Some
Observations
on Pediatrics:
Its Past,
Present,
and
Future
David E. Rogers, MD,* Robert J. Blendon, ScD, and
Ruby P. Hearn, PhD
From the Robert Wood Johnson Foundation, Princeton, New Jersey
I am honored to be with you today. I am partic-ularly flattered that the American Academy of Pe-diatrics-an institution with such a proud history of single-minded advocacy of the health and welfare of children-would permit an internist-turned-phi-lanthropist to make this keynote address.
I have long admired the Academy. I tend to believe that the secret of your remarkable success and the respect you have been accorded by Ameri-can society derives from your unswerving devotion to your original mission. Many of our professional societies, while initially spawned to help address the needs of those who are their special concern, have come to be more preoccupied with the special
needs and problems of their membership.
Not so with this organization. Better health and better opportunities for children have remained your rallying points, and the needs of pediatricians as such have been distinctly secondary. This has not been lost on your admirers. I hope you can keep this refreshing idealism intact in our current cynical
world. Your 1980 ten-point agenda for American children has a magnificent Jeffersonian ring to it.’ It is a bifi of rights for children that deserves wide attention and circulation, and I congratulate you.
So this is a historic and significant occasion. It is historic because it represents your 50th An-niversary.2
It is historic because we have just completed a decade in which many of the programs designed to
* Because I gave this address, I have kept the personal pronoun.
Because my colleagues, Drs Blendon and Hearn, were so
in-volved in data collection and its preparation, they have joined
me in authorship.
Keynote Address delivered by Dr David E. Rogers at the 50th Anniversary Meeting of the American Academy of Pediatrics, Oct 27, 1980.
Reprint requests to (D.E.R.) The Robert Wood Johnson Foun-dation, P0 Box 2316, Princeton, NJ 08540.
PEDIATRICS (ISSN 0031 4005). Copyright © 1981 by the
American Academy of Pediatrics.
improve the health and welfare of children launched with your help in the 1960s have borne fruit.
It is significant because you are launching your lofty ten-point agenda.
Lastly, it is significant because the world has now entered a new decade-that of the 1980s. It is a decade in which there will be fewer children born to Americans. Also it promises to be a decade which will pose a very different set of challenges for pe-diatricians, the Academy, and those generally con-cerned with the welfare of children.
So this seems an appropriate time to take stock: to both look forward to try and decide where we are or should be going to bring the best of health
and medical care to children and to all Americans, and to look back to see where we’ve been and what we’ve accomplished during the decade. From my position on the sidelines, I propose to try and do a little of both in addressing you today. Some of what I will put before you represents an analysis of what has taken place during the past 10 to 15 years in improving the medical care available to Amen-cans-particularly our children. Some represents an effort to forecast what challenges the next dec-ade may bring for those working in health affairs. Finally, I wifi offer some tentative suggestions about areas which may deserve Academy attention during the period to come.
those seeking to yet further improve American health and medical care.f
Based on those studies, we have come to believe that this nation is entering a period of uncertain length in which there will be a marked slowdown in the rate of growth of national expenditures for most social programs. While pressures wifi mount to de-velop more programs to help many in our growing populations who are experiencing hardships, there
wifi be fewer new dollars to apply to such programs. Health care, health institutions, and perhaps par-ticularly services directed toward children will be among the first to feel the pinch. Thus unless we are quite vigilant and quick on our feet, we may
witness some serious disruptions of gains in medical care made during the last decade.
Let me stress, however, that my message today is not one of gloom and doom. I would emphasize that I am projecting a slowdown in rates of growth, not a depression. However, moving from highway speeds of 75 miles per hour to a 55 miles an hour speed limit requires significant readjustments, and a different mindset for many of us. Such changes do not come easily. But, based on the studies I wifi report, I would like to raise two broad but serious issues which I believe deserve the attention of the American Academy of Pediatrics, and to suggest that these issues might help set the agenda for some of your work in the period to come.
Let me give you my two conclusions first and then fill in around them.
