Making the Most of the Muskoka Initiative

MAKING THE MOST OF THE MUSKOKA INITIATIVE

Laura Ghali, Margaret Clarke and Chelsea Ritchie

The Muskoka Initiative on Maternal Newborn and Child Health was Canada’s major foreign aid contribution in 2010. Canada and its partners committed $7.3 billion to provide a coordinated response to the global crisis of preventable maternal and childhood deaths. United Nations statistics estimate that over half a million girls and women die during childbirth in developing countries and 9 million children die from preventable causes before their fifth birthday. The Muskoka Initiative aims to improve the quality and dissemination of health care services in developing nations over the next five years. Missing from the agenda are parallel strategies targeting early brain and child development, an area where Canadian researchers are recognized internationally. This article examines the economic and societal consequences of failing to attend to new research on early brain development as well as the policies necessary to promote optimal and sustainable human development.

L’Initiative de Muskoka sur la santé des mères et des nouveaux-nés a constitué en 2010 la principale contribution canadienne en matière d’aide extérieure. Le Canada et ses partenaires ont pris l’engagement de consacrer 7,3 milliards de dollars à une intervention coordonnée ciblant les principales causes de la mortalité des mères et des enfants. Selon les statistiques des Nations unies sur les pays en développement, plus d’un demi-million de femmes et de fillettes y succombent à l’accouchement et 9 millions d’enfants y meurent avant l’âge de cinq ans de causes évitables. L’Initiative de Muskoka a pour but d’améliorer dans ces pays la qualité et la disponibilité des services de santé au cours des cinq prochaines années. Mais elle ne prévoit aucune stratégie parallèle visant le développement sain de l’enfant, notamment le développement du cerveau pendant la petite enfance, un domaine où les chercheurs canadiens jouissent pourtant d’une réputation internationale. Les auteures examinent les conséquences économiques et sociétales de cette mise à l’écart de la recherche sur les premières années de vie, de même que les mesures politiques qui favoriseraient un développement humain à la fois optimal et durable.

lobal concerns regarding preventable maternal and opment, based on leading Canadian research and policy, childhood mortality prompted the Canadian-led would vastly increase the rate of return from this significant G Muskoka Initiative on Maternal Newborn and Child investment. This article will review the importance of early Health (MNCH). Through this initiative Canada, partner nations brain development and early human development in promot- and private foundations have committed US$7.3 billion to ing a healthy future for society. address the global health crisis of preventable maternal and childhood deaths. In September, Prime Minister Stephen Harper arly brain development in the prenatal period and early addressed the United Nations Summit on Millennium E years of life impacts health, learning and behaviour Development Goals, urging countries to pay direct attention to throughout the lifespan. The brain develops rapidly in the goals 4, 5 and 6, which are aimed at reducing maternal and child- early years, a time at which one’s experiences interact with hood mortality. Over half a million women die during childbirth genetics to shape the developing brain. Epigenetics and 9 million children die before the age of five because of lack of describes how experiences affect gene expression, by access to factors such as clean water and immunizations. enhancing or depressing the translation of genes into pro- The investment of $7.3 billion is focused on advancing teins. Epigenetic modifications affect everything from how the quality and dissemination of health care in developing we respond to stressful events to our risk for disease and our nations. Parallel strategies incorporating healthy brain devel- ability to learn. Positive early conditions such as a stable

POLICY OPTIONS 61 DECEMBER 2010-JANUARY 2011 Laura Ghali, Margaret Clarke and Chelsea Ritchie

and nurturing caregiver, a language- Inadequate investment in early Canada also fails to meet the stan- rich environment and access to good child development has caused dards of its industrialized counterparts in quality nutrition, medical care and Canada to fall behind other industri- two other important areas, infant mortal- community supports provide the nec- alized nations with respect to sup- ity rate and low birth weight. Infant mor- essary foundation for lifelong health porting the development of young tality rate (IMR) is defined as the number and well-being. Negative early experi- children. In 2008, the UNICEF of newborns who die during their first ences including maltreatment, pover- Innocenti Report Card revealed that year of life, and has generally been iden- ty and poor health result in an Canada met only 1 out of 10 bench- tified as the single best indicator of popu- increased risk for poor outcomes marks for transition to early child- lation health. Dennis Raphael’s 2010 including chronic diseases, poor men- hood education and care. Of the 25 article “The Health of Canada’s tal health and low educational OECD countries included in the Children” reveals an upward trend from achievement. report card, Canada and Ireland tied 5.2 infant deaths per 1,000 live births in for last place, meeting the fewest 2001, to 5.4 in 2005, placing Canada 24th ames Heckman, an American econ- benchmarks. among 30 OECD countries. J omist and Nobel laureate, has highlighted the economic implica- FIGURE 1. RATES OF RETURN ON HUMAN CAPITAL INVESTMENT AT DIFFERENT AGES: tions of investing in early brain devel- RETURN ON AN EXTRA DOLLAR AT VARIOUS AGES opment through research on the

impact of preschool programs. l a Programs targeted toward the earliest years

Heckman argues that investing in pit a early childhood development pro- c

gramming results in greater returns uman

h Preschool programs than investments made in the later n t i n

years of life such as post-secondary e education and job training (figure 1). m Schooling vest

