Health disparities across the lifespan: where are the children?

A 2003 publication by the Institute of Medicine raised awareness regarding persistent disparities in health care in the United States.1 However, of the 103 studies reviewed in the report, only 5 focused on disparities for children. Based on the expectation of a significantly more diverse child population by 2020,2 and the large number of children living in poverty, greater attention is needed on vulnerable children and their potential for a healthy and productive adulthood. Much research has documented persistent or increasing child health disparities by population, disease, risk factors, and geography, but there is a paucity of research on successful interventions. Life-course research demonstrates the power of early childhood health and experiences influencing adult health such as cardiovascular disease, type 2 diabetes, hypertension, and mental health.3 To eliminate health disparities, greater attention is needed for research and intervention with in a life-course perspective,3–4 with collaboration horizontally across the age span for obstetrics, pediatrics, and adult medicine, and vertically across multiple disciplines and perspectives. First, to address health disparities, an early investment in children must be made. Heckman5 demonstrated that early investments in the well-being and skill formation of disadvantaged children pay off. His work shows that there is an over investment in remedial skill programs at later ages and an under investment during the early years of development, increasing costs and reducing results.5 Returns to human capital investments are greatest for the young because younger individuals have a longer time horizon over which to recoup the fruits of the investment and learning begets learning. Later attainments build on cognitive, linguistic, social, and emotional competencies developed earlier and early investment promotes later investment and the highest marginal returns. For example, the rate of return on a preschool program investment for disadvantaged children has an estimated real return on investment (adjusting for inflation of 15%–17%) with a benefit-to-cost ratio of 8 to 1.6 The Telluride Principles for Investing in Young Children, recently articulated by business, finance, and policy leaders, posit that long-term US economic strength and fiscal sustainability depends on a future workforce; investing in children is a vital economic growth strategy and should be a priority of business, government, and philanthropy.7 Second, investment in children must guarantee access to healthcare. The recent passage of the Children’s Health Insurance Program Reauthorization Act of 2009, the insurance program for low-income children, is an important first step in improved health insurance coverage for US children. This program provides consistent coverage, avoiding the disruptions that cause under use of services and greater unmet medical need. Scientific evidence supporting the benefits of the Children’s Health Insurance Program and health insurance for all children demonstrate improved preventive care, immunization rates, chronic disease care, and quality of life of enrolled children.8 Racial disparities in healthcare access and unmet need also have been dramatically reduced with health insurance coverage.9 Guaranteeing health insurance, however, while necessary, is not sufficient to eliminate health disparities. Third, there must be an investment in the health, education, and well-being of all children, especially those living in poverty. The life-course perspective can examine the influence of poverty across a lifetime from childhood to adulthood, but also allows the study of intergenerational transmission of social advantage or disadvantage and health. It is estimated that nearly 13 million children, 17% of US children, live in poverty.10 Initiatives like the Harlem Children’s Zone11 must be supported.12 The Children’s Zone provides comprehensive education, health, and social services to children while helping parents become more self-sufficient. President Obama has committed to the development of children’s zones in other cities. Fourth, to address health disparities and evaluate innovative models, multidisciplinary approaches involving multiple disciplines and perspectives are needed for research and intervention. Research and action must incorporate an ecological approach that includes family, community, and other contextual layers. It is necessary for physicians to transcend traditional disciplinary silos to collaborate with educators and other professionals addressing child development. The perspectives of children, adolescents, families, and community members must be included in all steps of research and research translation. Fifth, coordinated leadership is critical to transforming systems and really investing in children. This should start with a presidential commission on children and expansion of the Institute of Medicine’s “Unequal Treatment” report1 and the 2004 “Children’s Health, the Nation’s Wealth” report by the Committee on Evaluation of Children’s Health, a project of the National Research Council and the Institute of Medicine.12 There must be an understanding of what programs are best investments, the development and implementation of integrated new models, and evaluation and improvement on their effectiveness. The United Nations Children’s Fund Innocenti Report Card in 2007 assessed the general welfare of children in North American and European countries of the Organization for Economic Cooperation and Development.13 The report reviewed 6 dimensions: material well-being, health and safety, educational well-being, peer and family relationships, behaviors and risk, and subjective well-being. Of 21 nations included in the report, the United States was in the bottom third of the rankings for 5 of the 6 dimensions. This sobering report highlights the need for the United States to refocus on the needs of children and families. It is time to reflect on the legacy left to future generations and recommit to prioritizing children. Commitment means quality medical care and quality education for all children. Commitment also means creation of a national children’s agenda as a link to improving the health of all US individuals in the future, not only those experiencing disparities today. Committing to children is a wise investment for the future of the United States in the global community.