There is a great deal of confusion when it comes to the issue of child poverty. Who are these children and what are the consequences of this poverty on their health and well-being? Where do they live? How many are there in Quebec and in Canada in general, and, for that matter, around the world? Is poverty real or only the cause of the complex social problems faced by these children, problems that lead to an irreversible loss of human and social capital?

Poverty is relative and can endure over time. It has always existed and in many different contexts, its impact varying as a function of various individual, cultural, and environmental factors. In today’s society, poverty continues to exist, even worsen, in many communities to the point that it impacts all facets of children’s lives.

Campaign 2000, an initiative of the Canadian Chamber of Commerce, set the goal of “eliminating child poverty in Canada by the year 2000.” However, according to its last report in 2014, 1.3 million children—that is 1 in 5 children—are still living in poverty. In fact, child poverty increased from 15.8% in 1989 to 19.1% in 2014 [1].

If we compare Canada to other countries, the situation is even more worrisome. A 2013 study concluded that “13.3% of children live in households with equivalent incomes lower than 50% of the national median after taxes and transfers, ranking Canada 24th out of 35 industrialized nations.”[2]

Where do we go from here? Do we continue to denounce and attack the problem in the same old way? Do we sweep it under the carpet? Or do we try to look at the problem in a new way, focusing on approaches that are effective and efficient while also respecting the rights of children?

To add to the complexity of the problem, there appears to be no direct, inevitable link between child poverty and the negative effects that we observe in many of the children affected by poverty. It is clear that children living in the same conditions, sometimes even in the same family, respond differently to poverty and its effects. In fact, some children turn out just fine; we call such children ‘resilient” for they seem to be somehow protected or “inoculated” against the effects of poverty [3]. This suggests that we can take preventive measures to counter the effects of poverty.

Action on eliminating child poverty must target the significant social inequalities that extend far beyond just economic poverty.

As we know all too well, humanity has great difficulty in ensuring that everyone is given the same chance to succeed in life. However, a family’s financial situation—rich or poor—is not what counts when it comes to ensuring the overall well-being of children. In fact, it is well known that many families living in precarious financial circumstances are more successful in this regard than well-off ones. That being said, we do know it is more difficult to get ahead when a child starts out in disadvantaged circumstances.

The State too has difficulty ensuring that all children have the same chance in life. Governments feel free to repeatedly cut services to our most disadvantaged—every day we hear about new cuts to services in our schools, hospitals, CLSCs2 and other essential services. The net effect on vulnerable, the so called “poor” neighborhoods is catastrophic and only feeds the development of greater poverty and inequality. Can we not do better than this?!

Throughout the world, children are often the first victims of extreme poverty. Children are vulnerable and at the mercy of just about everyone, from the unscrupulous to those who do not think twice about using them as objects, cheap labor or cannon fodder.

The field of medicine often finds itself ill-equipped to deal with children suffering the effects of poverty. Its time is taken up with the physical consequences of poverty and the necessary fight against life-threatening diseases, leaving very little time for prevention and the more psychosocial diseases that nevertheless cause a great many medical problems, including hospitalizations and deaths.

Although the concept of “new morbidities” has been around for decades, it has still not gained significant traction and is used but timidly in the clinical setting. This is despite these psychosocial morbidities being a long-term cause of many physical disorders, such as cardiovascular disease, diabetes and hypertension, all major concerns in medicine today.

In recent years there have been significant advancements in our knowledge and in research, particularly in the neurosciences, on the impacts of toxic stresses on the development and functional specialization of the brain [4]. However, the medical interest is still not there, available tools are suboptimal or not being used, and the time needed to properly invest in the problem is limited.

It is the cumulative effect of different toxic stresses on families and children that is key, for this is what exerts the greatest harm on children’s health and well-being, not to mention family equilibrium, which can do miracles but only when it remains intact.

Faced with this somber portrait, perhaps it is time to rethink our approach, time to change the discourse and our way of doing things, time to focus on concrete actions at the level of the individual child. So that we can all succeed, once and for all.

I propose that we reinvent/rehabilitate social medicine.

I propose that we leave to others the task of taking on the “capitalist monster” that is incapable of guaranteeing social equality. I propose that we use basic human values and the strength of communities found everywhere and in all political systems, whether capitalist, socialist or otherwise, to create, together, a form of progressive social equality for all children.

The real causes and their consequences

There are two main determinants of child health and development: the quality of bonds created between the child and others, and the living conditions and environment in which the child grows up.

Strong bonds are clearly the most powerful tool for fostering the development of the skills and motivations needed for global health and well-being [5]. Such bonds cannot be bought and they in fact have little to do with poverty. They involve a combination of love, guidance and availability that ensures the child’s basic needs are met and the child does not fall between the cracks. They are linked to the notion that it takes a village to raise a child and so relate to the health and mobilization of communities.

