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Presidential Address

Indian Pediatrics 1999; 36:243-247

Presidential Address XXXVI National Conference of lAP, Jaipur February 13, 1999

 

Indian Academy of Pediatrics at the Threshold of a New Era: Preparing for the Next Millennium

T. Jacob John

Reprint requests: Dr. T. Jacob John, 2/91E2, Kamalakshipuram. Vellore,
Tamilnadu - 
632
002. India.


 

There is one view that the last year of the present century and millennium is 2000 and the next millennium begins in the year 2001. I personally disagree. On the other hand, I accept the other school which considers that 1999 is the last year of the present century and the next one begins in 2000. It is on the first birthday of a child that we say the child is one year old. The child had been born one year earlier and for that one year, up to the first birthday; we say the child is 'zero year' old. Incongruous, it may sound, but the first year of the child's life is less than one. The day of birth is not even called the birthday but the first anniversary is. This is my justification for believing that the 'birth' of the next century will be on January 1,2000. In the year 2001 the new century will already be one year old. Not that it matters too much; you cannot tell the difference by looking at the sky; and at any rate, the Gregorian Calendar is only a tool of convenience for chronometry and almanac. Yet, I believe that I have a special responsibility to prepare the Academy to face up to the challenges and opportunities of the future, so crisply conjured up in our consciousness as the threshold of a new era. I have understood and accepted the task and I shall sketch very briefly the course I have charted.

How Fortunate the Present Day Medical Students Are

On a personal note, let me tell you that I became a pediatrician the year the Academy was born. Those days there was no pediatric postgraduate training in the State of Kerala where I graduated in Medicine. Indeed, pediatrics was just one part of general medicine, not even recognized to be  independent. During my final year as undergraduate student we were fortunate to have one Swedish Professor of Pediatrics and an Indian Lecturer with MD in Pediatrics. In Vellore where I did my Diploma in Child Health there was no MD degree training and I had to go overseas for higher training both in general pediatrics and in pediatric infectious diseases. Today under­graduate medical students are .taught pediatrics on par with adult medicine, surgery and obstetrics and gynecology, and all four disciplines are included in the final examination. After all, the medical graduate should be equipped to offer quality primary health care not only to men and women, but also to children who constitute about 40% of our population. Many of us, individually and collectively under lAP banner, had worked long and hard to achieve this goal through the Medical Council of India. For this, I record our gratitude, on .behalf of the Academy and the children of India, of whom we are the strongest ally and advocates. The urgent need for a textbook of pediatrics, to conform to the new syllabus and curriculum of undergraduate pediatric teaching, was recognized by the Academy leadership and action taken very promptly. I am happy to see the fruit of their toil, in the form of the just-released lAP Textbook of Pediatrics. The editors, authors and the publishers can justly be proud of their dream becoming a reality during our conference.

Today's medical graduates are doubly fortunate in that they have openings and opportunities to pursue further (higher) training in general pediatrics as welI as in several sub (or super) specialties, in many centers alI over the country. The Academy had contributed significantly to this growth. However, one deficiency remains, in my opinion. Although we have a much heavier burden of infectious diseases than in most, if not alI richer nations, we still do not have facilities for formal training in pediatric infectious diseases. We must strive towards a better understanding of the intricacies of infectious diseases management and towards its establishment as a field of specialization and of formal training. Some preliminary steps have already been taken: Our Chapter on Infectious Diseases is just two years old, but we have already conducted several symposia and even one major national conference. We have invited the Indian Association of Medical Microbiologists, of. which I had the privilege of serving as National President in 1994, to join with the Chapter on Infectious Diseases to form a core group to examine how best we can bring about evidence-based diagnosis at the primary and referral levels of care of the sick.

The Unfinished Tasks of the Twentieth Century

What is our unfinished work and what is our vision for the future? How can we make the Academy an effective Agent for Progress, to expeditiously complete the tasks of the present century spilIing over to the next, and simultaneously to expand the horizons of our vision and arenas of our action? Let us examine our unfinished agenda first.

Primary Health Care of the People

We had pledged solemnly, not simply as the Academy but as a nation, indeed not just ours alone but all nations, to achieve two goals by the year 2000. To provide Health for All by 2000 and to eradicate poliomyelitis by 2000. We failed to fulfill the Alma Alta declaration of Health for All because we did not know how to achieve it. There is a general tendency to blame our failure on poverty. After all, the rich nations have declared that we are poor. The moment we also accept their diagnosis of poverty, we lock ourselves in the prison of inaction. We do not have to solve our problems since everybody says that we cannot solve our problems as we are poor! I challenge the diagnosis. We are not rich, for which reason our options are limited. We are not so poor that we cannot give primary health care to our people within the limits of our affordability. If we do not provide primary care where people live, it is not due to poverty of funds, but is it due to the poverty of intelligence to design functional models? No, we are blessed with abundant intelligence. So it is due to a poverty of vision, of faith, of hope, on the part of both our leaders and ourselves the followers, alike.

