Not an obligation, not a mission, a privilege

A running joke among residents in the wards at the Montreal Children's Hospital ([MCH] Montreal, Quebec) is that when Pekeles is your attending paediatrician, the differential diagnosis and management plan are not enough. You need to know when and from where the family came to Canada, what were the circumstances and what are the social supports (as well as, subject for a second column, who is the primary physician and whether he or she has been contacted). For Aboriginal patients, you need to know what nation, what community and what resources. As a largely inpatient paediatrician, the slice I see of the life of a child and a family is even smaller than it used to be. We need to situate that slice in a broader social, financial and health care context. It was not my childhood passion to become a doctor. Having taught English in a high school in North Africa for one year, medicine became attractive as a skill that would allow me to work, at least for part of my life, in the developing world. As it turned out, this pull to the tropics extended, as it often does for Canadian doctors, to the circumpolar world as well. It is the truth, and not a truism, that poverty (economic and social) is the most important cause of ill health among children. This is true globally and locally. For example, when comparing length of stay (one of our current obsessions) by disease, a major determinant is family income. We work on the margins of this fundamental truth, both in the care we provide to individual patients, and in our advocacy for specific change, from expanded immunization programs to injury prevention measures to more accessible mental health services for children. Working with families with more limited resources, even in the Canadian context of few financial barriers to medical and hospital care, the need to push on the broader political issues is heightened. My own bond to Aboriginal child health began when taking care of sick Inuit children who were referred to the MCH with Escherichia coli 0111. The outbreak in the late 1970s and early 1980s spread to Cree communities in Quebec and Ontario. Seven children died. My involvement shifted from treating patients at the MCH to conducting an epidemiological investigation of the outbreak for the Ministry of Health. I then worked for the Grand Council of the Crees, as part of an ultimately successful campaign to improve housing, water supply and sewage in those communities. At the MCH, we had the unique opportunity to work with the first three autonomous regional health boards in Aboriginal lands–the Quebec Cree, Nunavik and the Baffin region. The relationship was completely different from our previous contracts with the federal government. We directly answered to the communities in which we worked. The major challenge was to provide support that helped these boards to take real control. We could succeed only by working in true partnership with local leaders. Over the past 30 years, there has been a major shift in mortality and morbidity in these regions. The burden of infectious disease, with the exception of the respiratory syncytial virus, has been greatly diminished. The eradication of Haemophilus influenzae was a sea change in many Inuit villages where one in 20 children developed meningitis. The major challenges we face now are in the domains of suicide, other injuries and families in crisis. It is clear that the major improvements in health status for the next 30 years will come primarily not from more and better medical services as important as those are, but from social and economic development, which allows children and youth to see a fulfilling future for themselves in their communities. On the global level, the urgency for action is even greater. The focus shifts to what more we can do as a rich, benevolently inclined country, and what we can do in a variety of specific ways to increase capacity in poor countries with a very young population, many of whom are suffering from ill health. My work in east Africa and Southeast Asia has been primarily as a teacher. I have taught medical assistants, medical students and residents about child health and, more importantly, flexible clinical problem solving. I have taught district health officers and public health students about assessing population health, and planning and evaluating interventions. This was always done in close collaboration with local colleagues and not in imported, stand-alone projects. The major prerequisite to sustain the impact of such effort is stability and peace, which allows health professionals to continue to work in their own countries. The fundamental driver for better child health is broadly based economic development. The next most important factor in many countries is more education for girls and young women. We do this work, I do it, because there is hope of making a difference. But I also do it because it is enriching. Our individual practices afford us the privilege of intimacy with families whose children we try to help. Practising and teaching in places far from home or in communities very different from our own allows us the privilege of learning more about people who we would otherwise just meet in passing. To do right by them is the only justification for this opportunity. These are the privileges I cherish most and that sustain me as a doctor in the wards of the MCH, the villages of Ungava Bay (Nunavik), and the hospitals and health care centres of east Africa, where I have taught and worked alongside colleagues.

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