In the latest episode of In Pursuit, host Patrick Seed, MD, PhD, discusses with Michelle Macy, MD, MS, the genesis of her research into child water safety and injury prevention, as well as the risk factors that contribute to accidental drowning. Dr. Macy also explores the deep-rooted, historical barriers to swim safety in Chicago, and shares how research can guide our response to this alarming public health and safety issue.
Host: Patrick C. Seed, MD, PhD, FIDSA, Attending Physician, Infectious Disease; President & Chief Research Officer, Stanley Manne Children’s Research Institute; Children’s Research Fund Chair in Basic Science; Professor of Pediatrics (Infectious Disease) and Microbiology-Immunology, Northwestern University Feinberg School of Medicine
Guest: Michelle L. Macy, MD, MS, Attending Physician, Pediatric Emergency Medicine; Associate Professor of Pediatrics, Feinberg School of Medicine; Director of the Smith Child Health for Outcomes Research and Evaluation Center, Stanley Manne Children’s Research Institute; Scientific Director of the Community and Population Health and Outcomes Pillar, Manne Research Institute. Dr. Macy also holds the Mary Ann and Jay Milburn Smith Research Professorship for the Director of Child Health Research.
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Childhood Injury Prevention Focus
Macy’s research focuses on the complex science around childhood injury prevention. She says after the first year of life, unintentional injury is the leading cause of death. The CDC estimates that a child dies from unintentional injury every minute. Macy says for each child death, there are about 30 kids who are hospitalized and nearly 1,000 emergency department visits. And one in five deaths in childhood are attributable to unintentional injury.
Water Safety and Its Complexities
Much of Macy’s recent research on this topic is related to water safety. Macy explains that drowning has taken the lead over motor vehicle collisions as the leading cause of death for one to four-year-olds and this is a much bigger problem than simply learning to swim. In younger children, unintentional access to water is often the culprit; in older children and teens it shifts from pools and home injury to accidents that occur in bigger open water situations. Those cases require that children not only know how to swim but recognize dangerous waves and currents.
Addressing Inequities in Drowning Rates
Through her research with the Metro Chicago Water Safety Task Force, Macy has discovered, especially in the adolescent age group, inequities, with Alaska Natives, American Indians, as well as black populations drowning at significantly higher levels in the Chicago area.
The Voices of Child Health in Chicago Survey
Macy explains the importance of the Voices of Child Health in Chicago survey, a parent panel survey that is administered tri-annually to families from each of the 77 community areas throughout Chicago to help understand perspectives of families and is a valuable resource for researchers studying various health threats.
Shifting Focus in Injury Prevention
Through ongoing research projects with Dr. Sadiqa Kendi, Macy focusing on moving the field of injury prevention away from individual behavior change to considering social, societal, and structural factors and then the intersectionality of individual characteristics within the context of their family and community and how all of those come into play in terms of creating environments that have more or less safety.
Encouraging Results from Swim Skills Pilot
Macy describes a pilot project she is working on in Evanston, IL which is teaching Black boys and girls, 3rd to 8th grade, swim skills. In the first session of the program 45 kids who had fairly limited swim skills took part and by the end of the summer, 77% were able to do 15 skills that could help save them if they get into a situation where they're in the water unexpectedly. The program is aimed at older kids to “catch up” with peers who had earlier opportunities to learn to swim.
Why Community Input is Essential
Input from community members is key to the success of such programs. Macy says some of the best “aha” moments she’s had as an investigator is through conversations with people who struggle to get their child up-to-speed on swimming. She says those lived experiences are essential in helping her team think of creative ways to provide solutions.
Balancing a Career in Research and the ER in Chicago
Macy’s says her work in the emergency department is reinvigorating and provides a nice balance to her research. She says working in Chicago is also important to her research because the city provides different segments of the population and forces her to team to develop interventions that work for a diverse group.
Read the transcript
[00:00:00] Patrick Seed, MD, PhD: This is In Pursuit, research perspectives from Ann & Robert H. Lurie Children's Hospital of Chicago. I am your host, Dr. Patrick Seed, President and Chief Research Officer of Stanley Manning Children's Research Institute, one of the nation's largest freestanding pediatric research centers. My guest today, Dr. Michelle Macy, focuses on the complex science around childhood injury prevention. Michelle is a Pediatric Emergency Medicine Attending Physician and Associate Professor of Pediatrics at the Feinberg School of Medicine. In the Stanley Manny Children's Research Institute of Ann and Robert H. Lurie Children's Hospital, she serves as the Director of the Smith Child Health for Outcomes Research and Evaluation Center and the Scientific Director of the Community and Population Health and Outcomes Pillar. Michelle also holds the Mary Ann and Jay Milburn Smith Research Professorship for the Director of Child Health Research. Welcome Michelle. Thanks for joining me on today's episode.
