change; but with planning and a desire for and recognition of the need, the child's treatment, education, and recreation can be incorporated into an allday program that allows him to live a more normal life. This entails utilizing available personnel to the best advantage.

Teacher should be recognized as part of team

Too often the school teacher is exeluded from the hospital team and relegated to an extraneous position. She is accepted neither professionally nor socially as a bona fide member of the hospital staff. Her program suffers when she must "catch as catch can" to get enough time with her patients and enough facilities with which to work. Such a position, frequently underpaid, is not attractive to competent teachers.

Yet in institutions where the teacher's special contribution is recognized, she is often called on for valuable services beyond the call of duty. At University Hospital a little girl in a complicated apparatus was tearing her bandages in a state of emotional disturbance. A teacher who was called upon to help with the case interested her in doing something to occupy her mind and hands. Under the teacher's influence, the child became quiet and more content. At the Sigma Gamma Hospital, near Mt. Clemens, Mich., the teacher is informed when a child is to undergo special treatment or surgery. She discusses it with the children in the group, and the patient who is to have this treatment is helped to understand and to accept it. This helps to take away the frightened, hurt look in a child's eyes after he has undergone an operation.

To review principles of child development

It has been suggested that in-service training in the field of child development for all hospital workers might raise present standards. An orientation program, starting with basic principles and assumptions, would point nurses, social workers, teachers, and others in the same direction. Very few institutions have this correlation, although the principles are taught in professional schools for nurses, teachers, doctors, and social workers. What is lacking is a review and reemphasis of this training when the worker joins the

staff of a hospital. Regular staff meetings, where all workers come together, are especially recommended.

As new hospitals are planned and built, provision for educational facilities should be kept in mind. In existing institutions, when space becomes tight and schedules crowded, the education program usually suffers.

War conditions hit hospital education

In one New York hospital, before the war, the whole top floor was given over to the teacher and her pupils, with excellent provision of space, light, and air. Under today's regime, the schoolroom has been reduced to a small, crowded area, with poor lighting and lack of storage space.

New hospitals should be planned to include a classroom, supply closets, and storage facilities near the wards. The room should be large enough to accommodate a group of children in beds, wheelchairs, or carts, and it should be well-lighted and attractively arranged. There should be enough space in wards for group work also. In a small hospital, where children who are long-term patients are few and far between, classroom space, when not needed for children, could be adapted to other usesfor adult patients' use, nurses' classes, or conferences. The important thing is to have the space available for children when they need it.

Although data on the number of disabled children in hospitals are incomplete, there is sufficient information to conclude that these children's needs are tremendous. Every day in the year there are some 3,300 patients in children's hospitals; 4,300 more in orthopedic institutions; and thousands more in general hospitals.

A survey within the past 5 years made by the Children's Bureau of the Federal Security Agency reports more than 341,000 crippled (badly handicapped) children in the United States. Infantile paralysis stands at the head of the list of causes, with more than 62,000 young patients. Cerebral palsy is next with more than 33,000. When we remember that in 1946, 1947, and 1948 there were approximately 64,450 new cases of infantile paralysis reported in the United States, we realize that children recovering from this disease remain one of our greatest obligations.

Community leaders can help a great deal in building a happy future for orthopedically handicapped children, especially in education, which is a vital part of therapy. First, local groups must find out how many such children there are in an area and what conditions prevail as to their care and education.

Volunteers in the hospital and board (Continued on page 189)

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TOW THAT the American Academy of Pediatrics has completed its 3-year Nation-wide study of child-health services, we know much more about what health services are available to the children in the 3,000 counties of the United States. And health planners can use this information as a base for positive and constructive action toward the goal of better health for every child.

Summary of findings available

The study was made with the help of the Public Health Service and the Children's Bureau, both of the Federal Security Agency. Substantial aid was given by the National Foundation for Infantile Paralysis; the National Institute of Health, Public Health Service, Federal Security Agency; the Field Foundation; and many leading commercial houses. The findings have been summarized in a report, Child Health Services and Pediatric Education, published by the Commonwealth Fund, New York City. A second volume is to be issued soon, giving the methods used in the study and basic tables from which the summary report was written.

The two-volume report represents the most comprehensive inventory of health services ever undertaken. It includes information from most of the practicing doctors in the United States; from all of the 6,000 hospitals that admit children; and from official and

voluntary community health agencies. Also, since a study of child care must involve an evaluation of the training of the doctors who give the care, it reports the results of personal visits to each of the 70 approved medical schools in this country and all their affiliated teaching hospitals.

The general practitioner is the bulwark of child care

A startling result of the Nation-wide inventory comes from the answers of the physicians who have child patients and most physicians do treat children. According to doctors themselves all too many gain their first real experience in the care of children after they enter practice. There should have been more opportunity for them to have such experience while in medical school and hospital internship. As it is, they get their training the hard way-from experience and from postgraduate courses and clinic work.

The problem of physician training for child care is directly traceable to the financial crisis in medical schools. High standards of medical education are being threatened by lack of funds for teaching budgets and by the resulting inability of schools to attract and hold the teachers who are needed to give the requisite clinical training.

