Что такое социальная педиатрия?

Ватерстон Тони

современном мире. Общественные инициативы по снижению вреда самых разных социальных факторов (семейный алкоголизм, жестокое обращение с детьми, бедность, недостаточное развитие доступной среды для детей-инвалидов, дети мигрантов и др.) являются неотъемлемой составляющей деятельности педиатров.

Так исторически сложилось, что система детского здравоохранения в России имеет определенные отличия от таковой в развитых странах. Одним из существенных отличий является сохранение в нашей стране педиатрической помощи в первичном звене здравоохранения. В структуре детской поликлиники приказом Минздравсоц-развития России от 16 опреля 2012 № 366н «Об утверждении Порядка оказания педиатрической помощи»предусмотрено отделение (кабинет) медико-социальной помощи, в задачи которого входит выявление детей, находящихся в трудной жизненной ситуации, и их медико-социальное сопровождение. Такие отделения получают все более широкое распространение в регионах России, но для повсеместного развития этого направления мы призываем российских педиатров опубликовать свой личный опыт внедрения подходов социальной педиатрии. Было бы интересно узнать, что в первую очередь двигало теми нашими коллегами, которым удалось организовать успешно функционирующие отделения медико-социальной помощи детям, с какими проблемами они сталкиваются и как их решают.

В целях приумножения усилий специалистов по защите здоровья и благополучия детей России от воздействия неблагоприятных социальных факторов, в составе межрегионального общественного объединения «Союз педиатров России» работает секция социальной педиатрии. Среди главных задач секции - развитие системы медико-социальной помощи детскому населению, включающей своевременное выявление социальных факторов риска нарушений здоровья у детей и последующее мультидис-циплинарное сопровождение ребенка и его семьи. Приглашаем всех заинтересованных в развитии социальной педиатрии активно участвовать в работе секции.

Социальная педиатрия - основная стратегия, обеспечивающая охрану здоровья детей в XXI веке.

WHAT IS SOCIAL PAEDIATRICS?

Waterston Tony

MD FCPCH, retired consultant paediatrician and senior clinical lecturer in Child Health, EC member of ISSOP and moderator of CHILD20156 Newcastle upon Tyne, UK

There is presented the own conception about the role of social pediatrics in the modern world. The author introduces the reader with his experience of the work in Africa, which led him to an understanding of the needfor the development of the principles of social pediatrics. He draws attention to the key figures in the field of health of Anglophone countries (David Morley, Maurice King, David Werner, Ivan Illich, James Spence), their role in the shaping of ideas about effective approaches to child health care. He talks about his work as a pediatrician- consultant within the framework of the UK National Health Service. He emphasizes the need for a comprehensive approach to the assessment of the health of the child, with taking into account not only biological, but also social and psychological factors. Particular importance he attached to the protection of children's rights. In conclusion, there is provided the information on the International Society for Social Pediatrics and Child Health (ISSOP), its aims and tasks.

Key words: social pediatrics; children's rights protection; International Society for Social Pediatrics and Child Health

Citation: Rossiiskii Pediatricheskii Zhurnal. 2015; 18(1): 30-32.

My understanding of social paediatrics is influenced by my working experience and by contact with role models in paediatrics and public health. I was fortunate enough to meet David Morley1 - a leading figure in global health in the West - in the 1960s and he influenced my whole career because of his interest, research and writings in why children are sick, the role of mothers and primary health workers in the health care system, and the

ear Russian paediatricians, I am delighted to introduce you to some of the ideas about social paediatrics which are now being embraced in many parts of the world and I know in Russia too.

Correspondence to: Tony Waterston, MD FCPCH, retired consultant paediatrician and senior clinical lecturer in Child Health, EC member of ISSOP and moderator of CHILD2015, Newcastle upon Tyne, UK

Tony Waterston

see a specialist consultant egpaediatrician or cardiologist. Secondary care normally takes place in hospital. Patients can only access secondary care through a GP. Consultants may also see patients in community clinics or GP surgeries but only after a referral from a GP. This is how a community paediatrician would work.

Tertiary care

This means highly specialised care egpaediatric neph-rology, intensive care or neurological rehabilitation. A secondary care consultant would normally make a referral to this level which operates from regional centres.

A comprehensive health record is kept by the GP for each patient with copies of the letters sent from all consultants kept together and these may be inspected by the patient (indeed normally a copy is sent to the patient following a consultation)

The basis of community paediatrics is -

• to see children in the community rather than in hospital whilst practising as a consultant (secondary level of care);

• to work in a team with general practitioners (primary care doctors), community nurses, psychologists and therapists (the community paediatric team);

• to combine treatment with prevention;

• to tackle the determinants of child health through public health and advocacy;

• to carry out teaching and research in the context of the community (this means families in their home settings);

• to improve the communication with parents and children and facilitate their understanding of the health care system.

My work included seeing children with a complex variety of problems including learning difficulty, ADHD, autistic spectrum and family breakup; child abuse; neglect; behavioural difficulties; and neurodisability. I have also been involved in the development of a wide variety of preventive initiatives particularly involving ways of improving parenting.

