Presidential Address

Indian Pediatrics 2002; 39:238-243  

XXXIX National Conference of Indian Academy of Pediatrics, Bangalore January 24, 2002

Correspondence to: Dr. Dilip Mukherjee, 9/1 Ramnath Pal Road, Kolkata 700 023, India.

I take this opportunity to express my heart felt gratitude to all members of IAP, for electing me as President of IAP 2002 and giving me an opportunity to serve the Academy.

What decides that a country be called developed? Its progress in health, knowledge and a decent standard of living, has been used to rank countries by United Nations Development Program on a Human Develop-ment Index. India comes 139 among 174 countries of the Globe. The gender disparity index compares the difference in human development between men and women and India ranks 128 out of 163 countries. The change in the ecosystem due to thoughtless use of nonusable resources and pollution of water bodies, air and soil is matter of great concern. We should all be conscious and raise our hand to fight these effectively.

India with a population over 1027 million, the management of various diseases in view of the vast linguistically diverse population and chronic under treatment and lack of homogenicity in the treatment protocol is unique in the world.

At present only one infectious disease has been eradicated and another is at the verge of eradication because of effective immuniza-tion strategies, i.e., small pox and polio, respectively. The possibility of eradicating measles exists. Perhaps some day, we will be able to say the same about vaccine preventable diseases like dipththeria, pertussis, mumps, rubella, typhoid fever, hepatitis-B. Encephali-tis especially in areas like Lakhimpur districts of Assam and Burdwan district of West Bengal, needs careful consideration for prevention and management. A new group of infectious diseases are emerging and another old group reemerging.

The national health care in general and child health care in some aspects have come a long way. From a totally non-existent infra-structure for delivery of health care, the country has established a reasonably effective health delivery system from primary to district level for its vast rural population. A national health policy has been adopted in the last decade, which identified priorities and defined targets for maternal and child health. In addition several national intervention programmes for improving child health were launched from time to time which related to control and prevention of diseases to appropriate treatment.

The hospital care for sick children has been available but the number of pediatric beds and hospitals exclusively for children have been limited. Newborn care has been accepted as the primary need and has become part of national RCH programme at country level. Pediatric subspecialities has now become realities with improved facilities or specialized care with appropriately trained pediatric specialists.

Research on issues related to child health, delivery of health care, diseases afflicting the children, operational research and other areas have been undertaken at national, state and district levels.

(i) Infant and Young Child mortality remains unacceptably high. About 12 million deaths occur annually in under 5-year-old children. Seven out of every 10 of these are due to diarrhea, ARI, measles, or malnutrition and often a combination of these conditions.

(ii) More than 22% of children are born with LBW.

(iii) Despite broad and advanced sick care services, many (that needy) are denied access to health and medical care.

(iv) More often a particular disease / condition gets attended than the child as a whole.

(v) Mentally retarded children are still neglected as a whole.

(vi) Inadequate diagnostic facilities are still a problem particularly in rural areas.

(vii) The child risk measure (CRM) indicates the risk of child born in each country. India has a CRM of 45, a child in Europe 6 and that in USA less than 5 when the world average is 30.

The child has always been considered the best resource for human development. But unfortunately it has never been accorded the priority it deserved - be it the family or the national concern in health, nutrition or education. The approach has been to look at the health for a specific problem/disease and hardly ever as the child as a whole or in its totality.

A review on the host and environmental factors and institutional setting that influence risk trend in diseases in last 50 years, show that absence of breastfeeding is an important risk factor for bacterial meningitis. Approxi-mately, 5 million children die each year of diseases that are, preventable by existing vaccines. Our challenge is that to 16 million more children die each year because of our failure to develop effective vaccine against disease. Given the negative impact infections have on the nutritional status of children these failures represent only the apex of much more serious problem, that negatively affect the growth and development of children through-out the world.

Hence, there is a need to redefine, or repackage or extend the scope of the present child health programme to a comprehensive child care programme. This would include care of the child from pre conception to conception and from birth to adolescence. The current knowledge clearly and unambigously dictates that the child care should be in totality and not piece meal. It should be preventive and promotive with appropriate quality care of the sick child should be accorded a high priority. Hence the quality care - is the apt theme of the conference.

