Paediatrician Dr Renee Liang takes an unflinching look at the realities of child poverty in New Zealand and the need for a political pathway to change.
The grants, sponsored by Mark and Deborah D’Arcy, an expatriate Kiwi couple living in New York, were designed to encourage the writing of essays of 10,000-12,000 words on New Zealand life and culture. Subjects featured over the past four years include a look back at the colourful history of Auckland’s Karangahape (K’) Rd; the importance of an education in the arts to encourage diversity and freedom of speech; and most recently a tribute to Christmases past – from Pātea to Montpelier – by Wellington-based writer Linda Burgess. Our thanks to the D’Arcys for investing in such a legacy project, which not only celebrates excellence in longform essay writing but is an invaluable record of the disparate life and times of this country.
A consultant paediatrician based in Auckland, with a special research interest in child health and development, Liang is a named investigator with Growing Up in New Zealand. This longitudinal study is tracking 7000 children from birth to young adulthood, to provide information about what shapes early development and how interventions might be targeted to give every child the best start in life.
Also a poet, short-story writer, blogger and playwright (Lantern, The First Asian AB, The Bone Feeder), Liang holds a Master of Creative Writing from the University of Auckland, and a Postgraduate Diploma in Drama Studies, as well as her medical qualifications. The daughter of Chinese immigrants, she produced a season of the absurdist farce The Chairs in Cantonese last year. She became a Member of the NZ Order of Merit for Services to Arts in 2018.
In her essay below, Liang describes poverty as a “heritable condition” that perpetuates and amplifies through generations: “It is also not hard to see how individual poverty flows into communities and society, with downstream effects on economics, crime and health, as well as many other systems. Loosen one strand and everything else unravels.”
A Kete Half Empty
Poverty is your problem, it is everyone’s problem, not just those who are in poverty. – Rebecca, a child from Te Puru
My morning has been full of the cases commonly seen by general paediatricians: smiley babies born prematurely coming to show off how well they’re developing, grumpy toddlers with eczema and food allergies, teenagers who have headaches and are being bullied at school. I pick up the notes for my next case.
The details* are all too familiar: James is a 10-year-old who’s running off the rails. The public health nurse has written a long note detailing her concerns. He was initially referred with soiling at school, but the deeper she dug the more she uncovered. He hardly eats lunch. She thinks he’s got glue ear and can’t hear properly. He can’t sustain a conversation for long. Last winter, James had only 60% attendance at school: the teacher says his mother keeps telling them he’s got another chest infection. Indeed, when at school, he’s often in the sick bay for asthma, which she suspects is undertreated.
His teacher has filled in a screening form. James throws punches to settle arguments; he can’t sit still in class. He finds it hard to make friends, because he tends to take over the game and not listen to others’ opinions. She suspects he finds it difficult to interpret what others are feeling. He struggles with maths and paying attention in class. Other students have accused James of stealing food – his nickname is now “Thief”. The previous week, he brought a knife to school and now the school board is meeting to discuss him.
More paper, more information, letters from a community social worker: he has a young mum, who for years has been trying to get help to manage him. She’s had to move several times, and each time they have to wait again for services. Like her child, she too fell behind at school. She’s had counselling for domestic violence and is no longer with her son’s dad.
I gulp my cold coffee and head for the waiting room. Already, I recognise a story I know far too well. I know I will make many diagnoses, but there’s one unifying diagnosis, which will not be written down.
Doctors are trained in the analysis of stories. We look for patterns within individuals, families and societies. The symptoms of poverty are evident to any doctor practising in the public system in New Zealand. It is as telling as a rash. We’re good at recognising the signs because right now, we’re seeing a lot of it.
* A hypothetical case, based on Liang’s experiences as a paediatrician.
Why fix it?
This has been happening for decades and it will take a lot of resource to fix. So why try? Humour me, if you know already: I know people who still think poverty is a lifestyle choice.
Firstly, fairness. At an individual level, often through no fault of their own, people become trapped in a health-poverty cycle: a downward spiral of health due to the effects of poverty. The less you earn, the higher the proportion of your income that goes on health care. And it’s harder to access that care because you’re more likely to live further away from centralised services, such as my clinic.
The system is also rigged against those who move frequently, due to housing availability or for work. If you move, you may lose your spot on the waiting list (and access to a GP or nurse who knows your child and can push for you to be seen sooner). It costs money to travel to where the clinic is, to travel for lab tests, to top up the phone you need to receive text reminders or to be rung for follow-up care. It’s hard too, with some jobs, to ask for time off to take your kid to the doctor. You might be in the kind of job that doesn’t pay unless you work.
Those are just the practical effects of poverty, but the insidious effects run deeper and are ultimately more damaging. For example, a child from a poor household is more likely to have had poor nutrition from infancy. This leads to a raft of issues, including greater susceptibility to infections, and growing evidence that this predisposes them to a raft of chronic adult diseases. Nutrition also plays into behaviour and academic achievement. A hungry kid will find it more difficult to learn; likewise a child who is tired from living in a noisy, crowded house. An older child might find it hard to study for NCEA if they are looking after younger siblings while parents work. It is not hard to see how poverty perpetuates and amplifies through generations. It is a heritable condition.
It is also not hard to see how individual poverty flows into communities and society, with downstream effects on economics, crime and health, as well as many other systems. Loosen one strand and everything else unravels.
But let’s say you’re a politician and you don’t care about the human cost of poverty, about the moral and ethical reasons why you would want to give kids a chance. (Ouch.) Let’s say you’re just interested in giving the New Zealand taxpayer a good return for their money. Fair call, right?
Even then, the numbers come down heavily in favour of doing something, and fast. It’s estimated poverty such as that experienced by Kiwi children poses an economic burden in the order of 3-4% of GDP. Based on Aotearoa’s 2017 GDP of $289 billion, that’s roughly $9-11 billion we lose a year in downstream effects such as lost productivity, pressure on social services, the justice system and so on, when we ignore the problem. Tens of millions of that probably blows away on the health service machinery I’m part of. Let me be clear: that is millions of unnecessary spending on health problems that are preventable.
For me, though, it boils down to morality. It hurts when I see kids unable to reach the full extent of their talents because of something they never asked for. It also hurts because I know I have spun a luckier number than them on the wheel of fortune. It hurts because we paediatricians see a little of ourselves in each child we meet: it’s one of the ways we stay young and ever-so-slightly immature.
