Published online April 1, 2005
PEDIATRICS Vol. 115 No. 4 April 2005, pp. 1121-1123 (doi:10.1542/peds.2004-2825B)

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SUPPLEMENT ARTICLE

Introduction: Addressing the Millennial Morbidity—The Context of Community Pediatrics

Judith S. Palfrey, MD^*, Thomas F. Tonniges, MD, Morris Green, MD and Julius Richmond, MD^¶

^* Harvard Medical School and Children's Hospital, Boston, Massachusetts
American Academy of Pediatrics, Elk Grove Village, Illinois
University of Indiana School of Medicine, Indianapolis, Indiana
^¶ Harvard Medical School, Boston, Massachusetts

The test of the morality of a society is what it does for its children.

Dietrich Bonhoeffer¹

Pediatrics is a contextual specialty concerned about children, their families, and the communities in which they live. Historically, US pediatricians have demonstrated a deep appreciation of the relationship between community forces and child health outcomes. Abraham Jacobi, MD, and Job Lewis Smith, MD, the founders of American pediatrics, fought to ensure a clean water supply and decent housing for poor urban infants and children who were poor. They set the stage for pediatric activism in the community. In the decades since then, pediatricians have grappled to incorporate knowledge about the influences of the external environment into the practice of pediatrics.² Although the morbidity and mortality of children have changed over the past 150 years, the need for engaging in the community with families and community-based partners has not. Rather, the salience of community pediatrics has risen as the effects of societal forces have intensified and knowledge of the bioenvironmental interface has become more sophisticated. This supplement is a collection of articles about training and practice in community pediatrics that offers specific examples of clinical practice and research aimed at fulfilling the promise that our profession has made to children in our society.

	TRENDS IN CHILD HEALTH

TOP TRENDS IN CHILD HEALTH THE MILLENNIAL MORBIDITY CURRENT HEALTH STATUS OF... HOPE FOR THE FUTURE REFERENCES

 
The past century has seen astounding changes in the configuration of childhood health and illness (Table 1). In the early 1900s, infant mortality was as high as 140 per 1000 live births per year³; child health clinicians struggled to handle malnutrition and contagious illnesses. The major biological and medical breakthroughs of the midcentury created the basis for the subspecialty care of children with congenital and acquired organ-system illness. By the 1960s and 1970s, acute infectious morbidity increasingly was held in check by antibiotics and vaccines. Pediatricians began to address what Haggerty and Aligne termed "the new morbidity" (ie, developmental disability, school dysfunction, emotional problems, violence, and injuries).⁴ Incorporating the science of child development into daily practice, clinicians responded to the whole child. Pediatricians began collaborating with others in the community to prevent disease and promote health.⁵–⁷ Beyond the clinic doors, they found clear patterns and explanations. Child health outcomes were in a dynamic interplay with the environment, secular trends, commercial developments, the economy, family customs, and cultural norms.

View this table: [in this window] [in a new window]   TABLE 1. Trends in Pediatric Morbidity

 

	THE MILLENNIAL MORBIDITY

TOP TRENDS IN CHILD HEALTH THE MILLENNIAL MORBIDITY CURRENT HEALTH STATUS OF... HOPE FOR THE FUTURE REFERENCES

 
In the ever-moving swirl of environmental and social change, there is now a new "millennial morbidity."⁸ The causes of poor physical and mental health are multifocal. What happens on the highways,⁹ over the airwaves,¹⁰,¹¹ and in the culture determines the health and well-being of children and youth. The very process of rapid and continual change renders its own effects on children's health.

Twentieth-century technologic advances (eg, enhanced food production, television, automobiles, oral contraception, computers, the Internet) have resulted in enormous lifestyle changes for US families. Although our forebears often cared for children who had too little to eat, children and youth today are offered an excess of available calories and a barrage of fast-food advertising as they sit passively in front of the TV. The societal emphasis on getting ahead and the high-speed pace of family life open vast opportunities for children and youth but leave many young people exhausted and some dangerously confused and anxious.

Many of the new developments have been positive for the health of children and youth, especially those that result from fundamental discoveries in biological science, medicine, pharmacology, surgery, and bioengineering. These new developments have ensured longer survival of children with complex and severe disabilities.¹² For many children, the medical advances have resulted in stunning cures; for others, the cost of a prolonged life has included multiple hospitalizations and much pain and familial suffering. The human genome project has opened potential vistas for prevention and cures never previously imagined.¹³

At the millennium, child health clinicians face a serious dilemma. The benefits of progress and promise for children are not equally distributed. The ever-widening gap between rich and poor has produced large differentials in child health outcomes by class and race.¹⁴ Moreover, underlying cultural, racial, and ethnic misunderstandings, biases, and miscommunication have resulted in an inequitable distribution of health care that is unconscionable in a country that has our level of resources and talent. The millennial morbidity includes ailments of the society as well as its citizens.

