Health care for handicapped adolescents: International legislative and policy trends

JOURNAL OF ADOLESCENT HEALTH CARE 3:103-109, 1982

Health Care for Handicapped Adolescents: International Legislative and Policy Trends J O H N M. P A X M A N , JD

Between 1970-1976, 45 countries enacted or made adjustments to laws on health care for the handicapped. This article explores some of the legal arrangements made to address the issue of health care for the handicapped adolescent. It reviews the legal definition of "handicapped" and analyzes the legislative support created for health care programs. Most programs are comprehensive. They focus on prevention, detection and reporting, as well as treatment and rehabilitation. Better care for disabled adolescents is one of the more important intended results of recent legislation directed to the handicapped. Rehabilitation has been increasingly recognized as a fight. Prevention is an increasing focus. Legislation, however important, is only a beginning; it expresses the political will be create programs to address the issue. The challenge is to implement the law. KEY WORDS:

Handicapped adolescents Health care Legislation Policy

Some years ago, the United Nations' Report on Children estimated that at least 5% of the children in a given population are severely handicapped, and between 10% and 15% need special attention due to physical abnormalities, chronic illness, accidents, or mental disabilities (1). There are 60,000 children born with physical or mental handicaps annually in the Federal Republic of Germany (2). Nearly a million young people in France suffer from the effects of mental retardation, cerebral palsy, or other develFrom the Population Policy Division of The Pathfinder Fund. Requests for reprints should be addressed to: John M. Paxman, Chief, Populat!on Policy Division, The Pathfinder Fund, 1330 Boylston Street, Chestnut Hill, Boston, Massachusetts 02167. Manuscript accepted June 1, 1982.

opmental problems (3). An estimated 15% (about 761,000) of all children in Turkey are "different" as defined by local euphemism (4). There are an estimated 4 million handicapped Filipinos, one-half of w h o m are children and adolescents (5). A decade-old British Commonwealth survey put the number of blind children in Bangladesh in need of surgery at 50,000; the number of children with leprosy and polio in Tanzania from 20,000 to 25,000 and 20,000 to 30,000, respectively; the number of "orthopedically" handicapped children in India at 400,000, and those with symptoms of mental retardation between 1.4 and 1.8 million (6). The "disabled" in the United States number more than 35 million, of w h o m roughly one-half are adolescent or younger (7). The numbers alone are daunting. So are the difficulties in providing care. Health care for the handicapped adolescent is no simple matter. It is as complex as it is specialized. The brusk fact is that given the weight of numbers, the scarcity of health resources of most countries, and the variety of special needs, only a portion of the handicapped adolescents who require health care, worldwide, get it. Where health care is accessible to them, the simple model of the physician or health care worker providing treatment in isolation is often inapposite. As one World Health Organization (WHO) expert committee report stated, "The [health care] problem of adolescents with multiple handicaps is so complex that neither parents nor the physician alone can cope with the situation" (8). Handicaps imply a special set of health care needs, some which focus on diagnosis , others on treatment, and ultimately on rehabilitation or maintenance. In the end the response must be an individualized one. Programs that focus on adolescents are of necessity public in nature. They draw their mandate from public health legislation and policy.

© Society for Adolescent Medicine, 1982 Published by Elsevier Science Publishing Co., Inc, 52 Vanderbilt Ave., New York, NY 10017

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This paper will explore the various legal arrangements that have been created in the last decade to address the issue of health care for the handicapped adolescent.

Legislative Support for Handicapped Health Care The year 1981 was designated as the International Year for Disabled Persons. As a way of directing attention to the legislative aspects of the subject, it drew on two important precursors: the First (Rome 197!) and Second (Manila 1978) International Conferences on Legislation Concerning the Disabled. The Manila Statement offers the following lofty encouragement: Every developing country should legislate before !981 to ensure the right of access to and the provision of educational, medical, social and vocational services needed to enable all disabled persons to enjoy their rights and develop their full potentials. (9) •

