A/Prof Nikki Turner, School of Population Health,
University of Auckland
Sept 2013
Why does childhood poverty matter?
Poverty in childhood affects their whole life
– affecting every health outcome
– educational outcome
– future jobs and income
Poverty leads to poor health
"Income is the single most important
determinant of health. There is a
persistent correlation worldwide
between low income and poor health.“
The National Health Committee in its report to the MOH in June 1998
“Determinants of Health in New Zealand: Action to Improve Health"
Poor children get sick more often
• The likelihood of a child being sick is 3 times
higher for those in the bottom household
income quintile
( Easton and Ballantyne, 2002)
• Hospital admission rates for children are
significantly higher in low income areas
(Graham, Leversha and Vogel 2001)
The reality?
Hospitalisations for Bronchiolitis by Ethnicity and NZDep
Index Decile, New Zealand Infants <1 Year 2002-2006
NZ Children's Social Health Monitor 2012
Hospitalisation for Preventable Serious Bacterial
Infections and Respiratory Diseases, Risk by ‘Deprivation’,
0-14 years, 2002-2006
Cause of Hospital Admission
Least deprived
(NZDep1)
Most deprived
(NZDep10)
Meningococcal disease#
1
4.93
Rheumatic fever
1
28.65*
Serious skin infection
1
5.16
Tuberculosis
1
5.06*
Gastroenteritis
1
2.00
Bronchiolitis##
1
6.18
Pertussis
1
3.70*
Pneumonia
1
4.47
Bronchiectasis
1
15.58
Asthma
1
3.35
#
0-24yr ##<1yr
*NZDep9-10
Source: Craig E, et al. NZCYES: Indicator Handbook. 2007.
Figure 1. Hospital Admissions for Selected Viral Infections with a Social Gradient in
Children Aged 0–14 Years (Excluding Neonates), New Zealand 2000–2011
9
Acute Bronchiolitis
Acute Upper Respiratory Infections
Viral Infection of Unspecified Site
Croup/Laryngitis/Tracheitis/Epiglottitis
Viral Pneumonia
Viral/Other/NOS Meningitis
8
Admissions per 1,000
7
6
5
4
3
2
1
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Source: Numerator Admissions: National Minimum Dataset; Denominator: Statistics NZ
Estimated Resident Population (projected from 2007); Acute and arranged admissions
only.
NZCYES The Health Status of Children and Young People in NZ Feb 2013,
Hospital Admissions for Conditions with a Social Gradient in Children Aged 0–14 Years
(Excluding Neonates) by Primary Diagnosis New Zealand 2007–2011
About two –thirds are respiratory conditions
New Zealand
Primary Diagnosis
Number: Total
2007−2011
Number:
Annual
Average
Rate per
1,000
% of Total
Medical Conditions
Acute Bronchiolitis
Gastroenteritis
Asthma
Acute Upper Respiratory Infections Excl Croup
Viral Infection of Unspecified Site
Skin Infections
Pneumonia: Bacterial, Non-Viral
Urinary Tract Infection
Croup/Laryngitis/Tracheitis/Epiglottitis
Epilepsy/Status Epilepticus
Febrile Convulsions
Dermatitis and Eczema
Otitis Media
Pneumonia: Viral
Inguinal Hernia
Osteomyelitis
Rheumatic Fever/Heart Disease
Meningitis: Viral, Other, NOS
Bronchiectasis
Vaccine Preventable Diseases
Meningococcal Disease
Nutritional Deficiencies/Anaemias
Meningitis: Bacterial
Tuberculosis
New Zealand Total
27,420
26,230
24,003
19,580
19,050
15,926
14,606
6,918
5,686
4,070
3,514
3,317
3,258
1,997
1,332
1,175
963
765
706
534
433
292
214
55
182,044
5,484.0
5,246.0
4,800.6
3,916.0
3,810.0
3,185.2
2,921.2
1,383.6
1,137.2
814.0
702.8
663.4
651.6
399.4
266.4
235.0
192.6
153.0
141.2
106.8
86.6
58.4
42.8
11.0
36,408.8
6.13
5.86
5.36
4.38
4.26
3.56
3.26
1.55
1.27
0.91
0.79
0.74
0.73
0.45
0.30
0.26
0.22
0.17
0.16
0.12
0.10
0.07
0.05
0.01
40.68
NZCYES The Health Status of Children and Young People in NZ Feb 2013,
15.1
14.4
13.2
10.8
10.5
8.7
8.0
3.8
3.1
2.2
1.9
1.8
1.8
1.1
0.7
0.6
0.5
0.4
0.4
0.3
0.2
0.2
0.1
<0.1
100.0
But why are they getting sick…..
“If you have five bucks left to feed the family with
at the end of the week, you’ll go and get $4
worth of chips and a loaf of Rivermill bread, not
fruit and vegetables.”
NZ Teacher 2005
Juliette
Juliette’ s background
• Had first vaccination event, none since
• Mum – solo parent, 17 years old
– Hard background……..
• Dad – awol, drug and alcohol problems
• Home
– Aunty’s house
– Currently 16 in the house
- smokers
– Moved 4 times since birth
Why does she get sick?
Spread of the organism
Weaker immune response
Reduced access to health care services
Jack is a 9 year old boy well know to the general practice. He has
come in very many times to the GP and local A & M with a range
of health issues: asthma, eczema, chest infections, skin
infections, injuries.
Since birth he has had TEN hospital admissions:
bronchiolitis (baby x2) asthma (x3), broken leg, head injury,
cellulitis (x2), dental abscess
Jack is overweight, doing poorly at school,
described by the school as having a learning
difficulty. Furthermore the school are concerned
because he is a playground bully.
