Poverty as a Childhood DiseaseBy PERRI KLASS, M.D.
Poverty is an exam room familiar. From Bellevue Hospital in New York to the neighborhood health center in Boston where I used to work, poverty has filtered through many of my interactions with parents and their children.
I ask about sleeping arrangements. Mother, father, older child and new baby live in one bedroom that they’re renting in an apartment, worrying that if the baby cries too much, they’ll be asked to leave.
I encourage an overweight 9-year-old who loves karate, and his mother says, “We had to stop; too expensive.” I talk to a new mother who is going back to work too soon, leaving her baby with the cheapest sitter she can find.
Is your housing situation secure? Can you afford groceries? Do you go with the cheapest fast food? Can you get the prescription filled? Raising children in poverty means that everything is more complicated.
Me, I’m one generation out. My mother will tell you about her Depression childhood, the social worker who checked the family’s pots to see whether they were secretly able to afford meat, the landlord who put the furniture out on the street. It wasn’t character-building or noble, she says. It was soul-destroying, grinding and cruel.
And it’s even crueller, now that social mobility has decreased and children who grow up poor are more likely to stay poor.
At the annual meeting of the Pediatric Academic Societies last week, there was a new call for pediatricians to address childhood poverty as a national problem, rather than wrestling with its consequences case by case in the exam room.
Poverty damages children’s dispositions and blunts their brains. We’ve seen articles about the language deficit in poorer homes and the gaps in school achievement. These remind us that — more so than in my mother’s generation — poverty in this country is now likely to define many children’s life trajectories in the harshest terms: poor academic achievement, high dropout rates, and health problems from obesity and diabetes to heart disease, substance abuse and mental illness.
Recently, there has been a lot of focus on the idea of toxic stress, in which a young child’s body and brain may be damaged by too much exposure to so-called stress hormones, likecortisol and norepinephrine. When this level of stress is experienced at an early age, and without sufficient protection, it may actually reset the neurological and hormonal systems, permanently affecting children’s brains and even, we are learning, their genes.
Toxic stress is the heavy hand of early poverty, scripting a child’s life not in the Horatio Alger scenario of determination and drive, but in the patterns of disappointment and deprivation that shape a life of limitations.
At the meeting, my colleague Dr. Benard P. Dreyer, professor of pediatrics at New York University and a past president of the Academic Pediatric Association, called on pediatricians to take on poverty as a serious underlying threat to children’s health. He was prompted, he told me later, by the widening disparities between rich and poor, and the gathering weight of evidence about the importance of early childhood, and the ways that deprivation and stress in the early years of life can reduce the chances of educational and life success.
“After the first three, four, five years of life, if you have neglected that child’s brain development, you can’t go back,” he said. In the middle of the 20th century, our society made a decision to take care of the elderly, once the poorest demographic group in the United States. Now, with Medicare and Social Security, only 9 percent of older people live in poverty. Children are now our poorest group, with almost 25 percent of children under 5 living below the federal poverty level.
When Tony Blair became prime minister of Britain, amid growing socioeconomic disparities, he made it a national goal to cut child poverty in half in 10 years. It took a coalition of political support and a combination of measures that increased income, especially in families with young children (minimum wage, paid maternity and paternity leaves, tax credits), and better services — especially universal preschool programs. By 2010, reducing child poverty had become a goal across the British political spectrum, and child poverty had fallen to 10.6 percent of children below the absolute poverty line (similar to the measure used in the United States), down from 26.1 percent in 1999.
“Poor families who benefited from the reform were able to spend more money on items for children: books and toys, children’s clothing and footwear, fresh fruits and vegetables,” saidJane Waldfogel, a sociologist at Columbia who has studied the British war on childhood poverty.
Dr. Dreyer said: “Income matters. You get people above the poverty level, and they actually are better parents. It’s critical to get people out of poverty, but in addition our focus has to be on also giving families supports for other aspects of their lives — parenting, interventions in primary care, universal preschool.”
At the Pediatric Academic Societies meeting, the most unexpected speaker — to a room full of pediatricians — was Robert H. Dugger, managing partner of Hanover Investment Group, who made the economic case for investing in young children. “History shows that productivity increases when people are able to access their rights to life, liberty and the pursuit of happiness,” Mr. Dugger told me. “There is no economic recovery strategy stronger than committing to early childhood and K-through-12 investment.”
Think for a moment of poverty as a disease, thwarting growth and development, robbing children of the healthy, happy futures they might otherwise expect. In the exam room, we try to mitigate the pain and suffering that are its pernicious symptoms. But our patients’ well-being depends on more, on public health measures and prevention that lift the darkness so all children can grow toward the light.