The social imprints of poverty

The biological effects of poverty are easy to describe and understand for a science nerd like me. As hard data, statistics and medical imaging have the added bonus of being harder for politicians to counter (although they can ignore them or do a blunt-force interpretation of the subtleties). But for me, the more fascinating aspect of poverty – the part I wade into with my patients every day – is also the part that is harder to define and measure.

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.

Related article: The Aunties' Jackie Clark and her big-hearted mission to help her 'girls'



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.