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Good afternoon.

Such great energy in this room.

Good afternoon and welcome to the City Club of Cleveland, where we are devoted to conversations of consequence that help democracy thrive.

It's Friday, August 28th, and I'm Celina Cunanan, Chief Health Impact Officer at University Hospitals, and proudly serve on the boards of both First Year Cleveland and here at the City Club.

I am honored and excited to introduce today's forum, which is presented in partnership with William J. and Dorothy K. O'Neill Foundation.

Today we have the privilege to hear from Dr.

Mona Hanna, Director of RxKids and Associate Dean for Public Health at Michigan State University's College of Human Medicine.

The last time Dr.

Hanna joined us at the City Club, it was 2018, a few years after her research exposed the Flint, Michigan water crisis.

She was named to Time Magazine's 100 Most Influential People in 2016, and her dedication to our nation's youngest and most vulnerable has not wavered since.

Once again, Dr.

Hanna was named a Time 100 Health recipient, this time for her work launching RxKids, the nation's first-ever community-wide prenatal and infant cash prescription program.

Launched in 2024 and serving more than 15,000 families, this public health initiative is built upon the foundation of trusting mothers and addresses infant mortality with a bold approach.

Mothers receive $1,500 during pregnancy and then $500 each month for the baby's first 6 months, no strings attached.

Now RxKids is coming to Cleveland.

It is the first expansion city outside of Michigan, and we'll hear more about what the program is and some of the outcomes here shortly.

What I will note is that this expansion comes at an important time.

While Ohio's infant mortality rates are declining, Cleveland continues to face a significant disparity with an infant mortality rate roughly twice the state average.

Moderating today's conversation is Angela Newman-White, Executive Director at First Year Cleveland.

Angela brings— Angela brings 2 decades of public health experience focused on addressing inequities in maternal child health, particularly to reduce infant mortality among Black babies.

Under her skillful leadership, First Year Cleveland will be the community championship— champion for RxKids here in Cleveland and will oversee community outreach, family engagement, and collaboration amongst local organizations and institutions to ensure that eligible families receive aid.

A reminder for our livestream and radio audience: if you have a question during the Q&A portion of the forum, you can text it to 330-541-5794, and City Club staff will try to work it into the program.

Now, members and friends of the City Club of Cleveland, please join me in welcoming Dr.

Mona Hanna and Angela Newman-White.

Oh, good afternoon, everyone.

Like Dave said, I didn't know there was going to be so many people in the room.

But I am so grateful because this is a testament to the community's commitment to reducing infant and maternal mortality, not only here at a local level, but thinking about at the state and national level.

On behalf of First Year Cleveland and Case Western Reserve University, and our partners at the city, county, health systems, community partners, but most importantly, the families that we serve.

We want to welcome back Dr.

Mona Hanna-Attucks to the City Club of Cleveland.

Dr.

Hanna did— had an opportunity to speak with us at the City Club in 2018 when she released her book, What the Eyes Don't See.

And I think that is the perfect title to not only describing the lead crisis in Flint, but also the realities that families face here in the city of Cleveland.

And so I'd like to start this conversation by asking you, Mona, what have you been up to since you solved the lit crisis?

Thank you, Angela.

And thank you for this opportunity to come back to Cleveland.

I love Cleveland.

I love all of you.

Thank you.

It's wonderful to be back here.

So yeah, it was about 8 years ago-ish that I was here on a book tour.

I wrote a book that I thought nobody would read, but amazingly, folks read it and continued to read it.

And it was called What the Eyes Don't See.

And it was the blindness that really brought forth the Flint water crisis.

Kind of people knew what was happening, but they looked away when an entire city and an entire population of children were drinking poisoned water.

But it wasn't a story so much about a crisis, but it was a story of resistance.

Refusing to accept the status quo.

We as a community, just like this beautiful community, stood up and said no.

Like, our babies deserve more.

We can do better.

And it's a story of fighting back and building hope in a community.

So for the last 10 years, since kind of blowing the whistle, I have not stopped working in our recovery.

Trying to reimagine how to be more prevention-driven, more child-centric, more evidence-based.

Because some of those were some of the biggest lessons of the Flint water crisis.

We had to react to a crisis that never should have happened.

Children were not at the center, were not part of conversations.

And science was attacked, and the voice of scientists was denied.

So since then, we have really tried to put into place so much awesome in Flint to make sure that our kids have the resources they need, not just to recover and thrive.

So we've invested in things like Dolly Parton's Imagination Library.

So another round of applause for Dolly.

So it's amazing that you guys have this for the whole state, right So that was— Flint was the first place in Michigan to have the Dolly Parton Imagination Library program.

It was the first grant I wrote to make sure kids had those books.

And now we have mailed hundreds of thousands of books to Flint kids because of that investment.

So we put into place all of these things that we know are good for kids, like literacy programs, and wraparound services, and trauma-informed care, and home visiting programs.

And we opened 2 brand new child care centers, and breastfeeding support, and nutrition programming, and expanded early intervention.

All of these things that you all do that we know are really important.

For kids and families.

