Changing Needs in Pédiatrie Education, ediled by
C. A. Canosa, V.C. Vaughan III, and H.-C. Lue,
Nestlé Nutrition Workshop Séries, Vol. 20.
Nestec Ltd., Vevey/Raven Press, Ltd.,
New York ©1990.
Health Education for the Domestic
Experiments of the Child in Industrialized
Countries
J. David Baum
Institute of Child Health, The Royal Hospital for Sick Children, Bristol BS2 8BJ, United
Kingdom
Child development does not progress on a linear time scale. As illustrated semidiagramatically in Fig. 1, there are enormous changes in early infancy and childhood and around the time of puberty and the middle teenage period. This contrasts
starkly with the homogeneity of the human organism in adult middle life. Whichever dimension of the development one measures from birth through infancy, toddlerhood, junior school âge, puberty, adolescence, and early adult life, the
heterogeneity of childhood is spectacular compared with adulthood. This créâtes a
problem in considering health care for children: we are in danger of focusing on a
prototype child, say an 8 to 12 year-old boy or girl, thereby neglecting by default
the very différent needs of the infant or burgeoning young man or woman.
We hâve an additional problem when considering issues of health care or éducation for children from the confines of the institutional office, Consulting room, library, or hospital ward. Unless spécial care is taken, plans for children's health will
Sits
Stands
School
Puberty
Adult
FIG. 1. Non-linear growth and development from early infancy onward.
235
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MEETING SPECIFIC NEEDS: INDUSTRIAUZED WORLD
be made with a prototype home environment in mind, thereby losing sight of the
huge diversity of family size and structure, and the enormous spectrum of family
dwellings, from suburban villa, to inner city bedsitting room, to industrial estate
high-rise apartment, to a mobile home or an isolated farm cottage. As with ail biological variables, the danger in considering the mean is losing sight of the range of
the distribution curve.
It is against the background of thèse obvious points that I shall address aspects of
health éducation as they apply to children's medicine now and in the future, and as
they impinge upon our plans for undergraduate and postgraduate éducation.
SECONDARY HEALTH EDUCATION
The very efficacy of technological médical advances has led to an increase in the
survival of children who would, in a previous era, hâve died, but who now survive
with chrome disorders that place burdens on the family and on their normal daily
lives. The classical example is childhood diabètes which, prior to 1921, was invariably a fatal disease, but which, following the introduction of insulin therapy, was
transformed into the new chronic lifelong disorder of insulin-dependent diabètes.
Similar and more récent examples can be drawn from advances in pédiatrie oncology, nephrology, hepatology, metabolism, and neonatology. While the specialist
hospital service is credited with the heroics of effecting the "cure," it is the family
who must act as the day-to-day therapists in the months and years to come. They are
in need of secondary health éducation, namely, the appropriate knowledge and
training to serve as the residential health care team. As an example of the issues involved, consider the care of the child with diabètes mellitus.
Childhood Onset Diabètes
It is generally believed that the lifelong health of an individual with diabètes will
be influenced by how effectively he or she can maintain the concentration of glucose
in the blood within the normal physiologie range. Failure to control blood glucose
carries with it an enhanced risk of developing the complications of diabètes (1). The
current prognosis for children with diabètes is grim: after 25 years, half will develop
eye problems, 50% of whom will become partially or completely blind, half will develop a neuropathy, 20% of whom will develop foot ulcers, and a fifth will develop
nephropathy, the majority of whom will progress to irréversible rénal failure (1).
It behooves the child's physician, therefore, to do his utmost to maintain blood
glucose homeostasis. This is not, however, an easy matter: many factors impinge on
blood glucose régulation, most of which are outside the sphère of influence of the
physician (Fig. 2). Indeed, the only modes of therapy the physician can influence directly are insulin, diet, and exercise (2).
DOMESTIC EXPER1MENTS
237
PHYSIOLOGICAL FACTORS
INSULIN
FOOD
EXERCISE
GROWTH
SEASONS
G.H.
