"Our smallest citizens"

While it is temporarily out from behind the pay-wall I've taken the opportunity to record the following Listener article by Karl du Fresne based on an interview with Russell Wills, the Children's Commissioner:

Our smallest citizens

Children’s Commissioner Russell Wills explains that the poor really are poorer now – and whoever forms the next Government will need to set policies to help stop the damage to our under-fives.

By Karl du Fresne In Life in New Zealand

26th September, 2014

Image/Thinkstock

“How long have we got?” I ask Russell Wills. “As long as you need,” he replies.
The Children’s Commissioner is as good as his word. It’s a generous two hours before he wraps up our interview because he has a son waiting to be picked up from school.
He looks tired. Every Monday morning he’s on the early flight from Napier to Wellington, where he puts in two days as Commissioner. First thing Wednesday he’s back here, in his tiny, cluttered office at Hawke’s Bay Hospital, dealing with sick and often seriously disturbed children in the paediatric outpatients department.
Friday he describes as his “peripatetic, could-be-anywhere day”. Often he’s heading somewhere on a plane to give a speech – he averages about one a week. And every seventh weekend, he’s on call.
“My last weekend on call,” he says, “we had a child with pneumonia, which is straightforward, but he had an empyema, so the whole lung was full of pus, from top to bottom. He needed to be put to sleep and have a hole made so that a big fat drain could be put in to let the pus out.”
How old was he? “He was three. That’s common.”
Wills is the sixth person since 1989 to hold the title of Children’s Commissioner, but the first to carry on doing his previous job simultaneously. He insisted on it as a condition of his appointment and Minister for Social Development Paula Bennett agreed.
He had two reasons for wanting to continue practising paediatrics. “I thought it would keep me grounded, but I also thought it would help my credibility with the public and with ministers. And I think it has.”
But back to that last weekend on call. “That weekend,” Wills continues, “I had three children in intensive care and one on the verge of being admitted, and that was a very usual weekend load.” Typically there are 40 inpatients spread between the hospital’s Special Care Baby Unit (or SCBU; he pronounces it “Skiboo” – I unscramble the code later) and the children’s ward. In an average year, the hospital admits 3000 children – that’s an average of eight a day from a region with a population of 155,000.
How come? It’s simple. “Half the children in Hawke’s Bay are born into the two poorest income deciles.” It’s one of five district health board areas that stand out as having high rates of child poverty; the others are Northland, South Auckland, Lakes (Rotorua) and Tairawhiti (Gisborne).
In Tairawhiti, three-quarters of babies are born into deciles nine and 10, the two poorest. (Confusingly, decile rankings in health are the reverse of those in education.) “Imagine that,” says Wills. He barely seems able to grasp it himself.
“The workload across those five DHBs is very similar – high poverty, cold, damp, crowded housing, and a high proportion of Maori and Pasifika families.
“What you get with that is a very high acute workload, particularly with respiratory, skin and gut infections, with all the complications that go with those. We frequently see kids who present late – kids who are really, really ill, needing resuscitation, who ought to have been identified in primary care, but weren’t, for various reasons.”
