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\OLUME 40 OCTOBER 1967 NUMBER 4, PART I
COMMENTARY
MORTALITY
AND
MORALITY
SREPORTED by James Joyce, the following
explanations of the problem of infant
mortality were advanced by the house staff
of a Dublin ?‘Iaternity Hospital:
Mr. \I. Mulligan (Hvg. et Eng. Doe.) blames
tINS sanitary conditions. . . . These factors, he
al-leg’s, an(1 the revolting SI)cctacles offered by our
stru’ts, hideous 1)Ublicitv posters, . . . niutilated
soldiers ilfl(1 sailors . . . p1rai1ic bachelors and
un-fruc’tifi1 (luennas . . . were responsible for any 1111(1 ever\’ falling off in the calibre of the race.
Kalipe(lia, he prophesied, W,’OUl(l 50011 be generall’ 51(lopted. . . . Mr. J. Crotthers (Disc. Bacc.)
attrib-Ut(’s 50fl1(i’ of th(’Se (k’IlliSes to abdominal trauma
in the case of women workers subjected to heavy
lahours . . . but by far the vast majority to neglect, pr1’1te or official. . . . An ingenious suggestion is
that thrown out by Mr. V. Lynch (Bacc. Arith.)
that . . . in all probability such deaths are clue to
some law of anticipation by which organisms in which some morhous germs have taken up their
resi(lence . . . tend to disappear at an increasingly
earlier stage of development, an arrangement
which, though productive of pain to some of our feelings (notably the maternal) is nevertheless, some
of us think, beneficial to the race in general.’
Joyce’s account of a medical bacchanal at
the turn of the present century reads not
unlike an overview of the world situation iii
1967. Interpolate social values throughout
substitute napalmed children for soldiers
and sailors, beatniks for bachelors,
preg-nant teen-agers for unfructified duennas,
child battering for Kalipedia, and genes for
germs and the jargon becomes almost
scientific.
For more than 100 ‘ears infant mortality
has acted as a statistical barometer of “con-cern for the welfare of children,” the pediat-nc analogue of “maternal feelings.” During the past few years infant mortality has been
thrust hard to the pediatric concern as a
vulgar but personal symbol first of
under-development in other countries, then of
poverty in our own, and now of the war in
Vietnam.24 Under the circumstances, the
ingenious suggestion of Mr. Lynch’ is little comfort.
The death of a child may be a biologic
event, but pediatricians know better than
most men that its etiology, prevention, and
treatment often fit more easily into a
con-ceptual framework based in human
behav-ior, environment, or society. Methods to
diagnose pathology in these frameworks are
less precise and more controversial than
those applied to the biological framework.
The mechanism whereby adverse
psychoso-cial factors (so crudely expressed in scales
of education, occupation, anomie, or aliena-tion) are translated into fetal or infant bio-logical pathology remain to he elucidated. Yet, “after the first death there is no other.”5
A single child’s death, whether by public or
private neglect, or by the fire of an air-raid
in London or Vietnam, is always a finite
bi-ological event whose social significance
must concern the pediatrician. Methods to
pre’ent or treat the underlying social
pa-thology impinge upon moral and ethical
value systems and the power structures of
548 MORTALITY AND MORALITY
human societies. Yet, his concern for the
welfare of children acts to impel the
pedia-trician to take a stand upon these values
and issues.
Only the most charismatic can lead the
peace marches or poverty fighters, but
pediatricians are well represented in these quarters. Few can afford to trade personal
obligations and life styles for the peace
corps or services of slums, but some do so.
Others divert their energies from
pre-serving life to preventing some of its
conception. Most are left struggling with
conscience, sometimes taking refuge in
scientific detachment, sometimes in pride of
accomplishment or possession, sometimes
in the consuming volume of daily work,
sometimes in counter-attack and
self-de-fense but always uneasy if their concern is
real.
The biomedical actions of napalm and
the disproportionately high mortality and
morbidity
which
it causes among childrenhave been described in a recent article in
The New England Journal o-f Medicine.6
The article is a companion piece to a
description of the armamentarium of
chemical and biological weapons7 and to an
account of crop destruction as a technique
of warfare.5 These methodological tools of
human devastation are relevant to
pediat-rics as a manifestation of modern
techno-logic capability and as the social expression
of this technology, whether conceived in
attack or self-defense. The extent and
re-sults of their application in Vietnam, and
the reasons for our own presence there, are
subject to debate. A tangle of emotional
bias and vested interest (conscious or
un-conscious) surrounds public positions on
either side of the argument. Yet, to charac-terize these sides in simplistic ornithologi-cal terms is, in itself, a symptom of the
flip-pancy with which the hidden imperative
can be concealed in our society. Surely the
extent to which this technology has been
applied in Vietnam is irrelevant to the
pediatric issue-the significance arid the
so-cial message of the picture as a whole.
