Paediatrician Dr Renee Liang takes an unflinching look at the realities of child poverty in New Zealand and the need for a political pathway to change.

Renee Liang's essay is the sixth and final work funded by the D'Arcy Writers Grants to be published in North & South.

A consultant paediatrician based in Auckland, with a special research interest in child health and development, Renee Liang is a named investigator with Growing Up in New Zealand. This longitudinal study is tracking 7000 children from birth to young adulthood, to provide information about what shapes early development and how interventions might be targeted to give every child the best start in life.

Also a poet, short-story writer, blogger and playwright (Lantern, The First Asian AB, The Bone Feeder), Liang holds a Master of Creative Writing from the University of Auckland, and a Postgraduate Diploma in Drama Studies, as well as her medical qualifications. The daughter of Chinese immigrants, she produced a season of the absurdist farce The Chairs in Cantonese last year. She became a Member of the NZ Order of Merit for Services to Arts in 2018.

Liang describes poverty as a "heritable condition" that perpetuates and amplifies through generations: "It is also not hard to see how individual poverty flows into communities and society, with downstream effects on economics, crime and health, as well as many other systems. Loosen one strand and everything else unravels."

A Kete Half Empty

Poverty is your problem, it is everyone's problem, not just those who are in poverty. – Rebecca, a child from Te Puru

I'm in clinic. Outside, pulled-cotton clouds signal a beach-worthy day. Inside, the waiting room is packed with energetic kids and their weary parents.

My morning has been full of the cases commonly seen by general paediatricians: smiley babies born prematurely coming to show off how well they're developing, grumpy toddlers with eczema and food allergies, teenagers who have headaches and are being bullied at school. I pick up the notes for my next case.

The details* are all too familiar: James is a 10-year-old who's running off the rails. The public health nurse has written a long note detailing her concerns. He was initially referred with soiling at school, but the deeper she dug the more she uncovered. He hardly eats lunch. She thinks he's got glue ear and can't hear properly. He can't sustain a conversation for long. Last winter, James had only 60 per cent attendance at school: the teacher says his mother keeps telling them he's got another chest infection. Indeed, when at school, he's often in the sick bay for asthma, which she suspects is under-treated.

His teacher has filled in a screening form. James throws punches to settle arguments; he can't sit still in class. He finds it hard to make friends, because he tends to take over the game and not listen to others' opinions. She suspects he finds it difficult to interpret what others are feeling. He struggles with Math and paying attention in class. Other students have accused James of stealing food – his nickname is now "Thief". The previous week, he brought a knife to school and now the school board is meeting to discuss him.

More paper, more information, letters from a community social worker: he has a young mum, who for years has been trying to get help to manage him. She's had to move several times, and each time they have to wait again for services. Like her child, she too fell behind at school. She's had counselling for domestic violence and is no longer with her son's dad.

I gulp my cold coffee and head for the waiting room. Already, I recognise a story I know far too well. I know I will make many diagnoses, but there's one unifying diagnosis, which will not be written down.

Doctors are trained in the analysis of stories. We look for patterns within individuals, families and societies. The symptoms of poverty are evident to any doctor practising in the public system in New Zealand. It is as telling as a rash. We're good at recognising the signs because right now, we're seeing a lot of it.

* A hypothetical case, based on Liang's experiences as a paediatrician.

Why fix it? Child poverty is real in New Zealand. By any measure, it's become worse as the income gap has widened. It is well established that income inequality correlates directly to disparities in health, with the poor getting sicker even as the rich access cutting-edge advances in treatment. If we do indeed have a "rock star economy", not everyone has been invited to the party.

This has been happening for decades and it will take a lot of resource to fix. So why try? Humour me, if you know already: I know people who still think poverty is a lifestyle choice.

Firstly, fairness. At an individual level, often through no fault of their own, people become trapped in a health-poverty cycle: a downward spiral of health due to the effects of poverty. The less you earn, the higher the proportion of your income that goes on health care. And it's harder to access that care because you're more likely to live further away from centralised services, such as my clinic.

The system is also rigged against those who move frequently, due to housing availability or for work. If you move, you may lose your spot on the waiting list (and access to a GP or nurse who knows your child and can push for you to be seen sooner). It costs money to travel to where the clinic is, to travel for lab tests, to top up the phone you need to receive text reminders or to be rung for follow-up care. It's hard too, with some jobs, to ask for time off to take your kid to the doctor. You might be in the kind of job that doesn't pay unless you work.

Those are just the practical effects of poverty, but the insidious effects run deeper and are ultimately more damaging. For example, a child from a poor household is more likely to have had poor nutrition from infancy. This leads to a raft of issues, including greater susceptibility to infections, and growing evidence that this predisposes them to a raft of chronic adult diseases. Nutrition also plays into behaviour and academic achievement. A hungry kid will find it more difficult to learn; likewise a child who is tired from living in a noisy, crowded house. An older child might find it hard to study for NCEA if they are looking after younger siblings while parents work. It is not hard to see how poverty perpetuates and amplifies through generations. It is a heritable condition.

It is also not hard to see how individual poverty flows into communities and society, with downstream effects on economics, crime and health, as well as many other systems. Loosen one strand and everything else unravels.

But let's say you're a politician and you don't care about the human cost of poverty, about the moral and ethical reasons why you would want to give kids a chance. (Ouch.) Let's say you're just interested in giving the New Zealand taxpayer a good return for their money. Fair call, right?

Even then, the numbers come down heavily in favour of doing something, and fast. It's estimated poverty such as that experienced by Kiwi children poses an economic burden in the order of 3-4 per cent of GDP. Based on Aotearoa's 2017 GDP of $289 billion, that's roughly $9-11 billion we lose a year in downstream effects such as lost productivity, pressure on social services, the justice system and so on, when we ignore the problem. Tens of millions of that probably blows away on the health service machinery I'm part of. Let me be clear: that is millions of unnecessary spending on health problems that are preventable.

For me, though, it boils down to morality. It hurts when I see kids unable to reach the full extent of their talents because of something they never asked for. It also hurts because I know I have spun a luckier number than them on the wheel of fortune. It hurts because we paediatricians see a little of ourselves in each child we meet: it's one of the ways we stay young and ever-so-slightly immature.

New Zealanders still cling to the idea that we're an egalitarian, classless society. The reality is we're increasingly stratified. The gap between rich and poor is wider than we like to admit and it's possible – depending on where you live and work – to avoid seeing poor families. This may be why some deny the existence, let alone the impact, of child poverty in our country.

As a student on my first clinical attachment, I remember the sinking realisation that I was poorly equipped for medical practice. I had spent years studying anatomy and physiology, but knew very little about real people and what their lives were like when they were not marooned on a bed in front of me. It was on a home visit with a community nurse, seeing the mattresses in the lounge and the teenager sitting at the kitchen table trying to write with younger siblings tugging at her arms, that I realised how much I had to learn.

Twenty-five years later I'm still learning, much of it from my patients. Part of the reason I wanted to write this essay was to try to understand some of the research on child poverty, and to apply it to what I do. I'm no expert on this topic – just a simple practitioner – but luckily there is no lack of detailed reports on every aspect of child poverty. They all agree that there is a problem – and there are solutions.

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