It’s an eye-opener for young British registrars who come to Hawke’s Bay for experience in paediatrics, observes Wills. “We have diseases that they’ve read about but never seen – tuberculosis, acute rheumatic fever.”
And there’s more. Wills and his colleagues also have a heavy outpatient workload that includes a lot of child-protection work – in other words, looking after children in violent households – and children with severe behavioural problems.
“There are three of us here and that’s most of what we do. We see a lot of quite young children with very severe behaviour disturbance, for a whole bunch of reasons. Typically there’s a mix of domestic violence, major mental illness in parents, serious addictions, very poor family and whanau support, fetal alcohol and fetal drug effects, and so those kids have, as you’d expect, delayed development and very challenging behaviours. So our task is to figure out why they behave the way they do and then start putting them back together again.”
THE POWER OF THE PARENT
It must seem a very long way, sociologically if not geographically, from Wills’ own childhood. He was born in the hospital where he now works. His upbringing couldn’t have been more comfortably middle class. Mum was a physiotherapist who pioneered antenatal physiotherapy in Hawke’s Bay. Dad owned a busy pharmacy in the Napier suburb of Marewa and was well connected in business and sporting circles.
As a boy, Wills rode his bike around Marewa, Napier South and Maraenui delivering prescriptions and junk mail for his father. He went to Lindisfarne, the state-integrated Presbyterian boys’ school in Hastings that his teenage sons, Peter and Michael, now attend. Weekends often involved helping on working bees with his father’s friends from Jaycees.
There was rugby, cricket and Sunday school too. The day of our interview, he was delighted to bump into his old Sunday school teacher in the hospital car park; he hadn’t seen him for 40 years.
It was in many ways a quintessentially conventional – you might say privileged – Hawke’s Bay boyhood. In one respect, though, Wills’ upbringing was far from normal. As a hyperactive three-year-old he fell while trying to extract a nail his father had just hammered into the wall of their garage. The blow to his head when he hit the concrete floor rendered him deaf for five years.
“There were plans to send me to Van Asch [a school for deaf children in Christchurch], but my five-foot-one-inch red-headed mother wouldn’t have a bar of it, so I went to Napier Central.”
He recalls being in the toilet at lunchtime on his first day of school and not hearing the bell ring. “I came out and the playground was empty. The teacher strapped me for being late back to class. I remember telling Mum and her saying, ‘Right – get in the car!’” He laughs at the memory. “She didn’t take that lying down. It didn’t happen again.”
Did the experience of deafness, which was eventually cured by reconstructive surgery, give him empathy with people who were sick or disabled? “It’s hard to know, isn’t it? A lot of my outpatient work is with disabled children, and I guess I really get that it’s the environment that is really disabling for a child. If a child has a disability and you create an environment around them that meets their needs, then they are less disabled.”
He also learnt an important lesson from his stroppy mother. “What Mum showed me was the power of the parent as an advocate for their child. When we’re good at partnering with parents, they can be amazing advocates for their children and make sure the stuff happens that perhaps we [the system] should have done.”
Not all parents can do it, though. “Some parents have their own needs: low IQ, mental illness, addiction. Then we have to make sure we do that work.”