[00:01:00] Michelle Macy, MD: Thanks for having me today, Pat.
[00:01:02] Patrick Seed, MD, PhD: Today I really wanted to focus on child safety and unintentional injury prevention, particularly water safety. And it's really remarkable how much of child safety issues seem invisible. When people hear the magnitude of the problems, however, in sheer numbers, most people go. Wow, I never knew. And don't think about the comparability to health problems that we think of every day, right? That seem more matter of fact. So can we just start with you telling our listeners about scope of child safety problems?
[00:01:31] Michelle Macy, MD: After the first year of life, unintentional injury is the leading cause of death for children and it changes in terms of which unintentional injury mechanism is leading that, but in total, unintentional injuries outpace cancer, pneumonia, heart disease, and other things that receive a lot of research attention and focus as things that we can be striving scientifically to make progress and gains towards. And instead of getting down to the cellular level with injury prevention, we really need to look at these complex systems, but they're complex systems of how we have our society and built environment and safety nets in place to be able to prevent these kinds of outcomes for kids. The CDC estimates that a child dies from unintentional injury every minute. For each child death, there are about 30 kids who are hospitalized and nearly 1,000 emergency department visits. And one in five deaths in childhood are attributable to unintentional injury. Unintentional injury has really been something that I've been interested in because it's such a preventable cause of death. And we've seen tremendous gains in the course of my lifetime in terms of the number of kids who are dying from car crashes and drownings and other common mechanisms. But in the last decade or so, those downtrends have really flattened, and I think we have seen that we can make differences, and we need to figure out what we need to adjust to continue to drive towards zero deaths across these common causes of injury for kids.
[00:03:11] Patrick Seed, MD, PhD: Summer does bring out a particular focus on water safety. And so I think it comes to top of mind for parents and certainly public health individuals and health practitioners of different kinds. So, we know the sheer number of bad injuries and deaths due to water related injuries. I think a lot of people sort of look at this problem and they say, Well, it's a pretty simple problem, right? It's a lack of swimming. This is a messaging problem, an awareness problem and things. Can you talk a little bit about all of the subtleties that go beyond sort of just, this is just a communication problem of us getting the message out that people need to learn to swim.
[00:03:47] Michelle Macy, MD: It's a much bigger problem than simply learning to swim, and it's a problem that changes across different developmental stages for kids. And drowning has taken the lead over motor vehicle collisions as the leading cause of death for one to four year olds, and in that age group, there's a lot to preventing access to water and that can be water from a kiddie pool that you put in the backyard to cool people off and then forget is back there and a toddler trips into it and can't right themselves to being on vacation in a vacation home that doesn't have four sided fencing and toddlers gaining access to a pool when nobody thought that swimming was going to be happening. Then we get into the teenage years, that's another point at which we see a bump in the number of kids who are fatally injured by drowning. And it shifts from pools and home injury to being a bigger open water situation. And with that, in addition to knowing how to swim, knowing how to recognize dangerous waves and currents and not getting into circumstances where trying to be a rescuer turns into a situation where you become a victim becomes more important. And that's another spot that we see with adults, they'll sometimes go in to try to help someone else and then are able to rescue a child, but then fall victim to a drowning death.
[00:05:16] Patrick Seed, MD, PhD: It sounds like a lot of those are, sort of, far less appreciated risks for drowning you just described, I think such key innuendo about the developmental stages, and I can imagine that then now when we translate that to the public health context of, how do you message and prepare people? You're talking about completely different campaigns to get people on the same page about how to then prevent the injuries.
[00:05:39] Michelle Macy, MD: Absolutely, and one of the things that I've really started to focus on in the last couple years since moving to Chicago. A group of activists and first responders and water safety experts have come together to create the Metro Chicago Water Safety Task Force. I've been thinking a lot in particular about that adolescent age group and the inequities that we see with Alaska Natives and American Indians, as well as black populations drowning at significantly higher levels. We've learned through some of our research that there are some intergenerational factors and historical factors where if a parent and a family doesn't have swim skills and experience and they've lived in a community that hasn't had pools or access to swim lessons, then kids are getting out of their early childhood in that point where it's sort of expected that you learn to swim and then going into adolescence without having those skills and maybe not having a way to attain those skills.
[00:06:43] Patrick Seed, MD, PhD: Those are really key aspects of being in an environment that not surprisingly raises the point of, are you educated? Do you have access? And, do you have awareness? You've looked at trends around , that structural access and, public pools , and the differences between different neighborhoods really even having the ability to learn to swim or to experience water and such.