New Zealanders still cling to the idea that we’re an egalitarian, classless society. The reality is we’re increasingly stratified. The gap between rich and poor is wider than we like to admit and it’s possible – depending on where you live and work – to avoid seeing poor families. This may be why some deny the existence, let alone the impact, of child poverty in our country.
As a student on my first clinical attachment, I remember the sinking realisation that I was poorly equipped for medical practice. I had spent years studying anatomy and physiology, but knew very little about real people and what their lives were like when they were not marooned on a bed in front of me. It was on a home visit with a community nurse, seeing the mattresses in the lounge and the teenager sitting at the kitchen table trying to write with younger siblings tugging at her arms, that I realised how much I had to learn.
Twenty-five years later I’m still learning, much of it from my patients. Part of the reason I wanted to write this essay was to try to understand some of the research on child poverty, and to apply it to what I do. I’m no expert on this topic – just a simple practitioner – but luckily there is no lack of detailed reports on every aspect of child poverty. They all agree that there is a problem – and there are solutions.
Related article: Child poverty a 'recurring and inescapable challenge'
How big is the problem?
This seems like a reasonable starting point. The main sticking point is in the different ways it can be measured.
Sharing the knowledge from many viewpoints and disciplines – building up the equivalent of a 3D MRI image of the issue – is essential. With an issue of such complexity, the more ways we have of spinning it around and mapping it out, the better. Each measure must be carefully selected for the question we have, so leadership and collaboration are important, too.
Secondly, there need to be set goals, and a timeframe. The National Government spent its years in power insisting that because there are many indices for measuring poverty, it would be too hard to measure or set targets. I find this disingenuous. In 2016, Prime Minister John Key told Radio New Zealand it was easier to count the number of pests in our native forests than it was to measure the number of children in poverty. (He was not called out on his Freudian slip, comparing children to rodents.) If I refused to treat a child purely because there were too many tests to choose from, I would be in breach of my duty.
Contrary to the obfuscation of politicians, experts in the field of child poverty have been calling for the adoption of standard measures for years. They even agree on what these baseline measures should be, and government agencies have collected plenty of information using (surprise!) these very same measures. These range from the purely economic to more complex measures of material deprivation.
The economic measures are the most black and white. They draw a line at an arbitrary cut-off (where this line should be is a point of debate): currently, families in households with less than 60% of the median disposable income are considered to be in poverty. There are statistical adjustments to account for things such as household composition, local cost of housing and other impacts. Progress is tracked by comparing to averages for the current year or a fixed reference point in the past. In 2016, 27% of New Zealand children were living in poverty: nearly one in three.
But what does that number actually mean? I find the measures of material deprivation better at painting a picture of what life is like for these families. These look at whether people can obtain the items they need for a basic quality of life, such as food, shelter and clothing. Income is only part of the resource measured: there is also varying access to other resources, such as community help groups, social housing, wider family savings and so on. Some families, because of where they live or the tenacity of their members, can mobilise more resources than others. But it’s the families unable to do this who silently slide into the cracks within our health, employment and education systems.
The DEP-17, constructed by the New Zealand Ministry of Social Development (MSD), is a questionnaire that asks families if they can provide 17 items considered essential by most Kiwis, such as electricity, home heating and visits to the doctor. There are a bunch of similar measures: most are focused on needs for the whole household, but in 2016, Stats NZ included a number of child-specific items in their New Zealand Household Economic Survey.
For a person from my side of the tracks, the survey makes for sobering reading. The items include: two pairs of usable shoes for each child; two sets of warm winter clothes; one waterproof coat; a school uniform; money to go on school trips; being able to play a sport; a separate bed for each child; fresh fruit and vegetables daily; a meal with protein every second day; books in the home; a place to do homework; having friends around to play and eat; being able to hold a birthday party; and access to a computer for schoolwork. In 2016, 12% of children up to the age of 17 lived in households where they lacked seven or more essential items. If New Zealand was ever a land of milk and honey, that time has long gone.
The “working poor” is a subject that has only recently hit mainstream reporting, though it’s been around for ages. Recent research shows that over the past decade, 15% of all New Zealand households with workers in fulltime employment have experienced poverty. Families where both caregivers have to work to stay above the breadline are on the rise – with flow-on effects for the children.
Even if these children have their material needs met, are their other needs also being met? How should we value the unpaid labour of love – of parenting, caregiving, keeping our community strands woven? What will it cost us in the end if we don’t?
I reckon you don’t have to be poor to live the life of poverty. We were impoverished by a lack of emotional support, love and security. – Anonymous, Paeroa
In the same way, poverty is just one aspect of wellbeing and can’t be measured nor treated in isolation. The Organisation for Economic Co-operation and Development (OECD) recognises that “child wellbeing comprises several components including material wellbeing, safety and security, health, education, the environment, housing, care and support, civil and political rights, cultural identity and social connectedness”.
In my experience, children are affected more by unmet social and emotional needs than by unmet physical needs. It is beyond belief that so many of our kids don’t have the basic necessities of life, yet these stories are just the tip of the iceberg. The effects of poverty spill over to affect the behaviour of family members and increase stresses on communities. Many of these are subtle and issues don’t show up until quite far down the track. It is therefore important that social, emotional, family and spiritual effects are specifically measured.
It is also important to address the societal structures that enable and perpetuate poverty. Reports from Stats NZ, Child Poverty Action Group, Growing Up in New Zealand and many others show a clear correlation of poverty with region, ethnicity and family makeup. This is not because being of a certain ethnicity or living in the sticks “causes” poverty: it is because the current set-up pushes these groups into disadvantage.
How shall we fix this? Here is where I start to get political. Our Māori and Pasifika (and yes, rural) communities are disproportionately affected by poverty. A centralised, one-size-fits-all approach won’t work. A monocultural viewpoint – such as the system of Western medical knowledge I work in – won’t work either. In fact, it is well accepted that it is part of the problem, but more on that later. So where should we start? I’m going to start with hope, and I’ll repeat that hope throughout this essay: we already have much of the knowledge and tools that we need.
