determinants ofhealth. Report ofthe CFPC's Task Force on. Child Health whose members were: Cheryl Levitt, Chair, MBBCH, CCFP. Mary Doyle-MacIsaac, MD.
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Our strength for tomorrow: valuing our children Part 8: Addressing the determinants of health Report of the CFPC's Task Force on Child Health whose members were: Cheryl Levitt, Chair, MBBCH, CCFP Mary Doyle-MacIsaac, MD Inese Grava-Gubins, MA Glenna Ramsay, MD, CCFP Walter Rosser, MD, CCFP T
o
have the healthiest children
possible in Canada, our children need to grow up in safe, healthy environments with enough
resources
Later development builds on this early foundation. Key factors-social, economic, genetic, and environmental-determine growth and development. Some of these factors can be identified by physicians in the normal
course of practice, and steps can be taken to prevent or alter expected outcomes. Five key research findings demonstrate the importance of early brain growth for health and well-being.3 * Brain development before the age of 1 year is more rapid and extensive than previously believed. * The brain is more vulnerable to environmental influence than ever suspected. * The influence of early environment on brain development is lasting. * The environment affects not only the number of brain cells and number of connections among them but also the way these connections are "wired."
to
feed, clothe, and house them. They need access to effective health care, nurturing homes, education, and good nutrition. The United Nation's Convention on the Rights of the Child' sets out special measures to protect the cultural, social, political, civil, and economic rights of children around the world. The Canadian government ratified the convention in 1991.2 Physicians have not traditionally considered the broad determinants of health as part of the health care sysnor as areas where they can intervene to improve health. To intervene effectively in these areas, special expertise is needed and might take years to acquire.
tem
Developmental determinants The period before birth (even before conception) and early childhood are crucial times in child development. This is an abridged and edited version of the Task Force report. A more detailed version of this paper was published as an
editorial in Canadian Family Physician
1995;41:1436-8. -*-
FOR PRESCRIBING INFORMATION SEE PAGE 638
Jake, Gregory, Elissa, Alison, and Stephanie Williams, son, daughters, niece, and nephew of Dave Williams, Computer Systems Manager VOL 44: MARCH MARS 1998 +Canadian Family Physician . Le Medecin defamille canadien 597 -
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* New scientific evidence shows that early stress impairs brain function. Babies of low birth weight fare much worse than babies of normal weight. Poor mothers are at much higher risk of bearing small babies than wealthier mothers. Children who are breastfed are healthier than those fed with substitutes; poor chiPdren are more likely to be bottle fed from birth. Nutrition is important at all stages of development. Many poor families find providing adequate nutrition for their children too expensive. Inadequate diet leads to poor health in parents and increased hospitalizadons, which further disturb the natural and settled care patterns that children need (and healthy parents LMt Secretary can provide) during the developmental years.4 our patients is undeniable. While Family physicians can help women most people accept that current ecoquit smoking. We can promote preg- nomic approaches and: government nancy planning, preconception and actions are logical and justified, prenatal care, and breastfeeding. physicians cannot assume that this However, to address the root causes is necessarily the case:when these of these morbidities realistically, we matters are determinants of health. need to address social and economic .Broad economic policies and pracconditions aggressively. tices and thie true necessit for, ad distribution of, reforms and cuts National and global economic profoundly affect health. Family policies physicians must become cO'mment'aCanada has developed comprehen- tors and informed critical evaluators sive social programs, but economic of political, economic, and social changes are affecting our capacity policies and practices that af:fect to maintain them. Federal and health. provincial governments are cutting deeply into resources for social:pro- Povertiy grams, support programs for Most children in Canada are doing women, and community and hospi- very well, and Canada has been cited tal facilities. by the United Nations as one of the How a government distributes its best places in theworld to live, based resources clearly affects the:pros- on many social and economic perity of a country, and especially of criteria.5 There are, however, conits children. The effects of declining cerns about the many Canadian chileconomic conditions and social ser- dren who are not doing well and vices on the health and well-being of could be doing better, and about 598 Canadian Family Physician Le Medecin defamille canadien * VOL44: MARCH * MARS 1998
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those who are doing poorly as a result of substantial cuts in social and health programs.: :: In Canada, one in five children lives in poverty.6 Poverty among children has economic, psychological, and social costs, and has been associated with poorer physical and mental health, lower levels of educational attainment, and persistent criminal offending.1 Statistics show that the poverty rate among Canadian families was 13.1% (949 000 poor families) ii 1991, up from 12.1% in 1990. Manitoba has the highest poverty rate (17.1%), followed by Newfoundland (16.4%) and Quebec (15.9%). The rate in Prince Edward Island, British Columbia, and Ontario is the lowest at 10%. tThe incidence of poverty is much higher among young families and singleparent families. Two out of every three female-led, single-parent families are struggling with poverty.8'9 Collaborating with economists and political scientists in lobbying for
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social and economic reforms that would alleviate poverty would enhance physicians' impact We could work with 'health care:.and social agencies:.to. advocate for.increased minimum wages and effective incentives to entering the labour force.
