EARLY CHILDHOOD DEVELOPMENT AND GLOBAL HEALTH ETHICS

A Sensitive Period

Avram Denburg, MD MSc FRCPCBIG Seminar SeriesFebruary 9, 2011

Objectives

Social determinants of child health• Global disparities in child health and development

Early Childhood Development• Experience-based brain development

• ECD Interventions

Global child health ethics• Existing paradigms: human rights and public health ethics

• Ethics and ECD: freedom, equity, and solidarity

INFANT MORTALITY

A Bottom-Heavy World

WHO 2006; Worldmapper 2006

Problems with Solutions

UNICEF 2007

Child Poverty and Health

Emerson, JAMA 2009

Child Poverty and Health

Emerson, JAMA 2009

Experience-Based Brain Development

Early Experiences and Neural Plasticity

Experience-Based Brain Development

Early Experience and Neural Plasticity

„Sensitive Periods‟ and Neural Plasticity

Knudsen 2004

0 1 4 8 12 16

Age

Brain Development: Language and Cognition

Sensorium(vision, hearing)

LanguageHigherCognitive Function

3 6 9-3-6

Months Years

C. Nelson, From Neurons to Neighborhoods, 2000; courtesy of Founders‟ Network

Stressful

Stimulus

PIT

Cortisol CortisolCRF

ACTH

Amygdala Hippocampus

AdrenalCortex

HypothalamusPVN

+ + - -

Thalamus Cortex

LeDoux, Synaptic Self; Founders‟ Network

Stress Pathway and Sensory Stimuli

Touch in the early period is critical:

Rats – Mothers licking pups

Monkeys – Peer vs. mother rearing

Humans – Attachment

HIGH LG LOW LG

Development of Stress Reactivity

Modest StressReactivity

Disease Risk

Increased StressReactivity

Risk: Heart Disease, DM II, EtOH, Depression, etc.

Maternal Behaviour & Stress Reactivity

Szyf & Meaney, 2002

0

0.4

0.8

1.2

Mea

n C

-Met

hy

lati

on

EmbryoDay 20

BirthDay 1

PupDay 6

AdultDay 90

WeaningDay 21

LickingLow

LickingHigh

Age

Epigenetics: Nurturing and Stress

Szyf & Meaney, 2002

Early Experience & Depression

None Moderate Severe

.30

.50

.70

Caspi et al, Science 2003

Depression (age 26)

LL

SS

SL

S = Short Allele L = Long Allele

Stressful life events

0

600

1200

12 16 20 24 28 32 36

High SES

Middle SES

Low SES

Age - Months

Vocabulary Growth – First 3 Years

Hart & Risley, 1995

Vocabulary

The 30 Million Word Gap

Words heard:

Welfare = 616 wph

Working-class = 1,251 wph

Professional = 2,153 wph

Cumulative early experience, age 4:

Professional - 45 million words

Working-class - 26 million

Welfare - 13 million

Vocabulary growth rate and use at age 3 predictive of measures of language skill at age 9-10

Hart & Risley, 1995

WHO SDH Commission Report 2008

Stimulation and supplements normalized development by 2 years of age

Age 11 - Benefits of stimulation still seen, but not supplementation

Abecedarian Study – Reading

Age 8 Age 12 Age 15 Age 21

Age at Testing

0

1.2

0.8

0.4

Effect Size

PrimaryGrades

Preschool Preschool &Primary Grades

Campbell et al, Dev Psych 2001

Rates of Return to Human Investment

Pre-school Programs

School

Job Training

ReturnPer $

Invested

R

2

4

6

8

0 6 18Age

Pre-School School Post School

Carneiro & Heckman, Inequality in America, 2003

Human Rights Public Health Ethics

Kantian tradition

Primacy to the inviolate person

Universal, indivisible, interrelated, and interdependent

Obligation at level of nation-state

Utilitarian and communitarian paradigms

Analytic domains: Professional ethics Applied ethics Advocacy ethics Critical ethics

Obligation at level of „community‟ (municipal, regional, national)

Global Health Ethics: Moral Denominators

The Right to Health

ICESCR Article 12 recognizes

“the right of everyone to the enjoyment of the highest attainable standard of physical and mental health”

Article 12.2

steps to be taken by States parties to achieve:

a. the healthy development of the child

b. healthy natural and workplace environments

c. prevention, treatment and control of disease

d. health facilities, goods and services

Limitations Advances

Progressive realization

Biomedical

Unenforceable

State-centric

CESCR General Comment 14:

SDH

„Collective rights‟

„Core obligations‟

IAC-H

UNCRC

The Right to Health

UN Convention on the Rights of the Child

Most widely ratified HR treaty

Incorporates civil, political, social and economic rights

Most detailed and specific RtH (Article 24.4): „States Parties undertake to promote and encourage

international co-operation [towards] the full realization of the right to health…particular account shall be taken of the needs of developing countries.‟

Explicit duty for IAC: specific application of IAC to health (24.4), education (28.3)

and disability (23.4)

UNCRC 1989

UN Convention on the Rights of the Child

Article 29:

“The education of the child shall be directed to the development of the child‟s personality, talents and mental and physical abilities to their fullest potential.”