GLUCAGON
PUBERTY
MENSTRUATION
INFECTION
IONAL OR
LLIOUS
RBANCE
PARENTAL
FACTORS
ADOLESCENCE
PSYCHOLOGICAL FACTORS
FIG. 2.
Factors outside the physician's influence that impinge on blood glucose régulation.
Insulin
It is clear from the literature that even with the most meticulous attention to the
détails of insulin therapy, blood glucose cannot normally be maintained within the
physiologie range. The rare exception is the child blessed with stable metabolism, a
well organized family, above average intelligence, and a sufficiently obsessional attitude to be able to perform his or her own daily blood glucose measurements and
modulate insulin therapy accordingly (3). However, an improved understanding at
least permits the child to know how to adjust his or her insulin in a rational manner
and to avoid the extrêmes of hypoglycemia and hyperglycemia (4).
Diet
Traditionally, in the United Kingdom (UK) at least, the diet for children with diabètes is prescribed as a fairly rigid and uniform package, broadly judged to match
the projected pharmacokinetics of the child's insulin regimen. It has, however, been
shown that by increasing the carbohydrate content of the diet and, in particular, enriching its fiber content, it is possible to improve the blood glucose profile and to
bring the prevailing sugars nearer to the physiologie range (5).
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MEETING SPECIFIC NEEDS: 1NDUSTRIAUZED WORLD
Exercise
Physical exercise in children with diabètes will certainly reduce high levels of
blood glucose, probably acting through a mobilization of insulin from the injection
dépôt (6). Thus, it is possible, if the individual child knows that his or her blood glucose is high, to engage in a bout of physical exertion, such as running, bicycling,
skipping, or swimming, and thereby bring down the blood glucose concentration.
DOMESTIC EXPERIMENTS OF THE CHILD
Thèse brief notes on diabètes management serve to illustrate the central place
of éducation for health among children with chronic disease and their families.
Whether the physician sees the diabetic child for a quarter of an hour every 3 months
or for an hour every month, for the vast majority of time, the child and his or her
family are on their own, manipulating insulin, diet, and exercise, and monitoring
their own daily interventions by blood or urine glucose testing.
Such domestic clinical experiments can succeed only if the family acquires a
sound understanding of diabètes far beyond a hospital prescription for insulin and
simple recommendations for diet and exercise. This requires a professional health
éducation program that takes into account the central social variables, namely, the
âge of the child and the structure and fabric of the family, their organizational and
social skills, and whether they hâve a car and téléphone. Thèse issues can be seriously addressed only by teachers who are orientated and organized toward visiting
the child and family at home and at school. Specially trained community nurses for
diabetic children hâve been appointed in the UK (7). While their base is in the consultant pédiatrie diabetologist's hospital clinic, they work predominantly in the community and hâve a first-hand knowledge of how best to teach the individual family
and child about his or her diabètes and how to interpret the physician's prescribed
regimen in the manner most appropriate to the child's particular needs and capabilities. The nurse's fine judgment balances the theoretical aspirations of the physician
for idealized blood glucose control against the rights of the child and the family to
live normally and "free range" in the home environment. Such appointments are
considered justified because it is a service that the families hâve demanded; it is a
service that has improved the families' understanding of diabetic management; and,
generally, childrens' blood glucose control has improved, at least to the degree of
keeping children out of hospitals (7).
From the paradigm of childhood diabètes, a case can be made that the care of any
chronic complex disease deserves secondary health éducation: namely, information
about the disease and support individualized to meet the needs of the particular child
in his or her everyday world and normal environment. Such considérations apply
equally well to asthma, cérébral palsy, cystic fibrosis, rénal dialysis, and many
other established chronic disorders of childhood.
