Social paediatrics

The social determinants of health (income, social status, support networks and social environments), operating in the early years of life, can have a profound effect on health, behaviour and school achievement in later childhood and adult life (1,2). Youth suicide, delinquency, unemployment, marital instability and violence have all been linked to adverse early experiences (3–5). The results of recent neuroimaging studies of maltreated children may provide a basis for understanding the early effects of neglect on childhood brain development. Exposure to early abuse and early stress has been associated with the emergence of epileptiform electroencephalogram abnormalities, alterations in corpus callosum area, and reduced volume or synaptic density of the hippocampus (6). Furthermore, there is evidence that different brain regions have unique periods when they are maximally sensitive to the effects of early stress in its broadest context (7). Social issues have always been an integral part of paediatrics. As paediatricians, we are familiar with consensus building and information sharing, which enhances the care of all children, especially our most vulnerable paediatric populations that frequently live in social exclusion. They are not reached by the health care system, and they cannot access it by virtue of their social exclusion (1). Wilkinson (2) stated that “In poor neighbourhoods, the inequality is socially corrosive, affecting the quality of social relations, levels of violence, involvement in community life, the degree of chronic stress, of violence, drug use, and depression”. These conditions are endemic in urban areas of poverty, in aboriginal communities and among recent immigrants. The current situation is not encouraging in Montreal; from 2004 to 2006, physical abuse has decreased by 8%, but there have been serious increases in neglect (12%), sexual abuse (9%) and abandonment (43%), with the largest overall increase (13%) in the youngest age group (zero to five years of age) (8). In the face of an increasing body of evidence stating that social factors strongly influence health outcomes (2–7), it cannot be assumed that every child has the same access to resources within their family and community to ensure normal health expectancy. It is recognized that the health concerns of children are often not given the same import as those of adults in public debate. For example, the issue of operating room wait times for coronary artery bypass or hip surgery has occupied media attention in many Canadian jurisdictions, despite the fact that the issue is as dramatic in paediatric surgery. Advocates such as Stephen Lewis, the United Nations envoy to Africa, summed it up succinctly by pointing out just how low a priority is often assigned to child health issues by public policy-makers. It is clear that enhanced advocacy for the health and well being of all children is indicated. It is worthwhile to revisit the United Nations Declaration on the Rights of the Child (9), as well as the earlier 1948 World Health Organization definition of health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. This biopsychosocial approach to health has strongly influenced the differentiation of the health of children from more general social and environmental issues. The European Society for Social Paediatrics and Child Health (ESSOP) was founded almost 30 years ago and has assumed a mandate to develop and promote social paediatrics, which principally comprises prevention and children's wellness. The ESSOP believes in working together to use skills, resources and knowledge to develop local and global strategies to improve the health and well being of children and young people. Their methods include improving communication between all those involved in child and adolescent health and well being; identifying the latest results on relevant research taking place worldwide; developing tools for advocacy and teaching, and involving children and young people themselves; providing information about the effectiveness and efficacy of interventions; meeting together at conferences; and maximizing individual and group effectiveness. The ESSOP works with national, social and community paediatric organizations; nongovernmental organizations working in the same field; child advocacy groups; health professionals involved with child health; and governments, economists, sociologists, lawyers and others with the same interests and aspirations. The outcome anticipated is that we can work together to make all of us a more powerful voice and force for change by having access to people, strategies and concepts. The ESSOP supports the journal publication Child: Care, Health and Development. The ESSOP 2004 annual meeting was held in Montreal on September 22 to 24, 2004. The main topic for the meeting was “Early Childhood Prevention: Theories and Practice”, with a focus on vulnerable children. For the first time ever, the ESSOP met at a location outside of Europe. According to Dr Gilles Julien, social paediatrician and President of the Congress Organizing Committee (1), the organizers chose to present the best practices in early childhood prevention as a pivotal piece in the promotion of better health and a better future for all children of the world (visit for annual meeting program details). “International health implies that the health issues are outside your home country; they are problems that affect others. In a 1997 report by America's Vital Interest in Global Health [10], the Institute of Medicine defined global health as “the health problems, issues, and concerns that transcend national boundaries, may be influenced by circumstances or experiences in other countries, and are best addressed by cooperative actions and solutions.” In other words, global health problems affect us all, and finding effective solutions demand that we work together and learn from each other. These collaborations run the gamut from looking at global social determinants of health to investigating pathogens and treatments at the level of the