Everyone is against burning or battering children ( as against sin ). However, many
of the official representations of past and
present history and many of the questions
in public opinion polls on Vietnam are
phrased to equate sin with an aggression of
others (which we are also against ). The
re-sponses pour out of the computer to mirror
the ambiguity of human nature and human
society but are interpreted in the name of
consensus. Published consensus acts to
reassure the individual; he is not alone.
Once the premise is accepted, logic and
reaction to insult harden the course of the
nation as they harden our personal and
col-lective ambiguity, making both increasingly painful to bear.
Kali is an Indian goddess symbolizing the
terror of human aggressions. The children
whom she was reputed to consume are
anal-ogous both to the burned and wounded
and to the battered, abused, and failing to
thrive now laid at the altars of our
hos-pitals. Psychosocial pathology, with all its
emotional overtones, whether deified or
defined in national or international terms,
unites the Vietnamese and American
chil-dren as any reader who cares to review
some recent correspondence which was
printed in PED!ATRICSPII can ascertain for
himself.
All members of a society in which man’s
capability of inhumanity to man has been
magnified so fearfully by scientific
technol-ogy should be concerned for its children.
However, as one of the contributors to the
exchange of correspondence has pointed
out, the pediatrician faces the problem with
a little more “immediate alertness” and a
little more “immediate usefulness” than do
others.’ As a professional with a scientific
background he is able to assess the
poten-tial of this technology for good or for ill; his
reasoning should penetrate the mist of
meaning in “public opinion” and the
pseu-doscientific premises which confound its
in-terpretation. As a physician he is able to
understand the conflicting forces which
EDITORIAL
POLICY
REGARDING
PAPERS
ON
CHROMOSOME
DISORDERS
CO\IMENTARY
barriers to communication; he knows also
that these inner conflicts and inner tensions
have an inevitable breaking point and that
treatment consists of exposing and
inter-preting the realities rather than disguising them in rationalizations.
The cynical explanations of Buck
Mul-ligan are not meaningless. There is a
symptomatic connection between revolting
spectacles, hideous publicity, beatniks or
hippies, and burned or battered children
which forms a clear syndrome for pediatric
diagnosis. Not as a sentimentalist (with
whom he can he ignorantly confounded)
hut as a humanist (for why else did he
choose this career?) the pediatrician is
forced to express his social concern in some active way. The simplest course is to offer
immediate usefulness; children are hurt and
in need of treatment. Yet, he must know
that palliative treatment, however humane,
is no barrier to the plague of deprived and
damaged children produced by untreated
psychosocial pathology. The plague may be
manifest half way round the world, but the
means of prevention are in our own home. The expression of pediatric concern,
mdi-viclually or collectively, should serve to
illu-innate the moral imperative behind this
psychosocial pathology and force
clari-fication of the basic issues upon which
political decisions should be based in a
democratic society. If it fails to do so we
may have to accept Mr. Lynch’s
explana-tion of the “law of anticipation.”x 111 1967,
however, few of us would think that such
an “arrangement” might be “beneficial to
the race in general.”
ALFRED YANKAUER, M.D.
Department of Maternal and
Child Health
Harvard School of Public Health
55 Shattuck Street
Bonton, Massachusetts 02115
REFERENCES
1. Joyce, j.: Ulysses. New York: Random House,
The Modern Library, p. 411, 1946.
2. Ceihorn, M.: The children of Viet Nam. The
Ladies Home Journal, January, 1967.
3. McLanahan, D.: Diary of an American medical
intern in Viet Nam. Saturday Review, March
25, 1967.
4. Salisbury, H. E.: A visit with the enemy. Esquire, May, 1967.
5. Thomas, D.: A refusal to mourn the death by
fire of a child in London. In Collected
Poems, 1934-53. New York: New Directions, p. 112, 1954.
6. Reich, P., and Sidel, V. W.: Napalm. New Eng. J. Med., 277:86, 1967.
7. Sidel, V. W., and Goldwyn, R. NI.: Cheniical
and biological weapons. New Eng. J. Med.,
274:21, 1966.
8. Mayer, J., and Sidel, V. W.: Crop destruction
in South Vietnam. The Christian Century,
June 29, 1966.
9. Bloch, H.: Pediatricians, society, and battered children. PEDIATRICS, 37:856, 1966. 10. Isaacson, E. K.: The eniotionally battered
child. PEDIATRICS, 38:523, 1966. 11. Fontana, V. J.: Recognition of maltreatment
and prevention of the battered child syn-clrome. PEDIATRICS, 38:1078, 1966.
12. Bloch, H.: The battered child. PEDIATRICS, 39:
625, 1967.
13. Halpern, S. R.: The battered child (continued).
PEDIATRICS, 40:143, 1967.
THE
availability of simplified techniquesfor the study of human chromosomes
has revealed that man is heir to a vast
van-etv of chromosome disorders. This has
re-suited in a deluge of case reports dealing
with this group of patients. PEDIATRICS has
shared in this wealth and now, like so many
