• No results found

Preventive Pediatrics: The Promise and the Peril

N/A
N/A
Protected

Academic year: 2020

Share "Preventive Pediatrics: The Promise and the Peril"

Copied!
10
0
0

Loading.... (view fulltext now)

Full text

(1)

SPECIAL

ARTICLE

Preventive

Pediatrics:

The Promise

and the Peril

Leon

Eisenberg,

MD

From the Departments of Social Medicine and Health Policy and Psychiatry, Harvard Medical School, Boston

I was deeply honored to have been invited by the Canadian Paediatric Society to serve as its 18th Queen Elizabeth II Lecturer. Even as I relished the

honor, I found it daunting, given the distinction of

my predecessors. Having considered at length how best to respond, I chose to address prevention, a field with which pediatrics has been concerned

since its inception as a specialty. Although the commitment of pediatrics to disease prevention has been unswerving, the diseases that have been the target of its efforts have necessarily changed as the distribution of disease in the population has changed and as scientific advances have created new opportunities for intervention.

What pediatricians were once almost alone among medical specialists in emphasizing has now become the target of government policy in Canada,’

the United States,2 and the United Kingdom.3 This, however, is not quite the triumph it may seem.

Physicians who advocate prevention do so in the hope of avoiding unnecessary suffering and pre-mature death for their patients. Politicians who do so may not be unmindful of these goals, but their primary motivation is controlling the costs of med-ical care. The US Forward Plan for Health2 was unabashed about it: “the primary focus of our pro-gram is a major attack on cost escalation.” The differences in motivation between physicians and

Received for publication Oct 20, 1986; accepted Dec 10, 1986. Presented as the Queen Elizabeth II Lecture of the Annual Meeting of the Canadian Paediatric Society, Sept 23, 1986, Toronto.

Reprint requests to (L.E.) Department of Social Medicine and Health Policy, Harvard Medical School, 25 Shattuck St, Boston, MA 02115.

PEDIATRICS (ISSN 0031 4005). Copyright © 1987 by the American Academy of Pediatrics.

politicians have important consequences for health policy, consequences that imperil the promise of prevention.

Let me, then, begin with a few words of history, move on to the promise of preventive pediatrics in the years to come, and conclude by discussing the hazards associated with the use of prevention as a political rather than a medical slogan.

THE BEGINNINGS

A century ago, when pediatrics was struggling to establish its legitimacy as a medical specialty, its pioneers emphasized two principal arguments: the necessity to study the unique physiologic charac-teristics of the infant and child and the special opportunities for the prevention of disease. In his presidential address to the first meeting of the American Pediatric Society in 1879, Jacobi stated: “Pediatrics does not deal with miniature men and women, with reduced doses and the same class of diseases in small bodies, but has its own independ-ent range and horizon, and gives as much to general medicine as it has received from it.”4 He went on

to add: “The most vital questions of public hygiene are connected with pediatrics most inti-mately. . . . Constitutional and infectious diseases

. . . . belong to early life and the vast majority can

be avoided, mortality greatly diminished, and ill health resulting therefrom prevented.”4’5

Blacklader5 of Montreal, who was to become the founding president of this society, stated in his 1893 address as the fifth president of the American Pe-diatric Society5’5:

The child is father of the man in his disease history as

well as in other important respects. . . . Prevention in the

eyes of the true physician is daily occupying a more and

(2)

important results be obtained, than in checking the de-veloping tendencies of child life.

That tradition was reflected at the meeting of the Canadian Paediatric Society by symposia on smok-ing control and on primary prevention in mental health. Such concerns were not foreign to our pred-ecessors. Indeed, Jacobi had himself contended that “many of the causes of mental disease in later life must be traced back to embryologic data and the morbid changes of infancy.”32 However, the first task of the pediatrician of that day was the man-agement of the infectious diseases that exacted such a heavy burden of morbidity and mortality.

