It is not unusual to criticize many public policiesfor doing “too little, too late.” Within the U.S.health care system, however, the more relevantcriticism is that we do too much, too late. Mostof our expenditures are dedicated to treating dis-eases that are already well established, andoccur disproportionately at the end of life. Whilemost cost containment strategies focus onusing more cost effective care within the med-ical sector,advocates for population health right-ly argue that tackling rising costs and improvingour comparatively poor national health out-comes will require more attention to preventingdisease by targeting the so-called “upstream”determinants of health. These determinants arefactors upon which families and communitiesexert considerable influence, in addition to one’sphysician. There is growing recognition thatmoving upstream also means addressing healthrisks earlier in the life span, during developmen-tally sensitive periods, when prevention, earlyintervention and health promotion can yield thegreatest benefits.1 Rather than spending toomuch too late, we can spend more wisely andassure more optimal health outcomes by focus-ing on the early determinants of life-long health.

A Revolution in our Understanding of

Health Development The past two decades have witnessed phenom-enal advances in our understanding of howhealth and disease develop. The field of lifecourse chronic disease epidemiology has yield-ed hundreds of influential population-level stud-ies demonstrating the link between early lifeevents and the occurrence of many commonchronic diseases that usually manifest in adult-hood.2 Meanwhile, complementary research onthe developmental origins of adult disease is pin-pointing the mechanisms by which early eventsare programmed into the developing immune,neurological, endocrine and other physiologic

systems. These studies are disentangling, forexample, how relative malnutrition of the fetuscan lead to lasting physiologic changes in fatand carbohydrate metabolism, increasing therisk of diabetes, heart disease, hypertensionand obesity in adulthood. Other studies demon-strate that individuals inheriting a common vari-ant of a gene that influences serotonin levels inthe brain are more likely to develop depressionas a teen or adult when they have a childhoodexposure to the high stress levels typically asso-ciated with extreme poverty.

Life Span, Life Stage and Life Course Health

Development This research has led to a burgeoning interest inLife Course Health Development (LCHD) as amodel for better understanding the developmentof disease and the promotion of health. TheLCHD approach builds on the life span (longitudi-nal connections) and life stage (developmentalperiods) models by specifying the biological andbehavioral mechanisms that determine healthtrajectories. From a LCHD perspective, health isa developmental process occurring throughoutthe lifespan.

The two different health trajectories depict-ed in Figure 1 show that the earlier years estab-lish different levels of functional health develop-ment, followed by stabilization of health trajecto-ries during the middle years, and declinetowards the end of life. The different life-longhealth trajectories are the result of competinginfluences. Risk factors that make us more vul-nerable to disease exert downward pressure onthe health trajectory while protective factors thatmitigate risk and enhance resilience supportmore optimal health functioning.

Achieving an optimal trajectory can have apositive effect on health throughout the life span,including delaying the onset of serious problemsthat lead to functional limitations later in life. Theimplications for our nation’s health spending areclear if we can delay disability and compress theperiod when morbidities are present.

Hertzman, Halfon and others have suggest-ed that the health development process is deter-mined not just by the cumulative impact of riskand protective factors but by the timing of expo-sures.1,3 For example, neurological research hastaught us that there are specific periods that arecritical to brain development for different typesof functioning. When positive or negative influ-

February 2009

NIHCM FOUNDATION: 1225 19th Street, NW, Suite 710, Washington, DC 20036 • tel: 202.296.4426 • fax: 202.296.4319 • web: www.nihcm.org

Source: Halfon N, Inkelas M, Hochstein M. "The Health Development Organization: An Organizational Approach to AchievingChild Development." Milbank Quarterly. 2000; 78(3):447-97.

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Life Course Health Development: A New Approach for Addressing Upstream Determinants of Health and Spending

Neal Halfon MD, MPH, Director, UCLA Center for Healthier Children, Families, and Communities, and Professor of Pediatrics,Health Sciences and Public Policy

ESSAYS ON TRENDS, INNOVATIVE IDEAS AND CUTTING-EDGE RESEARCH IN HEALTH CARE

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Figure 1: How Risk Reduction and Health Promotion Strategies

Influence Health Development

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ences occur during these periods, their impactscan be stronger and more lasting than when thesame exposures occur at other times. Thus,there are optimal times for positive interventionsor – more pointedly – missed opportunitieswhen these interventions do not occur duringthe important developmental periods. Likewise,there are periods of heightened vulnerability,during which negative exposures can be espe-cially damaging.

Transforming Children’s Health

The LCHD model necessarily shifts more focusto the early part of the life span, when long-termhealth programming is most intense and higherlevels of developmental plasticity enable interven-tions to exact greater returns on resourcesinvested. In many cases, promoting optimal life-long health may be best achieved through meansother than “traditional” health care interventions.For example, we know from the work of NobelLaureate James Heckman and others that com-paratively moderate investments in good qualityearly education and care can enhance the devel-opment of literacy and other school readinessskills that predict educational outcomes andworkforce readiness as well as long-term health.

