Diseases of Children in the Subtropics and Tropics

Paediatrics is often thought of as following two main routes. One is that of ultra-technology and ever-narrower specialization. The other is recognition of child health in a community context, related to family circumstances (especially the health and welfare of mothers) and influenced by the environment, social stresses, economic limitations, cultural attitudes and practices, and policy decisions and priorities based on the political system.

Neither is right, but rather a balance is needed. Thus, preventive programmes, such as immunization, depend on refined technology to produce appropriate vaccines and devise workable equipment for effective 'cold-chains'. Curative paediatrics, especially simplified methods in appropriate technology, has to be underpinned by science - both by necessity and to achieve acceptance by orthodox members of the Establishment. Examples include the work of gastroenterologists on the intestinal 'sodium pump' and how this can be 'primed' and made more effective by glucose. In this way, essential scientific credence has been given to the seemingly simple methods of oral rehydration, using prepared ORS packets or home-made mixtures of sugar and salt or dilute rice (or other staple) gruels.

However, as always, it can be difficult to persuade physicians, including paediatricians, to acquire a community perspective, understanding and, still more, a truly active role. This is often in part because of their training which frequently remains predominantly clinical - 'we teach what we have been taught'. However, things are changing in some more enlightened training establishments, and the trend is certainly indicated in this Fourth Edition.

Sound clinical work, as in a hospital environment, is vital and will always remain a major need. This approach alone cannot begin to touch the major issues of child health. Some of these may be beyond the scope of the paediatrician or of medical science. Nevertheless, an awareness of the need for an advocacy role has to be cultivated. In this way, advice and guidance may begin to move those in power towards policies which can improve community child health.

The 'complete' paediatrician anywhere, but especially in less technically developed countries, often in tropical regions, needs to be much more than a blinkered 'vertical' /'horizontal' expert. Rather, there is a need for 'lateral' thinking, training and action. This implies realization of the wide range of factors needing consideration in child health work and also recognition of the value of a dove-tailed curative-preventive approach, as part of a team including paediatricians, nurses, community health workers and (importantly) parents, particularly mothers, in the community itself.

The present edition of Diseases of Children in the Subtropics and Tropics moves in this direction and will most certainly be valuable not only as a clinical reference text. My hope is that it will also persuade its readers that a paediatrician should not only be clinically sound, but also able to recognize the wider community issues involved in the causation of problems and the need for imaginative interdisciplinary programes to improve the outlook for life and health of mothers and children in the Third World.

Cut Rita Zahara

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