Chapter 2: The Chief Public Health Officer's Report on the State of Public Health in Canada, 2009 – The role of public health in influencing the lifecourse trajectory

Chapter 2 - The Role of Public Health in Influencing the Lifecourse Trajectory

What is a lifecourse trajectory?

A lifecourse trajectory is, in the simplest terms, the path a person takes from birth until the end of life. A trajectory is a route travelled from start to finish. For instance, when a ball is thrown, the force used to propel it, the direction in which it is thrown, and any obstacles it encounters along the way will dictate when and where it lands. The path the ball follows through the air on its way to landing is its trajectory.

In reference to health, the path or trajectory followed can change during any life stage (childhood, adolescence, adulthood) and can vary from person to person depending on the factors interacting to influence health (biological, behavioural, physical, social). Both positive and negative factors evolve and interact within and across life stages, ultimately resulting in the positive and negative health outcomes that each individual experiences in his or her lifetime. Canadian researchers cite three models that explain the relationships between these influencing factors and health outcomes.^{footnote 5} The latency model shows the relationship between an exposure at one point in the lifecourse and the probability of a health outcome later (regardless of intervening or mitigating experience).^{footnote 5} For example, childhood exposure to high levels of ultraviolet rays from sunlight can eventually emerge as skin cancer in adulthood and adequate nutrition both in the prenatal period and the first year of life can reduce the risk of developing heart disease later in life.^{footnote 6–11}

The cumulative model shows the health impact of multiple or recurring exposures over the lifecourse.^{footnote 5} For example, growing up in a low-income environment and being repeatedly exposed to conditions of poverty can adversely impact adult health outcomes such as high blood pressure, circulatory diseases and weakened immunity. Alternatively, children who grow up in a household where the father works in a higher-income occupation and who themselves work in higher-income occupations as adults have been shown to have decreased rates of ischemic heart disease in adulthood.^{footnote 12 footnote 13}

The pathway model shows a dependent sequence of exposures, where an exposure that occurs at one stage of a life influences the probability of other exposures later in the lifecourse and – potentially – across generations.^{footnote 5} For example, children living in a family experiencing financial worries or marital discord may be at greater risk of cognitive and behavioural difficulties.^{footnote 14 footnote 15} A lack of readiness to learn and poor behaviour at school can reduce educational performance.^{footnote 16} In turn, in adolescence, this can lead to the adoption of health-damaging behaviours such as smoking and illicit drug use, having an unplanned pregnancy or dropping out of school.^{footnote 15} Consequently, this may limit employment options and financial success and impact health in adulthood.^{footnote 5 footnote 15} Conversely, activities such as reading, spelling of words or singing to a child can promote language development leading to a lasting impact on the child's literacy and lifelong learning.^{footnote 17 footnote 18} Being developmentally ready for school can influence school success and social competency among peers, which can lead to better decisions around risk behaviours and eventually better adult health outcomes.^{footnote 19 footnote 20}

Public health and the lifecourse trajectory

The value of the lifecourse trajectory model to public health is that it helps us to understand the links and timing between exposure to a factor or combination of factors (at one point in time or over time) and the later health effects tied to those factors.^{footnote 5, footnote 21–24} This knowledge can then be applied to identifying and understanding trends in the health of populations and links between life stages, and to proactively developing appropriate policies and interventions that address those trends and links.^{footnote 5 footnote 22} In this way, public policy that incorporates the lifecourse approach can be considered “prevention policy”, identifying opportunities for creating ideal conditions for health and wellness at critical points across the lifecourse.^{footnote 5 footnote 22}

Lifecourse trajectories and childhood investments

Events that affect health are important throughout life, but childhood is a critical period in which to establish a foothold on the road to good health.^{footnote 22} Children experience a phase of accelerated growth in the early years of their lives – including physical growth, brain development, and mental and emotional growth and development. The education, care and attention they receive during this period can have a crucial impact on their future health and well-being. In particular, the prenatal period to age six (and especially the first three years) is the time during which the foundation for developing competence and coping skills is formed, affecting learning, behaviour and health throughout life.^{footnote 25} It is also the stage during which nutrition, care and nurturing directly affect pathways of the brain that, among other things, affect risk for disease later in life.^{footnote 25}

