The childhood roots of health inequity: Part 1 – Dr. Paula Braveman

Children who grow up in stressful environments, without adequate adult support, are at much greater risk of developing heart disease, cancer, and many other diseases as adults. This is partly because of the coping behaviors that people use to deal with stress, but also because of the cumulative effects of toxic stress. Thus, many of the health inequities we see are rooted in childhood.

At the APHA annual meeting in Denver this year, the Medical Care Section’s Health Equity Committee presented a special invited panel called The Childhood Roots of Health Inequity. To a standing-room-only crowd, four eminent scholars discussed these ideas and how they manifest in different ways. This post is the first part of a series we’re running to highlight the theme of health equity.

Our first speaker was Paula Braveman, MD, MPH, Professor of Family & Community Medicine and Director, Center on Social Disparities in Health, University of California, San Francisco. Her talk asked, How can a life-course perspective take us further toward health equity? She defined the terms:

• Equity = justice
• Health equity: equal opportunities to be healthy, improving the health of socially and economically disadvantaged groups
• Health inequity: health differences that are unfair in a particular way
• Lifecourse perspective: looks upstream, seeking root causes across lifetimes and generations

This illustration is worth a thousand words right here:

P Braveman et al., University of CA., San Francisco, adapted from version originally created for the Robert Wood Johnson Foundation Commission to Build a Healthier America.

Dr. Braveman laid out the considerable challenges to using a lifecourse perspective to tackle health inequities, including:

• Few longitudinal data sources
• Recall bias
• Inadequate data on social determinants of health
• Short-term focus of government budgets and most funding sources
• Silos – the agencies that invest in children do not get the credit or see the savings from improved adult health

Without an equity focus, disparities will widen. Dr. Braveman concluded by laying out a research agenda for health equity research and interventions informed by the lifecourse perspective:

• Timely access to high-quality, affordable medical care is important, but not enough. We must also:
  • Reduce childhood poverty and its social and physical consequences
  • Prioritize early childhood and family well-being
    • Support parents: help them provide nurturing, stimulating, and secure home environments
    • Ensure access to high-quality Head Start, Early Head Start, and childcare programs
• Focus research and action upstream, applying an equity lens
• Change the time frame for assessing policy impact
• Break down the silos: requires action at highest levels of government
• Don’t talk about child health without talking about the health of families, women, and men

Ultimately, addressing health inequity requires shifting paradigms. Are you ready to start pushing for that shift?

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Lisa M. Lines

Senior health services researcher at RTI International

Lisa M. Lines, PhD, MPH is a senior health services researcher at RTI International, an independent, non-profit research institute. She is also an Assistant Professor in Population and Quantitative Health Sciences at the University of Massachusetts Chan Medical School. Her research focuses on social drivers of health, quality of care, care experiences, and health outcomes, particularly among people with chronic or serious illnesses. She is co-editor of TheMedicalCareBlog.com and serves on the Medical Care Editorial Board. She served as chair of the APHA Medical Care Section's Health Equity Committee from 2014 to 2023. Views expressed are the author's and do not necessarily reflect those of RTI or UMass Chan Medical School.

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