Inequality, poverty and family stress undermine child health in Australia

During the 20th century, life expectancy dramatically increased in Australia, primarily as a result of improved child health. Better living conditions and social facilities led to remarkable reductions in child mortality rates, particularly before 1960.

But at the beginning of the 21st century, according to a prominent professor of paediatrics and child health research, new problems in child and adolescent health present society with challenges similar to those of 1901.

In her report, Child Health Since Federation, published by the Australian Bureau of Statistics in a series marking the centenary of Australian Federation in 1901, Professor Fiona Stanley from the University of Western Australia states:

“Coincident with changes in our modern society in family life, in employment and in the economy, and the inequalities in wealth which have occurred particularly over the past four decades, we are observing epidemics of mental health problems such as suicides, risk taking behaviours, depression and eating disorders in our young people.”

To explain these disturbing trends, she points to complex underlying social factors, including the growth of unemployment, poverty, inequality and increased pressures on families. She concludes: “Today's social and environmental influences, as with those 100 years ago, are far more powerful in child health and disease than are the drugs or medical care facilities we have at our disposal to treat them.”

Stanley begins with the overall improvement in life expectancy. A person born at the beginning of the 20th century (1900-10) could, on average, expect to live 55.2 years (males) or 58.8 years (females). Near the end of the century (1995-97), males could expect to live 75.7 years and females 81.4 years.

Unprecedented achievements in child health were responsible for most of the improvement. Among children less than 5-years-old, the mortality rate per 100,000 fell from 2,604 for males and 2,214 for females in 1907 to 137 and 111 respectively in 1998. Much of the progress came in the early years of the century. More than half the fall in mortality occurred by 1930 and 80 percent by 1960.

The infant (under 1-year-old) mortality rate dropped even more sharply. For male babies the rate fell from 120 for every 1,000 live births in 1907 to 5 in 1998. Among female babies, the figure fell from 100 to 5.

“The social and economic environment around 1901 was harsh and difficult for many families; many children were malnourished and likely to die from infectious diseases such as gastroenteritis and pneumonia,” Stanley explains. Conditions in Australian cities were so poor that Sydney suffered an outbreak of plague at the turn of the century.

Improved health and nutrition of mothers and children, higher general living standards, public programs to educate mothers in hygiene and child care and the encouragement of breast-feeding had a significant impact in reducing the number of children dying from gastroenteritis. Local governments improved sanitation in the cities by providing garbage collection and sewerage systems. They also established baby health centres or infants' clinics, staffed by trained nurses.

Public vaccination programs after World War II were the next most significant contributor to reducing child mortality. Polio, one of the infectious diseases eradicated by vaccination, used to take the lives of up to 10 out of every 100,000 teenagers and left many more disabled.

The sciences of physiology, biochemistry and pathology blossomed throughout the 20th century, following hard on the heels of bacteriology, producing advances like X-rays, surgery anaesthetics, chemotherapy and other drug treatments. By the end of the century, however, new social problems had arisen and “public health, once centre stage and still vital, is often ignored”.

Stanley explains that the rarity of death among children masks the growing burden of illness and disability affecting young people. More complex diseases have appeared over the past three decades, including mental illnesses, asthma, juvenile diabetes, obesity and cerebral palsy.

Asthma has become the most common cause of childhood hospitalisation, with health surveys finding that 20 percent of children now suffer from it. Rates of insulin-dependent diabetes have risen from around 12 per 100,000 to 22 over the past 15 years.

Stanley identifies various “lifestyle risk factors,” notably tobacco and alcohol use as well as obesity and poor physical health. By the age of 14, half of boys and girls have started drinking, some regularly, and about one-third of the same age group admit to smoking a cigarette in the previous week.

Obesity is an increasing problem, with studies finding that 25 percent of 7-18 year-olds are overweight. At the other extreme, eating disorders driven by a desire to lose weight are at epidemic proportions among girls, and increasingly common among boys. Over 30 percent of 8-to-12 year old girls have tried to lose weight. Stanley notes that doctors are now finding longer-term mental as well as physical health problems flowing from poor childhood growth.