CHANGES

IN THE

DISEASE

BURDEN

It is instructive to reflect on the differences in health status between the turn of the century and the present. Life expectancy at birth in the United States has increased from 47.3 to 74.7 years.6’7 Mortality among infants has been reduced from 162 to 10.6 per 1,000 live births, among 1- to 4-year-old children from almost 2,000 to 50/100,000, and among 5- to 14-year-old children from 390 to 20/ 100,000, surely a remarkable change. Life expect-ancy and infant mortality rates in Canada, worse than those in the United States earlier in the cen-tury, are now significantly better.8’9

In 1900, infectious diseases were the leading cause of death. During the past 80 years, there has been a striking reduction in their incidence and lethality,’0 in part because of better nutrition, less crowding, safe water, and nearly universal sanita-tion.1’ Nonetheless, medical interventions, notably pre- and perinatal care, immunizations, and che-motherapy, were major factors in the dramatic change. Just how important medical care remains in the modern era is evident from a recent report

of birth outcomes among a group of women who refused obstetrical care on religious grounds. Mem-bers of this religious group experienced a perinatal mortality rate three times higher and a maternal mortality rate 100 times higher than statewide rates in Indiana.’2 In the first 20 years following the licensure of measles vaccine in the United States, the vaccine prevented more than 5,000 deaths and

17,000 cases of mental retardation.’3 Immunization with combined measles-mumps-rubella vaccine yielded a benefit to cost ratio of 14 to i.’’ And, I need not rehearse the remarkable impact of anti-biotics in the postwar era.

INFECTIOUS

DISEASE

TODAY

I do not mean to suggest that infectious diseases have been reduced to trivial issues in health care. For one thing, we have not yet succeeded in

ensur-ing that children in poor and minority families are immunized.’5 For another, what we had regarded as a battle won for pertussis control has had to be reengaged.16 Public resistance to pertussis vaccina-tion because of toxicity has been followed by in-creasing disease rates in the United Kingdom17 and Japan;’8 reluctance of manufacturers concerned about liability to continue vaccine production has increased costs sharply and threatens the adequacy of supply.’9 The treatment of recurrent otitis media remains an unresolved problem. There is increasing concern about the transmission of cytomegalovirus, hepatitis A, and Haemophilus influenzae type b in day-care centers. Although the existing H influen-zae type b polysaccharide vaccine is effective in children 18 months and older, it is not effective for younger children, the group at highest risk;20 there is, however, bright promise in new vaccines based on potentiating immunogenicity by the use of co-valent conjugates with carrier proteins.2’

New diseases have appeared; by the middle of

1986, 300

cases of pediatric acquired immunodefi-ciency syndrome (AIDS) had been reported in the United States; the figure is projected to increase to 3,000 by 1991.22 The problem posed by pediatric AIDS is particularly formidable in Africa, both in its own terms and in its consequences for the WHO Expanded Program of Immunization. The data from central African countries indicate that many infants may be acquiring human immunodeficiency virus infection perinatally.23 Vaccines, particularly

those based on live attenuated but replicating

vi-ruses, when administered to human

immunodefi-ciency virus-infected infants, may precipitate rapid progression to clinical disease. Screening before

vaccination would pose enormous technical diffi-culties in countries in which vaccine delivery is already problematic. Yet, to abandon immunization is to condemn tens of thousands of children to death and disability from preventable causes. The chal-lenge is daunting.

In developed countries, we face the paradox of problems that stem from our very successes. One example is the difficult challenge of treating infec-tions in children immunocompromised during

suc-cessful chemotherapy against neoplasms. Another stems from the fact that measles antibody titers are

(3)

would protect such infants but at the risk of making those with protective antibody titers refractory to reimmunization. In principle, identification of

mothers with low titers and selective early

vacci-nation of their infants is technically feasible, but it would entail a sizeable effort to prevent a small number of cases.

Nonetheless, with what has been accomplished through better living conditions and by more pow-erful medical interventions, the challenges facing preventive pediatrics as this century ends are dif-ferent from those that faced Jacobi, Blacklader, and their colleagues when it began. It is those challenges I now propose to address: first,

prevent-ing congenital and hereditary disorders; second, preventing psychosocial disorders; and third, pre-venting the abuse of the concept of prevention.

PREVENTING

HERITABLE

DISORDERS

Scriver25 has reminded us that, when we succeed, as we have, in diminishing the extrinsic causes of a particular disease, without eliminating that disease altogether, the residual cases manifest a net in-crease in heritability. Rickets is the paradigmatic example. Rickets is far less common now than it was prior to the discovery and use of vitamin D. However, among the persons with rickets we see today, the majority suffer from Mendelian disorders of calcium or phosphorous metabolism.26 It is a paradoxical measure of our success that a sizeable proportion of the children admitted to hospitals today are there because of inherited conditions.27

Some will take this for a message of doom because they equate “inherited” with “fated” or “inevitable.”

