editorial
Canada needs a vision for child health André Picard
I
f a child is in one of Canada’s 16 paediatric hospitals, they will be well cared for and, if a child is a patient of one of the country’s 3200 pediatricians, they will be in good hands. Medicine is not the problem with Canadian health care. The problem is that we focus too much on treatment and too little on prevention. Worst of all, medical services are often divorced from other sectors that make a tremendous difference to the health and well-being of children like education, social services, transportation and environmental safety. In short, we don’t have a vision. We don’t have a commitment, at the societal level, to raising healthy kids. Canada signed the United Nations Convention on the Rights of the Child in 1989 – 26 years ago. One of the obligations of that treaty was the establishment of an independent national Commissioner for Children and Young Persons. That position does not exist yet, and we need to wonder why. Thankfully, there are 11 provincial and territorial jurisdictions that have a representative of child and youth, a children’s ombudsman or a similar post. These advocates play an important role, including: • Working to ensure the rights of children and youth are respected and valued in communities and government practice, policy and legislation; • Promoting the interest of, and acting as a voice for children who have concerns about provincial government services; • Engaging in public education; • Working to resolve disputes and conduct independent investigations; and • Recommending improvements of programs for children to the government and/or legislative assembly. Why is no one playing this role at the federal level? It’s no wonder Canada’s children get short shrift in public policy. And it’s not a coincidence that, compared with other developed countries, Canada is a laggard on child health. Our federal leaders are failing children. Paediatricians can solve kids’ individual problems, one at a time, in their offices. But they cannot make kids healthier overall. There is no question that most of what we can and should do to improve the lives of children needs to be done outside the confines of paediatric hospitals and physicians’ offices. To build better kids, we need a significant cultural and philosophical shift. There is a widely circulated infographic that suggests genetics accounts for approximately 15% of illness and death and physical environment accounts for approximately 10% of risk. Next, there is medical care: having timely, affordable access to care accounts for about 25% of risk of illness and death. That’s why universal health care – medicare – is important, and it’s especially important to kids because prompt, thorough treatment can nip problems in the bud.
The single biggest impact on health – the other 50% – is, collectively, the social determinants of health. At least five determinants matter tremendously to children’s well-being: • • • • •
Income; Education; Housing; Early childhood development; and Sense of belonging.
Clearly these issues are intertwined and overlapping, but they are each worthy of examining in more detail.
INCOME
The incidence and mortality of virtually every serious health condition follows pretty reliably along the income gradient. Groups such as the International Monetary Fund and the World Bank recognize that poverty and inequality kill and stifle progress. People who are poor get sicker quicker and more often, and they die earlier. Why is that? It’s not genetics. It’s not access to care – at least not in Canada. Poverty unleashes a cascade of bad consequences: You tend to not live in a very nice place, you don’t eat well, you lack choices and so on. The health impacts of powerlessness and poverty are cumulative. Yet, we rarely see poverty listed as a health condition. We tend to view it as a social problem or, worse, a choice. You can prescribe an inhaler to a child with asthma, but if they go home to an apartment infested with mold and with two parents who smoke, their condition will not improve. There are limits to what universal health care can do. Intervening early and in a holistic way can prevent and mitigate many chronic health problems. This simple example illustrates the limitations of a medical model. But it also reminds us of the importance of a social safety net beyond medicare. The other hallmark of poverty is that we tend to be blind to it, and we tend to underestimate how many people are struggling to get by. In Canada – a wealthy, prosperous nation – approximately one in seven kids lives in poverty. And most poverty is invisible. About 11% of full-time workers in Canada live in poverty – the only developed country with a worse record is the United States. Short-sighted public policy is at the heart of this high rate of working poor. While we like to say that we have a social welfare state, it’s not exactly generous. In Canada, annual social assistance payments range from a low of $3,200 per year for a single man to $21,000 for a family of four. Some provinces expect a single mother to feed, house, clothe, educate and nurture a family with three children on $400 per week. You can’t live on that income. In fact, you can barely house yourself, and you certainly can’t
The Globe & Mail Correspondence: Mr André Picard, Editorial, The Globe and Mail, 999 Maissoneuve Boulevard West, Suite 1620, Montreal, Quebec H3A 3L4. Telephone 514-982-3063, e-mail [email protected] Accepted for publication December 14, 2015 Paediatr Child Health Vol 21 No 5 June/July 2016
©2016 Canadian Paediatric Society. All rights reserved
237
Commentary
raise a healthy family on it. We condemn children in these situations to a life of ill-health.