Hospital and Institutional care for sick children should become a part of compre-hensive care. The development of primary care and hospital care should be concurrent as even today a significant number of children need hospital care.

The quality of pediatric in-patient care has remained unchanged in last five decades. There is hardly any development in subspecialities. This is in sharp contrast to care for adults who have highly advanced state of the art care in these specialities.

Failure to perceive the change in the disease pattern and non development of appropriate care such as intensive care units and specialized services appear to be the main reason for failure to prevent death and stagnant mortality rates amongst hospitalized children.

Only recently the Medical Council of India recognised the need for Pediatrics as an independent subject with mandatory examina-tion at under graduate level. However, examinations are usually the prerogative of universities and hence the MCI recommenda-tion has still to be applied universally by all universities. The same situation or perhaps worse exist for pediatric curriculum for nursing, midwifery and other paramedical courses which sadly continue to remain unchanged over decades ignoring the recent developments in epidemiology of disease pattern and advances in patient care. Almost all the courses suffer from a disregard to acquisition of skills and practical training at an appropriate, reasonably developed center providing quality patient care.

There is thus an urgent need to revise the curricula and training programme in view of the vast changes in current situation. The Pediatric Education cells of Indian Academy of Pediatrics has already worked meticulously on the issue and have given our recom-mendations to the MCI for the undergraduate and postgraduate training and needs to be implemented as early as possible.

Today after 5 decades of independence we have seen lots of revolution in our country - be it in economic, food production, health status and raising the standard of living of the people. In India there are very affluent groups of people at the same time there are also very poor group who are compelled to live in very miserable conditions - they are not fed adequately and still there are deaths due to starvation. It is a shame on our part that still we have places like Kalahandi in Orissa where our unfortunate children suffer from malnutrition due to starvation which takes lives of the children in blossom, despite our country is self-sufficient in food and we have huge stock of foodgrains.

A national policy exists for nutrition in the country. Based on the reports of the national nutrition surveys, morbidity and mortality pattern and agencies for implementation a comprehensive action plan for children with prioritization in the existing situation can be formulated. The IAP could spell precisely its role at national, state and district level as its membership extends to all parts of the country.

This group of teenagers constitutes the second highest population (29%) but are totally neglected. They are not given proper importance in the community and family, by the government and even the medical personnel. The important segment as pediatrics now extended up to 18 years and in USA it is up to 21 years. Every pediatric department must be well versed with the physiological norms and the physical, social, environmental and psychological problems of the adolescents and try to help them best possible way. We should teach the parent that spare the rod and spoil the child is obsolete now. We must be friendly with them to solve their problems. Indian Academy of Pediatrics has come out with task force for Adolescent Care, which will make our members more confident and to do quality care for the adolescents.

Social concern and awareness for the need to help unfortunate children with disability has lead, to development of services for physically handicapped children in govern-ment and non-government sectors. Even these facilities are sparse and grossly inadequate. But the biggest current problem is the lack of knowledge, awareness and facilities for an early diagnosis in young infants with mild to moderate problem in whom an early intervention is very rewarding. In my tenure we shall try to focus on the early detection and intervention of the childhood disability and our members will be trained accordingly so that quality of life of the unfortunate victims will be improved by rehabilitation to near normal level.

The Government of India is committed to the Rights of Child at the international and national level and a national policy and commitment exists. The IAP members also had pledged for protections of Rights of the Child in 1994. The government has also enacted laws to prevent child exploitation and punish the defaulters. But a commitment in the true sense is required for effective perusal at different administrative and political level.

IAP has formed a group called CANCL which is doing commendable work on this issue and we hope, in future we shall be able to do away with this problem in our country.

There is tremendous need to direct the research which is undertaken at the post graduate level for dissertations for M.D. thesis. At individual level many Pediatricians persue research in their personal capacity or for department/ hospital or organization. But a lot of research is repetitive and suffers from poor methodologies. A corrective step is needed at the post graduate education level and opportunities in the form of courses on research methodologies be made available to those who wish to persue research seriously. In addition it is necessary to determine priority areas for research at individual, institution, state and national level. This would ensure utilization of the resources and also results which will be relevant to needs and not repetitive. The Indian Council of Medical Research and many national and international organizations and Indian Academy of Pediatrics could interact and act as initiator and providers for this effort. The supporting agencies should monitor this process for ensuring successful completion. IAP has already formed a Research Advisory Committee towards this commitment.