[00:07:07] Michelle Macy, MD: Yeah, and I credit a lot of my getting into learning more about this to focus groups that we conducted with community members in the Jackson Park area. When we had those conversations, they talked about drowning that kicked off the race riots of the red summer. So that history even a hundred years later was very present in the minds of community members, and they tied that drowning death to not having a pool be part of their community. And then their experiences as kids growing up in that area. The YMCA would offer one hour group lessons once a summer and they were really reflective on the fact that you can't really gain those skills with those infrequent touch points. That got me to read Jeff Wiltse's book Contested Waters, which provides this really fascinating history of public swimming pools in the United States. I think if people are interested in learning more, I'd recommend really understanding that history and the origins of swimming pools as bathhouses where there was mixing of different racial groups with segregation initially around gender. And then as recreational swimming came on in the 30s and 40s, there was segregation that was race based and income segregation really led to some of the inequities that we see today and drowning.
[00:08:39] Patrick Seed, MD, PhD: So it sounds like you really see threads that are drawn from that historical past even across all these generations you still see people somehow reflecting that past.
[00:08:51] Michelle Macy, MD: Yeah, it's been interesting to tell people about this work. I come at this from a position of being a kid who grew up a couple miles from Lake Michigan. And so I've got early memories of being like a two, three year old getting swim lessons and that's always been part of my life experience. And I went on to be a swimmer and a water polo player and a lifeguard, but I tell people, adult colleagues that I'm doing this kind of research and they're like, I never learned how to swim and my parents never learned how to swim. How could I even begin to learn? how to swim in as adult? So I think there are some conversations that lead me to believe that we've got these intergenerational pieces. We've done a few surveys with the Voices of Child Health in Chicago, and we do see some signal of parents who are Black and Hispanic saying that they didn't have access to formal swim lessons at much higher rates than our white parents who say that that happened less than five percent of the time. And we're seeing some progress in that the Black and Hispanic children are getting swim lessons more than what their parents had, but still about half of what the white and Asian families in our surveys have reported.
[00:10:09] Patrick Seed, MD, PhD: Can you tell people about that survey mechanism a little bit so that people sort of appreciate the breadth and the comprehensive set of parents who are offering their information to help researchers, like you, then guide next steps and even guide public health decisions.
[00:10:24] Michelle Macy, MD: The Voices of Child Health in Chicago is a parent panel survey that is administered tri-annually to families from each of the 77 community areas throughout the city. Assuring that we hear from families in all of these community areas and families who are demographically representative of the population of Chicago. It's been a tool that's been useful for investigators who are interested in leading health threats, such as mental health and gun violence, as well as helped inform some of the work of the Chicago Department of Public Health and the Voices of Child Health in Chicago is looking to expand to also be able to understand perspectives of families throughout the state of Illinois in the future.
[00:11:13] Patrick Seed, MD, PhD: Terrific resource for sure. When you think about your colleagues who are in this space, what are some of the big questions that you often are all debating that are, potentially the most impactful in the space of water safety, and other areas of injury prevention?
[00:11:26] Michelle Macy, MD: Yeah, one of the things that I'm really excited about is work that I've been conducting with Dr. Sadiqa Kendi and we're really trying to move the field of injury prevention from the focus on individual behavior change and individual educational interventions and thinking more holistically of all of the social and societal and structural factors. And then the intersectionality of individual characteristics within the context of their family and community and how all of those come into play in terms of creating environments that have more or less safety. For folks who experience an injury, how their local communities and emergency systems are able to respond. And then as folks go through a recovery period, if they have systems in place to help them with the physical healing, as well as the emotional healing that's important for an entire family after a child's injured.
[00:12:29] Patrick Seed, MD, PhD: If you think on a community level, is anybody doing better than someone else because of a particular effective program?
[00:12:36] Michelle Macy, MD: Drowning prevention has really been understudied in the United States, but there are important examples from Bangladesh where they've developed programming for survival skill acquisition. Teaching kids through school based programs and community based programs to be able to enter water unexpectedly, get themselves up to the surface to be able to float, and then get to safety. And so there are cost effective programs that have been demonstrated in other parts of the world. And that is something that we're working on doing some pilot work in Evanston and understanding how the Camp Kuumba program for Black boys and girls is really being able to teach them swim skills. We've got our first summer worth of data collection just in, and the team who's coaching these kids and instructing these kids went in with about 45 kids who had fairly limited swim skills, and by the end of the summer, 77% of them were able to do 15 skills that are going to be able to help save them if they get into a situation where they're in the water unexpectedly.
[00:13:51] Patrick Seed, MD, PhD: Fantastic. If that's successful, is that something that you can see that would be pretty scalable for public health measures?