His father is in jail. He has a brother and a
sister and another died as an infant.
His Mum is 29 with a chronic medical
condition. She has been in and out of a lot of
jobs, never lasts more than a few months
Jack’s future……
•
•
•
•
•
•
•
Poor health lifelong
Obesity
Drug and alcohol abuse
School failure, limited occupational options
Criminality
Broken relationships
Shorter life expectancy
Rate (95% CIs) of initial all cause pneumonia
hospitalisations, by NZDep, 2006 to 2012
Unpublished data, IMAC, University of Auckland Sept 2013
Rate (95% CIs) of initial all cause pneumonia
hospitalisations, by ethnicity, 2006 to 2012
Unpublished data, IMAC, University of Auckland Sept 2013
Who is in most hardship in NZ?
% in severe/significant
hardship 2008
Children 0 – 17 years
18 – 24 years
25 – 44 years
45-64 years
65 + years
Overall
23
15
16
13
4
15
Adapted from: Perry B Non-income measures of material wellbeing and hardship: results from the
2008 New Zealand Living Standards Survey MSD Wellington Dec 2009. p, 22
Restrictions Experienced by Children, by the Deprivation
Score of their Family, NZ Living Standards Survey 2008
0
1
2–3
4–5
6+
Distribution of children across DEP scores
41
18
18
10
12
Average number of children per family
2.2
2.3
2.5
2.7
2.7
Enforced lacks of children's items
Waterproof coat
-
2
8
11
39
Separate bed
-
-
3
13
20
Separate bedroom children opposite sex 10+ yr
2
3
6
14
24
Economising 'a lot' on children's items to keep down costs to afford other basics
Children continue wear worn out shoes/clothes
-
-
5
15
39
Postponed child's visit to doctor
-
-
-
5
13
Did not pick up prescription for children
-
-
-
3
7
Enforced lacks reported by respondent in child's family
Meal with meat/chicken/fish at least ev. 2nd day
-
-
-
6
18
Cut back/did without fresh fruit and vegetables
-
-
15
32
63
Postponed visit to doctor
-
4
18
38
65
Housing and local community conditions
Major difficulty to keep house warm in winter
9
13
27
38
58
Dampness or mould (major problem)
5
13
18
37
49
59% of children with Benefit as source of family income experienced 4 + of these (or similar) items
Severe/significant hardship means
•
•
•
•
•
Postponing visits to the doctor and prescriptions
Colder/damper houses
Poor quality food, less meat, less fruit
Less participation in sport, music, other hobbies
Living in an area with more crime
This is not inevitable
We have a choice as a country
Why has NZ has been so successful
protecting older people from poverty?
We made income a priority with NZ Superannuation
•
•
•
•
•
•
Universal - everyone gets it
Simple & adequate
Does not change with work status
Does not reduce in hard times
Linked to prices and wages (indexed)
We don’t judge
•
•
•
•
Awareness
Empathy
Practical help
Advocacy
The Nature of the Problem?
1.
2.
3.
4.
5.
6.
7.
8.
Low family incomes, inadequate child assistance and poorly
targeted resources
Low take-up rates for many child-related benefits
Relatively low employment amongst sole parents
A poorly designed child support system
Poor quality, unaffordable, overcrowded houses
Inequitable access to many social services, including health
Poorly integrated information and service delivery systems
No plan, no authoritative child poverty measures, no targets
OCC EAG Report 2012
NZ child poverty trends,
- After housing costs incomes
Proportion of children in low-income HHs (%)
50
40
60% 98 CV
60% 07 CV
30
20
10
0
1980
1985
1990
1995
HES year
Bryan Perry, MSD, March 2012
2000
2005
2010
‘Multiple bee stings’
December 2012
Prescription charges will increase from $3 an item to $5
an item in next week's Budget, as the Government
moves to offset the cost of extra health spending in the
"zero Budget".
Rationale
• Small increase
• Shouldn’t be a problem
• Low income families have other options
– Disability allowance forms…..
URGENCY to ACT
"Many things we need can wait. The child
cannot. Now is the time his bones are being
formed; his blood is being made; his mind is
being developed. To him we cannot say
tomorrow. His name is today.”
Gabriela Mistral
Wicked problems…..messy solutions
Poverty Reduction Examples
• Macro:
– Structural economic change
• Taxation
• Social Security
• Minimum living wage
• Health
– Meningococcal B vaccination campaign
– Reduction in costs of health care for children (still not
free)
– Housing Insulation
2012 targets
National Health Targets
National Strategy
Parliamentary Enquiry
NHC report
NIR
PHC report
Priorities for Action Report
1995 Strategy
Percentage fully immunised by two years of age
Turner N, unpublished; using combined data from national surveys and the NIR
NIR data from 2009 to 2012 showing national immunisation coverage rates at 2 years
of age by the NZ Deprivation Index in quintiles
39
Specific Proposals
OCC EAG 2012: A Child Poverty Act
•
•
•
•
We need a plan
Measures, targets, reporting
Legally mandated
Our proposed targets are ambitious, but realistic:
– to reduce overall child poverty by at least 30-40% within 10
years
– to reduce those living in severe and/or persistent poverty by
over 50% within 10 years
E aku rangatira, he aha te mea nui o tenei ao?
Maku e kii atu,
he tamariki, he tamariki, a taatou, tamariki.
Dame Anne Salmond
With thanks to IMAC whanau for the children illustrations