Children’s Commissioner Russell Wills. Image/Hagen Hopkins

Could he ever have imagined, growing up in a secure, middle-class home with devoted parents, that there was another side to Hawke’s Bay? Or did it simply not exist then? “It was there. An early memory is having lunch next to a Maori boy at primary school. He didn’t have any lunch, so we shared mine, and he said, ‘Gee you’re lucky’, and I said, ‘Why’s that?’ And he said, ‘Because your parents love you.’”
That aside, some things are different now. For example, it never occurred to Wills as a 10-year-old that riding his bike around working-class Maraenui with two saddlebags full of drugs wasn’t a good idea. “It wouldn’t have occurred to Dad either. It was safe. You wouldn’t do that now.
“The world has changed. It really has. I still have lots of patients in Maraenui and Napier South and Flaxmere, and I’ll go and visit them, and it just feels different.
“Marewa is not the flashest suburb in Napier. Dad would often not charge people because it was very clear they couldn’t afford it. But the poor are poorer now, they really are. And there are more of them.”
What’s the explanation? He’s not sure. “It’s complex. The solutions are complex too, but they are within our hands.”
REASON ENOUGH
Paediatrics wasn’t Wills’ career choice when he began studying medicine. He wanted to be a GP. So what altered his course? “A year of paediatrics,” he says with a laugh.
He can be intense at times but laughs readily, often in a gently self-mocking way. He’s 50, but has a boyish good humour that, combined with his earnest desire to do the right thing, somehow reminds me of Michael J Fox.
Wills did his initial medical training at the University of Otago and later acquired a master’s degree in public health in Brisbane, as did his wife, Mary. (He says Mary, originally from Invercargill, is the clever one, with two master’s degrees. She has a managerial job at Hawke’s Bay District Health Board.)
He did his paediatric training in Britain, intending it to be merely an adjunct of general practice. Though he loved working with children, the experience wasn’t entirely encouraging: he found himself working 80-hour weeks in Winchester and admits it was hard going. A six-week stint in a neonatal unit in Southampton was no better. Junior doctors were responsible for as many as 12 ventilated babies.
It was terrifying, he says; a good lesson in how not to do things. “I very nearly left medicine at that point. I was looking for a job as a drug-company rep.”
What changed his mind was a stint working as a community doctor in the south of England, doing developmental checks on children who were about to start school. Driving around the red-brick schools of Hampshire in a VW Kombi he and Mary had bought for a tour of Europe, Wills fell in love with paediatrics again.
What was the appeal? “I just love kids. It’s not very complicated. If I wasn’t doing this, I’d probably be a teacher.”
Children can be very complicated medically, says Wills, but as people, they’re not. “If they like you they give you a hug. If they don’t like you, they tell you.”
But surely it’s difficult dealing with patients who are often too young to explain their symptoms? “Well, sometimes communication is a challenge. It’s just a skill you have to work at. You have to get down and make friends with them. That’s the deal.”
THE OTHER CHILDREN
That comforting bromide about New Zealand being a great country to raise children – is it still true for most families? Unquestionably, says Wills. “My sons play four sports. They’re busy every night. My brother in the UK says just getting access to a playing field there is really difficult.
“We go camping at Mahia in the summer holidays. It’s cheap as chips. We go with friends. Our kids have learned to surf, we go fishing … three-quarters of kids in New Zealand have opportunities that kids of similar incomes in other countries don’t have. In some countries, you have to pay to go to the beach.”
But it’s those other children, the ones living in cold, overcrowded homes and going to school without food or adequate clothing, whom Wills has made his No 1 priority as Children’s Commissioner. More than any of his predecessors, he has championed the issue of child poverty and helped place it squarely on the political agenda.
He notes that there are 44,000 poverty-related admissions to New Zealand hospitals every year – an increase of 7500 since the global financial crisis unfolded.
What has struck Wills and his colleagues is that admission numbers no longer fall off in summer. “We used to have this fabulous quiet time in January and February. We don’t get that any more. So we see what used to be winter illnesses – pneumonia, bronchiolitis, that sort of thing – all year round.” Again, it’s the very young who are most affected.
Any idea why? “When you look at the determinants, the strongest associations are crowding and poverty. It seems likely that there are more families bunking in together. Evidence from household surveys suggests that’s true.
“Crowded conditions mean illnesses spread easily. Very commonly families all sleep in the living room because they can only afford to heat one room. It only takes one kid to bring a cold or school sores home. Adults and older kids get a cold, but the baby gets bronchiolitis or pneumonia and ends up in hospital.”