To

the contrary, there are now multiple opportun-ities to intercept genetic and chromosomal disor-ders. Genetic counseling for families at risk can help parents make informed decisions about child bearing. In an ever-increasing number of inherited disorders, affected fetuses can be identified

pre-natally and selectively aborted. By this means, par-ents who might otherwise deny themselves a family can now be enabled to bear healthy children. The possibilities grow apace with progress in the detec-tion of chromosomal abnormalities, abnormal me-tabolites, defective genes, informative restriction fragment length polymorphisms,28 and, most re-cently, what have been called DNA fingerprints; that is, restriction fragment length polymorphisms that vary in the number of short sequence tandem repeats.29 In other conditions, the effects of the

genotype can be controlled postnatally, either by supplying the missing gene product, as in athyreo-sis, or by diet as in phenylketonuria. And, to high-light the pace of progress, the first

phenylketonuria-causing mutation has just now been identified in

the human phenylalanine hydroxylase gene as a single base substitution;3#{176} because it is tightly as-sociated with a specific restrictive fragment length polymorphism, it should prove possible to detect carriers of the genetic trait even in the absence of a family history of phenylketonuria.

We are not far from the day when gene therapy will become a reality. In severe combined immune deficiency, the lack of the enzyme adenosine de-aminase impairs T cell maturation. Although bone marrow transplantation can correct the immune deficiency, it can also lead to graft v host disease. Recently, a team of Canadian and American re-searchers has succeeded in cloning a human aden-osine deaminase cDNA into a replication-defective retrovirus vector that was able to transfer the hu-man gene to mouse bone marrow cells.3’ Once per-fected, this technique may permit safe and effective treatment of adenosine deaminase deficiency and other inborn errors of metabolism by somatic gene therapy. What yesterday was science fiction will tomorrow become standard treatment.

It is, however, important to recognize that such single-gene disorders are relatively rare. Cystic fi-brosis, the most common serious genetic disorder in white children and now a candidate for prenatal diagnosis by a polymorphic DNA marker,32 occurs

no more often than in one of 2,000 live births in North America. Far more common are diseases whose causation is multifactorial; that is, in which the disease phenotype results from the interaction between genes at several loci and provocative en-vironmental agents. Diseases likely to fit this cat-egory include atherosclerosis, hypertension, diabe-tes, and perhaps alcoholism. Assume, as seems al-most certain, that researchers will identify genes that substantially increase the odds that heart dis-ease will develop in a given individual. Unless the research also provides a means to arrest disease expression, that discovery will not only be of no use to the individual but may be entirely to his or her detriment. Employers and insurance companies, eager to reduce financial liability, are only too ready to introduce genetic screening tests once they be-come commercially available. It would be absurd to suggest that we interdict research which, if properly applied, can yield important health benefits. What we must be alert to is the importance of civil legislation to minimize the potential social costs of screening programs before they are introduced.

PREVENTING

PSYCHOSOCIAL

DISORDERS

(4)

of a genetic predisposition, but by far the largest amount of variance is associated with social disad-vantage. I will limit my exposition to three inter-related problems: developmental retardation, teen-age pregnancy, and low birth weight, chosen be-cause of the morbidity they represent and because they illustrate the complex interaction between be-havioral and physical factors in producing detri-mental psychosocial outcomes. The very

complex-ity of the causal network means that there can be no simple and certainly no single preventive mea-sure: no analogue to vaccination. Social interven-tions, however, can reduce risk.

DEVELOPMENTAL

RETARDATION

In every country in which child development has been studied, children born into poverty fail to progress, on average, as well as those born into comfortable circumstances, whether the outcome is measured in terms of physical health, cognitive test performance, academic attainment, or work re-cord.33 The repetition of this sequence through in-tergenerational cycles of disadvantage burdens such families as well as the neighborhoods in which they are aggregated.34 Such outcomes have been shown

to be diminished by preschool programs that pro-vide a stimulating learning environment for chil-dren at the same time that they effectively engage parents as active participants in child care.35 Two recent long-term follow-up studies36’37 report the benefits of such programs. A study in Ypsilanti, MI,36 undertaken when the former preschoolers had reached the age of 19 years, reported that the ex-perimental children in comparison to the control children had significantly higher rates for gradua-tion from secondary school, for post-high school education, and for employment, less use of welfare, fewer adolescent pregnancies, and fewer arrests! The findings from a New York City study37 were remarkably similar: rates for high school graduation and vocational training were half again as high and rates for employment twice as high among those who had been exposed to early enrichment than among neighborhood control children.

