Pediatricians must confront community-based threats to health

Pediatricians must look beyond the walls of the examining room and into their own communities to understand and confront the socioeconomic and environmental threats to the health of children and adolescents, such as poor nutrition, exposure to violence, and substance abuse. That was the recommendation of a special supplement of the journal Pediatrics released today by the American Academy of Pediatrics, the nation’s largest professional organization of pediatricians.

The supplement’s lead editors and contributors included several University of Rochester Medical Center pediatricians and many of the recommendations and conclusions in the study are based on the pioneering work done by Rochester-based practitioners in the field of pediatric community health.

“In the past, pediatricians focused solely on the patient and the treatment of disease,” said Jeffrey Kaczorowski, M.D., a pediatrician at URMC, co-director of the Pediatric Links to the Community program, and one of the supplement’s editors and contributors. “The health problems that we are confronting in kids today, such as obesity, mental health concerns, drug use and violence, are the result of the conditions in their communities.”

The supplement focuses on socioeconomic, environmental, and lifestyle impacts on the health of children and the need for pediatricians to partner with community-based organizations, state and local government, schools, churches and families to improve the delivery of health care.

Pediatricians are becoming more sensitive to the direct relationship between socioeconomic status and child health. Economically disadvantaged youths are more susceptible to teen pregnancy, violence and injury, sexually transmitted diseases, and mental health problems. Racial and economic disparities are particularly glaring. Black and Hispanic children are more likely to be under immunized, become overweight, develop diabetes, become pregnant as teens, and suffer from asthma than their white counterparts. The mortality rate for black infants is twice that of white infants.

“Factors such as race, poverty, and education are among the most important determinants of the future health of an individual,” said Andy Aligne, M.D., a URMC pediatrician and co-editor and contributor to the supplement. “These factors have their roots outside what has traditionally been considered the realm of pediatric care. But in order to have a meaningful impact on health, we have to engage with the community to confront these problems.”

The supplement details several models for community-based approaches to improving the health of children, including the groundbreaking efforts at URMC. Building on an already strong institutional commitment to community health, in 1996, the Pediatric Links to the Community (PLC) program was created at URMC to further the study of the unique health challenges for economically disadvantaged children and adolescents in the Rochester area and develop partnerships with community-based organizations to improve the delivery of care. The program has received national recognition and in 2001 received the Ambulatory Pediatric Association’s Outstanding Teaching Award, the American Academy of Pediatrics Professional Education Award, and a $2.5 million grant from the Dyson Foundation.

Using those funds, the Pediatrics Department at URMC created the Child Advocacy Resident Education (CARE) program that trains pediatric medical residents in the special needs of poor children and partners them with community-based organizations for “hands on” experience. Over 450 residents, medical students, and undergraduate students have participated in the program and have worked with over 40 different community organizations in Rochester since the program’s inception.

“Teaching hospitals must seize the opportunity to change the behavior of next generation of pediatricians,” said Laura Jean Shipley, M.D., a pediatrician at URMC and Panorama Pediatric Group and co-director of the PLC/CARE programs. “By integrating community pediatrics into advanced medical training, pediatricians will go forward in their careers with an appreciation and commitment to pursuing community-based solutions to children’s health problems.”

Ultimately, says Kaczorowski, pediatricians must cross over the line of being solely practitioners and also become advocates on the behalf of all the children in their community and press for policies and resources that improve the health conditions in their communities.

Writing in the supplement, Kaczorowski, David Satcher, M.D. the former U.S. Surgeon General and senior advisor to URMC on community health, and David Topa, M.D., a former pediatric resident at URMC who practices at Pittsford Pediatrics, called for such a transformation in the role of pediatricians:

“Although a pediatrician can write a prescription for an antibiotic, the pediatrician cannot write a prescription for 1 of the 9.2 million children who are uninsured. Although a pediatrician can refer a patient to a nutritionist, the health foods that are recommended often cost more than junk food and may not be geographically or financially available… A surgeon may be able to extract a bullet from a wound, but is unable to remove the victim from the environment of failing schools, gangs, drugs, violence, and struggling families that constitute the culture of poverty. Such obstacles to health require pediatricians to expand their roles to include that of advocate, not just for the individual but for the population of children as a whole.”