Why Should We All Focus on Health Inequalities in the Foetus and Early Childhood

Michael Marmot1 is clear that reducing health inequalities is a matter of fairness and social justice and is also vital for the economy. 'Giving every child the best start in life' is his prime recommendation in recognition that the effects of social disadvantage start before birth and accumulate throughout life, a theme reinforced by the British Medical Association (BMA) and the Chief Medical Officer (CMO).2,3The Moral ImperativeThe United Nations Convention on the Rights of the Child (UNCRC) underpins the moral imperative to reduce health inequalities. Children have no control over the socioeconomic conditions into which they are born, but are clearly affected by them on their journey from total dependence to self-realisation as mature human beings.The idea that individuals can always be held responsible for their behaviours and lifestyle choices, a view prominent in the health inequalities debate, obviously does not apply. Health is much more than the result of personal choice, and is clearly influenced by the environment in which individuals are conceived, raised and age.Children do not choose to be born into poor families, or disadvantaged circumstances, to be exposed to maternal smoking, alcohol or poor nutrition as a foetus, nor maternal depression and poor stimulation in infancy, or even poor diet, domestic violence and early school failure. The effect of 'fuel poverty' on the day-to-day lives and wellbeing of many children is often overlooked, and many other adverse environmental factors (such as housing, road safety, bullying) affect their ability to develop physically, emotionally and socially. Children adopt the lifestyle choices to which they have been exposed, and those from a disadvantaged background lack the emotional, intellectual and material capacity to make lifestyle changes, once in charge of their own destiny. It is the cumulative experiences over time which are so insidious and detrimental to a healthy life trajectory.Poverty is one of a number of socioeconomic factors which leads to disadvantage. It is also a consequence of and compounder of others. Nearly one-third of children, and up to 70% in some areas of the United Kingdom, are growing up in poverty.3 Social disadvantage reduces parental capacity to meet their own emotional needs, and the child's, with a direct effect on the health and wellbeing of the child. There is also a vicious circle whereby the most vulnerable are susceptible to further adverse experiences, giving rise to mental health problems, violence, alcohol and substance abuse, involvement in the youth justice system and teenage parenthood. Poverty breeds ill health, but ill health also maintains poverty.The United Kingdom has one of the highest levels of inequality in the developed world, and rates of out-of-home care in Europe.2 Yet, children thought to be suffering significant harm from chronic failure of adequate parenting (manifesting as neglect or emotional abuse) are prioritised for a 'forensic assessment', that 'can be intrusive and punitive, less cost effective, and less likely to encourage parental engagement'.2The Consequences of Disadvantage and Poverty on Child HealthThe intergenerational cycle of disadvantage is largely passed across generations through pregnancy.4 Women from poor families are more likely to suffer from ill health with poor nutritional status and psychological problems, more likely to smoke and less likely to breast feed. Pregnancy outcomes are poorer, and there is a consistent social gradient in perinatal mortality. Poor babies are more likely to be born small or early.4 Throughout childhood, increased mortality and morbidity from causes such as Sudden Unexpected Infant Death, injury and poisoning occurs proportionately to decreasing socioeconomic status.3Infant brains develop extremely rapidly in the first two years, and adverse experiences such as high levels of maternal stress and poor attachment, lead to raised cortisol levels which have a direct toxic effect on developing brain structures and circuitry, leading to emotional and attentional dysregulation. …