseverance who may or may not overcome the conditions over which they have no control. Many of these kids are brilliant or artistic, many filled with undaunted dynamism. They could be our next generation of statesmen, generals, physicists, entrepreneurs, doctors, artists, scientists, and teachers.

They are neither less than nor different from middle- or upper-class children when it comes to their desire to live a full and successful life. This recurrent story, the impact of enduring poverty, is about the rise and fall of aspirations extinguished by adversities that most Americans can barely imagine.

I pull out of my thoughts and ask, “Raymond, what do you think might stop you from realizing your dreams?”

He looks at me for a moment. I think he may cry—or maybe that’s me I’m thinking about. He looks suddenly older than his fifteen years.

“We have to move too much. We have no money, and I know my family won’t be able to buy me the books I’ll need. I have some art supplies now, but I worry that they’ll be gone soon because I draw so much.”

He pulls a small tin of colored drawing pencils from his bag, many of them just stubs. “My teacher gave me these.”

“Raymond, clearly you love art—and you’re damned good at it. I think your dreams will come true if you stick with it.”

I try to sound like I mean it. I can’t tell if he believes me.

Is there some way—any way—I can help this impoverished homeless kid with big aspirations?

“Raymond, have you been to any of the art museums in New York?”

“No, sir,” he responds. “I’ve never been to any museum. Never in my life.”

“Never?”

He shook his head.

I think about this minor travesty as we leave the office. I see Luis, the shelter director, in an adjacent waiting room, so I ask Raymond to hang back for a minute.

“Luis, this kid is a wonderful artist and could have a great career ahead of him—if he can break out of the cycle of poverty his family is in.” Luis sighs and shrugs. He is a wonderful shelter director in an awful system, and he can only do so much.

“This boy has never been to a museum,” I tell him.

Luis grimaces. “I don’t know what will happen to families like his,” he says. “I have no magic answer to solve the poverty issue.” Then a flicker of a smile comes across his face. “But the museum situation I can deal with.”

He gets an idea. “I’ll organize a van trip to the Museum of Modern Art for Raymond and some of the other teens staying here.” Now we’re talking. Within a few weeks, a bunch of teenagers who had been living their lives disconnected from the cornucopia of art and culture in their own city got to see one of the world’s great museums. For some, those few hours of invested time, a rented bus, a light lunch, and an unforgettable experience would help solidify a sense of belonging in society and offer up what could be a bit of hope that, somehow or other, it would be okay to imagine a future that would be fulfilling and meaningful.

By March of 2016, Raymond and his family were living in Camden, a dingy impoverished South New Jersey urban wasteland. “Why there?” I asked when he told me that the family was planning on moving. He explained that they were sick of living in shelters and they had heard that apartments were very affordable. Plus they had lived there some years prior.

“But, Raymond, what about school?” I asked. “You’re doing well in Brooklyn, and you have a lot of support for your artwork.”

“I think it will be fine. Anyway, I have no choice,” said Raymond. I didn’t say it, but I thought, “You’ve got that right.”

That’s the problem right there. For so many children and their families who are stuck in the groove and grip of poverty, choices are limited for everything—where they live, what they can purchase, the capacity to make education decisions that lead them to the lives to which they aspire, the ability to visit a museum or travel someplace just for the adventure of it, the clothes they want, the privacy we all crave sometimes, the ability to save for the future, the resources to choose healthy food, the money to pay for a blazer that Raymond needed to go with his class on a field trip to a New York art gallery that was to show his work or buy a uniform for the baseball team, the capacity to once in a damn blue moon to eat in a restaurant with tablecloths, the big and small things of life, the non-extravagant things and possibilities that should be accessible for any American kid. Those are the choices that I have, that my children and grandchildren benefit from, that should be Raymond’s American birthright, too.

Raymond called from Camden one Saturday morning in late March. He was coughing and hard to understand, but he told me that he had been sick for four or five days with high fevers, cough, and wheezing. He was feeling generally lousy. He told me that his mom had taken him to an emergency room at Cooper Hospital in Camden a couple of days before, but his symptoms just were getting worse.

“What did they do for you, Ray?”

“Not much. Just told me to stay home from school and take Motrin and Tylenol.”

“No blood tests? No x-rays?” I asked. “What about any prescriptions?”

“No, nothing like that.”

