Before The Bough Breaks: Children in contemporary Australia. Professor Fiona Stanley

Portrait of Professor Fiona Stanley

This transcript is directly from the sound recording of Professor Fiona Stanley delivering the Kenneth Myer Lecture in the theatre of the National Library of Australia on Thursday 24 July 2003. It forms part of her powerpoint presentation.

Russell Doust: Good evening ladies and gentlemen. I’m Russell Doust. I’m the Chairman of the Friends of the National Library - for this year anyway. Distinguished guests, Sir James Gobbo and other members of the Council of the National Library of Australia, ladies and gentlemen, as Chairman of the Friends of the National Library I welcome you to the library and to the 2003 Kenneth Myer Lecture. Many of you will know, but it is worth repeating, that the Kenneth Myer Lecture, which has been an annual event since 1990 was named for a long time Friend of the Library, Kenneth Bailleau Myer, AC, who was Chairman of the Council of the Library from 1974 to 1982. The prescription for the Kenneth Myer Lecture is simple. It is to provide an opportunity for an eminent Australian to make a significant statement on a broad subject of particular interest, both to the lecturer and, it is hoped, to an audience much wider than you here this evening, for the Lecture goes on to and remains on the Library’s website for anyone interested to read.

The list of former Kenneth Myer lecturers is formidable. Gough Whitlam, Nugget Coombs, Gillian Broadbent, John Mulvaney, Gus Nossal, Fred Chaney last year are to name but some of them. It is now my great pleasure to welcome this year’s Kenneth Myer lecturer, an eminent Australian indeed, the Australian of the Year for 2003, Professor Fiona Stanley, AC. She has had and continues an extraordinary distinguished career as and epidemiologist and biostatitician and researcher in public health matters, which especially include maternal and child health. Professor Stanley is the founding director of the Telethon Institution for Child Health Research. She is the Chief Executive Officer of the Australian Research Alliance for Children and Youth and manages to find time to be a professor in the Department of Paediatrics in the University of Western Australia. Professor Stanley has called her lecture ‘Before the bough breaks: children in contemporary Australia’. Please welcome her.

Prof. Fiona Stanley: Russell Doust, who’s Chairman of the Friends of the Library, and I’d also like to acknowledge Jan Fullerton, who’s the Director General of the Library, and James Gobbo and I’d also like to acknowledge Frank Fenner, who’s one of my heroes, who I can just see in the audience. I’d also like to acknowledge the traditional owners of the land, the Ngunnawal people, and in acknowledging them acknowledge also that the history that we have had with our indigenous people are framing many of the problems that we’re now seeing in our Aboriginal children and young people. Something I’ll be touching on again.

So before the bough breaks, of course, refers to the nursery rhyme: Rock a bye baby in the treetop, when the wind blows the cradle will rock. When the bough breaks the cradle will fall, down will come baby, bough, cradle and all. What I want to do is to give you a snapshot of children’s health and well-being in contemporary Australia. I’ve attempted to attain information across a range of conditions and problems and really ask the question: have improvements in the social and economic and general conditions that we’ve experienced in Australia resulted in improved outcomes for children and youth? I’m afraid I conclude that, whilst death rates are low and life expectancy is terrific, trends in almost all other outcomes have got worse. Even in deaths for Aboriginal and Torres Strait Islander children there haven’t been the improvements at all that we looked for. So I want to share these data with you. I want to try to attempt to tease some explanations for, reasons for these increases and I think then we need to talk together and at least leave you with some suggestions as to how we must respond to this.

But I will start off with something funny because really the rest of it isn’t going to be funny at all. This relates to me being made Australian of the Year. I really look upon this as an award that all of those interested in children and youth share in Australia, because really this is something that’s enabled me to get on a soapbox and talk about these issues that I care so deeply about. However, one of the nice things was that somebody wrote from Adelaide and said would I like to have a rose named after me and I thought this was rather fun and so did my daughter. She emailed me from Melbourne, knowing that one of my heroines is Eleanor Roosevelt. We should clone Eleanor Roosevelt I think, as well as cloning Kenneth Myer, by the way. She said, ‘Eleanor Roosevelt, mum, was very pleased that she had a rose named after her too until she saw the caption underneath the rose which said, “Not very good in a bed but very good against a wall”’.

So now we get on to the really difficult stuff. So let’s have a look at this. As I read the material about Kenneth Myer I thought that he probably would really enjoy this lecture tonight because many of the things that I’m going to be talking about are really things that I think he would hold dear and near. I mean, what an amazingly wonderful man to have contributed so much to the intellectual and other social capacity of this country. In fact, I had an email from Bailleau Myer this afternoon apologising that he couldn’t be here. So it goes on, it continues on in that wonderful family.

