Finding common ground: the necessity of an integrated agenda for women's and children's health

Framework as metaphor: the promise and peril of MCH life-course perspectives

Life-course analytic frameworks expressly link the determinants of health and illness across the lifespan. Such frameworks could serve as a foundation for integrating child and adult health policies by emphasizing the potential that social and biologic processes early in life can find clinical expression as adult-onset disease. However, there are elements of these frameworks that can be misinterpreted in ways that obscure scientific processes and fragment rather than integrate health policies. First, casting early life influences as determining rather than merely influencing adult health obscures the complexity of social and biologic etiologies over a lifetime and diminishes the impact of events in adolescence and adult life. Second, oversimplifying the impact of early influences on adult disease tends to imply that such processes are particularly unamenable to clinical and public health interventions, a suggestion without an empirical basis and likely to undermine pleas for enhanced access to such interventions. Third, exaggerating early life events as being highly deterministic of adult illness in order to shift societal resources from the elderly towards children can generate unnecessary antagonisms between potentially allied constituencies. Together, these considerations suggest that the utility of life-course frameworks will depend upon cautious interpretation and an ongoing process of active refinement.

Reproductive health and blurred professional boundaries

We recognize that many of the issues raised are not simple. Our proposal calls for the same thoughtful deliberation applied in other settings to be brought to bear on reproductive health care. Some have already tried alternative approaches. In Albuquerque, New Mexico, a university hospital neonatologist and the district attorney have collaborated to create an alternative to sentencing program for women who are arrested for drug-related crimes and found to be both pregnant and drug addicted. Rather than proceed with criminal sanctions, these women are offered entry into a drug treatment program that is geared to families with young children and run by the pediatrics department. Here, the physician and the district attorney collaboratively responded in ways congruent with the professional integrity of each. In another example in Portland, Oregon, physicians, drug treatment providers, and child protective social service representatives cooperatively defeated a legislative proposal to mandatorily test and report pregnant women for illicit drug use and, instead, formed a task force to jointly develop state policy regarding the issue. Drug use, HIV infection, child abuse, and poverty are all cause for alarm. Yet it is critical that our frustration about these difficult problems not be translated into blaming individuals for "deviance," or into short-term inadequate responses. In developing policy we should consider the impact on the legal and ethical rights and obligations of both patient and physician. For every course, we should evaluate both immediate and long-term efficacy, the consequences for the doctor-patient relationship, and the consequences for medical integrity. In the midst of the present regulatory and fiscal turmoil affecting health care, we urge physicians to be careful and deliberate in the policies they embrace and the actions they take.