It is the undergraduate clinical teaching in hospital wards and outpatient departments that fixes in the medical student's mind the practical use of his classroom knowledge. This knowledge must be strengthened by providing him with more clinical teaching hours. That means more money to

recompense teachers so that they can afford to take more time away from their private practice to teach.

The survey of medical schools shows that, although a few schools provide as many as 300 hours of clinical teaching in pediatrics for undergraduates, the average is only 161. And some schools provide less than 50 hours, which means that students are graduated from these schools having received less than 50 hours of actual contact with child patients in wards and out-patient clinics.

But when he receives his M. D. degree, the medical student is only beginning his practical training in child care. A period of well-rounded graduate training in a hospital, in which the doctor-patient relationship is estab lished under faculty supervision, is essential preparation for good medical practice. Interns and residents, with the guidance they receive from experienced physicians, acquire sureness in applying their theoretical learning to actual child problems before they are thrust entirely on their own. Many students, however, cannot afford to acquire special hospital training. Financial aid in the form of fellowships must be increased to allow more physicians to round out their training as hospital interns and residents.

Family doctor needs pediatric training

The doctor who plays the greatest role in the care of the Nation's children, the study shows, is the general practitioner. Three-quarters of the private medical care of children in this country is in his hands. Of the Nation's 116,000 practicing physicians, two

thirds are general practitioners. And it is the family doctor who braves the rigors of country practice. Hospitals and diagnostic aid and specialists are few and far away. He must depend largely on his own judgment, skill, and resourcefulness. Thus, the Academy holds, it is particularly important to give the student preparing for general practice a good pediatric education while he is in medical school and good opportunities for graduate hospital training in child care.

Once in practice, the busy family physician has little opportunity to take

postgraduate courses, to catch up and keep up. It is therefore, important to extend or "beam," directly from medical centers, the postgraduate training and special diagnostic and therapeutic services that our practicing physicians, especially the remote country doctors, need and want in order to provide upto-date child care.

In some sections of the United States plans for "decentralizing," or extending training and services from medical centers directly to isolated communities, are being developed by philanthropic foundations, State and county

medical societies, and medical schools. Where the programs are in effect, a

high quality of medicine is being brought directly to the most remote communities. The Academy's pro

gram at the national level is adapting these techniques in a demonstration program which it has just started and which it hopes will ultimately encourage heads of pediatric departments in all medical schools to disseminate their services to regions surrounding their medical centers.

Before describing that program, however, let us take a brief look at the county-by-county study which the Academy's State chairmen conducted throughout the Nation with the cooperation of public and private health and medical organizations.

County-by-county score revealed by the
State studies

There is a geography of health that is linked closely with the geography of medical care, the local studies showed. In some counties where modern medical services are scarce, five times as many infants (per thousand live births) die as in more favored communities.

Children in or near cities receive 50 percent more care than those in isolated counties-areas to which the advantages of metropolitan areas are not readily accessible. Two-thirds of the 3,000 counties in the United States are in this category. Children in these areas particularly lack specialist care, clinic care, and the highly skilled diagnostic and treatment services that are available to their city cousins.

Hospital out-patient services are almost nonexistent outside the metropolitan counties. Some States provide over three times as much hospital care for children as others do. One State has five times as many physicians as another in relation to child population.

Community health services such as public-health nursing, clinics for physically handicapped children, well-child conferences, and premature-infant and rheumatic-fever programs are not filling the gaps left by private practice.

Two over-all needs

Therefore, if one were to distill from the entire 3-year study of child-health services the two most significant con

1

clusions, these would be, in informal phrase: We need to do something about the medical training of all physicians general practitioners as well as pediatricians to give them the best possible preparation for child care; and we need also to make it possible for children in isolated areas to have the same opportunities for good care that they have near our large medical centers.

Thus we are brought back to the original objective that prompted the study: How to make quality medicine available to all children, regardless of where they live or the income of their parents.

The study was from the outset recognized as only the first step. Now that the Academy has answered the question "What is?" there is ahead the far more difficult question, "What to do about it?" That is, how to meet the needs that have been revealed.

The Academy is not leaving future action to chance. It has created a continuing committee, aptly designated the committee for the improvement of child health. This committee, under the chairmanship of Dr. James L. Wil

son of the University of Michigan, is made up of pediatricians in private practice and in academic and administrative positions. Under the executive direction of Dr. John P. Hubbard, who also directed the study, the committee has established offices in Philadelphia, and it is already well along the road on the important assignment of translating the study into positive action. Also, to dovetail the childhealth program with State and county health programs, the Academy and the American Medical Association each has appointed a three-man liaison committee for cooperative planning and effort.

