I completed my pediatric training in 1989, the same year that the Canadian parliament voted unanimously to eradicate child poverty in this country by the year 2000. At that time, the LICO poverty rate was 15.1% (LICO = low-income cut-off, or the proportion of the population who spend more than 2/3 of their pre-tax income on basic food, shelter and clothing). As of 2006, the rate was still 15.8%, suggesting that we’ve failed to honor our legislative commitment, with 700,000 Canadian children still below the LICO threshold. Lest I be accused of exaggerating, we do even worse by other metrics, such as the low-income measure (LIM, or the proportion living on less than half the median income), which saw 1.6 million (23.1%) of Canadian children living below the poverty line. Of course, as the current global financial crisis evolves, rising food prices , collapsing currencies, and a host of other trade imbalances have meant worsening access to even the basics in many poorer countries. Last week, Oxfam reported that more than a billion people are now going hungry. Yet, donor countries have delivered only $1 billion of $12 billion in promised emergency food aid, claiming their own financial distress by way of mitigation.

This troubling discordance between idealistic intentions and concrete delivery on our pledges has provoked my ire today, in part because I find it so profoundly disturbing. More to the point, it is also a perennial danger in a forum such as this, dedicated to “promoting collaboration among maternal and child-health researchers working in developing and developed countries”. That danger is of course a rather sanctimonious tendency on the part of those of us in richer countries to think that we know best, which risks turning collaboration into sermonizing, an approach that is one-sided, insulting, and doomed to failure. Now, I’m not claiming any particular virtue here. Quite the opposite. Just last week, I was preparing a statistical methods seminar and wanted to illustrate the value of variable transforms for linearizing relationships prior to analysis. Many of you will of course be familiar with the example I chose, the sadly ‘famous’ UN dataset illustrating the relationship between infant mortality rate and per capita GDP in 193 nations, which may be found at

http://www.mother-child.org/files/UN193.jpg

While I am prepared to swear that I was only looking for an example to illustrate the utility of Mosteller and Tukey’s ‘bulge rule’ for finding linearizing transformations (which you will admit this does quite convincingly!! ), I cannot help but wonder if my example had inadvertently suggested some particular moral superiority on our part. The truth is that child poverty is endemic here, as it is across the developed world, where a widening gap between rich and poor is the legacy of failed neoliberal economic policies. Moreover, it is associated with dire health consequences that are too often ignored by a ‘gee whiz’ media that is interested in reporting medical advances only if they involve computers, rockets, or the genome project!!! And if you don’t believe me, you really ought to watch the BBC documentary series “Superdoctors”, whose August edition focused on robotics in medicine and described a Canadian neurosurgeon using a variant of the ‘Canadarm’ (the made-in-Canada robotic arm developed for the space shuttle program) to perform a delicate procedure. Mid-way through, he concluded that the $25 million dollar arm was no more dextrous than he was and abandoned the effort, finishing the operation manually. Of course, that part was left on the editing room floor, considered insufficiently ‘sexy’ for prime time (I think the latin word is ‘boondoggle’ :). And that attitude is too often part of the problem, the front pages dominated by news of technological advances that do little to improve health or health care, while pressing and remediable issues languish without attention or support. Don’t misunderstand me, ‘gee-whiz’ has it’s place (it attracted many of us to science in the first place), and I have no grudge against robots. In fact, the same moral could be inferred from almost any random selection of ‘medical headlines’, while the important and well documented link between poverty and ill-health is unlikely to engage serious media attention.

Again, I needn’t look far for to illustrate my thesis. Only a few miles from my home, Louise Séguin and her team at the Université de Montréal have long been publishing the results of their Quebec Longitudinal Study of Child Development, which includes a detailed examination of poverty and its impact on maternal and child health. Their results are depressingly consistent over the years. Using the Beck Depression Inventory score, they reported that that depressive states were 2 ½ times as common among pregnant women from lower socioeconomic strata (47% vs 20% in higher income peers), and these symptoms were statistically associated with ‘chronic stressors’, such as financial and housing problems and a lack of adequate social support (Séguin et al, Obs Gyn 1995). In a 2003, they concluded that infants with lower household incomes suffered from poorer overall health and higher hospital admission rates in the first 5 months of life, even after adjustment for maternal education and other factors known to affect infant health (Séguin et al, CMAJ 2003). More recently, they explored the association between duration of poverty and health in a birth cohort of 1950 children followed until age 3 ½ (Séguin et al, Pediatrics 2006). Of this total, 13.7% (268) experienced intermittent poverty and another 14.4% (280) experienced chronic poverty, and the latter was associated with an increased frequency of health problems, such as asthma attacks and a higher cumulative health problem index score. Even intermittent poverty had a measurable impact, despite universal health care and a public drug plan in this province.

Although I am a nephrologist and her research falls somewhat outside my academic sphere, I should still probably be embarrassed to admit that I was not acquainted with Dr. Séguin’s work until I chanced across a 2005 editorial in the Journal of Epidemiology and Community Health by Nick Spencer, who praised her ongoing longitudinal study for its size and methodological soundness. Dr. Spencer, now Emeritus Professor of Child Health at the University of Warwick, is the author of “Social Pediatrics”, a canonical text in the field, and has always been one of my heroes. And so I was directed to an article by Dr. Seguin in Journal of Epidemiology and Community Health, where I discovered to my surprise and chagrin that she was writing about my own city!! Nevertheless, despite a sustained and internationally lauded research focus on a problem singled out by our national parliament in an unprecedented show of unanimity, I’ve never heard Dr. Seguin present grand rounds in our hospital and I’ve most certainly never read accounts of her work in the Montreal press, only too eager to promote (for example) local research on DNA helicases,telomere unwinding, and the promised revolution in anti-wrinkle creams!

Of course, some might cite Dr. Spencer as an exception to my observations about media interest, in that he manages at times to be something of a minor celebrity, as he was this past August with his report 'Health Consequences of Poverty for Children' for the UK charity End Poverty Now. His report enumerated a number of alarming statistics from the UK, that children from poorer families were ten-fold more likely to die from sudden infant death, were more likely to suffer from low birthweight and its complications, were twice as likely to develop chronic illness as toddlers, were twice as likely to suffer from cerebral palsy, were three times as likely to suffer mental illness, twice as likely to suffer from asthma, etc, etc. And the impact of child poverty conferred life-long disadvantage, with a 50 per cent increase in serious adult morbidity, such as diabetes and heart disease. In a number of the British papers commenting on his report last month, Dr. Spencer observed that “If poverty were an infection, we would be in the midst of a full-scale epidemic”, a rather pithy summation and depressingly apt.

All of which brings me back to the question with which I opened this piece, which was intended to apply to both myself and the goals of this forum in general. Unfortunately, it is by its very nature, the type of question that I can pose but not answer, that task falling to other members of this forum, particularly those from less affluent corners of the globe, whose perceptions hold the key to this particular self-examination. To be clear, I ask the question not out of a misguided sense of noblesse oblige, but because forums like this must be truly bidirectional and open to diverse voices if they are to realize their full potential. For all I know, the cure for our own epidemic of poverty may already be found in the likes of a Mohammed Yunus’s microcredit revolution, in the successful adult literacy programs of the government of Kerala, or in the cogent analyses and prescriptive remedies from Amartya Sen on the causes of famine. Through multilateral forums such as this one, we in the west must be open to what the rest of the world can teach us, if we are to inoculate our children against Dr. Spencer’s epidemic, well on its way to becoming a plague of biblical proportions.

So perhaps I should rephrase my question as a plea for help. All replies are welcome.

Atul Sharma MD, FRCP(C)
Montreal, QC