And our work was not just about Flint and its recovery, but it was also about making sure that Flints never happened again.

So I came back to Cleveland and worked on lead prevention programs here.

And I know that you guys all as a city have done more work in making sure that kids aren't exposed to lead.

We helped pass the Infrastructure Act, which was the largest federal investment in water infrastructure, included $20 billion to replace lead pipes across the country, which is amazing.

Strengthened other laws, but really have tried to focus the nation's attention on, once again, how can we be prevention-driven?

How can we be child-centric?

And how can we make sure that we follow the evidence and build a nation, build a society that values kiddos?

So that has been my whole work for the last decade, which has kind of led us to RxKids, which we will talk about.

Yes, absolutely.

And that is, you know, no easy feat.

I think what you've been able to accomplish in the state of Michigan not only provides inspiration, but it solidifies the fact that the impossible is actually possible when you have folks at the table that really want to make a difference.

And so here in Cleveland, we've continued to struggle with addressing our lead crisis.

I mean, a little bit different from the pipes, more apparent and evident in the paint.

And so how do we remove all the paints?

And we'll continue to work on that.

But the conversation today, you know, it's going to primarily focus on our infant mortality crisis because this also is a time where some folks are just— it's what they don't see.

There's a lot of assumptions about behaviors that families are expected to implement with the lack of understanding of the difficulties in navigating systems and to achieve those optimal health outcomes.

The city of Cleveland's infant mortality rate, as Celina mentioned, is higher than the county's.

I think the 2024 rate, well, the 3-year rate averaged around 13.5.

But if you look at particular communities across the city of Cleveland, it's over 20, 20 per 1,000 live births.

And so even if there are some communities doing well, we can't look away to say, well, 13 is terrible.

It's terrible.

But when you really take a deeper dive into the direct the communities by zip codes and census tracts, it's even more apparent that we have to look in instead of looking away.

And so when you're working with your pediatric patients and knowing that you've got all these recommendations, right?

And what do you see the needs are?

What did you initially see the needs are for the patients that you were serving?

And how could you help?

Yeah, that's a great question.

It's really frustrating as a pediatrician and as anybody who works directly with families to keep band-aiding.

So much of what we do in health care and social services is band-aiding because we can't go upstream and prescribe what families really need, which is not to be poor.

So, you know, and as a pediatrician, like, Ever since I became a pediatrician, first in Detroit and then in Flint, I have wanted to go into my doctor's bag and prescribe away the pathogen of poverty.

It makes kids and families sick.

And I haven't been able to, but I see the consequences of poverty every day in my clinic, be it developmental delay, prematurity, chronic diseases, asthma, lead poisoning, missed appointments, all of these things that shape health and specifically shape health at a community level, when you keep asking why, why, why, it often goes back to that root social driver of health, which is poverty, economic instability.

So for so long as a pediatrician, I used to shrug my shoulders.

I'm like, I can't— what am I going to do about poverty?

Like, how can I treat poverty?

And it was frustrating, and it was maddening.

And then something amazing happened in our nation in 2021.

Angela, do you remember what happened during COVID in 2021 for kiddos?

What happened?

Yeah, we definitely had— The ARPA dollars that allowed some significant investments in families, child tax credits.

We had renter protections put in place, increased SNAP benefits.

And what we saw here locally and nationally is the outcomes improved.

Who would have thought?

Who would have thought?

So some money— COVID was terrible.

It was a terrible time.

But like, oh my gosh, as a nation, we did better.

We did better in taking care of each other.

And we expanded something called the child tax credit that Angela mentioned.

And we finally became like every peer country in the world, and we gave families monthly unconditional child allowances.

We did it.

We did it.

We dropped child poverty to the lowest level ever in the nation.

It was unreal.

It happened literally within months during the expanded child tax credit of 2021.

This is conversations that folks have been happening for— had been happening for decades.

Like, let's just do child allowances.

Let's be like other countries.

Other countries see Social Security as investing in the old, investing in the disabled, and investing in children.

And we never were really good at investing in children.

So we saw it.

We saw it in our communities.

I saw it in my patients.

Lots of incredible outcomes happened— more food security, improved health, less stress, less child abuse and neglect.

All these amazing things happened when the expanded child tax credit took effect.

And then something terrible happened after 6 months.

Do you know what happened, Angela, with the expanded child tax credit?

It went away.

It went away.

It went away because of how many votes in the US Senate?

Who knew this was audience participation?

One.

One.

One.

One vote in the US Senate.

Votes matter.

One vote.

You have a big election.

One vote.

One vote.

And the expanded child tax credit was not renewed, and millions of children went back into poverty, and those outcomes all reversed.

So seeing this as a pediatrician, having so much hope and excitement, like, yay, we became like other countries.

This is not far-fetched.

We can do this.

We can do hard things.

And having that all go away and having all those outcomes reversed was an inspiration.

Like, that we can do hard things.

We can do things at scale.

We don't have to be OK with status quo.

So in the same spirit that Flint was not OK with poisoned water and we fought back, we decided as a community, listening to our mamas and our families who continuously tell us how hard it is to get by— like they say, thank you for all these amazing programs that you put into place, but we can't make our ends meet.

