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The Real Brain Drain
Why putting children first is so important in Australia
Professor Fiona Stanley, NATIONAL PRESS CLUB ADDRESS Wednesday 6 August 2003
I would like to acknowledge the traditional owners of the land the
Ngunnawal people.
I would like to acknowledge that the current health status and
problems in Aboriginal and Torres Strait Islander communities stem directly and
indirectly from the history of colonisation.
I am both privileged and honoured to
be here as Australian of the Year.
What I want to say today reflects my own
development and evolution from a doctor for child health to child health
researcher to using research to improve child and youth outcomes.
So I started out
learning about how the body works and how to treat it when things go wrong. I
then began to realise the limitations of modern medicine were that it did
not prevent disease. I then decided that the best way for me to practise medicine
was to try and find out the causes of diseases and prevent them. To me that
seemed the most logical, the most humane, the most cost effective way to practice
and certainly the best way to have a major impact on improving our society.
So I
left the clinic behind and became a population health researcher
an epidemiologist.
Epidemiologists look at the patterns of diseases and problems
in the whole population the questions which we pose are, how often does this
occur?, who gets it?, why? and can we prevent it?
Travelling further on my
evolutionary path, I realised that to really understand causes you had to bring
together not just epidemiologists, but researchers in genetics, biology, and
clinical sciences hence the establishment of our exciting and novel Telethon
Institute for Child Health Research in Perth. Here we can study, for all
The complex modern diseases and problems affecting our children and young
people, how genetic risks interact with environmental risks during development
and throughout life to produce disease. Great stuff.
But more recently we now
realise that the real gains in reducing disease and improving health will come
from the social and economic circumstances operating in families, communities and
the wider society, that is that the most effective preventive strategies lie
OUTSIDE the traditional areas of the health professions. The exciting
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thing is that outcomes other than health such as educational and
behavioural competencies may also be enhanced. This is a long way from the
medical model of my original training!
Epidemiologists get excited about data my
challenge today is to excite you about data and research in relation to children
and young people in Australia today, a pretty impossible task!
And what do I mean
in the title of this talk what is the real brain drain?
I would like to
answer that by giving you 2 statistical stories to illustrate the power
of prevention compared with the costs and limits of treatment; I then want to
pose some questions about children and young people in todays Australia; I will
attempt to answer the questions but probably will raise as many again in my
answers and finish by calling Australia to action. By then I hope I will have
made the case that by placing a greater value on children's futures will be of
benefit to the whole of our society.
The first statistical story describes
recurrent otitis media (middle ear infection) in disadvantaged Aboriginal
children, and the second, suicides in children from moderately advantaged
families.
So picture my Aboriginal child with runny ears, living from birth in
poor housing on the fringe of a rural town in any Australian state. She has
probably been given several courses of antibiotics, may now be resistant to
penicillin, so needs more expensive and maybe less effective antibiotic
treatment. She has been intermittently deaf throughout all her pre-school and
primary school years and is significantly delayed in both language and
educational performance compared with her age peers. Her young parents, loving
and caring, take her on the advice of the local community health nurse, to have
grommets inserted to enable the pus and fluid in the middle ear to drain properly
and to give her a chance to hear. This entails long distance travel, the costs of
surgery which is not particularly successful and significant trauma for her. With
increasing delay in her schooling she becomes a naughty teenager, feels that
she is stupid and starts sniffing to escape the pain. The story could continue
on a number of paths, the most likely (statistically) are fairly grim and do not
auger well for her, or in the future, her own children. She is unlikely to become
a competent contributor to Australian society and her brain has certainly not
been given an opportunity to develop to its full potential. How wonderful if we
could have avoided the cost, pain and anguish of this story which is common to so
many of our Aboriginal children?.
And now to my other statistical story one all
too common of suicides in young people. Many young people in relatively
advantaged families with a good standard of living, start on pathways to high
risk behaviours, substance abuse, poor school performance, low self esteem,
depression and suicide. This young man may have been bullied, may have been
overweight, not confident about friends ??" pretty common in todays schools. There
may have been considerable attempts to diagnose and treat a range of mental
health or behavioural problems in the primary school years, but of course less
than 10% of young people with problems actually get to use the already stretched
mental or other health or educational services. Alcohol
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and cannabis was involved and the young man ends his own life. This brain
is certainly not going to contribute to Australia future and the situation has
left a family devastated. Forever they will ask could they or others have turned
our young person around? Could the cost, pain and anguish of this story have been
prevented? How DO you count the cost of a suicide? The questions I want to ask
are:
1. Are outcomes for children and youth improving in Australia? As so
many outcomes are related to social disadvantage, surely as economic
prosperity and living conditions improved, so have the health, educational,
behaviour and general status of our children?