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The statement also includes some all-inclusive guidance on the issues that legislation should address, including the types of care and services to be authorized, the preventive programs to be created, the resources to be made available, and the administrative arrangements necessary to watch out for the needs of the handicapped. It establishes ambitious goals. Many so-called "developed" countries have yet to address these issues satisfactorily. Nevertheless~ it serves as a point of departure, an expression of international will. The drive to legislate solutions over the last decade should be placed in its proper context. At an international level, the most significant document is the recent United Nations Declaration on the Rights of the Disabled (1975). Article 6 sets the ideal: Disabled persons have the right to medical, psychological and functional treatment, including prosthetic and orthotic appliances, to medical and social rehabilitation.., and other services, which will enable them to develop their capabilities and skills to the maximum . . . . (10) Earlier, the Declaration of the Rights of the Child (1959), noted that "The child who is physically, mentally or socially handicapped shall be given special treatment, education and care as required by his particular condition" (11). There is every reason to expect that this right to treatment and rehabilitation will become more than theory only if nations begin to put in place the legal machinery through which

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these types of services can operate. This is for a simple reason: United Nations declarations do not legally bind countries to do what is said in them. Declarations state the acceptable ideal. Countries themselves must enact their own laws. That is the first step. In the last decade an increasing number of countries have legislated on the issue of care and rehabilitation of the handicapped• A comparative study undertaken in 1976 by the Department of Economic and Social Affairs of the United Nations revealed that as of 1970 many countries had legislation on rehabilitation services for the handicapped (12). An update of that study indicates that during the ensuing 6 years nearly 45 countries enacted laws on the subject (13). Two general trends were noted: (a) an expansion in the coverage of programs for the handicapped, and (b) a more carefully orchestrated attempt to link the numerous programs for the handicapped together, so that their needs are being addressed in a coordinated manner. The examples cited below reemphasize those trends. They also indicate that the health philosophy underpinning the legislation is four-pronged, aiming at prevention, detection, care and treatment, and rehabilitation. Some of this legislation is directed toward the handicapped as a group, some toward adolescents specifically. Where the former prevails, program s for adolescents are subsumed under the general legislative provisions rather than separated out for special treatment. This will be seen later. But first a word about legal definitions.

Definitions The dictionary defines a "handicapped" person as one w h o is "suffering from some disability or disadvantage" (14). Handicaps, in general, impede one's ability to function in a way that is considered "normal." The dictionary definition is, however, sparse. Some of the legislative definitions on the handicapped are more detailed, and are important because they establish who is eligible for specialized care. Four brief examples will suffice. Zambia's Handicapped Persons Act of 1968 states that the "handicapped" are: those persons who by reason of defect of mind, senses, or body, congenital or acquired, are unable to take part in normal education, occupation and recreation or require special assistance and training to enable them to take part in [these] normal [activities]: (15)

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In Portugal a "handicapped" individual is defined as one: who by injury, deformity or disease, whether congenital or accidental, suffer permanently from diminished capacity to engage in the occupational or ordinary activities of daily life. (16) In the United States the federal government, in truly legal language, defines as "disabled" (synonymous with "handicapped"): any person who has a physical or mental impairment which substantially limits one or more major life activities o r has a record of such impairment o r is regarded as having such impairment. (17) There are distinct parallels between these statements and the definition found in the United Nations Declaration on the Rights of the Disabled. It describes a disabled person as anyone who is "unable to ensure by himself or herself, wholly or partly, the necessities of a normal individual and/or social life, as a result of a deficiency, either congenital or not, in his or her physical or mental capabilities"

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Table 1. Comprehensive Handicapped Health Care Legislation Applicable to Adolescents in Selected Countries Country

Legislation

Costa Rica

Decree No. 5347 (1973)

Egypt

Law No. 39 (1975)

France

Law No. 75-535(1975)

Germany, Democratic Republic of

Decree of 10 June (1971)

Italy

Act of 10 March (1971)

Japan

Basic Law for the Welfare of Physically and Mentally Handicapped Persons (1970)

Mexico

Regulation on Prevention of Disabilities and Rehabilitation of Disabled Persons (1976)

Netherlands

General Disablement BenefitAct (1976)

New Zealand

Disabled Persons Community Welfare Act (1975)

Spain

Crown Decree No. 2828 (1978)

United States (federal)

The Rehabilitation Act (1973); regulations (1977)

(10). There are, of course, varying degrees of disability. Some legal texts acknowledge this. The U.S. Department of Health Education and Welfare states that a "severely handicapped" person is one who requires "multiple services" over an extended period of time. Though few of the legal definitions are exact copies, they do focus on four crucial factors. First, they use similar language to describe the handicapped or disabled. Among the syonymous, recurring words seem to be "injured," "deformed," "diseased," "impaired," "defective," and "deficient." Second, they distinguish the type of handicaps: physical, sensory, mental, or any combination of these. Third, they identify the origin of the disability: "congenital or acquired." And fourth, they describe how the handicap "limits" a person's ability to participate in the "normal" or "ordinary" activities of life.

