TH

HE importance of rheumatic fever as a cause of mortality in childhood. has been stressed in recent discussions from all parts of the world, and particularly in the United States. States. Every year between 800 and 900 children under 20 years of age die in the United States from acute rheumatic fever, not including the deaths reported from chronic rheumatic heart diseases. Clinical experts say that between 80 and 90 percent of all deaths from heart disease among school-age children (5) through 19 years of age) are due to rheumatic infection. When these deaths are added to those actually attributed to acute rheumatic fever we find that approximately 4,000 children (under 20 years of age) die each year as a result of this disease.

A leading cause of death

Since the decline of tuberculosis and the genuine acute infectious diseases of childhood (diphtheria, scarlet fever, measles, whooping cough, etc.) heart diseases, including acute rheumatic infections, have become one of the leading causes of death among school-age children. If accidents are disregarded, heart disease and rheumatic fever combined is the leading cause of death among white children 10 through 14 years of age and white boys 15 through

19.

Mortality rates for the six leading causes of death (in these age groups) are given in table I in the order of the rate for males; the rank of the rate for females is given in brackets. This table shows clearly the relative importance

of rheumatic fever and heart diseases at different ages in both races and sexes. Among white children in all age groups the latter conditions are a principal cause of death and are of increasing importance with increasing age.

Among nonwhite children of all ages tuberculosis takes a higher toll than heart disease plus rheumatic fever, as does pneumonia-and-influenza except among the 10-14-year-old girls. Rheumatic fever and diseases of the heart ranks fourth as a cause of death among nonwhite girls 15-19 years of age, with tuberculosis first and diseases of preg nancy second. Early child bearing in this age group of nonwhite girls might also be a contributing factor in the high mortality for both tuberculosis and heart disease.

ese figures make it plain why the aign against rheumatic fever must nsidered one of the outstanding of public health. In such a camit is necessary to know just where igh mortality rates occur and for purpose we must break down the crude rates and consider various oups of the child population. Children's Bureau has recently

a statistical analysis of rheue fever mortality in which the 1 rates are studied on the basis of race, sex, and geographic location. ace, and sex differences

e age, race, and sex differences in ality from rheumatic fever and

disease throughout the total ed States are shown graphically in e 1; the exact rates on which the t is based can be found in table II. he chart shows clearly the rise in mortality rate in each succeeding age p. This is true for both races and

sexes.

he chart also shows plainly the h higher rates for nonwhite children white in both sexes and all age ups.

he racial difference in rheumatic r mortality is not as great as in some r diseases which are aggravated by vorable socio-economic conditions,

as tuberculosis, but the pattern is ciently strong to suggest that a more avorable environment, which doubtexists for the nonwhite group, tends ncrease the risk of dying from rheuic diseases. That is, rheumatic fever ears to belong to that group of ases in which, besides the specific logical agent, the social environment re reflected in racial grouping) plays aggravating part.

enerally speaking mortality rates m acute rheumatic fever and diseases the heart, combined, are higher ong girls than boys. A marked extion is the much lower rate for white s as compared with white boys in 15- to 19-year-old group. The tendy toward higher rates for girls than s is most pronounced in the age up 15 through 19 years among nonite children.

Childhood Mortality From Rheumatic Fever and rt Diseases by George Wolff, M. D. Children's eau Publication 322. Federal Security Agency,

shington, 1948. 66 pp. 25 cents.

Annual rate per 100,000

Cause of death and race (Numbers of International List of Causes of Death, Fifth Revision of 1938)

Nonwhite

White

Nonwhite

Ratios: Nonwhite to white

1. 4

1.5

1. 6

1. 7

1. 4

1. 6

1. 6

1. 6

1. 2

1. 2

.9

1. 4

1.7

Geographic differences

1. 2

8

1. 1

7

Mortality from acute rheumatic fever and diseases of the heart varies among the geographic divisions of the United States. For both white and nonwhite children, the death rates for acute rheumatic fever plus heart diseases are below average in the South while in the Northeast, especially in the Middle Atlantic division, they are significantly above average. In the Pacific division. the death rates are as low as in the South and significantly below the country's average, while in the Mountain division they are exceptionally high for the white children in all age groups.

This geographic tendency becomes still more evident when rates are considered separately for white and nonwhite children, or the regional differences in the proportion of white and nonwhite children are discounted by adjustment of the rates.

The crude and the adjusted rates for the geographic areas of the United States, per 100,000 children, 5 through 19 years of age, are as follows:

of the individual States within the geographic areas. A few of the more outstanding facts of the report may be mentioned briefly.