2. Is there any evidence more
recently of a levelling of social gradients, that is fewer differences between
the 'haves' and the 'haves not'? Are all in societywinners from the dramatic
economic and social changes in our society?
3. What has been the impact of
services? (mostly focussed on treatments notpreventions).
4. Why have so many of
the problems in children and youth not improved? Are there some common
explanations?
5. What do we know about the causes and possible prevention of
them?
6. What should Australia do?
7. Are outcomes for Children and youth
improving in Australia?
As so many outcomes are related to social disadvantage,
surely as economic prosperity and living conditions improved, so have the health,
educational, behavioural and general status of our children?
I have pulled
together the best data on the total population trends that I can from the best
sources available. We are observing increases in poor outcomes for children and
youth across a wide range of health, development and wellbeing domains. These
include things as diverse as low birth weight, child abuse and neglect, behaviour
problems, educational problems, mental health problems, substance abuse,
unemployment and juvenile crime.
The common pattern is that these are increasing
in younger and younger children , and in girls as well as boys even for those
areas in which girls were rarely observed 20 - 30 years ago, such as aggressive
behaviour, substance abuse and violent juvenile crime. And whilst these problems
are much higher in our Aboriginal children, this pattern is across the whole
population.
Suicides have increased fourfold in 15-19 year old males since the
1970's and the worrying thing is that the rates are now higher still in 24-35
year olds; nearly 20% of teenagers have a mental health problem; obesity has
increased in teenagers fromaround 10% in 1985 to nearly 25% in the latest years.
And in our cerebral palsy data
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in WA we observed the rise in irreversible brain damage due to
non-accidentalinjury/shaken baby syndrome from 4% to 18%.
2. Is there any
evidence more recently of a levelling of social gradients, that is
fewerdifferences between the 'haves' and the 'haves not' Are all in society
winners fromthe dramatic economic and social changes in our society?
What do I
mean by social disparity - social gradients? It describes the differences ina
particular characteristic across the social strata from the most to the
leastadvantaged. If there is a gradient, that is a difference between people's
experiencesaccording to their social status, then it can be described as a
disparity. If there areno differences then there is no disparity. Example -
there is a strong disparity (social gradient) for low birth weight; there is
virtually no disparity for childhood cancers.
Our expectation of the increases in
wealth and better living conditions in Australia was that they would they deliver
better situations for all Australians, that is that socia lgradients would not be
so steep but would flatten out. The PARADOX OF PROGRESS is that not only are we
seeing the increases in serious problems in our children that I have mentioned,
but the social gradients, the differences between the 'haves and the 'haves
not', have INCREASED not decreased!
So for example, if you compare babies born to
the most disadvantaged groupscompared with the most advantaged (these data are
hot off the press from our WApopulation data base) the disparity between their
levels of low birth weight (that isless than 2500g) in 1984-6 was 171% (that is
1.7 times more likely to have a lowbirth weight baby). Rather than decreasing
this has now risen to 190%(that is 1.9times more likely). And as birth weight is
such an important predictor of later childand adult health, disability and other
problems, this is of concern. You see lots ofmedia coverage of smaller and
smaller babies being heroically treated in neonatalintensive care units, but
where is our interest in prevention?
More data on increasing disparities - for
example for infant deaths 250% (2.5 timesmore likely in disadvantaged) in 1984-6
rising to 320% (3.2 times) in 1996-98; forsuicides and drug abuse the social
gradient is not so strong and we have seenincreases across all social groups,
but particularly higher in Aboriginal and ruralyouth. And Aboriginal youth are
still 300 times more likely than non-Indigenousyoungsters to be locked up in our
prisons.
Of course the differences are extreme when we compare all Aboriginal and
TorresStrait Islander versus non-Aboriginal and Torres Strait Islander children
and youth - they have 3 times the rate of low birth weight; 7 times the rate of
SIDS and 7 timesthe death rate from infectious disease and accidents in
childhood.