For Māori and Pasifika people, the social, cultural and religious dimensions of poverty are inseparable. In fact, many cultural groups in New Zealand recognise the interconnectedness of all the strands that wrap us together. There are well-established models of Māori health based on this. There are also long-running government policies based on these principles: the Whānau Ora programme, for example, empowers community and extended family, rather than treating children as individuals. Techniques based on indigenous knowledge and culture are used by health and social workers every day. These are supported by a growing body of research, yet I get the impression these increasingly successful initiatives are still flying under the public radar.
We are using new and wiser ways of working, constructed to take cultural perspectives and capabilities into account. There is a drive to develop new measures of health that reflect Māori and Pasifika values, spirituality and capabilities. We need to cater for the people from other cultures who also call Aotearoa home, including Pākehā. Such techniques and research might even, shockingly and necessarily, break out of the statistical, quantitative approach that is the comfort zone of scientists and academics.
Back in my room at the clinic, James is sitting warily on one of my uncomfortable wooden chairs. Something in my toy box catches his eye. He pulls out a toy dinosaur and starts pressing its button to make it roar. Roaarrr. Roaarr. His mother Aleisha tries to talk over the electronic noise.
She’s petite; she and I can see eye-to-eye, and her son too is tiny. She tells me her dream is to study early childhood education. But they were kicked out of their rental a few months ago and are now living in the garage at her aunt’s place while they wait for a Housing NZ home. Aleisha is scared to get work because she keeps being summoned to school to pick up James. He gets into fights all the time, but she suspects he’s being bullied. When I ask James if this is true, he pretends not to hear and goes on pressing the dinosaur. Roaarrr. Roaarr.
I decide to use one of my best strategies. I ask his mother what he is good at. Her eyes light up. He is amazing at anything involving words. Stories, comics, poetry – he has a rare talent, just like Aleisha when she was young. The roaring of the dinosaur ceases and James shuffles a little closer. I know I’ve got his attention now.
Bit by bit, I gain a picture of James’ early life. Aleisha was the oldest child in a large family. Both her parents were away a lot and she had to take care of her siblings. At 16, social services found out and put her sisters and brothers into foster care. By then, Aleisha was pregnant with James. She tried to continue going to school but found the pressures too much. When James was born, four weeks premature, her family members were too stressed out with their own issues to help her much with the baby. Aleisha doesn’t blame them – they’ve helped out since. A nurse from the hospital visited for a while. Then everything fell apart when she left James’ father and went into a Women’s Refuge shelter.
The biological scars of poverty
Recent research has uncovered the deep scars poverty leaves on genes, brains and bodies. And it was South Islanders who first lit the path, with knowledge that has since informed policy around the world.
Between 1 April 1972 and 31 March 1973, just over 1000 babies born at Queen Mary Hospital in Dunedin were enrolled in what is now simply known as the Dunedin study. Every two years, they were asked to participate in tests: everything from blood samples to observation of parenting styles. The Dunedin study was one of the first longitudinal population studies in the world; four and a half decades on, it’s still collecting information.
The longitudinal study design, which follows the lives of a whole population over many years, is one of the strongest for testing if an event early in life reverberates further down the lifespan. (The Dunedin study has now been joined by many longitudinal studies around the world, including a more recent local study, Growing Up in New Zealand, whose cohort – reflective of the current ethnic and socioeconomic makeup of Aotearoa – are now celebrating their 10th birthdays.)
Researchers who are working with this precious data-set noticed something interesting: at age 32, adults who had a background of poverty as children were more likely to demonstrate some early risk factors for chronic disease. Having a risk factor means you are more likely than the average person to get the disease; having more than one risk factor multiplies the risk.
The risk factors being studied in Dunedin were a diagnosis of major depression; high levels of an inflammatory marker called C-reactive protein (CRP); and a set of warning signs GPs obsessively screen for: obesity, high blood pressure, high cholesterol, prediabetes (glucose intolerance) and poor lung function.
Between them, these risk factors are linked with most of the super-villains of Western medicine: heart disease, diabetes, dementia, autoimmune conditions and cancer, among others. And the results? Those who had grown up in poverty were more likely to have one or many of these, whether or not they were living in poverty as adults. Worse, those who were abused in childhood or who experienced social isolation in addition to being poor had the greatest number of risk factors of all.
But what of the other things we already know influence disease, what we call “confounders”? The researchers asked about family history of heart disease and depression, and also questioned participants about their habits as adults, including diet, fitness, smoking and whether they were currently living in poverty. They used statistical analysis to remove these confounders and found that childhood poverty still posed a significant risk.
Then they made their most startling discovery: childhood poverty, abuse and social isolation is a stronger predictor for adult chronic disease than either family genetics or bad habits. In other words, preventing or alleviating poverty may be more effective at saving lives than all the resources we currently put in to battling obesity, smoking, poor diet and bad lifestyle choices (although these things still have a significant effect, so dealing with them is important).
A word on that judgy term, “bad lifestyle choices”: it’s not a choice at all. I’ve counselled families enough on their eating and exercise habits to know that choosing healthy food and having the time and resources to exercise is an option reserved for the better off. So tackling poverty has a flow-on effect – in that it will also prevent or reduce these so-called “lifestyle issues”. Yes, there is hope.
Research using other methods widens the picture. We now know that the first 1000 days from conception to age three are critical in terms of a developing baby’s future. Maternal nutrition is an early, key factor. A mother with a poor diet and poor health is more likely to give birth to a thinner and smaller child. It’s thought the period of “starvation” in the uterus programmes the baby to hold on to fat, leading to childhood obesity and later issues such as heart disease and stroke.
The mechanism by which this programming happens is as fascinating as its effects. Epigenetics is a new field of science, looking at how genes can be turned on and off by environmental factors. It seems there are critical periods during a lifetime – with most occurring early on – where chemical signals, a bundle of molecules called a methyl group, can get attached to the genetic code, permanently modifying it and affecting how it is translated into proteins and, eventually, bodily functions. These methylation groups act like biological Post-It notes, marking the point on the DNA strand where the protein-making machinery starts transcribing code.
Researchers have made a further startling discovery: this genetic tagging can be passed down at least a few generations. It is thought the period around pregnancy and early infancy is particularly vulnerable to epigenetic changes. A baby is in effect a tiny CCTV, recording the stress, nutrition and parenting behaviour around it. The baby’s DNA then modifies to adapt, altering the course of its adult life – and potentially those of its descendants.
