Geriatric paediatrics.

Interest in the medicine of childhood is shifting from concern with mortality and short term morbidity to the long term effects of childhood ill health on the well being of adults. There is a clear need for very long term studies of the outcome in children exposed to deprivation and illness in early life. It has always been known that the infant mortality rate is a good index of the well being of a population, as indeed straightforward biological considerations would imply; but only recently have hard data been available linking such rates to the health into old age of the survivors in a definable cohort. We now have the work of Barker and Osmond to remind us that, though it may be the fittest who survive disease in childhood, a proportion of the survivors are to some extent rendered unfit for the rest of their lives by having to surmount too testing a challenge at a vulnerable time in their development.' In some cases it can even be shown that this relationship applies to particular organ systems-for example, recurrent bronchitis in childhood predisposes to chronic bronchitis in middle age. We do now of course have the lowest mortality rates in childhood that have probably ever been attained in this country as a whole; but nevertheless major class differences persist within our population and our rates are not as low as those of better off or better organised 'neighbours'.3 To take some obvious examples: nephritis and pyelonephritis acquired in childhood probably account for something like a half of all cases of renal failure requiring dialysis or transplants in adult life. 7 The same can be said for chronic valvular heart disease in adults, which used to be the long term consequence of childhood rheumatic fever,8 while there is a probably justified suspicion that atherosclerosis and hypertension may be the late effects of processes beginning in early life.9 "' Yet what we know to be demonstrably so in some instances is more than matched by what we do not know but may suspectsuch as Dr Murray's suggestion (coming from no less an authority than the Dean of the Institute of Psychiatry) that there may be a relationship between perinatal insult and schizophrenia.'1 Nor should we forget that our success in prolonging the lives of children suffering from what used to be fatal conditions like diabetes, leukaemia, and cystic fibrosis now presents physicians for adults with quite large numbers of patients whose adult existence will remain medically precarious until better ways are found of treating them. Thus we have the paradox that if we wish to minimise ill health in our increasing population of pensioners, we need to start at their conception, not catch up with their problems in middle age. Moreover, it needs to be pointed out that their pensions will be paid for by the work of the generation treading on their heels, and will depend therefore on its physical and psychological well being. This, of course, is not necessarily an argument for increasing medical and nursing provision for our child population: economic and cultural factors are probably more important in determining their well being. "' But nevertheless, without study of what it is that relates poverty and ignorance to physical and emotional illness, we shall not succeed in applying resources in a cost effective way, and only medical research will enable these relationships to be worked out in sufficient detail for preventive measures to be properly focused. Attributing ill health to inferior genes will only lead us into the morally suspect field of eugenics. Success is more likely to come from the discovery of what is the best environment for a particular genetic constitution-for example, a phenylalanine deficient diet for those with phenylketonuria. It is clear that there is great scope for a widening of the concept of preventative medicine in line with the recognition that the future of medical child care lies in the appointment of more, and better educated and organised, community paediatricians, using hospitals as community resources and concerned with the provision of the best possible environment for successful child rearing by the removal of what gets in its way,8 and by the identification of special needs.