[00:13:57] Michelle Macy, MD: That's part of what we're going to be looking at with this pilot. And I think one of the unique features of the program is it is working with children who are entering third through eighth grade. So it's that group of kids that we were talking about earlier who might've missed that window where it was socially expected that you would learn how to swim and giving this opportunity for them to really gain those skills over the course of three weeks. And I think in a lot of ways, catch up with peers who had earlier opportunities to learn to swim.
[00:14:30] Patrick Seed, MD, PhD: These are one of the quote, it takes a village types of problems, right? And I think your research is an exemplar of that. It's really multidisciplinary. It pulls from medicine and public health, education, and there's even design aspects,
[00:14:43] Michelle Macy, MD: It's, you know, got the features of being cost effective, et cetera. How do you navigate and sort of integrate these different fields into your work? I think that being able to take this zoomed out view of the whole picture and bring the different constituents together to think about how all those moving parts can intersect and where there's overlap and where we can help carve out areas, where one group can really take a bigger lead and another group can be focusing on a different activity has been helpful.
[00:15:22] Patrick Seed, MD, PhD: Who are unsung heroes in this? Who are the people that are part of the teams that make this happen that we don't often hear about but are keys to the secret sauce, so to speak.
[00:15:31] Michelle Macy, MD: Yeah, I think that the academic team members are ones that we often focus on when we're thinking about research, but being able to have the opportunity to hear from community members who are going to be implementing or advertising or tweaking the programs that we develop in an academic context is really important. Because without those perspectives, we can be in an academic way, designing something that makes perfect sense to us, but then when you get it out into that community context you've missed a few steps because you didn't have the group in at the start. The coaches and instructors, the parents, the kids themselves are really important voices to understand. Some of the best aha moments I've had as an investigator is through conversations with people who are having that lived experience having their kid try to find swim lessons that are available or overcoming a scary experience that a kid had early on with swimming and pushing through and hearing from their stories gives us new ideas as an academic team of angles and perspectives that we need to be looking at these problems and thinking about creative ways that we can provide solutions.
[00:16:51] Patrick Seed, MD, PhD: Tell me about being an emergency room physician. How does this change your perspectives, renew your perspectives, drive you?
[00:16:58] Michelle Macy, MD: I love being in the emergency department and being able to help patients from the I'm worried about this hiccup that my baby had, but everything's going to be okay. To the more critically ill and injured patients that are really the source of a lot of my inspiration for the research that I do. Being in a trauma bay with a family who's had a child who I know we've got preventive strategies that could have kept them out of that situation, has been a big motivator for the areas of research that I focused on. And I think you tell people you're a pediatric emergency department doctor and they're sort of like, Oh my gosh, I'm so sorry. And it's really a wonderful place to work and a big opportunity for us to serve everybody in our country, whatever background they're coming with. It's a very reinvigorating space and provides me a nice balance to the research. I think research kind of moves on a pace that sometimes feels like a glacier and the emergency department is always hot and hopping. And I think helps keep for a balanced career to be able to be in both of those environments.
[00:18:10] Patrick Seed, MD, PhD: Being a researcher in Chicago, how does that change or influence your research?
[00:18:17] Michelle Macy, MD: Chicago really brings the entire spectrum of diversity. From linguistic diversity to racial ethnic diversity as well as economic diversity. And I think that that's really important for this type of work because a solution for an affluent community might not be helpful for a population that has recently come into this country. So we really need to have those different segments of the population to be able to holistically think about making sure that all populations are benefiting from the interventions that we develop.
[00:18:54] Patrick Seed, MD, PhD: Those are such great points. We often talk of precision medicine. It's really precision public health, right?
[00:19:00] Michelle Macy, MD: I think it's a great point about precision public health and the broad public health measures of legislation and education are what have been able to help us get from where we were in the 70s to where we were in the 90s, but I do think that that precision approach is going to be important for us to continue to keep driving unintentional injury deaths down.
[00:19:23] Patrick Seed, MD, PhD: I think we see the ebb and flow of our society trying to fit everybody into the same form, the same container, the same likeness and I think the more we as researchers study things, the more we realize that that doesn't work. It doesn't work with everything from behavior to public health to infrastructure to biology, right? It's such a common lesson across all the things that we study in the Manny Research Institute. Well, I certainly know Michelle, we could go on for a long time with this conversation. It's so interesting to talk to you. I want to thank you so much for joining me on today's episode.
[00:19:57] Michelle Macy, MD: Thanks so much for having me, Pat.
[00:19:59] Patrick Seed, MD, PhD: For more information on Stanley Manning Children's Research Institute at Ann and Robert H. Lurie Children's Hospital of Chicago, visit our website, research.luriechildrens.org.