Overlapping agendas or serendipitous synergism

In the course of reviewing the articles in this issue of the journal, as both a paediatrician and a community medicine specialist, I was repeatedly struck by the similarities in the two fields of medicine in which I have had the privilege to practice. In the last 50 years, paediatricians have been in the forefront of securing magnificent gains in child health through changes in public policy, ranging from advocating the addition of Vitamin D to milk, to championing the development and uptake of many lifesaving vaccines. Moreover, the promotion of breastfeeding, advocating proper sleeping positions to prevent sudden infant death syndrome and fostering healthy early childhood development are common themes in both paediatrics and public health. A sense of common purpose is most obvious in the area of injury control. Paediatricians and public health practitioners have been at the podium successfully advocating measures such as infant, toddler, and more recently, booster seats in automobiles; the need for graduated licensing for young drivers; the promotion of smoke detectors to prevent injury and death from household fires; the endorsement of personal flotation devices and proper fencing around pools to reduce drowning risks; the promulgation of standards that ban dangerous devices such as baby walkers; and measures to control excessively hot tap water generated by hot water tanks. The tap water scald paper in this issue by Mezei and myself (pages 153–155) captures an approach often employed successfully by the disciplines of both paediatrics and public health. A sound scientific foundation is established to define the magnitude of a problem or the effective burden of illness. In the course of the acquisition of such data, interventions are identified, often with an emphasis on approaches that have the safety built in (the passive approach) rather than one requiring frequent and sometimes difficult manoeuvres on the part of the individual (active prevention). Using this understanding of how and why events such as tap water scalds occur, strong coalitions of public health and paediatric advocates pursue interventions that will reduce pain and misery, such as that associated with the tap water burns, by shaping and promoting healthy public policy. Such gains are often only secured by the forging of new legislation or regulations, as it was for tap water scalds (through a CSA Standard, the National Building Code or the National Plumbing Code). The synergism of such partnerships becomes apparent when these issues come to or are brought to the attention of the media. It is often the public health advocates who collect the surveillance data and provide the statistics on how large an injury problem, dangerous device or practice poses for Canadian children. Paediatricians, because of their close and personal relationship with patients, are able to identify and enlist parents and children who can speak to the consequence of these injuries from both a physical and psychological perspective by putting the proverbial ‘human face’ to these injuries. Such melding of information captures both the minds and hearts of the public, helping to create political will and precipitating action. Moreover, this same systematic approach is similarly required to convince other partners to participate in the assembly of critical coalitions, ones that have the breath of expertise and credibility to bring these issues to a successful conclusion. While the goodwill and commitment of the multiple members of the coalition are essential, the need for committed resources to maintaining the momentum cannot be overstated. While not explicitly referenced in the article by Mezei and myself (pages 153–155), the support of Safe Kids Canada, both to allow for experts to be brought in to provide critical information to committees pondering codes and standards, and to cover the expenses of victims so that they could tell their stories firsthand, should not be underestimated. Also captured in this issue are the very troubling developments in the health of children in our schools. Kendall et al (pages 151–152) speak to the need for Canadian children to consume a healthy diet and lead an active lifestyle, yet paint a picture of a paediatric population that is becoming more obese and sedentary. The consequences of this unhealthy lifestyle are well documented and range from the development of cardiovascular disease to type II diabetes, high cholesterol, as well as psychological sequellae. A ‘super-sized’ epidemic is brewing and early effects are already creating pressures on our acute care system. Failure to address these issues in childhood, a time when lifelong patterns are being formed, has the potential to overwhelm our health care system, as well as have collateral systemic impacts on our population's productivity and our nation's competitiveness within the global village. The daunting lifestyle challenges will require a concerted effort on the part of paediatricians and public health practitioners. Not only must the chronic problems associated with clinical obesity in the office be addressed by clinicians, but both sets of practitioners must immediately begin advocating healthy public policies. These could include increased physical education programs in schools, greater options in terms of nutritious and inexpensive foods within cafeterias and in vending machines in schools, as well as ensuring accessible and affordable recreational opportunities. The paper by Hu and Bernard (pages 157–158) points out an additional complexity in addressing some of the challenges facing both paediatricians and public health practitioners; the growing disparities within the populations we serve. While our acute health care system has made significant and laudable gains in addressing infant mortality, the growing disparity in outcomes within the first year of life is disconcerting, and reveals disturbing inequities within Canadian society. Despite our federal government embarking on a strategy to eliminate child poverty by the year 2000, this goal proves as elusive as it did two decades ago, with one in six children in Canada still living in poverty. Children living under such circumstances, and often relying on our social support networks, frequently reside in families where nutritious diets are financially out of reach. Not only are resources likely to be insufficient, but the situation is also compounded when the most common sources of inexpensive and highly nutritious foods such as fresh fruits and vegetables are often not available within disenfranchised neighbourhoods. Ironically, the foods that directly contribute to our current obesity crisis – those high in refined sugars and fats – are the very ones that are within the budgets of poor families and seem to be available on every corner. Moreover, residents and nonresidents alike often consider the neighbourhoods in which these children live unsafe. Frequently, there are no readily available destinations for children to walk to, such as parks with safe and plentiful playground equipment and surfacing, or recreational facilities/centres in which children can gather and participate in active living pursuits. Even when available, the fees for participation in many of the activities are prohibitive for low income and impoverished families. As has been done with other threats to the health of children and ultimately the population, paediatricians and the public health practitioners must document the magnitude of this burden of illness, especially when certain populations are being disproportionately affected. This recommendation was articulated in the CPS statement (pages 171–173) on measuring growth parameters for children contained in this issue of the journal. The barriers that prevent all Canadian children from eating a healthy diet and engaging in active living must be addressed. We must continue to advocate healthy public policies that ensure that disparities be mitigated or eliminated. Although it may be contrary to current economic wisdom, clinicians and public health practitioners must still speak out on behalf of children and their families, especially in the face of a shrinking social safety net, which in some jurisdictions will soon be associated with reductions rather than increases in support for families with children. In addition, Hu and Bernard's article (pages 157–158) points out that while poverty may be relative when developed countries are compared with developing countries, the deleterious effects on health are well documented in both sets of circumstances and are very real. A promising development at the federal level is the recent creation of a Secretary of State for Public Health. Statements by the new Minister carried in the media are encouraging and demonstrate a recognition of the problems facing Canadian children, as well as the consequences of not addressing these problems. However, the threat to the health of children, and ultimately the general population, of the looming epidemic of noncommunicable diseases must receive the same attention and funding currently being sought for new and emerging communicable diseases such as severe acute respiratory syndrome and avian flu. We must come together and use our collective voices to advise and shape policy or this issue of the journal will merely serve to bear witness (be it with greater reproducibility and accuracy [CPS Statement, pages 171–173]) to the initial phase of a mutual public health and paediatric disaster –one that we documented but failed to respond to. The time is right for public health practitioners, paediatricians and those who care for children and youth to build on the solid foundations of past public health partnership successes in order to tackle the current and emerging serious public health problems that face our children and youth.

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