Women's. .status Women raise -and feed. their families, love and :support them.: Many women -do so in the face of poverty, neglect, abuse, and lack of social support. Raising the social and economic status of women in our society will ultimately bVene:fit the children who will grow up to provide healthier environments for their own children. Family physicians, because of long-term relationships.with their patients, are well situated to assist women to become more informed about the health consequences of their actions, to provide them with tools to address their circumstances, and to refer them to.community resources. that can further eenable them to meet their full potential. Poor women are not inclined to trust their physicians any more than other privileged authority figures, such as policem..en. and teachers. By .reinforcing the principle of patient-centred doctor-patient relationships, family physicians might be able to alter traditional hierarchical relationships with women.,
Workplace policies and practices Certain workplace policies and practices can prevent women from. participating inth-e work force .on. an equal basis with.:men. Most workplaces do not recognize the child-ce and nursing requirements of women. Workplace policies and practices
@-
influence women's incomes, their infant feeding practices, and the health and well-being of their children, and prevent them from re-enter-: ing the work force. a.s .new mothers. The CFPC and family physicians can play a strong role in supporting women who work dunrng their childbearing years by advocating for better .workplace legislat.io'n, by ensuring that both national :an.d provintial 'CFPC offices are models of workplace support for motherhood, and by making their own offices more baby
encouraging research projects to
evaluate the effectiveness of programs designed to address the broad *determin.a.nts of health, improved working environments, and.baby- and child-friendly offices; and emphasizing the,principles of social, economic, genetic, and environmental determinants of health in scholarly activities, teaching, .and research. Barriers to addressing the broad determints of health Many barriers influence how effec-
Thomas and Robert;, nephews of Leslie Challis, Communications and Marketing Officer .........0...0............................................ .........................
Education and research Canadian experts in child health have emphasized the need. to improve ihe knowledge and skills of family doctors regarding the broad determinants of health. This could be done through promoting CME on the broad determinants of health; designating funding for research and educational pursuits on child health issues, especially those arising from the broad determinants of health;
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determinants of health. Obstacles should be anticipated; addressing them could result in lively and healthy debate.
Physician barriers. Many physicians will not be comfortable addressing the root causes of illness outside traditional health service systems. The way family physicians promote and maintain health would change, as family physicians move away from
VOL 44: MARCH * MARS 1998o Canadian Family Physician . Le Medecin defamille canadien 599
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as blended.funding, as advocated by the CFPC and by the Chairs of family medicine in Ontario, would *c o m p en s a t e physicians for participating in a much broader range of activities that would benefit the overall population. Much resistance to this concept remains, but many family Lee and Jennifer, son and daughter of Gloria Bowes, Advertising Manager, Canadian Family Physician
purely one-on-one relationships with patients to a broader role that sustains the one-on-one role, but also involves critical comment, liaison with agencies, and dealings with populations at large.
physicians
sup-
port the idea of blended funding.