DOMESTIC EXPERIMENTS
239
VOLUNTARY SUPPORT FOR THE FAMILY
In addition to the statutory médical services available for the care of the family
with a child with a chronic disorder, in the UK there are a growing number of voluntary organizations that offer powerful family support. Some of thèse organizations
are strictly local, voluntary, and more or less unfunded: offering, for example, hospitality for a handicapped child while the mother does the shopping, providing a
baby-sitting service for a toddler with diabètes while the parents hâve an evening
"off duty;" or arranging a discussion circle for families of children with cystic fibrosis, to exchange advice and give mutual support. Other voluntary groups are organized on a larger scale, some of which are national and highly effective in fundraising for patient welfare services, for research, for political lobbying, and for mutual support and health éducation. Thus, in the field of diabètes, it is the British
Diabetic Association that provides information packs and booklets for parents and
for schools, and that runs educational holidays for diabetic children and educational
weekends for their parents. The families enthusiastically support their specialist voluntary organizations, whether the problem is diabètes, cérébral palsy, muscular dystrophy, mucopolysaccharidoses, leukemia, Down's syndrome, cystic fibrosis, or
congénital heart disease. There are well over 100 such voluntary organizations in
the UK (8); parents find they can learn more from fellow sufferers, who are the professionals by virtue of having a child with a particular disorder, than they can from
the hospital-based theoretical expert.
A particular example that illustrâtes the power and complexities of voluntary input to éducation and family support is that relating to the child with life-threatening
or terminal illness.
Hospice and Respite Care for Children
Only recently has it become socially permissible to discuss matters relating to
death in childhood in the UK. There is no established body of information to guide
the practitioners on terminal care or bereavement counseling as it relates to childhood, and there is therefore no curriculum time given to the subject. The whole issue was brought to the surface when the first hospice for children, Helen House in
Oxford, was opened in 1984 as a resuit of the visionary and energetic leadership of
Mother Frances Dominica, head of an Anglican order of nuns. Established by voluntary subscription, the children's hospice provided a "home away from home" for
children with life-threatening and terminal illness, allowing families blighted by
neurodegenerative disorders, mucopolysaccharidoses, muscular dystrophies, and
neoplasias to be cared for with dignity in the tranquility of a home that did not attempt to treat the children as patients. Instead, it allowed the children, often accompanied by siblings or parents, to follow their own routine, with the appropriate
provision of symptom relief should the children or families find this necessary (9).
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MEETING SPECIFIC NEEDS: INDUSTRIAUZED WORLD
This extraordinary experiment was so "successfùl" that it won widespread public
respect and support and led to the opening of two other children's hospices. Independently, other diverse initiatives were established, most notably the network of
domiciliary care nurses established by a régional charity, the Cancer and Leukaemia
in Childhood Trust, throughout the length of die South West of England (10).
Each of thèse charitably funded organizations is dedicated to providing a service
complementary to that currently provided by the established médical service. The
hallmarks of the groups involved are the provision of experts who can listen, share
information, solve individual problems, liaise with the other agencies involved, be
they statutory or voluntary, advise and assist with spécial nursing care, offer emotional and spiritual support appropriate to the individual family, provide advice relating to the management of death, and provide friendship throughout the period,
which may be brief or protracted over years frorn the tirne of the lethal diagnosis to
the moment of the child's death and beyond (11).
Thèse initiatives hâve been local, unplanned, and at times hâve run the risk of duplication. However, in the UK, there is no established document on which to draw
to define the needs for such facilities nor the existence and distribution of the voluntary groups as they currently exist. We hâve therefore set up a research program at
the Institute of Child Health in Bristol to serve as an information and resource unit
to integrate the services available and catalog needs and provisions. However, one
thing is very clear: on this subject, the parents are the experts, and it is they who are
best placed to define their needs and offer information and support to afflicted fellow
citizens. After ail, they hâve been through it! Ail this has happened outside the immédiate orbit of our médical schools and illustrâtes the éducative authority of voluntary groups whose expertise we need to integrate into our teaching program if we are
to prépare undergraduate and postgraduate students for their work in community
child health.