It has been shown baby rats that are well cuddled by their mothers will be more resilient in dealing with stress as adults, while rats who were separated from their mothers cope less well. While we have to be careful about extrapolating from rat to human behaviour, it seems likely that poverty, with all its disruptive capabilities, can reach deep into the genetic code of an individual and change it for life. A person’s health and behaviour may already be burned into their DNA by the time they turn three. To an even greater extreme, some DNA changes may have been predetermined by things that happened to one of your parents or grandparents. Poverty could well be inherited genetically, as well as economically. Perhaps we are not free agents after all, with our life courses being determined not by the gods but by history.
As if this wasn’t mind-boggling enough, there are other changes in the genetic code not related to epigenes. In 2014, a group of nine-year-old American boys were studied, half of them from poor and half from rich households. It was found that the telomeres of the disadvantaged boys were 19% shorter than the average for that age. Telomeres are little protein chains at the end of chromosomes; they act as protective “caps” as the chromosomes continually duplicate themselves through the lifespan. Older people tend to have shorter telomeres. It’s thought that telomeres shortened by age expose an individual to errors in the genetic code, which can progress to diseases such as cancer. But here’s the kicker. If poverty leads to premature “ageing” of chromosomes, wealth does the opposite. The kids in the study from rich households had on average telomeres that were 35% longer.
Biology is a sexy field, because there’s even more to it than that. Poverty can actually be seen in the brains of affected people. Shahria Hafiz Kakon is a researcher in Dhaka, Bangladesh, where up to 40% of children have stunted growth from chronic poverty. She scanned the brains of affected babies and toddlers in this region, and found the brains of children as young as two months old showed a significant decrease in grey matter (brain cells).
This is known to lead to slower language development and diminished visual memory. When Kakon used an imaging technique called fNIRS, which measures blood flow to the brain, she saw that healthy children’s brains lit up with increased blood flow when they were shown pictures of women’s faces. Stunted children’s brains lit up to pictures of trucks. Kakon theorised that healthy children are conditioned to respond to social stimuli, while stunted kids respond to non-social stimuli.
But then Kakon found something else. Using electroencephalography (EEG) to capture the electrical activity of thoughts crisscrossing the brain, she saw the brainwaves associated with problem solving were stronger in the small, stunted children than their healthy peers. This suggested children respond adaptively to environments, and that poverty may, in certain cases, predispose them to certain skill sets.
The research continues, but these results provide an early and tantalising clue as to how exposure to poverty early in life can affect later behaviour, learning and patterns of thinking. They also provide us with hope: intervene early enough, and history can be changed.
Indeed, a hefty group of studies worldwide has left us in no doubt as to the cost of poverty and malnutrition. As well as being the cause of at least a third of total child deaths, these factors cause children to do worse in school, be less healthy, and – budget-conscious governments, take note – result in an 8% drop in productivity in affected countries. The numbers are so convincing that even the famously tight-fisted and cynical World Bank is contributing to early childhood nutrition as a long-term investment.
But what about Kiwi children living in poverty? Starvation and growth-stunting is less of a concern for us in Godzone, surely. Should we be as worried? Let’s go back to the international studies for a moment. Charles Nelson, an American neuroscientist, tracked the brain development of children growing up in Romanian orphanages. Although their physical needs were met, these children had almost no stimulation, social contact or emotional support.
MRIs showed that by the age of eight, these children had smaller regions of grey and white matter associated with attention and language than did children raised by their biological families. This correlates with what I see in my clinics in New Zealand, where children from deprived households are more likely to have learning difficulties and be diagnosed with attention-deficit hyperactivity disorder (ADHD). However, studies also suggest that supporting families early enough can reverse some of the harm.
A growing body of research suggests exposure to “toxic” stress can impact a child’s brain development. Stress is normal for children – it has adaptive properties. But living in constantly chaotic environments, such as those caused by poverty, can create a toxic stress response. This causes permanent changes to brain structure and function, showing as increased anxiety, impaired memory and mood control. Children find it harder to learn, solve problems, follow rules and control impulses. The release of stress hormones can also create a “wear and tear” effect on the child’s organs, including the brain.
At a biological level, socioeconomic stress is “embedded” through the overloading of stress-sensitive systems: the nervous, immune and endocrine systems. These interact with other factors, such as food and shelter insecurity. Parents may be unable to parent well due to themselves being affected by poverty-related stress. Whether this stress translates down the line into long-term health effects seems dependent on other factors, such as whether there is a parent figure available to buffer that stress, the internal resilience of the child, and how long that stress continues. Yet still, there’s hope: if we know where and how to intervene.
The social imprints of poverty
Moving houses, always moving – stressful. Having to move in the middle of the night – unable to pay rent, scary. – From a young persons’ group, Paeroa
Cold – got hardly no clothes, looking for some. Wonder if there’s any money in here [clothing bin]. No money, no clothes! Desperate. – Anonymous, Paeroa
Not getting proper opportunities like going on school trips, hard to take part in things like sports and other activities. – From a young persons’ group, Dunedin
It’s a really hard night’s sleep. It’s normal. It’s better than listening to my parents fighting and drinking all the time… I’m hungry, I’m cold and I don’t want to go home. No use going home to no food in the cupboards. I’m alright here! – Mere, Paeroa [wrapped in a mat and sleeping under a bridge]
Teachers causing shame to students in front of their peers because they have no stationery, uniform etc. Schools should deal with parents and not punish the kids for not having shoes, books, etc. – From a young persons’ group, Whanganui
The comments above are from a 2010 survey that asked young Kiwis about their experiences of poverty. The kids have no trouble defining the issues: chronic stress, food and shelter insecurity, social isolation, public misunderstanding and judgement.
How does poverty unravel the layers of support around a child? How does it leach into communities, wearing down whole extended families? And what are the lasting effects into adulthood?
First and most obviously, income insecurity leads to families being unable to give kids the necessities of life: food, clothing and shelter. Although actual starvation is rare in New Zealand, food insecurity – defined as lack of access to sufficient, safe and nutritious food that provides for an active and healthy life – is common and likely increasing. The 2018 Christmas period saw media reporting on people queuing at food banks for hours – and, as we’ve recently seen, that doesn’t happen just during the festive season.
