The 57th Boyer Lecture Series: Over four lectures and four weeks, the World Medical Association president, professor Sir Michael Marmot, explores the challenges communities face in solving issues of health inequality.
In episode two, professor Marmot explains how the good and bad things that happen in early childhood set the stage for health and well-being throughout a person’s life. “Early child development is influenced in part by quality of parenting or caring from others; which in turn are influenced by the circumstances in which parenting takes place,” he says.
You can listen to the lecture or read the transcript below.
Courtesy of The 2016 Boyer Lectures on ABC RN – on air and online
Professor Sir Michael Marmot: In October 2014, Peter killed himself. He was found hanging from a tree near his grandparents’ house in Geraldton Western Australia. He was an 11 year old Aboriginal boy. The death of any child is a tragedy, especially if he dies by his own hand. We can, and should, enquire into the particulars of Peter’s suicide. But we will understand his tragic fate better when we acknowledge that his story was far from unique. The youth suicide rate in Aborigines and Torres Straight Islanders is several times higher than in the non-Indigenous population of Australia. Among young Indigenous people, aged 15-19, the suicide rate in boys was four times higher, and in girls nearly six times higher, than the rate in non-Indigenous young people.
Why do so many young Indigenous people see no way out, and end their suffering in the most dramatic way possible?
We can think of suicide as a response to disempowerment – the last desperate attempt to control an uncontrollable situation. More generally, I think of health inequalities as resulting from disempowerment. Conceptually, we can view empowerment in three ways: material, psychosocial and political. Material: if you don’t have enough money to pay the rent or feed your children you cannot be empowered. Psychosocial means having control over your life. Political empowerment means having voice. Australia’s Indigenous population, and disadvantaged people, more generally, are disempowered in all three ways.
In this lecture I want to focus on a particular way of understanding troubled young people. We should be empowering children by helping them develop the personal resources that are key: good early child development.
Early childhood development, the good and bad things that can happen in early childhood, sets the stage for health and well-being through the life course. The mind is the gateway by which the social environment affects mental and physical health. Development of the mind is therefore crucial.
But first some context. I was commissioned by the UK government to conduct a review and make recommendations on how to reduce health inequalities in England. I published my review as Fair Society Healthy Lives. In the Marmot Review, so-called, I had six domains of recommendations:
First, give every child the best start in life.
Second: education and life-long learning to achieve the means of taking control over one’s life.
Third, employment and working conditions.
Fourth, every person should have the minimum income necessary for living a healthy life. What a radical idea for a rich society: everyone should be able to afford to eat.
Fifth, healthy and sustainable places in which to live and work.
The sixth is prevention: not just individual behaviour but looking at the causes of the causes
Although these recommendations were made for England, they have found ready take up in many countries. Action on these six areas is likely to improve health and reduce health inequalities among all Australians. It is tempting to see inequalities in health as the differences between Indigenous and non-Indigenous Australians. These inequalities are large, to be sure. But we also see inequalities within the non-Indigenous population – the social gradient in health that I introduced in the first lecture: the fewer the years of education, or the lower the income, the worse the health.
In my view, the reasons why Aborigines have worse health than the non-Indigenous population is because of inequality in these six groups of causes. There is not difference in kind but in degree: more adverse conditions in early childhood, fewer educational opportunities, fewer opportunities for good and meaningful work, low income, worse environments, and high rates of smoking, poor diet, alcohol and drugs.
With that in mind, we can then review evidence on early child development from wherever in the world the best evidence comes.
In Aldous Huxley’s dystopia Brave New World there were five castes. The Alphas and Betas were allowed to develop normally. The Gammas, Deltas and Epsilons were treated with chemicals to arrest their development intellectually and physically. The result: a neatly stratified society with intellectual function, and physical development, correlated with caste.
That was satire, wasn’t it? No relation with real life. We would never, surely, tolerate a state of affairs that stratified people, then made it harder for the lower orders, but helped the higher orders, to reach their full potential. Were we to find a chemical in the water, or in food, that was damaging children’s growth and their brains worldwide, and thus their intellectual development and control of emotions, we would clamour for immediate action. Remove the chemical and allow all our children to flourish, not only the Alphas and Betas.
Yet, unwittingly perhaps, we do tolerate such a state of affairs. The pollutant is poverty or, more generally, lower rank in the social hierarchy, and it limits children’s intellectual and social development. We should want that removed as if it were any other toxin so that children can develop their potential to flourish across the whole social gradient, not only at the top.
What happens to children in the early years has a profound effect on their life chances and hence their health as adults. At the heart of it is empowerment, developing the capacities to enjoy basic freedoms that give life meaning; and early child experiences have a determining influence on that development. Early child development is influenced in part by quality of parenting or caring from others; which in turn are influenced by the circumstances in which parenting takes place.