I told Raymond to go back to the emergency room now and have them reevaluate the situation. They’d need to carefully reexamine him, order the right tests, make a more informed diagnosis, and treat accordingly. He agreed to go. I asked him to call me back when he was in the ER so he could hand the phone to the doctor who’s treating him. The well-reputed hospital was affiliated with a new and innovative medical school, part of Rowan University, and I was at least comfortable that he was likely to get good care.

More than an hour later, Raymond called back.

“Where are you?” I asked.

“We’re heading back home,” Raymond said through the coughing. “The bus never showed up, and my mom doesn’t have money for a cab. We’ll ask my stepdad if he can help me out.” Fine, I said, just keep me posted—my plan being to prepay a car service by credit card to pick him up at his apartment building and take him to the hospital.

Eventually the story ended okay. He got to the hospital by car service, and he was evaluated properly. The treating physician told me that the chest x-ray looked clear and his blood count was not suggestive of a bacterial infection that might have required antibiotics, so a presumptive diagnosis of influenza was made. Because Raymond and his doctors felt that his asthma was under control, just symptomatic treatment was recommended to manage his viral flu, in addition to keeping up with his asthma attack prevention medications.

But here’s the problem that is a grave issue for millions of children. There may well be a perfectly fine hospital or clinic that would see a family like Raymond’s on Medicaid, the government’s health insurance program for the poor—or, if necessary, provide care at no charge or at a reduced rate according to the family’s income. But for an economically stressed family, just getting to the doctor or hospital is the challenge. Raymond’s family didn’t have a car. And although there was an affordable metro bus system, service was generally minimal and essentially skeletal on the weekends.

According to the 2016 Distressed Communities Index published by the Economic Innovation Group, Camden, New Jersey, was rated the most distressed city in the United States. Average family income there is 36.4 percent of New Jersey’s overall average. Nearly a third of the population has not graduated from high school.14 With the city’s tax base in a permanent slump, Camden had to pare down all government services, including public transportation—that in itself being a health care issue and an example of the realities of living poor in America.

Asthma is the most common chronic illness among children of all socioeconomic groups. But the challenges and consequences faced by poor children with the disease versus how the condition plays out for children whose families are not economically stressed is striking—and informative.

This is how it goes for children with asthma who have timely access to decent medical care: Typically, a child with, say, persistent cough and wheezing is evaluated by a doctor, a diagnosis is made, and medications are prescribed both to prevent acute asthma flare-ups and to treat an attack if there is a breakthrough. The health care team provides asthma management education, teaching families about factors that could trigger acute flare-ups and how to avoid or manage them. If the medications are correct and the family sufficiently educated about controlling the disease, emergency room visits or hospitalizations are rarely necessary.

But the realities of asthma management for a child living in poverty are strikingly different—and far more dangerous. If there is not regular access to a “medical home,” opportunities for early diagnosis, proper prescriptions, and asthma education are severely limited. The medical care of childhood asthma under such circumstances becomes a series of emergency runs to the nearest hospital, often so late in the course of an attack that treatment must be done in an inpatient setting, occasionally in the pediatric intensive care unit, where a breathing tube and mechanical ventilator may be necessary.

But the outcomes of poorly controlled asthma go far beyond a child’s medical well-being. There are other important consequences that can even affect a child’s academic success or the family’s economic security. Children with undertreated asthma often suffer from severe nighttime coughing. This commonly results in disturbed and restless sleep or even difficulty falling asleep. With school-age children, parents may keep them home. These are the children at risk for chronic absenteeism—a condition highly associated with academic failure.

Even if they go to school, children with unchecked asthma are likely to be too exhausted to concentrate in class, sometimes chastised by an unknowing teacher for failing to pay attention. That’s why we call undiagnosed or undertreated asthma a “health barrier to learning.” Worse still, the perceptions of teachers, parents, and even their peers get internalized by the child, creating a negative self-image that is reinforced by ongoing criticisms and mislabeling. Children start to fall behind, academic success becomes increasingly elusive, and aspirations for a productive, fulfilling future seem more and more out of reach.

And there is always the possibility of an asthma attack so severe that an ambulance must be called—a situation traumatic for the child and very disruptive to the rest of the class. I’ve spoken to principals of inner city elementary schools who report having to call an ambulance three or four times a month to transport a child with respiratory distress to the emergency room.

Sometimes a parent’s job is at risk if he or she stays out of work to care for a sick child. At the least, a parent who stays up with a wheezing child during the night may be too exhausted to function in the workplace.