So I’m now trying to share with you some of the indicators of health and well-being that we’re seeing in Australia and, of course, being an epidemiologist, you measure health and well-being with things like death and low birth weight and diseases and problems. But there is a flip side to this that, in fact, many children in Australia are doing well. I want to, however, because I’m an epidemiologist, look at how we’re travelling in these things and what it really means. So let’s look at the deaths and here we see for all Australian infants - this is infant mortality - and we’re travelling really well. If you look at this last decade for all Australian children we’re as good as anywhere in the world. Where we’re not so good, of course, is that whilst indigenous infants deaths have fallen, they are still increasingly disparately higher than non-indigenous children. It seems that we only can count indigenous deaths accurately in three states. We need to be more caring about collecting infant information.

But when we start to tease out this mortality - I apologise if these aren’t as clear - the bottom two relate to neonatal and post neonatal mortality in all Australian children; this is actually West Australian children from 1980 right through to 1997. That pattern where you have a higher level of neonatal mortality, that’s deaths in the first four weeks of life, compared with post neonatal mortality, deaths in the rest of the first year of life with that higher level, is the pattern that we see in developed countries with good services and good support. On the whole that’s the pattern we’d like to see. The worrying pattern above that is that for Aboriginal children and you can see that’s what’s happened is a fall in Aboriginal neonatal mortality and that should be the one that’s higher. What we’re seeing, in fact, is the post neonatal mortality, the most preventable causes of death in infancy, has actually gone up and is now higher than neonatal mortality. That’s the pattern we saw in 1900 in all Australian children.

When we start looking at other places and say, ‘Well, are they seeing the same problems?’ you can see here that we’re actually travelling not very well in terms of these indigenous children compared with North American, Canadian and Maori children. So we’re seeing a much higher rate amongst our indigenous children than other colonised indigenous populations. It’s really that post neonatal, that preventable mortality, where we’re travelling much worse than those other countries. So in the other colonised nations, they have managed to reduce their indigenous mortality and we have not. I think that’s a very important message and the good news from that is they’ve done it; we can do it. It’s just a matter of how we turn that around.

So now let’s look at some of these other measures of health and well-being. Low birth weight. The weight that you’re born with is one of the most important predictors of your life chances of health and well-being. So one would have anticipated that as Australia improved in terms of its social milieu that we would be seeing a reduction in the proportion of babies born of low birth weight. This is for all Australian births and you can see the proportion born less than 2,500 grams is actually steadily rising over this last decade. So this isn’t auguring well for the improvements that we’re anticipating. If you take this data back 40 years, in fact, we haven’t seen any improvements at all in low birth weight, which is remarkable given that many of the factors we think are improving birth weight have actually increased in the population. So there must be as many factors reducing birth weight as there are improving it. There have been changes to increase it recently.

Now I’m going to look at three of the common and rising diseases that are occurring in children and this, of course, is asthma, the well known increase in wheeze over time. Now up to around 30 to 40 per cent of children now have an asthma or a wheeze that is likely to be asthma. I’m sure if I asked for a show of hands about whose children or grandchildren had asthma, about 30 to 40 per cent of you would raise your hands. So this is now a hugely costly, hugely worrying and so is this, type one diabetes - not type two diabetes. Type two diabetes is also going up. This is type one diabetes and this is probably the only one that relates to an increase in our genetic risk. Almost all the other things I’m going to be showing to you tonight, in fact, are really environmental - they’re so rapid. But this one is probably contributed to not just by lifestyle but by an increase in the genetic risk due to the increased survival of people with diabetes, type one diabetes.

But this is the one that’s most worrying and it’s really come upon us very quickly and unexpectedly and this is obesity. This has been very much more recent than some of the other increases I’m going to show you and it’s only really since 1985 that we’ve seen such a dramatic increase in children who are obese. This shows you for both boys and girls in Victoria and New South Wales. Got to make sure that the Melbourne/Sydney axis here both get a mention. The latest data from South Australia from the social atlas of Di Hetzel and John Glover has shown that in four and a half year old children we have seen a doubling of obesity in the last 10 years. So this is getting younger and younger and it’s getting worse and worse.

When we look at intellectual disability from a variety of causes, and this is again our West Australian data, you can see that rather than decreases and improvements in outcome we are seeing actually increases in all of intellectual disability, quite substantially. Most of those are mild or moderate, which is the most common group. But, again, the pattern here is increases and quite a significant proportion of these are things like autism for which we actually don’t know the cause. I’ll speak about them later. I’ve just thrown this one in because it shows you - this is one cause of intellectual disability and this is Down’s Syndrome - it just shows you how dramatically a social factor can influence a rate like this.