However, better beginnings cannot assure better endings unless early benefits are captured and rein-forced by quality public education. Rutter and his colleagues38 have shown that the quality of second-ary schools in inner London make a substantial difference to the behavior and achievement of their pupils. Their research strategy took into account differences in the educational and behavioral char-acteristics of the children at the time they left primary schools at 10 years of age to partial out effects attributable to the problems they brought with them. Children who attended certain of the

secondary schools did much better than those who attended others; that is, some schools “produced” more delinquents than would have been predicted on the basis of the pupils they admitted and some schools many fewer. The differences were not due to school size or physical plant but rather to the character of the school as a social institution; that is, good outcomes correlated with such features as the amount of emphasis on academic performance, the extent of interactive teaching, the availability of incentives and rewards for good performance, and the degree to which pupils were given respon-sibility in the classroom. Good schools did not obliterate social class differences in behavior and performance; those remained; but outcomes for both lower- and middle-class children were better in the better secondary schools. As the authors of the study concluded: . . . schools can do much to

foster good behavior and attainments . . . even in a

disadvantaged area, schools can be a force for the good.”38205

TEENAGE

PREGNANCY

It is during the secondary school years that the second of the three interrelated psychosocial prob-lems becomes manifest: teenage pregnancies. Most are unintended.39 Their consequences are often ad-verse for the mothers as well as the children.40 Among industrialized countries, the United States has the highest teenage pregnancy and abortion rates at the same time that it has the highest teenage birth rate! The resolution of the apparent paradox lies in the fact that U.S. teenagers have the lowest rate of contraceptive use.4’ Pregnancy rates among 15- to 17-year-old girls are half as high for Canada as for the United States, because a smaller number are sexually active at each age and because of higher rates of contraception among those who are sexually active. Nonetheless, the percentage of pregnancies terminated by abortion or leading to nonmarital births are similar in the two countries.4’

Although the percentage of adolescent girls hay-ing had intercourse is higher by half in Sweden than in the United States, pregnancy rates are only half as great. Sweden was the first country in the world to have established an official compulsory sex education curriculum in its schools, with a close link to contraceptive clinics for contraceptive serv-ices. It is no coincidence that Swedish adolescent abortion rates have declined dramatically since

1975. During the same time period, the United States and Canada, where school sex education is a community option of local authorities, abortion rates have shown no change.4’

(5)

edu-cation in the schools. They insist that sex education

is the responsibility of home and church despite the evidence that neither home nor church has been effective in curbing either premarital sex or preg-nancy. Those of us who advocate teaching about responsible sexuality in the schools are no less opposed to premature sexual experimentation than the self-declared moral majority. Where we differ is in our conviction that responsible sexual behavior is based on openness rather than repression, on an accurate knowledge of the facts rather than igno-rance and misinformation, on teaching about sex as an expression of love rather than behaving as though it were something secret and dirty, and on teaching youngsters that saying no is more grown-up than going along on the assumption that every-body does it. Because Freud was the first to unmask the power of the sexual instinct and to explore its vicissitudes, psychiatrists have been accused of

sup-porting its unbridled expression. The facts are quite to the contrary. Freud42 himself was unequivocal on the point: “Civilization is built up on the ren-unciation of instinctual gratification.”

