Current methods of delivering health care to kids are woefully unable to cope with a pediatric disease pendulum that has swung from acute to chronic illnesses, says a researcher at the Stanford University School of Medicine and Lucile Packard Children's Hospital. In addition, some of the most effective clinical advances for children may increase the disparity between children teetering on the bottom rung of the social and economic ladder and their more fortunate peers.
"There's a growing gap between where child health is moving and how we're attempting to deliver health care to kids," said pediatrician and health policy researcher Paul Wise, MD, MPH.
Wise is a clinical professor of pediatrics in the medical school and a core faculty member at the university's Center for Health Policy and Center for Primary Care and Outcomes Research. The two appointments allow him to straddle the worlds of medicine and health policy, applying the strengths of both to enhance the care of children. His conclusions appear in the September issue of Health Affairs, a special thematic issue of the journal devoted to the health-care needs of children.
Acute childhood illnesses, particularly infectious diseases, are now prevented or managed so well that chronic illnesses such as asthma, obesity and diabetes have become more important threats to kids' health, according to Wise. Other chronic illnesses are on the rise in part because children are surviving previously lethal congenital and perinatal conditions.
"Helping children with these complex problems is the primary challenge facing pediatric hospitals today," said Wise. However, current policies and programs don't respond to the needs of chronically ill children, particularly as they move into their teen and adult years, and often ignore the increasingly evident linkages between adult-onset diseases – such as heart disease, high blood pressure and diabetes – and child health.
"The programs that tend to support kids with chronic illness often end abruptly when the child turns 18, although their needs can remain profound," said Wise. "It's not unusual for families to find themselves with virtually no support, which is really quite tragic."
Wise also made a strong case for looking at disparities in child health in a new way. "Medical progress cannot guarantee equity in health outcomes," he said. "Indeed, under our current health policies, new medical interventions are more likely to widen rather than reduce inequalities in child health."
More than one in six children in the United States lives in poverty, according to recent data from the U.S. Census Bureau. In addition to struggling for adequate food and shelter, the frequent lack of access to health insurance and regular checkups leaves many of these children medically adrift.
The report documents that despite remarkable strides in medical capacity, the disparity between white and African-American children has actually increased over the past 30 years. For example, the introduction of surfactant, a treatment that can help the lungs of premature babies function properly, has proven highly effective in reducing mortality. However, evidence suggests that the disparity between white and African-American newborn mortality rates has actually widened over this same time period. The report provides evidence of the same kind of phenomenon for interventions designed to prevent or treat Sudden Infant Death Syndrome, severe birth defects and asthma.
"We can't just keep throwing clinical improvements out there and expect to reduce disparities in health outcomes," Wise said. "Each new intervention must be accompanied by programs to ensure it's reaching those kids who need it most."
Wise explained that treating children regardless of their ability to pay – a policy at Lucile Packard Children's Hospital and other children's hospitals – is one way to overcome some of the observed disparities in health-care access. Nationally recognized programs to reduce and treat obesity, cardiovascular disease and asthma, which draw both on the research strengths of Stanford's School of Medicine and the clinical expertise of Packard Children's Hospital physicians, are also successful ways to deliver the benefits of bench-to-bedside practices to children, he said.
Finally, he said he believes programs that teach pediatric advocacy to medical students and residents, like those initiated at Packard Children's Hospital, are critical to providing the best that modern pediatrics has to offer to all children, whatever their social status.
"It's a sad fact of modern medicine that, despite major improvements in health care for children, a growing number of poor and chronically ill children are not getting the care they need," he said. "These issues are the central challenge to all those who worry about the health and well-being of children."