523905 research-article2014
RSH0010.1177/1757913914523905OtherOther
CURRENT TOPICS & OPINIONS
Why should we all focus on health inequalities in the foetus and early childhood? Just as children were treated clinically as mini-adults a century ago, do we dismiss them in terms of wellbeing, life chances and ability to be in control of one’s life as simply the responsibility of their parents? Dr Jane Ritchie, Vice-Chair of the Academy of Medical Royal Colleges Health Inequalities Forum, makes the case for an increased focus on the beginning of the life course and questions whether a change in societal attitudes may be needed to tackle these inequalities. Michael Marmot1 is clear that reducing health inequalities is a matter of fairness and social justice and is also vital for the economy. ‘Giving every child the best start in life’ is his prime recommendation in recognition that the effects of social disadvantage start before birth and accumulate throughout life, a theme reinforced by the British Medical Association (BMA) and the Chief Medical Officer (CMO).2,3
The Moral Imperative The United Nations Convention on the Rights of the Child (UNCRC) underpins the moral imperative to reduce health inequalities. Children have no control over the socioeconomic conditions into which they are born, but are clearly affected by them on their journey from total dependence to self-realisation as mature human beings. The idea that individuals can always be held responsible for their behaviours and lifestyle choices, a view prominent in the health inequalities debate, obviously does not apply. Health is much more than the result of personal choice, and is clearly influenced by the environment in which individuals are conceived, raised and age. Children do not choose to be born into poor families, or disadvantaged circumstances, to be exposed to maternal smoking, alcohol or poor nutrition as a foetus, nor maternal depression and poor stimulation in
mental health problems, violence, alcohol and substance abuse, involvement in the youth justice system and teenage parenthood. Poverty breeds ill health, but ill health also maintains poverty. The United Kingdom has one of the highest levels of inequality in the developed world, and rates of out-of-home care in Europe.2 Yet, children thought to be suffering significant harm from chronic failure of adequate parenting (manifesting as neglect or emotional abuse) are prioritised for a ‘forensic assessment’, that ‘can be intrusive and punitive, less cost effective, and less likely to encourage parental engagement’.2
infancy, or even poor diet, domestic violence and early school failure. The effect of ‘fuel poverty’ on the day-to-day lives and wellbeing of many children is often overlooked, and many other adverse environmental factors (such as housing, road safety, bullying) affect their ability to develop physically, emotionally and socially. Children adopt the lifestyle The Consequences of choices to which they have been Disadvantage and Poverty exposed, and those from a on Child Health disadvantaged background lack the The intergenerational cycle of emotional, intellectual and material disadvantage is largely passed across capacity to make lifestyle changes, once generations through pregnancy.4 Women in charge of their own destiny. It is the from poor families are more likely to cumulative experiences over time which suffer from ill health with poor nutritional are so insidious status and psychological problems, and detrimental more likely to smoke and less likely Children adopt to a healthy life to breast feed. Pregnancy the lifestyle trajectory. outcomes are poorer, and there is a choices to which consistent social gradient in Poverty is they have been one of a perinatal mortality. Poor babies are exposed number of more likely to be born small or socioeconomic early.4 Throughout childhood, factors which increased mortality and morbidity leads to disadvantage. It is also a from causes such as Sudden consequence of and compounder of Unexpected Infant Death, injury and others. Nearly one-third of children, and poisoning occurs proportionately to up to 70% in some areas of the United decreasing socioeconomic status.3 3 Kingdom, are growing up in poverty. Infant brains develop extremely rapidly Social disadvantage reduces parental in the first two years, and adverse capacity to meet their own emotional experiences such as high levels of needs, and the child’s, with a direct effect maternal stress and poor attachment, on the health and wellbeing of the child. lead to raised cortisol levels which have a There is also a vicious circle whereby the direct toxic effect on developing brain most vulnerable are susceptible to further structures and circuitry, leading to adverse experiences, giving rise to emotional and attentional dysregulation.