Integrating the Forces in the Community
In the UK, the single most important future force for integrating child health services and health éducation in the community will be the consultants in community
pediatrics (12). Thèse are the professionals who bring the skills of epidemiology and
management to bear on ail the health problems facing children in a defined population; it is they who champion the préventive efforts in those areas of ill health related
to social disadvantage where progress has been so slow; it is they who coordinate
the collection and présentation of data relating to children's health and the practice
of children's medicine in the community; and it is they who must be the specialists
on patterns of childhood morbidity within their social context, acting as the advocates for children in the health care political arena. Above ail, it is the community
consultant pediatrician who has me best chance of producing a liaison network,
bringing together for die benefit of the child patient ail the appropriate médical and
non-medical services in the community, be they statutory or voluntary. In the UK
DOMESTIC EXPERIMENTE
241
thèse include social services, educational services, the law, psychology, adoption
and fostering, housing, and ail the paramédical services such as physiotherapy,
speech therapy, audiology, chiropody, and dentistry (Fig. 3). The community consultant pediatrician also carries the responsibility for the provision of a service to
promote good health, a service for primary health éducation.
PRIMARY HEALTH EDUCATION
The community-based doctor's responsibilities include the supervision of universal immunization and vaccination, die promotion of breast feeding, and the prévention of accidents. It also extends to protecting children from recognized
environmental health hazards whether they be carbon monoxide in the home; insecticides in the food; lead in the air, paint, or earth; radioactive isotopes in méat or
milk, whether locally produced or imported (we can be sure that Chernobyl will not
be the only disaster of its kind!); cigarette smoke in the lungs; and what might be
FIG. 3.
Médical and non-medical services for children.
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MEETING SPECIFIC NEEDS: INDUSTRIAUZED WORLD
thought of as social toxicants such as excesses of coffee, sucrose, and alcohol. Similarly, someone must take on the responsibility for the insidious pollution of children's minds by the média, especially télévision, which possibly represents a more
serious threat for the future health of humankind than we currently care to countenance. Télévision and videos bring to the family home the opportunity for children
of ail âges to see physical and sexual violence, obscenity, and the world as a brutal,
alarming, and uncaring place (13).
How might our students prépare for their rôle as primary health educators?
Whether as undergraduates or postgraduates they will require the training to assess
critically the évidence supporting the value of initiatives in health éducation. They
will hâve to weigh the évidence as to whether a particular campaign for better health
succeeds in changing individual patterns of behavior, especially those rooted in
trans-generational family styles of living, eating, drinking, cigarette smoking, and
exercising. They will also need the intellectual sophistication to décide whether
such campaigns, even if shown to be effective, are well founded biologically. Are
the data sound enough to justify an attack on individual rights and freedoms?
Our community-based pediatricians must carry children's health forward to a
dream of health characterized by a style of living that respects the long-term health
of the individual coupled with the health of the local, national, and international environment, within a framework of care in which the families are participants and
partners with the médical professionals; the alternative is a nightmare of continued
unhealthy living, with selfish individual family units, communities, and nations,
and a belief that illness, current and future, will be cured by dramatic "breakthroughs" in médical technology. We must endeavor to steer our students and our
communities toward health promotion as their preferred option.
REFERENCES
1. Leslie ND, Sperling MA. Relation of metabolic control to complications in diabètes mellitus.
J Pediatr 1986;108:491-7.
2. Baum JD, Kinmonth AL, eds. Care of the child with diabètes. Edinburgh: Churchill Livingstone,
1985.
3. Kinmonth AL, Baum JD. In: Baum JD, Kinmonth AL, eds. Care ofthe child with diabètes. Edinburgh: Churchill Livingstone, 1985:136-48.
4. Allgrove J. Improved diabetic control in a district gênerai hospital clinic. Arch Dis Child
1988;63:180-5.
5. Kinmonth AL, Angus RM: In: Baum JD, Kinmonth AL, eds. Care ofthe child with diabètes. Edinburgh: Churchill Livingstone, 1985:92-116.
6. Greene SA. In: Baum JD, Kinmonth AL, eds. Care ofthe child with diabètes. Edinburgh: Churchill
Livingstone, 1985:117-28.
7. Strang S. In: Baum JD, Kinmonth AL, eds. Care ofthe child with diabètes. Edinburgh: Churchill
Livingstone, 1985:193-203.
8. The Voluntary Agencies Directory for the National Council for Voluntary Organisations. London:
Bedford Square Press, 1988.
