‘We must not underestimate the impact that poverty and financial problems have on public health’
The rate of infant mortality is much higher in impoverished neighbourhoods than in wealthy neighbourhoods. Even in the Netherlands, which hosts highly accessible care, rich people have a greater life expectancy. Marike Knoef, economist, and Eric Steegers, gynaecologist, are calling for action. The first measures that were implemented are already reducing infant mortality in Charlois.
Infant mortality in Rotterdam Charlois is comparable to Albania' - Eric Steegers
The office of Eric Steegers, at the fourth floor of Erasmus MC, overlooks the sleekly designed Museumkwartier in the heart of Rotterdam and presents a sweeping view of its exceptionally modern skyline. But Steegers is not oblivious to the other realities of Rotterdam. ‘Back in 2001, when I accepted a position in Rotterdam, problems such as infant mortality were much more prevalent here than in other parts of the country. The rate of infant mortality in Charlois, an impoverished neighbourhood of Rotterdam, was comparable to Albania. That really gave me chills.’
Low birth weight, stress, and nutrition
As professor of Obstetrics and Gynaecology, Steegers monitors embryonal development during the first weeks of pregnancy. In Rotterdam, they use highly sophisticated virtual reality techniques for that purpose, allowing Steegers to study an embryo by projecting it as a hologram in a virtual space. ‘You can, for instance, see the blood vessels in high detail.’
According to Steegers, medical complications within these blood vessels are often caused by pre-eclampsia; a pregnancy disorder characterized by the onset of high blood pressure in the mother. ‘Various other complications, such as premature birth and low birth weight, are also typically caused by a malfunctioning placenta. This is related to blood vessel health which, in turn, depends on all kinds of hormones. But stress and poor nutrition also play a role.’
A new insight in gynaecology: the impact of poverty impact
In 2001, when Steegers moved from Nijmegen to Rotterdam, there weren’t yet any data on the course of pregnancy and any regional differences therein. So, in 2003, he spent much more time outside his office to try and uncover any relation between his medical specialty and the social circumstances in his new hometown.
Generation R , a long-term Rotterdam-based population research programme involving ten thousand pregnant women and their children, has yielded much of the knowledge that Steegers was looking for. The most important finding was that poverty substantially increases the rates of infant mortality, premature birth, and low birth weight. ‘No one within the field of obstetrics had ever suspected this to have such a large impact,’ Steegers says.
Passing problems on to the next generation
‘The risk of cardiovascular disorders or diabetes increases for children born prematurely or with a low birth weight,’ he continues. ‘And they often pass their problems on their own children, making social problems last for generations. Eventually, this will create a nearly unbridgeable health gap. It is simply intolerable for a society to have its children be put at such disadvantage from the moment they’re born.’
More wealth, longer lives
Marike Knoef, professor of Empirical Microeconomics, also found a relation between poverty and health conditions in the Netherlands. She studied the relation between life expectancy and the economic circumstances of people: ‘In 2018, we created a graph showing the age of death as a function wealth. It resulted in a straight line that just kept on rising with increasing wealth. We performed this research in follow up to a similar study in the United States. Our outcomes hardly differed, even though access to health care is much better here in the Netherlands.’
Poverty has a major impact
As a micro-economist, Knoef aims to determine the impact of economic circumstances at the level of individuals, families, and neighbourhoods. ‘We must not underestimate the impact that poverty and financial problems have on public health,’ she says. ‘Poverty increases financial stress, leading to health problems which, in turn, make it much more difficult to find a job. And being out of a job negatively impacts your health. It is a vicious circle.’
So, what are the forces creating these health inequities? ‘It often is directly related to your early life circumstances,’ Knoef says. ‘Scientific publications show that parental educational level and cognitive ability play a role. Highly educated people are more adept at living a healthy life and maintaining a healthy diet. But stress and financial worries also play a role, as do growing debt problems.’
From welfare to employment: decreasing medication use
Together with Erasmus MC, we studied the re-integration of people on welfare in Rotterdam. By looking at their medication use, we saw that going back to work boosted their health by reducing stress levels. It means that pregnant women dealing with financial stress are in dire need of support, and I believe that gynaecologists can make a difference.’
And they do. The Generation-R project gave rise to a large municipal obstetric care innovation programme – first in Rotterdam and then nation-wide, across seventeen more municipalities. By now, the Healthy Start action programme is active in 285 municipalities, providing care and support to vulnerable families.
A pack of cigarettes a day
In conjunction with the municipality of Rotterdam, Steegers developed care paths giving physicians helpful information as to who may provide support to patients that have social or financial problems. ‘It has already reduced infant mortality in neighbourhoods such as Charlois,’ he says. ‘In 2001, if I had a consultation with a woman smoking a pack of cigarettes a day, it took great effort to figure out available support in her neighbourhood to help her stop smoking. Now, it only takes a single button press to see which primary-care doctors practice offers a program for quitting smoking, or who can assist in debt rescheduling.’
Steegers feels an obligation to put his knowledge to good use. ‘High impact publications are still valued more than achieving societal impact. We must obviously maintain a high research quality, but we also need scientists to take a more activist stance.’
In thirty years’ time, despite countless policy reports, nothing much has improved’ - Marike Knoef
Knoef chairs the Social and Economic Council (SER) committee advising the Netherlands government on health differences between people of varying socio-economic backgrounds. ‘In thirty years’ time, despite countless policy reports, nothing much has improved. That is partly because a sense of urgency is lacking, as is collaboration. In healthcare, investment costs often outrun the immediate monetary advantages. But society does certainly benefit from these investments. Health interventions aimed at mothers and children in impoverished neighbourhoods help close the health gap.’
Steegers looks out his window, lost in thought. ‘Why did we have so many problem pregnancies in impoverished neighbourhoods such as Charlois? It has to do with stress, the combined impact of addiction problems, domestic violence, financial worries, debt. I always wondered how we could connect the social and medical domains. To me, it is obvious that care professionals should inquire about any social problems their patients may have. And they should be empowered to act.’
Marike Knoef (1983) is professor of Empirical Microeconomics at the Leiden Law School. Her research focuses on the relation between public health and economic factors. She also chairs the Committee for Socio-Economic Health Differences of the Social and Economic Council (SER).
Eric Steegers (1961) is professor and head of the department of Obstetrics and Gynaecology at the Erasmus MC. His research interests include the relation between embryonic and foetal development and socio-economic circumstances. As a corollary, he also develops obstetric care programmes for vulnerable women in impoverished neighbourhoods.
Original: Hans Wetzels; Translation: Merel Engelsman
This is a prepublication of the white paper Healthy Society, published by Leiden-Delft-Erasmus Universities and Medical Delta. The white paper will be presented on Tuesday 15 November at the Medical Delta Conference in the Hooglandse Kerk in Leiden. You are cordially invited to join this conference. More information: Medical Delta Conference 2022: Technology: THE Gamechanger for Health