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EYE ON WASHINGTON

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President asks pediatricians' help at AAP meeting

They came early, passed through the metal detectors, filled every seat in the hall, sat in the aisles, and lined up against the walls: thousands of pediatricians at the American Academy of Pediatrics Annual Meeting, come to hear an address by President Clinton. Judging by the repeated applause, most were pleased by what they heard.

"Pediatricians have a special place in the hearts of every person whose child has been treated by one," the President began, acknowledging former AAP President Betty Lowe, MD, who treated his daughter Chelsea at one time and his own pediatrician, Joe Rosenzweig, MD. "And you should feel a great personal bond to the work I do," he told the audience, since "Washington is the only place outside of a pediatrician's office where you can hear so much screaming and crying on a daily basis."

He thanked the AAP for fighting side by side with his Administration for programs like the family and medical leave law, the Brady bill, the Vaccines for Children program, and the Children's Health Insurance Program. "Because of these efforts, America is a better place for children; they're healthier and safer than they were seven years ago." The President went on to provide a lucid explanation for what he called the "food fight" going on in a Congress trying simultaneously to stay within the budget caps agreed on in 1997, keep their hands off the Social Security surplus, increase spending, and refrain from raising taxes—even on cigarettes.

And then he asked for pediatricians to help out once more, in three particular areas:

• Thanking members of Congress who voted for the Norwood/Dingell version of the patient protection act (see Eye on Washington for details) and working to get a similarly tough bill through the Senate and the conference committee

• Lobbying House members to pass the Work Incentives Act already approved in the Senate, which will help disabled citizens go to work without losing their Medicaid or Medicare benefits.

• Reaching out to bring eligible children into the expanded Medicaid and CHIP programs.

"It is simply inexcusable that we're sitting here with the money to provide health insurance to five million kids, and 80% of them are still uninsured," he said. "A lot of folks don't know CHIP from blocks, or Medicaid from Legos; normal people worry about their lives, not government acronyms. I implore you to do what you can to help parents understand this [and] to get your community to do the needed outreach. It is profoundly important."

Few pediatricians would quarrel with that.

DeAngelis takes over at JAMA

Last month's appointment of Catherine DeAngelis, MD, as the new Editor-in-chief of the Journal of the American Medical Association was a matter of special pride to her sister pediatricians and vastly reassuring to all physicians who prize the editorial independence of the journals they rely on. Dr. DeAngelis, who has been serving as Editor-in-chief of the Archives of Pediatric and Adolescent Medicine, has a sterling reputation for independence and integrity.

Her appointment appeared to resolve the drama that began last January when JAMA's previous editor, George D. Lundberg, MD, was fired in a dispute over the propriety of printing an article that had relevance to the then-current Presidential impeachment proceedings. It was preceded by an agreement between JAMA's editors and the AMA guaranteeing editorial independence for all AMA journals in the future.

The unease over the Lundberg affair was renewed during the summer, when Jerome P. Kassirer, MD, was fired as Editor-in-chief of the New England Journal of Medicine. The New England Journal, like JAMA, is owned by a medical society—in this case, the Massachusetts Medical Society. According to Marcia Angell, MD, then NEJM's executive editor, Kassirer's contract was not renewed because of a "long-standing struggle" with the society's leadership over plans to launch and acquire new publications, repackage NEJM content for consumers, and co-brand with various information-based commercial enterprises. If that happened, Dr. Kassirer believed, he and the other editors would be seen as giving approval to products that, in fact, they had never reviewed. And that, Kassirer believed, was a threat to the credibility of the journal. All the other NEJM editors threatened to resign over the issue.

The NEJM furor, like the one at JAMA, has now died down. The Massachusetts Medical Society has named Dr. Angell interim editor, pledged to maintain the editorial independence of the journal, and said it will refrain from using its name and logo on other products without the specific, prior approval of the Editor-in-chief. But the issue of the proper relationship between a medical journal's editors and its owners may continue to be a thorny one. Medical information is a valuable commodity these days, and the stakes are high.

Infectious diseases, old and new

It's been a difficult summer in New York State. On August 23, an infectious disease specialist in Queens reported two patients with encephalitis to the New York City Department of Health; the department soon identified a handful of additional cases, almost all of them residents of a two-square-mile area in Queens. Preliminary tests indicated that the culprit was the mosquito-borne St. Louis encephalitis virus. On September 9, the city began to spray mosquito-killing insecticides from helicopters and give out free cans of insect repellent. Nearby suburban counties followed with mosquito-control programs of their own, and the mini-outbreak petered out. To date, six deaths have been reported, all in elderly patients.

An outbreak of St. Louis encephalitis would have been a rare enough occurrence on the East Coast, but the real truth—arrived at after a pathologist at the Bronx Zoo thought there might be a connection between the human outbreak and the odd plague that was killing local crows and rarer birds in the zoo's aviary—was even more exotic. The villain, responsible for both the human and the avian illness, was not St. Louis encephalitis but rather the West Nile virus, known in Africa since the 1930s but never before isolated in the western hemisphere. The outbreak caused a brief flutter at the CIA, as experts in bioterrorism briefly entertained the notion that Iraq's Saddam Hussein had unleashed infected mosquitoes over Queens. On further reflection, terrorism seemed an unlikely reason for spreading this generally mild infection, but the outbreak was certainly a reminder of how easily, whether by migratory birds or international airplane travel, unfamiliar infectious diseases can spread across the globe.