All countries show a relationship between socio-economic status and
health andother outcomes. I have a list here of all the problems and conditions
for which asocial gradient has been observed - from this list you can begin to
understand theextent to which socio-economic status is so important and why we
need to askquestions as to why:
Substance abuse in pregnancy;
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Teenage pregnancy;
Low birth weight;
Birth complications;
Physical growth in children - poor growth and obesity;
Exposure to environmental contamination;
Poor nutrition;
Behaviour problems at 3-4 years of age;
Capacity to start school;
Educational outcomes in 1 and 2 school (school does
not even out thegradient);
Mental health problems;
Infections;
Asthma;
Accidents;
Suicide;
Substance abuse in adolescence - and back to the beginning
again and theimpact becomes intergenerational.
So the paradox of progress is that
not only are all these problems increasing and sois the disparity across the
social gradient BUT also these disparities tend to besteeper NOT less steep, in
richer countries (for example far greater in USA thanCanada or China or Japan)
and as GDP (Gross Domestic Product) increases so dothe disparities! And the
evidence also suggests that the overall levels of problemsacross the whole of
society are higher in such countries.
As Australians we pride ourselves on being
an egalitarian society. It is obvious thatthe economic reforms and technological
changes have not delivered theimprovements in society that were expected. If as
Australian of the Year I representsome sense of national feeling - my feeling is
one of considerable concern. Themore we look the more we see that there are
winners and losers from these changesin our society.
And the impact is lifelong -
if you start off compromised, then your whole-of-lifechances are affected and if
you start off healthily and well-nurtured then you aremuch more likely to reach
your genetic potential.
This is the stuff that was omitted from the Generational
Report which Costellobrought out around the 2002 Federal Budget, that is not
only can we see theincrease in the aged and a shrinking fertility resulting in
fewer in the workforce tosupport the old in our society, but also the REAL BRAIN
DRAIN is the increase in theproportions of young people falling out of that
competent workforce.
The trends that I have described suggest that this brain
drain is continuing to rise.The success of knowledge economies will result from
a competent workforce andhigh levels of social capital. Failure to invest in all
stages of human development,particularly in the early years, is being recognised
by organisations such as the WorldBank to negatively affect future economic
prosperity in two ways. First, we may lackthe human resources needed to sustain
future economic growth and second, thedrain on the welfare and health budgets in
looking after these groups.
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3. What has been the impact of services (mostly focussed on treatments
notpreventions)?
The current policies and practices reflect our neglect of
prevention as an overallstrategy and instead we see a very unequal focus of
effort and dollars into costly andon the whole ineffective interventions too
late in the causal chain to make anydifference to the OCCURRENCE of these
problems.
Quote Rutter and Smith 1995 -
"The effects of the criminal justice
system on crimerates are complex. There is strong evidence that imprisonment
increases thelikelihood of re-offending. There is no evidence that increasing
the rate of detentionand conviction reduces crime rates. Punishment should be
justified on grounds otherthan crime reduction".
School programs for children
with literacy and numeracy problems ignore the mostpowerful predictors of
success - the pre-school home and neighbourhoodenvironments. As mentioned above,
very low birth weight babies are "saved" at earlier and earlier gestations in
neonatal intensive care units and so on.
Quote:
"90% of the health dollar is
spent on people who will be dead in 12 months"
Many services for schools, health,
mental health, child protection and justice are incrisis in Australia with
people demanding more and more spending on band-aidsolutions. At the same time
there has been a reduction in those services which aremost likely to prevent
problems and enhance developmental successes such as earlychildhood, child
health nurses, preschool and primary school teachers, public healthprograms,
tobacco control and so on.
So, without even asking the questions as to why are we
observing such increases inproblems?, can we prevent them? and can we enhance
child development?, we keepputting money into activities which are too late
because the problem has becomeirreversible, and we keep cutting services which
are earlier and more effective. Andthen the media and public rightly question
"we have put all this money into mentalhealth or Aboriginal and Torres Strait
Islander health so why isn't it improving"?
I hope it is becoming obvious to you
why it is not; the interventions are too late - providing more renal dialysis
machines to Aboriginal and Torres Strait Islanderpeople is important and humane
but it will not decrease renal failure in these people.Programs to reduce skin
sores, vaccines against infections, better nutrition and so onin children are
much more likely to do so.
4. Why have so many of the problems in children and
youth not improved? Are theresome common explanations?Why ARE we observing these
increases? Surely we cannot blame only economicreforms? Are there some common
pathways here that influence both educationaloutcomes and behaviour problems in
young children and suicide rates in teenagers?We now have a lot of research data
to start to answer some of these questions.