In 2002, a nationwide study by the Ministry of Health found that 20% of households with children could not always afford to “eat properly”. In 2010, different research suggested the problem had increased: in a survey of Dunedin and Wellington families, 47% of low-income families reported they often ran out of food due to a lack of money. This group could also afford fewer vegetables per week.
This highlights that many families may need to choose between volume and quality when it comes to food. Yes, we’re back to the issue of “poor lifestyle”. It is a sad irony of our globalised world that the cheapest items in our supermarkets are the most processed items from the furthest away. These are often high in processed fats and carbohydrates, resulting in higher cholesterol intake and increased risk for obesity. And yet, we still judge people at the checkout counter for the “choices” they make.
As we know, the topic of food insecurity is clouded by emotion and misinformation. Jackie Clarke, of social-aid agency The Aunties, caused a social media storm for begging people not to donate tinned tomatoes. Women under stress, she said, do not have the time, resources or emotional energy to plan and cook a meal. Others have pointed out that smug magazine articles suggesting poor families “save money” by growing their own vegetables miss the point: it costs money to start a garden, time to maintain it, and many families don’t have stable enough housing to justify one in the first place. It’s easy to forget that driving to the farmers’ market or some relaxing Sunday gardening is largely the domain of the middle class.
Ditto for lecturing about nutrition, a common failing of my profession. Who’s heard this before? Eating food high in sugars is bad for you. Skipping breakfast will mean your child can’t learn as well as they should. These are facts borne out by multiple research studies, but telling this to someone, say in my clinic room, doesn’t help parents to feed their children better, buy them breakfast or (research has shown, ironically) change their behaviour. I cringe at the memory of writing out recipes for my favourite bread (wow – it doesn’t need a breadmaker!): it was probably as effective as giving tinned tomatoes.
What of housing insecurity? That’s another emotive topic on which everyone has an opinion. It’s also one in which New Zealand researchers lead the world. There is a direct link between damp, cold and overcrowded housing and a wide range of illnesses and diseases, including respiratory infections, asthma, rheumatic fever, tuberculosis, skin diseases, depression and other mental illnesses. In the sterile language of research reports, there is a “social gradient” for the rates at which children suffer these diseases – and that means some are preventable if we level the social gradient. In 2007-2011, there were an estimated 1343 hospital admissions per year for infectious diseases caused by household crowding in New Zealand. Incidentally, there are a number of non-infectious childhood conditions also with a social gradient: road traffic accidents, drownings, falls, assault, neglect and maltreatment.
Related article: 1600 deaths attributed to cold houses each winter in New Zealand
But there is hope. Here, health leaders, among them the late infectious diseases specialist Diana Lennon and public health physician Philippa Howden-Chapman, have pushed for years for government agencies to act. Their persistence has led to regional programmes to decrease overcrowding and improve building quality. These programmes have been an unqualified success, leading to fewer admissions and overall better health in the areas they have been active. It seems strange that in a country where the media delights in every All Black triumph or misdemeanour, we don’t celebrate our scientific successes more.
With our current laws, private tenancies are insecure. People are forced to lead a peripatetic lifestyle. In DHBs, huge resources are spent tracking down families, making sure they receive letters about their appointments, and transferring care when they move to a different area. Despite this, families still “slip through the cracks”, with potentially catastrophic results. This is just one of many issues. Research confirms the obvious: children who frequently move houses and schools tend to have behavioural problems and trouble making friends. They fall behind in their learning and their mental health suffers, with flow-on effects to adulthood.
People in state housing fare little better; the view that “beggars can’t be choosers” is combined with limited housing stock. Parents will ask me to write letters requesting faster allocation of a Housing NZ home, or for one closer to family support, or one more suitable for a family’s needs – if you have more than eight people in your household to accommodate, forget it. In clinic, people discuss their conundrums with me: should they say yes to the firm offer of a house, or squeeze in with relatives so they can find work and have help with childcare? It is not unusual to hear of a parent commuting to work in Auckland and sleeping in their car during the week while their partner takes care of the kids up north, where they can afford to live.
The support of family is critical. Commonly, I see parents who are trying to function alone, without the “village” around them: wise heads and hands to take the kids when it all gets a bit much. I have young children: we’ve all been there. Again, my privilege means I can call in the resources to cope, or at least tape over the issues while I work out what to do.
The situation becomes worse if a child is admitted to hospital, especially if they live far away from the treating service. For example, we only have two centres in New Zealand to treat child cancer; one to treat heart diseases. There are only three units capable of looking after extremely premature infants. Sick kids of all backgrounds have to endure long trips to get to clinic or hospital, but it’s worse when there are fewer options for looking after the other kids or taking time out from work.
In addition, the parenting brain can take a big hit from being poor. Living in poverty is a fulltime job, with parents called on to queue at WINZ, attend meetings with teachers, work several jobs and work out how to scrape together the resources to get the car fixed. Some of the people turning up in my room will be stressed and emotional, and need more time to take in information. They may find it harder to follow through on long-term plans or work out a failsafe way to make sure their kids get medication regularly. Nurses, social workers and community workers all understand and help – but it’s something we’d love to have to do less of.
Social and emotional problems in children have been shown to correlate with parental stress levels. Parents with lower socioeconomic status are more likely to use authoritarian parenting styles, which are ineffective at preventing kids from acting out and tend to spiral everyone’s behaviour out of control. A sure sign a family needs more support is when a school describes a completely different kid from who the parent is describing.
The education system is where kids can get marked with the stigma of poverty. Lack of money for “extras” such as school fees, computers, stationery and uniforms can lead to ridicule, bullying and ostracism. Sometimes this comes from the school system itself (shockingly, I’ve heard of this from staff as well as students) and inflexible rules. It’s the poor kids who often have to travel farther and have less money to spend on transport. It’s the poor kids who can’t do their homework because of a lack of space, mental energy or a grown-up to help them. It’s the poor kids who will leave formal education earlier, or not take up that position at university, or not apply for it in the first place.
In education, the gap widens between children from rich and poor households as they progress through the school system. At NCEA Level 2, there is a seven-percentage point lag between the pass rates of students from the most and least deprived households. This has stretched to 18 points by NCEA Level 3. Half of kids from high-decile schools go to university, only 17% from low-decile schools.