78 Perspectives in Public Health l March 2014 Vol 134 No 2
Copyright © Royal Society for Public Health 2014 SAGE Publications Downloaded from rsh.sagepub.com at UNIV OF CONNECTICUT on April 13, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914523905
CURRENT TOPICS & OPINIONS cultural meanings in the three countries’: losses of £31–33 billion per year, lost taxes and higher welfare payments in the in Sweden – preparation for a responsible adulthood; in Spain – a range of £20–30 billion per year and cherished special time, mainly for direct National Health Service (NHS) children to learn; and in the United healthcare costs of £5.5 billion. Kingdom – rules and roles are less clear UNICEF, looking at a ‘mere handful’ of and children ‘are often left to their own illnesses where breast feeding is thought devices’. Children did not see material to have a protective effect, suggests that possessions as essential to wellbeing, the potential annual savings to the NHS apart from poorer children in the United from a moderate increase in breast Kingdom who used brands to cover feeding would be around £40 billion per social exclusion, but UK parents seemed year.5 The annual short-term costs of to feel ‘under pressure to purchase a emotional, conduct and hyperkinetic surfeit of goods’ while ‘compulsive disorders among children aged 5–15 consumption was almost absent in Spain years are estimated to be £1.58 billion and Sweden’. Inequality restricts access and in the long term to be £2.35 billion; for poorer children to creative, sporting the annual public sector cost of preterm or outdoor birth to age 18 is estimated activities, resulting at £1.24 billion, with total in a more societal costs at £2.48 there are concerns sedentary and billion (including parental that NHS reforms in disconnected costs and lost productivity).3 England will lifestyle. The approximate cost of a As societal range of preventable health increase service culture is and social outcomes faced fragmentation rather important, so is the by children and young than integration culture(s) within people over a 20-year and between period, according to services. Sir Ian research by Action for Kennedy’s7 report highlighted the Children and the New Economics Foundation, is £4 trillion.3 structural and cultural barriers that operate within the NHS and between it and other organisations, thus hindering The Effect of Child Poverty the provision of integrated, safe, costSocietal, Cultural and and Disadvantage on Adult effective services which optimise Political Inhibitors Health children’s health outcomes. With the A highly publicised There is growing evidence increasing health and social needs of an UNICEF report on in support of Barker’s It is now widely elderly population, children have a child wellbeing in ‘programming hypothesis’ accepted that disproportionately low priority in countries with the whereby adverse management, delivery and funding Organisation for intrauterine events intrauterine events during allocation. Additionally, there are Economic affect the foetal and infant life, concerns that NHS reforms in England Co-operation and development of importantly nutrition, can will increase service fragmentation rather Development permanently alter the cardiovascular than integration. (OECD), placed the hormonal and metabolic disease and stroke Why have policies to reduce child United Kingdom at processes for life.2 It is now poverty and health inequalities not the bottom of the widely accepted that worked? Law et al.8 suggest several league table. intrauterine events affect the Subsequent qualitative research, possible reasons, including the lack of development of cardiovascular disease comparing the United Kingdom to Spain sustained interventions delivered at and stroke, type 2 diabetes, chronic and Sweden,6 found that UK parents scale, and quote Mackenbach:9 obstructive airways disease and some appeared to face greater pressures, on ‘reducing inequalities in overall health is cancers.3 time particularly, and family roles, currently beyond our means’, his boundaries and expectations, which argument being that it would take a govern family life, were more clearly greater redistribution of resources than The Economic Imperative defined in Spain and Sweden. Rules and the UK population would be prepared to Marmot calculates that if everyone had roles differed to the extent that tolerate, and so is politically untenable. the same health outcomes as the richest ‘childhood seemed to have different Perhaps this again points to a societal 10%, we would save on productivity These changes in turn influence later educational attainment. Disadvantaged children may also have a depleted learning environment, and are often delayed in their social, emotional and language development when they start school, influencing their chances of benefiting from the most important social leveller of education.3 The ‘millennial’ morbidities in childhood include both mental health problems and obesity, both of which are strongly patterned by social determinants of health. Emotional and behavioural problems affect one in five children, and one in eight has a mental health condition.2 Those beginning early in childhood are strong predictors of educational failure, involvement with the criminal justice system, teenage pregnancy, smoking, and alcohol and substance abuse.3 The National Child Measurement Programme data show a consistent gradient in child obesity according to deprivation quintiles. Calls to reduce the obesogenic environment are welcome, but harder to achieve for poor children with their families’ reliance on cheap, fast-food outlets and decreased opportunities for free, safe exercise.