OK?

We don't need another this program, this program.

We just need not to be poor.

So that was really the inspiration as a pediatrician to do something big and to learn and to keep— and to do something at a scale that would keep this work in the public imagination so that we could then get back to the point of renewing things like the expanded child tax credit.

Now, is that not amazing, right?

I mean, she's stating facts.

I mean, I think at least from First Year Cleveland's perspective, You know, we were so excited when the, when the rates went down.

And then in 2023, when they shot right back up, you know, some folks were looking at us like, well, what are you doing?

And I was like, trying to solve poverty, but we can't, right?

This is— it seems impossible.

And especially when we also have the challenges around the, the lack of access for paid leave.

And we've been thinking about, at least at our— in our office, about ways to how can we get cash to moms?

And so we were absolutely over the moon when we were contacted by the O'Neill Foundation to think about, hey, have you heard about RxKids?

Is this something you can do?

And immediately we were like, oh yes, we're gonna, we're gonna make this happen.

And not just from my perspective, but knowing that we've had these longstanding commitments from our partners, these folks across all sectors that support not only the work of First Year Cleveland but represent what we all represent here.

Was fully confident that we were going to make it happen.

And it's going down.

You did.

And so I'd like to talk a little bit about what you've been doing with RxKids in Michigan and the outcomes that you're— that's actually— and it's only been 2 years.

Now, let's be clear.

It's only been 2 years.

And your mind will— be prepared.

It's about to be blown.

So RxKids, so what is it?

So it is the nation's first community-wide mom and baby cash prescription program.

So we call RxKids a prescription for health, hope, and opportunity.

Every pregnant person in an RxKids community gets $1,500 after mid-pregnancy.

So it's a one-time lump sum of $1,500 in mid-pregnancy.

And then once a baby's born, it's $500 a month.

So it's a super, super time-limited program, laser-focused on moms and babies.

So why is it laser-focused on moms and babies?

Like, I wish it was like the child allowance in all countries and the expanded child tax credit that went to the age of 18, but that would be a lot of money to raise.

But we can do that too.

But it is laser-focused on moms and babies because it turns out that the maternal-infant period is the poorest in the entire life course.

In pregnancy, moms often have to come out of the workforce, so there's a drop in income.

We are one of only 6 countries in the world that has no national paid leave policy.

No paid leave.

One of the inspirations for RxKids came from seeing a patient before we launched.

It was a 4-day-old that was coming in for a newborn visit.

And I love newborn visits.

They're so, so fun.

And the 4-day-old was a preemie, had a low birth weight, and really needed to come in to see us to check on weight and see how the baby was feeding.

And the baby was a no-show.

They didn't come into clinic.

And so my amazing staff finally got a hold of the family and got a hold of the mom.

4-day-old, remember?

And the mom said, I had to go back to work at 4 days.

Half of American moms go back to work at 2 weeks after birth.

That is not okay.

That is not okay.

So income drops.

We have no paid leave and babies are expensive.

So having a baby where it's It's estimated that first year of life is an added $20,000 in expenses from healthcare expenses and copays and transportation and childcare is impossible and diapers and diapers and diapers and diapers.

So many people are not having children.

But also families are then making impossible choices.

Do I go to the doctor or do I go back to work?

Do I pay for rent or do we not have heat today?

So the maternal-infant period is the poorest in the whole life course.

So that is why this program is just laser-focused on moms and babies.

And I know there's a lot of other pediatricians and scientists here.

It's all— and early childhood superstars.

This is also the most consequential time in a child's life.

The most consequential time.

What happens in utero, what happens in those first few months of life shapes an entire life course.

We have learned so much about early adversity and toxic stresses and that this is a period of life where we should be smothering our families with goodness and resources and creating this nutrient-rich environment to make sure that they can be healthy.

We know that investments in this window pay dividends for generations to come.

So RxKids is just laser-focused on this maternal-infant period, which once again is the most economically unstable, and also the most consequential when it comes to health and development.

So we launched the program in January of 2024 in Flint, Michigan, where I practice.

And at Michiganders, we always hold up our hands.

I know there's Michiganders in the audience.

So here's Flint, kind of in the middle of the state.

And Flint's a small big city.

We have about 1,000 births per year.

But we also are this engine of innovation.

What we do there, we really try to share with others.

Places throughout the nation that are suffering from very similar inequities.

RxKids started because of philanthropy.

The C.S.

Mott Foundation based in Flint, Michigan also was tired of band-aiding, also was tired of giving grants to, you know, after-the-fact complications of not treating poverty.

They came in with a $15 million grant.

Amazing.

I mean, give them a round of applause.

Amazing.

Incredible.

We would be nowhere without our philanthropic partners, and another shout-out to the O'Neill Foundation, who was the inaugural funder for our school.

But their grant was a challenge grant, the CS Mott Fund, which meant that you have to go find another $15 million before you unlock this $15 million.

So that got us really busy raising other funds.

We were able to unlock other public dollars, and then fairly quickly we launched in a city of in January of 2024.

