When Dr. Jeff Kaczorowski suggested to the mother of one of his patients that she try using a highchair to improve her baby's appetite, he was dismayed to learn that the family did not even own a table.

"I felt like an idiot," he says. "You learn a lot from people."

Another patient suffered from a bad skin condition. After showing improvement, the baby experienced a serious setback. The child's mother explained that the condition was made worse after plaster fell on him.

"I said, ‘Plaster from the ceiling is falling on your baby?'" Kaczorowski says. "And she said, ‘Well, when the gunshots came through the front window and hit the ceiling, that's what happens.'"

Kaczorowski is one of the good guys: a pediatrician at the Golisano Children's Hospital at Strong and executive director of The Children's Agenda, an advocacy group for children. He also travels all over the US to talk about community health issues on behalf of the American Academy of Pediatrics.

There is a frustrating dichotomy in Rochester, Kaczorowski says. For example, the city is home to exceptional early child care and educational programs like the Nurse Family Partnership Program, where nurses help low-income, first-time mothers for the first two years of their children's lives.

"It's the program that people say on a national level is perhaps the most effective program ever created for vulnerable children and families," Kaczorowski says. "And it was invented right here."

But then there are those terrible statistics: Rochester is the 11th worst city in the US for child poverty, certain ZIP codes has infant mortality rates that rival third-world countries, 30 percent of children entering city schools have witnessed a violent assault or worse in their neighborhood.

"This is the unbelievable thing," Kaczorowski says. "On one hand, we have terrible poverty. On the other hand, we have this incredible thing."

The bridge between the two is access to these programs in the form of subsidy supports, Kaczorowski says, "and we are going in reverse."

Kaczorowski's lament came even before County Executive Maggie Brooks's announcement last week that she is changing the eligibility threshold for subsidized day care from 165 percent to 125 percent of the poverty rate. Brooks blames state funding cuts.

Kaczorowski talks briskly and passionately about the challenges facing children in Rochester and his fear that those challenges will increase as a result of the fiscal problems confronting every level of government. He chokes up several times during an interview and pulls out a slow smile - coupled with a pregnant pause - when he wants reassurance that you've understood his point.

In an interview last week, Kaczorowski talked about the well-being of children in Rochester and Monroe County and his work with The Children's Agenda. The following is an edited version of that interview.

CITY: Infant mortality is often seen as an indicator of the overall health of a community. In Rochester's suburbs, it's about four deaths for every 1,000 live births. In the city, it's three times that - 12 deaths per 1,000.

Kaczorowski: I would argue that it's the single most important predictor of health for a community.

People talk about how long in the United States we live or don't live - life expectancy. We do this exercise with our residents every year: We have them go to the Mt. Hope cemetery, and they're always amazed that there are people who, at the turn of the century, lived to be 80 years old. Life expectancy supposedly was much younger back then. But even life expectancy is greatly influenced by what happens to children, because the real loss of years of life happens when kids die, happens with infant mortality. So when people talk about life expectancy in the United States being an important predictor, really it's a reflection of infant mortality. A lot of people don't understand that.

There are multiple social contributors that have to do with low income, family status, and, I think, there are certainly contributors like drug use, cigarette use. But there is no one contributor that you can point your finger at and say, "All those moms must be drug users." It's much more complicated than that. They're families that are caught in terrible, stressful lives where there may not be enough food, there may not be access to medical care.

It's hard to be a good parent when you haven't had good parenting. There may not be a whole lot of knowledge about what you need to do during pregnancy to have a healthy baby.

You've said that the two most important predictors of a child's health are maternal education and a family's socioeconomic status. If a child starts out with deficits in those areas, how do you overcome that?

Childhood sets the pattern for so many important things later in life. There was a study called the ACE study - Adverse Childhood Experiences - that looked at health outcomes for adults. And there was a linear correlation between adverse childhood experiences and bad outcomes as adults. And not just things that you would think of as necessarily correlated. For example, we might all say that if someone was abused as a child, they might have mental-health issues. But it turns out that things like child abuse are correlated with heart attacks, liver disease. Adverse childhood experiences impact our communities the whole life of a person. These things that happen to babies haunt us, haunt them, haunt their families, haunt their communities their whole lives.

It's really hard to catch up if kids have had terrible life experiences prior to school entry. People talk about the Rochester city school district and how come the test scores don't get better. We all want our schools to function very effectively, with the highest standards. But a lot of the battle is happening far before those kids ever get to school. It's happening from 0 to 3, from 0 to 5.

With sophisticated technology now, we can look at brains of kids who have been nurtured and have had good opportunities and good parenting, and kids who have been neglected. And you can actually see differences in their brains at 3 years old. How do you overcome that? It's very hard.