An article in the NZ Herald last year exposed how entrants to medical school tended to come from the higher socio-economic bands and more elite schools; this was certainly the case with my medical school class. I, too, am guilty as charged. Although my parents are migrants, they had university degrees: my father’s was in medicine. It wasn’t easy on a single income, but he and my mother decided to send their three daughters to a private school. I had my own room, with a study desk at the centre of it. At school, we were told daily about our potential as young women and future leaders. It should not be surprising that I spent the latter years of secondary school focused on getting into med school. I had been told I could achieve anything, and nothing I have experienced since has led me to believe any different.
It was only after I left school that I began to realise how my world view had been moulded by my environment. It has taken the past 20 or so years of practice in medicine to realise that having full control of my life trajectory is a privilege reserved for people like me. It has taken this long to challenge the assumptions I have around poverty.
A friend got into Auckland Medical School at the same time as me. He told me he had turned down the place, because his dad needed help running the shop. I remember feeling incredulous about his choice. I am only now beginning to understand the factors involved. At the same time, I remain blinkered by my background. I still catch myself when my conversations with parents remind me they have the same aspirations for their kids as I do: it is not lesser ambition or capability that restrains them, it is circumstance and resourcing. My friend, had he become a doctor, would have known this intuitively.
When children from poor households grow up, they are more likely to also be poor as adults. The likelihood increases the more years they spend in poverty as children.
Poor children become adults with a higher chance of dying early. The correlation between socioeconomic disadvantage and chronic health issues is independent of traditional risk factors such as family history, ethnic background and cigarette smoking. Poverty fits all the criteria for a chronic health disease. If it was treated as such, there would be an outcry. Scientists would get awards and grants for finding a treatment; there would be government funding and screening programmes. But poverty, for all its clearly documented effects on health, is not regarded as a public health issue. Maybe it should be.
Effects on health
Data released in 2012 show New Zealand children living in poverty are:
- At 1.4 times higher risk of dying during childhood.
- More likely to die of Sudden Unexpected Death in Infancy (SUDI or cot death).
- Three times more likely to be sick.
- More than twice as likely to be admitted to hospital for acute infectious diseases.
- Less likely to have fresh fruit and vegetables, and more likely to eat fast food and to skip breakfast.
- 5.6 times more likely to be hospitalised for injuries from assault, neglect or maltreatment.
- Less likely to attend early childhood education.
- Less likely to complete NCEA level 2.
A 2018 report by the Ministry of Health found children living in areas of high socioeconomic deprivation were more likely to experience emotional symptoms, conduct problems and peer problems. Kids from poor areas were also more likely to show signs of hyperactivity.
Poor children have more accidents. They have an increased rate of falls, burns, poisonings and injury. Their homes are more likely to be unsafe, which is not always the fault of the parents. I recently treated a head fracture in a young toddler who fell down some stairs, a few days after his family were placed in emergency housing. Their old place had been carefully fitted with safety gates; there hadn’t been the chance to fit them to the new place before the family moved in. In another recent case, a child presented with burns after her dad tried to wash her hands under a tap: they hadn’t checked what temperature the hot water had been set to by the landlord.
Related article: 'Tooth decay is a socio-economic disease'
Experience tells me a child from a poor family is likely to be sicker by the time they come to see me; their conditions are more complex, they have less capacity to deal with any complications and so I have a lower threshold for admitting them.
I also know admitting them and subjecting them to the scrutiny of a concerned but institutionalised treating team will likely expose them to more stress. Health professionals are the first to admit they have bias, much as we try to fight it. If families are admitted after having an accident, they are likely to be questioned to make sure it really was an accident.
Poor families also tend to have a history of contact with social services that will make them skittish of a referral to more services. Even if their prior experience was good, they will have “service fatigue” from having to tell their story to yet another concerned professional. And yet offering help may be the best way I can prevent another admission to hospital.
James is dancing. His well-worn sneakers rock gently from side to side. The dinosaur has been tossed aside; now he can’t sit still, moving from floor to bed then back again, then over to the sink to turn on the tap. He’s gone back to ignoring my questions, but I can tell he’s listening avidly.
Aleisha tells me that yes, James is disruptive in class and sometimes he hits others, but every time she goes to a school meeting she feels like she’s being talked down to. He hit another child, but that child told him he was ugly. The school has pushed her to come to my clinic today as they feel they’ve tried everything. This is the third school her son has attended in three years.
Aleisha has waited for four months for this appointment: she’s pinned all her hopes on this moment. She waits for me to tell her how I am going to make things better. But I am just a simple paediatrician. I possess no magic, nor a time machine.
The irony of her coming to see me is that most of the treatments at my disposal are not health-related. In this job, I am more like a ringmaster, coordinating services. Counselling, behavioural support, referrals to community agencies: if there’s a form, I can fill it in. I’m pretty good at forms; I have years of being a junior doctor under my belt.
Sometimes, I’ll need to prescribe drugs to help with anxiety or sleep or hyperactivity, but not yet for James; not today. But as I listen further to his story, I can’t help feeling once again like an ambulance at the bottom of a cliff. Surely there must be more I can do.
The fixes might not be as hard as you think
PLEEZZE To people in power + the Government – don’t tuck us away as a statistic. – Alice, Te Puru
Ultimately, we get the society we demand. If we really want to see fewer children in poverty, we will need to make some tough choices. We will need to send clear messages to decision makers about our priorities. – Dr Russell Wills, NZ Children’s Commissioner 2011-2016
Here’s where I go to the devastatingly obvious elephant in the room. When talking about poverty and inequality in Aotearoa, it is impossible not to mention colonisation as part of this conversation. It is inconvenient that I’m bringing this up now, because it would take a whole other essay – a series of essays, really – and a far more informed commentator. But please let me acknowledge it.
The original settlers of this land, our tangata whenua, had a complex, economically stable civilisation and an advanced society with norms and behaviours that were rooted in relationships with family and land. As blogger Tina Ngata recently pointed out, once were gardeners... lovers... and poets – and if you believe any differently, it is because you have been reading history influenced by the colonisers.
Foreigners came and inflicted violence and a legal document, Te Tiriti o Waitangi, which through the succeeding centuries was routinely dishonoured. Moana Jackson, activist and lawyer, points out that “by its very nature, the colonisation of indigenous peoples has always been an abusive process – if only because the imposition of the colonisers’ values and institutions could never be achieved peacefully or with any pretence to good faith”.