My first point-to my sorrow, I believe the re-ductions in expenditures for health and medical care that we are predicting will not be particularly
logical. They will occur because rates of increase in public monies to support medical care services for the less fortunate will be sharply reduced, and this will threaten a number of health care gains made
by our most vulnerable citizens during the 1970s. It follows that significant numbers of poor children, the poor elderly, and minority citizens may be sub-tly disenfranchized without us really recognizing that this is occurring. These groups, particularly
children, may once again find it difficult to obtain the medical care they need.
My second point, equally painful and one of in-creasing concern to pediatricians today-even if we wished to avoid this harsh solution to reducing
t The results of our studies attempting to forecast the economic future as it relates to health and medical care, and the sources
from which the information was derived, are appearing in more
extended and somewhat different form in two other publications:
(1) Blendon RJ, Schramm CJ, Moloney TW, et al: “The 1980’s:
A period of stress for health institutions. JAMA, in press 1981.
(2) Rogers DE, Aiken LH, Blendon RJ: Personal medical care:
Its adaptation to the 1980’s. Proc Natl Acad Sci USA, in press
1981.
health care costs by setting sensible priorities for the day-to-day care of patients in ways that would do the least harm, we would find this a nearly impossible task.
The reasons for this are straightforward. We have no agreed upon end results with which to judge the successes of our enormous, one-on-one personal health care system, or targets around which to set priorities. Our traditional measures of health simply do not show us the effects of what pediatricians or other health professionals do each day in caring for children or adults in their daily lives. Thus we are left without defined goals against which to evaluate
the work of our medical care efforts, or to agree on priorities.
Let me try to fill in the background from which those views arise.
First, I would remind you that the end of the 70s marks the end of a highly significant period in American health affairs. During the early 1960s and continuing into the 1970s, this nation markedly increased its national commitment to improving medical care for all of its citizens. The academy was instrumental in launching many new programs to improve the care of children. These efforts were part of a general optimism about our abilities to better shape our world and Americans had high hopes, indeed considerable confidence, that we could create in this country a society that could offer dignity, equity, and good medical care to all of our citizens.
However, by the late 1960s and becoming intense in the early 70s, was a gradual shift to a spirit of disifiusionment and pessimism. Despite the large
national commitments of funds made during the
1960s to improve medical care, there was a general belief abroad that things were getting worse, and the “health care crisis” was much in the discussions of the day. General, out-of-hospital medical care seemed hard to come by for many, and the dwin-ding numbers of health professionals who rendered general medical care services was of deep national concern. Institutions-hospitals, academic medical centers, and practicing physicians-were viewed as being unresponsive to unmet needs, and horror stories about the unavailability of care were much in the public eye. Access to personal health care services was viewed as a major problem for many people, and the problems experienced by children
particularly troubled the American conscience.
However, as all of you know, things were not as static as portrayed. The current health and medical care scene is significantly better than that which the nation and the Academy faced in 1970.
No. Of Physician Visits 4 2 Per Person Per Year - - . 4 0
-37... 4.5
4.0
3.5
3.0
25
20
38
25
1967 1971 1978
- Poor -- - Non-Poor
1967 1971 1978
No. Of Physician Visits
Per Person Per Year 4.5
37
3.5
-.34
3.0
28
2.5
1967 1971 1978
- Urban -- - Rural
Fig 3. Per person physician visits: urban and rural
chil-dren, 1967 to 1978.
2.50
2.25
2.00
1.75
1.50
1.25
1.00
.75
.50
.25
0
No Of Dental Visits Per Person Per Year
.-.--.-19O 1 60 - -
-70 1 00
j National Health Interview Survey, Public Health Services,
Dept of Health, Education and Welfare, National Center for
Health Statistics, unpublished data, 1971 and 1978.
1969 1978
- Poor --- Non-Poor
Fig 4. Per person dental visits: poor and non-poor
chil-dren, 1969 to 1978.
Fig 1. Per person physician visits: poor and non-poor children, 1967 to 1978.
4.5
No Of Physician Visits Per Pc so Pc
40 r n
3.5
3.0
34
-.
