Twenty years ago, an exciting new program promised equal opportunity for every child in Ontario. So why are kids in poverty still falling behind?
In the mid-1990s, early childhood intervention was the hot topic of study in psychology circles. A growing body of evidence, produced by researchers such as David Olds and Fraser Mustard, suggested that disadvantaged kids—if given the right support early on—were as likely to thrive and succeed later in life as kids born into privilege.
In Ontario, public health advocates and nurses and staff within the Ministry of Health lobbied for a comprehensive, province-wide program based on that evidence and modelled after new initiatives cropping up across the United States. At first, the government hesitated on rolling out the program advocates were calling for: it would be cumbersome and expensive, and there were concerns it wouldn’t produce the dramatic results researchers predicted.
Their idling ended in the summer of 1997, however, shortly after five-week-old Jordan Heikamp starved to death in a downtown Toronto women’s shelter.
Jordan was just four pounds, two ounces of skin and protruding bones when he died. His mother, who was 19, said she didn’t know her son was starving—she mistook his long periods of sleep as a sign that he was satisfied, not realizing his frail body didn’t have the energy to stay awake. The incident sparked outcry as the public wondered how something like this could happen—how it could continue to happen. Throughout the 90s, child welfare cases in Canada jumped 40 per cent to 66,000, and as children continued to suffer, people demanded change.
“There was tension in the system,” recalls Jane Underwood, director of public health nursing in Hamilton during the 80s and 90s. Around that time, the Ministry of Health approached Underwood and her team, who had done research in early childhood intervention, for advice on how to build an effective program. “What we needed was very intensive, early intervention with public health nurses,” says Underwood. “And you had to really hang with it.”
In the spring of 1998, the Ontario government launched Healthy Babies, Healthy Children (HBHC). The program would be fully funded by the Province, and municipal health units would be responsible for administering it at the local level. The Province earmarked $10 million for the program in its first year, to be scaled up to $50 million by 2001. The news was hopeful, encouraging Canadians that, moving forward, kids born into poverty would have as much opportunity for success as any other child in Ontario.
To Underwood, HBHC didn’t look perfect, but it was a start. “We knew there weren’t enough resources going into the program at the time,” she says. “But there was enough political will that a little bit could be done. So we said ‘Okay, get started,’ thinking more [resources] would come.”
Nearly 20 years later, however, chronic underfunding is threatening the program’s vitality, and scores of at-risk children continue to fall through the cracks.
“Every year, our resources get smaller, and the need gets bigger,” says Cassandra Churm, a Toronto public health nurse who’s worked with HBHC since 2000. “We’re just stretched more thinly trying to do the same amount of work.”
Ideally, and according to the program’s guidelines, HBHC nurses should screen every woman in the province when she gives birth. Typically, about 30 per cent of women who are screened are identified as having a child at-risk of physical or cognitive developmental challenges. Those families are meant to receive regular home visits from a public health nurse who would offer a range of supports, be it breast-feeding counselling, nutrition advice, or help getting to and from appointments. Nurses, who also act as counsellors and advocates for their clients, are meant to stick with each family until the child is six years old.
If implemented properly, evidence shows that by the time nurse-visited children start school, they demonstrate higher intellectual functioning, a larger vocabulary, better math scores, less aggression, and fewer behavioural problems compared to at-risk children who don’t receive home nurse visits. For at-risk mothers who are visited by nurses, they have fewer subsequent pregnancies, longer relationships with their current partners, and rely less on welfare and food stamps than at-risk mothers who aren’t visited by nurses.
“How far can we stretch? Every year, I worry that this is going to be the year we get crossed off the budget.”
While the results are impressive, Ontario has not achieved them at the scale promised through HBHC. A 2014 evaluation of the program [PDF] found less than one per cent of potential clients province-wide were being reached. In Toronto, approximately 65,570 women who need screening aren’t getting it, and 12,850 at-risk families are missing out on home visits from public health nurses.
Since 2006, the Toronto Board of Health has appealed to the Province seven times for more funding. The first time they asked, the Board estimated that Toronto Public Health needed an extra $12 million on top of the $17 million allocated for HBHC that year, in order to fully implement the program. Their request was ignored, however, and funding for HBHC has been frozen since 2007.