Likewise, Pasifika migrants living with the effects of colonisation and political disenfranchisement in their own countries flowed into New Zealand to fuel our low-wage economy. Here, they were caught in the rip-tide of yet another system designed by a colonial power. Separated from family and community supports, they couldn’t use their language or culture to advocate for themselves.
This isn’t something theoretical – this is something I see on the hospital wards every day. Families who can’t claim benefits they are entitled to, because staff at official agencies question them in ways they don’t know how to respond to. Kids who cram into a relative’s mouldy home because, I’m told, if you’re brown you have a harder time getting a private rental. Forms that require time, travel, money and waiting for a specialist appointment to fill out. (Most of the forms needing a “specialist signature” don’t actually need a specialist’s knowledge to fill out. Requiring my signature is just a way of gatekeeping.)
Asking a family if they face discrimination in their daily lives might be one of the most important questions I ask when I take a medical history. My colleagues in social work have started accompanying these families to their welfare appointments, because they find just being there changes the outcome. If that isn’t an indictment on our broken system, I don’t know what is.
People who have had their lands and family ripped away from them become traumatised and disorientated. That’s just common sense, but fascinatingly, Western science supports the lived experience of trauma that our writers and storytellers have documented for generations.
Biology: the epigenetic research I mentioned provides a biological mechanism by which trauma is passed down through generations. Psychology: emotional memory, and its bedmates, depression and anger, are powerful transmitters. Sociology and economics: the initial hit is amplified by further hits on economy, health, self-esteem, society and culture.
Poverty spreads in populations like cancer. The first hit and then subsequent ones cause a break in the code, then more breaks until the system becomes chaotic and the cancer grows to impact on our whole society. Political, biological and social causes intertwine and coalesce. How ironic that in Godzone, we’re blaming the most vulnerable for the problem. But let’s get back to hope. Policies driven by politics are the cause – and ultimately where the fix must occur.
At its core, the question of whether child poverty should be addressed is about equity. Child poverty is just one of the many issues disproportionately affecting Māori and Pacific peoples and other groups vulnerable to the same factors, such as refugees, new migrants and many Pākehā families. The parting of people from their tūrangawaewae (traditional lands) led to poverty both economic and spiritual; and the breaking of one strand leads to strain on all other strands, from family to education to health.
Is this fair? New Zealand is a signatory to the United Nations Convention on the Rights of the Child, which promises every child will have access to good health, to be heard, to have a family and social circle and to be protected by the adults around them. Periodically, the New Zealand Government has to report to the UN, and the latest 2015 report contains the telling admission: “Ensuring access to comprehensive education, health, welfare, housing, justice and social services has been a challenge… New Zealand continues to grapple with the persistent and complex problems of eradicating child abuse and addressing child hardship, particularly amongst Māori.”
But in order to change the policies, we have to give our politicians a clear directive. Here, unfortunately, I have less hope. A recent report revealed 40% of New Zealanders believe the poor have only themselves to blame for being poor. Forty per cent! What’s wrong with us?
As people’s attitudes have changed, so have the policies peddled to us by politicians. New Zealand has slipped from being a socially progressive nation to one that is self-obsessed. We now rank within the lowest band of developed nations on child-welfare measures, and in 2017 received the dubious accolade of the OECD country with the highest youth suicide rate per capita. And there are even more trophies to claim. Child poverty rates have risen in this country since the 1980s; in parts of provincial New Zealand, it reaches Third World levels, coinciding (not that coincidentally) with high rates of drug dependency, crime and illness.
Our prejudices are misplaced: research into the psychology of poverty has shown many behaviours considered personal weaknesses are triggered by the state of poverty. For example, being poor can lead to undue focus on short-term gain (updating a phone rather than saving money for a rent bond). People who are poor have loss of hope, leading to inertia or self-sabotage. They are more likely to self-medicate with alcohol or drugs. The stigma and negative stereotypes are hard to shrug off, as any bullying victim knows.
Other behaviours can be traced to the slow spiral of poverty through families, with skills not being passed through generations. How can we expect these new parents to have cooking or budgeting skills or the knowledge of when to get help for a sick child, if their support systems have never been in place? It is not that we shouldn’t hold individuals accountable for their actions, but understanding how those actions came to be might help promote, rather than prevent, change.
Will tomorrow be better than this? – Nick, a child from Porirua
In fact, a clear pathway for moving ahead has already been mapped, underpinned by international research and experience. Poverty cannot be separated from politics. We need to take responsibility at every level, from individual to organisational to regional to national. The wrongs of the past can’t be reversed, but at least we can urgently move to address current inequities, and prevent new vulnerable groups from sliding into poverty.
As a clinician, my duty lies at the individual level: what can I do to help Aleisha and James? Often, I find starting with one strand and following it will help me unravel the rest.
I could write to James’ teacher to see what behaviour supports we could put in the classroom; I could make sure the cause of his soiling is not constipation or anxiety; I could work with the public health nurse to educate his classmates on why it’s not okay to bait him; I could give his mother clear instructions on how to treat his asthma attacks as soon as they begin; I could write to Housing NZ to advocate for his family getting into a warmer, dryer house. I could also refer him to the ENT surgeon to fix his glue ear and get his hearing checked. It is likely at least some of these would work, and then the three of us could meet again to set new targets.
It’s rewarding work, but I know that to truly fix things at their source, policy needs to change. Kindness (that political buzz word) is a good start: on an individual and societal level, it gets us talking to each other. Empathy opens doors. A boy looks up from his toy; a mother smiles for the first time. But practical measures must follow.
At a policy level, there has been at last some action. The Child Poverty Reduction Bill has made measuring, reporting on and identifying issues to do with poverty mandatory. It also requires the setting of specific child-poverty reduction targets. The recent Budget is to be lauded for taking significant steps into funding housing, education and mental health, chipping away at what has been decades of decaying policy. But these are only first steps.
The real test of this Government will be in the action, and this will require political courage. There are already enough reports, enough evidence for things that will work, and plenty of proposed targets. These have been written and in some cases commissioned by governments for decades, then ignored or apparently forgotten. You can hardly blame the politicians: the deeper results of any action will take longer than a three-year election cycle to show. Poverty is so deeply entangled with other thorny issues such as crime and unemployment that it may be impossible to pin an effect to a policy. But just as with individual cases, the patient unravelling of one strand will help to untangle other strands: fixing poverty will fix a whole lot of things.
