Peter A. Gorski , M.D., M.P.A. Director of Research and Innovation

1. Babies Need Bathwater – Bathwater Needs Advocates:Policies that Promote Rights and Routes to Well-Being Peter A. Gorski, M.D., M.P.A. Director of Research and Innovation The Children’s Board of Hillsborough County Professor of Public Health, Pediatrics and Psychiatry University of South Florida FAIMH Keynote Speech - May 15, 2008

2. Lessons From Research On Infant Development

3. For survival, growth and development, all infants need: Intimacy Reciprocity Trust Security Predictability Efficacy Reliability Love Dignity Respect Hope and Peace

4. Babies need the bathwater of family care. • Families need resources and support from their community. • Communities are built, grown and sustained by citizens and the relationships and policies they create.

5. Anyone (i.e., everyone) who has heard anything about the brain in recent years already knows the importance of infancy to Lifespan Health Behavior Emotional Development

6. Take-HomeMessages Infants respond to, act upon, and develop from interaction with social, emotional and physical environment. Infant brain and CNS organizes most rapidly during first 18-24 months, laying neural infrastructure for subsequent patterns of social, emotional, cognitive, communicative and motor behavior.

7. Infant’s corticolimbic development also sets course for immune system and biological stress reactivity. Development corresponds with and directed by infant’s relationship experience and development of bio-behavioral attunement and attachment systems. Take-Home Messages (Cont)

8. Parents are primary agents/guides in these biopsychosocial organizing processes. Parents bring a set of capacities to this cause based on their early relationship histories and current contexts/supports. Take-Home Messages (Cont)

9. Primary environmental supports for parental health, well-being, motivation, knowledge and capital resources: economic sustenance safety and interpersonal peace – community personal dignity – inner peace health of natural environment sound educational system access to quality health care Take-Home Messages (Cont)

10. Two theoretical explanatory models for reciprocity between infant mental health and society: Fetal Programming Life Course Development Take-Home Messages (Cont)

11. Equity All children have the right to the conditions and supports necessary for optimal health, growth and development – indeed each child’s outcome is influenced by all children’s outcomes. Take-Home Messages (Cont)

12. Policies, practices and personal behavior must lead the way toward achieving positive outcomes for infants, families and the prospects for civil society and human development. Take-Home Messages (Cont’d)

13. Biological systems are most sensitive when they are least differentiated early in life. Implications

14. Whereas: Infancy plays such a big role in setting a course for health and behavior through childhood and adulthood; and Early brain development is largely experience-dependent; Therefore: Disparities in population health trajectories must somehow reflect inequalities in the social experience of infants and young children.

15. Individual Differences and Group Differences in the social experiences that drive biological systems beginning very early in life.

16. Inequalities vs. Inequities Individual differences within groups and classes likely result from stylistic inequalities (diversity) or variants in the expression of care among children of one family, culture or neighborhood – e.g. different customs, traditions, personalities.

17. Inequalities vs. Inequities (Cont) Population differences common to most members of a group who live in close physical or cultural proximity are more likely the result of inequities in consistent access to health-inducing opportunities, resources and supports.

18. Why Do Some Populations Experience: Higher maternal and infant mortality Higher death rates for most diseases Shorter life expectancies Less health insurance Fewer diagnostic tests/therapeutic procedures

19. Beyond the background study of the bio-behavioral interface of early brain development, focus the lens of science on finding: • the root sources that create unequal health outcomes • when these root sources begin to shape lifespan health in the life of children.

20. Here the story gets challenging for us who have worked so long and hard to provide therapeutic and even preventive health and mental health services to vulnerable infants and families or to all infants and families.

21. Common causal pathways to: • growth retardation, • susceptibility to disease and • chronic illness • premature birth and • early death Cumulative stress and the consequent dysregulation of the neuroendocrine system

22. StressandInfectionDuringPregnancy? Stressful life events or perceived stress or anxiety Stress →norepinephrine and cortisol release → placental CRH → preterm labor Stress alters immune function, increasing susceptibility to intra-amniotic infection or inflammation Undocumented cause of increased susceptibility to infections during pregnancy

23. Sources of Unequal Health Outcomes: Inequitable Distribution Of Capital

24. Unequal Wealth

25. Post-neonatal Infant MortalityPer 100,000 Live Births (1986)

26. Unequal Education

27. Illinois School District 1 $10,000/student School District 2 $3,000/student School District 1 starting teachers $40,000 School District 2 starting teachers $18,000