Comprehensive Handicapped Health Care Programs There is a trend in recent legislation to fix health care activities within a larger, comprehensive framework that coordinates a wide range of services for the handicapped (see Table 1). France is a prime example: In 1975, legislation established a comprehensive system that provides not only medical, but also

social protection to the handicapped. According to the law "the prevention and detection of handicaps" as well as the "care, education, training, vocational guidance, employment, a guarantee of minimum resources, social integration, and access to sports and leisure activities" for persons who suffer handicaps is a national obligation (18). To further this obligation, a National Advisory Council for the Handicapped was established for a 3-year period (19). The council, emphasizing the cross-disciplinary nature of the problem, was created under a joint order of the Ministers of Justice, Education, Agriculture, Labor, Social Security, and Health. It is composed of representatives from some 25 associations or governmental bodies that deal with the handicapped. Similar arrangements are in evidence in Spain, Trinidad and Tobago, and Costa Rica. In Spain the Royal Association for the Education and Care of the Handicapped replaced a number of other agencies as the principal coordinating body for matters relating to the handicapped. Section 4 of Crown Decree No. 2828 of i December 1978 (20) gives responsibility to the Board of Administration of the Association for encouraging measures for the effective preven-

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tion of handicaps; ensuring coordination between the various services necessary for the proper and comprehensive care of the handicapped; promoting the quality and extension of special education and strengthening all related activities; encouraging the general rehabilitation of the handicapped; encouraging the social rehabilitation of the handicapped through the removal of any barriers that hinder the process; and, promoting research, information, and the collection of data concerning topics relating to the various types of handicap and their prevention-e.g., special education, rehabilitation, and care. The Tobago Council for Handicapped Children has similar responsibilities (21). In Costa Rica the title of National Council on Rehabilitation and Special Education sets its priorities. It is charged with the task of determining policy and coordinating activities with the Ministry of Public Health in matters having to do with the promotion, organization, establishment and supervision of rehabilitation services and special education (22). Programs in other countries tend to be less centralized and coordinated, though attempts are being made to meet the needs of all handicaps. In Italy, for example, the Act of March 10, 1971 extended assistance to all categories of physical and mental handicaps not otherwise covered by other legislation (13). This points out another legislative pattern. Legislation exists in m a n y countries that supports programs specially focused on one type of handicap or another: those for the deaf-mutes, blind, crippled, mentally ill or subnormal, etc. Each represents a legislative part of a larger program. This pattern emphasizes the wisdom of eschewing the idea that the handicapped are a monolithic group with similar needs. The variations are vast, and so are the specialized legislative responses. That is not to say that no common ingredients apply to handicaps in general. The following are examples of issues that can be generally applied. Prevention. The task of prevention is enormous though in the United States the responsibility for handicapped make provision for some form of prevention. France has a program that does (18). Although in the United States the responsibility for carrying out programs for the handicapped belongs to the states, the federal government does provide monies for preventive programs. Under federal guidelines, states may qualify for funds if they can show that the proposed programs will (a) reduce the incidence of handicapping conditions caused by

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complications of childbearing, or (b) reduce infant and maternal morbidity and mortality by providing health care to mothers who are likely to have complications (23). Maternal and child health services are often the logical focal point of preventive programs. Spain, in an effort to prevent "subnormality" associated with pregnancy, has instituted a system of uniform periodic examinations and record keeping--the National Plan for the Prevention of Subnormality. The goal is to more carefully monitor the health of the expectant mother and fetus. The key document is a free booklet--available to each woman with a confirmed pregnancy--in which the results of pregnancy-related visits, examinations, and treatments are kept. The system offers specific safeguards to protect confidentiality and personal privacy. Indeed, if a w o m a n objects, the records will not be kept (24). In Mexico the Regulations on Prevention of Disabilities and Rehabilitation of Disabled Persons, 1976, promote a preventive program that includes education in hygiene, genetic counselling, prevention of accidents, and timely detection in addition to appropriate medical treatment. Of these components genetic counselling is emerging, worldwide, as a key to the prevention of congenital handicaps (13). On a wider scale, a number of preventive programs exist that aim at reducing birth defects and in general preventing diseases that may precipitate handicaps. The innoculation and vaccination programs for rubella and polio are among these. Programs linked to accident prevention are important here also. Detection and reporting. Detection is the linchpin in health care programs for handicapped adolescents. Some countries have instituted special reporting or registration requirements to ensure that those with disabilities, particularly those who are classified as "high risk," are identified early and get the types of services they need. In Canada the federal government maintains a voluntary register; the provinces require more (12). Czechoslovakia imposes an obligation on community doctors to report the handicaps they detect. Schools there also keep a register of handicapped students (13). In Denmark, schools and physicians are required to notify social welfare agencies w h e n anyone under the age of 20 years needs special disability care (13). The other side is notifying the disabled themselves about the need for special treatment and its availability. In the Federal Republic of Germany, under Section 126 of