9. Frances Dominica. The rôle of the hospice for the dying child. Br J Hosp Med 1987;88:33-43.
10. CLIC News (Cancer and Leukaemia in Childhood Trust newspaper). Article on Domiciliary Care
Team, Autumn 1988.
11. Thrones R. The care of dying children and their families. Birmingham: National Association of
Health Authorities, 1988.
DOMESTIC
EXPERIMENTS
243
12. Kinmonth AL, Baum JD. Primary and secondary carc: a créative interface. In: Hart C, Bain J, eds.
Childcare in gênerai practice. Edinburgh: Churchill Livingstone, 1989;16-24.
13. Golding J, Hull D, Rutter M. In: Forfar JO, éd. Child health in a changing society. Oxford: Oxford
University Press, 1988;122-152.
DISCUSSION
Dr. Burg: Help me to understand the différence between what the community-based pediatrician does and what the gênerai practitioner does.
Dr. Baum: Each family has a gênerai practitioner to whom they go as the primary source
of health care. The gênerai practitioner may then send the child to a consultant pediatrician,
who is almost entirely hospital based, for a secondary opinion. The community pediatrician,
as he is developing, is a public health physician who has the chance to take charge of primary
health care: making sure the immunization program and the school health program are functioning, making sure that someone is responsible for health problems arising from alcoholism, poor housing, child abuse, accidents, and so on. He is a différent kind of physician. He
does not provide primary care for the family.
Dr. Guesry: Who is going to undertake the training of the family pediatrician in the community environment? Is this going to be the gênerai practitioner? Although the gênerai practitioner may be a very good, he will not necessarily be an equally good teacher.
Dr. Baum: There is always the problem of how to teach the first team of teachers. The proposai is that the gênerai practitioner of today serves as the primary teacher of the community
pediatrician of tomorrow. However, the information base, postgraduate training, and work of
the community pediatrician are différent from those of the gênerai practitioner. The community pediatrician needs to be familiar with the world and work of the gênerai practitioner, but
he is not a primary health care physician. He does not see children whose parents think they
are ill. He does very little "hands on" clinical work. He is a health administrator, a measurer, an epidemiologist, an officer responsible for immunization programs, and so on.
Dr. Guesry: What will you remove from the présent curriculum when you change its content, assuming that you do not intend the training course to be lengthened?
Dr. Baum: I think there is a great deal of scope for removing detailed sections of the curriculum. There are existing models to which we can refer, the McMaster curriculum, for example. The greatest challenge for a curriculum committee is to remove détail and create more
time for student reflection, personal growth, and the acquisition of lifelong leaming skills.
Dr. Gabr: Will the way of teaching of community pediatricians resuit in a two-tier System
of pédiatrie médical practitioners, with lower prestige in the community?
Dr. Baum: In the United Kingdom, in the higher échelons of science, epidemiology is on
a par with DNA, genetics, cell biology, and so on. If we choose to portray community child
health as a clinical epidemiological science, we can be in the top league and win research
money and prizes in compétition with other clinical scientists. The students will then see that
it is respectable and prestigious to work in community child health.
Dr. Ballabriga: Two models exist in Europe. One is similar to the British System in which
family doctors give primary care to families and children; in the other System, pediatricians
attend nearly 90% of the child population. This is the situation in Spain. Both models hâve
given good results. There are also countries in which pediatricians work full-time only in
hospital and other countries in which they work part-time in hospital and are also involved in
private practice. Now that Europe is increasingly becoming a community with common standards, it is important to consider how thèse various Systems can be made compatible.
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Dr. Baum: I do not believe we need hâve only one model of child health care ail over the
world, or even in Europe. There are good traditions that work well for a particular country or
culture, or for the tempérament of a particular people.
Dr. Gupte: In India, pediatrics has been community oriented for many years. We hâve a
country-wide maternai and child health project called the Integrated Child Development Services Scheme. This has been in opération for over 10 years and is rurally oriented, providing
services in the villages of the needy. The scheme has had a considérable impact, as judged by
feedback and impact studies (1).
Dr. Baum: Is it possible and désirable to impose one model of child health care intemationally? If so, which model, who will design it, and how will it be evaluated?
