Vulnerable and marginalized children: Who are they and how can we help?

The Montreal Children’s Hospital, Montreal, Quebec Correspondence: Dr Saleem Razack, The Montreal Children’s Hospital, 2300 Tupper Street, Room C-808, Montreal, Quebec H3H 1P3. Telephone 514-412-4475, fax 514-412-4311, e-mail [email protected] Accepted for publication March 25, 2009 Before I proceed with the present commentary, which is broadly in the field of social paediatrics, I have something to confess: my name is Saleem Razack and I am a hightechnology, all-the-beeps-and-whistles paediatric intensivist. I love analyzing the waveforms of central lines and contemplating the mysteries of sodium metabolism. By the end of the present commentary, I hope the reader will appreciate that even in this world of fascinating physiology, to be an efficacious and compassionate practitioner, I must integrate an understanding of the social determinants of health in my day-to-day practice, both as a physician-technocrat and as a teacher. It is natural for those of us who work in child health to appreciate the links among social vulnerability, marginalization and health. To be a child means that one exists in some sort of social context that involves parents (or caregivers who stand-in in loco parentis), and the links between social context and health are often hiding in plain sight. They are there with the 26-week-old Inuit baby on high-frequency oscillatory ventilation, whose mother is 16 years of age (prematurity has a significant social determination) (1); they are there with the six-year old child of Rwandan refugee parents, with limited access to quality primary care and frequent visits to the emergency room with asthma exacerbations (marginalization through the peculiarities of the health care insurance system for refugees); and they are there with the 15-year-old adolescent who attempted suicide after being ‘taxed’ (extorted for money) and bullied at school because he happens to behave effeminately (social discrimination and health). So who are Canada’s vulnerable and marginalized children? They are children largely born into poverty and income disparity (with the vulnerability operating largely through associated social exclusion and discrimination). In a country like Canada, these children can be “camouflaged by the apparent affluence around them” (2). There is no standard definition of poverty in Canada, but the concept of ‘low income cut-off’ (families who spend 20% or more of their income after taxes on housing, food and other basic necessities than the average household expenditure) has been used. As of 2005, 1.2 million Canadian children (17.6%) were living in poverty by this definition (3). The country’s poorest children are most likely to be found in single-parent households (42% poverty rate), in Aboriginal families (40% poverty rate) and among new immigrants (40.4% poverty rate), versus a poverty rate of 18.4% for all Canadian children (4). It can be hard to appreciate poverty in our affluent, firstworld country, with its ‘universally’ accessible health care system. Journalist Ryszard Kapuscinski points out how these psychological barriers to appreciating poverty might work – “The products of poverty are fear and...the feverish dream, to tear oneself from it at all costs. To separate oneself from it by the tinted glass of a limousine, the wall surrounding a villa, a fat bank account...” (5). We may have trouble appreciating the social vulnerability created by poverty and marginalization, but as child health professionals, we are able to appreciate the very real effects of poverty and concomitant social exclusion on the health of our young patients. We see the outcomes of life in neighbourhoods with fighting and drug dealing (children from low-income families are twice as likely to live in such neighbourhoods), the impact of developmental disability (children from lowincome families are twice as likely to be registered in special education classes than children from middleor upper-income families) and the paradoxical rise in obesity among low-income children (three-quarters of children from low-income homes do not participate in organized sports compared with onequarter of children from high-income families) (6). So what can we, as paediatricians and child health professionals, do about it? A great deal, it turns out, but doing so will take no less than a paradigm shift in our understanding of the causality of disease, and it will have profound implications on the way we engage families and communities, and on the knowledge and skills we inculcate in the next generation of child health professionals. Not only will this need to include training that is successful at demonstrating the links between social determinants and health status, but also, given that the solutions to social vulnerability and exclusion are complex (requiring action in the social policy and political arenas), a shift in focus of skillbuilding that is more collaborative and team based. When I was a critical care medicine fellow, a particularly sage supervisor of mine once said that bronchiolitis is not caused by the respiratory syncytial virus (RSV). This was a somewhat revolutionary statement, especially given that this was the middle of winter, and there were approximately six patients admitted and on mechanical ventilation with Commentary