28. Unequal Environments

29. Toxic Pollutants • Environmental Racism • waste dumps/incinerators more common in lower SES neighborhoods • “Cancer Belt” (Baton Rouge to New Orleans) • “White residential neighborhoods” - 1.7 acres parkland/1000 residents • “African-American neighborhoods” - 0.3

30. Unequal Support

31. Community - HealthfulInfluenceofSustainingRelationships • Social Ties and Susceptibility to the Common Cold - Cohen et al JAMA 6/25/97 • larger social network, greater host resistance • if >5 types of social ties, 4x less susceptible than if 1-3 types of social ties • also: smoking, poor sleep, alcohol abstinence, low dietary Vitamin C, elevated catecholamines and being introverted

32. CommunityandHealth • Children Who Prosper in Unfavorable Environments: Relationship to Social Capital - Runyan et al, Pediatrics, 1/98 • Def: benefits that accrue from social relationships and affiliations • Church affiliation, mother’s perception of personal social support, neighborhood support – 1 of these increases the odds 29%, 2 increase them by 66%

33. CommunityandHealth (Cont) • Collective efficacy reduces crime - Science, 8/15/97 • Not related to community wealth but to neighbors watching out for each other.

34. ChallengingParadoxes Low SES and race - risk for IM and LBW Grandmothers and LBW Real estate and social justice

35. Where you live (and who’s your daddy) largely determines your access to all four of the essential capital investments in children, all four of the major influences of children’s outcomes.

36. Infant Mental Health(i.e. healthy primary relationships during early childhood) develops resilience to and helps inoculate children from the full virulence of: Inequity Injustice Indignity Loneliness (Remember the 40 developmental assets from Peter Benson and the Search Institute!)

37. At the same time, we must remember that: • Parents’ energy for caring can be weakened, • Their sensitivity to others’ needs can be blunted, and • Their biological endowment to their offspring disordered by: poverty, hunger, ill health, toxins, isolation, prejudice, fear and shame • Cumulative life stress gets passed on to subsequent generations.

38. Cumulative Life Events

39. Therefore: healthy, resilient, hopeful families and children are most likely to thrive in neighborhoods that are safe, peaceful, clean, green, connected, socially and economically vibrant where all children and adults have equal access to caring relationships, nutrition, education, health care, and human dignity.

40. Questions: What gives residents the will and the ability to create and sustain communities as healthy places for young children and families? What provides resources to strengthen their resolve and reward their efforts? What can enable all people willing to work hard an equal chance to achieve their dreams? What can prevent the color of their skin, the accent of their speech, the worship of their faith, or the location of their neighborhood from setting a nearly irreversible course of opportunity or despair?

41. Answer: The impact of policy on the social determinants of health and development.

42. Policies that support Equity, Justice, Personal Dignity and Community

43. Promising Strategies National subsidies for healthcare – not stigmatizing the disadvantaged Livable wage Microcredit programs to poor people Community Networks/Weavers

44. Policy Recommendations • Narrow gap in wealth, education and social opportunity: • increase minimum wage • increase tax credits for child care • increase quality and affordability of child care • increase wage scale for licensed child care/early childhood educators and teachers • National, equitable school funding

45. Child Poverty Before and After Transfers (2003)

46. Public Spending on Family Benefits in Cash, Services and Tax Measures Percentage of GDP (2003) Average Total (2.4%) Cash Services Tax Breaks 4.5 4.5 4.0 4.0 3.5 3.5 3.0 3.0 2.5 2.5 2.0 2.0 1.5 1.5 1.0 1.0 0.5 0.5 0.0 0.0 Spain Japan Korea France Ireland Iceland Austria Canada Finland Mexico Sweden Norway Belgium Australia Denmark Germany Netherlands New Zealand United States Czech Republic United Kingdom

47. Overall Child Well-Being - All Countries

48. Livable Wage • Minimum wage adjusted for inflation (cost of living) at lowest since 1955 (federal going up from $5.85 to $6.55 in July, FL $6.79, MA $8.00) • Annual minimum wage earnings are well below the poverty level for family of three. • Increasing numbers of wage earners, well above minimum wage, cannot keep pace with mortgages, rent, gas and utilities, food prices.

49. Livable Wage (Continued) Social Justice Issue Women account for 61% of minimum wage workers 71% of minimum wage workers are age 20 and older 44% of minimum wage workers work full time

50. Policies That Drain Resources From Children And Families