Dr. Canosa: Although I do not feel that I am the best qualified person to try to answer this
question, it has been stated again and again in this workshop that taking into account the numerous factors which affect child health and health care delivery, it is necessary for each
country, and probably each région in each country, to develop its own model of health care
and pédiatrie training.
Dr. Visakorpi: I don't disagree, but I think we could define the kind of pédiatrie éducation
we think is necessary for physicians who hâve primary responsibility for health care, including child health care. Maybe the standards of minimal pédiatrie compétence could not be applied in ail countries, but I think they could in most. Is the undergraduate pédiatrie course
sufficient for a doctor who has primary responsibility for child health care, as some believe
in my country, or do we need something more?
Dr. Burg: I agrée with Professor Canosa that each country must décide what model it
should choose. This is a reasonable and wise political position. However, I believe it is important for us to at least provide some thoughts about what the éléments of a particular type
of model should be. One of the things I hâve leamed from this conférence is that we are ail
facing the question of how we can best provide high-quality primary care for the children and
their familles whom we work with on a regular basis. I think we must try to develop a model
of the particular skills and abilities that are necessary to ensure high-quality health care in a
région or area.
Dr. Guesry: When I visit less developed countries, I often see the most up-to-date transplantation center within a few meters of homes where children still die of diarrhea and malnutrition. I cannot agrée with a policy that allows this to happen. Perhaps one recommendation
we can make is for well thought out programs of health care progressing in steps. We should
start with basic measures and then build on them.
Dr. Okeahialam: I do not think we can adopt a universal model. A good pédiatrie curriculum in any community should form the basis of effective training of health personnel who can
provide the answers to the questions posed earlier by Professor Cravioto: "Do they survive?
Do they grow? Are they happy?" The curriculum should cover the epidemiology of major
diseases that impede child survival, factors that affect growth, and the social and environmental factors that influence the overall well-being and happiness of the child.
Dr. Litt: It is critical to the development of any model to hâve the appropriate database.
When we look at the data that hâve been presented in this conférence, we still see the old
model, with data divided on the basis of âges 0 to 4, 5 to 14, and 15 to 24 years. We do not
therefore, hâve the necessary epidemiologic database for half the children we are responsible
for, namely, the adolescents. I suggest that each of us, onreturnto our own countries, pursue
the aim of ensuring that the data are organized and collected in ways more appropriate to the
tasks we hâve on hand. In this way, we can develop an appropriate content for teaching pediatrics as well as a way of evaluating any changes we make in our teaching programs.
DOMESTIC
EXPERIMENTS
245
Dr. Baum: Who is responsible in a nation for the promotion of child health: parents, pediatricians, or politiciens?
Dr. Gabr: I would like to change the word "politicians" to "décision makers" because
they might not be politicians. I think that pediatricians, the public, and the décision makers
can ail work together without specifying who is specifically responsible.
Dr. Guesry: I think there is some danger of giving up responsibility for children's health
to so-called "specialists," as seems sometimes to be occurring in Switzerland. For example,
in Switzerland, nearly every parent of a schoolchild at some time receives a letter from one
of the social workers who visit schools regularly: every time a child is noisy or is not working
very well, the social worker suggests a visit to a psychiatrist; every time there is a tooth
slightly out of place, they propose that the child wears a brace for several years, which is
probably harmful for the child's psychological development. I think it is very important that
the child's health is looked after by someone who understands the overall picture, and does
not delegate responsibility to people who only know about part of the picture.
Dr. Cravioto: We don't delegate responsibilities, we delegate tasks. For me, the main
point is to define the rôle of each one of the différent groups that hâve an interest in child
health: parents, educators, social workers, and gênerai practitioners.
Dr. Canosa: I agrée with Professor Cravioto. The task ahead is to define precisely the responsibilities and rôles of physicians, nurses, auxiliary health workers, and so on. The physician-pediatrician cannot delegate responsibility, he has to share tasks. Numerous difficulties
arise when différent groups of professionals caring for children do not agrée on their rôles.