Although opportunities to maintain or return to good health exist along the lifecourse, establishing initial good health and developing resilience can make it easier to maintain a positive health trajectory in the face of later challenges.^{footnote 26} Evidence suggests that the greatest return on investment, in terms of lifelong health and quality of life, can be realized through interventions made during the earliest stages of the lifecourse (prenatal and childhood).^{footnote 25 footnote 27 footnote 29}

A brief history of Canada's experience with creating the conditions for a healthy start to life

Canada has made substantial progress creating healthy starts, as noted in the following chronicle of actions taken over the last 150 years. These highlights illustrate how public health and other influencing factors have evolved in their approach to children's health and wellbeing. Looking to the past provides a sense of where we stand today on children's health and the foundation from which future actions in this important area can also be taken (for a more detailed history of public health in Canada, see The Chief Public Health Officer's Report on the State of Public Health in Canada, 2008).^{footnote 30}

Pre-20th Century

Before the 20th century, the health and safety of children in Canada was not a specific area of focus for government policy and community interventions. Most pregnancies were unmonitored and birth complications presented potential risks to mothers and children primarily due to the limited effectiveness of health care at that time, as well as limitations in access to health care.^{footnote 31} In the early 1890s, Canada's infant mortality rate (IMR) was approximately 145 deaths for every 1,000 live births.^{footnote 32 footnote 33}

During this period, many children were expected to help support the family – at home, on the farm, with family businesses or activities that generated income, or through participation in the paid labour force. For those abandoned or orphaned, early provisions made for them through legislation included the Orphan's Act of 1799 and Apprentices and Minors Act of 1851. Both provided legal recognition of these children but only in exchange for their labour by binding them into apprenticeship.^{footnote 34 footnote 36} For all children, working conditions were often difficult and dangerous, resulting in high rates of injury and death.^{footnote 37 footnote 38}

In the second half of the 19th century, the recognition of poor living and working conditions (particularly in industrial areas and among the poor and working classes), and the relationship of these conditions to health and safety, brought about initiatives for improvement. For example, policies such as Ontario's Factory Act of 1884 set minimum wages, imposed limits on hours worked and banned employment where injury was likely for women and children.^{footnote 39 footnote 40} Similar legislation followed across Canada during the early 1900s.^{footnote 39}

The care of abandoned or orphaned children also evolved during this period. Charitable organizations were given the legal authority to intervene in the maltreatment of apprenticed children. These organizations were also involved with the emergence of adoption, fostering and institutional care as alternatives to apprenticeships. Ontario's 1888 Act for Protection and Reformation of Neglected Children (also known as the Children's Protection Act) took child protection measures one step further: it allowed courts to make any neglected child – not just those orphaned or abandoned – a ward of institutions and charitable organizations.^{footnote 41 footnote 42}

During this period, school attendance was on the rise and by the end of the century compulsory attendance legislation had been passed in British Columbia, Ontario, Prince Edward Island and Nova Scotia. Most other provinces followed suit within the next decade.^{footnote 43}

For Aboriginal children, health and safety issues are not well documented for this period. It can be assumed that their health paralleled that of adult Aboriginals. The arrival of European explorers and settlers had a detrimental impact on Aboriginal health – from the introduction of various diseases and non-traditional foods to a reduction of resources due to their confinement to specific areas of land.^{footnote 44–46} The health and well-being of First Nations and Inuit children experienced another setback with the introduction of the residential schools system in 1849. The system was based on the premise that if First Nations and Inuit learned English, adopted European customs and Christianity, they would be culturally assimilated into European-Canadian culture.^{footnote 47} As a result, children were removed from their homes and isolated from their family. In addition, many children suffered from verbal, emotional, physical or sexual abuse, harsh discipline, neglect and the loss of cultural identity. This had an impact not only on residential school attendees, but also on their children and grandchildren.^{footnote 47–51}

