This is an important book. It challenges the reader to respect our society’s fundamental values in our approach to the problems of children living in disadvantaged conditions. It is a sober, documented, eloquent, often heart rending appeal for action, action to remedy problems. But what kind of problems?

In the spring of 2008 the Montréal Public Health Department published a report on children’s school readiness. On average, 35% of Montréal children were not ready for school. In the most disadvantaged areas this rate rises to 46%. We know these findings have social origins and quite often, serious social consequences. However, after one day’s headlines and a few comments, this would be forgotten like yesterday’s news.

And yet, these findings represent a human and a social disaster. Children are our future. How can we sideline one third of our future population from fruitful participation in a society that needs them? An enterprise loosing one third of its production would not survive.

When we look at the children behind these numbers, what do we find? We find children that have developmental delays in language, in motor and social skills; they have a reduced attention span and abnormal activity levels.

Why is this? What is their family history likely to be? Parents of such children often have a small family circle and lack a support network. They feel isolated, excluded, insecure, and discriminated.  They have few opportunities or choices. They lack access to transportation and are often un- or underemployed. Their housing is poor. They have a high incidence of chronic illnesses. As a consequence, such parents do not feel good about themselves, they feel “down” and are often depressed. They are tired of struggle, often afraid, frustrated, and their minds are filled with worries. Things appear hopeless, and their dreams die. Substance abuse is common. In such circumstances their behavior with their own children is characterized by impatience and an inability to listen. They never have time to pay attention to their children, bedtime stories are rare but neglect and abuse of all kinds is common.

What is the child’s experience? A child growing up in such circumstances is likely to lack attention, love, food, sleep, stimulation, good experiences, opportunities to challenge him – or herself, consistency, praise, and a feeling of success.  Abuse is frequent. The physical environment is poor. It is noisy, dirty, unsafe, and filled with traffic. There are few public sports facilities or parks to play in.

And what are the consequences of such experiences? These children are likely to be tired, hungry, and have little interest in anything.  Their activity levels may be abnormal, their impulse control – poor and they may lack empathy. There is a reduced capacity to learn, which accentuates feelings of failure. Social skills are poor and recourse to violence is frequent. Dreams are absent or die early. Their life takes place in a blighted urban environment that offers little contact with nature or with cultural activities.

What happens as the child grows older? The child’s story is likely to be one of school failure, resulting in a lack of education and poor skills that lead to early unemployment. Then there is frustration acting out, and violence. Disappointment, exclusion, and a poor self-image lead to drug abuse, illness, and antisocial behavior. There will be a huge need for public services – health, support, rehab, security– and a shortened life span.

These observations on the impact of the social environment are not new.

In the 19th century Manchester it was recorded that the mortality of people living in a poor section of the city was 78% higher than of those living in better neighborhoods.

The infant mortality experienced by the royal families of Europe in the 1850s was not achieved by the population of any country until one hundred years later.

Better housing, nutrition, and working conditions were largely responsible for the decline in the mean annual mortality from tuberculosis in England and Wales from 4,000 in 1840 to 500 by the time the first effective antibiotic became available in 1948.

More recently, the “Whitehall Studies” demonstrated beyond any doubt that a person’s status and the level of control exercised over life’s activities has a direct impact on illnesses and life expectancy.

A WHO (World health Organization) summary of hundreds of studies confirmed the strong impact social conditions have on the health and longevity of people according to the stress they live under.

More recently we have understood how this relationship between the environment, the development of the human being, and health operate. An infant’s brain develops progressively. Simple structural frameworks come first, and progressively more complex internal relationships develop in response to the intensity, frequency, and nature of sensory and perceptual experience. Positive experiences, by their frequency and intensity strengthen pathways, increase interconnections between brain cells and build capacity.  The brain’s development is influenced most strongly before the age of three or four, after which its capacity to change reaches a lower steady state by about six or seven years of age .

We know that programs aimed at stimulating preschool children living in poverty, the cost of which is modest in contrast to those of later less effective corrective services, have a tremendously favorable effect on development, with measurable positive outcomes still evident three decades later.

We have learned that stress, when caused by persistent adversity becomes toxic because of its severity and duration. It leads to a prolonged increase of steroid secretion, which leads to the death of cells in certain areas of the brain, and to a delay in forming connections with higher brain centers as well as to a loss of connections already made.

The result? A smaller brain, a lower IQ, and an abnormal function. This altered function is expressed as a decrease in attention span, in control of activity and of emotions, in ability to learn and in empathy. Impulsivity is increased, as is an early recourse to violence.

By the time the child becomes an adult, the continued higher steroid levels will cause an increased incidence of chronic problems such as diabetes, cardiovascular disease and cancer. Life ends early.

Do we have proof of this in Montréal? Yes, we do. The average life expectancy in good health in Montréal (1999-2001) was 66.2 years. In the higher income CLSC area of Lac St. Louis it was 77.1 years. In the lower income CLSC area of Les Faubourgs it was 58.9 years. In the same city some people’s lives in good health is shortened by almost twenty years, because of where they live. As we know, this was already noticed in Manchester over one hundred years ago. Are we the fair and just society we claim to be?

In recent years we have learned that toxic stress also changes the expression of our genes. Research has shown that pregnant animals, if stressed, will give birth to female offspring that will become fertile earlier than normal, will behave differently and will themselves become pregnant when very young.  These stress induced biological changes seem to be inherently stable and persist into the next generation.

Does this apply to human beings? In Montréal, the teenage pregnancy rate in the CLSC area of Lac St Louis is 10%. In the Hochelaga-Maisoneuve CLSC area, being one of Montréal’s poorest, where social stresses are high, and where the incidence of children’s lack of school readiness stands at 46% , the teenage pregnancy rate is 65% .

In summary, then, what have we learned about child development, about the impact social determinants have on this process and about related social consequences?

We have learned that genes and experience determine brain structure; that brain structure and capacity develop progressively from the simple to the complex; that toxic stress during pregnancy and in early childhood leads to damage of the brain’s structure, and to persistent changes in the function of the nervous and hormonal systems that lead to potentially life long problems with learning, behavior, mental and physical health and to a shorter life.  We have learned that assuring favorable conditions for development in early childhood is better than early intervention, which is better than late intervention. We know that normal child development leads to a capable adult, to a productive and civilizing citizen and to a prosperous, sustainable society. On the other hand, we have also learned that abnormal child development leads to an incapable adult who is likely to be a dependent, non-productive citizen prone to exhibit antisocial behavior and to be both a burden and a danger to the society.

Our society has not succeeded in solving this fundamental problem of equity. The authors of this book propose an approach to do so. From successful experience they describe a way to heal present injury as well as to prevent it in the future.

They point out that by respecting the rights of the child, the social determinants of health will be favorable for the full development of each child’s potential. They point out that this is everyone’s responsibility. It is the highest responsibility we have as human beings.