March 2014 Vol 134 No 2 l Perspectives in Public Health 79 Downloaded from rsh.sagepub.com at UNIV OF CONNECTICUT on April 13, 2015
CURRENT TOPICS & OPINIONS attitude to children that sees their potential, or lack of it, as being purely the responsibility of their parents and not an issue for society as a whole. Media reports tend to focus on the extremes of parental failure to manage their situations and provide for their children, and there is a need to value parenting and recognise the challenges many parents face.
Conclusion There is now a large accumulated evidence base from life course
epidemiological studies, developmental and neurobiological studies and the developing science of epigenetics, demonstrating the effects of social determinants on foetal and child health and on the future health and wellbeing of us all. The moral, and often understated economic imperatives, are well described and the argument for early preventive intervention frequently stated. The challenge will be to develop and share effectively the evidence base of what works. At times of great financial constraint and crisis management, this
will require child public health champions at all levels of the system, advocating for the most vulnerable in society. If we are successful, there will be a cultural change in our society which values children for who they are now, and who they will become in the future. Children, young people, their parents and carers will feel respected and supported by child and family orientated, joined-up public services, underpinned by strong child public health policy. ‘Rarely in health are there such opportunities to improve lives as well as show economic benefit’.3
References 1.
2.
3.
4.
The Marmot Review. Fair society, healthy lives: Strategic review of health inequalities in England post 2010. The Marmot Review, February 2010. BMA Board of Science. Growing up in the UK: Ensuring a Healthy Future for Our Children. 2013. Available online at: http://bma.org.uk/ working-for-change/improving-and-protectinghealth/child-health/growing-up-in-the-uk (Last accessed 30th January 2014). Department of Health. Our children deserve better: Prevention pays. Annual Report of the Chief Medical Officer, October 2013. Available online at: https://www.gov.uk/government/news/ chief-medical-officer-prevention-pays-ourchildren-deserve-better (Last accessed 30th January 2014). Spencer N. Health consequences of poverty for children. End Child Poverty, 2008. Available
5.
6.
online at: http://www.endchildpoverty.org.uk/ files/Health_consequences_of_Poverty_for_ children.pdf (Last accessed 30th January 2014). UNICEF. Preventing disease and saving resources: The potential contribution of increasing breast feeding rates in the UK. UNICEF Policy Document, 2011. Available online at: http://www.unicef.org/nutrition/files/ Preventing_disease_saving_resources.pdf (Last accessed 30th January 2014). UNICEF UK. Children’s well-being in UK, Sweden and Spain: The role of inequality and materialism. June 2011. Available online at: http://www.unicef.org.uk/Documents/ Publications/IPSOS_UNICEF_ ChildWellBeingreport.pdf (Last accessed 30th January 2014).
80 Perspectives in Public Health l March 2014 Vol 134 No 2 Downloaded from rsh.sagepub.com at UNIV OF CONNECTICUT on April 13, 2015
7.
8.
9.
Kennedy I. Getting it right for children and young people – Overcoming cultural barriers in the NHS so as to meet their needs. September 2010. Available online at: https://www.gov.uk/ government/publications/getting-it-right-forchildren-and-young-people-overcomingcultural-barriers-in-the-nhs-so-as-to-meettheir-needs (Last accessed 30th January 2014). Law C, Parkin C, Lewis H. Policies to tackle inequalities in child health: Why haven’t they worked (better)? Archives of Disease in Childhood 2012; 97(4): 301–3. Mackenbach JP. Can we reduce health inequalities? An analysis of the English strategy (1997–2010). Journal of Epidemiology & Community Health 2011; 65: 568–75.