Early 20th Century: Pre-World War II

By the early 20th century, community programs targeting parents and young children (e.g. well-baby clinics, immunization, dental health promotion, in-school medical inspections and greater health care access) were being put in place to fight high rates of infant mortality and contagious diseases.^{footnote 37} A vaccine against diphtheria was introduced in 1926, while widespread smallpox inoculations led to the disease's eradication from Canada by 1946.^{footnote 52 footnote 53}

Municipal water fluoridation programs were also introduced and recognized as beneficial in tooth decay prevention.^{footnote 54} Other improvements to water supplies reduced illness and deaths associated with water-borne diseases.^{footnote 30 footnote 55} Infants’ diets were supplemented with vitamin D during the 1920s, which contributed to the decrease in the incidence of rickets in children over time.^{footnote 56} Additionally, foodborne illnesses were addressed to some extent with the requirement that saleable milk be pasteurized.^{footnote 57 footnote 58}

Some women, particularly middle- and high-income women living in urban areas, began receiving prenatal care and often delivered their babies in a hospital setting.^{footnote 31} Health services specifically aimed at the care of infants and children emerged during this time with, for example, paediatrics being recognized by the Royal College of Physicians and Surgeons of Canada as a separate freestanding medical specialty in 1937.^{footnote 59}

This period was also marked by the introduction of broad social initiatives. In Manitoba and Ontario, for example, a Mother's Allowance was established in response to the poverty faced by families that were left fatherless after World War I.^{footnote 60} At the federal level, the Government of Canada initiated income support to families with children through the Child Tax Exemption of 1918.^{footnote 61}

School attendance continued to grow, with more children attending school for longer periods of time. Compulsory school attendance was in force in all provinces of Canada except Quebec and Newfoundland.^{footnote 43} This had an important influence on child health because school was often a child's only link to health care.^{footnote 43 footnote 62} In-school health inspections and examinations were common, as was inclusion of health promotion in curricula.^{footnote 62} Through these inspections, the need for childhood dental care and tooth decay prevention became apparent. Some provinces initiated travelling dental clinics to service remote areas (e.g. Newfoundland, Northern Ontario, Alberta and British Columbia).^{footnote 63–65}

A very different school system was being experienced by First Nations and Inuit children at residential schools, where conditions were often neglectful and detrimental to the children's health. In 1907, the Chief Medical Inspector reported numerous deficiencies in the schools to the Department of Indian Affairs, including elevated tuberculosis rates and inadequate nutrition, health standards and staff training.^{footnote 44 footnote 46 footnote 66 footnote 67} By 1920, it had become mandatory for every First Nations and Inuit child between the ages of 6 and 15 years to attend school, and by 1931, the residential schools system was at its peak with about 80 schools operating in Canada.^{footnote 66 footnote 68}

A decrease in infant and maternal mortality rates occurred during this time, although gaps in these rates were notable between upper- and lower-income families.^{footnote 69 footnote 70} By the end of this period (1936–1940), Canada's IMR had fallen to an average of 71 deaths per 1,000 live births.^{footnote 71}

Post-World War II to 2000

Advances in children's health continued as Canada built upon the broad prevention initiatives and social and infrastructural change that had been initiated in the pre-World War II period. The success of immunization programs resulted in the eradication or near-eradication of many vaccine-preventable diseases that typically strike during childhood. The inactivated polio vaccine, introduced in 1955, combined with the initiation of in-school vaccination programs, resulted in Canada's certification as polio-free by 1994.^{footnote 52 footnote 72} Similarly, widespread vaccination for diphtheria, pertussis and measles contributed to making these diseases rare by the end of the century.^{footnote 52}