Image/Thinkstock

A high proportion of patients are from single-parent households. Other common factors are unemployment and low qualifications. Maori and Pasifika children figure disproportionately.
But Wills shoots down the notion that it’s all about solo mothers or welfare dependency. It’s more complex than that. “Forty per cent of kids living in poverty have a parent who’s working. Half are from two-parent households. Sole parenthood and benefit dependency do not account for our high rate of child illness.”
A crucial factor is the price of housing. “At the bottom end it’s common for families to spend between half and two-thirds of their income on housing, which is why they crowd together. That’s very different from when we were kids.”
And then there are power prices, the very mention of which makes Wills shake his head in mystification. “I’m not an economist, but I simply don’t understand how power prices have gone up the way they have.”
STRAIGHT SHOOTING
Wills has never shrunk from taking a stand on the issues he regards as important. Before his appointment, as a spokesman for the Paediatric Society, he was an outspoken supporter of former Green MP Sue Bradford’s bill outlawing parental smacking. Now it’s child poverty.
It’s an issue that often gets muddied by ideology, but with Wills you get the impression that dogma doesn’t enter into it. He simply cares about children and thinks it’s shocking that some get a poor start – one that’s likely to hold them back all their lives.
He doesn’t mince words, either, in the way that a risk-averse bureaucrat might. On TV3’s The Nation in June, interviewer Lisa Owen asked whether he agreed with Professor Jonathan Boston – who co-chaired an expert advisory panel Wills set up to investigate child poverty – that it was scandalous that New Zealand treated its elderly so much better than its children.
“Of course I do,” replied Wills. He also agreed with Boston that benefits were “woefully inadequate”.
Such blunt talk might be expected to invite censure from his political masters, but Paula Bennett insists Wills’ stand on child poverty causes her no discomfort. In fact, she says she likes his independence: “I don’t appoint someone and then tell them what to do. I believe in setting people up to do the best job they can and I’m very comfortable with the work that Russell does. Whether he always agrees with the Government or not is completely irrelevant.”
She describes Wills as totally child-centred. “I’ve found him to be incredibly driven by his work for children and never doubted that that’s where his commitment lies. As long as he’s coming from a place of putting children first, then I would support him in whatever work he’s doing.”
The admiration is mutual. Wills took a liking to Bennett when he was first interviewed for the job. She had already signalled her interest in children’s issues with the publication of a Green Paper on child protection. “She said, ‘I really want to make a difference to child protection outcomes and I need some help,’” recalls Wills. It was clearly a factor in his decision to apply for the job.
He and the minister meet regularly. “It’s a free and frank relationship,” he says. “She hasn’t always agreed with what I’ve done or said.”
He agrees he has probably said things that ruffled Government feathers, “but that’s my job. I don’t just upset her. I upset the left as often as I upset the right. I think it’s my job to speak truth to power. I think she’s very comfortable with that. I think she likes people to be frank with her.”
In any case, Wills likes some of the things the Government has done: extending paid parental leave, for example, and putting more effort into early childhood education. He also approves of National’s and Labour’s pledges to extend free doctors’ visits and prescriptions to children under 13, and would be even more pleased if after-hours access to medical care could be made easier for low-income parents who often work shifts or long hours.
It’s not enough, though. Wills wants a national conversation about child poverty. He thinks we should all agree it’s not okay that if a child in New Zealand is born poor, that determines their lifetime prospects.
When I suggest no one would disagree that having 170,000 children living in poverty is a bad thing, he pulls me up. “Actually, there’s a high level of tolerance for this still. When we ask voters what’s the most important thing for them this election, among centre-left and female voters, child poverty is usually in the top three. Among males, business owners and centre-right voters, it’s down at seventh or eighth.”
WEALTH DISTRIBUTION
But child poverty remains an ideological minefield. A substantial body of opinion holds that welfare is already too big a drain on the productive sector. Many of the ideas Wills endorses, such as the universal child payment recommended by his expert advisory group, would inevitably require more welfare spending.
Moreover, there’s concern that throwing more money at poor families risks perpetuating the problem. Child advocate Dame Lesley Max, founder and chief executive of the Great Potentials Foundation, says that a universal child payment, programmed to run out once the child reaches a fixed age, could nudge parents into paid employment as intended, but it could also serve as an incentive to have another child once the payment starts petering out.
Another with misgivings is Wellington welfare researcher and former Act Party candidate Lindsay Mitchell. “There is ample international research showing the rate of single parenthood increases with higher benefit payments,” she says. “There is a strong risk that raising benefits, which also reduces the gap between income from work and welfare, aggravates benefit dependence. Long-term benefit dependence is bad for children. That’s beyond dispute.”
Mitchell describes Wills as a good-hearted man and says it’s understandable that he wants immediate action on child poverty, but adds: “Advocates for greater wealth redistribution need to think about the long-term picture. The breakdown of the two-parent family is a major contributor to child poverty and all the associated risks: ill-health, abuse and neglect, educational underachievement and behavioural problems. The trend won’t be reversed by doing more of what caused it in the first place.”

