Map of life expectancy at birth from Global Education Project.

Friday, April 06, 2012

A brief moment in history?

Margaret Hostetter, as part of NEJM's 200th anniversary celebration, reviews the history of pediatrics. She tells us that the very concept of pediatrics - of children as a group with particular medical needs - did not exist until the end of the 19th Century.

One reason for this, it seems, is that children in general were not expected to live. The wise approach to the death of children was acceptance. Hostetter writes, "By the middle of the 19th Century, a child's death, far from intolerable, was frequently viewed as blessed, a release from the torment of hectic infection or the lingering complications of diseases . . . " The old graveyard in my home town in Connecticut is full of children's tombstones. Yet the death of a child, once a routine occurrence, is today an unbearable, and rare, tragedy -- in North America and Europe, anyway.

What has changed is not so much living standards -- the children of the wealthy had little more chance in the 19th Century than the children of the poor. It is the conquest, by science, of infectious disease. There are three branches of the militant force which has won this world historic victory: environmental public health, antibiotics, and immunization. By environmental public health I mean such measures as the provision of clean water and safe handling of sewage, pasteurization and other food safety measures, isolation and quarantine (seldom needed today), sterilization of medical instruments, environments, and providers -- that sort of thing. Killing the germs before they get to the people, or keeping them away. The understanding of the nature of infectious disease, and measures such as these based upon it, made a tremendous difference even before there was much in the way of medical intervention against infectious disease.

Antibiotics, in fact, did not become important until after World War II. My mother lost an eye to infection as a child, something that would not happen today. Smallpox immunization was available in the 19th Century, or course, but the ability to immunize against a broad range of infectious diseases also came in the second half of the 20th Century.

So nowadays, for the first time in 2 million years of genus Homo, and 250,000 years or more of Homo sapiens, we expect our children to live. We take it for granted, in fact. But will this be true 30 or 50 years from now? Quite possibly not, if we continue with our present folly. This includes indiscriminate use of antibiotics -- including using them to fatten cattle even while maintaining them in unsanitary conditions. It includes the idiocy of people who refuse, and even campaign against, immunization. And it includes increasingly dangerous underinvestment in public health infrastructure. Maybe people who talk about a right to life should think about this.


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