Community. Communities in general have a high respect for physicians, but where money is concerned, have a tendency to perceive physicians as self-serving. Some people think physicians should stick to medicine and see physicians who advocate for economic change as having a conflict of interest The CFPC and.family physicians must be perceived as knowledgeable commentators and protective of the well-being of Canadians if the importance of economic and social policies as broad determinants of health is to become apparent
College of Family Physicians of Canada. The CFPC Board of Directors and some members might see this new role as burdensome and as detracting from some of its critical work. The College will require very strong leadership and financial planning to advocate for and implement the changes necessary to better address the broad determinants of health. Municipal, provincial, and federal governments. Governments have Fee schedule. Most physicians in intrinsic bureaucratic and time conCanada are paid on a fee-for-service straints that inhibit shifts in resource basis. This payment schedule tends allocation. Politicians need education to demand direct one-on-one contact and support to understand how their with patients and does not compen- economic policies affect health. sate in any way for broader contact Corporate interests and political influwith groups or agencies outside the ence prevent readjustment of taxes, health sector. Payment systems, such influence global economic attitudes to 600 Canadian Family Physician Le Medecin defamille canadien * VOL44: MARCH * MARS 1998
the Canadian dollar, and force social policy shifts that in the long term result in illness. The kinds of social support necessary to maintain health will involve policies that might not show immediate benefit. + References 1. United Nations. Convention on the Rights ofthe Child. Ottawx Supply and Services Canada; 1991. 2. Human Rights Directorate. Convention on the Rights of the Child. First report of Canada. Ottawa: Department of Canadian Heritage; 1994. 3. Carnegie Task Force on Meeting the Needs of Young Children. TIe quiet crisis. In: Starting points: meeting the needs ofyour youngest children. Report of the Carnegie Task Force on Meeting the Needs of Young Children. New York: Carnegie Corporation of New York; 1994. 4. Ontario Ministry of Community and Social Services. Low income and child development: a case for prevention strategies. Toronto: Ontario Ministry of Community and Social Services; 1987. 5. UNICEF. The progress ofnations. New York: UNICEF; 1997. 6. Hanvey L, Avard D, Graham I, Underwood K, Campbell J, Kelly C. The health ofCanada's children: a CICH profile. 2nd ed. Ottawa: Canadian Institute for Child Health; 1994. 7. Greene B. Canada's children: investing in ourfuture. Report of the Standing Committee on Health Status and Welfare, Social Affairs, Seniors, and the Status of Women. Subcommittee on Poverty. Ottawa: Supply and Services Canada; 1991. 8. Lochhead C. Update: family poverty in Canada, 1991. Perceptions 1993;17(1):21-4. 9. Rhyse C. Thursday's child: child poverty in Canada: a review ofthe effects ofpovert on children. Ottawa: National Youth in Care Network; 1990.
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plus precisement, celle de ses enfants. Les effets du d6clin des conditions economiques et des services sociaux sur la sant& et le bien-etre de nos patients sont indeniables. Bien que la plupart des gens considerent logiques et justifiees les approches economiques et les actions gouvernementales actuelles, les medecins ne peuvent en dire autant lorsque ces questions deviennent des determinants de la sante. Les politiques et les pratiques economiques generales ainsi que le besoin veritable et l'application des reformes et des coupes affectent profondement la sante. Les
medecins de famille doivent se faire les commentateurs et les evaluateurs critiques avertis des programmes et pratiques politiques, e&conomiques et sociaux qui affectent la sant6.
la pauvreti La majorite des enfants du Canada se portent bien. Le Canada a d'ailleurs ett cite par les Nations Unies comme l'un des meilleurs pays au monde pour la qualite de vie sur la base de nombreux criteres sociaux et economiques. On s'inquiee toutefois des autres enfants canadiens qui ne se portent pas aussi bien et de ceux qui
se portent mal a cause des reductions substantielles dans les programmes de sant6 et sociaux. Au Canada, un enfant sur cinq vit dans la pauvretO6 Chez les enfants, la pauvrete entraine des coutts economiques, psychologiques et sociaux. Elle a aussi ete associee A une diminution de la sante physique et mentale, un faible niveau d'instruction et des actes criminels a r6petition. Des statistiques revelent que le taux de pauvrete chez les familles canadiennes etait de 13,1 % (949000 familles a faible revenu) en 1991, une augmentation de 12,1 % par rapport a 1990. C'est le Manitoba qui affiche le plus haut taux de pauvrete (17,1 %6), suivi de Terre-Neuve (16,4 9'o) et du Quebec (15,9 %). L'Ile-du-PrinceEdouard, la Colombie-Britannique et l'Ontario affichent les taux les plus faibles a 10 %. L'incidence de la pauvret6 est beaucoup plus elevee chez les familles jeunes et monoparentales. Deux familles monoparentales sur trois otu la femme est chef de famille sont aux prises avec la pauvrete.89 Les initiatives des m6decins seraient plus fructueuses si ceux-ci collaboraient avec les economistes et les politi-
cologues afin d'influencer les r6formes sociales et economiques et diminuer la pauvret&. Nous pourrions joindre nos efforts a ceux des organismes sociaux et de sante pour demander une hausse du salaire minimum et des mesures incitatives efficaces pour acceder au marche du travail.