HOUSING
Approximately 30,000 people are homeless on any given night in this country, and another 50,000 or so are considered to be the ‘hidden homeless’, people who are living with family or friends with no prospect of permanent housing, usually due to lack of income. In addition, about 400,000 households spend more than one-half of their income on rental housing, which means that they have little money for anything else, and no equity. They are trapped in a cycle of poverty and precarious housing. In recent years, however, we’ve substantially cut back on social housing and programs that provide low-income residents with subsidized rent. At the same time, we’ve expanded shelters, and the number of children removed from their families and put into foster care or other forms of state care (ie, ‘flea bag’ hotels) has grown tremendously, particularly in Aboriginal communities. In fact, more Aboriginal children are in foster care today than at the height of residential schools. It should make us wonder whether we have really learned anything from our shameful history. In mental health, we talk a lot about a ‘housing first’ approach. Until someone has housing, it’s virtually impossible to have the stability to deal with – let alone prevent – other health problems. That philosophy needs to extend to all families. If you don’t have a home, it is quite likely you will not have healthy children.
EDUCATION
As someone who has written about health policy for almost 30 years, one of my greatest frustrations is the education system. Our schools are virtual factories for the production of unhealthy children. We drive children to schools in buses and cars, sit them down, teaching them to be passive, feed them unhealthy food, then pack them up in vehicles again to go home where they sit to do homework and play video games. Then we make token gestures like gym class – where kids actually move for about 6 min per hour – and we have recess, where we outlaw ‘dangerous’ activities like ‘tag’ and running. Our children get less activity and stimulation than zoo animals. Furthermore, we eliminate courses like home economics, where they could learn practical skills like cooking, and replace it with more classroom time. And we wonder why we have epidemics of obesity and mental illness. In many ways, the education system is symbolic of our wrong-headed approach to child health. In schools, as in public policy circles more generally, we spend a lot of time talking about health rather than practicing health. If you want to build better kids, schools should be a place where we model healthy, not unhealthy living.
EARLY CHILDHOOD DEVELOPMENT
Research shows that the first 1000 days of life set the stage, especially for neurodevelopment. That’s why some of the most important health programs are prenatal and well-baby initiatives. Early investments pay off. One of my favourite stories over the years is one I wrote about a program called OLO (oeuf-lait-oranges) where pregnant women in low-income areas of Montreal are ‘prescribed’ eggs, milk, oranges and prenatal vitamins. This simple approach is to cut the number of lowbirthweight babies by 70% in high-risk areas. That’s a tremendous
238
savings to the health system, but also a tremendous benefit to the children – years of follow-up show that they do markedly better in school. On an individual level, even if you have material resources, probably the single most important thing you can do is read to your child. Literacy is a great gift. You should start young and read to your child every single day. On a societal level, daycare, pre-K and full-day kindergarten are wonderful initiatives, especially if kids are fed nutritious meals. In Quebec, where universal, affordable daycare has been in place for two decades (but is now being rolled back), the number of single-parent families has fallen by two-thirds. Why? Largely because single moms have daycare and they can work. That cohort of daycare kids is working its way up through the system. Test scores are up, and the dropout rate is falling. These investments pay dividends over the long term.
SENSE OF BELONGING
Research has shown that two of the best predictors of illness and early mortality are powerlessness and isolation. Community and a sense of belonging are important to our health, especially for children. The philosophy that ‘it takes a village to raise a child’, is profoundly important, even if it has been co-opted into a cheap political slogan. Inclusion is important, but too rarely practiced. Research shows that about 60% of kids with disabilities have no friends. That’s a tragedy. As Mother Teresa said, “Loneliness is the most terrible poverty”. The over-arching message is that we have to pay a lot more attention to the vulnerable and marginalized children. Kids with a good family income, education, homes, daycare and friends, tend to be okay; they are generally healthy – physically, emotionally and spiritually. But children have an obligation to help others, and the best way is collectively, through social programs, be they governmental, not-for-profit or private initiatives. Not every kid needs the same programs and benefits. We don’t need equal access for all, we need equitable access. Special attention needs to be paid to Aboriginal communities, where the baby boom is astounding. In many Indigenous communities, fully one-half the population is younger than 15 years of age (compared with about 15% in the general population). What future awaits them? Right now, it’s pretty grim.
CONCLUSION
In Canada, an average child born today – essentially a Caucasian child in a city – can expect to live to the age of 82. Fully one-half can expect to live past 100. But a Métis child can expect to live to 77, and a First Nations child to 75. An Inuit child has a life expectancy of 67 years – fully 15 years less than a non-Aboriginal child. That number is so shocking, so shameful, that no words can do it justice. If we want to build better kids, if we want to build a better Canada, we need to start with those in most need, but also be sure to leave no child behind. Sir Albert Aynsley-Green, the passionate and eloquent child commissioner for England, said it well: “The badge of honour of a civilized nation is to protect its most vulnerable. The views, needs and interests of children and young people need to be taken seriously.” Canada today wears a badge of dishonor. We can do a lot better. But we need a plan, a vision, some advocacy and some leadership.