In Australia, the higher the income of parents, and the more education, the better do their children score on measures of early child development. Interestingly these inequalities are rather similar in Australia and Britain. We have been monitoring early child development in Britain and find that the more economically deprived a neighbourhood is, the lower the proportion of children, at age five, that have a good level of development: cognitive, linguistic, social, emotional and behavioural. There is a clear relationship: more deprivation means worse early child development. But that’s not all there is. Pick any given level of deprivation, and you will see that some local areas are doing better than others – they have a higher proportion of children ready for school.
These findings serve as a political litmus test. People on the right politically blame poor parenting; those on the left say it is poverty and deprivation. I say they’re both correct. The social conditions in which parents are trying to raise their children affect their ability to be “good” parents.
To test out the contribution of parenting activities to the social gradient in child development, a group of us at University College London analysed data from the Millennium Birth Cohort Study, a national study in England. Looking at fifths of household income, we saw a clear gradient: the lower the income the worse the early child development. We then asked mothers of children aged three: was it important to talk to a child? About 20% of mothers denied that talking to a child was important. And this followed the social gradient – the lower the income the more likely were mothers to deny the importance of talking to a child. We asked: is it important to cuddle a child? Is there anything in the world more fulfilling than cuddling a child? About 20% of mothers denied that it was important to cuddle a child aged three. Talking, cuddling, playing, reading singing – all those “normal” parenting activities – showed a social gradient: the lower the income the less frequent these activities.
Our analyses suggested that about a third of the social gradient in linguistic development and about half of the differences in social and emotional development could be attributed to differences in parenting. Think about these findings in relation to a family living in material deprivation, whether aboriginal or non-aboriginal. A do-gooder like me comes and says: you should read bed-time stories to your children. The response might be: I would if I were sure I had a bed, let alone a book. Remember the gradient, though. Families in the middle of the income range were, to be sure, engaging more with their children than the poor; but were engaging less than those with more income.
Finding that good child development is less common in deprived areas suggests one strategy for improving early child development: reduce deprivation and, more generally, inequality. Finding that for a given level of deprivation some areas are doing better than others suggests a complementary strategy: support parents and families. There is evidence of benefit from both strategies.
One measure of deprivation and inequality is child poverty. We can compare countries by looking at the proportion of children living in families whose income is less than 50% of the median. Of course, no society takes poverty as a given. The finance minister can use the tax system to redistribute income. He (ministers of finance are rarely she – perhaps things might be better if they were) can also apportion benefits to the needy: so-called social transfers. Some countries use these mechanisms more than others and thus policy can have marked differences in its effect on child poverty. I was writing about this for an American publication and wanted to compare the US with another country. I thought if I took Sweden as my comparator, Americans would say Sweden?! A Marxist-Leninist hell hole. So I chose Australia. To some Americans, Australia sounds a bit like Texas. Or perhaps California.
In the US before actions by the minister of finance, 25% of children were in poverty, defined as households at less than 50% of the median national income. In Australia, 28% were in poverty. In the US, after taxes and transfers, poverty levels were reduced just a little, from 25% to 23%. But in Australia poverty levels dropped from 28% to 11%.
The editor of the US publication for which I was writing said: “I think we should take this section out. I think you are talking about redistribution and there is no appetite for that in the US.”
I replied: “I am talking about redistribution. If there is no appetite for it in America, that is precisely why we should leave it in.”
The editor said: “OK. But I don’t get it. I know what taxes are. But what are transfers?”
“They’re benefits paid.”
“Let me see if I understand this” said the editor. “You are saying that in Australia middle income earners, let’s say, pay taxes and that money provides money and services to poorer people?”
“Really,” he said, “some countries actually do that!?”
Australia uses taxes and transfers to reduce inequality and child poverty to a far greater extent than the US does. There are grounds for pleasure but not complacency for two reasons. First, many countries have a fairer distribution of income and lower child poverty than Australia. In Report Card 13, the latest report on inequalities in child well-being from UNICEF, Australia ranks behind 15 other countries on child poverty. These 15 countries include Korea and Slovenia as well as the usual suspects: the Nordic countries, Switzerland, Netherlands, Germany and France. The second reason not to relax in a haze of self-congratulation is that within Australia there are great pockets of deprivation, most notably the Indigenous communities that I have been discussing.
Here the second strategy comes into play, supporting families and children, whatever the level of deprivation. Not long ago, I got on my bicycle and peddled off to Hackney, traditionally a very deprived area in East London. Now, it shows the economic and social gradient in pure culture, ranging from pockets of deprivation all the way to rapidly gentrifying areas where house prices are beyond the reach of mere university graduates. I showed graphs of the link between deprivation and poor early child development and poor school performance. The head of education said:
“Your figures are out of date!”
That was hitting me where it hurt. “What do you mean?”
She said: “We tell ourselves everyday: poverty is not destiny! We have broken the link between deprivation and poor early child development.”