And what's unique about the program is it's focused on moms and babies, but it is for everybody in a community, for everybody.

So, so often we talk about place-based disparities.

We talk about how zip codes can predict life expectancies and mortality rates in different places.

But then we knee-jerk create programs for individuals.

High-need individuals, and we do means testing.

Like, you have to be below this certain income, or you have to have a high-risk pregnancy, and that's not what we wanted to do.

We wanted a place-based solution for place-based inequities.

We wanted to do something at scale.

So RxKids is for an entire community, and when something is for an entire community, it's really easy for participants to figure out, like, do I qualify?

'Cause hey, you all qualify.

Everybody qualifies, which is why we've— one of our outcomes is we have a near 100% participation rate.

That's amazing.

Everybody, it's amazing.

Thank you.

Because it's easy to understand.

When something is also universal rather than means testing, it sends a different message.

And so much of what RxKids is, yes, we're eliminating poverty, and yes, we're improving health, but we're also trying to shift a narrative of how we fundamentally care for each other.

We are wearing red.

The logo is a heart.

There's lots of red in the audience.

This is fundamentally a program about love.

This is about how we're supposed to love and welcome our littlest people.

So when something is for a whole community, it's telling— it's conveying things like dignity and deservingness rather than shame and stigma.

There's tons of programs for our families out there to, you know, you're not making it, you don't— something's wrong with you, go sign up for— you qualify for this program.

And that's not what we wanted to share here.

We wanted to tell families that you— like, we see you, we hear you.

It is so hard to have a baby and we are standing alongside you and there's a whole village standing alongside you to make sure that you have what you need during this very difficult time.

So it's universal for a place.

It's this concept of targeted universalism.

So it's everybody is eligible in a place.

And also that makes it really administratively efficient.

And that's one of the kind of strengths of this program and why we've received so much kind of broad support is that we don't have a lot of bureaucracy.

This program is for everybody.

We're not figuring out— there's not lots of staff figuring out who's in, who's out.

It's for everybody.

You know, yes, there are robust verification processes, but it's administratively so efficient.

More than 85% of every dollar goes directly into the hands of mamas and families.

That is a tremendous level of efficiency.

Amazing.

And the other design element that was really critical— and all of this is based on evidence, all this is based on global practices and recommendations— is that the program trusts mamas.

We are trusting women.

Can you imagine?

We are trusting women.

We're trusting families.

So we, you know, we're not— this is not just for food, and it's not just for housing, and it's not just for rent.

This, you know, this is allowing families to best meet their needs because some people need help with rent, and some people need help with transportation, and some people need help with, you know, diapers, and some people need help with paying that last tuition bill so that they can better their career.

So this is allowing families the agency and empowerment to best meet their needs.

So that's kind of the— those were the critical design elements.

It's for everybody in the place.

It's laser-focused on moms and babies, and it's trusting families.

So what have we learned?

You asked about impact.

I'm getting there.

Okay, what have we learned?

So we've learned that everybody signs up, which is amazing, that high take-up rate, and that's kind of unusual.

Most of my career has been like getting people to sign up for stuff, like how do we reach hard-to-reach populations?

It's like, how do we encourage folks to sign up?

And that's not the case with this.

You know, we do marketing, and, you know, there's gonna be materials in OB and pediatric clinics and everything to get people to sign up.

But it's easy to sign up.

The program is administered by the international leaders in cash transfers, GiveDirectly.

Give them a round of applause.

They are incredible.

When we, when we knew that we wanted to eliminate poverty at scale, and like, I'm a pediatrician, and I teamed up with this amazing child poverty expert.

Like, whoa, I don't know how to give people cash.

Like, I don't know how to do that.

I literally don't know how to prescribe cash.

And we didn't want to reinvent the wheel, so we went with the experts in this field, the nonprofit GiveDirectly, who do this around the world.

They already had the systems built for enrollment and verification and safeguarding and fraud detection and getting mamas the cash quickly and safely and securely.

So enrollment is easy.

Mamas go online at rxkids.org.

It's mama-tested.

Everything we did was hand in hand with our mamas.

It takes about 20 to 30 minutes to apply.

They upload verification documents, and then they get their cash.

So in other programs in this maternal-infant window, like WIC, WIC has about a 50% sign-up rate.

Home visiting programs have about a 20 to 30% sign-up rate.

And once again, we have a near-universal sign-up rate.

And what we're also seeing is that once folks sign up for RxKids, they're more likely to then take up all the awesome other things in the community.

Because poverty robs people of time and bandwidth and energy and trust.

And what we're seeing is that when we have a little bit more economic stability, there is more of a breathing room.

We hear all the time from mamas, I can breathe.

I can wake up in the morning and I know it's gonna be okay.

A weight's been lifted off my shoulders.

So then, and there's more trust.

In our research, we also see more trust in government and more trust in healthcare.

So they're more likely to take up all the other stuff.

So first outcome, first impact finding is a great participation rate.

We're also seeing that 90-plus percentage of mamas sign up in pregnancy.

So they're getting the, they're getting they're getting the benefits of that prenatal dose.

What we're also seeing is more prenatal care.

