Why should we all focus on health inequalities in the foetus and early childhood?

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 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 choices to which they have been exposed, and those from a disadvantaged background lack the emotional, intellectual and material capacity to make lifestyle changes, once in charge of their own destiny. It is the cumulative experiences over time which are so insidious and detrimental to a healthy life trajectory.

Poverty is one of a number of socioeconomic factors which leads to disadvantage. It is also a consequence of and compounder of others. Nearly one-third of children, and up to 70% in some areas of the United Kingdom, are growing up in poverty. ³ Social disadvantage reduces parental capacity to meet their own emotional needs, and the child’s, with a direct effect on the health and wellbeing of the child. There is also a vicious circle whereby the most vulnerable are susceptible to further adverse experiences, giving rise to 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

The Consequences of Disadvantage and Poverty on Child Health

The intergenerational cycle of disadvantage is largely passed across generations through pregnancy. ⁴ Women from poor families are more likely to suffer from ill health with poor nutritional status and psychological problems, more likely to smoke and less likely to breast feed. Pregnancy outcomes are poorer, and there is a consistent social gradient in perinatal mortality. Poor babies are more likely to be born small or early. ⁴ Throughout childhood, increased mortality and morbidity from causes such as Sudden Unexpected Infant Death, injury and poisoning occurs proportionately to decreasing socioeconomic status. ³

Infant brains develop extremely rapidly in the first two years, and adverse experiences such as high levels of maternal stress and poor attachment, lead to raised cortisol levels which have a direct toxic effect on developing brain structures and circuitry, leading to emotional and attentional dysregulation. 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.

The Effect of Child Poverty and Disadvantage on Adult Health

There is growing evidence in support of Barker’s ‘programming hypothesis’ whereby adverse intrauterine events during foetal and infant life, importantly nutrition, can permanently alter the hormonal and metabolic processes for life. ² It is now widely accepted that intrauterine events affect the development of cardiovascular disease and stroke, type 2 diabetes, chronic obstructive airways disease and some cancers. ³

The Economic Imperative

Marmot calculates that if everyone had the same health outcomes as the richest 10%, we would save on productivity losses of £31–33 billion per year, lost taxes and higher welfare payments in the range of £20–30 billion per year and direct National Health Service (NHS) healthcare costs of £5.5 billion.

UNICEF, looking at a ‘mere handful’ of illnesses where breast feeding is thought to have a protective effect, suggests that the potential annual savings to the NHS from a moderate increase in breast feeding would be around £40 billion per year. ⁵ The annual short-term costs of emotional, conduct and hyperkinetic disorders among children aged 5–15 years are estimated to be £1.58 billion and in the long term to be £2.35 billion; the annual public sector cost of preterm birth to age 18 is estimated at £1.24 billion, with total societal costs at £2.48 billion (including parental costs and lost productivity). ³ The approximate cost of a range of preventable health and social outcomes faced by children and young people over a 20-year period, according to research by Action for Children and the New Economics Foundation, is £4 trillion. ³

Societal, Cultural and Political Inhibitors

A highly publicised UNICEF report on child wellbeing in countries with the Organisation for Economic Co-operation and Development (OECD), placed the United Kingdom at the bottom of the league table. Subsequent qualitative research, comparing the United Kingdom to Spain and Sweden, ⁶ found that UK parents appeared to face greater pressures, on time particularly, and family roles, boundaries and expectations, which govern family life, were more clearly defined in Spain and Sweden. Rules and roles differed to the extent that ‘childhood seemed to have different cultural meanings in the three countries’: in Sweden – preparation for a responsible adulthood; in Spain – a cherished special time, mainly for children to learn; and in the United Kingdom – rules and roles are less clear and children ‘are often left to their own devices’. Children did not see material possessions as essential to wellbeing, apart from poorer children in the United Kingdom who used brands to cover social exclusion, but UK parents seemed to feel ‘under pressure to purchase a surfeit of goods’ while ‘compulsive consumption was almost absent in Spain and Sweden’. Inequality restricts access for poorer children to creative, sporting or outdoor activities, resulting in a more sedentary and disconnected lifestyle.

As societal culture is important, so is the culture(s) within and between services. Sir Ian Kennedy’s ⁷ report highlighted the structural and cultural barriers that operate within the NHS and between it and other organisations, thus hindering the provision of integrated, safe, cost-effective services which optimise children’s health outcomes. With the increasing health and social needs of an elderly population, children have a disproportionately low priority in management, delivery and funding allocation. Additionally, there are concerns that NHS reforms in England will increase service fragmentation rather than integration.

Why have policies to reduce child poverty and health inequalities not worked? Law et al. ⁸ suggest several possible reasons, including the lack of sustained interventions delivered at scale, and quote Mackenbach: ⁹ ‘reducing inequalities in overall health is currently beyond our means’, his argument being that it would take a greater redistribution of resources than the UK population would be prepared to tolerate, and so is politically untenable. Perhaps this again points to a societal 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