A 2006 study conducted by the n Job training Organisation for Economic Co- to i

operation and Development (OECD) urn et compared the investments made in r

early years programming in 20 devel- te of a oped countries as a percentage of each R nation’s GDP. While average invest- 0-3 4-5 School Post-school Age ment across the countries was 0.7 percent, Canada invests only 0.3 percent Source: J. Heckman (2008). of its GDP toward early years programming. Nations such as Denmark, Sweden, Finland and France spend 1-2 FIGURE 2. PUBLIC SPENDING ON SERVICES FOR CHILDREN, SELECTED OECD COUNTRIES percent of their GDP on supporting early child development (figure 2). 2.0 Taking into account current research on the sensitive periods for early brain development, it makes 1.5 sense that substantial public expenditure should be focused on the first three years of life. As demonstrated in 1.0

the OECD report, Canada is failing to t of GDP n

make investments where they stand to ce r

achieve the greatest return. The sensi- Pe tive period for investing in Canadian 0.5 children is being neglected and majority of investments are being made after developmental trajectories have been 0.0 set and potential for change in terms of brain growth is significantly Denmark Sweden FinlandFrance United States Australia Canada reduced (figure 3). Source: Figure adapted from OECD (2006).

62 OPTIONS POLITIQUES DÉCEMBRE 2010-JANVIER 2011 Making the most of the Muskoka Initiative

Also considered to be an impor- ing how policy impacts the health and Failure to invest substantially in tant indicator of population health is well-being of children. The Early early human development results in the incidence of low birth weight, as it Development Instrument (EDI), devel- high costs to society in many areas. is associated with numerous health oped at McMaster University, meas- Lifelong issues related to early devel- problems occurring across the lifespan ures the developmental status of opment include health issues such as such as a weak immune system and kindergarten children across five obesity, diabetes, heart disease and neurological issues. Although Canada domains. The EDI has been imple- poor mental health; education issues ranks 9th out of the 30 OECD coun- mented across Canada and interna- such as lower graduation rates and higher unemployment; and Inadequate investment in early child development has caused behaviour issues including Canada to fall behind other industrialized nations with respect higher rates of crime and to supporting the development of young children. In 2008, substance abuse. It is estimated that the cost of men- the UNICEF Innocenti Report Card revealed that Canada met tal health and addictions to only 1 out of 10 benchmarks for transition to early childhood Canadians is $100 billion education and care. annually. Heckman’s analysis of the cost of crime to tries, the disparity across Canada is dis- tionally. Community maps of EDI Canadian society is over $100 a year. couraging, with 43 percent more low- results indicate the proportion of chil- Economic analysis by the Human birth-weight babies found in the poor- dren vulnerable on one or more Early Learning Partnership has con- est income quintile than in the richest domains of the EDI. Vulnerability cluded that at current vulnerability quintile. rates across communities in Canada rates measured by the EDI, British In general, the OECD countries vary greatly, from lower than 10 per- Columbia is forgoing 20 percent GDP with lower IMRs and lower low-birth- cent to higher than 70 percent. growth over the next 60 years, equiva- weight rates than Canada are, with Children who are vulnerable in lent to investing $401.5 billion at 3.5 respect to GDP, less wealthy. This indi- kindergarten often don’t catch up, percent — a figure that is 10 times the cates that the wealth of a nation can- resulting in poor academic achieve- province’s current debt load. This not be used as the sole predictor of ment and lower employability. It is analysis can be applied across Canada, maternal and child health. Although important to note that the majority of with similar rates for each province Canada is a wealthy nation, the 2009 vulnerable children do not come from based on population. Innocenti Report Card indicated that the poor families; they are in the more child poverty rate in Canada was an populous middle class. The propor- here does Canada go from alarming 11.3 percent. Recently, tion of child vulnerability in Canada W here? There are two critical researchers have begun to examine threatens to severely compromise the issues that urgently require remedia- environmental and social factors to nation’s future economic growth. tion by the federal government. First, explain Canada’s deficits in child development. The social determinants FIGURE 3. PUBLIC EXPENDITURE AT STAGES OF BRAIN DEVELOPMENT of health are nonmedical factors influ- encing health, including early child Brain growth and development, income, education, maximum potential Spending on health, for change education, income employment, housing, food security, support, social services t

n and crime

working conditions and the quality of e m health and social services that are e ur available. “The Health of Canada’s dit n

Children” has suggested that these ’s develop n i social determinants have more influ- ra blic expe u ence on development than one’s P sity of b

genetic makeup. This aligns with n te n research on epigenetics, which shows I that developmental trajectories are determined largely by one’s early environmental experiences.