/ 30 ,
2.5 /
, /
2.0 20”
- White -- - Non White
Fig 2. Per person physician visits: white and nonwhite
children, 1967 to 1978. s.o
have serious problems in finding a doctor, and it is critically important that we not forget or ignore these groups, overall access to physician services is much easier to come by. Yet more satisfying to those of you in this room, physician care is now
more readily available to those children who need it most.
As shown in Fig 1, poor children, often poorly served in the mid-GOs, are now seeing physicians almost as frequently as their more well-to-do coun-terparts.4
Similarly, as shown in Fig 2, black children and those from other minority groups, have also made significant gains, though they still lag behind.4’
Fig 3 shows that we have not done as well with children from rural areas. Although again, they are now seeing physicians more often than in times past, they continue to fare less well than their urban counterparts.4’
There is one area in which we continue to do
poorly. As noted in Fig 4, we are not bringing poor children into the dental care system very satisfac-torily and this needs continuing effort.5’
It is worth stressing that I could show you much more impressive gains made by adults. Adult blacks and the adult poor are now seeing physicians at rates equal to or above those of the non-poor or whites. As is too frequently the case, we do not do as well as we might by our children.
These gains have been the result of two forces: first, the marked increase in the numbers of physi-cians we have, as a nation, made available in recent years,6 and second, the marked increase in public funds to support child care, particularly Medicaid.
One caution, these projections represent
aggre-gate data. They can hide within them considerable human misery. We now have considerable evidence to suggest that simple physician capacity does not necessarily gain everyone access to personal care.
Recently we have coined the term “structurally underserved” as a shorthand to characterize certain groups who continue to have problems. I find this term helpful. The term “structurally unemployed” has come to mean those people who, regardless of the availability of jobs, are unable to find or hold employment. It now appears that there are also
1900 1910 1920 1930 1940 1950 1960 1970 1980
Rate Pc
Rat. P#{149}r 1.000 Livi
Births
1950 1055 1080 1965 1970 19751977
Ysar
Fig 7. Infant mortality by race, 1950 to 1977.
100 90 80 70 60
50
40
30
20
10
Fig 5. Infant mortality in the United States, selected
years 1915 to 1977.
1.O 800 700 600 500 400 300
200
ic
60 50 40
30 1 1 T T I
1900 1910 1920 1930 1940 1950 1960 1970 1980
Fig 6. Death rates for ages 1 to 14: in the United States,
selected years 1900 to 1977.
risk here. Clearly we must make special and specific arrangements to reach out to these groups-and particularly to children-if they are to share in the greater abundance of physicians most of us now
enjoy.
Lastly and obviously of most importance, occur-ring in parallel with improvements in access to care, but with no suggestion of causal link, the health status of Americans during the decade as measured by faffing age-adjusted death rates, deaths due to coronary artery disease, and similar gross statistics has improved more sharply than at any previous time during this century. Mortality rates more spe-cific to children have also decreased substantially. As noted in Fig 5, the improving lot of infants and children since the turn of the century is a monu-mental success story.8 Yet more satisfying-without
much heralding, infant mortality fell by almost 50% between 1960 and 1978-from 26 to 13.6 infant deaths per 1,000 live births, the lowest ever recorded in the United States. This seems of particular in-terest because the conventional wisdom of the 1960s was we had gone about as far as we could go in reducing infant wastage.
The similar gains made for those in the 1- to 14-year-old age group are shown in Fig 6.8
That we still have a way to go in certain areas, however, can be shown by contrasting those
na-tional infant mortality statistics with those of this city of your birth-Detroit. Here infant mortality rates in 1978 remained at 22.3/1,000, despite overall Michigan rates of 13.8 (National Center for Health Statistics, Division of Vital Statistics, personal
com-mumcation). There are other pockets of similarly unacceptable infant wastage in many parts of the country, but we know where they are and we know the special groups at greatest risk. I believe we have ways of addressing the problem.
Fig 7 shows how well we’ve done recently in improving the chances of survival for American Indian children.9 By 1990, I would hope we could see similar improvements for black children.
So this is the good news, and we should take heart from it. As a nation we have made progress.
