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
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.
THE MILLENNIAL MORBIDITY
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
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
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.
This work was made possible through a grant from the Dyson Foundation.
- Accepted December 22, 2004.
- Address correspondence to Judith S. Palfrey, MD, Children's Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail:
No conflict of interest declared.
- ↵Children’s Defense Fund. A Nation and Century Defining Time: Where Is America Going? Washington, DC: Children’s Defense Fund; 2004:22. Available at: www.cdfactioncouncil.org/actionguide/2004.pdf. Accessed February 18, 2005
- ↵US Department of Commerce, Bureau of the Census. Infant mortality rate for Massachusetts, 1851–1970. In: Historical Statistics of the United States: Colonial Times to 1970. Part 1. Bicentennial ed. Washington, DC: US Bureau of the Census; 1975:57
- ↵Haggerty RJ, Roghmann KJ, Pless IB. Child Health and the Community. New York, NY: John Wiley and Sons; 1975
- Palfrey JS. Community Child Health: An Action Plan for Today. Westport, CT: Praeger Publishers; 1994
- ↵Green M, Palfrey JS, eds. Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 2nd ed, revised. Arlington, VA: National Center for Education in Maternal and Child Health; 2002
- ↵Palfrey JS, Richmond JB. Health services: past, present, and future. In: Cosby AG, Greenberg RE, Southward LH, Weitzman M, eds. About Children. Elk Grove Village, IL: American Academy of Pediatrics; 2005
- ↵Smedley BD, Stith AY, Nelson AR. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press; 2003
- ↵US Census Bureau. Poverty: 2003 highlights. Available at: www.census.gov/hhes/poverty/poverty03/pov03hi.html. Accessed February 10, 2005
- ↵Forum on Child and Family Statistics. America's Children 2002. A percentage of related children under age 18 living below selected poverty levels, by family structure, race and Hispanic origin, selected years 1980–2002 Table Econ 1. Available at: http://childstats.gov/ac2002/tbl.aps?id=3&iid=14. Accessed October 28, 2004
- ↵Blackwell DL, Tonthat L. Summary health statistics for U.S. children: National Health Interview Survey, 1999. Vital Health Statistics 10(210). Washington, DC: National Center for Health Statistics; 2003
- ↵National Center for Educational Statistics. The nation's report card. Available at: http://nces.ed.gov/nationsreportcard. Accessed November 2, 2004
- ↵Maternal and Child Health Bureau. Child Health USA 2002. US infant mortality rates by race of mother: 1980–2000. Available at: www.mchb.hrsa.gov/chusa02/main_pages/page_23.htm. Accessed September 18, 2004
- ↵Maternal and Child Health Bureau. Child Health USA 2002: comparison of national infant mortality rates. Available at: www.mchb.hrsa.gov/chusa02/main_pages/page_22.htm. Accessed November 2, 2004
- ↵Martin JA, Hamilton BE, Sutton PD, Ventura SJ, Menacker F, Munson ML. Births: final data for 2002. Natl Vital Stat Rep.2003;52 (10):1–113
- ↵Maternal and Child Health Bureau. Child health USA 2002: leading causes of death to adolescents ages 15–19. Available at: www.mchb.hrsa.gov/chusa02/main_pages/page_46.htm. Accessed October 28, 2004
- ↵National SAFE KIDS Campaign. Injury facts: childhood injury. Washington, DC: National SAFE KIDS Campaign; 2004. Available at: www.safekids.org/tier3_cd.cfm?content_item_id=1030&folder_id=540. Accessed October 28, 2004
- ↵Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic profile of children with special health care needs. Pediatrics.1998;102 :117– 123
- ↵Wolraich ML, Lindgren S, Stromquist A, Milich R, Davis C, Watson D. Stimulant medication use by primary care physicians in the treatment of attention deficit hyperactivity disorder. Pediatrics.1990;86 :95– 101
- ↵National Institute of Mental Health. Children and mental health. In: Mental health: a report of the Surgeon General. Available at: www.surgeongeneral.gov/library/mentalhealth/chapter3/sec1.html. Accessed October 28, 2004
- ↵Maternal and Child Health Bureau. Child Health USA 2002. Thirty day prevalence of drug abuse among adolescents ages 12–17: 1990–2000. Available at: www.mchb.hrsa.gov/chusa02/main_pages/page_45.htm. Accessed October 28, 2004
- ↵Maternal and Child Health Bureau. Child Health USA 2002. Long-term trends in thirty-day prevalence of cigarette smoking for 8th, 10th and 12-Graders: 1975–2001. Available at: www.mchb.hrsa.gov/chusa02/main_pages/page_44.htm. Accessed October 27, 2004
- ↵Maternal and Child Health Bureau. Child Health USA 2002. Adolescent birth rates, by race of the mother: 1990–2001. Available at: www.mchb.hrsa.gov/chusa02/main_pages/page_35.htm. Accessed October 27, 2004
- ↵Brunk D. Black-white gap in pneumococcal disease closing. Pediatr News.2003;37 :1 , 7
- Copyright © 2005 by the American Academy of Pediatrics