Health disparities are a major challenge in American medicine, and particularly in pediatrics. American children today are more likely to live in poverty than adults, and social disadvantages tend to cluster in families across multiple generations. This intergenerational cycle of disadvantage creates a succession in which families have limited means of escaping. Cheng et al. take us on a thorough tour of these cycles of disparity in their State of the Art Review (10.1542/peds.2015-2467)
In this article, the authors review the current frameworks for intergenerational transmission of health disparities, highlighting models that focus on (1) intrauterine and early life exposures, (2) exposures across the life course, (3) and the cumulative response to environmental stressors over time. Based on these models, the authors review the current 2-generation approach to blocking intergenerational transmission. This approach focuses on supporting the child, but also improving the family’s circumstances by supporting the parents. By targeting both parents and children, the goal is to help lift the entire family out of poverty.
However, the authors argue that this is not enough. Instead, they recommend going further by outlining a 3-generation approach. The author’s approach would include the same components of the 2-generation approach, with the addition of considerations for subsequent generations. This forward-thinking model is rooted in the vein of preventive medicine, fixing problems before they start for future generations. The authors propose four areas that a 3-generation approach could help to improve: (1) youth’s capacities for educational attainment, transition to work and adult productivity; (2) preconception health; (3) reproductive life planning; and (4) parenting skills and capacities.
This 3-generation approach has the promise of breaking the intergenerational cycle of disadvantage, but there are obstacles in the path. First, this intergenerational approach requires longitudinal integration of medical services, which the authors term “vertical integration of health services.” However, this integration is at odds with our current age-based system of medicine (i.e. pediatrics, obstetrics/gynecology, internal medicine, and geriatrics). Additionally, reimbursement algorithms are not currently suited to support the necessary inter-professional collaboration. The 3-generation approach would also necessitate the merging of health services with non-medical service sectors including schools and social services---something much needed but more easily said than done. Lastly, this 3-generation approach may run into political headwinds as a result of costs associated with potential programs and the inherent controversy surrounding universal family planning. Given the importance of breaking intergenerational cycles of poverty, these are obstacles that are well worth confronting.