The Editor's Letter
Enabling child health is the main focus of my career. While I am often inspired by the great strides that have been made in terms of fostering child health, my many encounters with children and their families, healthcare providers and health system policy and decision-makers also make me acutely aware of the significant health-related obstacles young people still confront. Very few – if any – of us are satisfied with the current state of children's health. We know we can do better, and we believe we ought to do more. In order to bring about positive changes for children, we must move swiftly, decisively and in a carefully planned and coordinated manner.
This journal series – Child Health in Canada – was born out of a spirit of collaboration and a fierce determination to improve children's physical and mental well-being. It is also a call to action to address the specific issues that impede children's health. The goals of the series are not tame; its aims are to inform public policy and to improve systems of care across the country and, in so doing, to enhance child health outcomes.
My vision for this series is also anchored in pride and optimism. These feelings arise from working with brilliant, talented and passionate child health experts, individuals who are motivated to improve the lives of children in our communities, schools, homes and hospitals.
Child Health in Canada will be composed of four issues, each one focused on a theme that is critical to the overall subject:
- Social determinants of health
- Mental health
- Health systems performance
The remarkable team of authors assembled for this series represents diverse educational and professional backgrounds. It includes influential policy makers, leading scholars, experienced decision-makers and dedicated care providers. Uniting all these authors is a passion for achieving optimal health for all children, a commitment to knowledge sharing, the courage to ask difficult questions and a profound sense of the rightness of championing genuine – if sometimes uncomfortable – dialogue.
I am deeply grateful to Longwoods Publishing for taking up my challenge to explore at length the unique world of child health in Healthcare Quarterly. My editorial board also deserves sincere thanks and credit; its members generously committed their time and expertise to ensuring the quality and relevance of the material you will encounter in this series.
Social Determinants and Child Health
This first issue of our Child Health in Canada series investigates social determinants and their relation to child health. Fundamental to a consideration of health for people at any age, the social determinants of health have been defined by the World Health Organization (n.d.) as "the conditions in which people are born, grow, live, work and age, including the health system." These conditions, the same definition notes, are the primary factors determining health inequities within and between countries. And that is a serious concern, for, as Avram Denburg and Denis Daneman state in their contribution to this issue, "Where inequality thrives, health does not."
Throughout both the industrialized and developing worlds, there is a widespread desire to lay a foundation for and then build young people's optimal physical and mental well-being. Here in Canada and most other countries, however, the playing field is not at all even. The evidence overwhelmingly shows that social determinants such as socio-economic status, education level, language, culture/ethnicity and access to medical services and technologies affect not only children's health but also, as several contributors remind us, their social, economic and medical futures as adults. In Clyde Hertzman's words, "What happens to children in their earliest years is critical for their development throughout the life course."
Theories and Consequences
The first three essays in this issue explore the topic of social determinants and child health from approximately the 10,000-foot level. Neal Halfon, Kandyce Larson and Shirley Russ begin the discussion by reviewing evidence on the nature of social determinants and their mode of operation within "the social ecology of childhood." Central to the authors' analysis is the theory that "non-biological influences" function in "dynamic nested systems of mutually reinforcing interactions at individual, family and community levels." As a result, "incremental change strategies" involving the addition here and there of new programs are insufficient for addressing the "wide range of disturbances" that can undermine children's developmental health. The authors' seven strategies for transforming children's health and social systems are, instead, "comprehensive and integrated," operate through multiple channels and include both overarching national policies as well as more local "place-based initiatives."
Zeroing in on the connections between social inequality and health outcomes, Avram Denburg and Denis Daneman address experience-based brain development (neural epigenetics), societal gradients and the social policy implications that arise from those considerations. "Inequalities in child health outcomes trace an impressively linear socio-economic gradient," the authors contend. While poverty and ill health are strongly associated, so too, Denburg and Daneman argue, are "the effects of relative social or socio-economic inequality." The authors therefore caution that emphasizing policies aimed exclusively at stimulating economic growth will not succeed in improving overall health. Rather, they call for a "synergistic" approach, one that addresses socio-economic conditions and "the importance of mitigating disparities in social circumstance." The solutions Denburg and Daneman present in their conclusion are striking in their simplicity and good sense. Whether Canada is ready to move forward with their implementation is another matter.
Social geography is a field of inquiry I find hugely informative. In his article, Clyde Hertzman follows that discipline's theoretical contours in order to explore children's developmental health as it is shaped by their interactions with other people in their "intimate environments." Not unlike Denburg and Daneman, Hertzman focuses on both economic and social resources. He presents a layered environmental framework that maps various intersecting influences on "the quality of children's early experiences." Use of the Early Development Instrument (EDI) at the neighbourhood level, for instance, has been shown to have greater analytic and explanatory power than random sampling for illuminating the factors that support or undermine child development. The statistical rigour associated with the kind of EDI health mapping Hertzman has conducted (and that Ted McNeill also endorses in his article) will prove indispensable not only for cross-jurisdictional and temporal comparisons, but also for forging solutions that can reduce children's developmental vulnerability.