Higher suicide rates

Stanley points to higher death rates among teenagers in the latter third of the 20th century. In 1907, the mortality rate for 15-19 year old males was around 80 per 100,000. In the late 1930s, it fell to about 60 but climbed to a high of 125 in the 1970s before dropping to around 60 at the end of the 1990s.

The 1970s peak was related to high numbers of traffic and other accidents. The later decrease followed compulsory seatbelt legislation, laws against drink driving and public education campaigns on road and workplace safety.

Teenage suicide, however, rose to high levels in the 1970s and remains there. In 1907, the teenage male suicide rate was 5 per 100,000; by 1973-74 it had risen to 20. During the 1990s, deaths from suicide among teenage males were more common than deaths in car accidents. Female teenagers had lower suicide rates—between 2 and 6 per 100,000—but attempted suicide at a greater rate than young men.

Stanley suggests that social factors are responsible for these trends. Among them are falling marriage rates, rising divorce rates and a growing proportion of children born outside marriage. She provides a list of themes associated with marital breakdown, including unemployment and work related problems, addictive behavior, poor communications, poor parenting skills, domestic violence and social isolation.

The number of sole parents has increased—usually single mothers who are generally poor and have low education levels. Their children are less well off socially, educationally and physically. But these problems primarily result from extreme poverty. Forty percent of sole parents with three or four children live on incomes below 80 percent of the poverty line. Stanley concludes that “the critical issue is not necessarily how many parents a child has but the social and environmental context in which the single parent family operates”.

She notes that high levels of poverty and disadvantage were a powerful influence on the poor level of child health around 1900 and that “as we move into the new millennium, increasing levels of inequity in social and health status are worrying”. Overall, 12.6 percent of children live in relative poverty—in households whose incomes are less than 50 percent of the national median.

Apart from higher unemployment levels, the most important work-related influence on child health has been the increased numbers of mothers working. Studies show that most women with young children now work, either part- or full-time and that 73 percent of children have attended childcare by the age of 3 years. Stanley comments: “Arrangements for child care vary, as does the quality of this care and so its impact on the child's social and physical welfare.”

Depending on the home environment, children can face emotional, psychological and physical abuse that may result in depression. Stanley suggests that child abuse is becoming more frequent. One indicator is that rates of post-neonatal cerebral palsy due to non-accidental injury rose from 3.4 percent to 14.9 percent in Western Australia between 1956-75 and 1980-92.

Other studies show a significant increase in childhood mental illness. A Western Australian Child Health Survey found that 20 percent of 12-16 year olds suffer from health problems. Yet, says Stanley, “there is a huge unmet need” for preventative strategies, both in and out of school.

Stanley's report is weaker when she seeks to examine the political conceptions that guided the attention paid to child health during the 20th century. She points to the desire of early governments to rapidly expand Australia's small population and produce healthy youth for fighting wars. She quotes a 1930s official document advocating physical education in schools with the aim of producing “a race of strong, virile, stalwart individuals who would provide an invincible bulwark for defence in times of crisis or emergency”.

While no doubt these views were influential in ruling circles, Stanley makes no mention of the political struggles of the working class for better living conditions, shorter working hours and the provision of public health and education.

She concludes by asking: “Are we going to respond to change our social, emotional and economic environments to improve child health as effectively as our forebears in the years after Federation?” She expresses the opinion that people are beginning to react against “the excesses of this era” by seeking to protect the environment, be better parents, work less and do more for the community.

Her sentiments seem well intentioned, but the reversals in child health are not the result of economic “excesses” or individual greed. As many of Stanley's statistics indicate, today's child health epidemics are bound up with systematic cuts to living and working conditions and mounting social inequality. These trends can be reversed only by overturning the subordination of all aspects of social life—from longer working hours to public health funding cuts—to the dictates of corporate profit.