Jake, Gregory, Elissa, Alison et Stephanie Williams, respectivement le fils, les filles, la niece et le neveu de Dave Williams, responsable des systhmes informatiques 602 Canadian Family Physician . Le Medecin defamille canadien 4 VOL44: MARCH * MARS 1998
La condition feminine Les femmes s'occupent de leurs enfants, les nourrissent, leur prodiguent de l'affection et les soutiennent; bon nombre d'entre elles le font dans un contexte de pauvrete, de negligence, d'abus et d'absence de soutien social. En fait, ameliorer la
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condition 6conomique et sociale des femmes beneficiera aux enfants qui pourront ainsi offrir un environnement plus: sain a leurs propres enfants. Parce qu'ils ont une relation a long terme avec leurs patients, les medecins de famille sont bien places pour mieux renseigner les femmes sur les consequences de leurs actes sur leur sant6, leur offrir des outils de pnse en main de leur condition et les redrer A des ressources communautaires qui les aideront a exploiter leur plein potentiel. Les femmes demunies n'ont pas tendance a faire confiance a leurs m6decins. nl a quiconque en position d'autorit, notamment les policiers et les enseignants. En renforyatnt le principe des relations medecin-patient centr6es s:ur le patient, les medecins de famille pourront peut-tre: modifier leurs relations hierarchiques traditionnelles avec les femmes.
Les politiques et les pratiques en milieu de travail Certaines politiques et pratiques en milieu de travail peuvent emp6cher les femmes d'acc6der a des emplois dont le salaire est egal a celui des hommes. La plupart des employeurs ne tiennent pas compte des besoins des femmes entourant 4e soin des enfants. Les politiques et pratiques en milieu de travail influencent le revenu des femmes, I'allaitement des nourrissons ainsi qiue Ia sante etle Ibien-&re de leurs enfants, et les emp&zhent de r6intgrer le marche du travail apres l'accouchement. Le CMFC et les medecins de famille peuvent jouer un role de soutien important pour -les femmes qui travaillent durant leurs annees de procr4ation en revendiquant une meilleure legislation en milieu de travail et en s'assurant que les sections
provinciales et le siege social du CMFC solent des modeles de soutien pour les meres qui travaillent et leurs enfant-s.
sociaux, 4conomiques, genetiques et environnementaux de la sante dans les activitls scolaires, l'enseignement et la recherche.
Les obstacles aux principaux L'education et la recherche Les experts canadiens en sante de d4terminants de la sant6 l'enfant ont insiste sur le besoin De nombreux obstacles viennent
Paulette Cromwell,;avec ses amis, Mfine de Lucie Ranglin, secr6taire au Service de FMC ....*
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comp6tences des m6decins de famille en ce qui a trait aux principaux d6terminants de la sant6 Il est possible de r6aiiser cet objectif en encourageant
les grands determinants de la sant6. On peut anticiper ces obstacles; les surmonter pourrait entralner un debat sain et anim6.
les activites de FMC axees sur les grands d6terminants de la sante; en allouant un financement pour des activitMs e'ducatives et de recherche en sate de l'enfant, plus pr6cis6ment celles qui touchent les determinants de la sant6 ; en encourageant les projets de recherche qui evaluent l'efficacit6 des programmes portant sur les determinants de la sante, I'am6lioration du milieu de travail et l'acces a des cabinets de consultation plus amis des enfants; et en insistant sur les principes des determinants
Les obstacles pour les medecins. Beaucoup de m6decins ne seront pas a l'aise de s'attaquer aux causes des maladies en dehors du cadre traditionnel des services de sante. Si les medecins de famille adoptaient un role plus vaste qui, tout en preservant la relation individuelle, integrait l'evaluation critique, les relations avec les organismes de sante et une dimension communautaire, ils reussiraient ainsi a modifier la fa9on dont ils
VOL44: MARCH * MARS 1998, Canadian Family Physician . Le Medecin defamille canadien 603
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m..6decins pour leur participatio.n. it des aciis p}lu.s..g}n& r.l*s dont bevef.icie at la poEpu.lation. Ce. concep:t e.t..%..0 encore peu favoris6 mais bon nombre e..m. decis de e appuiet
globales du. dollar canadien et forcent des changements dans les politiques sociale qui, ~i.along: tere, entainent une. hsse des maladies Pour assu.rer..le. maintien de Ia sante, i1 faudra accepter que les politiques sociales ne d6montrent pas necessai.. imm'diats. . * rement:.d'avantages rement:..:.. .:..... 1. Ls Ntion Unes.S. onvntin -relative aux droits. de- enfant. Ottawa: Imprimeur de la Reine pour le Canada; 1991. 2. Direction des droits de la personne. .Convetio reive aux droits de 'enfant. Premier.appod u Canada.Ottawa Patrimoine canadien; 1994. 3. Carnegie Task Force on Meeting the Needs of Young Children. The quiet crisis. Dans: Starting points: mtgthe needs of .