This increase, which we’ve seen really in the nineties, dramatic increase in overall Down’s Syndrome, this is the increasing rate of terminations in the dots. So the birth prevalence of Down’s Syndrome is still probably on the way up but not as prevalent as it would have been if there hadn’t been an antenatal screening and termination program for this. But you can see this dramatic increase and this has been due to maternal age - women delaying having their babies has been really the thing that’s moved that. So, you know, how profoundly these things can be affected by social changes in our society.

This is the real worry that I think causes us the most anguish and this is the so-called epidemic of mental health problems that are occurring in this 21st century. This is from our West Australian child health survey because you can’t actually use routine data to reflect mental health problems because only about 5 per cent of children with significant mental health problems are actually in contact with mental health services. We’re coming back to that issue later on. So you actually have to go out and find children in the community and ask their carers and themselves about these things. About 18 per cent of all children in Western Australia aged before 4 and 16 - this has now been confirmed in a wider national survey - have a degree of mental health morbidity, depression, anxiety, behaviour problems and so on that interfere with their daily functioning. You can see it’s higher in males than females, but even in 4 to 11 year olds. We’ve seen recent data in Australia to confirm that it’s around 16 per cent. So even if we were all turned into psychiatrists tomorrow or psychologists, which is quite a frightful thought, we would not be able to cope with the amount of morbidity that we’re seeing in our childhood population with this.

So these kinds of levels of problems demand preventive strategies rather than ones that relate to services. This is some very important data. This is international comparisons. We’re not alone in these things and this is an international study done by Sir Michael Rutter and David Smith from the United Kingdom, published in ’95. They looked at international trends in crime, suicide and self-harm, depression, eating disorders and the use of alcohol and drugs. This is a recurring theme through this talk, that these are associated with disadvantage and so the expectation was that they should’ve reduced as living conditions improved. That was what everyone was expecting. But there’s now a clear and substantial and sudden increases in these disorders since the 1950s in most developed countries. So that’s a very important message and this is shown here.

I’ve put this on because I really wanted to go back as far in history as I could do it. I had this wonderful chance when I was asked by ABS to write a chapter for their millennium year book and I could choose it on anything I wanted to. Like a kid in a sweet shop, I could use any ABS data I wanted. It was lovely. I had a wonderful time. I wrote a chapter on child health since federation and a lot of that data I was able to get something like this, going right back to 1907 suicide rates in males by age and you can see the 0 to 4 and the 5 to 14 really don’t appear much because the big rate, of course, the rate that is so overpowering there is that of 15 to 19 year old males.

You can see here that we are now in the 1990s, or the eighties and nineties, seeing rates of child and adolescent suicide in these young men that we haven’t ever seen before. Australia has got very good data on suicide but other countries, developed countries, have similar rates like this. You can see this encouraging plateauing and even a fall of this adolescent suicide and I think this is really encouraging and we’re very interested as to why that’s happened. I think a non-availability of heroin may have contributed to that, as well as I hope some of the preventive programs that have been implemented in schools. We certainly had some interesting research in Western Australia on those kind of interventions and I hope that they have had that impact.

I apologise for the smallness of this slide but this just shows the bad news about suicide. I mean, all news about suicide is bad but whilst the 15 to 19 year old rate seems to be going down, the peak age for suicide now is in the 20 to 35 year olds. This is males for WA, South Australia and Northern Territory, those three groups that managed to look at Aboriginal race. You can see here the pattern of suicide by age over time for ’96 to ’98 and you can see that peak in the red stripes for all Australians. For non-Aboriginal Australians you can see that peak up in the 30 year olds now. So those cohorts of high risk people are going through and so there is no diminution of this adolescent risk of suicide. It’s travelling now through into the younger adult age group. But look at those rates for adolescent and young men in Aboriginal communities and you can here the high rates, those green bars there. So, again, the disparity is there for Aboriginal people, a high rate of people in despair who are taking their own lives.

Increase in child abuse. I told you this wasn’t going to be a pleasurable night, but I think it is really important to share with you these data. It’s very difficult to get good information on child abuse but our sense is, from the data that the AIHW are producing and other places around the country, that reported cases are on the rise, as shown here. The number of children placed in out of home care have risen and we’re certainly seeing this kind of pattern of children coming into our hospital in Western Australia showing from 1982 through to 1994. The blue bars are non-accidental injury and you can see that these certainly aren’t falling. There’s an increase, in fact, in irreversible brain damage occurring from non-accidental injury in Western Australia and this has been in spite of ‘Don’t Shake the Baby’ campaigns that have been actually pretty ineffective because they don’t look at what the root causes of these things are. But look at those rises in the black bars, which is child sexual abuse, and I think that this is one of the things which is causing us so much anguish today, about these increasing rates. I mean, really it’s the kind of thing you can’t contemplate, isn’t it?