RSH0010.1177/1757913914523905OtherOther
CURRENT TOPICS & OPINIONS
Why should we all focus on health inequalities in the foetus and early childhood? Just as children were treated clinically as mini-adults a century ago, do we dismiss them in terms of wellbeing, life chances and ability to be in control of one’s life as simply the responsibility of their parents? Dr Jane Ritchie, Vice-Chair of the Academy of Medical Royal Colleges Health Inequalities Forum, makes the case for an increased focus on the beginning of the life course and questions whether a change in societal attitudes may be needed to tackle these inequalities. Michael Marmot1 is clear that reducing health inequalities is a matter of fairness and social justice and is also vital for the economy. ‘Giving every child the best start in life’ is his prime recommendation in recognition that the effects of social disadvantage start before birth and accumulate throughout life, a theme reinforced by the British Medical Association (BMA) and the Chief Medical Officer (CMO).2,3
The Moral Imperative The United Nations Convention on the Rights of the Child (UNCRC) underpins the moral imperative to reduce health inequalities. Children have no control over the socioeconomic conditions into which they are born, but are clearly affected by them on their journey from total dependence to self-realisation as mature human beings. The idea that individuals can always be held responsible for their behaviours and lifestyle choices, a view prominent in the health inequalities debate, obviously does not apply. Health is much more than the result of personal choice, and is clearly influenced by the environment in which individuals are conceived, raised and age. Children do not choose to be born into poor families, or disadvantaged circumstances, to be exposed to maternal smoking, alcohol or poor nutrition as a foetus, nor maternal depression and poor stimulation in
mental health problems, violence, alcohol and substance abuse, involvement in the youth justice system and teenage parenthood. Poverty breeds ill health, but ill health also maintains poverty. The United Kingdom has one of the highest levels of inequality in the developed world, and rates of out-of-home care in Europe.2 Yet, children thought to be suffering significant harm from chronic failure of adequate parenting (manifesting as neglect or emotional abuse) are prioritised for a ‘forensic assessment’, that ‘can be intrusive and punitive, less cost effective, and less likely to encourage parental engagement’.2
infancy, or even poor diet, domestic violence and early school failure. The effect of ‘fuel poverty’ on the day-to-day lives and wellbeing of many children is often overlooked, and many other adverse environmental factors (such as housing, road safety, bullying) affect their ability to develop physically, emotionally and socially. Children adopt the lifestyle The Consequences of choices to which they have been Disadvantage and Poverty exposed, and those from a on Child Health disadvantaged background lack the The intergenerational cycle of emotional, intellectual and material disadvantage is largely passed across capacity to make lifestyle changes, once generations through pregnancy.4 Women in charge of their own destiny. It is the from poor families are more likely to cumulative experiences over time which suffer from ill health with poor nutritional are so insidious status and psychological problems, and detrimental more likely to smoke and less likely Children adopt to a healthy life to breast feed. Pregnancy the lifestyle trajectory. outcomes are poorer, and there is a choices to which consistent social gradient in Poverty is they have been one of a perinatal mortality. Poor babies are exposed number of more likely to be born small or socioeconomic early.4 Throughout childhood, factors which increased mortality and morbidity leads to disadvantage. It is also a from causes such as Sudden consequence of and compounder of Unexpected Infant Death, injury and others. Nearly one-third of children, and poisoning occurs proportionately to up to 70% in some areas of the United decreasing socioeconomic status.3 3 Kingdom, are growing up in poverty. Infant brains develop extremely rapidly Social disadvantage reduces parental in the first two years, and adverse capacity to meet their own emotional experiences such as high levels of needs, and the child’s, with a direct effect maternal stress and poor attachment, on the health and wellbeing of the child. lead to raised cortisol levels which have a There is also a vicious circle whereby the direct toxic effect on developing brain most vulnerable are susceptible to further structures and circuitry, leading to adverse experiences, giving rise to emotional and attentional dysregulation.
