Debating WIC - response to Douglas J. Besharov et al, The Public Interest, no. 134, Winter 1999 - Women, Infants and Children nutrition program

In their critical review of the Women, Infants and Children (WIC) nutrition program ("Is WIC As Good As They Say," The Public Interest, No. 134, Winter 1999), Douglas J. Besharov and Peter Germanis conclude that WIC is less effective than commonly believed and that the research evidence is flawed. They suggest various ways to restructure the program in fashions more to their liking, although they offer little evidence that their proposals are feasible or would be more effective. I appreciate the spirit of constructive criticism brought by Besharov and Germanis, but I disagree with many of their conclusions.

Let me begin by observing that Besharov and Germanis's article is incomplete and stilted. Public-health research about the WIC program has been amazingly fertile. A brief search of scientific papers published in health journals collected by the National Library of Medicine found more than [pounds]00 published studies concerning WIC, and there are other excellent papers in public-policy or economics journals, as well as unpublished reports. Despite its relatively small size, WIC has been one of the most thoroughly studied federal programs. Researchers have investigated WIC's effects on: birth weights, infant mortality, reductions in Medicaid expenditures, nutrient intakes, children's cognitive development, immunization rates and use of health services, childhood anemia, and breastfeeding rates. Many of the most interesting papers are not rigorous evaluations but reports of field studies or descriptive analyses that help us look at questions just like those that Besharov and Germanis raise: how to improve breastfeeding rates and nutritional counseling, and how to use WIC to improve immunization rates or to coordinate WIC with home-visit programs.

Much of their paper discusses flaws in studies about whether WIC improves birth outcomes. They note methodological problems, like selection bias in many of the studies, but fail to note that Jack Metcoff of the University of Oklahoma and his associates conducted a randomized experiment to determine how WIC affects pregnant women's birth outcomes. This study, published in 1985, found that WIC increased birth weights by an average of 91 grams and meets most of their methodological objections.

Growth in the program since then has made it ethically impossible to replicate this randomized study, but most subsequent studies, conducted using a plethora of data sources, statistical methods, and outcome measures, generally reach the same conclusions - that WIC helps low-income pregnant women bear heavier, healthier babies. Come on guys, how long do we have to study something to conclude reasonably that it works? Are you acting like the fringe groups who wonder whether smoking tobacco really causes lung cancer?

Besharov and Germanis also understate the strength of the evidence. For example, they note that Ray Yip and his colleagues at the Center for Disease Control (CDC) found that decreasing anemia among WIC participants could be caused by a secular decline in childhood anemia. What they do not mention is that the CDC also found that fewer WIC children were anemic between the time they first entered the program and recertification, usually six months later. These specific and rapid improvements could not be caused by general secular changes and almost certainly are due to the iron-fortified foods in the WIC food package. These clinical findings are consistent with results from the National WIC Evaluation and those from Donald Rose of the Economic Research Service of USDA and his associates, indicating that WIC children consumed more key nutrients, including iron. While there have not been definitive, randomized studies for children, the research findings are consistent and compelling.

Equally important, WIC can improve children's health by boosting immunization rates. Because WIC is typically located in health clinics and serves millions of low-income children, it is well-suited to promote immunization. Mothers and their young children must regularly come to WIC clinics to be certified or to get food vouchers. The National WIC Evaluation found that children participating in WIC were more likely to be immunized than nonparticipating children. Several recent studies, including two published in the Journal of the American Medical Association, showed how changes in WIC program operations can further increase immunization rates. State and local WIC clinics have also formed partnerships with Vaccines for Children, Medicaid, and local maternal and child health programs to reinforce preventive health care for children. By increasing immunizations, WIC can indirectly reduce the incidence of preventable diseases like measles.

Other aspects of the WIC program have been less thoroughly studied. But contrary to Besharov and Germanis's assertion that they are unveiling a secret hidden from the American public, these gaps have been well-known for a long time and publicly discussed by the General Accounting Office, the National Academy of Sciences, myself, and fellow researchers like Barbara Devaney of Mathematica Policy Research. And we have made steady gains in our understanding of the program; the U.S. Department of Agriculture, which administers WIC, has long funded research about WIC. Do I wish for more and better evaluations? Of course. I would love to see more research about the effects of participation in WIC during childhood and whether the current program design provides the best package of benefits. However, I realize that rigorous studies are difficult to design, cost a lot, and take many years to complete. The fiscal reality is this: Research budgets are limited, and evaluation studies must compete for resources with other priorities.