In New England, industrial and densely populated Massachusetts shows a distinct tendency to higher mortality and is closer to the neighboring Middle Atlantic area than the other States in New England. There are no striking differences among the Middle Atlantic States except that among white children in New Jersey the boys have the lowest rates for this whole region while the girls as consistently have the highest. Why white boys should have more favorable rates in New Jersey than in New York or Pennsylvania while white girls have the most unfavorable rates among the three States cannot be answered without further study. In Indiana there is a similar situation. Here the white boys have the lowest rates and the white girls the highest to be found in the five States of the East North Central area (Ohio, Indiana, Illinois, Michigan, Wisconsin).

In the Mountain States the mortality rates in Arizona for heart disease are consistently below the group average

and as consistently above in Utah. Population factors can hardly explain these differences. Similar findings have been mentioned by former investigators of the rheumatic-fever problem and they merit a more thorough examination. In particular the high mortality for 15- through 19-year-old white boys in Utah, highest among all States, challenges the attention of public-health workers and local physicians. On the Pacific Coast the highest mortality rates among white children for heart disease are found in Oregon and the lowest in California. This cannot be attributed simply to a northern climate, since Washington has better rates than Oregon, nor to overcrowding, since population density is lower in Oregon than in California; the contrast should therefore be studied more intensively locality by locality.

The trend in rheumatic fever mortality since 1920

The fact that rheumatic fever and heart disease has now become one of the leading causes of death among children is due to a decline in other childhood diseases and not to an increase in rheumatic fever mortality rates. Table

The most impressive fact brought out by table III is the distinct decrease in mortality among white children, reported over the past decades. This decrease is in the neighborhood of 70 percent for the age groups 5 through

9 and 10 through 14, and of 60 percent for the age group 15 through 19 years. However, the story is very different for nonwhite children. Among these children no consistent downward trend

is visible, except in the oldest age group 15-19 years; even this decrease is far behind that of the white adolescents in both sexes and amounts to hardly more than 25 percent from 1919-21 to the last report in 1944. It appears from the reported figures that in the early period (1919-21) the nonwhite children had very low death rates, lower indeed in most instances than those of the white children. This result is contrary to later experience in the detailed study of the 1939-41 period, when the nonwhite children almost everywhere demonstrate consistently higher death rates from rheumatic fever and heart diseases than the whites.

How far the statistics reflect the true

epidemiological trends of rheumatic fever among white and nonwhite children during recent decades is open to question. It is improbable that the socio-economic conditions, including availability of medical services to nonwhite children, was so superior in the earlier period as to bring out these results. The most plausible explanation of the apparently increased mortality rates would seem to be that for nonwhite

children the reliability of the medical diagnoses and their reporting on the death certificates has increased.

All combined (crude) rates necessarily obscure finer differences by age, race, and sex. Therefore age-race-sex specific death rates are given in the Children's Bureau report for the individual States; they provide more detailed information of special interest for the local State health authorities.

Child Guidance Clinics

(Continued from page 88)

psychology can be applied more interchangeably in work with children or in

work with adults than can basic education in psychiatry. Two years of accredited training in adult psychiatry are required as preparation for advanced training given in child-guidance clinics in psychiatry for children. If his preliminary training in work with adults has been adequate, the psychiatrist trained in a child-guidance clinic can work with both child and adult patients. But because there are few so trained and because pressure from the public to have clinics established gives so powerful an incentive, some all-purpose clinics may start to operate under the direction of psychiatrists who are not satisfactorily grounded in work with children.

Interest, funds, but few specalists

A critical issue confronts the childguidance clinic. The new, keen public interest in seeing psychiatric services extended, combined with greater availability of funds for establishing them, has created pressure for more children's clinics. Some communities, disregarding the advice of experienced counselors and undismayed by the shortage of qualified specialists, are employing workers unable to operate efficiently in a child-guidance clinic.

Fortunately, a source of help on standards is at hand for communities wanting to build a service. Recently organized, the American Association of Psychiatric Clinics for Children will serve as an accrediting agency. Acting with the Division on Community Clinics of the National Committee for Mental Hygiene, this association will provide criteria that communities may use in planning and operating clinics.

The importance of sound planning and building cannot be too strongly urged. Otherwise the high level of child-guidance practice, the source of the clinics' success for for a quarter of a century, may not be maintained universally.

Reprints available in about 3 weeks

Guides for Fluorine Program

(Continued from page 89)

should routinely include the topical application of fluoride and, since it is a preventive measure of great promise, it should be available to all children in the area.

Recognizing that the services of dentists are already at a premium and so urgently needed to provide corrective dental care which only dentists are qualified to render, the statement suggests that auxiliary personnel be trained to provide the fluoride treatment. In this way, the maximum number of children can be reached.

To further promote efficiency and economy of the topical fluoride program, it was felt the service could best be provided in places where it was possible to reach groups of children, such as schools, clinics, and institutions.

The Health Officers believed that two administrative methods would be feasible: (1) Adding the topical fluoride applications to existing dental clinic services; and (2) Organizing new programs devoted exclusively to the use of fluorides, so that the services could be made available to children in areas that do not now have highly developed dental programs.