So despite really national trends of a decrease in prenatal care, especially in the first trimester, we're seeing earlier prenatal care.

We're seeing more often prenatal care.

When mamas are going to more prenatal care, they're getting more education.

They're getting more services.

They're getting more diagnoses and preventative services.

So in Flint, we're actually seeing an uptick in diagnosis of gestational diabetes and hypertension.

And it's getting closer to the state rate.

So these are— we're not seeing more cases.

We're just seeing more diagnoses because of more access to care, because they didn't have access to care before.

We're seeing less smoking with our mamas.

And we think that's because of less stress and more access to prenatal care and the awesome services.

And these are population-level outcomes.

Because we have full saturation of the population, we can use, like, really high-quality data like birth certificate data, vital records data.

So more access to care, better healthier behaviors.

And then the beauty of this work is that we're seeing healthier births, healthier babies.

So at a population level, we're seeing a decrease in premature babies, a decrease in low birth weight babies, a decrease of almost a 30% decrease in NICU admissions.

This is incredible.

From a simple, simple, simple intervention.

We also are seeing early findings of improvements in neonatal mortality.

Neonatal mortality is death within the first month of life.

And early neonatal mortality is death within the first week of life.

We have a 75% decrease in early neonatal mortality.

Yes.

And a 50% decrease in neonatal mortality.

And it all makes sense because those are largely driven by prematurity and low birth weight.

We're seeing a decrease in child welfare involvement.

So the CPS system— the peak age of involvement in the CPS system is the first year of life, more than double any other year, and largely related to that economic instability of that time period.

Families are investigated, which is so traumatic.

If a baby is taken out of their home, often they're in foster care until they're 18.

That's also very expensive for society.

And we're seeing a prevention, a 32% decrease in investigations of infants in the child welfare system.

So all of these amazing outcomes, and there's more.

Oh, maternal mental health is a big one.

A decrease in postpartum depression, less stress, less anxiety.

Also improvements in positive well-being.

Mamas feel more loved, which is yay!

Mamas feel more loved, more respected, more empowered, more trust.

I mentioned that earlier.

So lots and lots of outcomes.

Check out our website, rxkids.org.

We also have a dashboard, which is my favorite thing on the website, that updates every day at 2:00 AM.

So if you're up at 2:00 AM, you can go to the dashboard, and you can see how much money has been prescribed.

I just checked earlier today.

I think $55 million has already been prescribed.

Incredible.

To over 15,000 families.

So after RxKids launches next week in Cleveland, you can check that dashboard and you can see the dollars that are going out the door and where they're going.

Yes, I know this is all so amazing and so exciting, and our cheeks have been hurting from smiling for the last 3 months.

But, you know, what's most exciting about this work is it is place-based.

You know, Cleveland has been working tirelessly around this model of collective impact, and shout out to the Place Matters folks out in the room that really understand the that whole community strategy implementation that is rooted in the feedback and lived experiences of families is where you make the greatest impact.

And so we've seen that, you know, early on years ago, shout out to all the partners that are involved in One Community that's being led by the Neighborhood Leadership Institute, you know, in the zip code 044128 that was experiencing, you know, averaging like 10 deaths a year.

We brought the whole community out, had everybody involved, and And during that time, no baby died.

And so we saw that this works.

And so as Dr.

Hanna mentioned, despite the amazing menu of services that we do provide, there are a lot of restrictions with high-fidelity evidence-based models.

And so what's unique about the RxKids Program is it's for everybody.

And so we have, using some of the data, the vital statistics data and child poverty, data, selected 3 zip codes in the city of Cleveland, all of which have an infant mortality rate higher than 22 per 1,000 live births and a child poverty rate of over 25%.

And so those zip codes are 44103, 44110, and 44114.

Angela, say them again.

What are those zip codes?

44103, 44110, and 44114.

Our goal is to, of course, serve the entire city of Cleveland, but we're starting there because place matters.

We're focusing on these zip codes initially that are of greatest need.

And as we continue to raise funds, we will continue to expand and add more zip codes.

And we're hoping— these are also zip codes when you talked about the hypertensive disorder in pregnancy.

Some of the research coming out of our work with Partners for Change has identified over a a 700% increase in hypertensive disorder in pregnancy for pregnant women.

And in these communities, in these 3 zip codes, 1 in 3 women has high blood pressure that leads to prematurity.

And high blood pressure is greatly impacted by your stress level.

And so this is an opportunity for us to have community-level impact, population-level impact, and hopes that this is going to continue to spread not only throughout Cleveland but across the state of Ohio.

So I have one last question before we move to the audience questions.

I mean, why Cleveland?

Why are we the first?

The first, and definitely not the last, but why?

Why not Cleveland?

Thank you.

Of course Cleveland.

Of course Cleveland.

Of course.

So RxKids started in Flint, but we're now in 60-plus Michigan communities.

In the city of Detroit, which is ginormous.

We are in the entire Upper Peninsula of Michigan, so it's an urban and rural solution.

So in Michigan, we're serving about— about to serve about 25,000 babies a year for the next 3 years, which is about a quarter of all of our babies.