Our major disease is that we lack the conviction that we do have the responsibility, individually and collectivity, to return to society more than we have received from society. The more educated, the more affluent and the more powerful, the greater our responsibility to the Nation. Are we not, the Academy members, blessed with all three, good education, a degree of affluence and the power to influence? So, my dear friends, I take upon myself the role of leadership to channelise these our strengths and assets to fulfill our commitment to the Nation. There is flaw in the political leadership, both at the Centre and in the States, in matters of health, no matter by whom and under what banner we have been ruled over in the past several decades. As far as the Academy is concerned, we will fully and enthusiastically support our Governments in all the projects and programs for taking primary health care to the people. Thus we pledge that we will accept, participate, propagate and train our members in all activities concerned with the principles and practice of child health through the full   cycle of reproduction till the age of reproductive competence. Therefore we whole­heartedly endorse the Government's program on 'Reproductive and Child Health' (RCH). The care of the sick child is weak in RCH, and the World Health Organization's program on the 'Integrated Management of Childhood Illnesses' (IMCI), covers that deficiency and strengthens the spirit and goals of RCH. Therefore we endorse and support IMCI and urge the Government to do the same. India's infant mortality rate (IMR), has stagnated at about 75 per 1000 live births for over 5 years. Neonatal mortality contributes about half of the IMR and without addressing Good Care of Mother and Fetus during Birth, and Good Care of the Newborn, we will not progress in further reducing IMR. Without reducing IMR we will not achieve further lowering of . fertility and population growth. These three, RCH, IMCI and Birth and Newborn Care form one continuum, to be fully integrated in implementation, even if they are somewhat compartmentalized in conceptualization. This expanded vision of primary health care for the full cycle of reproduction till reproductive competence will transform our previous efforts and successes of the Expanded Program on Immunization, Family Planning, Control of Diarrheal Diseases, Control of Mortality due to Acute Respiratory Tract Illnesses and Child Survival and Safe Motherhood Program. This transformation will lead these programs from Isolation to Integration, from Rigidity. of Design to Flexibility of Performance, from Vertical to' Horizontal, from Selective to Comprehensive and from Hierarchical to Decentralization. Thus we will transform our unfinished agenda of 'Health for All' into a new vision, mission and action for making primary health care accessible to all communities, in the first decade of the next millennium. The Academy stands committed to this National cause.

The Eradication of Poliomyelitis

Our second pledge pending redemption is the eradication of poliomyelitis. At the close of 1998 it has become clear that were faltering in its achievement, inspite of reportedly consuming some 8 to 10 doses of oral polio vaccine, OPV, per capita by the under-five children. Either the estimate is grossly wrong, or the vaccine is grossly defective. I will not elaborate much on these issues as I have written extensively on them, particularly in the columns of our excellent journal, Indian Pediatrics. I had pointed out the history of our poor performance of Smallpox eradication; India was the very last country in the world to eradicate Variola major. For polio eradication we as a nation had put our trust in the expertise of those who ought to have been wiser than they actually were. As we are being guided into being one of the very last countries in the world to achieve polio eradication, we shall always wonder if we were misled deliberately or inadvertently. The more delayed India achieves eradication, the larger the quantity of OPV we shall consume. All OPV is imported in India, either as finished product or as bulk concentrate to be diluted and repacked. With these diagnoses in hand, we pledge our full support to the Government to complete the task in the remaining 22 months before the end of the year 2000. We shall lead or follow, design or implement, manage or assist, advise or evaluate, as we are asked to do by the Government.

Consolidating Successes of the Twentieth Century

There are two' items which marked unprecedented successes of health care or public health in the present century, but upon which we must put our full trust.

The first is oral hydration to prevent death due to. dehydration in diarrheal illnesses. If all health care givers, who treat children with diarrhea, especially in the vulnerable age of infancy and early preschool years, pledge that we will promote oral hydration to prevent dehydration and oral rehydration to treat dehydration, can we not prevent all death due to' dehydration? I am aware of same colleagues who. feel that the solution of oral rehydration is not sophisticated enaogh for doctors. The oral rehydration salts are not drugs, they say. So why should we promote oral rehydration therapy (ORT)? Well, let me reiterate what greater persons than I, in The Lancet have said a few years ago', that ORT is perhaps the single greatest medical advance of the twentieth century. So', next time, do not hesitate to write a prescription far an OR preparation of your choice, for every child with diarrhea. Such recognition by prescription will give mare respectability and wider acceptance to the practice of oral hydration and rehydration.