Although our understanding of the mecha-nisms underlying health trajectories is still nas-cent, it is increasingly clear that we can no longerafford to delay investment in early developmentand children’s health. Even as the evidence isbeing gathered, we can begin designing a sys-tem that is more likely to promote better healthand developmental outcomes.

Figure 2 provides a schematic depiction oftwo developmental trajectories. The more posi-tive trajectory is supported by a scaffolding ofevidence-based programs. At each time period

children are afforded the benefit of the basic sup-ports they may need, including appropriatehealth care, family support and early learningexperiences. This diagram also shows that theseservices are integrated both horizontally acrossthe health, education and family support sectorsas well as longitudinally over time. In the idealscenario, a comprehensive health informationsystem tracks children across settings andacross time. By linking and integrating these evi-dence-based programs, we can create the serv-ice delivery scaffolding necessary to help chil-dren withstand the stressors that inevitablyemerge during childhood and ultimately supporta more optimal developmental trajectory.

Many nations have already begun to con-struct such a scaffolding by guaranteeing mean-ingful health care coverage, routinely utilizingteams of visiting maternal child health nurses,establishing readily accessible child care andchild development centers, and providing otherincome and family support for families withyoung children. These kinds of supportive meas-ures are now the norm in the Scandinavian coun-tries, France, the Netherlands, many parts ofItaly, Spain and elsewhere. Interestingly, theEnglish speaking countries – the U.S., U.K.,Canada and Australia – have lagged behind indeveloping systems of early childhood supports.It should come as no surprise, then, that theyhave also consistently ranked low on measuresof child health and well-being compared to othernations.4

In an effort to improve this poor performanceover the past decade, the U.K., Canada, andAustralia have all adopted new early childhoodpolicy agendas. England has led the way with itsambitious Sure Start Program, which will build3,500 centers, each serving as the hub of a sup-port scaffolding network in a low income neigh-

borhood.5 Canada and Australia are institutingsystems to measure the health, developmentand school readiness of all five-year olds.6,7 Onlythe U.S. has failed to take aggressive stepstoward implementing structural and financingchanges that will provide our children with oppor-tunities for optimal development. Without correc-tion, this deficit is likely to lead to widening per-formance gaps when the U.S. is compared topopulations abroad.

Conclusions

The LCHD framework prioritizes life-long preven-tion and provides a powerful rationale for healthsystem transformation.8 This transformation willrequire meaningful health insurance coverage forall children plus significant investments in com-munity-based prevention, health promotion,developmental support services, and informationsystems to provide the health development scaf-folding that children need to thrive. Innovativefunding mechanisms will also be needed, such asa children’s health and wellness trust that couldfund cross-sector approaches to prevention andassure investments over longer time horizons.Adopting this strategy would help to reverse thealarming trend of diminishing investments for theyoungest generation, a dangerous course forany nation that envisions a strong future. Byadopting the logic of the LCHD framework, theU.S. health system can be transformed from asystem that provides too much care too late,toward a more rational, higher-performing sys-tem that emphasizes early, high-return invest-ments. n

1 Halfon N, Hochstein M. “Life course health development: anintegrated framework for developing health, policy, andresearch.” Milbank Quarterly. 2002;80(3):433-79, iii.

2 Kuh D, Ben-Shlomo Y, Eds. A Life Course Approach toChronic Disease Epidemiology, 2nd Edition. Oxford: OxfordUniversity Press, 2004.

3 Hertzman C, Power C, Matthews S, Manor O. “Using aninteractive framework of society and lifecourse to explainself-rated health in early childhood.” Social Science &Medicine. 2001; 53:1575-85.

4 UNICEF, Innocenti Research Centre. Child Poverty inPerspective: An Overview of Child Well-Being in RichCountries, Innocenti Report Card 7. Florence, Italy: UNICEF,2007.

5 United Kingdom Sure Start Programme. http://www.surestart.gov.uk/aboutsurestart/about/thesurestart-programme2/. Accessed 22-Dec-2008

6 The Royal Children’s Hospital Melbourne. Australian EarlyDevelopment Index. http://www.rch.org.au/australianedi/edi.cfm?doc_id=6211. Updated 16-Dec-2008. Accessed22-Dec 2008.

7 Offord Centre for Child Studies. School Readiness to LearnProject (SRL): Early Development Instrument.http://www.offordcentre.com/readiness/. Accessed 22-Dec-2008

8 Halfon N, DuPlessis H, Inkelas M. “Transforming the U.S.child health system.” Health Affairs. 2007; 26(2):315-30.

NIHCM FOUNDATION: 1225 19th Street, NW, Suite 710, Washington, DC 20036 • tel: 202.296.4426 • fax: 202.296.4319 • web: www.nihcm.org

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Figure 2: Trajectory Optimizing

Service Linkage Pathway

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