A significant attachment to parents and later to a teacher or mentor can help ensure the security and motivation needed for the child’s healthy global development. The creation of a significant bond is a personal investment that links two people, involves no monetary remuneration and carries a deep emotional connection. Such a link creates in the child, and even in the adult, a desire to please, to achieve, and to make the other happy, as well as an incomparable state of well-being that is conducive to success. It also serves to build resilience in the long term, an effect that mobilizes the individual’s strengths and prevents uncontrollable and toxic anxieties.

A child deprived of essential human bonds cannot develop properly or preserve good health [6]. They are at risk of falling prey to various physical disorders, developmental difficulties, and social and mental health problems.

It is clear that the creation of human bonds that is essential in conditions of great poverty are perturbed by mental illness in family members, or alcohol and drug addiction in parents. It is also true that rich and poor alike can suffer from such effects.

Social medicine can act as a catalyst and set the stage for bringing together the family, care providers, and other involved citizens with the goal of working together for the well-being of the child. In social pediatrics, the Child’s Protective Circleis a good example of mobilizing to find solutions for problems linked to the violation of children’s rights. The doctor and associated care providers can also become important significant individuals for the child, even mediators for their health and well-being.

Living conditions and the surrounding environment have a direct influence on the availability and accessibility of tools that can foster the child’s healthy development and well-being. Because overall good health is essential to success throughout the child’s trajectory. Difficult living conditions and the resulting toxic stresses also cause significant disease and deficiencies, which in turn can lead to major deficits.

The poorer you are, the more likely you will lack the resources to properly care for your children [4]. Unsanitary housing, for example, often leads to chronic diseases, in addition to creating harmful anxiety, school absenteeism, sleep disturbances, frequent use of medications, impaired ability to learn, and a feeling of helplessness—all of which have negative effects on one’s development and well-being.

Seen from another angle, the more resources are lacking, the more stress accumulates and the greater the risk of going off track; exposure to violence, drug addiction, abuse, and negligence are frequently the fate of children exposed to continued poor living conditions [7; 8; 9; 10]. What follows, too, is more frequent involvement of child protection services, higher rates of early school abandonment, an attraction to criminality and, ultimately, the perpetuation of global and unjust poverty from one generation to the next.

It is such blatant social inequalities linked to poverty that clearly harm children, many of whom also find their rights violated at the same time because of such poor conditions.

We now better understand how an absence of stimulation and traumatic phenomena impact the development of the child’s brain, and we also know that these effects are reversible [11-12]. This means that we can repair the damage and, in a sense, “catch up”. Thus, the child who is a victim of poor conditions—what we call toxic stresses—can be rapidly put back on track in their community and by their community, the place with the greatest potential impact on the child. This means that services adapted to children’s needs and rights must be available in the child’s community, and that these services must be intensive, continuous, and available at an early age. The social pediatrics approach developed in Montreal over twenty-five years ago has proved effective at providing this type of care.

What role can medicine play in this basic care paradigm? How can we use medicine to act in the child’s best interests and ensure that all of their rights are respected? How can we reduce the effects of dire poverty on the future of our children? How can we end the vicious cycle of poverty that exists in vulnerable communities? How can we mobilize communities to do better for their children?

Engagement rather that eradication

There is no longer any doubt about the urgent need for a new care paradigm for children suffering from deficient human bonds, poor living conditions, and cumulative toxic stresses in the context of poverty.

We will certainly not eradicate poverty with this paradigm, at least not completely, but we will be able to help a much greater number of children succeed in life.

The engagement of medicine is essential to the success of this endeavor, as is that of governments at different levels, the labor movement, community organizations and, especially, communities themselves. Everyone must rethink their priorities as a function of the well-being of children and adopt a model that is collaborative, non-competitive, supportive, and innovative.

Governments must do their share to ensure collective well-being by providing full employment, basic support to families and standards for safe and healthy housing. They must ensure proximal access to health care and social services, to culture and recreation for everyone, and to education oriented toward the success of all children.

The labor movement and communities must come together to fight for a guaranteed minimum salary for all families and living conditions that are safe and healthy for everyone.

Communities and neighborhoods must watch over families and intervene to provide direct support through mutual aid and sharing, the only true way to ensure children grow up healthy, strong, and empowered. Such proximal support serves as the foundation of human development and the rightful domain of communities and families, who must have the means to fulfill their aspirations. Without this common commitment, little can be achieved. Medicine’s contribution to this social project is crucial and also directly linked to its mission.