The second item is something I hope no one will write a prescription for, to be collected by the parents from the medical shop and to be brought to the clinic for injection. I mean vaccines and the likelihood of break in cold chain if parents carry vaccines. The Expanded Program on Immunization (EPI). was a great idea. The choice of vaccines was excellent. The training component and the cold chain management were remarkable. But EPI had two flaws which were identified early but not corrected due to its inflexibility. First, it gave more importance to the development of 'herd immunity' (or herd effect), for the community control of the infectious agents than to the best interests of the individual children who participated in the program. Therefore, vaccine, failure in the participating children was ignored, violating principles of ethics. Secondly, EPI measured success by assessing the achievement of  targets of children to be covered (for herd effect), rather than by' measuring disease reduction. This violated principles of management. Much of our current impediments of progress; including the faltering polio eradication, the Government's inability to introduce newer vaccines such as those against hepatitis Band Measles-Mumps-Rubella and our inability to measure disease burdens to. assess the need far vaccines against Haemophilus influenzae type band others far which vaccines are already licensed or are in the process of approval, are all due directly or indirectly to the flaws in the design of   EPI, RCH plus IMCI plus Birth and Newborn Care will hopefully learn from past mistakes and will incorporate elements of disease reporting in the program. The seed of decentralized, district level, response-oriented, reporter-friendly, disease surveillance must be introduced now, if we are to build an our successes of the past. The Academy is ready with a workable and tested model and we urge the Governments, Central and State, to. adopt and implement it or its modified version, without any more delay.

The Directions for the Growth of the , Academy

The Academy has three groups of activities, namely Academic, Advocacy and Administrative. My agenda is to lead the Academy along all three paths. These goals are now enshrined in a Mission Statement which has been approved by the Executive Board and which will be presented to. the General Body Meeting and also published in our official publications.

The Academy will provide ample opportunities for continuing medical education and we will introduce steps for the standardization of diagnosis and treatment of illnesses. Our Intensive Care Group is being converted to a Chapter and it will prepare training modules and begin conducting training programs in Intensive Care.

We have just declared our policy that we accept the responsibility of care of children and adolescents up to and including 18 years of age. We will develop training manuals and modules and provide training for those who are desirous of giving comprehensive care to our teenagers. We must provide easy access to adolescents to come to us with confidence and trust; this is a relatively new avenue for many of us, but we are the best equipped to help them.

We have, with the assistance of the Committee on Immunization, made several clear statements of policy, of recommendations and of guidelines. You will see all these published in our official publications.

The Academy will provide leadership and guidance and even same support, for research in its broadest sense, relevant to the health and well being of children.

Regarding our Advocacy role, we have pledged that we will serve as advocates for the legitimate causes of children, their growth, development, health, emotional nurture, opportunities and rights, equity and justice. We will serve as competent and responsible source of information relevant to the health and well being of children, to other organizations, the public and the Governments.

We shall stand up against discrimination and inhuman. cruelty to female fetuses and female children. We shall oppose the use of investigations to determine the gender of the fetus for the purpose of feticide for gender selection.

We shall protest against all adulteration of food and drinks.

We shall develop guidelines for the safe transportation of children to and from schools.

We shall strive to bring justice, comfort and fairness to children in difficult circumstances, such as in employment and labor, bonded or otherwise, neglected and abused children and children used in prostitution.

We shall strive to prevent injuries to children and to provide tobacco free environments to grow, to play and to sleep.

We shall demand that the human right to primary education be implemented everywhere, and take to task any who may violate it, even if it is the Government.

We shall endorse that adequate nutrition be declared as a fundamental right of the child, as it forms an integral component of the Right to Life.

We shall propagate and practice ethics, equity and justice in clinical practice and clinical research.

These are some of the issues for advocacy on behalf of children.

On matters of Administration, I am sure you will agree with me that now is not the occasion to elaborate. I will have the opportunity at the General Body Meeting to update you with administrative innovations and improvements.

These, then are the ways in which we shall prepare the Academy to be worthy of our call and as we move to the threshold of the new Millennium. Had I not been confident of your approbation and cooperation, I would not have been so bold as to take such clear stands on specific issues. Please continue to uphold me in your thoughts and guide me in areas in which you are better qualified than I am. Once again let me thank you for reposing your confidence in me so overwhelmingly, to lead the Academy, and to be your minister and spokesperson.

 

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