Unnatural Causes: Social Determinants of Child Health and Well-being FREE

Although nationwide trends like obesity and violence have gradually interwoven themselves into pediatric health care, we have been struck recently by the seemingly familial relationship among these disease entities. A young man visiting his cousin shortly after her gastric bypass operation recalls meeting the surgeon years earlier, as a victim of child abuse; as his stab wound is explored in the emergency department, another teenager remembers his brother's treatment in the same room for an acute asthma exacerbation.

While seemingly unrelated, these entities—obesity, asthma, and violence—all share the common trait of being heavily influenced by environmental factors. The incidence of crime, including violent crime, is known to be increased in poor neighborhoods, and low socioeconomic status has long been known to be associated with poor health throughout an individual's lifespan. However, it is only recently that a direct correlation between crime and health disparity has been described. In Chicago, Illinois, neighborhoods marred by the highest rates of violent crime also have the highest rates of infant mortality. Again, while this connection at first glance seems obvious, the block-by-block spatial relationship of these 2 entities is striking. More than 75% of census tracts with high homicide rates contain a high level of clustering for infant mortality and low birth weight.¹ The same neighborhoods exhibit poverty, increased high school attrition rates, and joblessness.² However, the incidence of several seemingly unrelated pediatric illnesses, including obesity, asthma, and unintentional injuries, is also increased in these areas.^1,3- 4 These neighborhoods represent microcosms of “new urban poverty,” demonstrating the previously described relationship between poverty, crime, and now poor health care on the street level.⁵

Similar results have been duplicated in Cincinnati, Ohio, which recently has possessed both the highest homicide rate in the Midwest (89 per 100 000 in 2006) and the highest infant mortality in the state of Ohio (17 deaths per 1000 births in 2004). As in Chicago, violent crime and high infant mortality cluster in several historically black poor neighborhoods; our pediatric patients presenting with asthma and obesity likewise predominantly live in these same neighborhoods. Ironically, several of these areas geographically abut one of the world's premier pediatric medical centers.

Now that the relationship between poor health and new urban poverty has been described, the next logical steps are to further dissect the specific factors that perpetuate the cycle, determine how pediatric illness is related, and devise solutions that address this entity in its entirety, rather than tackling its individual components. Programs to decrease infant mortality or child abuse through education may be marginally successful, but counteracting the altered reproductive timing observed among young women in these communities would make a long-standing impact on both disease processes.⁶ Likewise, nutrition and exercise goals, while instructional, are hopelessly unattainable on a block where grocery stores, gym or recreation facilities, and pharmacies have been driven out by high crime rates and decreased property values.

As caretakers of children, we strive to polish our clinical acumen, advance accepted therapies through research, and pass our acquired wisdom and passion to new generations of providers, all in the name of delivering optimum care to our young patients. Although these ideals have advanced pediatric care and treated innumerable children in our hospitals and clinics, new urban poverty erects barriers to both halting epidemics of asthma, childhood obesity, and other pediatric diseases that threaten national pediatric health and to advancing the well-being of these same children as they grow into adulthood. Our resources and intellectual energy must be turned toward solving the problems of new urban poverty if we hope to truly impact the health and well-being of children.

Correspondence: Dr McClaine, Department of Surgery, University of Cincinnati College of Medicine, 234 Goodman St, ML 0558, Cincinnati, OH 45267-0558 (mcclair@ucmail.uc.edu).

Author Contributions:Study concept and design: Garcia. Analysis and interpretation of data: McClaine. Drafting of the manuscript: McClaine and Garcia. Critical revision of the manuscript for important intellectual content: Garcia. Administrative, technical, and material support: McClaine. Study supervision: Garcia.

Financial Disclosure: None reported.