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the Federal Social Assistance Act (1971), health centers perform this duty (13). Treatment and rehabilitation. Rehabilitation is the mainstay of most programs for the handicapped adolescent and is the most frequently mentioned longterm aim. Legislation and regulations in Belgium, Costa Rica, Denmark, France, the German Democratic Republic, the Philippines, Portugal, Spain, Trinidad and Tobago, the United States, and Zambia mention rehabilitation. The goal of the program for the handicapped in Portugal is to make it possible for individuals "to maximize their physical, mental, professional, economic and social potential" (16). The Rehabilitation Services Administration of the U.S. Department of Health, Education and Welfare provides grants to states for a fairly comprehensive set of services: (a) vocational rehabilitation (including medical, social, and psychological); (b) testing, fitting, training, and use of prosthetic and orthotic devices; (c) recreational and vocational therapy; (d) psychological and occupational therapy; and (e) speech and hearing therapy (25). Under the Development Disabilities Act (1970), federal funds have been provided to support rehabilitation services for the more than 8 million children and adults who suffer "development disabilities" caused by mental retardation, cerebral palsy, epilepsy, or neurologic conditions related to mental retardation. To be eligible for such programs individuals must fit the following profile: the disability must be substantial, be detected or become evident before 18 years of age, and be expected to continue indefinitely (26). The severely disabled are those for w h o m rehabilitation is practically impossible, though recent theory holds that most handicapped can be rehabilitated to a greater or lesser degree. Among this group are many who must finally be institutionalized. Many of these individuals suffer from mental disabilities. The "institutionalization" of the handicapped involves a special set of procedural issues, not the least of which is, on whose authority should the handicapped be placed in an institution? The legislative answers vary. The Child and Youth Welfare Code in the Philippines permits the handicapped to be placed in a public or private institution that can provide proper care, training, or rehabilitation. It is for the Department of Social Welfare to screen the applications of parents or guardians. These must be supported by the opinion of a "reputable" diagnostic center (27). There are also special procedures, for instance, to

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be used if the parents disagree with the recomm e n d e d course of action. Many other countries have more elaborate legal protection to safeguard not only the rights of the parents but also those of the adolescents. Some include the use of ombudsmen or child advocates, others have special judicial hearings. The past rush to institutionalize .physically or mentally "abnormal" adolescents has been largely stifled in favor of community or family-based solutions. Save for the severely disabled, the current tendency is to leave adolescents in familiar social settings. Programs focus principally on assisting the families of disabled adolescents, both in terms of finances and services. This may be as much a result of reality as a change in philosophy. In Japan, for example, only 18% of young people who are severely handicapped (mentally or physically) can be accommodated by the 27 treatment facilities. The other 82% must be cared for at home (28). Nevertheless, the preference for leaving, where possible, handicapped adolescents in their familial and social settings now predominates. The World Health Organization has recognized that "it is remarkable how well most handicapped young people can cope if given substantial understanding and assistance (8). This has been borne out in recent studies of the interaction between families and young people with birth defects in the United States (29). This approach is in evidence in the German Democratic Republic (GDR) and France. Under Section 3 of the Ordinance of July 29, 1976, local and district councils in the GDR are responsible for maintaining a variety of modes of care and education, depending on the extent of the disability. These include health care and social welfare establishments for (a) the care, training, and education at preschool and school age of severely disabled children and young people who are able to attend school but require care; (b) the care and development of children and young people who are unable to attend school but are capable of development in nurseries and homes; and (c) the care of children and young people who are both unable to attend school and incapable of development, and who therefore are in need of care (30). In France the emphasis is on early detection and treatment. When a handicap is detected the young person may be targeted for medical-social assistance that is designed to prevent or reduce the "aggravation" of the handicap. The regulations note a clear preference for outpatient care (18,19).

