Dangers in disparity: Impending issues in child health

Abstract

The improvement in child health is one of the most significant achievements of the 20th century. In Canada, a variety of performance measures document the dramatically improved living standards, health service quality and health outcomes. Infant mortality, accepted as one of the most sensitive indices of social welfare and public health (1), declined from 24.0 to 5.5 per 1000 live births between 1965 and 1999 (Figure 1) (2). This rate was ranked the fifth lowest infant mortality rate across countries in 1999. As an indicator of the general health of newborns and a key determinant of infant survival, health and development, low birth weight rate was 5.6% in 1999, low relative to countries like France, Germany, United States and United Kingdom. The overall life expectancy of 79.0 years in Canada, an increase of five years in the past two decades, and the second highest in the world in 1999, is in large part based on improvements in the early years of life. Despite ongoing concerns about the quality and sustainability of the health care system, more than 84% of Canadians were very much satisfied with the quality of the overall health services they received, according to the 2000/2001 Canadian Community Health Survey (3). Figure 1) Trends of infant mortality in Canada, 1965–1999 Although these great achievements of the 20th century should be enjoyed and celebrated, a closer examination of the statistics reveals some disturbing trends. One of the key values of the Canadian health care system is equity. We are striving to ensure that every child has good health as a resource for a happy and productive life. If the system is functioning, as we believe it should be, disparities in health outcomes across Canada should be decreasing as part of improvements that we observe. This is not the case. For instance, in reviewing the infant mortality rate in British Columbia from 1981 to 1996, Hu found that the declines in the infant mortality rate were not distributed equally across all regions of the province (4). In fact, the weighted coefficient of variation, which was a single measure developed to quantify the regional variation in infant mortality, tended to increase during the same time period. Further examination found that similar trends existed for both neonatal and postneonatal mortality rates. The postneonatal mortality rate, however, showed a significant increase in regional differences. The overall reduction of postneonatal mortality rate from 1981 to 1996 was 48%; the regional variation, however, increased by nearly 60% (Figure 2). Figure 2) Postneonatal mortality and its regional variations in British Columbia, 1981–1996 It is in the examination of the determinants of these health outcomes that the challenges become more obvious. Overall infant mortality is considered to be an aggregate measure of underlying social, environmental and genetic determinants, and perinatal health care services. The dramatic improvements across all regions and communities are a testimony to the advances in obstetric and paediatric care. Postneonatal mortality is considered to be more heavily influenced by social and environmental determinants, and it is in this statistic that we see the danger signal of a widening disparity (4). Reducing health inequity is one of the six specific objectives outlined under the first theme of Health Canada’s 2000 Sustainable Development Strategy (5). The health discrepancies that exist in Canada are not surprising. There is extensive documentation of the socioeconomic gradient in health (6). In Canada, the differences between Aboriginal and non-Aboriginal populations have long been noted. The life expectancies for Aboriginal men and women in 1999, for example, were 68.9 and 76.6, respectively, that is 7.4 and 5.1 years shorter than life expectancy for the general Canadian male and female population in the same year. Infant mortality was 8.0 per 1000 live births for Aboriginal people in 1999, almost twofold the overall Canadian rate in the same year (7). Such health disparities also exist among other strata of populations, including urban and rural regions, socioeconomic and culture groups, as well as across regions and provinces. Without appropriate action, these health inequalities are likely to persist and have an impact not only on the children now, but also on the adults that they will become. On both a personal and societal level, the downstream consequences of these early experiences can be overwhelming, and eventually may overshadow our achievements to date (8). Why do health inequities persist while the overall health status of Canadians is improving? Where are the opportunities to improve health? Our major efforts have been on risks and clinical factors related to particular diseases and individuals, most of whom already have a health problem or are at significant risk of developing one (9). Current research shows that the health status of young people in Canada is influenced by a wide range of social, cultural, physical and economic determinants, many of which lie outside the traditional health sector (8). It is therefore necessary to address these wider determinants of health. We need to continue to develop strategies to emphasize the broad range of health determinants in ways that are both comprehensive and integrated. We must recognize that ongoing improvements in health status can be achieved through a reduction in the disparity of the determinants of healthy child development, such as family income and housing affordability. Collaboration and active support across many sectors is necessary to raise healthy, engaged, and socially responsible citizens (9). Poor social and economic circumstances affect health throughout life. People further down the socioeconomic ladder usually run at least twice the risk of serious illness and premature death as those near the top. It has been confirmed that family income has a direct influence on children’s health and well-being (6,8). In Canada, however, the economic development has resulted in the rich becoming richer and a greater number of people living in abject poverty. In only two years, the number of children in Canada living in poverty had increased to 1.5 million, compared with 1.1 million in 1994 (8). Children living in the poorest income areas were at the greatest risk of dying as a result of injuries (10). As more immigrants come to form the cultural mosaic of Canada, the population will become more diverse with respect to culture, religion and perceptions on health. Twice as many children living in families with immigrant parent(s) who have been in Canada less than 10 years are of low-income status than children who live in families where neither parent is a recent immigrant. This difference has consistently increased from 1980 to 2000 (11). While medical care can prolong survival and improve the prognosis of disease, the social and economic conditions that make people ill and in need of medical care in the first place are more important for the health of the population. The connection between income and health cannot be readily explained by any other factors. Once a society reaches a minimal level of affluence, it is relative, rather than absolute poverty, which is associated with poor health outcomes (12). There is a profound association between economics, sociology, psychology, and neurobiology and medicine. It is not simply that poor material circumstances are harmful to health; the social meaning of being poor, unemployed, socially excluded or otherwise stigmatized also matters. With all these influences we become more prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health (6). It is our responsibility to continue to draw attention to the direct link between social and economic policies and the health outcomes of children, and to integrate this concept into our everyday practices. This challenging path is the only route to improved child health.