What we do know is that the longer we delay, the more it will cost us to fix, in cold, hard cash as well as lives and wasted potential. We know that poverty in New Zealand became far worse from the early 90s on, after the Mother of All Budgets in 1991 – that’s almost 30 years ago, so we’re at least one generation into an entrenched intergenerational poverty cycle. Yet fixes are not only possible, but already mapped out for us.
The Office of the Children’s Commissioner released an excellent summary in 2012 of what needs to be done, convening opinions from a multidisciplinary panel of experts, public consultation, and previous research. Most important, they also asked a bunch of children what they thought.
The 78 recommendations (the Child Poverty Reduction Bill achieves recommendation one) are all immensely practical and achievable, stretching across the fields of housing, employment, welfare, health, community services, nutrition, education, justice, research and reporting, and with specific provisions for Māori and Pasifika children. Some of the other recommendations, like ensuring rental accommodation is insulated, and a more navigable benefit system, are already happening. For others, there has been encouraging movement, such as lifting GP-funded visits to age 13 (a further lift to age 17 is recommended).
What do we do first?
There is the face-off of socioeconomic factors (being poor leads to poor choices and lack of resources to deal with them) versus biological reasons (poverty gets under the skin, changing our bodies at the organ, cell and DNA level). And then there is the choice over whether to fix factors that meet people’s basic needs in the short term (sustaining factors) or to prioritise investment in capability building, so people have the long-term skills to pull themselves out of poverty (empowering factors).
Finally, the drivers of poverty occur at different levels. Some things are individual, such as training, skillsets and family support. Some fluctuate regionally, such as the local job market or housing availability. And some are national, such as minimum wages, tax credits and benefits.
The proposed action plan takes a balanced approach to the above issues, recommending a mix of strategies. Fittingly, there was even one entirely suggested by the children: they said they wanted the opportunity to play with friends, even if they were poor. So, Recommendation 72 asks all local governments ensure their parks, playgrounds and public spaces are safe and welcoming for children, and that free leisure and recreational activities are available, especially in disadvantaged neighbourhoods.
Wrangling over priorities aside, there is one thing everyone agrees on: poverty needs real money to fix. This should be seen as an investment. If the money is not invested now, it will be spent later patching up the effects: increased need for medical care, housing subsidies, benefit payments, education support and social services.
There are also the downstream effects: children growing up in poverty are more likely to become adults earning lower wages (leading to less tax revenue), to have chronic health conditions, to spend time in the criminal justice system, and to themselves raise children in poverty.
“A stitch in time saves nine” is a saying little heard in these days of disposable fashion, but it rings true when it comes to fixing child poverty. To put it more bluntly: when considering people as commodity, the earlier you invest, the greater the return. But because we are talking about complex beings, not money, that investment might bear fruit faster than you think.
Just cos people are poor doesn’t mean they can’t be strong. Support from your family and supporting families helps. – Child, anonymous.
The more I treat people, the more I notice most of their healing isn’t my doing. Sometimes simply having someone listen to their story clarifies things for them, or enables a family member to see them in a different light. But realistically, 30 minutes with me is unlikely to change things: the important work will be done by the patient and their family.
In the same way, I don’t think families in poverty are passive receivers of aid. It’s a common misconception, but the ones I meet are the opposite. They are bolshie, energetic and full of hope. With a little help, they will help themselves.
What makes one person vulnerable while another is able to rise above? What about those people, like that former prime minister of ours who was raised in a state house but ended up holidaying every year in Hawaii and lowering taxes for the rich? Resilience is the term used for the process by which people adapt positively to adversity. Unsurprisingly, seeing people in terms of those resiliencies – rather than making long lists of their problems – reframes things differently. And the framing of poverty is part of the problem.
Research on resilience suggests a nurturing adult can be a powerful buffer, reducing the risk of social, academic, and psychiatric difficulties for a child under stress. Remember those cuddly baby rats? Studies in humans have shown a mother’s emotional warmth may act as a buffer against an inflammatory marker called IL-6, which is triggered by stress. Other studies suggest epigenetic changes may be reversible under the right conditions.
You actually find that a lot of these families [who don’t have much money] have a strong family base because they help each other and when they know that someone is struggling they look after one another. – Child, anonymous
They neither desire nor demand to be helped or supported by others. With a little help, they will help themselves.
James and Aleisha have left my room. James gave me the wisp of a smile as he left, and Aleisha gave me a huge hug and cuddled James as they walked out.
Instead of dictating my clinic letter, I eat my lunch in the playground next to the clinic, seeing how the sun chases the shadows from under the swings.
I realise I haven’t been dealing with child poverty this morning. That’s the wrong term, because poverty never affects a child in isolation. In the uterus, a baby is surrounded by the walls of its mother, and she in turn is supported by her close and wider circle. Upon birth, this cocooning continues. A healthy child is wrapped in successive layers of support: family, community, culture, society, and the wider environment. These layers morph and change in significance as a person travels through their lifespan, but it’s impossible to treat a child – indeed anybody – without considering these.
Child poverty is really family poverty, or just poverty. Poverty rips off the protective layers from around a person, poisons them and transmits itself through successive generations. It is a heritable, chronic condition. It affects families, communities, cultures. It reflects history, politics and environments. It also reflects the strength of a nation and its soul.
As James and all my other patients teach me, they are also individuals, not conditions. Each has a unique story and, as their doctor, I have the luxury of responding to them as people and watching them grow over time. James might come from a poor background, but he is also a future writer, poet, paleontologist, dreamer. And he is a challenger.
Kids like James challenge me to think beyond my role in treating him. Considering the impact it has on our workload, it’s not surprising many of my colleagues are interested in poverty and social justice. Many of us wonder if we could do more – make more impact in policy, for example. We could build fences and level the cliff instead of just waiting at the bottom. Or maybe my role is to write something to combat some of the misinformation about poverty.
Whatever we decide to do about poverty, it will be worth it. Every child is worth it.
The author would like to thank Janet McAllister, Dr Te Kani Kingi, Dr Jin Russell and Leilani Tamu for their help with reviewing this essay. All views are her own.