New York's second disaster was a more down-home affair. It started in September, when the state health department received reports of at least 10 children hospitalized with bloody diarrhea or Escherichia coli O157:H7 infection in counties near Albany. All of the infected children had attended the Washington County State Fair in the last week of August. By mid-September, state health authorities had assembled 15,921 reports of diarrhea in people who had attended the fair, and stool cultures yielded E coli O157:H7 from 116 persons. This time the contamination was traced to a shallow well that supplied food vendors in one small area of the fair. Health officials believe the well may have been contaminated by runoff from nearby fields where dairy cattle graze. The state health commissioner has issued an order requiring county fairgrounds to use disinfected water when hosting public events and begun a review of regulations applicable to fairs.

How much do you know about inhalant abuse?

According to a survey sponsored by the American Academy of Pediatrics, most youngsters are aware of others who inhale fumes from products like paint, glue, and cleaning fluids, and about one quarter of respondents to the nationwide survey say friends or classmates "huff." On average, children first see or hear about classmates who huff at 12 years of age. "Abusing inhalants can cause severe permanent damage, especially to the brain," says AAP President Joel J. Alpert, MD, "and the scariest thing is that your child could die from using inhalants only once."

Because inhalant abuse is an underrecognized form of substance abuse with significant morbidity and mortality, the AAP recommends that pediatricians:

• Increase their awareness of the clinical aspects of inhalant abuse, particularly central nervous system damage and sudden sniffing death syndrome

• Educate children, parents, and teachers about inhalant hazards

• Include inhalant abuse in all substance abuse curricula in primary grades

• Back research efforts to identify and evaluate prevention and treatment approaches to this problem.

Copies of the parent education pamphlet on inhalant abuse (shown) are available from the AAP Division of Publications, 141 Northwest Point Blvd., PO Box 927, Elk Grove Village, IL 60009.

For the first time since the Clinton Administration's plan for universal health insurance came a cropper, health care was back at the top of the national agenda last month. As new census data drew attention to the 43 million Americans who have no coverage, Presidential aspirants Gore, Bradley, and Bush began to outline their approaches to the problem. Meanwhile, the managed care reform bill cosponsored by Representatives Charles Norwood (R-GA) and John D. Dingell (D-MI) passed the House of Representatives by a resounding vote of 275 to 151, with 68 Republicans voting for the bill. Norwood-Dingell has the backing of a raft of professional associations, including the American Academy of Pediatrics. The AAP is particularly pleased by the bill's guarantee of access to pediatric specialists and the designation of pediatricians as primary caregivers for children. The bill must still be reconciled with a version already passed in the Senate and uncoupled— if possible—from a companion bill President Clinton has threatened to veto that provides tax credits for medical insurance premiums.

In other agencies of government,

The National Transportation Safety Board castigated state governments for failing to establish facilities to install and check car safety seats, many of which are installed incorrectly. Since the NTSB first made the request in January, only 12 states have complied. The Board also decided against recommending seat belts in school buses, calling instead for improvements in bus design and better data on which to base future recommendations.

The General Accounting Office has issued a report saying that most states do not comply with a 1989 law requiring that children on Medicaid be tested for lead. The GAO found that few Medicaid children are screened for blood lead levels, even though the risk of lead poisoning is highest for low-income children living in dilapidated housing— the population served by Medicaid.

The National Center for Health Statistics reported good news and bad. The good news is that deaths from AIDS and homicide dropped substantially in 1998, and the teen birth rate continued to decline, a trend that has now been going on for seven years. The bad news is that infant mortality remained unchanged from the year before at 7.2/1,000 live births (twice that for African-American babies), nonmarital childbearing increased by 3% from the 1997 rate to 44.3/1,000 births, and the number of low birth-weight babies increased slightly overall and continues to be almost twice as high among African-American women.

Calendar

November 19­20, European Society of Ambulatory Pediatrics, Grenada, Spain. To register, call José Luis Bonal at 34-93-454-5400

December 2­5, Society for Ear, Nose and Throat Advances in Children, Colonial Williamsburg, Williamsburg, VA. To register, call Dave Parsons at 864-281-9440

December 3­5, Zero to Three National Training Institute, Anaheim, CA. To register, go to the Zero to Three Web site at www.zerotothree.org or call the conference coordinator at 703-271-1296

December 7­10, National Forum on Quality Improvement in Health Care, New Orleans, LA. To receive a registration package, call 617-754-4800

January 24­28, 2000, Partnerships for Health in the New Millennium, Washington, DC. For registration information, call 800-367-4725, or send e-mail to partnerships@health.org

February 18­20, 2000, First Annual Pediatric Integrative Medicine Conference, Tucson, AZ. For information, call 520-626-6858 or e-mail pedsimc@peds.arizona.edu.

—Judith Asch-GoodkinContributing editor

Judith Asch-Goodkin. Updates. Contemporary Pediatrics 1999;11:11.