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Complementary Forms of Assistance for Handicaps The legislation surveyed is quite explicit as to who has the responsibility for providing care to the handicapped. Of necessity, the initial legal responsibility falls to the parents. But the care of the handicapped can be a costly matter and so the state, as a matter of public policy, often takes on the task and offers assistance to those w h o are eligible (see Table 2). In the Philippines, Article 62 of the Child and Youth Welfare Codes makes this plain: when a child has special health problems the parents are entitled to assistance from the government to the extent it is necessary to get the appropriate care and treatment (27). There, it is up to the provincial and local governments to provide for children with physical disabilities (31). In Costa Rica youth have the right to expect both the parents and the state to take measures that will safeguard their health (32). This would extend to the handicapped. Regulations in Ireland are more precise and are supported by the philosophy of socialized medicine. There costs for outpatient services for young people with long-term disabilities--mental handicaps, mental illness, phenylketonuria, cystic fibrosis, spina bifida hydrocephelus, hemophilia, and cerebral palsy--are borne by the state (33).

Table 2. Selected Legislation With Special Provisions Relating to Health Care for Handicapped Adolescents Country Denmark

Subject(s)

Detection and reporting Ministry regulation of handicaps in (1976) children and adolescents

Special schools, with medical services for handicapped students Prevention, registration, France treatment of handicapped children and adolescents Germany, Federal Mandatory medical Republic of exams Notice of service availability Japan Prevention, detection, treatment of handicapped children Special education, with Turkey medical services for handicapped services Finland

Source

Decree398 (1976)

Law No. 75-535 (1975)

Federal Social Assistance Act (1971) Child Welfare Law, as amended (1948) Law of 16 February(1975)

The system of state support for the care of the handicapped is more extensive in the German Democratic Republic. The Ordinance of 29 July 1976, wrought several improvements in the social assistance available for the severely disabled and handicapped. It provided special maintenance allowances for the severely disabled or mentally handicapped between the ages of 3 and 18 years of age. Section 6 of the Ordinance goes as far as making "suitable dwellings" available to the families of those who are severely disabled (30).

Conclusion Better care for disabled children is one of the most important aims of recent legislation concerning disabled person. Rehabilitation has been increasingly recognized as a right. Increasingly, prevention is the focus (13). From a formal legal point of view this is encouraging, but the matter does not end with legislation. If one inquires as to the adequacy of the programs, one could well expect to find that the services established in law are insufficient in fact. Legislation, albeit important, is but one facet of a comprehensive approach to the health problems of handicapped adolescents--a special group with special needs. The World Health Organization has stated that: Governments should pay attention to the special needs of handicapped adolescents and ensure that the services providing care are not merely custodial; they should also take into account the fact that the handicapped have to cope with many additional difficulties in adolescence and that inadequate care during this crucial period may have lifelong negative effects on their health and work. (8) It has been asserted that "a society should be judged by the kind of support it gives to the handicapped" (34). If that is the measure, perhaps our modern, technological society at best receives only mixed marks. Many programs have been legislated into existence. Yet, on a global scale it can be argued that support for the handicapped remains unaddressed. Shortages of resources, human as well as material, restrain programs designed specifically for adolescents. Health care as it is known in the modern sense is unavailable to most of the world's populace (35). The goals of providing health care to the handicapped adolescent will remain, in a practical sense, largely illusory if appropriate legal and policy decisions are not given to this subject initially. It appears that in the past decade some inroads have been made

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i n this area. But l a w a n d policy are o n l y a b e g i n n i n g . W i t h o u t l e g i s l a t i o n , p r o g r a m s for t h e h a n d i c a p p e d h a v e n o e x i s t e n c e . T h e w o r d s e n s h r i n e d i n legislat i o n o f t e n state, h o w e v e r , a m b i t i o u s i n t e n t i o n s . T h e n e e d is to i m p l e m e n t t h e m b y f i n d i n g r e s o u r c e s a n d i n i t i a t i n g p r o g r a m s f o c u s i n g o n t h e h e a l t h n e e d s of h a n d i c a p p e d a d o l e s c e n t s . T h e c h a l l e n g e really is to take t h o s e e n a b l i n g w o r d s b e y o n d the four c o r n e r s of t h e p a g e s t h e l e g i s l a t i o n is p r i n t e d on.

