Taking a social determinants perspective on children's health and development.

In early 2007, then Minister of Health Tony Clement appointed Dr. Kellie Leitch, Chief of the Division of Paediatric Surgery at the Children’s Hospital of London, Ontario, as his Children’s Health Advisor. Her mandate was to review the role of the federal government in the health of Canada’s children. Dr. Leitch submitted her report, Reaching for the Top, 1 to the Minister in July 2007. The report was subsequently made public in March 2008. In her report, Dr. Leitch made it clear that in terms of child health and well-being, Canada did not compare well with other nations. Specifically, she highlighted the fact that when compared to other OECD (Organisation for Economic Co-operation and Development) nations, Canada ranked 21 st of 29 for child well-being (a category that included mental health), 22 nd in terms of preventable childhood injuries and deaths, and 27 th for childhood obesity. Reaching for the Top was widely endorsed by health professionals and organizations working in the area of child and youth health. The report provides a solid foundation to support such work and, in amassing and presenting a large body of evidence, Dr. Leitch throws into sharp profile the urgency of the need to act to improve the health and well-being of Canada’s children and youth. What is more, the report identifies specific options and a number of priority areas for action, which we shall discuss shortly. An area that is not adequately addressed in the report is that of social determinants of health. Dr. Leitch acknowledges that “a look through the lens of social determinants of health tells us a lot about our children,” but she goes on to assert that her mandate did not extend to addressing those determinants. Rather, the report includes a brief appendix “to reference the three social determinants that affect child and youth health that were raised repeatedly during [our] roundtables: poverty, housing and education” (ref. 1, p.174). The need for a substantive treatment of social determinants of health to complement the contribution of the Leitch Report was one of the motivating factors in the genesis of this supplement. The observation that health outcomes tend to be poorer among individuals and within areas of lower socio-economic status (SES) compared to individuals and areas of higher SES is now a commonplace one. In a nutshell, we know that experiences of health and illness are “stratified along various lines of social and economic inequality”. 2 What is more, we do not only see differences between the wealthiest and the most poorly off. Differences in health are seen across the entire socio-economic spectrum: individuals with the highest income tend to have better health than those who fall into the middle-income group, who in turn experience better health than those individuals who fall into the lowest income group. This relationship, found consistently over many years, has been labeled the social gradient in health. Such observations are not new of course. They have become almost tiresomely familiar. That there are direct and indirect links between material deprivation and health was the central message of the UK’s landmark Black Report, which is thirty years old. 3 At the same time, the influential Whitehall Study of British civil servants was demonstrating the effect of social position such that “each group had a higher mortality rate than the group one step higher in the hierarchy”. 4