Social paediatrics: From ‘lip service’ to the health and well-being of Canada’s children and youth

Social paediatrics refers to the health and well-being of children, specifically those living at the margins of society, the disadvantaged, disabled or dispossessed. This description hinges on the recognition of social determinants as critical mediators of child health. While social paediatrics got its start in Europe, its first proponents in North America were groups of Canadian paediatricians, led now by Gilles Julien in Montreal, Quebec, and a group in Vancouver, British Columbia, influenced by Haggerty and others (1,2). However, similar to the children and youth targeted by these paediatricians, the concept of social paediatrics has been paid ‘lip service’ until recently. The 2013 UNICEF report ‘Child Well-being in Rich Countries’, which benchmarks health and well-being among the world’s richest countries, underlines once again that Canada’s performance is spotty at best (3). Overall, Canada remains right in the middle of the pack, ranked 17th of the 29 countries included. We rank 27th in childhood obesity, 22nd in infant mortality and 21st in child poverty rates. Furthermore, for Aboriginal children and youth, health outcomes continue to be far lower than Canadian averages. On the other hand, Canada ranks 10th in the percentage of low-birth-weight newborns and second in educational achievement by 15 years of age. Furthermore, Canada scores in the top six countries on the Program for International Student Assessment (4), which reports results of 15-year-old school pupils’ scholastic performance in mathematics, science and reading. First performed in 2000 and repeated every three years, its aim is to improve educational policies and outcomes. The data have increasingly been used both to assess the impact of education quality on incomes and growth, and for understanding what causes differences in achievement across nations. However, studies such as the HighScope Perry Preschool Program remind us that for every tax dollar spent on preschool education there is a return of >$16 by 40 years of age (5). Here, the Chairs of the 16 departments of paediatrics at Canadian medical schools argue that not only is the practice of social paediatrics evolving rapidly but, more importantly, it is time for a two-pronged approach. First, we need to ensure its inclusion in the mainstream of curriculum development in our medical faculties, using a broad interprofessional approach; second, the knowledge gleaned from the UNICEF and other reports should stimulate a vigorous child health advocacy strategy. The increasing popularity of available electives in social paediatrics for both undergraduate medical students and postgraduate trainees in paediatrics underlines the desire of our trainees to receive more exposure to these topics (6,7). In a recent survey of medical faculties in Canada, all reported offering electives that address one or more of the following: the health of children and youth in Aboriginal communities or members of refugee or immigrant families; the health of children in the school system; and the impact of environmental factors on children and youth. Although the social context of children receiving care in children’s hospitals is given attention in didactic lectures and bedside or clinic teaching, we contend that, to truly understand the social determinants of health, they must be experienced firsthand in community, school and home settings where they are brought into stark focus. These experiences move from the medical model of hospital care to an increasingly interprofessional sociological model as we move from tertiary through secondary and primary care to the public health issues affecting children and their families. Data also show clear relationships between income inequality (the discrepancy between the highest and lowest income earners in society) and a wide variety of child health outcomes (8). The mechanisms by which income inequality impairs access to and delivery of excellent health care have not been adequately defined; however, the absence or inadequacy of the social security net is likely a major contributor (9). Another mechanism may be through educational outcomes: Siddiqi et al (10) found that income inequality is a significant determinant of adolescent reading literacy, while direct spending on education and overall national economic prosperity are not. Many of the available electives in social paediatrics provide participants with firsthand exposure to the children and families most in need of attention from the psychosocial point of view, eg, pregnant teens living on the street, single parents who cannot afford the necessities of daily living for their often developmentally challenged children and the financially marginalized without access to welfare support (9). These electives provide vivid exposure to the realities facing disadvantaged children and youth, beyond the scope of the usual clinical placement. For these educational opportunities to be effective, partnerships must be forged with community health care professionals who provide students with exposure to children and their families in a variety of urban, rural and remote settings, including the education and legal systems, and in-home assessments. We are training family practitioners, paediatricians and other health care providers, many of whom interact with children and their families for whom the social determinants of health have daily ramifications: food and lodging insecurity, inferior education, and neglect and/or abuse. It is only through robust educational exposures that medical students will be prepared to address the needs of these children and youth. Preclerkship placements within community agencies that deal with these groups is a first step, provided these are of sufficient relevance to the students’ future medical practice, eg, children’s aid societies, youth centres and refugee health clinics. These learning opportunities should be an integral part of clinical training, not only for specialists who interact regularly with children and youth and their families (eg, family physicians, paediatricians and psychiatrists), but also those dealing with chronic diseases impacted by the social determinants. But here’s the rub: what do we do once we are producing physicians increasingly informed about ‘social paediatrics’? This requires an understanding of what programs are available and what new strategies are needed to support disadvantaged children and youth and their families throughout the life cycle. This starts with preconception maternal health (eg, preconception weight and maternal smoking are predictors of childhood obesity), continuing throughout pregnancy (teratogen exposures, including alcohol), to early newborn experiences (prolonged, exclusive breast feeding significantly improves health outcomes), early childhood evaluation to begin early remediation for those in need with developmental challenges, to school and mental health of children and youth, and a ‘medical home’ for children with complex care needs (11,12). It reaches full circle when these children reach adulthood with access to, for example, parenting education programs, with specific attention devoted to particular high-risk groups such as Aboriginal Canadians (13). In a time of relative austerity, many argue that we simply cannot afford an all-inclusive social security net. We would contend that the status quo should not be an option. Countries that score highest on the UNICEF index of child well-being also have the lowest degrees of income inequality (8): Scandinavian countries score in the highest ranges, the United States lowest, with Canada right in the middle, which is not good enough. The large size of our country, its remote and scattered communities, our history as a country of immigrants and the longstanding poorer health in our Indigenous peoples may be among the factors that impede a change in position. Before we reach such a conclusion, however, every effort should be made to move up the slope. In terms of advocacy, UNICEF Canada has suggested that we demand of our government leaders that the rights of children be prioritized in policy decisions and that regular state-of-children reports be published to identify progress and emerging concerns (14). One step in ensuring the well-being of our children and youth may be to provide the provincial children’s advocates with wider responsibilities, and with sufficient resources and authority to be effective. A Federal Office of a Children’s and Young Persons’ Commissioner may be an inevitable consequence of successful provincial programs. Such a commissioner would ensure that efforts to improve the health and well-being of Canadian children are equitably applied across the country. Community programs that ensure food, shelter, and security and protection against neglect and abuse must be enhanced for those in need. Schools have a crucial role to play in ensuring optimum education, which means not only teaching the curriculum but ensuring nutrition and physical activity (15). Appropriately nourished and active children simply do better at school. Our neighbourhoods must be safe so that children and youth do not have to be locked in their homes after school. We have a long way to go to achieve these goals. But this is Canada, so let’s get on with it.

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