This, of course, is now looking at the disparity between what’s happening to our non-Aboriginal and Aboriginal girls. So these are rates of child abuse and the blue bars are 0 to 9 year olds and the first bars are for Aboriginal children aged 0 to 9 and the lower bars are for non-Aboriginal children aged 0 to 9. And look at the high rates for Aboriginal and non-Aboriginal girls from 10 to 17. I mean, these rates are just unacceptable. I mean, people say to me, ‘Oh, you know, some of these rates of child abuse aren’t really increasing. They’re just better reporting and so on. People are coming forward and disclosing and so on’. Okay, if that’s the case. This is still an unacceptably high rate of child abuse amongst our population in Australia in 2003.

If we look at care and protection orders, these are children who are taken in to care and there’s a substantiated neglect. You can see here again the disparity between indigenous Australians in the dark blue and other Australians in the purple. So we are seeing coming through on the data now these unacceptable rises.

Now we’re looking at lifestyle factors and the kinds of things that are going to put children at increased risk of many of the things I’ve talked about. There’s been dramatic changes in the last, well, even 20 years in the patterns of smoking and drinking, particularly amongst females. I can remember when I was at university we never went to pubs and to see a drunk woman, you know, drunk girl student was so shocking and amazing that it was the most unusual thing. I’m afraid not so in today’s Australia. In fact, smoking rates for girls are higher than for boys and drinking rates for girls, as I’ll show you in a minute, are equal to those of boys. This is a major social change. It is a major public health concern because in about 5 to 10 years time many of these girls will be mothers and will be at high risk of some of the problems that we know are associated with things like foetal alcohol syndrome.

So this is hazardous drinking. This is binge drinking reported; five drinks or more reported in the last two weeks. You can see that going from 1983, which is the light colour, through to 1996, which is the dark colour, for 12 year olds around about 10 per cent of 12 year olds reported this - this is males. It’s gone up to 20 per cent in the latest figures. These are David Hill’s data from Victoria but it’s an Australia-wide survey. You can see between 40 and 50 per cent of 16 year old males are hazardously drinking and that’s remained about the same level. If you think these figures are any different for girls, here they are for girls. You can see for 16 year old girls, they’re drinking hazardously at about the same level as boys. But look at those 12 year old girls. Nearly 20 per cent of them too reported hazardous drinking patterns in the last two weeks.

This is now illicit drug use. We know it’s on the rise, it’s a major problem. This is a different axis here so don’t think that marijuana and cannabis is actually less than injecting drugs. This is a very different axis here for the injecting drugs. But you can see that amphetamines and ecstasy and designer drugs, injecting drugs and cannabis and marijuana are all on the increase. These are, in fact, very good data from a range of surveys that have been done on these characteristics.

This now getting into crime and this is some data again from the Rutter and David Smith book and this is incomplete but this is trying to look at what’s happened and patterns of crime internationally are actually notoriously difficult because it’s how the justice system handles some of these things, so that you may get rises and falls in crime rates depending on how the justice actually handles, for example, juveniles or handles people. So there you have to take these with a grain of salt. But based on Rutter and Smith’s best interpretation - and you can see this is Interpol data here - there have been quite dramatic increases in offences being recorded across many developing countries. I’ve just here shown Australia from 1951 through to 1990 - but we’ve missed out the sixties there for some reason - Canada, England, much lower rates in Italy and Japan just hasn’t shown the same increases that other countries have shown.

Juvenile crime has been particularly worryingly increasing in many of these developed countries. As they say here, it’s difficult to explain why juvenile crime has increased so much in developed countries in the post war period. Changes in family functioning, increased mobility and associated declines in cohesiveness of local communities, along with changes in the pattern of crime opportunities are the most likely explanations. I think that they’re touching on some of the things that I’m going to touch on in a minute.

But these data are very interesting and very worrying, I think. This is again showing the changing pattern amongst females. So if you look at males in the 1970s and compared adult to juvenile arrests, in 1970 it was about two adults to one juvenile were arrested for violent assaults. This is violent assaults. That’s gone now to about one to two, so that’s an increase in juvenile arrests for violent assaults. In females we used to have 3.4 adults to juvenile arrests. Now it’s reversed; it’s one to two. So that means for one adult there are two juvenile females arrested for violent assault. If you look at boys and girls it used to be 24 boys to one girl; now it’s only four girls to one boy arrested for juvenile violent assault. I find that extraordinary. Many of these may be drug related. I just find it amazing that we’re seeing this.

Here it just shows again the disparity between Aboriginal and non-Aboriginal. The little dotted lines right at the bottom of these bars are the non-indigenous rate of juvenile incarceration from 1994 to 2001. Up at the top in the dark waving bar, which is going down, is the indigenous rate of incarceration. I think that that’s good news that it’s going down because it obviously means that there’s probably a better handling of children who possibly would’ve been incarcerated before and now are going into other sorts of programs. The bars, however, show the rate ratio that is how many times more the indigenous children are being incarcerated compared with non-indigenous and it’s 300 times the rate still in 2001.

