Pediatricians must partner with others on disease prevention
FernandoStein, M.D., FAAP, President, American Academy of Pediatrics
Letter from the President
From 2008-’10, I participated in the Vision of Pediatrics 2020 project. Eight transformational
drivers of pediatrics were identified, No. 1 being the changing social and clinical
demographics of the child population. The Vision of Pediatrics 2020 report postulated
increasing rises of health problems related to social determinants of health and chronic
I believe the changing demographics and epidemiology of morbidity and mortality in
childhood and adolescence are both challenging and transforming the practice of pediatrics.
During the early 1900s, pediatricians concentrated on educating parents about child-rearing,
treating infectious diseases (for which neither antibiotics nor vaccines were available),
respiratory and diarrheal illnesses, and the care of minor trauma. With the advent
of antibiotics, vaccines and infection control and the explosion of scientific knowledge
regarding health and disease toward the middle of the 20th century, pediatricians
were able to diagnose and treat diseases in a consistent, predictable way.
Mortality in children under 5 has decreased by more than 75% in the last 50 years.
Mortality in the pediatric intensive care unit dropped from nearly 30% in the early
1970s to 3% last year.
The absolute number of children living with congenital and genetic disorders, the
decrease in morbidity and mortality from infectious diseases, and the increase in
survival rates in neonatal and pediatric intensive care units have contributed to
a shift in the nature of diseases encountered in everyday pediatrics. This shift has
been in the direction of greater complexity, with increasingly frequent visits from
children with neurodevelopmental disorders and sequalae correlated to social determinants
After age 5, the majority of the burden of disease in children now is from noncommunicable
diseases (NCDs). Traumatic injuries, malignant neoplasms, diabetes related to obesity,
suicide and homicide lead the list.
Life expectancy at birth has been increasing every year in the U.S. for the last 50
years — until 2015 when it decreased. The World Health Organization makes a compelling
case for the difference between life expectancy at birth and healthy life expectancy.
The U.S. is seeing an increase in the number of years lost due to disability, and
we saw with concern the absolute decrease in life expectancy in 2015. In 2016, our
country ranked 42nd in the world for life expectancy at birth at 79.6 years. At the
top are Monaco and Singapore with 89.6 and 84.8 years, respectively. The top three
causes of mortality are cardiovascular diseases, malignant neoplasms and chronic lower
What also should concern us is that the premature death rate (dying before the average
life expectancy) is on the rise. Even more alarming is the fact that according to
the Population Reference Bureau, half of premature deaths in the U.S. are preventable. The keys to prevention are modifiable behaviors known so well by all pediatricians,
including poor diet, lack of exercise and tobacco use, according to the National Research
Council and the Institute of Medicine.
When looking at NCDs in order of prevalence and as a cause of death, we draw the inevitable
conclusion that work must start during the pediatric ages to prevent them. But our
patients grow up and leave us. One thing we can do is engage our adult medicine colleagues
in disease prevention efforts that continue for a lifetime.
While the pediatrician clearly plays a pivotal role, along with all physicians, we
know these challenges cannot be solved in the doctor’s office alone. To win the battle
against NCDs, there has to be a convergence of physicians, medical scientists, educators,
legislators, government, business and industry.
The pediatrician’s office already is a cross-section of the social, economic and political
problems manifesting themselves in a variety of forms. The social determinants of
health are raising their claws more and more every day. Is the pediatrician capable
of solving this in the 15 minutes per patient expected by the health plan? Hardly.
We as pediatricians are witnesses to the consequences of policies being decided elsewhere.
Now more the ever before, we have to raise our voices in defense of children and families.
We must play a leadership role and articulate the important difference between life
expectancy at birth and years lost due to disability.
The challenge for the pediatrician is the tension between wanting to do what is right
for the patient and family and the sense that the problems are too big, too complex
or both. This is a known factor contributing to pediatrician burnout. I believe it
is too heavy a lift for pediatrics alone. To me, the answer is clear. We must follow
the call of past AAP leaders and double our efforts to engage new partners to work
with us in innovative ways.