So we have had massive expansion in Michigan, but from the moment— even before we launched in Flint and really kind of the design of the program, we built it not for Flint.

We built it once again to figure this out so that we could share it.

So from the onset, it was designed to be scalable.

It's just cash.

That's it.

It's the same program in Michigan and Cleveland and Mississippi and wherever we go.

It's the same program, purposeful so that it's easily, you know, shared and has that same fidelity.

So, you know, even before we launched in Flint, we were being contacted from communities across the nation that say, hey, we're also struggling with maternal infant mortality, or with the impossible cost of childcare, or housing stability, or nutrition issues.

And RxKids is like the solution to a polycrisis that families are facing.

And it's plug and play.

It's already built.

It's a national program, but it is locally championed, and we are so grateful to work with Angela and First Year Cleveland and all of the amazing partners, the city, Mayor Bibb, all these amazing folks that are making this program possible here.

So it's— you guys are a special place.

You know this.

You can feel it in this room.

You can feel the energy.

This is a community that comes together and is also refusing the status quo.

Is also saying we can do better.

We don't have to be okay with these terrible rates.

We don't have to keep doing the same thing and expecting different results.

Let us think bold, let us think upstream, and let's come together.

And I think that's what, that's kind of the ethos of Cleveland, and just like the spirit in Flint, and it's, there's no, it's obvious why our first place out of Michigan is Cleveland.

And I know there's like some Michigan-Ohio rivalries, you know, and football season's coming up.

But I think we can all agree we are all on Team Babies, right?

And just a little— just to speak to the rivalry, we are wearing red.

We're wearing red for Ohio.

So let's see Ohio State.

Well, thank you so much, Dr.

Hanna.

We will begin— we're about to begin the audience Q&A.

For those just joining via our livestream or radio audience, I'm Angela Newman-White, Executive Director at First Year Cleveland at Case Western Reserve University and a moderator for today's conversation.

Joining me on stage is Dr.

Mona Hanna, Director and Founder of RxKids, the nation's first-ever community-wide prenatal and infant cash prescription program.

We are discussing the impact of RxKids and what Greater Cleveland can expect with the expansion that is set to take place the beginning of fall on Tuesday, September 1st.

September 1st.

We welcome questions from everyone— City Club members, guests, and those joining via our livestream at cityclub.org or live radio broadcast at 89.7 WKSU Ideastream Public Media.

If you'd like to text a question for Dr.

Mona Hanna, please text it to 330-541-5794.

That's 330-541-5794, and City Club staff will try to work it into the program.

May we have the first question, please?

Hi, my name is Bridget O'Callaghan.

I'm the executive director of Womankind, a free prenatal clinic and maternal care center.

Thank you, Dr.

Hanna and Angela, for all this wonderful information So we're excited for this program beyond words.

Could you share how, with your participation rate, how do you get over the hurdles of no bank account, housing instability, lack of internet to even sign on?

A lot of our clients struggle with these items.

Yeah, that's a great question.

So the— actually, the most housing-unstable population are moms and babies.

It's the greatest demographic in shelters are often moms with young children.

I think 30% of pregnant, low-income pregnant people are housing unstable.

They're couch surfing.

They're, you know, they're in, they're in shelters.

So we, you know, and that they're all still eligible for the program depending on their housing instability.

And one of my favorite outcomes that we saw after we launched was a 91% reduction in evictions in Flint after the program launched, and a greater ability to pay rent, pay back owed mortgage.

Even the threat of eviction to a pregnant person in the community, not even to the person as an individual, but living in a place where there's more evictions in the community increases the risk of preterm labor.

So it's, it's, it's, you know, it's, it's wonderful that that is one of the outcomes of this program.

So families find out about the program most commonly, no matter where we are, but from friends and family, from trusted media, from trusted sources, from social media, and from medical providers.

It is a very simple application.

Most mamas do it on their phone or online.

It takes a very short period of time.

It's translated into other languages.

We also have an RxKids staff who is hired here.

She's a Clevelander.

She's here in the audience.

And today, today is day 2 for her.

So she will have office hours as well.

She'll work closely with First Year Cleveland to make sure that families who need extra support can get that extra support to sign up.

So the— about 80% of families choose to get their cash via direct deposit to a bank account.

For those who are unbanked or choose otherwise, they can get mailed or pick up a reloadable debit card.

We were worried about high rates of folks being unbanked, but by and large, even in our poorest places, there are more— there's a greater percentage of people banked than we thought, but there are options for those families as well.

Dr.

Hanna, I'm Doris Evans.

I would like to thank you for your enormous skill, but even more your huge heart that you've brought to this important work.

I also want to thank I want to thank Mrs.

Newman-White and First Year Cleveland for embracing this opportunity, and I'm certain it will be done consummately well.

My question has to do with follow-up of these families.

But before I get to that, I want to say, Angela, beware an influx of population into 44103, 44110, 44114.

Anyway, seriously, my question is, how will you follow up these families?

Do you think it's important?

And how will you do that?

Thank you so much.

This work is just such a joy, and I pinch myself every day that I can do this work.