When we look at education and completion rates, these are students who commenced Year 11 and went to secondary graduation in Western Australia in 2001 and you can see that 56 per cent of non-indigenous students got through those two years and of the students who started Year 11, the indigenous students, only 18 per cent got through. So again there’s this disparity. But of the 1,300 children, indigenous children, who entered Year 1 in Western Australia 13 years ago, about 70 got through to Year 12 and six got their tertiary entrance exams. Now, when I show these data to our indigenous researchers in the institute they say, ‘But this is great, we’ve got 18 per cent through. My reading of it is that we’ve got to do better than this in terms of indigenous education because, as we know and as many of our indigenous friends tell us, education is going to be the key to Aboriginal advancement. So we’ve got to start turning around the way that we can educate and therefore increase the success of Aboriginal people in this country.

This is just to remind me to say, because these are birth cohorts from a national institute and mental health collaborative study in the states. You can see that these are cohorts of people with major depressive disorders and they are comparing people who were born in the early part of the last century, 1904, right up to people who were born in the 1955s. You can see that most recent birth cohort. What really is the message that I’m trying to give you here is that what we’re seeing is earlier and earlier diagnosis of these problems. That we’re now seeing not only an increase, and you can see these dramatic increases in depressive illness here in the successive birth cohorts, but earlier and earlier diagnosis.

So that’s the kind of pattern that we’re seeing across all of these problems in children, that we’re seeing earlier and earlier alcohol exposure, earlier and earlier diagnosis of autism, earlier and earlier diagnosis of behaviour problems and violence and so on. So in addition to an increased proportion of children being so labelled, we’re seeing them at a younger age with these problems. So childhood is rapidly vanishing.

So I now want to get on to talk about why these things may be happening and why this answer to my question about have our improvements in our social circumstances, which have been so lauded as increasing wealth and opportunity, why are we seeing such increase in social disparity and an increase in problems in our children and young people? The Canadians, Hertzman and Keating, who’ve written about this extensively, call this ‘modernity’s paradox’. We have increasing wealth and yet the expected changes are not being delivered and why do we think this is happening? I think possible explanations, and we don’t know the reasons for all these things, I mean, many things have been changing in society in the last 30 to 50 years, as you know. I haven’t got time to go through all of them.

But if you start to look at - and I hope you can see this slide, it’s a very busy one - if we start to look at the pathways to resilience in young people and so we’re looking at the kinds of things that are going to make a person in our society capable and have the competencies, both intellectual, social and emotional, then we can actually start with the kinds of things that happen - and you can’t see this at the bottom of the slide - things like we start to look at the complex interaction between the multiple genetic factors and the multiple environmental factors over-development which result in this capacity, or lack of it - as the case may be.

So what I’m trying to draw for you here are the trajectories to these outcomes are actually starting at conception obviously, but health pregnancy, reduced maternal smoking, alcohol and drug misuse. You know, if we can avoid these at least then that interplay between genes and environment as early as in-utero will mean that that child starts to have a good opportunity to at least be born with a chance of optimal brain development and, therefore, going along a trajectory which will end up in this right hand top corner here. But a whole lot of other things have to happen as well. We have to have good nutrition throughout childhood and adolescence. We have to have social and emotional and economic environments which support child rearing, particularly the absence of poverty and exposure to violence. If you look at children who are consistently exposed to violence through their early years, this is one of the most powerful negative influences on their own capacity to control and to be a self-regulated - as it says here - self-regulation of emotion, attention and social interaction.

Then we’ve got to have responsive parenting and appropriate care and stimulation of monitoring. We’ve then got to move through our education system so that you can effectively learn. Think of pathways here. If you’ve got otitis media and you’re deaf and you’re an Aboriginal child and you can’t hear, then you’re not going to be able to have effective learning. There are many bits to these pathways and come in and out of them. Availability of positive adult role models, reduced exposure to harmful drugs, positive interaction with adults, positive interaction with peers, opportunities for achievement. Then we move into this sense of being able to socially connect and to move through it. So these pathways to resilience and the resilience of the things which, in fact, will enable a child in this complex world be able to cope with the kinds of challenges that he or she is going to face.

So these are complex interactions but I think it gives you a sense of now you can start to think, ‘Well, what are the things in our society which might not be delivering this kind of nurturing environment?’. If we now start thinking about what happens in that brain and why we think that early brain development is so important, this is not a particularly good photo but it’s a slide of giving you an idea of the kind of neurones, the brain cells at birth, at six years of age and at 14 years of age. You can see at birth that basically the genetic, you know, potential of that brain really relates to … this has gone off here but I’m not going to worry about, so I’ll just continue looking at this slide. It’s gone black but I don’t think that matters.