Although school-based family planning clinics will not in themselves solve the problem, they can make a substantial contribution to the reduction of teenage pregnancy. In St Paul, the birth rate among students in schools with clinics declined from 59 to 37/1,000 during an 8-year period during which the percentage of female students seeking birth control services increased from 7% to 35%#{149}43A Johns Hop-kins Hospital program, offered at one of two matched junior high and one of two matched senior high schools in Baltimore, has provided education

on sexuality and contraception, individual and group counseling, and medical contraceptive serv-ices for a 3-year period. In that short time, the

students enrolled in the demonstration schools (in contrast to those in schools without programs) re-vealed a substantial increase in their knowledge about fertility and contraception, a sizeable in-crease in the number who used contraception when coitus was initiated, and a significant decrease in pregnancy rates.44 Of equal interest, in view of the fixed beliefthat making contraceptive devices avail-able encourages promiscuity, was the finding of a small but significant delay in the age at which coitus was initiated. The debate on sex education must begin with facts and not wishful thinking!

American and Canadian adolescents are born-barded by sexual titillation on TV and in movies and popular music on the radio. What they are denied is information about contraception. The Committee on Adolescence of the American

Acad-emy of Pediatrics has joined the American College

of Obstetrics and Gynecology in calling for the

responsible advertising of nonprescription contra-ceptives on TV.45 The initial response of a network spokesman (Boston Globe, Sept 5, 1986, p 8) was phrased in double-think: “We just don’t feel it’s appropriate for us to advertise that product (con-doms). We have our own standards here.” Need I comment on “standards” that permit the message that sex is all fun and games but not the importance of responsible sexual behavior?

LOW

BIRTH

WEIGHT

Teenage pregnancy is associated with low birth weight infants, the last of the three interlinked psychosocial problems chosen for review. It is not so much that young maternal age is in itself an independent risk factor for having a low birth weight infant, except for mothers younger than 15 years of age, but that each risk (that is, for teenage prenancy and for low birth weight) is associated with low socioeconomic status, minority group membership, poor nutrition, and late or no prenatal care. Low birth weight is a major determinant of neonatal mortality, total infant mortality, and de-velopmental retardation among those who sur-vive.

(6)

of these preventive services would amount to as little as a quarter and at most a half of the medical costs associated with the care of low birth weight

infants. Yet, since 1978, the proportion of women in the United States not receiving care until the third trimester of pregnancy or receiving no care at all has remained unchanged. What has been miss-ing is a social commitment to abolish the barriers

to care: inadequate health insurance coverage, too few service providers willing to serve socially dis-advantaged women, inadequate child care and transportation services, and insufficient effort to recruit hard-to-reach women into care. Once again, we confront a problem that persists, not because we lack the knowledge needed to diminish it, but because we have thus far not shown the necessary social will to get on with the job.5’

PREVENTING

THE

ABUSE

OF PREVENTION

I have thus far stressed what remains to be done in the control of infectious disease, the bright prom-ise ahead in the prevention of hereditary disease, and how applying what we know now can contribute to the control of psychosocial disorders. In view of these extraordinary possibilities, why do I place peril along with promise in the title of this paper on preventive pediatrics?

The peril, and I do not use the word lightly, is that the public may come to accept cost control rather than the improvement of health as the pri-mary justification for prevention. This is no mere matter of semantics. Using the one criterion rather than the other implies a different policy decision in those instances in which the cost of a preventive measure is greater than that of treating the cases that it averts.

Consider the case of free erythrocyte protopor-phyrin screening for presymptomatic lead poison-ing.5’ A population-wide screening program for 3-year-old children will cost less than treating chil-dren when they become symptomatic only if the prevalence of lead poisoning is at least 7%. At the other end of life, vaccinating those 65 years and older against influenza costs an additional $2,000 for each year of life gained when the calculus takes into account the costs for medical care among those who survive because of the vaccine.53 If we accept the economic terms on which cost-benefit analysis is carried out, we are led to the conclusion that we should forego the sizeable health benefits of free erythrocyte protoporphyrin screening for children in the one case and of influenza vaccine for the elderly in the other, because dollars spent exceed dollars saved. Indeed, preventing premature death increases the number of individuals in the popula-tion who survive to 65 years and beyond, when the

infirmities of age increase the need for care.54

In-creases in costs are inevitable, not only despite prevention but to some extent because of it, until such time as we have learned, if we do learn, to avert the chronic diseases that accumulate with age.55 None of this diminishes the case for preven-tion when it is weighed on a scale of human values;

my examples highlight the wrong-headedness of calibrating our scale in dollars alone.

There is another problem for pediatrics. Long-term benefit is commonly invoked to justify pro-grams for children. A new pediatric service may be defended on the ground that the investment will yield healthier adults and a more productive work force. Arguing for children solely on the basis of the future is not only a risky strategy but it is morally unacceptable.