The engagement of politicians and giving children a voice

There exists a great vacuum in Canada’s political apparatus that may explain, at least in part, its relative powerlessness to end child poverty and its harmful effects. In essence, there is no one to speak for children at the federal level and so help parliamentarians reflect on the future repercussions of laws and policies affecting the living conditions and well-being of children.

Children’s voices are rarely heard and used to orient discussions about what is in their best interests. Yet children are full citizens who are perfectly capable of representing themselves and making their voices heard in different ways. For the world’s children, it is a question of respect.

A Commissioner for Children with delegated powers would be able to monitor the situation and ensure the rights of children are respected at the federal and local levels. They would be able to examine complaints concerning violations of the children’s rights, make recommendations on national strategies and policies, and create a space in which children’s voices can be heard.

The engagement of medicine: what it needs to be effective

We have the knowledge at our fingertips, the findings are clear, and the population is waiting for more holistic care adapted to our changing society and oriented toward the needs and rights of all members of society. The engagement of medicine is vital and natural for it is an intrinsic part of our mission.

Research confirms not only the fragility but also the plasticity of the brain, starting in pregnancy and the first years of life. Global stimulation fosters rapid brain development in terms of both volume and the specialization of higher functions. Lack of stimulation, toxic environments, and problems with attachment and identity all contribute to slowing the brain’s development and drastically decreasing its performance. However, these effects are largely reversible with intervention at the proper time [13].

Research also shows there is a significant number of Canadian children living in unfavorable conditions that are often, but not always, linked to poverty. Most of these children are poorly served by existing systems, many are under stimulated or live in toxic traumatic situations, and still many are unable to succeed in life because of a lack of available resources. It is not a question of talent, but rather one of unequal chances, particularly with respect to support and quality education. All children start out in life with talents but we let many of them, the less lucky ones, waste these talents.

The expectations of the population, especially in vulnerable communities, are very simple: respect, accessibility to care, and participation in addressing issues around the development and health of their children. They do not want to be judged, excluded or stripped of their power.

Doctors are ideally placed to mediate these important issues against a backdrop of protecting children’s rights. First of all, they can develop a medical practice that is more “social” and at the “level” of patients by adopting a proximal model of care. But they cannot do this alone: they will have to join forces with many individuals in different sectors and disciplines who provide care to children, relying on a paradigm that posits the co-construction of health. The doctor could even choose to play the role of a coordinator for this large and diverse group of specialists.

Starting in pregnancy, there is an opportunity to expand our field of action in partnership with various actors, including nurses, midwives, doulas, and volunteers. This will enable us to provide full, continuous support and preventive services to the future mother so she can better take care of her baby. The experience of Les Maisons Bleues, two social perinatal centers in Montreal, attests to the efficacy of this approach.

Starting at birth and the earliest years of life, families need to be surrounded and supported by an understanding community that can assist in ensuring optimal stimulation for their children. In this model, the raising of children is a shared task. Doctors are in a privileged position: their proximity to families enables them to educate and mobilize the community to ensure the child’s optimal health and development, while also fostering a form of guidance focused on the child’s success. The experience of community social pediatrics in this role shows excellent results.

During the primary school years, the school alone cannot meet all of the needs of children living in difficult situations. Based on a collaborative approach that fosters school success, the medicine-school partnership enables a better understanding of the problems, more accurate diagnoses, and effective support to teachers and specialists. It becomes easier to bring parents on board and obtain their support for the school and its rules. Community social pediatrics proposes a number of different programs aimed at helping children succeed, including specialized educative services like Garage à musique, which offers music lessons to disadvantaged youth.

The transition to secondary school and adolescence is a key developmental period for children. It is crucial that we continue to support them at this time. We must give them space but also continue to provide a “negotiated” presence using flexible tools adapted to their needs, including consultations in school corridors, even in the streets—in short, wherever they hang out. When it comes to teenagers, we need to be particularly creative in finding ways to reach them: offer them small jobs, either paid or unpaid; arrange spaces where they can express themselves; and provide them with opportunities to practice sports, arts and, in general, challenge themselves. The doctor can serve as a guide, mentor, and “a preventive agent” for their teenage patients, helping them to promote good health and staying in school.

Accessibility, flexibility, empathy that inspires, and a deep commitment are all needed to implement sustained medical actions in communities. The American Academy of Pediatrics (2012)outlines the expertise required by doctors working in social pediatrics:

• Consider psychosocial problems and “new comorbidities” as acting together as causes and consequences in certain biologically based health problems.
• Fully incorporate the abundant scientific knowledge about these morbidities into all training programs for doctors.
• Educate parents, children, care providers, teachers, politicians, decision-makers and the population at large on the long-term consequences of cumulative toxic stresses on children’s health and on the benefits of prevention.
• Serve as advocates and promote the implementation of interventions suggested by the evidence and scientific research for reducing the effects of toxic stresses on child development [14].