A further component of the work of a community paediatrician is advocacy. This mean bringing about change in systems which work against the interests of children. I have found that using the UN Convention on the Rights of the Child6 helps to improve systems including education, housing and social services which do not always put children first.

Such work requires working in a team and having the support of social work, school teachers and good psychology services. Lack of such services is a constant challenge.

So for example, a 'social' paediatrician (or general paediatrician with a social orientation, a term I prefer) would ensure that whena child presents with otitis, his immunisation status, growth and speech development are also checked; that the developmental level and hearing are assessed in a four year old presenting with oppositional behaviour; that an eight year old complaining of persistent abdominal pain is asked about parental relationships and whether he is being bullied at school; and for a child of 8 presenting with obesity, the social background and availability andcosts of healthy food for the family are investigatedbefore jumping into dietary advice.

benefits of simple technology - particularly in relation to growth monitoring. In his turn he introduced me to Maurice King2, the author of Health Care in Developing Countries, and to David Werner3, author of Where There is No Doctor and Helping Health Workers Learn - the latter a key reference for this interested in developing the role of doctors as teachers.

I had also been introduced to Ivan Illich4 in my formative years - the author of Medical Nemesis, an attack on the medicalization of society.

Working over two three year spells in Africa - first in Zambia as a general medical officer and later in Zimbabwe as a lecturer in child health, I learned much about paediatrics but also saw the connection clearly between sickness of the child and the problems of society: poverty, inequalities, oppression of women, and the risks of over-promotion of infant formula. These were behind the ubiquitous diseases of malnutrition, infectious disease, HIV infection and child abuse. I also saw the defects of the health system in the form of the over-prescribing of expensive drugs, poor communication by doctors and the lack of access to essential health care.

I was fortunate to return to work and train in Newcastle where the first Professor of Child Health in the UK Sir James Spence, had practiced in the 1950s and had researched the connection between the environment and child health. His successor Professor Donald Court was the author of an influential report5 on child health services in 1968 which described the role of the Consultant Community Paediatrician, who would bridge the gap between community services in schools and clinics and hospital based paediatrics. In 1986 I was appointed as the first community paediatrician in Newcastle upon Tyne in the North east of England.

In the UK, we have the National Health Service which is free at the point of use and funded by taxation so no one has to pay their doctor. The structure of the system is primary, secondary and tertiary care as shown in the Box.

The National Health Service

Primary care

This is the level of first contact

Every person chooses a personal doctor (General Practitioner or GP) and joins their 'list'. He or she is then the Family Doctor for the whole family. The GP is part of a primary care team which includes midwife (who carries out home delivery for those who choose, and provides infant care for the first month), health visitor (well baby care up to school entry), district nurse (nursing care at home), and practice nurse (nursing duties in the practice). The GP works in partnership with perhaps 4-5 other doctors and is based in a 'surgery' or local clinic which is maintained by the GPs as a small business (paid by the State).

The primary care team covers the whole family age group from 'cradle to grave'.

The GP may refer patients on to secondary care which is normally in hospital but may be in other settings.

Preventive care such as immunisation and screening are provided by the primary care team.

Secondary care

Patients are referred to secondary care by the GP to

The 'social' paediatrician would go further by working with other disciplines (includingsocial work and school teachers). In a world when social conditions have a very major impacton children's lives, a socially orientated approach is not only necessary, but mandatory.

ISSOP.The International Society for Social Pediatrics and Child Health was founded in 1978 as ESSOP,the European Society. Its aims were education, teaching and research in relation to social paediatrics, together with advocacy to improve children's health. Advocacy has always been acentral part of ISSOP's work - since children'shealth is severely hampered by factors in societysuch as poverty and inequalities, marketing ofjjunk food aimed at children, smoking, pollution from motor traffic, climate change and many more.

In a globalised society, paediatricians need to stand together with other groups in civil society groups to removethe external pressures which hamper children'shealth, development and wellbeing.

Originally most European countries were represented in ESSOP, the most active being Sweden,UK, Netherlands, Greece, Spain, Hungary, Turkey,Switzerland and Iceland. From the earlydays, there were members from outside Europe -mainly the Anglophone countries

Canada, USA, Australia and New Zealand. We are now delighted that Russia is an important member with influence. In 2012 it was decidedby members that ESSOP should become international and extend its remit globally - whichwas a major challenge, since global health issuesare much wider than those we encounter inEurope. ISSOP would need to get to grips with malnutrition, HIV/ AIDS, malaria, female genital mutilation and child labour - as well as recruiting members from Africa, South America and Asia.

We hope that all Russian paediatricians with an interest in social paediatrics will join ISSOP.

REFERENCES

1. David Morley http://en.wikipedia.org/wiki/David_Morley_ (paediatrician)

2. Maurice King http://www.leeds.ac.uk/demographic_entrapment/ curriculum.htm

3. David Werner http://en.wikipedia.org/wiki/David_Werner

4. Ivan Illich http://en.wikipedia.org/wiki/Ivan_Illich

5. Court Report (Fit for the Future) https://www.scribd.com/doc/43159026/ Fit-for-Future-Report-of-the-Committee-on-Child-Health-Services-Court-Report