The medical ecological context of children
Children are clearly resilient, no doubt, but immersion in impoverished, abusive, dangerous, neglectful and/or toxic environments pose challenges and imbalances to their health and well-being extending deep into adulthood.
By: Timothy D. Dye, Maternal and Child Health Journal
Practically all events occurring in the very early period of development have a disproportionately greater influence on physiological characteristics and behaviour than have events of the same type or magnitude occurring later in life. The effects are greater; they are often irreversible; they extend to a large variety of characteristics, such as longevity, health, learning, and behaviour. René Dubos, So Human an Animal, 1968.
The influence of early childhood exposures and experiences exert an outsized effect on the rest of the human lifespan. Children are clearly resilient, no doubt, but immersion in impoverished, abusive, dangerous, neglectful and/or toxic environments pose challenges and imbalances to their health and well-being extending deep into adulthood. While the social and cultural importance and role of the child varies greatly across the world, the reality is that children have biological systems that are developing – neurons, organs, form and functions – that are the same, regardless of locale and culture. The combination of culture, health care, biology, and physical environment provides the ecological context for a child. Viewing the child in this context helps us to better understand the larger picture of their lives, how these dimensions interrelate, and how balanced and in equilibrium a child and its community may or may not be. We know that when we have an imbalance in our personal ecosystem, we often are considered ‘sick’ as our bodies, minds, and cultures try to bring us back into balance. An infection, trauma, or deprivation can push us into this disbalance; therapies, interventions, and time bring balance back. Though, in fact, many religious and traditional medical systems are based on these same ideas, Western medicine and modern science still grapples with this notion of our integration of body, mind, biological, and physical worlds (just look to the never-ending nature v. nurture debate for evidence of this conflict).
Three ecosystems I’ve worked within recently highlight these ecological, integrated perspectives: rural, mountainous Haiti, post-hurricane Puerto Rico, and refugees from the Tibetan plateau living in India.
Rural northern Haiti is quite distant – and distinctly different – than the urban or coastal areas of this Caribbean nation. As with many mountain communities, resources are scarce, lives are hard, often the consequence of great distances and poor transportation access in the mountains. Mountain Haitians frequently rely on the products of their environment (trees, streams, plants, animals) for food and local medicine – however sufficient or effective they might be. Because they have few options, they use the ecosystem around them to sustain their lives as best they can. Communities rely on strong religious and traditional beliefs to help them stay nourished and as healthy as they can with the materials that they have access to in their environment. The children growing up in the mountains of Northern Haiti frequently experience – and sometimes die from - infections and injuries that result from their local exposures, and there are often few alternatives available to them to mitigate those risks. While these children benefit from a strong culture and perhaps are more closely tied to their local environment and local treatments, situations requiring Western medicine or hospital-level care can be fatal given the - sometimes insurmountable - barriers in accessing resources and institutions that require complex and costly transportation arrangements. More than many, the people of mountain Haiti know the resources of their immediate environment and incorporate them deeply into their culture; indeed, other options are rarely available to them in any sustained way.
Puerto Rico was devastated by two back-to-back hurricanes in 2017 that caused widespread destruction and more than 4,000 deaths across the country. Such disasters re-configure the ecosystem itself, in many ways, and can dramatically create new opportunities for the spread of infectious organisms; social disruption; challenges to food, water, and shelter; and post-traumatic physical and mental issues.
A sluggish aid response embedded within colonial political systems created anxiety, stress, depression – and even suicide - in families, and many families further experienced the exasperation and pain of having a loved one die. Many people fled the conditions in the islands for the mainland US - creating a further disruption to the ecosystems with which they are most familiar – finding temporary, incomplete, and sometimes hostile circumstances when they arrived. With the chaos of a country-wide disaster such as these hurricanes, children are impacted deeply from the upheavals in their social, physical, biological, and health care environments at all levels of the community (personal, family, society). The unanticipated dislocation of children and families creates turmoil and an almost permanent sense of disconnection and stress, circumstances that we anticipate will become more common as weather-related events resulting from climate change become more frequent throughout the world.
Situations of war, disaster, and oppression for millennia have catalyzed movements of human populations across borders and cultures, creating refugees and diaspora communities. Tibetan refugee communities arose in India since 1959, and today thousands of ethnic Tibetan families live in refugee settlements scattered throughout the country. Tibetan communities evolved in their homeland in high altitude, arid, rugged landscapes that shaped Tibetan culture, diet, and even physiology, given the impact of altitude on the human body. The food system that supports Tibet is fragile and specific, largely centering around barley, yak, and the few root crops that can grow within the Tibetan ecosystem. When families trekked across the Himalayas and subsequently settled in India, the social and environmental conditions were dramatically different, even in regions like Ladakh that share borders and cultural elements with Tibet. Since the settlements have now been operating for 50–60 years, several generations of Tibetans have now never lived in Tibet or even outside a refugee settlement, and communities often suffer from the impacts of decades of impoverishment, stigmatization, neglect, and poor physical infrastructures.
Children in refugee situations are at great risk for destabilizing disruptions in their ecosystems, compounding the circumstances that led to their departure from their homeland. When outside of the ecologies that they are familiar with, children and families can have great difficulties adapting to food, climate, and culture. Even after multiple generations existing outside of their homeland, many communities remain stigmatized and live in deprived conditions. Refugee and diaspora experiences often create strong bonds within a community as people try to retain elements of their cultures in a foreign land, but in time and over generations these bonds and resources may not easily withstand the pressures to integrate, yet another social dynamic with biological consequences.
Children – while often surprisingly resilient – are disproportionately vulnerable to changes in their ecosystems that create opportunities for disease to thrive. Seismic shifts in natural or human-caused disasters create permanent change, with biological, social, and environmental factors interrelating at many levels, creating disequilibrium and long-lasting impact. Research and guidelines aimed at children’s mental, physical, social, and educational health can increase their uptake and impact when such research contextualizes the focus within this ecological frame, acknowledging that we are all integrated biological-social-psychological beings in physical environments “wrapped in an envelope of heat, humidity, bacteria, fungi, and mites…” (Meade and Emch 2010). Social factors matter. Biology matters. The environment matters. Ecosystem health encourages us to see how our research, innovations, and interventions all attempt to help prevent, treat, or lessen the various manifestations when these dimensions are not balanced to support well-being.
Dubos R. So human an animal: How we are shaped by surroundings and events. New York (NY): Scribner; 1968.
Meade MS, Emch M. Medical geography, 3rd Edition. New York (NY): The Guilford Press, New York; 2010.