Vulnerable years

l'uhl, tilt& Lmtd. ( 1971 ) 85, 175- 177

SPECIAL

R E P O P,T

VULNERABLE YEARS The regional office for Europe of the World Health Organization has produced in recent years a rmmbcr of reports on various aspects o f child health, all o f which have been o f considerable value. A newly published one, under the perhaps slightly misleading title of "('hild ilealth", takes a look at the health needs and problems o f children in the age range from I to 6 years aud thus lills a very important gap in its coverage, it starts from the premi,,c thal ~ hilt mortality is a ma.ior preoccupation ira the first year o f life it is morbidity ~har becomes signitic:mt after the lirst year and that the succeeding pre-school years have the vital imporumce that it is during them that the child having survived the first year t(ae quality of that surtival is dclcrmined. They are. as it says. "the years of formation or deformalion in the physical, mental and social aspects of health." It begins b} selting out the aim'~ and needs of child health work in this period and it is g o o d t o see thal mental hcalth receives considerable prominence and that dental health is b~. n,~ means forg,mcn. ,,Xf~ amdysis of provision in the 19 countries represented in the ,,',mposmm on ~,,hosc meeting the report is based indicates that there is a commori pattern i~ rhc past provision of "'child welfare" services, with a general mechanism of periodical mcdicat examinations held at pr~gressivdy tess frequent, intervals as the child grows older. British e×periencc, that the presentation of the child for inspection becomes less consistent a,~ he gro~v,~ older, so that by the fourth year the service covers perhaps as few as 25,°,0~ o f children, is apparcmlv shared bv most of the other countries included. ( o m m o u . atso. is the experience that it is by no means easy to get enough staff" o f the right quality 1o provide even the present limited se,'vice and tim consequent feeling that if all children a~tended clinics as regularly as they are in theory expected to the staff would bc quite inadequate Io cope with the load. And so the basic question posed in the report is whether there should be an attempt to maintain the old s.vstem or whether there should be a change to a selective system which ~vot, hl give cioser attention to those children who might be most at need. The consensus of opinion was cx iden0y in favour of the latter and a large part of the document is devoted to discussing how a selective system might be organized. In the last few years the British system has been changing, with conside?able emphasis on the detection and follow-up o f the child with hand/capping defects. Handicapped children receive only incidental mention in this report; their special needs were discussed in detail in an earlier report published in 1967. The stress is on the concept of "vulnerability", something which has been growing i~. Britain but has rarely as yet been delined in detail. The "al risk." child is one whose pre-natal, peri-natal and neonatal history gives some cause to suspect that he may have been exposed to some factor or factors which might have produced some kind o f disability. The "'vulnerable" child is defined as " o n e who m a y not yet have sustained any damage but who, because o f something in himself or his environment, is actually or potentially exposed to some hazard." While in the "at risk" child one is looking for damage which has already occurred, in the hope o f minimizing its extent or effect and preventing secondary disability, "in the case of the vulnerable child there is a reasonable possibility of preventing damage by either removing the hazard or protecting the child against it." An annex to the report attempts to outline a list of indices of vulnerability. " A n y t h i n g which goes wrong with the family may affect the child; anything which happens to the

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child may affect the family. Both the vulnerability o f individual children and th: ~hility o f families must therefore be considered." There may be little in the o u l h . :~hich would be new or revolutionary to the forward-looking first-talc health visitor ,~ t~ritain, but it is nevertheless a potentially useful guide. In the British conlext, perhaps the most useful part of this annex will be its reminder that one must think in terms of screening thmilies for vulnerability and that for this purpose inter-disciplinary contacts -.and interdisciplinary understanding---are in'tperative. Both in detecting vulnerability and in'doing something about it, adequate orgauization is vital. With this in mind, the report gives co,lsiderable attention to the princil~les which must be followed in organization. There is useft,1 comment on ti'ae provision o f clinical care for the child who needs it. Should specialist care be given in p:tcdiatric hospitals or in specialist hospitals ? What can be done to minimize the risks attcndant on hospilalization '? What can be done to keep children out of hospital ? The questions are asked a~ld hints arc given as to possible answers. Another annex takes up in some detail the problem of parent deprivation, it is interesting to see that the symposium was not merely co~lcerned about some new trends wl~ich arc apparent in most of the countries concerned but took the point It~:ft some of those trends the greater tendency of married women to go out to work and the increasing numt~ers of unsupported m o t h e r s - - a r e probably things which must be accepted as part of the pattern of society in the future. This is a particularly diilicuh field for crystal-gazing. There arc countries in Europe where it is virtually a matter of course ib': the majority of womeN. mothers or not, to go out to work. There are others where the mother who goes out to w o r k for any reason other than dire poverty is exposed to overt or covert disapproval nnd where that disapproval shows in a reluctance to provide nursery thcilities or othcr support which might m a k e going out to work somewhat easier for the mother. It may be that the " W o m e n ' s ' L i b e r a t i o n " mc,;'ement's m o r e extreme demands ha~.e only minorit~ s u p p o r t but there is no doubt that the demand for work-opportunity for more women is genuine, substantial and based on reason. But what effect will automation have on the labour market, so far as opportunity tbr w o m e n is concerned, in the next 20 years? And how far are some o f the apparent changes in family patterns transient responses to general unrest and dissatisfaction with things as they are simply because some things have been as they are for rather a long time ? Health records, also, are passed under scrutiny in the report. Morbidity data during the age range covered are incomplete and unreliable. There is considerable uncertainty about the significance o f some of the data which a r e available. It is suggested, with good reason. that m a n y countries persist, year after year, in collecting a great deal of information simply because they have got into the habit of doing so and that they could profitably scrutinize their systems and see how much labour could be saved by cutting out the unnecessary. Computerization is making the storage and retrieval of information so much easier that it might well encourage "the accumulation of unnecessary statistics simply because they happen to be available". This, the report goes on to say, "might not involve any great waste of computer time, but it could certainly waste much human time in the initial w o r k o f extracting and p r o g r a m m i n g the data." It is tempting to pick out m o r e plums from the pie, but one will have to suffice--the way in which it combines with so m a n y other recently published documents to build up the case for a re-thinking o f the.shape of paediatrics,- its organization and the deployment and training of those engaged in it. There is no doubt that all paedialricians need to be far m o r e socially aware than are most o f them at the present time, but there must be developed a cadre of doctors---call them "social paediatricians" or "child health doctors" or lind

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some new designation--who will be communily-based but hospital-linked and whose concern will be essentially with child life and health rather than with the illnesses which affect children. And this in itself will not be enough. Their work will have to be supported by a comprehensive child health team, para-medieal and non-medical, which includes many workers whose role is not yet fully appreciated by the medical Establishment. The implications of this for muhi-disciplinary and inter-disciplinary education are going to need a, good deal of exploration. The report has some useful practical suggestions which will be of value to even those countries which have good reason to be salisfied with their services, but its principal value in this country is ttlat il questions assumptions which have become too habitual and is certain to provoke a good deal of long-overdue thiltking. Every health department would benefit by having a few copies circulating among its staff, especially at a time when health service re-organization is impending. From this point of view it has the usual merit of W.H.O. Regional Office productions; copies are supplied free on application to the Copenhagen Office. "'Chih! tfeahh". Report on a European Symposium. Pp. 85. Regional Ofiice for Europe, World

t tealth Organization. 8 Scherfigsvej. Copenhagen. 1970, Copies available free of charge on requesl.