La. comm.u.
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u.aut&s t.un a r ad resniect'l rou ;les mEdecins m-ais, lorsqu'il est qesl..i.on d'argent, el.lees ont tendance :: les les eCins -com ser-. consid...:6.,re.r *....X~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~. .w.......... i;t ofIthe ildr:. Report. vant lurs ,prop-r ersentts. Cerain yoryoung.esthil.dren. .penent que le m..dcins devraint Carnegie TaskFrce on M eeting th Needs .s.e limiter A exercer la mEdecie .et of YoungChi.ldren. New York: Carnegie per9oivent un conflit d'inte.r6tcheiz Corporation of Newyork; 1994. ceux qui r&Iament des changemets 4. Minist&re des services communautaires et 6conoiques...*. LeCMCet .lesmle socia dIOrio. Low in and child '\.:!......
encouragent et assurent.le maintien de la sant6. e. Le CoMg des medeipcns de famill da Canada. Le Conseil . d'admin aion duCMF-C. ainsi que certains.. membres peuvent consideer ce nouveau r6le. cornme un far-,:" deau e ue atente it cetaes n des
initiative importantsd^A r&als~e et & d':autres en cor..tLe Collage devra faire preuve d'une grande autorite et d'une excellente planification financiere s'il veut pr oniser et appliquer. l.eachangements nessaires pou:r s'impliqurdanr lea principaux determinants de la sant&
::
ti.nsde .fm l ..doivet r p . . r.u
deve
et:a ce for prventio* strate-
comme desg co ursin gies. . : Ministere,des services cor-et protecteurss du bien-e des munautaires et sociaux de 1'Ontario; 1987. Canadiens si l'importance des politi- 5. UNICEF. 7Te progress of nations. .qu.es. sociales et..Aconomique.es doit New York.:. UNICEF; 1997. tans.pa;ritre comme 'un des prc 6. H dK D. Grah paux d&er.m. .dSminants a st-. de............la.a.
chidren, a CJCHpmfis.2ieZ Ottawa Instiitu Les gouvernements municipaux, canadien pour Ia sanai de renfantl994. Le mode de rdmun&ration. La plu- provinciaux et fedtral. Les gouver- 7. Greene B. Les enfants du Canada: notre par.t des mAdecinsca nadiens sont out.des...c.ontraintes ..:intrin- avenire:. Rappott;du ComitE peranentre de la :r enk.a l'acte. Cem derTmu- s~ques en temsd bure ie et *sant* et...du~ bien.trtr..i-? socia,,ds affaires... n&ration exige un tc personnel de.temps qulen t -le ag sociaes, du oeisieme ge e6tadein condiavec les..patients et ne.le. compense mentZs au niveau de I'affectaton des tion f*nunine. Sous-comit: sur la pauvreth. pas pour les contacts 6Margis avec les ressources. Les politiciens ont besoin Ottawa: Imprimeur de la Reine pour le groupes .et organismes. ext6rieurs au .d'tre 6d.uqus.s .et soutenus: pour Canada; 1991 syste m de aante.lLeameodes de comprendre lea effets.de leur.spol- 8. oh d Update: fiy p in r6nnm. rti nnt finance- tiqes 6onomiquse :ur la.sant Lea Canada, 1991. Perceptions ;17.(1):214. le .souha:ite ..in#t&s des. ent-reprises prives ,et 9. Rh C. ursday's c ildd p men.t mixte comm.e in le CM:FC: et les directus des depar- li'influence politique empAhent le Canada : a review ofthe effects ofpoverty on
.:n.ements
~~~~~~~~~~~~~~~...
tements de m4decine- familiale rajustement des taxes et des impbts, de l'Ontario, indemniseraient les influencent les attitudes economiques 604 Canadian Family Physician Le Medecin defamille canadien * VOL 44: MARCH * MARS 1998
.
children. Ottawa: National Youth in Care Network; 1990.