So that basically the child is born, it’s got its neurones, it’s genetically programmed with appropriate stimulation to have healthy brain development. But it’s exquisitely dependent upon having the kind of nurturing and appropriate social interactions with loving carers. Its got to have good nutrition and it has to have visual stimulation and mental stimulation and auditory stimulation - all of those things. So at the age of six what’s happened is an incredible growth, not just of neurones but of connections. Look at the difference there between those things. By 14 years of age those connections are, as you can see, there’s been some neuronal death, there’s been more wired up. So there’s, in fact, been a weeding out of these things so that the 14 year old brain is even more geared up to be responding and to have capacity in its environment. So that this is a long period of development over which this child has a capacity to modify and get its brain wired up to cope with the world outside. So there’s this wonderful interaction between our genetic potential and the environments in which we live are the things that are so important in terms of what’s going to happen to this kid for the rest of its life. So this is actually influencing its whole life chances.

This just shows the difference between a child who has had normal stimulation and development and this is a child who has been in a Romanian orphanage and you can see the dramatic difference in activity. This is magnetic resonance imaging of the brains of these two different kinds of children. You can see the almost lack of any neuronal activity in those temporal lobes in that right hand brain. If some of these important stimuli and interactions don’t occur then, in fact, you’ve really lost the opportunity, although it does depend very much on exquisite timing and interaction. So there may still be opportunities to turn some of these children around.

A lot of the research that we’ve done has started to broaden out from just saying: what are the factors that are close to the child in terms of its family, its community and its school? What are these bigger factors in the broader society that are impacting upon the positive and negative factors in this inner circle. Those are the larger socio-structural, political and cultural and economic environments and, dare I say, also spiritual environments that are enabling the kinds of communities and families and schools to deliver for children and for child development. So to ignore that bigger picture, that bigger outside circle, is really to ignore what I call the complex causal pathways that are actually impacting on many of these problems that we’re seeing.

So this is really to introduce that complexity and to point out that there are going to be things that we need to fix up, if you like, in that bigger circle, rather than just targeting parents to say, ‘This is your responsibility’. I’m mindful of Hilary Clinton’s wonderful quote from her book, which is, ‘It takes a village to raise a child’. I think that’s a really important one. So there are going to be many things that have changed in our society. Most parents want the best for their child. But many, many things get in the way and I think some of those things are in that outer circle.

So I’m now going to look at some of the multiplicity of factors to try and address this question further about what have been influencing these declines in development, health and well-being in our Australian children since the 1950s. Things that have been increasing is wealth and, I guess, how that’s utilised and distributed. Working hours have increased. Apparently, Australians work more hours than any other OECD country. Women are working outside the home more than ever before. How do we support them so that they can still value and manage their parental role? Unemployment has gone up. Family discord and breakdowns have been a major factor. Two per cent of marriages ended in divorce in the 1950s; now it’s nearly 50 per cent. About a million children in Australia are living without both natural parents.

Violence, I think, has increased in our society quite considerably and that’s an incredibly negative effect, as I’ve said, on children. Youth alienation and, at the same time, adolescent dependence. How many of you have still got your 24 year olds living at home? The influence of the media, drug and alcohol availability and I could go on. There are many, many things which have changed both in the inner circles that I’ve put up there and that outer circle which are having probably a negative effect on some of these trends that I’ve talked about. What’s been decreasing are some of the protective factors for these things. Community cohesion and participation, neighbourhood trust and, I think, children’s services and facilities in many communities. I think that, you know, have you talked to any child health nurses lately to see how angry and worried they are about support for what they used to be and what they used to have. So I think that there has been a decrease in facilities at a time when parents actually need them more than ever, given these other changes that have been happening in our society.

This is one of my examples of a causal pathway, which starts off with colonisation. I think it’s very important to think in these pathway models if we’re going to actually not only find out what are the root causes of these problems, but how are we effectively, most effectively, going to address them. So you can see here with colonisation and the loss of Aboriginal lifestyle and the kinds of housing, the kinds of environmental conditions in which many Aboriginal people have been forced to live, compounded by poor nutrition, Stolen Generation, marginalisation from white society, discrimination, unemployment and poverty, this is the sort of acknowledgement of history I think we have to have. Then at the bottom, of course, this is now leading to the alcohol and substance abuse, the domestic violence, deaths in custody, low birth weight, diabetes, hypertension, cardiovascular disease, respiratory diseases, ear diseases and so on - these unacceptable post neonatal causes of death that I was talking about.