But what of the 1980s? This is the more
worn-some side of the ledger. Our review of the available evidence suggests a dramatically different decade which promises to make further improvements in health care much more difficult to effect. The
im-pact of the current deteriorating economic situation on the whole continuum of biomedical research, the training ofhealth professionals, and further
improv-ing health and medical care appear to be in for tough sledding.
Let me give you those forecasts. They are derived from both macroeconomic forecasts and opinion polls which also have predictive value in signaling shifts in public policy. What then do they suggest?
First, an indeterminate period of slow real eco-nomic growth, perhaps the slowest since World War
II. This is already putting enormous pressures on the health care sector to better control expendi-tures.
Second, continuing inflation similar to the 1970s. Continuing rises in health expenditures exceeding what is happening in the rest of the economy will
probably be less acceptable than in the past.
Third, decreased real purchasing power for indi-vidual consumers.
80
60
40
20
10
8
6
Fourth, a sharp dampening in real growth of expenditures by federal and state government with rates of increase falling very sharply below that of the last decade. This suggests that growth in the health sector which now claims 13 cents of every nondefense federal budget dollar will fall cone-spondingly.
These pessimistic economic forecasts are paral-leled by public perceptions of a worsening economic situation. Sixty-two percent of Americans believe we are entering an era of enduring shortages, and 38% indicate they are already having difficulty in handling their expenses for routine health care.’#{176}
Further, even when the public is asked exclu-sively about issues in health and medical care, their principal preoccupation is overwhelmingly with costs of that care.’#{176}
If these projections have validity, it seems clear that the changing circumstances will have profound effects on the nation’s health care industry which now employs 7 million people. Thus the following seem real possibilities.
1. It seems unlikely the country will expend large
sums for any new publicly supported domestic health care program. Enactment of any form of comprehensive national insurance seems more re-mote, and it will be much more difficult to spend more on upgrading the health care provided to our children or our growing population over 65.
2. Many of the nation’s hospitals and academic
health centers will find themselves financially hard-pressed because of their dependence for more than half of their operating funds on constrained public
and philanthropic support.
3. Reduced real personal income will limit the ability of some individuals to meet out-of-pocket medical expenses and some may forego needed medical care.
Obviously slower increases in the supply of dol-lars will lead to intense competition between var-ious groups and institutions for that more limited level of public and philanthropic support. Projec-tions suggest that there will be more unemployed, more young lower-income minority people, more
elderly and disabled who will need assistance. More new immigrants and undocumented residents will also create demands for dollars previously devoted to improving health and medical care.
Left alone, it seems probable that government and private funding sources will have no alternative but to cut funds from the support of health and medical care now devoted almost exclusively to our most vulnerable citizens. Indeed there is evidence that this is already happening. Last year (1979) 250,000 less people in New York City received
Med-icaid benefits than in 1970. Unpublished studies by Dr Cliff Gaus of Georgetown University suggest
that the rollback is already widespread. Since 1976, almost 3 million people have lost Medicaid
assist-ance.
Clearly those of us concerned with the adequacy
of and equity in distribution of medical care for children need some ways of monitoring what is occurring here and should take steps to prevent the very real human problems continuing retrenchment may create. Over 75% of our poor children now
have their care paid for from Medicaid sources.” Simply by keeping before the public the fact that
our least fortunate children are getting hurt, and developing other options for cutting health care costs, the Academy could play a powerful and so-cially important leadership role.
To turn to my second point, even with the rec-ognition that this is happening, and with a clear desire to reverse the trend by setting sensible pa-tient care priorities, we do not have the means at hand to do so. We have not agreed upon end points or defined outcomes of what we wish to see result from the personal physician-patient interaction.
Here we are the victims of our own technologic successes, and this is particularly the case for pe-diatrics. Let me put this dilemma before you.
Traditionally, improvements in medical care have been, in the public mind, synonymous with decreases in infant mortality or death rates and increased life expectancy. However, during the last several decades most of what we do as health professionals has shifted from a simple focus on the prevention of death to efforts to restore individuals who are physically or mentally below par to their maximal potential function within the larger soci-ety. Pediatricians have been at this for a long time-and way out ahead of the rest of us. However, now most physicians in all specialties have moved well beyond the concerns of simply preserving or ex-tending life per se, to deal primarily with technolo-gies and treatments aimed at improving the capac-ities of individuals to assume more fully their work or school or family roles.