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"Children who have good early childhood experiences before age 6, in
stimulating,nurturing environments have better outcomes throughout their life
and the earlierthey have these experiences, the better the result. They have
better school grades,better self esteem, fewer social problems, and fewer health
problems and less likelyto be teen parents, use drugs or be involved in crime"
- Hertzman, Canada, 2003.
So it seems that there is evidence that if we neglect the
early years of childdevelopment then there can be profound effects on a range of
problems. Familyenvironments then are crucial to the issues we are discussing.
Most parents want tobe good parents and want the best for their children but
they need to be equippedand capable to do so. We also need to look beyond the
family to neighbourhoods,workplaces, the social and economic policies and
environments and to ask what is itabout modern Australian communities which are
what we might call "family-disabling"?
And here we come to the crux of all this -
there are new and powerful drivers ofthese poor outcomes and social disparities
in our society, ones which are increasingrisks for individuals, families and
neighbourhoods and decreasing the nurturing andhence the protective factors
which enhance resilience. This is the broad explanationof these trends and yes,
this includes economic reforms as Peter Saunders says:
"The key to improving
social outcomes lies in abandoning the idea of marketsupremacy in favour of an
approach that sees the market as one of the MEANS ofachieving social objectives,
not as an end in itself."
- Saunders 2003.
There have been lots of other changes in
our society, many quite rapid which havealso impacted negatively on early child
development and youth problems. Theseinclude disparities in opportunities and
services (privatisation of things like child caremeans that those most in need
may miss out), family breakdown, increasing hours ofwork, rapid technological
change, the information explosion, stress, violence(violence has a particular
and extreme effect on young children), reduced trust andsocial capital in
neighbourhoods (less likely to call on neighbours for child care,advice, social
support etc).
As the Australian of the Year, trying to reflect on these issues
for the nation in aconstructive way to enhance children's and hence the nations
futures, I think that weneed a serious national debate about the role of work
and family time as keydevelopmental resources for children. We should look at
other countries such asFrance which has legislated for a shorter working week
and should look at what theeconomic, social and community impact of that has
been.
5. What do we know about the causes and possible prevention of these
problems? Can we "vaccinate" our children against later school problems, drug
addiction andsuicide? If these rates have increased so much surely we can
decrease them? There are 3 main points here -
1. The mechanisms appear to be
explained by new research in braindevelopment and the interactions between genes
and social environments;
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2. Adverse social environments interact with genetic potential to
influencecompetencies which act over the whole life course and result in
theintergenerational transmission of childhood vulnerability and further
worsenssocial disparities; and
3. We have lots of evidence that early
intervention to enhance child developmentis extra-ordinarily effective.
Exciting
new research in neuroscience, the human genome, linking social andbiological
research, demonstrates the huge importance of early social environmentsin
successful brain development. Childhood exposure to abuse and less severelevels
of stress can actually change the brain through the 'switching on' of geneswhich
influence other biological processes which govern brain responses - for example
how we self regulate. This helps explain the increased rates of commondisorders
such as child and adolescent behaviour problems, attention and
learningdifficulties, obesity and eating disorders, depression and addictive
behaviours.
Whilst research may deliver new drugs to influence some of these gene
switchingpathways, they are a long way off and are likely to be expensive. There
is suchstrong evidence that providing a more nurturing social environment from
birth is sucha powerful factor to prevent such a range of problems and to
enhance resilience andcapacity - it seems to me more logical to implement such
activities.
Programs to enhance child development and readiness for school, that
is thosefocussing on the early years, have given further proof that what I have
been talkingabout is likely to be true. You might expect that 'Head Start' and
'Early Head Start' (the Perry preschool project and Chicago child development
programs) would have had an enormous impact on special education placements,
better behaviour andacademic performance in primary school, which they have. But
they have alsoimproved much later outcomes such as retention rates to year 12,
intelligence tests,dental health, mental health, employment, teenage arrests,
teenage pregnancy,welfare payments and substance abuse!!! Hey, why aren't we
putting more efforts into early programs - this must be at least part of the
answer to our fifth question.
6. What should Australia do? Why is this so
important? Even if we don't particularly care about kids (which I do),even if we
have not got children of our own, even if we only judge everything by aneconomic
bottom line - this 'brain drain' I have described is the most concerning
andworrying problem we have. Surely all of us want to be a fair Australia, an
advanced Australia, a clever country that can both compete in an international
knowledgeeconomy AND look after the social problems of our modern world?