78 Perspectives in Public Health l March 2014 Vol 134 No 2
Copyright © Royal Society for Public Health 2014 SAGE Publications Downloaded from rsh.sagepub.com at UNIV OF CONNECTICUT on April 13, 2015 ISSN 1757-9139 DOI: 10.1177/1757913914523905
CURRENT TOPICS & OPINIONS cultural meanings in the three countries’: losses of £31–33 billion per year, lost taxes and higher welfare payments in the in Sweden – preparation for a responsible adulthood; in Spain – a range of £20–30 billion per year and cherished special time, mainly for direct National Health Service (NHS) children to learn; and in the United healthcare costs of £5.5 billion. Kingdom – rules and roles are less clear UNICEF, looking at a ‘mere handful’ of and children ‘are often left to their own illnesses where breast feeding is thought devices’. Children did not see material to have a protective effect, suggests that possessions as essential to wellbeing, the potential annual savings to the NHS apart from poorer children in the United from a moderate increase in breast Kingdom who used brands to cover feeding would be around £40 billion per social exclusion, but UK parents seemed year.5 The annual short-term costs of to feel ‘under pressure to purchase a emotional, conduct and hyperkinetic surfeit of goods’ while ‘compulsive disorders among children aged 5–15 consumption was almost absent in Spain years are estimated to be £1.58 billion and Sweden’. Inequality restricts access and in the long term to be £2.35 billion; for poorer children to creative, sporting the annual public sector cost of preterm or outdoor birth to age 18 is estimated activities, resulting at £1.24 billion, with total in a more societal costs at £2.48 there are concerns sedentary and billion (including parental that NHS reforms in disconnected costs and lost productivity).3 England will lifestyle. The approximate cost of a As societal range of preventable health increase service culture is and social outcomes faced fragmentation rather important, so is the by children and young than integration culture(s) within people over a 20-year and between period, according to services. Sir Ian research by Action for Kennedy’s7 report highlighted the Children and the New Economics Foundation, is £4 trillion.3 structural and cultural barriers that operate within the NHS and between it and other organisations, thus hindering The Effect of Child Poverty the provision of integrated, safe, costSocietal, Cultural and and Disadvantage on Adult effective services which optimise Political Inhibitors Health children’s health outcomes. With the A highly publicised There is growing evidence increasing health and social needs of an UNICEF report on in support of Barker’s It is now widely elderly population, children have a child wellbeing in ‘programming hypothesis’ accepted that disproportionately low priority in countries with the whereby adverse management, delivery and funding Organisation for intrauterine events intrauterine events during allocation. Additionally, there are Economic affect the foetal and infant life, concerns that NHS reforms in England Co-operation and development of importantly nutrition, can will increase service fragmentation rather Development permanently alter the cardiovascular than integration. (OECD), placed the hormonal and metabolic disease and stroke Why have policies to reduce child United Kingdom at processes for life.2 It is now poverty and health inequalities not the bottom of the widely accepted that worked? Law et al.8 suggest several league table. intrauterine events affect the Subsequent qualitative research, possible reasons, including the lack of development of cardiovascular disease comparing the United Kingdom to Spain sustained interventions delivered at and stroke, type 2 diabetes, chronic and Sweden,6 found that UK parents scale, and quote Mackenbach:9 obstructive airways disease and some appeared to face greater pressures, on ‘reducing inequalities in overall health is cancers.3 time particularly, and family roles, currently beyond our means’, his boundaries and expectations, which argument being that it would take a govern family life, were more clearly greater redistribution of resources than The Economic Imperative defined in Spain and Sweden. Rules and the UK population would be prepared to Marmot calculates that if everyone had roles differed to the extent that tolerate, and so is politically untenable. the same health outcomes as the richest ‘childhood seemed to have different Perhaps this again points to a societal 10%, we would save on productivity These changes in turn influence later educational attainment. Disadvantaged children may also have a depleted learning environment, and are often delayed in their social, emotional and language development when they start school, influencing their chances of benefiting from the most important social leveller of education.3 The ‘millennial’ morbidities in childhood include both mental health problems and obesity, both of which are strongly patterned by social determinants of health. Emotional and behavioural problems affect one in five children, and one in eight has a mental health condition.2 Those beginning early in childhood are strong predictors of educational failure, involvement with the criminal justice system, teenage pregnancy, smoking, and alcohol and substance abuse.3 The National Child Measurement Programme data show a consistent gradient in child obesity according to deprivation quintiles. Calls to reduce the obesogenic environment are welcome, but harder to achieve for poor children with their families’ reliance on cheap, fast-food outlets and decreased opportunities for free, safe exercise.