A twofold solution

To meet the twofold need-more

training for doctors who are caring for children and a better distribution of medical care-a twofold solution has evolved. Through extension of pediatric education and services to outlying areas, fresh knowledge is brought to the hard-pressed general practitioner, and the skills and up-to-date methods of the medical centers are brought to the chil

dren in the areas where deficiencies have been shown to exist. Through creation of opportunities for graduates of medical schools to receive portions of their training as pediatric resident physicians in outlying hospitals that become affiliated with teaching centers, many advantages result simultaneously. More places are provided to train more residents and hence turn out more well-trained physicians; community hospitals benefit by the services of a resident that they would not otherwise have had; the resident himself profits from a period of very practical training; the local general practitioner is on the receiving end of a direct channel from the medical center; and the child, even in remote and isolated areas, receives better medical care and health supervision. Thus immediately we are brought closer to our goal of better health for every child.

To give practical application to this broad planning, the committee has worked out a demonstration program for decentralization of teaching and services. Stemming from a large university medical center, this program is

being developed in three Eastern States. Under this set-up, small hositals, through affiliation with the large ediatric teaching hospital of the medcal center, will be brought into close ouch with metropolitan services and is modern techniques. The residents ain practical first-hand experience in he art of rural medicine, but they also erve while they learn. Their services pcrease the hospital's usefulness and heir active participation in community ealth services brings forth new wellhild clinics and similar health aids. However, no over-all national proram can be effective without initiative nd support by the States and the comunities. If children's health is to e brought up to a uniformly high vel everywhere in the United States, with better health and medical services eaching into every community, State rograms inspired by local medical and ealth organizations must be developed long with national programs.

Thus the Academy's own State chairen are preparing State reports and detailed operating plans suited to the needs of the individual States.

The study findings have already been eported and published in Florida, Louisiana, Mississippi, Missouri, New York, North Carolina, Oregon, South Dakota, and Wisconsin. Sixteen othrs are in draft form.

In some States, under the auspices of he State chairmen, new committees or ouncils for the improvement of child

ealth have been formed, or the repreentation of the existing ones has been roadened. Membership includes repesentatives from pediatric societies, State and local medical societies, health epartments, and other organizations in he States which are active in child. ealth and welfare.

Reports of local studies bring action

Recommendations by the State committees, based on the local study reports, re urging the expansion of many pubic-health programs, including the esablishment of more community health services such as public-health nursing, mmunization programs, mental-hyriene clinics, and aid for the physically handicapped. Recommendations involving better public-health measures have in some instances stimulated offiial action at the State capitals.

of the State findings was demonstrated in one Western State. A plan for a children's hospital had been canceled by the Governor on the ground that there was no need for it. The findings of the Academy's State study were brought to his attention, and as a result the hospital is now under construction.

Hospital administrators are acquiring constructive suggestions from these reports for improvement of their own services. But through all the State reports echoes a need for greater consideration of the trials and tribulations of the general practitioner-better training, extension of postgraduate education to him in his own community, and provision of special consultation and diagnostic aids when he is far away from cities.

The common denominator of the Academy's plan is better opportunities for all children

Reducing the idea to simple terms, the Academy says that under modern medicine your child and my child and the next child are entitled to protection of their health and to good medical care when they are sick.

That means health supervision from the time of birth in such matters as proper feeding, and immunization against diphtheria, smallpox, and whooping cough. It means continuing supervision to keep well children well during their preschool and school years.

It means skilled medical attention for the sick child by a doctor who, whether specialist or family physician, is adept through training and experience at recognizing and treating childhood ailments; who can have advice from consultants on the diagnosis and treatment. of difficult cases; who is versed in new drugs and therapies.

If your child and mine have these benefits, they are indeed fortunate. But until all children have them, there will continue to be youngsters growing up with defects unchecked or uncorrected, and there will continue to be many in whom diseases such as rheumatic fever gain fatal foothold for lack of early diagnosis and care.

Now for a vigorous action program at National and State levels to get good care to the other child.

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(Continued from page 185)

members of community agencies can lead in studying legislation and appropriations improve conditions.

to

Their interest can result in the appointment of well-prepared, well-adjusted teachers in this highly specialized field, at salaries adequate to attract other competent teachers to enter it.

Volunteers can also aid in supplying materials to teachers and occupational therapists; these may include special books, selected toys, wall cabinets, bedside storage cabinets, earphones for radio sets, motion-picture projectors, and films. They can promote plans for developing teaching space; for example, covering the roof, building an additional schoolroom, converting rooms already built. To keep a full-day and week-end program going, teachers can well use volunteer services in manning book carts, telling stories, and operating motion-picture projectors, as well as in other group activities.

Volunteers work under teacher's guidance

Volunteer groups have always been generous in bringing entertainment to hospitals, but passive looking and listening will not give children as much as active recreation, in which they have a chance to learn something and to express themselves. Under the guidance of the teacher, volunteers can help children create and plan plays, parties, musicales. Original work by the children is a release for their emotions and an encouragement for social growth.

The lives of hospitalized children are enriched, too, by trips to outside schools and other interesting places in the community. Volunteers can solve the problem of transportation and act as guides and attendants. To be taken to a ball game, or wheeled through a museum, or even given an ice-cream cone from the traveling ice-cream cart, means to the handicapped child being normal and, for the moment, a part of the life outside. Through these simple experiences he may be made ready for home and for companionship with other children when he leaves the hospital, without the shock of readjustment to a world which has become strange.

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