In India there are different culture, religion, socioeconomic and environmental conditions. As we all know that besides genetic factor growth of a child is the interaction of nutrition, illness episodes and the environment. The physical and physio-logical environment has got tremendous bearing on the outcome and the quality of nation’s children-upbringing and ultimate health and psychological makeup. Thus the environment of the child has got a direct bearing in pediatrics. Indian Academy of Pediatrics during my tenure will try and take it as one of the presidential projects with help of UNICEF/WHO/Government of India to propagate, enlighten, educate and train our members successfully to enable them to realize and understand the impact of environment on child health care and act accordingly so that our children have a better health and health care.

We should urge the Government and the policy makers on child-care to kindly think about the growth and development and nutrition of our children. Because if the nutrition is improved, preventable illnesses drastically reduced by adequate immunization and the environmental conditions betters, so that our nations children will have good growth to become a healthy child, to become healthy adolescent and finally healthy adult. I appeal to the Government of India to kindly consider this aspect and I would like to assure that Indian Academy of Pediatrics through our dedicated members will definitely make this programme successful to our community.

In keeping with the present days scenerio, the theme of the Conference "Quality Care in Pediatrics" and "The Evidence based Pediatrics" are not only the right approach, but is the need of the hour. We should think well ahead before we start managing a case. Each and every step we undertake, should be rational, evidence based as per as practicable to reach to the unreached the Quality Care. We should try our level best to be abreast with the knowledge and practice of the recent trends and advances in particular subjects -which in turn will empower us to offer quality care to our nation’s children.

Our endeavor must be to ensure that every child in India has access to rational and quality child care in the vast country - which has unity in diversity.

The IAP with 15000 committed and dedicated members is striving hard to contribute forwards this noble cause.

The challenge for the coming years will be to unlock the potentials of health and nutrition action inherent in many sectors of societies, among local communities and within families. There is a clear need to break through tradi-tional boundaries within government sectors between government and NGO, between medical academics and health programme planners and implementors, and between public and private sectors. Cooperation of all is essential. Specially, this requires the creation of new partnerships for health on equal ground between the different sectors at all levels of governance in societies. The challenge is to achieve more equitable, sustainable economic development in which well being of the majority of population is a primary goal, along with preservation of the global environment. The interventions that will make visible impact in the immediate term should-get the priority now. The maternal and child health care can be provided cost effectively to those most in need by collaboration between medical colleges, government health department and pediatri-cians and other health professionals with a commitment to equity and use of simple cost effective methods in a cost efficient manner.

Presenting social responsibility for health, increasing community capacity and empower-ing the individual consolidation and expan-sion of partnership for health, building new and diverse networks and increasing invest-ments are priority actions required. The increased investment for health development is possible through a truly multi-sectoral approach, including additional resources to education, and housing sector. Investments in health should reflect the needs of certain groups such as women, children and adolescents.

The priorities for the comprehensive childcare alliance include:

(i) Raising awareness about changing determinants of child health;

(ii) Supporting the development of collaboration and networking for child health development;

(iii) Mobilization of resources for health actions;

(iv) Accumulating knowledge on best practice,

(v) Enabling shared learning;

(vi) Promoting solidarity in action.

This is possible only if all of us work together with the community and contribute our might to the noble cause of making the dream theme of this conference a reality in near future.

Coming together is a beginning, keeping together is progress and working together is success. The best way to have our dream come true is to wake up. Please remember that attitude is everything. Awareness, persevarance and the persistent hard labour to reach the goal is our motto. A country that is a symbiosis of different cultures, echoing the inherent values of our tradition, a democracy that still propels its unity in diversity, we should try to maintain this UNITED spirit of India. We must be united. think united and work united to make IAP prosperous and strengthen our beloved IAP.

Let me conclude with the word of Swami Vivekananda, which was delivered in the famous Chicago Religious Conference in 1893. "Help and not fight, assimilate and not destruction, harmony and peace and not dissemination".

Long live children of India

Long live IAP.