‘Get rich or die trying’ – what drives poor children and what we can do about it

The public's response to global warming, amid a stronger scientific consensus, demonstrates that Canadians can view the ‘long-term’ consequences and demand current action. In a ‘high-tech’ world, the awareness of risk and risk ‘science’ can translate into effective advocacy and activity in Canada. Child poverty parallels global warming in terms of ‘long-term’ effects threatening all aspects of society and societal sustainability in the future. As health care practitioners, we have little doubt about how poverty, or its absence, constitutes a dominant determinant of health and well-being. Poverty is related to health in at least three ways: through the gross national product of countries, the economic inequalities among geographical areas and the income of individuals. Income is related to health through direct effect on the material conditions necessary for survival, the opportunity to control life circumstances and differential access to health care, even in countries with universal insurance. As the competition for fewer available amenities and goods and services increases in the community, individual income is more influential in the attainment of health (1). The effects of poverty on childhood influences outcomes as early as the prenatal period. Lower socioeconomic groups have a greater incidence of prematurity and low birth weight (2). In spite of the fact that in most countries childhood mortality and malnutrition continue to decline, large inequalities between the poor and the not poor exist, and appear to be widening (3). The negative effect of poverty on the mental health of children is undeniable. Children in poor families have higher levels of depression, and conduct and antisocial disorders. Rates of increase in antisocial behaviour are substantially higher for children with persistent poverty (4). While most children who develop a chronic pattern of severe aggression, including hostile and predatory behaviour, have faced a powerful accumulation of risk factors, whether they end up to be a destructive force to themselves and others depends on how toxic or benign the culture is around them (5). In 2007, child poverty is seen to restrict opportunity while additionally immersing children in television and audio content that is profit driven and violent, and reflects a superficial, materialistic outlook. The successful role models are few and the messages are harsh. A successful rapper says “get rich or die trying” because he reflects the aspirations of poor youth who engage in high-risk activity to ‘get rich’. Yet, all the while, these youth are falling farther behind in skills and knowledge that could help lift them out of poverty – skills and knowledge that ‘richer’ children take for granted. Over the past two decades, renowned child psychiatrist and Canadian Paediatric Society Ross Award recipient, Dan Offord (Hamilton, Ontario), was already raising awareness about how poverty robs children of opportunities. For example, poor children obtain instruction and gain particular levels of skill development at a much later age than middle-class children (6). As Dan Offord so often poignantly observed, “you can always pick out the poor children swimming – they do the dog paddle while other children do the crawl”. Like climate change, poor children, while mainly ‘invisible’ to all levels of government and society at large, increasingly make their presence felt to educators, physicians and paediatricians, and lawyers and police. Urban, poor children are over-represented in the 47% of all Ontario children who fail grade 3 literacy. In many Canadian cites, the overall high school dropout rate is over 25%; one would expect it to be higher in schools that serve only the inner-city poor. With child education experts telling us that failure to read by the end of grade 2 is a strong predictor of ‘high school dropouts’, these numbers are likely to radically rise if corrective action is not taken. As volunteers, two of us, on most weeks, go to the home of two inner-city poor children and their mother in Hamilton, Ontario. Generally, we advocate for them at school and take them to the Hamilton YMCA programs on Saturday mornings. While these, admittedly, are modest efforts, affecting only two of Hamilton's 22,000 children living in poverty (one in five children in the region), it helps us to directly see the benefits of: After-school programming with homework help (for example ‘Virtual YMCA’ including homework support); and Extended school year to prevent irretrievable summer slippage (including social skills, numeracy, literacy, swimming through a school and Virtual YMCA partnership). Unfortunately, of the 700 children to whom this program is offered at school, only 30 to 40 children attend because of insufficient resources. (The ‘Virtual YMCA’ is a literacy-based program focusing on academic support and social growth, with a program model based on learning enhancement, health and recreation, values, and building competence and confidence. Program objectives include improving reading, writing and speaking skills, facilitating learning, helping children develop confidence and competence, and developing self-respect and respect for others.) We have further learned through The Hospital for Sick Children, leaders in mental health and education, the merits of: Competency at an early age in one or more of sports, music and the arts (eg, regular weekly instruction and support with general emphasis on skills, not only play). This is said to reduce the risk of conduct disorders. Early learning and child care services. Lunch (note Norway and even many parts of the United States serve hot lunch). A considerable body of educational research proves hungry children do not learn or learn well in a school setting. Despite many years as paediatricians, the two of us who volunteered had no idea until visiting urban poor children how dispiriting life is for them. There is very little happening from one short school day to the next: just four walls and a television set. The long