If you just sort of looked at these things simplistically, which as an epidemiologist I used to do, I used to do the sort of single risk factor paradigm approach to things and I did studies which showed that alcohol and substance abuses, alcohol and smoking in pregnancy caused low birth weight, respiratory and ear disease in these Aboriginal children. So sort of the way you would interpret that kind of study is that you would go to Aboriginal mothers and you’d say, ‘Oh, look, we’ve taken your land away and we’ve taken your kids away and we’ve marginalised you and we haven’t educated you. And, by the way, don’t smoke or drink, it’s bad for your kids’. Those programs actually don’t work. But when you actually start to look earlier in the pathways and see if you can actually address some of these other things which are therefore about community capacity, providing employment, getting Aboriginal people to take a much greater role in solving these problems themselves, and I know this is very relevant to the kinds of things happening in Canberra in the last few days.

But we’ve got some fantastic examples of where they’re working. We’ve done a study called Non do diddy bearni, which is Wongai for healthy mothers, healthy children where 16 Aboriginal women with a 50 Aboriginal women council overlooking them have run for the last 10 years in the eastern goldfields one of the most successful ante and postnatal care programs that we know of. They’ve now, because they’ve gone earlier in this pathway and started to empower their own communities, we’re now seeing improvements in some of these downstream factors. So there are lots of good examples. I’ve just had the most fabulous trip up to the Torres Strait and the top of the Cape York Peninsula, Northern Peninsula area. I’ve been to Galiwinko on Elco Island. There is some fantastic good news stories out there about communities in control really. Those communities who have got the capacity to intervene on some of these things for themselves are showing really good outcomes for their children and it was really exciting to see that.

So some of the things that we are, as a group of researchers, realising is that we’ve really not served this agenda well at all. We’ve worked in silos, we’ve done some quite good research in our different epidemiological, economic, sociological, educational, genetics, criminology and, you know, psychology and so on, all these different silos but we haven’t really got our act together to say, ‘Can we work together more effectively to actually get this joined up kind of thinking into these problems?’. Policy, similarly, has been developed in silos and I think on the whole as well the response of policy to these kinds of problems that I’ve been mentioning have been to look after them. Too little emphasis has been put into why is it happening? Should we be thinking about preventing them? But some of these problems have been so overwhelming that the response has been to, you know, well, if people are behaving in a criminal way, got to put them in gaol. If people have got diabetes we have to treat them; if we’ve got people who are falling out of the school system then we have to do remediation and so on and so forth. With mental health problems we’ve got to treat them.

But really the major and most important improvements in these things is going to come from us doing joined up research, which is actually going to elucidate the causal pathways to these problems which will then come up with some solutions. We’ve got to start saying to people in policy, as we are already, ‘You’ve got to get joined up together too and put children in the middle and families in the middle and communities in the middle and we’ll then get some services and policies which are actually going to turn that around’.

This is just the other joke. I forgot I did have another joke. But this is just saying how hilarious this single risk factor, you know, quick fix is to things that are happening. This is today’s random medical news from the New England Journal of panic inducing gobbly-gook. The guy’s there in his little newsroom and he swings the first chocolate wheel and it goes around and around and around and it stops on coffee. Then he swings the next chocolate wheel and it goes around and around and around and it stops on causes depression. He swings the last chocolate wheel and says, ‘In twins’. You can laugh but this kind of thing is what you read in the newspaper every day. You know, if you drink 355 grams of alcohol and you’re pregnant, da, da. This is ridiculous. These complex diseases that we are now seeing, these complex increases in problems, have multifactorial causal pathways. If we think that by not drinking coffee when we have twins that we’ll get less depression, you know, it is a joke.

I think that this is just to illustrate again from the Rutter and Smith analysis, that intervening late in a pathway is actually not going to reduce the rates of problems and this is just their comments about the effects of criminal justice system on crime rates. Obviously this is complex but there’s strong evidence that imprisonment increases the likelihood of reoffending, not decreases it. There’s no evidence that increasing the rate of detention and  conviction reduces crime rates and punishment they feel, therefore, should be justified on grounds other than crime reduction.

Now, you’ve heard it again and again. We’ve spent so much money on Aboriginal health, we’ve spent so much money on mental health but nothing’s improving. It may be that we’re putting our efforts really a bit too late. We have to provide services for people. That’s obviously very important, but we’re only going to get reductions in these problems if we actually find out what they’re caused by and then do something to prevent them. That’s what they are basically saying here about crime, which is we’re going to have to concentrate on pursuing objectives that are indubitably good in themselves. That is improving family functioning and school socialisation, improving the effectiveness of formal social controls, especially in local communities, and reducing the opportunities for crime. Easy to say but this is actually needing some action research to find out how to do it.