In starting a community program, the statement of principles points out, a series of 4 sodium fluoride applications should be given to every child in the community. Thereafter, in order to provide protection for the permanent teeth during the period of changing dentition, the series of 4 applications should be repeated at approximately 3-year intervals.

The statement concludes with the suggestion that a technic which has been adequately tested should be rigidly followed.

The Children's Bureau, responsible in the Federal Government for administration of grants to the States for child-health services, has already approved the use of these grants for providing this essential dental service for children. It is anticipated that the States will request increasing amounts of child-health grants to help finance State-wide protection of children's teeth by the new method.

WING HUME MINDERENCE CLANNING

T1950

Progress Notes on State Action

AP ROOTS of action toward the 1950 White House Conference are spreading wider and deeper over the country. "Nation-wide" begins to have real meaning as the concept of a mid-century stock taking of America's children grips the minds and imaginations of people; as States and communities set to work to stimulate action toward objectives to be achieved by 1950.

At this time 35 States have some form of planning committee or council for children and youth, some officially established, others on a voluntary basis. At least three other States or Territories are in process of organizing a planning group.

Since January 1, the following State councils and commissions either have been established or strengthened:

Arizona Youth Council.
Colorado Council for Youth, Inc.
Kentucky Planning Committee for
1950 White House Conference.
Illinois Council for Children and
Youth.

Michigan White House Conference
Preparatory Committee, and
Michigan Interdepartmental
Committee on Child Services.
Oregon Governor's State Commit-
tee on Children and Youth.
West Virginia Committee on Plan-
ning for Children and Youth.
Wisconsin Committee on Planning
for the White House Conference.
Wyoming Council on Children and
Youth.

A number of States, at the call of their Governors, have held State conferences on children and youth. Some of these are specifically called and so designated, in preparation for the 1950 White House Conference. Others are that in essence but not so designated. They all denote. a growing awareness of the necessity to build stronger services for children and youth.

The result of this coordinated planning for children is a growing unity of effort between the public and private agencies, between professionals and lay

men-a partnership in the common cause of children.

Michigan in action

"Children are everybody's business." With that as its title, the Governor of Michigan called a conference on children and youth in Lansing, November 11, 12, and 13. In June, Governor Sigler had appointed two committees: One the Interdepartmental Committee on Child Services, made up of 12 State agencies dealing with children, and the other the White House Conference planning committee. These two committees did the spade work for the conference. Success of the conference, and all reports confirm that it was a success, was due, as one commentator puts it, "to cooperation and communal brain work." Nearly 800 persons jammed the general sessions; there were over 600 registered delegates. During the conference, 66 sessions were held, 7 regional conferences, and 21 discussion groups. Prof. Jay Bryan Nash of New York University was the keynote speaker at the opening and the closing sessions.

The conference laid the foundation for State-wide action for children. Karl F. Zeisler was chairman of the planning committee for the conference. Maine starts planning

The Maine State Conference of Social Work, meeting in November at Bangor, instructed the chairman, Dr. Burton Taylor, of the Department of Sociology of Bowdoin College, to take action, in cooperation with other groups, to further Maine's planning for the White House Conference. An informal planning group met in conference for this purpose on December 3.

Ohio conference in process

Too late to be reported, a State-wide conference on children and youth was held in Ohio, December 15. The conference expected to recommend organization of a permanent State committee with a paid director. Gov. Thomas J.

Herbert, in calling this conference, wrote:

"In this period of world-wide uncertainty and change, it is imperative that we in Ohio give serious thought to the preparedness and the conservation of our human, as well as our material, resources. Inasmuch as the children and youth of Ohio are the State's basic resources, we must assay how adequately the needs of children are being met, at the present time and must plan to improve facilities for child care so that every child will reach adult life equipped to fulfill his duty to society....

"Such steps will be in line with planning for the White House Conference for Children which will be called in 1950 for the purpose of evaluating the child-care facilities and programs in operation in the various States."

North Carolina looks at children

At a meeting September 28, which brought together lay citizens, including a group of young people, and representatives of private and governmental agencies, Gov. R. Gregg Cherry designated the North Carolina Conference for Social Service as the agency to spoli sor North Carolina's participation in the 1950 White House Conference. A steering committee was set up to assist the president and secretary of the North Carolina Conference for Social Service to carry forward plans and initiate. action.

The impetus for this conference came from the report, "What of Children in North Carolina?" issued in 1947 by the State Planning Board's committee on services for children and youth. The North Carolina Commission on Statutes Relating to Domestic Relations, authorized by the legislature in 1947, has been at work drafting bills embodying the recommendations made in the report.

Reports made at the September conference presented concretely a picture of how North Carolina has embarked upon the task of finding out about the status of its children and services to them and what it proposes to do about bettering the services.

A committee on projects outlined a wide range of projects for study and promotion. The first step is to be a stock-taking survey by each community of its resources, facilities, programs.