Yet the kinds of statistics currently used to track our efforts within the personal health care system do not monitor with any sensitivity the changes that are reflected by our new preoccupations. Infant mortality rates and other sets of current statistics do not measure the impact of what pediatricians spend their time doing. Until we have replaced these statistics with yardsticks that more accurately reflect what physicians do-to restore people to fuller functioning-we will be unable to agree on which adjustments or changes we should make in the ways on which adjustments or changes we should make in the ways we care for people that
Pre - Antimicrobial Era
Preservation of Life Present
$
Lb
Restoring Function Fig 8. Patient-physician preoccupations.of each 1,000 children in our population visit a physician on at least one occasion. Yet in the same year, less than one of each 1,000 die. I am convinced that most of those 750 children brought to you do not seek your care because their parents believe they have a life-threatening problem. They are
primarily concerned with unwellness in their young-sters which interferes with their day-to-day func-tion, and they wish their child to be restored to that which is maximally attainable.
Although some might argue this point, I would guess that this was not always so. In the pre-anti-microbial days when acute bacterial disease took a significant toll in young lives, I would wager that many more patients and much of the doctor’s time was preoccupied with the preservation of life. But
our way of measuring what the personal health system does today has lagged so far behind reality that we now are engaged in countless anecdotal arguments about the importance of medical care without any real data to support the enormous
sums and human effort devoted to it.
This dilemma is schematically portrayed in Fig
8. In the pre-antimicrobial era, more of your and
my activities in a much smaller universe were
de-voted to the preservation of life, and perhaps keep-ing book on success in only this area made
reason-able sense. But in the 1980s, very little of what we do in the personal health system relates directly or
immediately to the preservation of life, yet all of our yardsticks monitor only this small sector of our activity.
Thus it seems to me we should devote major efforts to developing better ways of measuring our
successes or failures in the personal health care system in functional terms so that we can begin to make wiser allocations of available resources to better the human condition.
How might this be done? I do not have a defini-tive answer, but a number of pediatricians have devoted years to developing ways to do this, while
I I I I I I I I I I I I
70 60 50 40 30 20 10 0 10 20 30 40 50 60
Percent
Fig 9. Changes in content of practice noted by
pediatri-cians, 1973 to 1978.
most of the rest of us have largely ignored their
work.
The use of a different set of yardsticks which
focus on function could, I believe, allow physicians to more precisely judge their performance. We could, then, individually and collectively better
de-termine the usefulness of particular interventions or technologies and decide what made the most cost-effective sense in our administration of per-sonal medical care.
This issue is of importance to all of us in medi-cine-but it is a particularly compelling issue for you as pediatricians. In preparing for this address,
and in reviewing some of your literature, I have been impressed with where practicing pediatricians
now spend their time.
As shown in Fig 9, the shifts in the problems brought to you by parents and children seem pro-found.’2 The pediatrician in practice is now
primar-ily concerned with problems relating to school health, with allergies, with problems requiring par-ent and child counseling, and with the supervision
of child growth and development. The former life-threatening problems and care of the hospitalized child seem to occupy less and less of the pediatri-cian’s day. This change in your realities coupled with the increasing pressures produced by the new legislation mainstreaming handicapped children seems to me to be generating three sets of questions
for our society.
For parents, the compelling question is, “What are our child’s assets and how can we most skififully support and reinforce them?”
For the schools, it is, “What are the child’s deficits and how can we best design remedial strategies to help youngsters cope with them most effectively?”
For you, the pediatricians, the central question is clearly, “How can we turn apparent childhood def-icits into assets, or mute them successfully, so that a child can become the most fully contributing member of society within his or her capacity?”
Decrease Increase
School Problems
Allergies
1
Counseling
I Newborn In 1. Hospital
To try to get at these questions, let me suggest a focus framed by three questions which might serve as underpinnings for your agenda for pediatrics for the 1980s.