Paediatr Child Health Vol 21 No 5 June/July 2016
Canada needs a vision for child health André Picard
I
f a child is in one of Canada’s 16 paediatric hospitals, they will be well cared for and, if a child is a patient of one of the country’s 3200 pediatricians, they will be in good hands. Medicine is not the problem with Canadian health care. The problem is that we focus too much on treatment and too little on prevention. Worst of all, medical services are often divorced from other sectors that make a tremendous difference to the health and well-being of children like education, social services, transportation and environmental safety. In short, we don’t have a vision. We don’t have a commitment, at the societal level, to raising healthy kids. Canada signed the United Nations Convention on the Rights of the Child in 1989 – 26 years ago. One of the obligations of that treaty was the establishment of an independent national Commissioner for Children and Young Persons. That position does not exist yet, and we need to wonder why. Thankfully, there are 11 provincial and territorial jurisdictions that have a representative of child and youth, a children’s ombudsman or a similar post. These advocates play an important role, including: • Working to ensure the rights of children and youth are respected and valued in communities and government practice, policy and legislation; • Promoting the interest of, and acting as a voice for children who have concerns about provincial government services; • Engaging in public education; • Working to resolve disputes and conduct independent investigations; and • Recommending improvements of programs for children to the government and/or legislative assembly. Why is no one playing this role at the federal level? It’s no wonder Canada’s children get short shrift in public policy. And it’s not a coincidence that, compared with other developed countries, Canada is a laggard on child health. Our federal leaders are failing children. Paediatricians can solve kids’ individual problems, one at a time, in their offices. But they cannot make kids healthier overall. There is no question that most of what we can and should do to improve the lives of children needs to be done outside the confines of paediatric hospitals and physicians’ offices. To build better kids, we need a significant cultural and philosophical shift. There is a widely circulated infographic that suggests genetics accounts for approximately 15% of illness and death and physical environment accounts for approximately 10% of risk. Next, there is medical care: having timely, affordable access to care accounts for about 25% of risk of illness and death. That’s why universal health care – medicare – is important, and it’s especially important to kids because prompt, thorough treatment can nip problems in the bud.
The single biggest impact on health – the other 50% – is, collectively, the social determinants of health. At least five determinants matter tremendously to children’s well-being: • • • • •
Income; Education; Housing; Early childhood development; and Sense of belonging.
Clearly these issues are intertwined and overlapping, but they are each worthy of examining in more detail.
INCOME
The incidence and mortality of virtually every serious health condition follows pretty reliably along the income gradient. Groups such as the International Monetary Fund and the World Bank recognize that poverty and inequality kill and stifle progress. People who are poor get sicker quicker and more often, and they die earlier. Why is that? It’s not genetics. It’s not access to care – at least not in Canada. Poverty unleashes a cascade of bad consequences: You tend to not live in a very nice place, you don’t eat well, you lack choices and so on. The health impacts of powerlessness and poverty are cumulative. Yet, we rarely see poverty listed as a health condition. We tend to view it as a social problem or, worse, a choice. You can prescribe an inhaler to a child with asthma, but if they go home to an apartment infested with mold and with two parents who smoke, their condition will not improve. There are limits to what universal health care can do. Intervening early and in a holistic way can prevent and mitigate many chronic health problems. This simple example illustrates the limitations of a medical model. But it also reminds us of the importance of a social safety net beyond medicare. The other hallmark of poverty is that we tend to be blind to it, and we tend to underestimate how many people are struggling to get by. In Canada – a wealthy, prosperous nation – approximately one in seven kids lives in poverty. And most poverty is invisible. About 11% of full-time workers in Canada live in poverty – the only developed country with a worse record is the United States. Short-sighted public policy is at the heart of this high rate of working poor. While we like to say that we have a social welfare state, it’s not exactly generous. In Canada, annual social assistance payments range from a low of $3,200 per year for a single man to $21,000 for a family of four. Some provinces expect a single mother to feed, house, clothe, educate and nurture a family with three children on $400 per week. You can’t live on that income. In fact, you can barely house yourself, and you certainly can’t
The Globe & Mail Correspondence: Mr André Picard, Editorial, The Globe and Mail, 999 Maissoneuve Boulevard West, Suite 1620, Montreal, Quebec H3A 3L4. Telephone 514-982-3063, e-mail [email protected] Accepted for publication December 14, 2015 Paediatr Child Health Vol 21 No 5 June/July 2016
©2016 Canadian Paediatric Society. All rights reserved
237
Commentary
raise a healthy family on it. We condemn children in these situations to a life of ill-health.