It takes a generation to know whether the pre-diction of adult benefit will be borne out. That uncertainty gives opponents grounds for denying

children what they need today. Measurement by distant outcome places a terrible burden of proof on childhood interventions. They will have to be powerful indeed to be able to show a clear effect in the face of the vicissitudes of subsequent life expe-rience. We have overwhelming evidence of the im-portance of infant nutrition; yet, the best fed baby will not become a healthy adolescent if he or she is starved in later childhood. Is that an argument against feeding babies? Judging by the future im-plies that things are not worth doing for children unless they have a long-run payoff. Do we really have to show that starvation produces mental re-tardation to justify feeding hungry children? Are we to be willing to have adolescents leave school illiterate because adults can be taught to read? Long-term benefits, when we find them, are a bonus

to be welcomed with delight, but it should be justi-fication enough for our efforts if they improve the quality of life in the here and now of our patients.

The time delays between input and outcome and the complex interactions between variables are such that it is not easy to demonstrate the precise impact

of early interventions. In the meantime, and that meantime is likely to be a long time, the patients who suffer from the disabilities that one day we may learn to prevent, will need care. It would be a grievous error to trade on the high hopes aroused by the concept of prevention to deny care to those who will continue to need it.

(7)

is stifled.56 Providing the best care we know how to give is no guarantee of a trouble-free future. Noth-ing is. But that care will make it more likely that our children will be equipped to face the problems

that are an inescapable part of the human

condi-tion.

THE RESPONSIBILITY OF THE PEDIATRICIAN

AS CITIZEN

In the concluding paragraph of Jacobi’s 1889 address, from which

I quoted

at the outset, he reminded the pioneers who had assembled to found the first pediatric society on this continent that4’7

Questions of public hygiene and medicine are both profes-sional and social. Thus, every physician is by destiny a

“political being” in the sense in which the ancients de-fined the term-viz, a citizen of a commonwealth, with many rights and great responsibilities. The latter grow

with increased power, both physical and intellectual. The

scientific attainments of the physician and his

apprecia-tion of the source of evil enable him to strike at its root by advising aid and remedy. ...

Not quite 100 years later, our “scientific

attain-ments” and our “appreciation of the source of evil” have grown beyond Jacobi’s imagining. With the

growth of that power, pediatricians have even

greater opportunities as well as responsibilities as citizens of the commonwealth to strike at the roots

of evil!

REFERENCES

1. Lalonde M: A New Perspective on the Health of Canadians. Ottawa, National Health and Welfare, 1974

2. A Forward Plan for Health, FY 1978-82, Department of Health, Education and Welfare publication No. (OS) 76-50046. Washington, DC, Government Printing Office, 1976 3. Department of Health and Social Security: Prevention and Health: Everybody’s Business, A consultative document pre-pared jointly by the Health Departments of Britain and Northern Ireland. London, Her Majesty’s Stationery Office, 1976

4. Jacobi A: The president’s address: The relation of pediatrics to general medicine. Trans Am Pediatr Soc 1893;1:6-17 5. Blacklader AD: The president’s annual address. Trans Am

Pediatr Soc 1893;5:8-16

6. Bureau of the Census: Historical Statistics of the United States: Colonial Times to 1970. Washington, DC, US De-partment of Commerce, 1975

7. National Center for Health Statistics: Health, United States, 1985, US Department of Health and Human Services pub-lication No. (PHS) 86-1232. Washington, DC, Government Printing Office, December 1985

8. Statistics Canada: Canada Yearbook, 1985. Ottawa, Minister of Supply and Services, 1985

9. Leacy FH (ed): Historical Statistics of Canada. Ottawa, Sta-tistics and Services, 1983

10. Kass E: Infectious diseases and social change. J Infect Dis

1971;123:110-114

11. McKeown TM: The Role of Medicine: Dream, Mirage, or Nemesis? London, Nuffield Provincial Hospitals Trust, 1976 12. Kaunitz AM, Spence C, Danielson TS, et al: Perinatal and maternal mortality in a religious group avoiding medical care. Am J Obstet Gynecol 1984;150:826-831