Conception Birth 1 3 10 60 80 onitoring early child develop- Age M ment is critical to understand- Source: J. Vandergaag (2004).

POLICY OPTIONS 63 DECEMBER 2010-JANUARY 2011 Laura Ghali, Margaret Clarke and Chelsea Ritchie

the proposal to improve child and of time (increased parental leave), Decisions regarding maternal maternal health in developing coun- resources (income and employment and child health need to be made tries needs to incorporate strategies supports) and services (childhood edu- from an informed position on what that promote healthy early brain cation and care). is necessary for healthy brain devel- development. Based on the societal While on the surface this may opment to occur. This requires a and economic impacts seen in Canada, seem a costly investment to make, the commitment to providing current it is clear that failing to dedicate cost to society of the status quo far and accurate information to those resources to ensure positive develop- outweighs the investment. Failure to individuals charged with making mental trajectories produces expensive invest in children and their families in decisions that affect outcomes for both young children and Maternal and child health is not an issue solely affecting their families. Such indi- developing countries; it is also threatening the well-being and viduals include but are sustainability of Canadian society. Promoting healthy early certainly not limited to health care professionals, brain development in Canada requires policy level change child welfare workers, and that directly influences environmental experiences on family and provincial development. court judges and lawyers, as well as new and expect- repercussions that far exceed the initial the critical early years period will ing parents. investment required. Initiatives result in a cohort of developmentally It is clear that attempts to sup- focused on improving child and vulnerable individuals who will be port child and maternal health are maternal health in developing nations unable to reach their full potential and not adequate without the promotion need to include services that support compete in an increasingly competi- of positive early childhood environ- healthy brain development to ensure tive global market. ments and experiences. Furthermore, sustainable human development. Investing in early childhood experi- the science of early brain develop- Second, maternal and child health ences has the potential to deliver eco- ment is a matter requiring the atten- is not an issue solely affecting develop- nomic and social returns in a very short tion of the international community. ing countries; it is also threatening the period of time. These “returns” can be Healthy human development is an well-being and sustainability of demonstrated in as little as five years as issue affecting both developing and Canadian society. Promoting healthy the first cohort of children reaches industrialized nations, and its early brain development in Canada kindergarten “ready to learn” with the achievement has the potential to cre- requires policy, level change that direct- potential to develop the skills they will ate future generations with increased ly influences environmental experi- require in the later stages of life and ulti- health, better quality of life, more ences on development. Providing mately in the labour market. Policies productive labour forces and ulti- supports and resources that foster posi- that support young children and fami- mately successful and sustainable tive environments for new families and lies would also have immediate returns communities on a global scale. young children needs to be prioritized to achieve the Decisions regarding maternal and child health need to be best developmental out- made from an informed position on what is necessary for comes. healthy brain development to occur. This requires a At present, an annual investment of approximate- commitment to providing current and accurate information ly $22 billion toward social to those individuals charged with making decisions that affect infrastructure is necessary outcomes for both young children and their families. to reduce Canada’s child vulnerability rates. At a provincial to society. The Human Early Learning Dr. Laura Ghali is a child development level it is estimated that Ontario would Partnership has identified a number of researcher and psychologist with the Fraser need to increase its investment by potential gains including attainment of Mustard Chair in Childhood Development $8.28 billion per year, with almost half work/life balance for parents, reductions at the University of Calgary. Dr. Margaret of this being put toward early child- in poverty and vulnerability rates pro- Clarke is a professor of pediatrics at the hood education and care. Alberta and ducing savings in health costs, University of Calgary and holds the Fraser Saskatchewan would require increases decreased expenditures on child welfare Mustard Chair. Chelsea Ritchie is a law of $2.96 billion and $883 million per from fewer children entering the system student at Queen’s University, after com- year respectively. The investments and fewer costs associated with the fam- pleting a summer research internship with would go toward spending in the areas ily and youth justice system. the Fraser Mustard Chair.

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