Now, with just over $19 million for the program per year, the funding gap has climbed to over $67 million. At the same time, the number of public health nurses decreases by two or three each year in Toronto, with other municipalities seeing a similar trend.
“In some ways it feels like you’re on that treadmill just trying to keep up,” says Churm, “trying to meet the needs of the people that you’re working with. But how far can we stretch? Every year, I worry that this is going to be the year we get crossed off the budget.”
Churm has worked in the Homeless at-Risk Prenatal (HARP) program, a branch of HBHC, since 2014. In HARP, public health nurses ideally have small caseloads of about 15 to 20 clients, each of whom they see once a week for a few hours. Clients in the program—all homeless or precariously housed mothers-to-be—typically face an array of challenges, including mental illness, drug addiction, and a history of crime. Most of them are considered not fit to take care of their child, and have their baby taken from them and placed in foster care after giving birth.
To say the least, these women require a lot of support to make sure they are mentally and physically fit to carry their baby to term.
That same intense dedication to the clientele is what HBHC was meant to offer to every at-risk family, not just those who are homeless. “In regular HBHC, we also work with women with the exact same issues,” says Churm. “They’re just a little more stable. They’re generally housed or staying in a shelter.”
In the early days, HBHC came close to meeting that mandate. The first few years were marked by increased funds as new services were phased in. “When I first started in HBHC, it was similar to HARP in that we had smaller caseloads. We had more [nurses] and the work was sort of spread out, so you had that intense, weekly, therapeutic relationship,” Churm recalls.
“We’re trying to prevent people from getting into a system they can’t get out of, but how do you prove that?”
Between 2002 and 2005, however, the number of full-time staff for HBHC dropped from 185 to 177; as a result, home visits decreased by 12.5 per cent during that time. In a 2006 City of Toronto staff report [PDF], medical officer of health Dr. David McKeown declared that “maintaining service levels from year to year has become impossible.”
Since then, the situation has only become worse. In 2013, universal postpartum follow-ups were eliminated, as phone calls and home visits (if requested) were limited to at-risk mothers. “This has raised concerns about the support that new families receive in relation to important, but not necessarily ‘risk’ factors such as breastfeeding and transition to parenting,” another Toronto staff report [PDF] reads.
Soon thereafter, follow-ups for at-risk mothers were reduced to a generic letters in the mail telling them about HBHC services—no more personal phone calls, no more home visits until explicitly requested. “It’s tough because you need to build that trust with your clients,” says Churm, something she says takes time, money, and and real human interaction—all increasingly scarce in HBHC.
When Churm left HBHC in 2014, she had 45 clients on her caseload, up from 30 when she started. “You can’t see 45 people weekly, you just can’t,” she says. “For me, one thing I really like about HARP is I can see my clients weekly. In HBHC, the needs were just as bad. People needed support to go to appointments, to go to developmental assessments, but I didn’t have three or four hours to go with a client anywhere. They had their allotted 45-minute visit, sometimes only once a month.”
Funding shortfalls are now affecting HARP, too. “One of the incentives was we used to give $10 food cards at every visit. That was a huge way to break down barriers,” says Churm. “It was some time last year we lost that ability due to budget constraints.”
Chumn points out that the lack of funding isn’t unique to HBHC, but part of the Province’s broader trend, starting in the 1990s, of stepping back from its responsibilities to municipal programs. At the same time, she says, advocating for preventative programs like HBHC isn’t always easy.
“We’re trying to prevent people from getting into a system they can’t get out of,” she says, “but how do you prove that? I can say that this little person went to school knowing his language, but how do I say, 20 years from now, that will make him a better citizen who contributes? How do I prove that to a political body who just sees a huge budget line?”
For Jane Underwood, looking back at the program she helped initiate is disappointing. “It’s kind of criminal that it never was given the opportunity to do what it was supposed to do,” she says. “At the time, people really felt strongly that we could get in front of so many health and social problems if we could support children from an early age. I realize turning elephants around is hard,” she continues, “but that one had a lot of hope, and then, a lot of frustration.”