hours after school – evenings, weekends, teacher professional development days, school breaks and summer holidays – are filled with little else but television. What can be afforded? Only occasional outings by some charitable group. There are no proper local parks to play in. There is no money for swimming lessons, team sports, drama classes, dance or art classes for these children. It is another world – invisible and alien. There is no organized play and no supervised skill development – just a short school day and then television, mostly unsupervised. Astonishingly, there is simply not widespread (and, in fact, hardly any) supervised after-school activity available such as there is for children of parents with cars. There are so few opportunities for so many children, so much social isolation and social exclusion, so much opportunity to be taught violence, which is the normal way of life, and pressure to use crime as the way out. This is a waste of childhood – a waste of life and a very dangerous, wasteful risk to our long-term social stability. While this threat gets nearer and nearer, and harder to deny or delay, we have many experts in Canada who have the know-how to turn this increasing pattern of degradation and violence around. We need to put as much energy and attention into this epidemic as we put into planning for pandemic influenza and other emergencies. This epidemic is happening right now – it is not just a theoretical risk. Child poverty will be the great tsunami for Canada without concerted efforts to address it now. The long-term consequences of not addressing it are increased poverty, desperation, and escalating crime and violence, all while robbing our youth of the opportunity to reach their full potential and ultimately jeopardizing our future as a model nation. For those who understand the epidemic model, the situation of urban child poverty can be viewed as an epidemic of school and skills deficiency. For those who may think that the highest level of attention is ‘optional’, rather than necessary, it is worthwhile to review the World Bank Report of 2007 (7). “There has never been a better time to push for concerted action to ensure that as many young people as possible grow up well educated, remain healthy, and have the opportunity to participate in society as active and valued citizens. Failure to invest now (sic) may lead to disillusionment, social unrest, and fragmented societies” (7). The social unrest referred to, of course, includes terrorism in which some, albeit illusory, sacrificial dignity is preferred by suicidal and/or homicidal bombers to the degradation of a poverty that appears inescapable. This desperation is an unfortunate close cousin to the high-risk gun and drug trader now operating in some parts of our society–those trying to ‘get rich or die trying’. While no one person and no group alone can be expected to solve child poverty single-handedly, we can draw societal attention to the issue and we can each do what we can to push for change in our own areas. This is not ‘simply’ a political problem. Like global warming, it is a generational problem because one generation, thus far, refuses to raise the resources necessary to reduce a threat that will be largely visited on a future generation. The consequences of current child poverty will result in crime, violence and the loss of opportunity for a better society a decade from now. Like global warming, it is hard to estimate its destructive and disordering effects. It is the responsibility of our generation – the one with primary responsibility for the resource allocation for our schools, for our child and family social support programs, for our community recreation and arts programs – to move beyond the status quo and to help to change our communities to ensure a livable world for future generations. This is not restricted to governmental efforts. Childhood poverty is a complex problem requiring multilevel solutions. Therefore, the private sector and individuals must join forces. Necessarily, the political process is required to address the complex issue of child poverty effectively through a realignment of public resources. In our role as advocates on population health issues, paediatricians (together with partners) must search out evidence-based interventions or pilot studies and sell these interventions to the government. Government policies and budgets, while not the only tools necessary to alleviate child poverty, are arguably the most important. Resource allocation is always political. For example, spending Canadian tax dollars on health care (currently approaching $0.50 on the provincial tax dollar, at least in some provinces) instead of increasing vocational and educational opportunities for poor children, or increasing the spaces available for quality early childcare, is a political decision. To deny this reality is to deny making real changes in the lives of poor families. We believe that there are four main imperatives requiring immediate attention at the provincial and national levels for those who set or advocate for policies for children's health and well-being: Elevate child poverty to a priority issue equivalent to emergency preparedness and pandemic flu planning; Advocate for social policies that alleviate child poverty and its effects (such as illiteracy), and engage the experts who can advise on the most effective strategies; Specifically address the roles of poverty and low education on access to health services by children, and develop best practices for improving disparities in access to care; and Advocate that all health quality monitoring include a focus on these vulnerable children. In October 2007, the editors of Paediatrics & Child Health will join 230 medical editors of the World Association of Medical Editors in devoting a journal issue to the topic of poverty. The issue will be both scholarly and practical. Our most precious resource is our children and their potential to work for the good of our society. We can do better with our poor children. We must. Now.

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