So thank you.

And with amazing partners.

But I'm going to continue on your joke about population.

So what we are seeing, or what we have seen in our early findings, is actually an increase in the number of births after the first year of launching.

We think it's threefold.

We think it's migration, maybe.

Maybe less people are leaving the city of Flint.

It's been bleeding people.

And maybe people are moving in.

So this was an increase in births after 25 years of a decrease in births in the city.

So really addressing kind of longstanding population loss.

So we think migration was part of it.

We think also that this program created more viable births.

With a decrease in abortions.

The number one reason people do have abortions is financial, but also a prevention of miscarriages.

And then lastly, we think that more people decided to have a baby.

The greatest increase in births that we saw were for older moms, 30 to 39, first-time moms, and higher-educated moms.

And in our kind of qualitative assessments, a lot of moms who have been delaying childbirth because of the incredible cost of having a baby said, hey, my community is behind me.

Maybe I can do this.

I'm gonna have a baby.

And we know that there's national conversations about a declining birth rate and different solutions about that.

So that's not answering your question, but I thought it was a good moment to talk about population.

So wouldn't it be amazing to have more population in these places, right?

Absolutely.

I know the mayor would be excited about that too.

Follow-up.

Follow-up is very important, and that's part of kind of our you know, our research and the scholarly work that we're doing.

We have something called the RxKids Research Network, and we're so excited to collaborate with academics here in Cleveland at Case Western and other places to be able to answer these questions and to be able to answer these questions with really awesome population-level data, vital records data, education data.

We were gonna be able to look at things like kindergarten readiness.

Of these babies, looking at child welfare data, looking at WIC data and things.

So our hope is that we can partner here in Cleveland, in Ohio— and I had a joy of meeting with some of those researchers yesterday— to be able to do more of this work to not only replicate our work, coordinate the work, and answer some of these longer follow-up questions.

So RxKids is not like a new idea.

It's not genius.

It's not brilliant.

Once again, it's done around the world.

Around the world, societies come along and support families during this critical window.

So it is really built on a global evidence base that when you support families in this time period, it pays dividends and there's improvements in education and health and wealth throughout the life course.

Hi, my name is Shelley Hunt.

I'm a director for New Voices for Reproductive Justice.

As a mother of twins, I was wondering if there has been some consideration for— even though my daughters are adults, is there consideration of mothers of multiples?

Because the biggest discount I've ever had of being a mother of twins is 10%.

That is a great question.

About multiples, we actually just had our first triplets born in the program in Southeast Michigan, but we've had many twins.

And actually, a lot of research shows that financial stability in pregnancy increases the number of twins, specifically male twins.

So that's another research question that we're looking at.

So the $1,500 in pregnancy goes to the mama, and no matter how many babies she's carrying, it's just $1,500.

For the mama.

But the $500 a month is per baby.

So every baby gets $500 a month.

Dr.

Hanna, thank you.

Incredible moment right now.

I'm Dr.

Mike Forbes.

I'm a pediatric ICU doctor by training.

Yay, I love that.

So well aware of kind of what happens when things go wrong.

I wanted to talk about maternal mortality.

We're focused on, on babies here, and rightfully so.

When I look at the maternal mortality data in the U.S., the, the overall is around 15 or so.

Uh, for Black women, it's about 45.

And when I look in European countries, it's 3, 4, 5.

So, you know, the narrative I propagate is it's not safe to be a pregnant woman in the United States.

It's worse, obviously, in historically marginalized communities.

Can you speak a little bit to what are those systemic drivers that make it so unsafe to be a mom in the US?

So I'm going to reiterate, we have a maternal infant health crisis in this nation.

Okay?

If you compare any of these measures, to other peer countries, we are failing.

We are absolutely failing.

We spend the most money than any other nation in the world on healthcare, and we have some of the worst outcomes to show.

All right.

And we equate healthcare with health.

We need to be investing in the upstream drivers of health to improve these outcomes.

Yes, we need to make sure that we have high-functioning ICUs and we have the best medication and treatments and gene therapy and blah, blah, blah.

That's all important.

But we fail to address what is truly making people unhealthy.

And one of those is income inequality.

Another huge factor is systemic racism that makes it— and recognizing that we can fix these things.

We can address these things at large scales, at a population level.

I'm a history buff.

I'm working on book number 2, which is kind of about all this stuff.

And we used to have, you know, we used to have so many Black medical schools that trained Black physicians.

And then in 1910, there was a report, and I'm blanking on the name— what is it?

Flexner.

The Flexner Report that shut down all these Black medical schools, shut down female medical schools for women.

So we lost a workforce that was reflective of their patients.

We used to have something called nanny midwives in the South, Black midwives, which birthed most of the Black babies.

And then inadvertently, there was more protocols on midwives in the 1930s and training, and that workforce was gone.

So we have to understand the history of how we got to these places.

It's not an accident.

It's not an accident that these 3 zip codes— we could probably trace lead line, redlining, and blockbusting, all these different things that made these 3 zip codes have some of the worst, you know, infant— worst health outcomes.

So we have to acknowledge that, and we have to stop band-aiding.