March 2014 Vol 134 No 2 l Perspectives in Public Health 79 Downloaded from rsh.sagepub.com at UNIV OF CONNECTICUT on April 13, 2015
CURRENT TOPICS & OPINIONS attitude to children that sees their potential, or lack of it, as being purely the responsibility of their parents and not an issue for society as a whole. Media reports tend to focus on the extremes of parental failure to manage their situations and provide for their children, and there is a need to value parenting and recognise the challenges many parents face.
Conclusion There is now a large accumulated evidence base from life course
epidemiological studies, developmental and neurobiological studies and the developing science of epigenetics, demonstrating the effects of social determinants on foetal and child health and on the future health and wellbeing of us all. The moral, and often understated economic imperatives, are well described and the argument for early preventive intervention frequently stated. The challenge will be to develop and share effectively the evidence base of what works. At times of great financial constraint and crisis management, this
will require child public health champions at all levels of the system, advocating for the most vulnerable in society. If we are successful, there will be a cultural change in our society which values children for who they are now, and who they will become in the future. Children, young people, their parents and carers will feel respected and supported by child and family orientated, joined-up public services, underpinned by strong child public health policy. ‘Rarely in health are there such opportunities to improve lives as well as show economic benefit’.3
References 1.
2.
3.
4.
The Marmot Review. Fair society, healthy lives: Strategic review of health inequalities in England post 2010. The Marmot Review, February 2010. BMA Board of Science. Growing up in the UK: Ensuring a Healthy Future for Our Children. 2013. Available online at: http://bma.org.uk/ working-for-change/improving-and-protectinghealth/child-health/growing-up-in-the-uk (Last accessed 30th January 2014). Department of Health. Our children deserve better: Prevention pays. Annual Report of the Chief Medical Officer, October 2013. Available online at: https://www.gov.uk/government/news/ chief-medical-officer-prevention-pays-ourchildren-deserve-better (Last accessed 30th January 2014). Spencer N. Health consequences of poverty for children. End Child Poverty, 2008. Available
5.
6.
online at: http://www.endchildpoverty.org.uk/ files/Health_consequences_of_Poverty_for_ children.pdf (Last accessed 30th January 2014). UNICEF. Preventing disease and saving resources: The potential contribution of increasing breast feeding rates in the UK. UNICEF Policy Document, 2011. Available online at: http://www.unicef.org/nutrition/files/ Preventing_disease_saving_resources.pdf (Last accessed 30th January 2014). UNICEF UK. Children’s well-being in UK, Sweden and Spain: The role of inequality and materialism. June 2011. Available online at: http://www.unicef.org.uk/Documents/ Publications/IPSOS_UNICEF_ ChildWellBeingreport.pdf (Last accessed 30th January 2014).
80 Perspectives in Public Health l March 2014 Vol 134 No 2 Downloaded from rsh.sagepub.com at UNIV OF CONNECTICUT on April 13, 2015
7.
8.
9.
Kennedy I. Getting it right for children and young people – Overcoming cultural barriers in the NHS so as to meet their needs. September 2010. Available online at: https://www.gov.uk/ government/publications/getting-it-right-forchildren-and-young-people-overcomingcultural-barriers-in-the-nhs-so-as-to-meettheir-needs (Last accessed 30th January 2014). Law C, Parkin C, Lewis H. Policies to tackle inequalities in child health: Why haven’t they worked (better)? Archives of Disease in Childhood 2012; 97(4): 301–3. Mackenbach JP. Can we reduce health inequalities? An analysis of the English strategy (1997–2010). Journal of Epidemiology & Community Health 2011; 65: 568–75.