References 1. United Nations: Report on children. New York: 1971. (UN publication sales No. E.71.IV.3, 1971) 2. Arendt W: The Federal Republic of Germany's programme of action for promotion of rehabilitation, in Proceedings Review. Surrey Hills, Australian Council for Rehabilitation of the Disabled, 1972, p 79-84 3. Fouratie T: Some economic considerations, !n Les Cahiers de 1' Institute de la vie, Nos. 32-36, 1973, p 111-117 4. United Nations: Obstacles limiting the access of disabled children to rehabilitation services and education. New York: Department of Economic and Social Affairs, 1976, p 7, 28 (UN Doc. No. ST/ESA/47,1976) 5. Council for Welfare of Children: National plan of action for health and nutrition. Manila: 10 December 1976, 4 pp; reprinted in Int Dig Health Legis 6. Commonwealth Secretariat: Directory of education provision for the handicapped in developing Commonwealth countries. London: 1973 7. Boston Globe: July 27, 1980, p 36 8. World Health Organization: Health needs of adolescents. Geneva: 1977,p 23, 47 (WHO Tech Rep Ser No. 609) 9. The Manila Statement on Legislation Concerning the Disabled in Developing Countries; reprinted in !nt Dig Health Legis 29:923, 1978 10. United Nations: General Assembly Resolution 3447, article 1, GAOR, 30th Sess., Suppl. No. 34, p 88. (UN Doe. No. A/ 10034, 1975) 11. United Nations: General Assembly Resolution 1386, principle 5, (UN Doc. A/9354, p 19, 1959) 12. United Nations: Comparative study on legislation, organization and administration of rehabilitation services for the disabled. New York: Department of Economic and Social Affairs, 1976. (UN Doc. No. ST/ESA/28, 1976) 13. United Nations: Recent trends in legislation concerning rehabilitation services for disabled persons in selected coun-

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tries. New York: Department of Economic and Sodal Affairs, 1977, p 15, 22 (UN Doc. No. ST/ESA/73, 1977) 14. Chambers Twentieth Century Dictionary, p 591, 1975 15. Act No. 56, section 2; reprinted in Int Dig Health Legis 21:434, 1970 16. Law No. 6/71 of 8 November, 1971;reprinted in Int Dig Health Legis 24:215, 1973 17. Regulations relating to Rehabilitation Act of 1973, section 504 in Code of Federal Regulations, Title 45, part 1151.11 (1977) 18. Law No. 75-534 of 30 June, 1975; reprinted in Int Dig Health Legis 26:785, 1975 19. Decree No. 75-692of 30 July, 1975; reprinted in Int Dig Health Legis 26:785, 1975 20. Crown Decree No. 2828, Section 4, of 1 December 1978; reprinted in Int Dig Health Legis 31:373, 1980 21. Trinidad Council for Handicapped Children (Incorporated) Act, Act No. 28 of 1975; reprinted in Int Dig Health Legis 27:891, 1976 22. Decree No. 5347 of 3 September, 1973; reprinted in Int Dig Health Legis 26:507, 1975 23. Reprinted in Int Dig Health Legis 27:689, 1976 24. Order of 24 October 1978; reprinted in Int Dig Health Legis 31:373, 1980 25. The Rehabilitation Act of 1973; reprinted in Int Dig Health Legis 25:692, 1974 26. Public Law 91-517 of 1970; Title 42, section 6001, United States Code Annotated 27. Presidential Decree No. 603, article 173; reprinted in Int Dig Health Legis 27:629, 1976 28. Osuku T, Noda T: The present situation of care for the homebound disabled (children) in Japan. In: Proceedings review. Surrey Hills: Australian Council for Rehabilitation of Disabled, 1972, p 51-56 29. Darling RB: Families against society: a study of reactions to children with birth defects. Beverly Hills: Sage Publications, 1979 30. Ordinance of July 29, 1976, Section 3, of the German Democratic Republic; reprinted in !nt Dig Health Legis 29:73, 1978 31. Child and Youth Welfare Code, section 134 (3) 32. General Health Law, article 13; reprinted in lnt Dig Health Legis 26:465, 1975 33. The Health Seryices (Amendment) Regulation, 1971; reprinted in Int Dig Health Legis 25:551, 1974 34. Hauerwas S: Learning morality from children. Hastings Cent Rep 10(5):25, 1980 35. Paxman JM: Introducing policy change on the use of nonphysicians. In Waife RS, Burkhart MC, eds: The nonphysician and family health in sub-Sahara Africa. Boston: The Pathfinder Fund, 1981, p 99-107