So what does this have to do with Raymond, coughing and sick, waiting in America’s poorest city for a bus that never came to take him to the hospital to get the care he needed? What does Camden’s barely functioning metro bus system have to do with asthma, poor children, and life success?

It starts with understanding the underpinnings of what it takes to have a robust, effective health care system that is “user-friendly” and equitable, accessible to everyone regardless of economic status, race, or geography. For decades, state-of-the-art hospitals and medical schools have been the primary focus of building a modern health care system, the citadels of advanced medical practice and technology integrated services.

However, in terms of real access to the fruits of advanced health services, and even to basic primary medical care, challenges have become intractable, leaving many Americans unable to get to a health care provider because of barriers ranging from the cost of care to maldistribution of doctors and clinics to public transportation deficiencies. These factors all matter to people living in the margins. And while the Affordable Care Act (ACA) has dramatically reduced the number of uninsured Americans, much work remains in terms of assuring actual access to health care services.

Most concerning at the time of this writing are the threats articulated by the Trump administration and the Congress, who seem determined to repeal the ACA. If the repeal efforts are successful, that would represent a remarkable step backward for many families who have finally gotten the security and comfort of having access to health care that every American should have.

Most people don’t realize how many “health care deserts,” or doctor-shortage communities, there are in the United States. The federal government tracks the distribution of medical professionals in the nation; if a community has less than one doctor for every 3,500 citizens, it is declared a Health Professional Shortage Area, or HPSA. The latest data, as of January 2016, show more than 6,000 federally designated HPSAs (two-thirds of them rural communities, one-third urban) in which at least 60 million Americans live, including 10–15 million children.15

This does not mean that everybody who lives in an HPSA doesn’t get care; it just means that the very act of getting an appointment at a doctor’s office is far more difficult. For the poor, especially those who experience other adversities, access to care can be overwhelmingly difficult—as it was with Raymond’s tough trip to the hospital. Even though their rental house was just a few miles from the hospital, he was really stuck in terms of how to get there. The bus didn’t show up, and his parents had no money.

Nationally, the Children’s Health Fund has found that between 3.5 and 4 million children each year miss primary care checkups and follow-ups for chronic illnesses.¹⁶ No bus, no subway, no affordable taxi service, no working car? In many places around the nation, this means you’re out of luck if you need a doctor. You could call 911 and get an ambulance to respond, but who would call an ambulance to get to a clinic for a routine immunization, an ear infection follow-up—or an asthma management visit?

For many poor families with few resources and limited, if any, public transportation, getting routine care becomes “optional.” So for children in families with multiple adversities, like poverty or homelessness, getting to the medical facility for anything that seems to be mild or routine drops far down the ladder of family priorities. Finding decent employment, looking for stable, affordable housing, and other issues may well be the most important day-to-day responsibilities. The children unlucky enough to be burdened with asthma become the ones who are most likely to live with chronic fatigue, high rates of absenteeism, and negative labeling by schools—a chain of events that often leads to poor academic performance, reduced chances of timely graduation from high school, and a highly constrained ability to imagine and realize dreams of a fulfilled life.

There is more here than just a call for logical policies based on understanding the long-term social benefit of making sure every child, regardless of economic status, gets high-quality and timely medical care. There is a compelling economic case to be made as well.

A study authored by CHF experts found that for every child with asthma properly treated in doctors’ offices and clinics with evidence-proven protocols and medications, the “system” saves more than $4,000 because of reduced frequency of emergency room visits and hospitalizations.17 With asthma seen in 8.6 percent of the general child population, rising to 33 percent among homeless children in cities like New York, we’re talking serious dollars in savings generated by properly managing this illness alone.

These data might even appeal to those who don’t relate to Mother Theresa’s philosophy of providing good care to people in need purely as humanitarian acts of kindliness. Beyond that, there are real and practical reasons for doing the right thing in terms of the nation’s future resiliency. So, maybe even for hard-core conservatives, small-government enthusiasts, and hedge funders, who always want to understand the “return on investment,” even for government programs designed to assist people living in poverty, the case has been made.

Meanwhile, Raymond and his family seemed to be getting by in Camden when I last heard from him. And there was big news, too. Raymond had gotten accepted to a local branch campus of Rutgers University and would be starting classes in the fall. He was still looking to major in graphic arts, but then my young pal observed, “You never know. Maybe I’ll find something else that’s really interesting!”