Minister for Social Development Paula Bennett. Image/Thinkstock

IT’S AFFECTING US ALL
Wills accepts that there’s no magic bullet. He also agrees that state spending to alleviate child poverty needs to be rigorously monitored to ensure it achieves the desired outcomes. “We just don’t throw money at the problem. We need to know what investments make the biggest difference. Early childhood education [ECE] obviously makes a big difference; that’s import­ant. ECE for kids in poorer areas is a must-have.”
A crucial first step, he says, is to measure the true extent of child poverty – a project his office has embarked on in collaboration with the University of Otago and the JR McKenzie Trust. “You can’t fix a thing unless you can measure it and monitor progress.”
Then he thinks governments should set targets for the reduction of child poverty. After all, they do it with other things. “We have a plan for biosecurity and the road toll. You have legislation, you set targets and you hold government and ministries accountable. That’s what you do.”
Target-setting should be mandatory for every incoming government and it should be linked to the Budget process, he suggests. It would be up to each government to set the target and choose the appropriate policy mix.
“Let’s understand that this really matters, because it affects all of us. Then we need to be clear about who’s affected most, and that’s the youngest children. So which children do we need to invest in, at what age, and how? We need to understand that well and communicate it well.
“And we need to use the language of investment. We have an ageing population. As people leave the workforce, we need to replace them. The proportion of people entering the workforce compared with those leaving is falling. Soon it’s going to be one to one.
“If we want to maintain our standard of living and national super and interest-free student loans, we have to be able to afford it, which means we need our workforce to be as productive as it possibly can be. If half of Maori kids leave school with no qualifications, that ain’t going to happen; we’re in real trouble.”
Note the references to investment. One of Wills’ missions is to get the business sector onside by highlighting the economic cost of children growing up in poverty, requiring expensive medical treatment for poverty-related illnesses, falling into crime, failing to achieve educationally and ending up on welfare – all at a cost to the productive sector.
“The evidence tells us that if we want our workforce to be as productive as it possibly can be, we need to keep doing the good things we’re doing.
“Our education system works pretty well. What we aren’t doing is investing in that period of children’s lives that makes the biggest difference, and that’s ages one to five. That’s when your brain is making those millions of connections every minute. Those connections are determined by the child’s environment.
“Now, if they are growing up in an impoverished environment where those needs are not met, where parents are stressed, where it’s cold and damp and they’re sick, they’re going to arrive at school not ready. By the time the education system picks them up, the damage is done.”
It’s a warning that’s not lost on Phil O’Reilly, chief executive of BusinessNZ. O’Reilly was a member of Wills’ expert advisory panel and has taken the message to business audiences.
“The Ministry of Social Development will tell you that if an 18-year-old kid gets on the dole and stays there for more than about six months, chances are they will stay there forever and die young and without qualifications,” says O’Reilly. “There’s only one answer to that if you’re a business person: well, we’d better invest in them at 18 then, or earlier, to make sure they don’t end up there. I can use that information to make business people see that child poverty can have a long-term economic impact – for example, more taxes – and that they’re not going to get the talent they need, which is what business is most interested in.”
Child poverty is enormously daunting and complex, says O’Reilly, but he admires the way Wills has gone about tackling the issue. The advisory group brought together people who wouldn’t normally sit around the same table – O’Reilly, the champion of private enterprise, found himself alongside left-leaning academics – but he says their deliberations were evidence-led and rose above polemics. He sounds slightly surprised that he wasn’t a lonely voice arguing against an increase to the minimum wage. “The evidence didn’t point to that conclusion, so we didn’t recommend it.”
He admits he found some recommendations in the group’s report “a bit uncomfortable”. They included policy measures that the report warned would be costly and require reprioritisation of government spending or higher taxes. But it was a consensus document and everyone agreed with its overall tenor.
There’s no bright, shiny, simple solution to child poverty, adds O’Reilly, but partly due to Wills’ commitment, there’s now a core of high-level people from both sides of the political divide engaging with the issue.
DOUBLE DUTY
I ask Wills how he copes with the stress of two jobs, both of which present complex and potentially overwhelming challenges. Planting trees helps, he says.
The family lives on a rural block west of Napier that was originally bought by Wills’ parents when he was 10. It was 4.5ha of gorse then – “gorse over my head. No power, no phone, no water. My adolescence was spent slashing gorse and building fences and moving stock, putting in watering systems.”
Now they’re reforesting it. “I’ll plant 150 trees and feel better; do something for the next generation.” He plants only natives, all locally sourced.
His appointment as Children’s Commissioner was for five years. Is he likely to seek a second term? That laugh again. “No one’s ever wanted one.”
Does he get tired? “Yes. There are some big days. I don’t add up the hours any more – I stopped doing that. But you only get an opportunity like this once in a lifetime. How lucky am I?”