You cannot create equal opportunities early enough

The circumstances under which you grow up - even when you are still in the womb - have an enormous influence on your health and well-being for the rest of your life. These circumstances are not equal for everyone by a long shot. “It matters quite a lot where your cradle was.” The Utrecht-based researchers Joyce Browne, Gonneke Stevens, Manon Benders and Thomas van Huizen speak with each other about the responsibility and possibilities to fight these unequal opportunities, in practical healthcare and in research. “We're not there by a long shot, but it's getting better.”

The four researchers we spoke with for this article work from various disciplines and have ties to Utrecht University or the University Medical Centre Utrecht. For instance, Thomas is an economist, and Gonneke is an interdisciplinary social scientist. And Manon works on a very specialist level on the repair of damaged brain tissue in babies. While Joyce, on the other hand, works very internationally on ‘Global Health’. What unites them is that they each want to contribute to more equality in healthcare and society from their fields. And that they seek interdisciplinary collaboration for this. They do not collaborate directly, but they do know each other's work. And they are enthusiastic to meet each other face to face for this story.

The conversation is about the cultural change currently observed in healthcare and what is gained from it. The view has become broader and more integral in recent years, they assert. Researchers of very different backgrounds collaborate in research programmes such as Child Health (UMC Utrecht) and Dynamics of Youth (UU). Attention for the circumstances under which children grow up increases therein, as well as the equality and inequality of opportunities that come with it. “Ten years ago, this was still a rare topic of conversation in healthcare. And equality of opportunities being on the agenda now is a development in the past few years,” Joyce says.

Early phase of life

This integral view means that health professionals look more and more at the surroundings and their influence on children and youngsters. Good health is about much more than just the question whether or not your body is functioning properly, Joyce says. It is also about factors such as livelihood security, health skills, mental health, education level, wealth and wellbeing, nutrition, schooling, growing up in an intact family or a broken family.

To indicate how determining these ‘external’ factors can be and how early they play these determining roles, Manon explains: “In neonatology, we often deal with children who are born prematurely. Imagine a child born after 24 weeks and therefore has fallen behind at the start (editor's note: a full pregnancy is 40 weeks). If that child has theoretically educated parents and grows up under socio-economically favourable circumstances, that difference of sixteen weeks can be caught up on. But if the child has practically educated parents and grows up in a more socially vulnerable environment, the disadvantages and problems of this starting phase will influence the rest of that child's life. In fact, that child is affected twice.”

Thomas concurs: “The first period of life is very important, possibly a determining factor for later inequality. That is why investing in preschool facilities is important. We can make a difference there, for instance, with smaller groups and a wider range - but there too, so many other factors are influential.” Gonneke says: “More and more research is available in which big groups of youngsters have been followed over a longer time. For instance, I'm in the Trails research team. This research project started approximately twenty years ago, back when the children were 11. Now that they're in their thirties, you can, for instance, see to what degree their situations during puberty were predictive for how they're doing now when it comes to their mental health.”

Manon says: “What it comes down to is that where you cradle was, is still an enormous determining factor. Children who grow up in unfavourable living circumstances have less favourable health outcomes in the long run. That is why we must support vulnerable families exactly around birth and the first years of life, where possible.”

Thomas says: “Policy can make a difference. On the other hand, the differences are so big that it's not realistic to think that a world with equal opportunities will one day be fully possible. You're dealing with a persistent problem.”

Health skills

In order to still increase the equality of opportunities as much as possible, quite much can be done, the four say. You are not there yet if everyone has health insurance and lives near a hospital, Joyce says: “Improving equality of opportunities goes beyond that. For people with low incomes, the travel expenses to get to the hospital can still be a barrier. Taking time off from work because you need to take your child to the hospital is problematic if that means you could lose your job. These are things we must take into account from the healthcare sector too.”

Our ‘health skills’ can still be a lot better. This goes for patients as well as the treating medical staff. “Examples of health skills are being able to recognise symptoms in your child, knowing which complaints require a visit to the general practitioner and then also being able to properly describe these complaints. There is still a world to gain. On the side of the care provider, intercultural sensitivity is becoming more and more important. Knowing what the norms, values and beliefs of the patient are and taking these into account,” Joyce explains.

The conversation moves to the importance of kangaroo care. Prematurely born children often have to stay in the incubator to gain strength in the first period. But you greatly improve this process by taking the child out of the incubator a few times a day and placing it on the parent's chest. This skin-to-skin contact has a big positive effect. Joyce says: “We know of the importance of kangaroo care from low and middle-income countries, by the way, where it is often a necessity. You often have no choice but to take your child everywhere with you.” Manon says: “At the same time, you see that kangaroo care in the Netherlands catches on better among the theoretically educated than among the practically educated.”

Good reflection

Besides, in the treatment room, there is also a starting cultural change going on in the research field. Gonneke tells that she is working with municipalities to set up a big research project into poverty and mental health among youngsters in two neighbourhoods in Amersfoort and Utrecht. “We no longer define the research questions by ourselves as researchers, but we do that together with the target group now. That time in which you, as a university, enter the neighbourhood and say: ‘We have an intervention (editor's note: treatment or approach), so just start using it,’ is over. But of course, it's also exciting to let go of a part of the control.”
Manon says: “We also try to work more and more from the patient's perspective. We then involve patient councils in that. The current problem is that these councils aren't diverse at all. They don't form a good reflection of the patient population yet. Something still has to be done about that for real. But the current trend is good.”

On the side of the care providers themselves, too, there is still much to be done in the field of diversity and equality, Manon, Thomas, Joyce and Gonneke ascertain. For starters, the admission system for academic healthcare degree programmes should undergo an overhaul. “Putting it bluntly, we currently mostly get many like-minded girls in medicine. Not that there would be anything wrong with these students, but if you want more equal opportunities in healthcare itself, a lottery system in cases of equal suitability like before might be more honest,” Manon says.

Joyce says: “Talent is currently searched for too much within personal circles. You see that in appointments, advisory committees and in the way in which vacancies are disseminated. It's important that we have more attention to the places where talent can also be, but which you didn't think of immediately. I notice in my own Global Health Department within the Julius Centre that this works well in searching for new researchers. And you currently also see that more and more people with different profiles apply with us by themselves. And then also bring in their research questions.” Thomas says: “I recognise that trend at Dynamics of Youth. In the determination of strategic themes and assessing research applications, we include equal opportunities and equality more and more often.” All say: “We're not there yet, but it's getting better.”