The tasks for practitioners in community practice settings, known as pediatric medical homes in the US and community social pediatric centers in Quebec, are as follows:

• Use the guiding principles to support the stimulation of the child’s social, emotional and linguistic skills and to promote positive parental practices.
• Screen for domestic toxic stresses and act to counter or diminish their effects.
• Develop recurrent funding and an expertise in supporting and encouraging innovative practices that help children at risk.
• Identify, support and collaborate with local resources in order to coordinate efforts to reduce toxic stresses in communities.

Social innovation is both a destination—the resolution of complex social and environmental challenges—and a journey—devising new approaches that engage all stakeholders, leveraging their competence and creativity to design novel solutions.”

In addition to commitment, excellence, and entrepreneurship, doctors practicing social medicine, along with their care teams, must develop excellent interpersonal skills. These make all the difference when providing integrated care and services to children and youth in our most vulnerable communities. Doctors must be respectful, attuned to nuance, empathetic, and highly skilled. They must be able to build caring relationships based on a sort of friendship and a healthy dose of attachment. They must be fully motivated to uphold the Convention on the Rights of the Child and adopt a perspective of social equality and mutual aid.

And so a new paradigm of social medicine is born! Our community social pediatrics is now an inspirational and promising model that is helping children in most vulnerable communities succeed in life.

References

[1] Campaign 2000 (2014). Child Poverty 25 Years Later: We Can Fix This. Campaign 2000 Report, Toronto. http://campaign2000.ca/wp-content/uploads/2016/03/Campaign2000ReportCard_2014English.pdf (Retrieved on September 15, 2017).

[2] De Boer, K., Rothwell, D.W., & Lee, C. (2013). Child and Family Poverty in Canada: Implications for Child Welfare Research. Information Sheet No. 123E, Canadian Child Welfare Research Portal.

[3] Center on the Developing Child (2013). Supportive Relationships and Active Skill-Building Strengthen the Foundations of Resilience. Working Paper No. 13. www.developingchild.harvard.edu (Retrieved on November 1, 2015).

[4] Shonkoff, J.P. & Phillips, D.A. (2000). From Neurons to Neighborhoods: The Science of Early Childhood Development. Committee on Integrating the Science of Early Childhood Development, Board on Children, Youth and Families. National Research Council (US) and Institute of Medicine (US).

[5] Center on the Developing Child (2015). Serve and Return Interactions Shape Brain Circuitry. Key Concepts. http://developingchild.harvard.edu/science/key-concepts/serve-and-return/ (Retrieved on November 1, 2015).

[6] National Scientific Council on the Developing Child (2004). Young Children Develop in an Environment of Relationships: Working Paper No. 1. Retrieved from www.developingchild.harvard.edu.

[7] Anda, R.F., Felitti, V.J., Bremner, J.D. et al. (2006). The enduring effects of abuse and related adverse experiences in childhood: a convergence of evidence from neurobiology and epidemiology. Eur. Arch Psychiatry Clin. Neurosci., 256, 174-186.

[8] Anda, R. (2011). Adverse Childhood Experiences: Connecting the Development Lens to the Health of Our Society. Early Brain & Biological Development, A Science in Society Symposium. Summary Report. Calgary, AB, Canada: The Norlien Foundation, 25.

[9] Diamond, A. (2006). The early development of executive functions. In E. Bialystock and F. Craik (Eds.), Lifespan Cognition: Mechanisms of Change (pp. 70-95). New York: Oxford University Press.

[10] Diamond, A. (1991). Frontal lobe involvement in cognitive changes during the first year of life. In K.R. Gibson and A.C. Petersen (Eds.), Brain Maturation and Cognitive Development: Comparative and Cross-cultural Perspectives (pp. 127-180). New York: Aldine de Gruyter.

[11] Pears, K.C., Kim H.K. & Fisher, P.A. (2008). Psychosocial and cognitive functioning of children with specific profiles of maltreatment. Child Abuse & Neglect, 32(10), 958-971.

[12] Perry, B.D. & Pollard, D. (1997). Altered brain development following global neglect in early childhood. Proceedings from Annual Meeting of the Society for Neuroscience, New Orleans.

[13] Kolb, B., & Gibb, R. (2011) Brain plasticity and behaviour in the developing brain. Journal of Canadian Academy of Child and Adolescent Psychiatry, 20. 265–276.

[14] Garner, A.S. & Shonkoff, J.P. (2012). Committee on Psychosocial Aspects of Child and Family Health; Committee on Early Childhood, Adoption, and Dependent Care; Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics, 129(1), e224-231.