First, can pediatricians develop ways to better identify, classify, and predict the outcome of func-tional disabilities which become apparent during childhood?
Second, can pediatricians focus more carefully and selectively on objectively validating the health
and medical interventions which really do improve the functional abilities of children?
Third, can you plan to do this kind of research in ways which will genuinely involve practicing pedia-tricians and their daily world of troubled children in their communities, and not confine your research to the hospital setting?
Clearly these areas, or careful study of them, create a special role and a special opportunity for practicing pediatricians. The kinds of problems now of major concern to parents, to schools, and to many of you are not the kinds of problems seen in academic medical centers. Academe deals with some very special problems of youngsters-they do
it well and further work on these complex problems desperately needs more support.
But the bulk of childhood problems, which are
the day-to-day life of the practicing pediatrician, now also need your best efforts. It is only through careful and systematic clinical observations and development of new knowledge about these prob-lems that their magnitude can be fully understood, the reasons for the disabilities dissected, and
pos-sible solutions begin to be developed.
Clearly, to work effectively on this agenda, you must take into account the harsh economic realities and constraints of the 1980s that I have suggested may lie before us. Thus you will note that I am not suggesting that the Academy pursue work on all of the interventions at your disposal in a diffuse effort to solve all of them. It is my belief that you will be most effective if you target very carefully on those problems which appear of most significance, and of
yet more importance, on those problems where you have evidence or believe you can develop the
evi-dence that your interventions can really signifi-cantly improve the lot of the children under your
care.
Let me use a recent study to support my thesis that in the present era, carefully proving that cer-tam interventions do improve the lives of children helps enormously in securing the support of an economically anxious public.
In the late 1960s and early 70s, the reports of James Coleman’3 and studies by Christopher Jencks and his colleagues’4 both suggested that the enormous efforts made during the early 1960s to
improve school performance by increasing amounts of monies expended per pupil, or reducing class size, made very little difference in the subsequent per-formance of children. These studies were accepted with gloom. They fitted with the then conventional wisdom that all of our efforts to improve the lot of
the less fortunate didn’t work, and interest in fur-ther expenditures to improve the performance and function of schoolchildren waned.
But almost a decade later, a much more carefully targeted study of 1,500 schoolchildren was con-ducted by Michael Rutter in England. This study,
which asked a much broader and deeper series of questions, has been recently published as a special
article in Pediatrics.’5 And here the answer is clear. Namely that certain efforts directed at children’s function in school can make a profound difference. Indeed, their studies show that children derive re-markable benefits from attending schools which set
good standards, where teachers provide good models of behavior, where children are praised and given responsibility, and where lessons are well
conducted. This broader study is yet more persua-sive because it agrees with the Coleman and Jencks
studies which preceded it in showing that simply more monies or smaller classes did not do the job. However, we now have elegant evidence that there are powerful school interventions which can make profound difference in the functional abilities of
youngsters, and this has renewed the interest of many in further work in this area.
These cheerful studies say two things to me. First, don’t try to do everything for all children, but be selective. Second, design your evaluation of ef-fects with great care so that you can detect it when you’ve improved the world.
I could cite other studies which make the same point-that targeting on groups at high hazard of trouble and careful study of interventions make a difference. The work of Heber and his associates showing that careful targeting of efforts on young-sters at high risk of mental retardation by virtue of having retarded mothers has high payoff in signifi-cantly improving subsequent intellectual function-ing is a case in point.’6 That simply reducing the thermostat setting on hot water tanks in homes can profoundly reduce the numbers of serious burns in young children (a study which involved practicing pediatricians) is another.’7 The Tennessee experi-ence showing that automobile restraint seats for young children can virtually eliminate fatalities in automobile accidents is yet another.’8 All of these
seem to me to couple careful clinical observations, thoughtful interventions, and validation of results in ways that have had payoff for better-functioning, healthier children.
practical research such as those cited is that it
seems to represent a tremendous amount of hard work just to demonstrate what we already know on the basis of experience or common sense. This is indeed true, for research into practical issues rarely comes up with findings that are totally unexpected. On the other hand, as Michael Rutter has pointed out, information of the kind cited here is often of
enormous help in showing which, of an abundance of good ideas available, are related to a successful
outcome. It is in areas such as these that I feel pediatricians, particularly practicing pediatricians, could make some important contributions to how we can improve the quality of life and function for certain children in the decade to come.