13. Bloch AB, Orenstein WA, Stetler HC, et al: Health impact of measles vaccination in the United States. Pediatrics 1985;76:524-532

14. White GC, Koplan JP, Orenstein WA: Benefits, risks and costs of immunization for measles, mumps and rubella. Am J Public Health 1985;75:739-744

15. Select Panel for the Promotion of Child Health: Better Health for Our Children: A National Strategy, US Depart-ment of Health and Human Services publication No. (PHS) 79:55071. Washington, DC, Government Printing Office, vol 3: Statistical Profile, 1981

16. Hinman AR, Koplan JP: Pertussis and pertussis vaccine: Reanalysis of benefits, risks and costs. JAMA 1984;251:3109-3113

17. Joint Committee on Vaccination and Immunization: The Whooping Cough Epidemic 1977-1979. London, Her Maj-esty’s Stationery Office, 1981, pp 170-184

18. Kanai K: Japan’s experience in pertussis epidemiology and vaccination in the past 30 years. Jpn J Med Sci Biol 1980;33:107-143

19. Hinman AR: DPT vaccine litigation. Am J Dis Child 1986;140:528-530

20. Cochi SL, Broome CV, Hightower AW: Immunization of U.S. children with Hemophilus influenzae type b polysac-charide vaccine. JAMA 1985;253:521-529

21. Robbins FC, Robbins JB: Current status and prospects for some improved and new bacterial vaccines. Annu Rev Public Health 1986;7:105-125

22. Public Health Service: Coolfont Report: A PHS plan for prevention and control of AIDS and the AIDS virus. Public Health Rep 1986;101:341-348

23. Institute of Medicine: Report of the Committee on a National

Policyfor AIDS. Washington, DC, National Academy Press, 1986

24. Lennon JL, Black FL: Maternally derived measles immunity in an era of vaccine protected mothers. J Pediatr 1986;108:671-676

25. Scriber CR: Window panes of eternity: Health, disease and inherited risk. Yale J Biol Med 1982;55:487-513

26. Scriver CR, Tenehouse HS: On the heritability of rickets, a common disease. Johns Hopkins Med J 1981;149:179-187 27. Hall JG, Powers EK, Mcllvaine RT, et al: The frequency

and financial burden of genetic disease in a pediatric hos-pital. Am J Med Genet 1978;1:417-436

28. Cavenee WK, Murphree AL, Shull MM, et al: Prediction of familial predisposition to retinoblastoma. N EngI J Med

1986;314:1201-1207

29. Lewin R: DNA fingerprints in health disease. Science 1986;233:521-522

30. DiLella AG, Marvit J, Lidsky AS, et al: Tight linkage between a splicing mutation and a specific DNA haplotype in phenylketonuria. Nature 1986;322:799-863

31. Belmont JW, Henkel-Tigges J, Chang 5MW, et al: Expres-sion of human adenosine deaminase in murine haemato-poietic progenitor cells following retroviral transfer. Nature 1986;322:385-387

32. Tsui LC, Buchwald M, Barker D, et al: Cystic fibrosis locus defined by a genetically linked polymorphic DNA marker.

Science 1985;230:1054-1057

33. Eisenberg L, Earls FJ: Poverty, social depreciation and child development, in Hamburg DA (ed): American Handbook of Psychiatry, New York, Basic Books, 1975, vol 6, pp 275-291 34. Rutter M, Madge N: Cycles of Disadvantage. London,

Hei-nemann Educational Books Ltd. 1976

35. Consortium for Longitudinal Studies: As the Twig is Bent: Lasting Effects of Preschool Programs. Hilisdale, NJ, Law-rence Erlbaum Associates, 1983

36. Beruetta-Clement JR, Schweinhart IA, Barnett WS, et al: Changed Lives: The Effects of the Perry Preschool Program on Youths Through Age 19, monograph 8. Ypsilanti, MI,

The High/Scope Press, 1984

37. Jordan TJ, Grallo R, Deutsch M, et al: Long term effects of early enrichment: A twenty year perspective on persistence

(8)

Hours: Secondary Schools and Their Effects on Children.