HOUSING
Approximately 30,000 people are homeless on any given night in this country, and another 50,000 or so are considered to be the ‘hidden homeless’, people who are living with family or friends with no prospect of permanent housing, usually due to lack of income. In addition, about 400,000 households spend more than one-half of their income on rental housing, which means that they have little money for anything else, and no equity. They are trapped in a cycle of poverty and precarious housing. In recent years, however, we’ve substantially cut back on social housing and programs that provide low-income residents with subsidized rent. At the same time, we’ve expanded shelters, and the number of children removed from their families and put into foster care or other forms of state care (ie, ‘flea bag’ hotels) has grown tremendously, particularly in Aboriginal communities. In fact, more Aboriginal children are in foster care today than at the height of residential schools. It should make us wonder whether we have really learned anything from our shameful history. In mental health, we talk a lot about a ‘housing first’ approach. Until someone has housing, it’s virtually impossible to have the stability to deal with – let alone prevent – other health problems. That philosophy needs to extend to all families. If you don’t have a home, it is quite likely you will not have healthy children.
EDUCATION
As someone who has written about health policy for almost 30 years, one of my greatest frustrations is the education system. Our schools are virtual factories for the production of unhealthy children. We drive children to schools in buses and cars, sit them down, teaching them to be passive, feed them unhealthy food, then pack them up in vehicles again to go home where they sit to do homework and play video games. Then we make token gestures like gym class – where kids actually move for about 6 min per hour – and we have recess, where we outlaw ‘dangerous’ activities like ‘tag’ and running. Our children get less activity and stimulation than zoo animals. Furthermore, we eliminate courses like home economics, where they could learn practical skills like cooking, and replace it with more classroom time. And we wonder why we have epidemics of obesity and mental illness. In many ways, the education system is symbolic of our wrong-headed approach to child health. In schools, as in public policy circles more generally, we spend a lot of time talking about health rather than practicing health. If you want to build better kids, schools should be a place where we model healthy, not unhealthy living.
EARLY CHILDHOOD DEVELOPMENT
Research shows that the first 1000 days of life set the stage, especially for neurodevelopment. That’s why some of the most important health programs are prenatal and well-baby initiatives. Early investments pay off. One of my favourite stories over the years is one I wrote about a program called OLO (oeuf-lait-oranges) where pregnant women in low-income areas of Montreal are ‘prescribed’ eggs, milk, oranges and prenatal vitamins. This simple approach is to cut the number of lowbirthweight babies by 70% in high-risk areas. That’s a tremendous
238
savings to the health system, but also a tremendous benefit to the children – years of follow-up show that they do markedly better in school. On an individual level, even if you have material resources, probably the single most important thing you can do is read to your child. Literacy is a great gift. You should start young and read to your child every single day. On a societal level, daycare, pre-K and full-day kindergarten are wonderful initiatives, especially if kids are fed nutritious meals. In Quebec, where universal, affordable daycare has been in place for two decades (but is now being rolled back), the number of single-parent families has fallen by two-thirds. Why? Largely because single moms have daycare and they can work. That cohort of daycare kids is working its way up through the system. Test scores are up, and the dropout rate is falling. These investments pay dividends over the long term.
SENSE OF BELONGING
Research has shown that two of the best predictors of illness and early mortality are powerlessness and isolation. Community and a sense of belonging are important to our health, especially for children. The philosophy that ‘it takes a village to raise a child’, is profoundly important, even if it has been co-opted into a cheap political slogan. Inclusion is important, but too rarely practiced. Research shows that about 60% of kids with disabilities have no friends. That’s a tragedy. As Mother Teresa said, “Loneliness is the most terrible poverty”. The over-arching message is that we have to pay a lot more attention to the vulnerable and marginalized children. Kids with a good family income, education, homes, daycare and friends, tend to be okay; they are generally healthy – physically, emotionally and spiritually. But children have an obligation to help others, and the best way is collectively, through social programs, be they governmental, not-for-profit or private initiatives. Not every kid needs the same programs and benefits. We don’t need equal access for all, we need equitable access. Special attention needs to be paid to Aboriginal communities, where the baby boom is astounding. In many Indigenous communities, fully one-half the population is younger than 15 years of age (compared with about 15% in the general population). What future awaits them? Right now, it’s pretty grim.
CONCLUSION
In Canada, an average child born today – essentially a Caucasian child in a city – can expect to live to the age of 82. Fully one-half can expect to live past 100. But a Métis child can expect to live to 77, and a First Nations child to 75. An Inuit child has a life expectancy of 67 years – fully 15 years less than a non-Aboriginal child. That number is so shocking, so shameful, that no words can do it justice. If we want to build better kids, if we want to build a better Canada, we need to start with those in most need, but also be sure to leave no child behind. Sir Albert Aynsley-Green, the passionate and eloquent child commissioner for England, said it well: “The badge of honour of a civilized nation is to protect its most vulnerable. The views, needs and interests of children and young people need to be taken seriously.” Canada today wears a badge of dishonor. We can do a lot better. But we need a plan, a vision, some advocacy and some leadership.
Paediatr Child Health Vol 21 No 5 June/July 2016