The Medical Care Act was passed in 1966, affording access to insured medical services for all Canadians. By the 1970s, all provinces had joined the universal health program.^{footnote 62 footnote 73}The Canada Health Act, passed in 1984, served to clarify health care funding conditions and identified the five principles — public administration, comprehensiveness, universality, portability and accessibility — of health care in Canada.^{footnote 74 footnote 75}

Children's safety also improved during this period with the introduction of legislation, standards and regulations to prevent childhood injury related to toys, equipment, furniture, sleepwear and transportation. These measures led to a decline in non-fatal childhood injuries by the end of the century.^{footnote 76–80} Additionally, provincial/territorial motor-vehicle restraint legislation and reduced speed limits contributed to a decrease in deaths from motor vehicle crashes during this same period.^{footnote 76 footnote 78 footnote 81–83}

While there is little information on the nutritional practices of pregnant women, Canada's decision to fortify select grain products with folic acid (which became mandatory in November 1998), and to recommend the use of folic acid supplements by all women who could become pregnant, helped to greatly decrease the number of open neural tube defects such as anencephaly and spina bifida. A seven-province study showed a 46% reduction in the overall rate of neural tube defects (see Figure 2.1).^{footnote 84–86}

In terms of broad social investments, a number of programs and policies to support families were introduced during this period, including:

• the Family Allowance Act of 1944, which provided a “Baby Bonus” to mothers of children under 16 years of age (later expanded to include children under 18 years of age) to support post-war families;footnote 73
• the 1971 Unemployment Insurance Act, which offered income assistance to all eligible Canadians during times of unemployment, and maternity benefits for families with newborns or newly adopted children;footnote 87
• the Refundable Child Tax Credit, which was introduced in 1978 to target and support families with net incomes below a certain threshold;footnote 61 and
• the Child Tax Benefit (1993), which consolidated refundable and non-refundable child tax credits and the Family Allowance into a monthly payment based on the number of children and level of family income. It also included the Working Income Supplement (WIS), which provided an additional benefit to lowincome working families with children. In 1998, the Child Tax Benefit was replaced by the Canada Child Tax Benefit, which is provided to low- and middle-income families, and the WIS was replaced by the National Child Benefit Supplement, which is provided to all low-income families.^{footnote 88 footnote 89}

In 1991, Canada ratified the United Nations Convention on the Rights of the Child and in doing so agreed that children have the right to the “highest attainable standard of health.”^{footnote 94 footnote 95} The following year, Canada launched Brighter Futures: Canada's Action Plan for Children to prevent and reduce conditions of risk among children through targeted programs such as the Community Action Program for Children (CAPC) and the Canada Prenatal Nutrition Program (CPNP).^{footnote 93 footnote 96} Similarly, Canada's Aboriginal Head Start in Urban and Northern Communities (1995) and Aboriginal Head Start On Reserve (1998) programs were established to address the unique challenges facing First Nations, Inuit and Métis children and their families.^{footnote 97 footnote 98} In 1997, the federal, provincial and territorial governments agreed to develop a National Children's Agenda, to co-ordinate and advance actions to ensure that all Canada's children have the best possible opportunity to develop to their full potential.^{footnote 99}

By the mid- to late-1950s, First Nations children began entry into mainstream public schools.^{footnote 100 footnote 101} In 1972, the National Indian Brotherhood, (which later became the Assembly of First Nations) called for “Indian control of Indian education” which was endorsed by the federal government in 1973.^{footnote 102–104} However, the last of the residential schools did not close until 1996, the same year that the Royal Commission on Aboriginal Peoples released its final report recommending a public inquiry to investigate and document the abuses faced by children who attended these schools.^{footnote 105 footnote 106} According to results from the First Nations Regional Longitudinal Health Survey (RHS) 2002/03, the four most common negative experiences affecting the overall health and well-being of survivors of residential schools were isolation from family, verbal or emotional abuse, harsh discipline and loss of cultural identity.^{footnote 50}

