Child Development

Time to Reframe our World View

By: Paul H. Dworkin, MD

Spirited debate over immigration policy in our country and controversial comments attributed to our president regarding immigrants’ nations of origin have fueled intense concerns for the international reputation of the United States. Pundits lament a loss of global standing and prestige due to such policies and comments, as well as question our capacity to respect the views and priorities of other sovereign nations, friends and foes alike. The increasing limits on immigrants and their nations of origin in our country seem discordant with our proud heritage of offering safe haven to “… huddled masses yearning to breathe free.” However, the origins of the limited capacity of our leaders to respect and even embrace the experiences and practices of other nations is, perhaps, more entrenched than we might realize.

Current events have encouraged me to reflect on my personal experiences with global engagement in the context of child health and child health services. Indeed, I am mindful of specific experiences that suggest our tendency to too-easily dismiss the relevance of successful foreign models; our failure to recognize how our actions, regardless of intent, may be viewed by others; our reluctance to openly acknowledge our modest international standing and strive for improvement; and our unwillingness to embrace the wisdom of colleagues from around the globe. As a consequence, I am inclined to view current events through the lens of some humbling international experiences.

Our chauvinistic tendency to dismiss successful models of other nations

The 1990’s are known as the “decade of the brain,” in recognition of the widespread dissemination in the popular and professional press of the remarkable explosion in our knowledge of early brain and early child development and the implication of this knowledge on how we design programs, services, and systems. During that decade, we became familiar with a remarkable French initiative that applied scientific advances to promote the well-being of mothers and children, La Protection Maternelle et Infantile, or PMI.  Eager to share this program with our state leaders in Connecticut to inform our own planning efforts, we invited the French American Foundation, conveniently located in New York City, to visit Hartford and share PMI with our legislative and executive branches. Our state leaders listened attentively and politely, and thanked the French delegation for sharing their experience. However, the presentations and discussions failed to stimulate or inform local actions. When we asked our state leaders their impressions of the French model, they were quite complimentary.  However, when asked whether they were inclined to consider a comparable model for Connecticut, they respectfully declined, citing the lack of relevance of an initiative designed for a foreign nation. Ironically, many of the components of the French system are today embedded in our national efforts, led by the Maternal and Child Health Bureau, to build comprehensive, early childhood systems of support for families. A willingness to explore how the French model could inform our state efforts may have accelerated this work by several decades. Even today, our current national focus on early childhood comprehensive system building fails to take full advantage of the many potential lessons from abroad.

Our inability to recognize how our actions, regardless of intentions, may be viewed by others around the world

At the University of Connecticut, we take justifiable pride in the admirable commitment of our pediatric residency program to meeting the training needs of gifted, international graduates.  Indeed, we embrace the opportunity to advance pediatric care across the globe through training and education. In fact, we have, for many decades, participated in training the majority of Iceland’s pediatric specialists through a novel partnership with the medical school of the University of Iceland in Reykjavik.

In 2009, I accepted an invitation to attend a convening of the International Pediatric Academic Leaders Association in Shanghai, China and participate in a discussion on postgraduate medical education. I was the sole American in attendance. I was, admittedly, taken aback when a distinguished professor from Sri Lanka lambasted the U.S. for “stealing their best and brightest” medical students who were educated at the expense of their government. The scathing criticism included accusations of our seeking to import cheap labor and depriving underdeveloped nations of their future work force. While this is certainly not our motivation, this challenging perspective is seemingly reinforced by the reality that many international graduates fail to return to their homelands following training in our advanced programs and facilities and seek to remain in our country. I confess to long viewing our offering of educational opportunities to international graduates as an example of our good global citizenship. My failure to appreciate how our actions may be perceived by others demanded humility, careful and honest reexamination, and attitude adjustment.

Our failure to acknowledge our limitations and strive to narrow the gap

In 1988, I was invited to participate in the 10th anniversary celebration of The European Society of Social Pediatrics and Child Health (ESSOP), held in the beautiful Bois de Bologne in Paris. The organizers assigned several of us to share our nations’ child health programs. My fellow speakers were from such countries as the United Kingdom, France, Norway, Portugal, and Vietnam, in view of the French influence on the development of the latter’s system of healthcare. Regretfully, I was the sole presenter unable to describe a national system of care, per se, since we in the U.S. have no specific, comprehensive child health care program. Rather, I was relegated to sharing the American Academy of Pediatrics’ guidelines for child health supervision services and the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) guidelines for our Medicaid program. Our lack of a clearly discernible system of care for children, coupled with our relatively mediocre international status with respect to child health and well-being (e.g., a recent Save the Children survey ranked the U.S. number 42 on children’s well-being), offer a less-than-flattering picture of the relative value placed on promoting children’s healthy development between our country and other developed nations. Such sobering comparisons must both incentivize and inform our actions.

Our need to embrace the research, policies, and best practices of our international colleagues

In 1988, I had the extraordinary opportunity to take sabbatical leave from the University of Connecticut and spend time in Oxford, England under the sponsorship of community consultant pediatrician, Dr. Aidan Macfarlane. I recall the morning that a staff pediatrician responsible for the region’s immunization program was frustrated by data indicating that childhood rates of complete immunization did not exceed 90 percent. Given the collaboration among health services, early care and education, and family support services (i.e., home visiting) in Oxfordshire, the pediatrician was frustrated that rates did not approach 100 percent. At the time, immunization rates in Connecticut were below 50 percent. For me, this experience reinforced the merits of engaging all relevant sectors to promote the health and well-being of children and families and informed our current thinking on comprehensive system building that is now the focus of Connecticut Children’s Office for Community Child Health.

During my sabbatical, my participation on the British Joint Working Party on Child Health Surveillance, convened by Sir David Hall, encouraged and informed my reframing of the early detection process to include the importance of viewing developmental screening as one component of an integrated process of surveillance and screening and the importance of eliciting and attending to parents’ opinions and concerns. I also began to recognize the imperative of embedding early detection within a comprehensive, integrated process of developmental promotion, early detection, referral and linkage to community programs and services. This shift in thinking set the stage for our development and dissemination of the Help Me Grow model, which advances developmental promotion for vulnerable children in more than 25 states. Our current opportunities to share the Help Me Grow model with others around the world, including the U.K., Philippines, Australia, and India, pay homage to the international viewpoints that informed this work.

Our nation’s remarkable medical advances and our capacity to provide highly specialized care are the envy of the world. Health care reform, with its focus on promoting population health and well-being, now affords us the opportunity to enhance the healthy development of all, especially those who are most vulnerable. We increase the likelihood of our success by our willingness to see the relevance and embrace the wisdom, practices, and knowledge of nations around the world.

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine. Learn more »

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