Health Promotion International, Vol. 15, No. 2, 181-182,
June 2000
© Oxford University Press 2000
Resource Reviews |
Developmental Health and the Wealth of Nations
Professor of Paediatrics and Child Health, University of Newcastle, Locked Bag 1014 Wallsend, 2287 NSW, Australia This is a brilliant and powerful book written by a number of members of the Human Development Program of the Canadian Institute of Advanced Research, an interdisciplinary virtual Institute established by Fraser Mustard after he left McMaster University in the mid-1980s. It is a synthesis of evidence from a number of fields in support of the hypothesis that the persistent socioeconomic gradients in health and well-being outcomes begin in early life, and have their origin in early life environmental experiences that influence brain development and affect coping skills throughout life. It draws together findings from the emerging fields of psychoneuroimmunology and psychoneuroendocrinology to outline some of the plausible biological pathways that might explain this. Whilst risk is not destiny, and as Mustard reminds us in his foreword ‘succeeding events over the lifespan also influence these characteristics and outcomes, the weight of the evidence suggests that the quality of nourishment and nurturing in the early years is far reaching’.
We owe Keating and Hertzman a great debt for conceiving the term ‘developmental health’ to summarize the broad range of conditions ‘from behavioural adjustment, to literacy, to mathematical achievement ... criminality, drug use and teen pregnancy’, the risks for which are profoundly influenced by psychosocial and socioeconomic circumstances throughout the life cycle, but particularly in the earliest years. It is a much more apposite term than ‘the new morbidity’ (how long can the changed patterns in the epidemiology of child health evident for the last quarter century be considered ‘new’?). The only improvement one could suggest to indicate its broader implications would be to add ‘and well-being’ to get around the difficulty in the minds of some of our colleagues in other sectors that ‘health’ relates only to conditions that are the responsibility of those working in the health system.
One of the great strengths of the book, as suggested by the title, is its analysis of the societal implications of steep socioeconomic gradients in outcomes. ‘The quality of early childhood affects the quality of the future population and prosperity of the society in which these children are raised’. In noting their lack of political clout, it recognizes that children are particularly vulnerable to environmental stress at times of rapid social change. As we enter more fully into the ‘information age’, a revolution distinguished from previous historical shifts by its ‘capacity for almost infinite acceleration’, the consequences of sharp gradients in developmental health and well-being outcomes for us becoming a ‘learning society’ are emphasized—allowing the status quo to persist will result in the separation of a technological and cognitive elite from an increasingly marginalized mass population, both within and across societies. An alternative pathway is to ensure that technology is introduced and disseminated in ways that facilitate mass participation in the collaborative building of knowledge ‘not only about our material and economic existence, but also in terms of our social functioning and societal structure’.
The other great strength of the book is its success in integrating the key contemporary discourses about the social determinants of health. Where else in one volume has the emerging knowledge about the impact of early environmental circumstances on genetic expression in brain development (biological embedding and neural sculpting), the role of attachment between young children and their primary caregivers on children's ability to self-regulate emotional and behavioural expression, been brought together with an analysis of the part played by social capital in contributing to those environments?
The book, as well as delineating problems, also points to solutions, pointing out that a ‘lack of knowledge of infants' capabilities and the environmental circumstances that best promote early growth and development is no longer a constraint to putting sound programs in place for enhancing children's development' ... rather ‘transforming knowledge into action is the major limiting factor and (overcoming it) requires the combined support of governments, non-government organizations, the private sector and the media'. Not covered in this book, but of some relevance, is the work summarized by Fonagy (1998) for the Acheson inquiry showing the promise of training parents to be more sensitive to the behavioural cues of very young children.
Who should read this book? Anyone who works with or trains those who work with children and families; the ideas in this book have the potential to change not only the philosophy of child health and paediatrics and child and family mental health, but give it increasing societal importance. (It is a recommended core text in our medical school.) The same applies to the other disciplines directly concerned with early childhood— education, child care, child welfare. But the potential audience is much broader than this and includes any who work in public health and health promotion as well as the increasing body of criminologists becoming concerned about the antecedents of criminal behaviour and those working to prevent substance misuse. But it is those who craft public discourse and policy—the media, and social policy makers—who would have most to gain from an understanding of the messages of this book, particularly, the economists who need to recognize the emerging evidence that wise expenditure on strategies to enhance the early years is an investment, not a cost; it is maintaining the status quo by doing nothing that in the long term will prove to be the more expensive route.
FOOTNOTES
D. P.Keating and C. Hertzman (eds), Guilford Press, New York, 1999
REFERENCE
Fonagy, P. (1998) Prevention, the appropriate target of infant psychotherapy. Infant Mental Health Journal, 19, 124–150.
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