So I just want to finish by telling you about one of the solutions that we’ve come up with, and that we being a group of Australian researchers, policy makers and practitioners who are saying ‘We don’t have to say that these trends in children and young people are an inevitable result of globalisation or economic reform or whatever’. We just say, ‘No, we think that we will be able to, as a group of people working together across the country, joining our databases together, joining our forces together in terms of research and ideas and evidence that we can actually make a difference’. I think I’ve gone through the summary of the rationale for why we need to collaborate together but the aim of the alliance is that it’s a national collaboration. It’s established to facilitate, coordinate and support the development of knowledge and its effective use, to enhance the well-being and life chances of children and young people. It aims to do this by setting a collaborative agenda that we’re, in fact, in the process of doing now and applying research to policy and practice for children and young people, which we hope will make a difference.

There are just some key activities. I’ve mentioned this consensus national research agenda. Currently we’re doing that around the country. From that we’re going to establish research nodes which will try and drive an action kind of research to find out what works. We’re going to get together, and we’ve already started this with a fantastic workshop here in Canberra with ABS and CSIRO and AIHW and others throwing their weight behind it and really taking leadership for a national data network. To be able to say, ‘How are we travelling in terms of our indicators for children and young people? Let’s have a report card as to how we’re travelling. What are the real factors in the community that seems to be driving these rates?’. Then it’ll give us a capacity to know whether we’ve made a difference when we start to intervene at fairly local levels to make a difference. So a national data network has to be data collection on every child. We want to get a clearing house of what works and we’re going to have a very carefully developed communication strategy for turning knowledge into action.

I just want to go back to this wonderful data that I was able to get from ABS going back right to the beginning of the century and just show this wonderful slide about what happened to infectious, this is really infectious deaths. I mean, this is deaths due to all causes by age of child. You see that 0 to 4 age group just rocketing down in the first 30 years of the last century. Now, most of that fall occurred because of environmental changes. Changes in the social and economic and particularly the physical environment in which children were living; the hygiene, the food, better nutrition, getting men into the workforce. It’s very interesting that this was before antibiotics - right, Frank? - before vaccines really came and had made a difference. So these infectious diseases, which were so strongly socially related, they were just taken by our founding fathers and they knocked them on the head even though they didn’t know the proper causal pathways to them.

So I think that’s a wake up call for us, that we can start to work together to start to turn around some of these adverse things. Even if we’re not absolutely sure about what the underlying mechanisms are, we know what’s good for children, we know what’s bad for children, and we have to start providing better trajectories for them. So I just want to leave you with a quote and then to just summarise at the end. I think this is a quote from here at ANU, from Butler Douglas and McMichael. They say ‘We need to place social and environmental sustainability and population health ahead of economic growth as a national goal in itself’. I mean, obviously we’re only going to be able to achieve some of the things if we do have a good economy. ‘And to develop social policies that enhance equity, social stability and trust. Our response must extend beyond conventional frameworks for social and economic policy’.

In leaving your with this lovely slide of the children, Aboriginal children, in our swimming pool study in Western Australia, I just want to quickly summarise what I’ve said. It’s really four points I want to make. We have very solid evidence that children who have good early childhood experiences in the first years of life in stimulating, nurturing environments have better outcomes throughout their lives. They have better school performance, better self-esteem, fewer social and behaviour problems, fewer health problems and are less likely to be teenage parents and use drugs or be involved in crime. Modernity’s paradox is that in contemporary Australia we just have not been providing enough good early childhood experiences and for some children, our Indigenous children, this has had major negative impacts on their life chances, in spite of us having such a success with our economy. That the policy responses on the whole have been at the end of pathways and, whilst that’s understandable, they will not deliver the long-term solutions to reduce those problems and neither have researchers actually adequately investigated these problems. I think the final point I want to make, that the whole of society, we need to respond to this by acknowledging these issues and acknowledging this is happening in today’s Australia and we need to start to change our emphasis and activities to make it a better place for our children and young people. Thank you very much.

Russell Doust: The last thing that you want me to do is to try and do a poor precis of what you’ve just heard, but I hope it has made you think as much as it made me think. So I would like you in a moment to thank Fiona Stanley for a most stimulating, a most important address to us tonight. Thank you very much indeed. On behalf of the Friends of the National Library and, indeed, on behalf of us all, I’d like you to accept this. It’s not chocolates, actually. At least I don’t think it is. We’ll have a look afterwards.

Prof. Fiona Stanley: It feels like a book.

Russell Doust: I think it might be a book. That is the end of the formal part of the proceedings. The fun part now starts. We invite you to come upstairs to the foyer and partake of some refreshment. There will be opportunity, no doubt, for some of you to buttonhole Professor Stanley and talk about the things which concern you and which she might want to talk about with you. But thank you all for coming and we’ll see you upstairs in a little while.


TRC 5010 
Oral History Section 
Kenneth Myer Lecture 
Recorded at the National Library of Australia 
Professor Fiona Stanley

Date of Recording:  24 July 2003

Conditions of Access 
Open for both research use and public use.

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