People might read that response and think, "If there's no hope, why bother?"

Well, we need highly effective programs for young children. We need high-quality early-childhood education. I'm talking about child care. I'm talking about good pre-K programs. I'm talking about programs that support young mothers, young families, and newborn babies - especially low-income mothers and families. Programs like the Nurse Family Partnership Program. I'm not just hypothesizing that's the case. There's the best level of scientific evidence that these programs work. Certain programs can overcome those barriers and really get kids on the right track. But they're hard.

We need to put together a system that is longitudinal, based where kids and families are, that relies on the highest level of evidence of what we really know works. It would be great, in my mind, if all low-income, first-time mothers in Rochester and Monroe County had access to the Nurse Family Partnership Program, which goes from prenatal to age 2. And then, at age 2, if they could all have access to high-quality early-childhood education experiences. We'd be in such a different place.

MonroeCounty Executive Maggie Brooks criticized the state for cutting child-care funding, saying it could leave 1,300 kids in the county without day care. But state officials say the funds were cut because the county consistently wasn't using the entire amount. What's the real story here?

It is not true that the county has leftover dollars this year. It's really true that the last two years, the county has been making more attempts to get kids into subsidized child care. They increased the number of kids who were eligible for affordable child care by increasing the eligibility level in terms of poverty level. They also did what's called a market-rate increase - which is, essentially, paying for better quality care - two times in 2007.

It depends on the timeframe you're talking about as to who's correct. When the state looked in October - which is when they always look - they saw that the county had about $5.8 million. But what they did not understand is that the county had raised the eligibility level the prior fall and they had two market-rate increases. It meant that the county was spending more than $1 million a month more than what it had been in the past. So by the time we get to the fiscal year of the state starting in April, there really weren't leftover dollars. It's one of those situations where I think there's truth on both sides.

But the ultimate result is terrible. In 2006, the child-care dollars that we got from the state was about $38 million. In 2008, we're at about $30 million. I think that the number that the county is talking about - 1,300 kids - is optimistic. I think we could easily lose 2,000 children in terms of access to child care this year. That's almost a quarter of our kids. And the trend would be, roughly over an eight-year period from 2000 to 2008, we could go from 13,500 kids in child care to 6,500. We'd lose half of our kids in the setting of incredible need here.

Governments from MonroeCounty right up to the federal level are struggling with massive deficits. The county's deficit is approximately $29 million. What are you worried about, in that context?

They either have to develop another source of revenue or make cuts. I worry all the time that the cuts will impact the most vulnerable kids and families. Boy, you wonder how long you can keep heading off deficits and balancing the budget in a setting of economic crisis like we're in.

Yeah, it absolutely makes me worried. It makes me panicked. I'm scared as could be about what could happen for kids and families.

Are you encouraged by what you've seen so far with the Rochester Surround Care Community Corporation, formerly the Rochester Children's Zone? How do you make something like that work?

I am very hopeful for the Rochester Children's Zone. And I'm very grateful for it. One of the things that I think the Children's Zone has done very well is to engage the members of the northeast neighborhoods, families who are living there, in terms of what their needs and assets are. And it's hard because many of those families have not had a whole lot of support from the broader community in the past.

I think that there are four lessons learned about how to do that kind of change. One is, ask people what their needs and abilities are. Second is, it's got to be longitudinal. It's got to be based on where kids and families are. Effective: do we know that the programs and policies we're trying to implement really have the outcomes that we want? And then the last thing, when we have all those things, we have to connect and sustain them.

And I think communities fall down on all four of those areas all the time. We do one-shot deals because it's very hard to think about these terrible, vexing problems. It takes work to sustain things and to grow things to capacity once we have them. We're fascinated by the next new thing. To some degree, our culture really promotes that. The stuff that really works, that we could take to capacity, we lose interest in because it's not brand new anymore. It seems not as exciting.

So what's the good news? What are some of things that are working?

The good news is improvements in test scores in the Rochester city school district. Good news is the quality of care that we have, even if we don't have all the access. The good news is expanding capacity for the Nurse Family Partnership Program and state funding for it this year.

For the first time in the six years that I've been doing this, I really see the leadership starting to fall into place in every major area affecting kids. I've worked and met with Superintendent Brizard on many occasions. I'm really excited about the energy and reasoned approach he's bringing to doing things within the school district. I keep on worrying that he's going to burn out. One day he said he liked my sport coat, and I said, "You can have it. I don't know what else I can do for you."

The worry that I have is that we don't have the resources; is that in the setting of tightening economic times, we don't have the financial resources.

Invest in effective programs for kids, because that is what is going to help us immediately, and it's what's going to help us in the long term. It's going to save us from spending all kinds of dollars, reactively, down the road for these terrible problems that we have.