While the research evidence about WIC's effectiveness is not perfect, it is hard to think of any public program with so consistent a body of positive research findings. Further, the federal government continues to invest in research to better understand and strengthen the program. No doubt this strong research record accounts for the program's popularity. But the program also receives high marks for its design. Steering a middle course between the problem of entitlements and the inherent vagueness of block grants, WIC is a federal program that allows for local and state administration. This has satisfied WIC's state and local managers, allowing them to be creative within a framework of broadly shared goals and a time-tested program structure.

One good example of state or local innovation is WIC's infant formula rebates, in which competitive bidding reduces the price of WIC infant formula. Typically, the rebates amount to 80 percent or more of the price of formula, collectively saving more than $1 billion annually. The rebates began as state initiatives and have become one of the best examples of the power of competitive bidding within government. Linking WIC to immunization efforts is another example of creative local initiatives.

WIC incorporates principles shared by conservatives and liberals. It seeks to prevent problems, not just cure them. It strives for efficiency and cost-containment in operations. It fosters family responsibility by teaching parents how to improve their children's diets, as well as by providing healthy food directly. It is not an unlimited handout but provides specific benefits during a critical stage in a child's development. Finally, it permits creative collaboration between program directors at federal, state, and local levels.

Besharov and Germanis suggest that WIC should have even more flexibility and that paying for additional services by providing fewer people with food benefits would be the right thing to do. In particular, they propose that WIC should try home visits for pregnant women, based on a model developed and tested by David Olds at the University of Colorado. There are indeed many proven merits to home-visit programs, but I am not sure that paying for the entire range of home-visit services is WIC's mission. Many other programs are better suited to financing non-nutrition-related services for pregnant women, including Healthy Start, Title V Maternal and Child Health Block Grants, Title XX Social Services Block Grants, and Medicaid. Providing WIC nutrition services through home visits, in coordination with other programs, is an attractive idea, but this is already permitted under current program rules.

Flexibility for state and local programs is important but does not, by itself, guarantee success. The Healthy Start program gives communities great autonomy to design and implement projects to improve birth outcomes, including home-visit programs, but preliminary, interim evaluations have been disappointing. Does it make sense to divert resources from WIC's relatively well-proven model toward one yielding inconclusive results to date?

Besharov and Germanis apparently believe that WIC provides food to too many mothers and children. For example, they complain that almost half of the infants in the country get WIC benefits. What they do not mention is that there is an alarmingly high level of poverty and near poverty among American families with young children. Mothers with infants are often unable to work full time and, even when they work, often have low-wage jobs. To qualify for WIC, a family of four must generally have an annual income of about $30,000 or less, which most of us would agree is a relatively low income. The main reason that almost half the nation's infants receive WIC benefits is that, sadly, about half the babies are in poor and low-income families.

Without WIC, a low-income family would need to spend more than $1,000 a year to feed its baby and purchase the infant formula and other fortified foods provided by WIC. Few low-income families can afford to spend this much on their own. WIC ensures that these babies have nutritious foods available. In addition, competitive purchasing allows tile government to purchase these foods at a fraction of the market cost. Rather than revealing a program run amuck, the high participation of infants in WIC signals a successful government policy that helps ensure the nutritional status of millions of low-income infants.

Overall, however, it has been estimated that only about 80 percent of those eligible for WIC (including women and preschool children) are able to get benefits. More health and social services for the mothers and children most at risk are urgently needed, but many other programs can provide these services, along with WIC. Let's be sure that we have utilized all the resources to their utmost and coordinated programs' efforts, before we propose taking food away from low-income women and children.

Besharov and Germanis have raised many provocative issues, and ! hope that this stimulates a constructive discussion of ways to improve services for low-income mothers and children. But I have read the research literature, and I remain confident that WIC is effective and well run. We can and should refine the WIC program to improve the health of low-income mothers and children, but let's not forget program fundamentals.

LEIGHTON KU is a senior research associate at the Urban Institute. He teaches public-policy research methods at George Washington University.

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