By the end of the 20th century, Canada's IMR had declined from an average rate of 45 deaths per 1,000 live births during the five-year period after World War II to 5.^{footnote 6} deaths per 1,000 live births for the period 1995–99.^{footnote 70 footnote 107}

Figure 2.1 Prevalence of neural tube defects in seven Canadian provinces, 1993 to 2002^{footnote 85}

Enlarge Figure 2.1

The 21st Century

Canada continues to focus on building positive childhood experiences and strong families through initiatives and strategies centred on improving children's physical and mental health and safety. The federal-provincial-territorial Early Childhood Development Agreement (2003) was introduced to promote health, strengthen early childhood development, and support families and communities through employment, training and better access to early childhood care.^{footnote 93 footnote 108} Social interventions to support families with children, including extended maternity and parental benefits (from six months to one year) were provided under amendments to the Employment Insurance Act in 2001.^{footnote 87 footnote 93} And many of the programs established under the Brighter Futures initiative (e.g. Aboriginal Head Start, CAPC and CPNP) continue to contribute to reducing conditions of risk for children.^{footnote 96 footnote 109 footnote 110} In the area of child safety, the legislation, standards and regulations to prevent childhood injury that were established in the second half of the last century, along with new measures like Canada's 2004 ban on baby walkers, have resulted in a continuing decline in rates of injuries.^{footnote 78 footnote 111}

More recent measures have also been introduced that are tackling issues relevant to children's health and well-being. Canada's Universal Child Care Benefit (2006) provides financial assistance to all parents of children under six years of age with child care costs.^{footnote 112} As well, Canada's Fitness Tax Credit (2007) is one approach to support children's participation in fitness while promoting active living and tackling risk factors for childhood obesity. It is too early, however, to evaluate the effectiveness of these newer programs.^{footnote 113 footnote 114}

In terms of Aboriginal children, Prime Minister Stephen Harper apologized in June 2008 on behalf of all Canadians for the Indian Residential Schools System.^{footnote 115} The Truth and Reconciliation Commission will prepare a historical account of residential schools and their impacts on the lives of First Nations and Inuit people and will provide recommendations on how public policy can assist in moving forward.^{footnote 116}

Over the past several decades (see Figure 2.2) Canada's IMR has fallen to 5 deaths per 1,000 live births, a vast improvement over the 145 deaths for every 1,000 live births experienced just over a century ago.^{footnote 32 footnote 33 footnote 117} Although international comparisons should be interpreted with caution due to differences in methods, it appears that Canada may not be keeping pace with some countries that have continued to make progress in this area.^{footnote 70 footnote 117–127} As seen in the enlarged portion of Figure 2.2, Sweden, Finland and Japan's IMRs have continued to decline while Canada's has flattened over the last 10 years.

Figure 2.2 Infant mortality rates, select countries, 1925 to 2005 ^{footnote 70 footnote 117–127}

Enlarge Figure 2.2

Summary

As seen in this brief historical overview, Canada's approach to creating the conditions for health and development in infancy and childhood has broadened over time, from reacting to disease outbreaks to proactively protecting and promoting the health and well-being of Canadians. There has also been a fundamental shift from viewing children's health as simply part of overall population health, to recognizing childhood as a unique stage in life that influences future health outcomes. Going beyond ensuring survival through the early years, Canada now strives to provide all children with the conditions and opportunities needed to grow up healthy and to live longer, healthier and more productive lives. These efforts include better prenatal and post-natal care, immunization, safety and social supports/programs, and legislation that have proven to be effective in preventing disease and injury both in childhood and across the lifecourse. Overall, the measures taken in Canada to improve children's health over the last 150 years have brought about a substantially lower infant mortality rate and a life expectancy that is now among the highest in the world. There are signs, however, that in some areas we are not keeping pace with the progress of others. Chapter 3 will explore the current health status of Canadian children under the age of 12, including the leading causes of death and patterns of ill health and disability within this age group.