Social Determinants in Context
The second section of this issue offers two contextualized accounts of the effects of social determinants in specific contexts: Aboriginal and immigrant children. Brian Postl and Michael Moffatt's article reviews the disturbing health disparities afflicting First Nations, Inuit and Metis children in Canada. Taking strong account of the impact of European colonization/colonialism, Postl and Moffatt emphasize the ongoing effect of legislation, policies and social determinants on Aboriginal social organization and health status. On the topic of harnessing social determinants in the interest of improved health, the authors argue not only for better education and housing but also for de-colonization "countermeasures" that include "processes that support self-determination, restore cultural pride and heritage and establish clear methods for acknowledging and dealing with racism." Postl and Moffatt conclude with three case histories that dramatically – and depressingly – illustrate the susceptibility of Aboriginal children to the "heavy burden of illness" wrought by social determinants.
Tony Barozzino is the chief of the Department of Pediatrics in the Inner City Health Program at Toronto's St. Michael's Hospital. In this role, he often encounters the uniquely challenging difficulties associated with providing healthcare for Canada's growing immigrant population. At the level of social determinants, Barozzino cites extensive evidence showing that immigrants are more susceptible than Canadian-born people to public policy–influenced risk factors (e.g., food security, gender and housing). Additional obstacles include immigrants' perceptions of authority figures, their levels of education, their linguistic facility and care providers' own assumptions and beliefs. Barozzino gives credit to the hard work individuals and community-based organizations are doing to care for immigrant children. Yet, he is also adamant that healthcare providers and policy makers must be active and honest in evaluating how well they are serving immigrant children's needs and, where there are shortcomings, rapidly developing solutions.
The third section of this issue addressing the social determinants of child health presents two considerations of the role of public and institutional policies. My colleague Ted McNeill, director of social work and child life at The Hospital for Sick Children, contributes to this discussion with a call to hospitals and governments to create and implement policies and practices that directly address the "social injustice of health inequalities." In no uncertain terms, McNeill underscores the service gaps, structural barriers and policy shortcomings that lead to increasing acuity among Canadian children. Targeting poverty's "toxic effect" on health and the widening gap between the rich and poor in Canada, McNeill argues that supporting families' ability to care for their children is essential for both health and economic reasons. In this regard, he pays special attention to the "social context" in which families thrive or wither and, drawing on examples from several Nordic countries, shows that generous government-supported social programs and successful economies can coexist. We must rely on "evidence, not ideology," McNeill urges, when looking for the international best practices on which to model Canada's family-focused health equity initiatives.
Following on from McNeill's piece is an article that lays out policy approaches – conceptual models used by decision-makers – for enhancing child health by tackling the social determinants of health. Adalsteinn Brown, Wendy Katherine, Katy Allen, Uyen Quach, Elizabeth Chiu and Lauren Bialystok bring considerable government knowledge and experience to their argument that improving child health requires a "comprehensive, joined-up approach" across ministries, agencies and providers. The authors reframe their topic through the inter-generational concept of population health inheritance (PHI), which "focuses on policies improving the societal asset of health passed from adults to children." They argue convincingly that public policies must align with a life course approach (see Australia, the United Kingdom, New Zealand and Nova Scotia), pay closer attention to transitions that occur at "developmental interfaces" and support multidisciplinary care. In order to help PHI to take root in Canadian soil, the authors recommend policy makers consider the Health in All Policies (HiAP) model, a high-level policy-alignment approach to population health employed in several European countries.
As I noted at the outset of this editorial, the next issue in our Child Health in Canada series will be devoted to the subject of mental health. As a way of looking ahead to that exciting issue, we decided to conclude the present one with the record of a conversation I recently had with Michael Kirby, the chair of the Mental Health Commission of Canada. Kirby is forthright in his assessment of the state of public perceptions, policies and services for young people combating poor mental health. Social stigma, government underfunding, human resources shortages, system and service fragmentation: these are some of the principal challenges that must be resolved if we are to deal effectively with children's mental health. As Kirby makes clear, failing to help children and youth achieve good mental health will result in dire consequences for individuals, families, society and the economy. Like me, I believe you will be struck by Kirby's call for "pragmatic" steps to improving Canada's mental health system, as well as by his concluding "optimistic" vision of a healthier tomorrow for our country's children brought about by swift and decisive actions today.
– Mary Jo Haddad, RN, BScN, MHSc, LLD, CM
President and Chief Executive Officer
The Hospital for Sick Children
About the Author
Mary Jo Haddad, RN, BScN, MHSc, LLD, CM, President and Chief Executive Officer, The Hospital for Sick Children, Toronto, Ontario
World Health Organization. n.d. Social Determinants of Health. Geneva, Switzerland: Author. Retrieved August 30, 2010. <http://www.who.int/social_determinants/en/>.
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