Indeed they have. One way of looking at family poverty is to use eligibility for free school meals as a marker for poverty. These children, eligible for free school meals, score worse than the average on various measures of development at the end of the first, reception, year of school. In Hackney, though, the gap is tiny. The difference in early child development between the deprived children and the average is hardly discernible. In more affluent parts of England, however, the gap is huge. Poverty is not destiny. Having quality pre-school services and educationalists who are committed to bringing the performance level of deprived children up to that of the average makes a major difference. My guess is that in more affluent parts of the country, where deprived children are more of a rarity, they are not geared up to deal with the problem. Poverty is not destiny.
There is a particular policy that can make a big difference to strengthening maternal and paternal bonds with the child, which are so vital in the early months of a child’s life. Paid maternity (and paternity) leave enables these bonds to develop while reducing financial disadvantage. Jody Heymann, at UCLA, has looked at the arrangements for paid maternity leave globally. The USA stands out as providing no – I repeat no – state-guaranteed paid maternity leave. It is not alone, however: neither Suriname nor Papua New Guinea provide state-guaranteed paid maternity leave. Every other country does.
To this point I have been discussing the good influences parents can have on children. We should look, though, not only at lack of positive generative activities but also at the presence of harmful influences – what have been styled Adverse Child Experiences.
A study in San Diego California was called ACE, the Adverse Child Experiences Study. People were asked if, during their first eighteen years of life, they had experienced any of three categories of childhood abuse: psychological – being frequently put down or sworn at, or in fear of physical harm; physical; and sexual – four questions about being forced into various acts. They were also asked about four categories of household dysfunction: someone they lived with a problem drinker or user of street drugs; mental illness or attempted suicide of a household member; mother treated violently; criminal behaviour in the household.
People love to quote Nietzsche: that which does not kill us makes us stronger. Well, it doesn’t actually. It makes us more likely to get sick. If we think of those who report no adverse experiences as the reference group, compared with them, the more different types of adverse experience a person had, the greater the risk of depression and attempted suicide. People who had four or more different types of adverse childhood experience had nearly five times the risk of having spent two or more weeks in depressed mood the previous year, and twelve times the risk of having attempted suicide. It took a while but now you see the link with suicide. More adverse child experiences, common in deprived disrupted and marginalised aboriginal communities, more suicide attempts – some of which fulfil their grisly aim.
Remember the story of Peter’s suicide with which I began this lecture. In general, the more types of adverse childhood experience, the more likely people were to describe themselves as alcoholic, to have injected drugs, to have had fifty or more sexual partners. Further, the more adverse experiences, the higher the risk of diabetes, of chronic obstructive pulmonary disease (bronchitis or emphysema), stroke and heart disease.
The Adverse Child Experience Study was not a one-off. A review of 124 studies confirmed that child physical abuse, emotional abuse and neglect are linked to adult mental disorders, suicide attempts, drug use, sexually transmitted infections and risky sexual behaviour. One haunting finding from the UK: half the adult perpetrators of domestic violence had been abused as children. Even more chilling: half the victims had been abused as children. Adverse child experiences have a long reach and they are more frequent lower down the social spectrum, thus contributing to the social gradient in adult mental and physical health.
The evidence we have just gone through helps with a current debate: isn’t health a matter of personal responsibility? If people fail to heed advice about smoking and healthy life style they have no one to blame but themselves. I invite you to go into a deprived community in Sydney or Melbourne, let alone the fringes of a benighted country town and start lecturing people about healthy eating. To put it politely, you would be given short shrift. It is not ignorance of the health consequences that lead to unhealthy behaviours. Making ends meet, avoiding violence and other crime all take priority. People are not responsible for the social forces on their life. Get the social conditions right, ensure optimal early child development, and then, of course, people can be expected to take responsibility for their own health.
My antidote to political prejudice – blaming the poor for their own misfortune – is evidence. I was lecturing to a meeting of the American Public Health Association – 7,000 people in the room. I showed them the high level of child poverty, post taxes and transfers, in the US compared to other countries, and said:
“You live in a democracy. This must be the level of child poverty that you want; else you would elect a government that reduced child poverty.” The audience looked uncomfortable.
Then, I said: “Republican, Democrat, I couldn’t care less. This is our children’s futures that are at stake. Is there a politician in the land who would not care about the nation’s children?”
A voice called out: “You’d be surprised.”
I am acknowledging that taking action on health inequalities requires political action. I have tried hard not to make it party political. People have said to me that you will never get governments to act unless you can show that there would be financial benefit. If there is financial benefit from taking action on social determinants of health, fine. But that is not why I am doing it. On the cover of the Report of the WHO Commission on Social Determinants of Health we said: Social Injustice is killing on a grand scale. The social injustice of condemning some children to a poor start in life should not be tolerated.
A poor start in life, of course, affects everything that happens subsequently, the kind of job you do, the amount of money you earn and these, in their turn will affect health. These are the issues to which I will turn in the next lecture.
Authors: Michael Marmot, Director, Institute of Health Equity; Professor, Dept of Epidemiology and Public Health, UCL