Dr. Baum: For us to become décision makers, we must first put our own house in order at
the level of the médical schools. We must not simply shed tears because child health is not
more prominent in the curriculum. We hâve to take up the Nigérian challenge and make sure
that the dean of the médical school is a parent and a politician, and the chairman of the curriculum committee is a parent and a pediatrician. We hâve to introduce a little more aggression
into the marketing of our ideas. My next question is how should we begin to teach the
teachers.
Dr. Gabr: If I understand the question correctly, this means how do we retrain teachers in
the new concepts we hâve been discussing, not how do we educate them in pedagogy.
Dr. Burg: We need both. I think we hâve a content that we want people to leam, but there
is also the process of éducation. In the United States, most of our médical schools hâve programs for assisting faculty members to develop skills in helping people to leam. The movement toward the problem base in learning has a great deal of support from national
organizations that offer workshops for helping people to apply this new learning technology.
There is a national group on médical éducation, of which I am chairman, that has the goal of
making it possible for faculties and médical schools to be more compétent at meeting their
educational responsibilities. The Liaison Committee on Médical Education of the Association
of American Médical Collèges has clearly stated the importance of having active programs to
assist faculties in developing their teaching skills as a requirement for accréditation of médical schools in the United States.
Dr. Cravioto: In Mexico, we hâve the Latin American Center, a régional center, for teaching teachers how to teach—both the médical aspects and the aspects related to other disciplines. This has been in opération for about 15 years. It started with courses of 1 year's
duration, and there are now other lS-day courses for managers of éducation in institutions;
the minimum length of the course for certification for university teaching is 6 months.
Dr. Canosa: I would like to comment on the importance of voluntary groups collaborating
with the health System and which, due to their spécial characteristics, are able to reach areas
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WORLD
that are difficult to cover by the regular health service. Based on the information provided by
Dr. Baum, the United Kingdom is a singular country in its organization of voluntary groups
that are fully integrated into the health service and are capable of performing important and
difficult rôles in society.
In S pain there are also voluntary pressure groups, but they hâve quite différent objectives
and perspectives from those described by Dr. Baum. Thèse organizations défend the interests
of groups of patients needing organ transplants or who are affected by certain spécifie and
chronic diseases such as hemophilia, various cancers, cystic fibrosis, etc. Health authorities
often surrender to pressure from thèse groups, which obtain support from the mass média, so
that more important health priorities may suffer.
A "silent" group is the AIDS population, which in Spain, being comprised mainly of persons from the lower social class strata, is unable to form itself into any sort of influential pressure group. I feel that in both Spain and Italy, which hâve the highest populations of HIV +
newborns in Europe, the philosophy and example set by United Kingdom should be followed
to improve the care provided for thèse families.
Dr. Baum: The gênerai point I was trying to make is that thèse voluntary forces do exist in
the marketplace and in the neighborhood, and the médical model must take account of them.
It is true that they may not be fairly représentative in one sensé, but, like many political develcpments, a cause is taken up by a vociferous group whose opinions need to be heard. Perhaps one of the jobs of the community-oriented specialist in child health is to take an
overview of thèse voluntary forces and perhaps modulate them to some extent to make sure
that there is sufficient voluntary effort in support of, say, breast feeding, as opposed to that
available to help children with cancer. This is a very difficult task.
In the case of a disease like AIDS, if the client group is itself socially and educationally
disadvantaged and cannot generate the necessary skills and energy to form such a pressure
group, then it is up to us to do it for them. People will certainly donate both their money and
their voluntary efforts to such groups.
Dr. Sawyer: Almost every médical school in the United States has a highly skilled professional at senior staff level who is specifically charged with looking after interactions with the
community. This person deals with voluntary groups and fund-raising, and spends considérable amounts of time coordinating activities within the institution so that staff work together
when dealing with the community rather than in an uncoordinated and sometimes opposing
way.
REFERENCE
1. Bajaj S. Review of research on the impact of Integrated Child Development Services Scheme. In: S
Gupte, éd. Newer horizons in tropicalpediatrics, 2nd éd. New Delhi: Jaypee Bros, 1986:268.