And get at these root causes to make a dent on the maternal-infant health crisis.

And there was a big report recently.

So 80% of maternal morbidity is preventable.

80% of maternal morbidity is preventable.

But we have a failure of imagination to think big.

And we talk about— we write reports on social drivers of health, social determinants of health.

We talk about income inequality.

We talk about poverty.

We talk about the hardship the window, but then we create complicated after-the-fact solutions that actually don't address the economic instability.

So for me, I think there's always been this failure of imagination.

The first 2 grants that we wrote for RxKids were denied.

They're like, you can't do this.

You can't give people cash.

I'm like, watch me.

Noah's a driver.

Watch me.

We are doing this.

So I have to— we have to be stubborn, we have to be persistent, we have to call out the history, and we have to create solutions that are at the scale of the problem.

Hello, my name is Christina Ratliff.

I'm the founder of Mother's Trust Alliance, executive director, Columbus, Ohio.

Thank you both for the work you're doing.

This is bold and courageous.

Also, you're speaking my love language of radical imagination.

Yeah, just had a dreaming session with mom and birthing people and But this is a great segue for my question.

I'm curious, have you seen any differences by race and if you're seeing any— the gap closing in Black maternal health and infant health outcomes?

Yeah, we are.

In the birth outcomes paper that was recently published in Lancet Public Health, this is where we saw the decrease in prematurity and low birth weight and prevention of NICU admissions.

The impact was greater for our Black mamas and our Black families.

And that is something that we will continue to look at, especially as our sample size increases.

So launching in Detroit is huge.

We have 8,000 babies born a year in Detroit, and that's going to enable us to look at these more nuanced subcategories because the sample size is going to be greater.

This is all maybe wonky statistics, but yeah, that is something that we're going to continue to look at, and the goal is eliminating the disparities at a place-based level.

The neonatal mortality information I shared earlier, so this is a disparity between Flint and the state of Michigan.

For years, Flint had a disparity of more than 2 times the state of Michigan, and then after RxKids, that disparity was statistically eliminated.

Amazing.

That is the hope, and it is our hope that we can actually grow in Cleveland to get to more babies, to be able to statistically more powerfully see the impact of these things.

Hi, Emily Campbell from the Center for Community Solutions.

As I listen to these conversations, it's reminding me of a time several years ago when Dolly Parton's Imagination Library was coming into our community, and we just lost Dolly this week.

Um, where we— it started in a few zip codes, the zip codes of greatest need, then expanded citywide, then through and through.

Now it's statewide in Ohio, supported substantially, um, you know, by, by public-private partnership.

Um, what is it going to take for RxKids to follow that same model of starting in the places of most need but then going universal?

And today Ohio has more kids than enrolled in Imagination Library than any state in the country.

That's the goal.

That is the playbook that we did in Michigan.

We started in Flint as a proof of concept.

We grew to other communities.

It became a proof point in rural places.

We're serving a quarter of the babies, and one of our actually candidates running for governor, in her platform, is that her first budget she'll make it it statewide.

So that's one way.

We're also having national conversations on what legislation would look like to do this all over.

It has been really bipartisan supported.

This is, you know, this is pro-family, pro-life, pro-baby.

It's really efficient.

It's solving housing stability, childcare issues.

So once again, it's solving so many problems.

We're also really excited to share, and I think this is the first time at a public space, it's okay that I'm sharing this, that we have a private funder who's supporting the program to launch in Belmont County, Ohio, which is amazing.

Rural, demographically different than Cleveland, on the east side.

So we're excited that that's gonna launch, and hopefully that will be another proof point to make this possible in more places in Ohio.

Thank you, Dr.

Monahan and Angela Newman-White, for joining us at the City Club today.

Forums like this one are made possible thanks to generous support from individuals like you.

You can learn more about how to become a member of the City Club at cityclub.org.

Today's forum is presented in partnership with William J. and Dorothy K. O'Neill Foundation.

Our gratitude, our deepest gratitude to the team there for the support in making this forum possible.

The City Club would also like to welcome guests at the tables hosted by Academy of Medicine Education Foundation, Case Western Reserve University Swetland Center for Environmental Health, First Year Cleveland at Case Western Reserve University Mandel School, Lerner College of Medicine, McCauley and Company, MetroHealth System, the Mount Sinai Health Foundation, the William J. and Dorothy K. O'Neill Foundation, the Center for Community Solutions, University Hospitals, and Womankind.

Round of applause for everyone.

Thank you all for being here for this amazing conversation.

Up next at the City Club on Friday, September 4th, we will be having a timely conversation between an Israeli Arab and Jew who hold different backgrounds and lived experiences and believe there is a path toward a future that works for all.

And on Friday, September 11th, the City Club will be back with the America 250 series to discuss how we can continue the legacy of Jesse Owens and support youth athletics and education.

Thank you once again to Dr.

Mona Hanna-White and Angela Newman-White, and to our members and friends of the City Club of Cleveland.

I'm Celina Kounianen, and this forum is now adjourned.

For information on upcoming speakers or for podcasts of the City Club, go to cityclub.org.

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