Because of these inequities, pediatricians are paying increasing attention to the relationship between socioeconomic status and child health. New systems of data collection and reporting allow an inflected view of these relationships and the toll that factors such as poverty take on children's health. Health services–research studies document the importance of accounting for contextual variables to explain phenomena such as teen pregnancy, injury rates, sexually transmitted diseases, and mental health concerns.

The most recent economic data (2003) document the poverty rate for US children at 17.6%.¹⁵ Children of single mothers are far more likely to be poor (28% among white, 48% among black, and 49% among Hispanic families).¹⁶ Children in poverty are more likely to experience poor health than are their wealthier peers (38% of poor families report less than very good/excellent health vs 10% of children who are not poor).¹⁷ School functioning also is affected by socioeconomic status. Fourth-grade achievement of children in poor inner-city areas is compromised, with two thirds of the children in the heart of cities such as Chicago, Illinois, Los Angeles, California, and Washington, DC, lacking the basic proficiency for reading at grade level.¹⁸

	CURRENT HEALTH STATUS OF CHILDREN AND YOUTH

TOP TRENDS IN CHILD HEALTH THE MILLENNIAL MORBIDITY CURRENT HEALTH STATUS OF... HOPE FOR THE FUTURE REFERENCES

 
Mortality
The US infant mortality rate for 2002 was 6.9 per 1000.¹⁹ Internationally, the United States ranks 28th on this measure.²⁰ In 2002, 7.8% of infants weighed <2500 g at birth, and 10.5% of infants were born prematurely (<37 weeks' gestation).²¹ Black infants are 2 to 3 times as likely as whites to be born prematurely and/or of low birth weight.²¹ Among children in the 1- to 14-year-old age range, injuries are the predominate cause of death. Children are at risk for falls and pedestrian, occupant, and bicycle injuries.²² In 2000, >5000 adolescents died in automobile crashes; homicide accounted for 15% and suicide for 12% of teenage deaths.²³ Racial disparities in adolescent mortality statistics are stark: black male youths are 15 times more likely to die from homicide than whites of the same age.²⁴

Illness and Disability
Nearly 13% of the nation's children and youth have special health care needs.²⁵ Half of these children experience impairment in daily functioning. Children and youth with special health care needs have 3 times as many school absences as their healthier peers.²⁶ Several new chronic disease "epidemics" account for substantial illness among children and youth. Twelve percent of US children are overweight.²⁷ These children are at high risk for hypertension, diabetes, obstetric complications, and all the other attendant health consequences of lifelong obesity. Asthma prevalence is rising in this country and worldwide.²⁸ Pediatric involvement in the diagnosis and management of attention-deficit/hyperactivity disorder has been increasing over the past 10 to 20 years.²⁹ The prevalence of autism seems to be increasing, with the most recent estimate being 4 to 6 per 1000 children.³⁰,³¹ As many as 21% of children and youth suffer from mental health problems during their early years, and many of these children and youth go on to experience lifelong emotional disability.³²

	HOPE FOR THE FUTURE

TOP TRENDS IN CHILD HEALTH THE MILLENNIAL MORBIDITY CURRENT HEALTH STATUS OF... HOPE FOR THE FUTURE REFERENCES

 
Not all is bleak at the millennium. In fact, there is some very good news. Trend data for some of the most health-impairing behaviors of young people show significant improvement. Over the past decade, there have been substantial declines in adolescent substance abuse,³³ smoking,³⁴ drinking, and teen pregnancy.³⁵ These trends represent the positive outcomes of huge, well-orchestrated efforts by pediatricians, public health officials, families, and communities working in concert to overcome some of the biggest threats to the well-being of children and adolescents. An additional hopeful sign is the fact that there are indications that some interventions also have begun to reduce racial disparities in some child health outcomes.³⁶

To ensure that children have the best possible chances, we need a vigilant continuation of successful models. To stem the forces causing substantial morbidity and bolster those interventions, we need to capitalize on the lessons of those who are pulling together powerful community partnerships for child health and well-being. This supplement provides examples of innovative interventions that have made a difference for children and youth. Within the articles gathered here, there is a visible commitment to engaging children and youth where they are: in families, in school, in church, at the YMCA, and in the community.³⁷–³⁹

There is a new day dawning in pediatrics. This supplement is the documentation of the challenges before us all and the celebration of all those brave and devoted practitioners, residents, students, families, community-based organizations, and public agencies who have banded together to make the context of children's lives as healthy and happy as possible.

	ACKNOWLEDGMENTS

 
This work was made possible through a grant from the Dyson Foundation.

	FOOTNOTES

 
Accepted Dec 22, 2004.

Address correspondence to Judith S. Palfrey, MD, Children's Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: palfrey{at}fas.harvard.edu

No conflict of interest declared.

	REFERENCES

TOP TRENDS IN CHILD HEALTH THE MILLENNIAL MORBIDITY CURRENT HEALTH STATUS OF... HOPE FOR THE FUTURE REFERENCES

 

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PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

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