General Comment No.7:

Emphasis on child rights from birth

Inequality of access to quality early childhood services labelleddiscrimination

Action: monitoring and evaluation of ECD programming; comprehensive, rights-based plans

UNCRC, 1989; 2005

PHE RtH RtH PHE

Ethical foundation for IHR law

Attunement to institutional power relations

Confronting tensions b/w individual and collective spheres of protection

Focus on needs of marginalized

HRs (social, political and economic) as a priori determinants of health

States‟ duties to realize health of citizens

PHE and RtH: Conceptual Synergies

Adapted from Nixon and Forman 2008

The Rudiments of a Language

FREEDOM EQUITY SOLIDARITY

Freedom

Capabilities:

„The substantive freedoms he or she enjoys to lead the kind of life he or she has reason to value‟, as fundamental to human development (Sen 1999: 87)

Model of „human flourishing‟ that places health at its ontological centre (Prah Ruger) Capability to ensure a baseline level of good health, through freedom from

preventable disease and death, construed as essential/irreducible (Ruger 2006a)

Health is the sine qua non of human functioning, a kind of higher-order capability: without health, one could exercise no other freedoms (Gostin 2008)

Health deprivations are deemed unjust insofar as they limit the capacity for human agency, and thus „human flourishing‟

Freedom: Capabilities and ECD

Proposition:

Early neural development, and its epigenetic residue, is a quintessential and irreducible capability

Implication:

the long range effects of epigenetic changes to early brain development, both across the lifespan and to subsequent generations, demonstrate that our chances ‘to lead the kind of life we have reason to value’ is radically contingent on our early environment

inequalities therein lead to discrepancies in freedom for full human development

The Rudiments of a Language

FREEDOM EQUITY SOLIDARITY

Health Equity

A Definition: •“equity in health is the absence of systematic discrepancies in health (or in the major determinants of health) between groups with different levels of underlying social advantage/disadvantage - that is, wealth, power and prestige” (Braveman and Gruskin 2003)

Rawls (1971): • social contract rests on a „fair system of cooperation‟ between people• justifies terms that protect and improve the lot of the least fortunate• „justice as fairness‟ endeavours to limit those social inequalities that obviate „fair equality of opportunity‟

Health Equity

Daniels et al (2004): • interpret equity in health as a function of justice in our social contract• extend Rawls‟ notion of equality of opportunity to encompass health and its social determinants, as a means of safeguarding a social contract that seeks to minimize health inequalities

Pogge (2004): ‘Relational justice’• demands inquiry into the causes of allocative disparities• our judgments about the equity of outcomes are incomplete without attention to the conditions and actions responsible for them

Equity, Epigenetics and ECD

Inequality of opportunity: • Social circumstance exerts adaptive pressure on gene expression • „Sensitive period‟ experience shapes developmental opportunities throughout the lifespan• RISK = enduring and potentially heritable patterns of social deprivation and illness

Equity and ECD:• differential risk in early childhood environments hampers equality of opportunity• need to mitigate disparities in social circumstance in order to attenuate enduring patterns of health inequality• RESPONSIBILITY = relational justice implications?

The Rudiments of a Language

FREEDOM EQUITY SOLIDARITY

Solidarity: Multiple Currents

• Sociocultural:•Ubuntu: derived from the traditional Zulu aphorism umuntu ngumuntu ngabantu(„a person is a person through other persons‟)• Canadian First Nations: „justice as healing‟ process of communal reckoning

• Religious:• Judaism: spiritual polity as organic body (Jerusalem Talmud, Nedarim)• Christianity: Christ‟s suffering and compassion in Christian moral theology• Buddhism: anatta („no self‟), sunyata (existential relativity and interdependence)

• Philosophical:• Communitarian: preeminent value on the „good society‟, searching out the character virtues that would constitute it Platonic, Aristotelian and Neo-Confucian traditions have cast social harmony as an essential goal of human life• Postmodern: Rorty importance of humility in identification with others• Humanitarian ethics: African Rights, Slim, Orbinski, Schweitzer

Solidarity and ECD: Synergies

ECD Equity

Solidarity

WHO Commission on Social Determinants of Health

Chapter 5: Equity from the Start

Recommendation 5.2:Governments build universal coverage of a comprehensive package of quality early child development programmes and services for children, mothers, and other caregivers, regardless of ability to pay.

…a sensitive period?

Ethics of ECD Policy: Food for Thought

Who decides what is a healthy environment for children, what they should be taught, and how to evaluate these decisions/priorities? How much variance within this scheme is tolerable?

When do early environments become inadequate for development and therefore unethical?

What are the implications for parental rights vs. child rights? What are the implications for how parents are allowed to raise their children, and where society is permitted/required to intervene?

Do transnational obligations to remediate disparities in early childhood environments exist? What is their content and scope?

THANK YOU

Neurodevelopment and Free Will

Sensitive periods vs. critical periods

ECD and teleology Plasticity in Aristotelian

„natures‟

ECD and Compatibilism Schopenhauer: ‘Man is free to

do what he wills, but he cannot will what he wills’

Criticisms: „freedom to act‟ as necessary

but not sufficient to „free will‟ Moral poverty of „soft

determinism‟ – does freedom to act confer moral responsibility for actions?

„Regenerative compatibilism‟?

Knudsen 2004