Maybe he will, I thought. In spite of the challenges Raymond faces, in terms of persistent poverty and housing instability, he is fortunate to have an intact family, loving parents, and his own internal resiliency—precisely the kind of attributes that make me guardedly optimistic about Raymond’s future.

Schools Filled with Dreamers, Neighborhoods of Adversity

It’s almost noon, and the cafeteria at P.S. 140 in the Bronx is filled with adorableness in the form of happy, beautiful, and eager children, kindergartners through third graders. The first lunch shift is over, and the room is buzzing. Children are laughing, but staying in their seats and chattering with their pals. I am watching them from the doorway, but stand aside when they are dismissed, filing out of the cafeteria, headed back to their classrooms; teachers are standing by, keeping a watchful eye on the brood.

It’s impossible to take my eyes off these children—and I can’t help thinking about my own children when they were this age of wonder and joy. I remember, too, as they got older and more complicated and became aware, at least unconsciously, of the real world, where it’s not all possible and not always simple. Certainly every age has its joys, and we, like so many parents, loved every landmark, every accomplishment, even through the setbacks and disappointments, also inevitable realities of every childhood.

And when our own children finally reached middle school and beyond, I remember missing those early years, babies in high chairs at the diner, cutie-pie toddlers learning to play and interact with peers, testing independence from Karen and me, kindergartners and first graders, seemingly awed by their new ability to read the written word.

And for the most fortunate of my generation, there comes a second round of pure joy. It’s when we become grandparents and can see these new kids in our lives. We watch them grow, unencumbered by the direct responsibilities of parenting, left only with a renewed sense of the future through the lives of the next generation.

That was my silent reverie at that school in the South Bronx, watching those kids in the cafeteria. And that was what was on my mind when I thought about how differently these children would experience life than my own children did. For sure, we had our own terrible setbacks—one of ours going through a hellish adolescence, others with very serious medical problems, from meningitis to severe infections and accidents, and the ultimate unspeakable sorrow of losing one of our gorgeous children in a terrible accident.

But no matter what we had to cope with or grieve for or adapt to, there was never a moment when we doubted the possibility of our children being able to envision a future of accomplishing almost anything they dreamed of.

Could six-year-old Michael Redlener, a talented Little League and, later, high school pitcher and first baseman who loved the New York Yankees, ever have a real shot at playing major league baseball? Not really. But he could dream about being a historian, majoring in the subject at a prestigious liberal arts college. And he could envision himself changing his mind, getting into medical school, and becoming a highly respected emergency medicine doctor. He did that. He could see himself married to the love of his life, a successful woman, also a doctor, and raising his own children, Naomi, Aaron, and Sam. He did that, too. And David, who became a lawyer, married Judith, and had two wonderful children, Caleb and Mia. That happened. And Stephanie, who married Arthur, brought Alia into our family, and gave birth to the irresistible Auren. All of that happened as well. What’s more, the whole cluster of Redlener grandchildren will have a good shot at achieving their dreams and fulfilling the potential they were born with. That’s good, of course, and I’m grateful that they’ll all have the opportunities that have been brought to them on six little silver platters

And then there are the children of P.S. 140. They, too, like my own children, were laughing and dreaming, their faces filled with joy, even though the rest of the day might not go so well. More than 20 percent of these children would return to a homeless shelter after school, some having been in facility after facility for a year or more, many being raised by a single struggling parent. Some would miss school because the shelter’s single washing machine was on the blink and they didn’t have a spare set of clean clothes; others would be absent because their asthma was acting up and they couldn’t get to the doctor, or they had severe pain from a dental cavity and Mom couldn’t find a dentist that would take Medicaid, the government-issued health insurance that reimbursed so little that few practicing dentists would accept poor children as patients.

Children at P.S. 140 may have been dreaming, but their moms were struggling to find housing and secure nutritious food. College? A career? A decent job eventually? Nearly every parent of every homeless child wanted those aspirations to materialize for their children; very few could imagine how any of this could happen.

“So, Shandra,” I once asked a twenty-eight-year-old mother of two children, “What do you hope for your kids?”

“Mostly, right now, that they get home safely from school,” she said. “If they go down the wrong street and run into one of the dope gangs, there will be trouble. I worry about that every day. I usually try to get to school and walk them home. But when I am working—which I need to do—I can’t always make it.”