I have
suggested that the quality of the social environments in which we live
impactspositively, particularly in early childhood but also across the whole
life span, which inturn secures better futures for our children and better
social and economic outcomesfor everyone. It means better workers and better
communities. We need to use theresources of the whole community to manage the
challenges of competing in a globalknowledge economy, to create and use
innovation and to manage complex problemsin today's world (such as the
environment, lifestyle, aging population etc).
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As Michael Pusey wrote in 'The Experience of Middle Australia: the dark side
ofEconomic Reform',
"a well ordered society needs strong markets and strong
active governments and strong families all working together to put people
first."
So perhaps now you may be starting to understand my excitement and
interest inthese interacting social, biological, family, child development,
educational and healthfor life patterns. And I am joined by a large and
increasing group of researchers,policy makers and practitioners across the whole
country, in universities, in centresand institutes, in government and
non-government departments and organisations.
We have established a fledgling
national network - the Australian Research Alliance for Children and Youth - with
the aims of pulling together as much of the Australian expertise and data as we
can to enable a new model for cross-disciplinary knowledge and 'research into
action' for children and youth. Working together andcopying both the United
Kingdom and Canada, we are pushing for a National Children's Agenda. The
Australian Research Alliance for Children and Youth andLongitudinal Study of
Australia's Children, both of which have received funding fromthe Federal
Government, are important first steps towards this. In these other countries the
children's agendas have resulted in significant changes already.
In the United
Kingdom they have a portfolio of programs to improve child and youth outcomes
such as 'Sure Start', run out of Treasury. In Canada the NationalChildren's
Agenda has influenced the uptake of early intervention and populationbased
research; a continuous longitudinal study to evaluate interventions and majornew
national research initiatives on human development and learning societies. Andin
USA they have initiatives such as 'From Neurones to Neighbourhoods'
influencingresearch, policy to "think joined up". All of these programs have
significantgovernment support, that is new money and all of them value hard and
rigorousevidence of what works.
So to summarise - our economic progress has not
delivered better outcomes forchildren and families in Australia nor has it
reduced the disparity across the socialdivide. The levels of these problems are
now so high that services are alreadystretched in providing for them and all
indications are that they are continuing toincrease. While expensive 'band-aids'
seem to be what the community areclamouring for, they will never deliver the
long-term effective solutions to theseproblems, some of which may be coming
entrenched in some groups in ourcommunity and crossing generations of
families.
So my call, as Australian of the Year, as an epidemiologist/public
health researchercommitted to prevention, as a mother and potential
grand-mother, as the CEO of anew national alliance aiming to reverse these
trends, is for Australia to harness itsgreat capacity, to work collectively to
make sure that we put children first, that wereverse the real brain drain.
I am
frightened about the road we are on, following the current trajectories towards
atechnological and wealthy elite, with increasing proportions of the
populationmarginalised. Such a pathway raises concerns about the stability of
society itself,with increasing social gradients, increasing problems demanding
more and more
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costly solutions. Alternative pathways may push us towards a more virtuous
cycleaimed at prevention rather than costly cures, on to a path that encourages
universalparticipation in collaborative knowledge building, not focussing only
on economicprosperity but also how we function as a society - the notion of what
the Canadiansare calling a "learning society" and "raising and levelling the
bar" (a reference toimproving educational success across the whole community of
children).Let me quote Canadian Strategy:
1. "safeguard the healthy development of babies;
2. strengthen early childhood services focussing on prevention and
support forparents;
3. improve schools and local communities;
4. reduce
segregation and the effects associated with poverty and
5. create a family enabling society."
And what may we find? My Aboriginal girl is far less likely to
get middle earinfections because her physical and social environment has
improved, and our youngsuicidal male was supported earlier in life before he
reached a crisis point. Bothfinished school and are contributors. We have
reversed the 'brain drain'.
And we have found that what is good for children
benefits the whole of society!
I would like to end with a quote from Gabriel
Mistral:
"Many things we need can wait, the child cannot. Now is the time his
bones arebeing formed, his blood is being made, his mind is being developed. To
him wecannot say tomorrow, his name is today."
As Australian of the Year I say to Australia - our time is now, we cannot wait.
Originating file:
http://www.ichr.uwa.edu.au/pdf/press_club_address.pdf
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