genome. Yet these projects share the common goal of improving health and health care. As members of a larger community of committed educators, scientists and health care workers, we also have much to learn from our colleagues. Global health recognizes this commonality and shared responsibility” (11). The evolution of paediatric practice makes it opportune to develop the idea of a social medicine focus in paediatric training programs in Canada. Over the past 50 years, paediatrics has evolved from a specialty dealing with largely acute diseases, to one with a significant population of children with chronic diseases and special needs. As we transition into the 21st century, we are again seeing an evolution in paediatric practice as more and more is understood about the lifelong impact of social factors on the health of children. Of course, paediatrics is a comprehensive specialty, and training needs to prepare residents for all types of practice; however, by designing advanced training in social paediatrics, we may increase the options available to candidates and, ultimately, encourage the development of a diverse, next-generation group of paediatricians who are prepared to respond to the needs of the children of Canada and the world at large. Since 2002, the paediatric residency program at McGill University (Montreal, Quebec) has had an obligatory four-week rotation for second-year residents in social paediatrics. The goal of this rotation has been to expose residents to the effects of the social determinants of health, to expose them to the advocate role (through the role modelling of community practitioners), and to sensitize them to the contexts in which specific local vulnerable populations live. An evaluation of learning outcomes for residents experiencing this rotation has demonstrated pervasive changes in attitudes toward social vulnerability and an appreciation of the social determinants of health for all children, as well as sensitization to the local context of social vulnerability (ie, within Montreal and Quebec); the rotation appears to be meeting its goals. Through this experience, the program has developed many links with community-based health organizations. To further develop advanced training in social paediatrics, a new two-year fellowship program for fourth- and fifth-year residents has been created to expand and develop the core curriculum program. In doing so, there was a need to reconcile two apparently opposed notions: first, the development of a paediatrician who has the knowledge, skills and attitudes to practice context-sensitive, community-based care among socially vulnerable populations, and who has the academic skills to advance the understanding of the health problems of these vulnerable populations; and second, the need to assure baseline competence in general paediatrics, including comfort with acute care and acute in-patient paediatrics. To accomplish the latter, the residents continue to rotate through the normal on-call schedule in general paediatrics and paediatric medical emergency. Longitudinal clinics are the core of social paediatrics fellowship training. A variety of community-based paediatric training sites have been developed where residents are exposed to models of context-sensitive, community-based care, and advocacy and outreach to community-based organizations. The different sites are chosen based on the resident's career goals and interests. In addition to clinical training on these sites, the resident is expected to participate in health promotion, education and advocacy collaboratively with the community-based organizations by working with their practitioner-supervisors. The Developmental Paediatrics and Youth Protection modules are mandatory. In the second year of the advanced paediatric training in social paediatrics, the block of longitudinal clinical exposures operates much the same way as in the first year, but with a reduced clinical load to allow the resident to undertake a major scholarly project in community-based clinical research or advocacy. The possibility also exists for the interested resident to undertake advanced-degree schooling (such as an MSc in epidemiology, or MPH degree programs). Global child health electives are actively encouraged. In addition to their clinical exposures, residents are expected to have ‘one major, and two minors’ in the areas of education, research/advocacy and administration. Each resident has an experienced mentor/faculty advisor. The role of the mentor is to provide advice, advise about career development, and provide the opportunity for reflective practice. As an example, minor exposure in administration might include participation as the physician representative on the board of a refugee shelter. A major exposure in advocacy might include undertaking a large health promotion project at one of the resident's training sites, or obtaining a degree in public health as part of this large project. Advocacy is thus a key anticipated deliverable of this fellowship training program. We hope to create a cadre of paediatricians who are firmly rooted in communities, and who have the skills to engage communities in improving their overall health. The authors recommend that responsible bodies, such as the Canadian Paediatric Society, the Paediatric Chairs of Canada and the Canadian Association of Pediatric Health Centres, join together to undertake the following proposed national objectives for social paediatrics: Develop a common working definition of social paediatrics that is relevant to the Canadian context; Define the location and core content in the future training of paediatricians and other health care professionals in social paediatrics; and Launch a national interest group of health professionals and community partners to advocate for better training of health care professionals in social paediatrics. The goal would be improved health care and advocacy for Canada's socially vulnerable children, as well as better public policy relevant to child health.

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