Cambridge, MA, Harvard University Press, 1979

39. Zelnik M, Kantner JF: Sexual activity, contraceptive use

and pregnancy among metropolitan area teenagers. Fam

Plan Perspect 1980;12:230

40. Furstenberg FF, Lincoln R, Menken J (eds): Teenage Sex-uality, Pregnancy and Child Bearing. Philadelphia, Univer-sity of Pennsylvania Press, 1981

41. Jones EF, Forrest JD, Goldman N, et al: Teenage pregnancy in developed countries: Determinants and policy implica-tions. Fam Plan Perspect 1985;17:53-63

42. Freud 5: Civilization and its Discontents. London, The Ho-garth Press, 1930, p 63

43. Kenney AM: School-based clinics: A national conference. Fam Plan Perspect 1986;18:44-46

44. Zabin LS, Hirsch MB, Smith EA, et al: Evaluation of a pregnancy prevention program for urban teen-agers. Fam Plan Perspect 1986;18:119-126

45. Committee on Adolescence, American Academy of Pediat-rics: Sexuality, contraception, and the media. Pediatrics 1986;78:535-536

46. McCormick MC: The contribution of low birth weight to infant mortality and childhood morbidity. N EngI J Med 1985;312:82-90

47. Paneth N, Kiely JL, Wallenstein S, et al: Newborn intensive

care and neonatal mortality in low-birth-weight infants: A population study. N EngI J Med 1982;307:149-155

48. Guyer B, Wallach LE, Rosen SL: Birth-weight standardized neonatal mortality rates and the prevention of low birth rate: How does Massachusetts compare with Sweden? N

Engi J Med 1982;306:1230-1233

49. Silins J, Semenciw RM, Morrison HI, et al: Risk factors for perinatal mortality in Canada. Can Med Assoc J 1985;133:1213-1219

50. Institute of Medicine: Preventing Low Birth Weight. Wash-ington, DC, National Academy Press, 1985

51. Richmond JB, Kotelchuck M: Political influences: Rethink-ing national health policy, in McGuire CH, Foley RP, Gorr

A,

et al (eds): Handbook of Health Professions Education. San Francisco, Jossey-Bass, 1983, pp 386-404

52. Berwick DM, Komaroff AL: Cost effectiveness of lead screening. N Engi J Med 1982;306:1392-1398

53. Office of Technology Assessment: Cost Effectiveness of

In-fluenza Vaccination. Washington, DC, US Government Printing Office, 1981

54. Gori GB, Richer BJ: Macroeconomics of disease prevention in the United States. Science 1978;200:1124-1130

55. Rice DP, Estes CL: Health of the elderly: Policy issues and challenges. Health Affairs 1984;3:26-49

56. Eisenberg L: Development as a unifying concept in psychia-try. Br J Psychiatry 1977;131:225-237

A YUPPY

TREND

ON THE

ACADEMIC

SCENE

In a world where scholars have to specialize so heavily and rely so much on external sources for recognition and support, loyalties are already divided between the university, the profession, and the agencies that supply them with much needed funds . . . . There is some danger that faculty will stray from their

academic goals as they seek to market their expertise in extramural ventures that provide them with a mounting source of excitement, variety, status and income.

Submitted by Student

(9)

1987;80;415

Pediatrics

Leon Eisenberg

Preventive Pediatrics: The Promise and the Peril

Services

Updated Information &

http://pediatrics.aappublications.org/content/80/3/415

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(10)

1987;80;415

Pediatrics

Leon Eisenberg

Preventive Pediatrics: The Promise and the Peril

http://pediatrics.aappublications.org/content/80/3/415

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

Related documents

The following sampling sites are at Vukovci (18 species) located along the lower course of the river 12 kilometers from the mouth of Lake Skadar.. In the area

The results of present study shows that is no significant difference between interval training method and continuous training method statistically but due to

fl avicollis (Fig. 37) in their smaller juxta, distally broadened valva with a large distal costal process, trigonal medial costal process directed distally, much longer basal

Frontal triangle black, pale pilose with some black pile laterally at level of antennal insertion, shiny medially with grey silver pollinosity laterally on eye margin.. Eye

Maternal plasma zinc levels after oral zinc tolerance test in pregnancies associated with neural tube defects in Turkey. Pregnancy outcome of mothers with defective oral zinc

The / aɪ / sound spelt –y at the end of words English Skills Introductory Book Adding –es to nouns and verbs ending in –y English Skills Introductory Book. and English Skills 1