We have taken this conviction seriously in our
own work. It has led us to redirect some of our resources toward carefully targeted efforts designed to obtain objective evidence that certain interven-tions work (or don’t work) in bringing new health care to children.
We are now supporting five national programs involving almost $30 million directed at the effects
of better birthing, early developmental assessment, medical aspects of chronic school absenteeism, and preventive dental programs on the health of chil-dren. All of these programs are preoccupied with function: how to guarantee children maximum use of their potential, how to move around defects, or how to restore them more swiftly and effectively to
maximal participatory function to home or in school.
In closing, let me state that I have always been mindful and admiring of pediatrics’ recognition that it has a broad mandate and broad responsibilities for the protection of the welfare and health of children. Indeed it was concerns in this area which led to the development of this distinguished Acad-emy.
I hope you continue in just this mind-set. But today I am suggesting that during the 1980s you may paradoxically best defend this broad mandate if you target quite precisely on those less dramatic but critically important problems of children which now occupy so much of the time, energy, and mon-ies of familmon-ies and society in general. I am suggesting
that you carefully assess which of your interven-tions truly better the lot of children, and whenever possible launch the necessary studies to prove that indeed this is the case.
What are desperately needed are practical medi-cally assisted programs supported by good data which can help children to function more ade-quately in our society today. I think where children are concerned there is little question that resources
will follow if such information is available.
My final point is, I believe, evident from what has
gone before. I believe the decade of the 1980s is an era in which the thoughtful science-based practicing pediatrician can truly make his or her mark. You have the lead role in dealing with the majority of problems which currently impair the full function-ing of this nation’s children. These are out-of-hos-pital problems. Pediatrics’ magnificent successes of
the past in profoundly reducing or eliminating
scourges which in certain areas killed as many as one out of three children at the turn of the century has left pediatrics with a series of less life-threaten-ing but no less important problems of function, or impaired function, which now need your best
atten-tion.
The basic biomedical science work in the neural
sciences, immunology, genetics, and cellular biology
so critical to a better future rests with your aca-demic center-based colleagues. But much of the work on identification of significant problems, their relative importance, their epidemiology can be done by you. Developing better ways to measure and document the pediatrician’s role in improving the functional abilities of children, and targeting care-fully on the problems where your efforts make a difference, can also be vastly benefited by the thoughtful efforts of practicing pediatricians
work-ing with children in their everyday lives.
This focus seems important for the 1980s if we are to protect, preserve, and further extend the
gains made in the care of children during the last several decades. It also seems much in keeping with the overall mission of the Academy of Pediatrics to which you have been so faithful over the last 50 years.
REFERENCES
1. An Agenda for America’s Children. Evanston, IL, American
Academy of Pediatrics, 1980
2. 50 Years of Child Advocacy: American Academy of Pedi-atrics, 1930-1980. Evanston, IL, American Academy of Pe-diatrics, 1980
3. Rogers DE, Blendon RJ: The changing American health
scene: Sometimes things get better. JAMA 237:1710, 1977
4. The Health of Children, 1970. Public Health Service,
Na-tional Center for Health Statistics, Department of Health,
Education and Welfare Publication #PHS 2121, 1967
5. Health in the US, 1975: A Chartbook. Dept of Health,
Education and Welfare, Public Health Service, HRA,
Pub-lication HRA 76-1233, 1969, p 35
6. Aiken LH, Lewis CD, Craig J, et a!: The contribution of
specialists to the delivery of primary care. N Engl J Med
300:365, 1979
7. Rogers DE: Testimony on the National Health Service
Corps hearing before the Senate Subcommittee on Health
and Scientific Research, Committee on Labor and Human
Resources, Sept 24, 1980. US Senate, 96th Congress, second
session on examination of the implementation of the
Na-tional Health Service Corps Program of the Health Services
Administration under the Department of Health and Human
Services, Washington, DC, Government Printing Office,
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