1301.0 - Year Book Australia, 2001
ARCHIVED ISSUE Released at 11:30 AM (CANBERRA TIME) 25/01/2001
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CHILD HEALTH SINCE FEDERATION
“The state of individual health is constantly being influenced by numerous factors. The racial stock to which the individual belongs may direct the general course of his health, the prenatal condition of maternal health, the quality or sufficiency of food taken as an infant and indeed throughout life are factors in which the relationship between cause and effect is direct; the presence in the community of other racial stocks, age composition of the population, the existence of communicable diseases in adjacent countries, the social conditions generally, and even the forms of government, have an influence no less important although indirect. In considering the public health in any community, it is clearly necessary that a study should be made of each of these aspects of social life with an attempt to estimate the extent of the influence of each on the aggregate total of individual health in the community.” J.H.L. Cumpston, Director General of Health, Commonwealth of Australia, 1928 (Cumpston 1989). Introduction A male child born at the beginning of the 20th century (1901-1910) had a life expectancy at birth of 55.2 years and one born at the end (1995-1997) of 75.7 years. For females the figures were 58.8 and 81.4 years respectively. At age 5 years the life expectancy was 57.9 years for males and 60.8 years for females in 1901 and 71.3 and 76.9 years respectively in 1995-97. These dramatic improvements over the last 100 years result from reductions in mortality at all ages, but particularly in early childhood, as shown by the impact in removing under fives mortality from the life expectancy calculations-the improvement in life expectancy at age five compared to life expectancy at birth was significantly greater in the early 1900s than in the 1990s. On the whole these increases were the result of considerable environmental and social changes early in the 20th century, with resulting improvements in the health of mothers and children. Indigenous life expectancy was not available for 1901-1910, but in 1995-97 it was only 54.1 years for males and 61.2 for females at birth-lower than for all children born 100 years ago.
Source: The Bulletin Magazine (originally published 21 April 1900). The social and economic environment around 1901 was harsh and difficult for many families; many children were malnourished and likely to die from infectious diseases such as gastroenteritis and pneumonia. The considerable social, educational and income changes over the century (described in Centenary Articles associated with the Population, Income and welfare and Education and training chapters), together with the conscientious efforts of those committed to improving maternal and child health in the early decades by community interventions, have had as much influence on reducing deaths and illnesses in children as has the extraordinary rise in knowledge in biomedical science in later decades, with its resulting improvements in diagnosis, treatments and prevention of disease (particularly by mass vaccination). In many ways, this last century has been a glorious one in which to have been involved as a child and public health professional. While the perinatal and infant period is still one of life’s most risky, the chances of survival now are much higher than 100 years ago, and once through to the end of the first year, the risk of dying in childhood is very low and only starts to rise again in older teenagers (15-19 years old), particularly in males. However, there is now possibly excessive emphasis on using expensive technologies to prevent death in children who are severely compromised, with much less effort into researching the antecedents to prevent the conditions which lead to the problems in the first place. And in later childhood and adolescence, risks are dominated by factors associated with lifestyle and mental health problems which require a complex range of preventive strategies over many years. This article is an overview of the changes in some markers of child and adolescent health throughout the 20th century and those trends which have been most influential. Many aspects will not be covered adequately and some left out completely, due to limitations of space and time. The hope is that the messages about the most important aspect of our future as a nation - the health of our children - will be heard and responded to. CHILD MORTALITY IN THE 20th CENTURY Mortality as a measure of health One major way in which epidemiologists measure health is actually to measure death. "This preoccupation is not so morbid as it sounds. In modern times the news has been almost entirely good. Western countries have doubled their life expectancies from around 40 years in the mid-nineteenth century to almost 80 years at the end of the twentieth. If we were to enter one of those competitions to nominate the greatest advance of the latter part of the millennium, it would be difficult to overlook the pushing back of the frontiers of death and the guarantee that most people will live to old age” (Caldwell 1999). The data on mortality below have been compiled by the Australian Institute of Health and Welfare (AIHW) Mortality Monitoring System from official death registrations. The under five mortality fell from 2,604 per 100,000 in males and from 2,214 in females in 1907 to 137 and 111 respectively in 1998 (graph C6.1). More than 50% of the fall had occurred by 1930 and most (more than 80%) by 1960. The rates at the end of the century are very low. The most important contribution to under 5 mortality was death in infancy (see below). The death rates in 1-4 year old children were much lower throughout the last 100 years, although the pattern of their fall was similar to infant death rates. Once a child survived beyond its first year, even in early 1900s, its chances of survival were good. Now they are excellent. In children aged 5-14 and 15-19 years the rates were initially much lower than in younger children and have fallen steadily. For 5-14 year old males the rate was 187 in 1907 and 17 in 1998; for females 172 falling to 12. In 15-19 year old males, the rate was 267 in 1907 and 75 in 1998; for females 237 and 37 respectively. Infant mortality Infant mortality, defined as deaths in children from birth to the first year of age per 1,000 live births, has been viewed traditionally as an important social indicator, reflecting general population health and wellbeing. It is of great interest to those assessing the social development of communities as groups with more advanced development in terms of social circumstances, educational level and income tend to have lower rates of infant mortality than those with less development. Infant mortality is strongly related to fertility rates and to life expectancy at birth. Falls in infant and childhood deaths have been shown to be followed by declines in fertility (Caldwell 1999). Infant mortality, influenced by preventive health measures, which include social improvements, is used as a measure of such services for a population. Graph C6.2 shows the infant mortality rate per 1,000 live births from 1901 to 1998. Female death rates are always lower than male rates for reasons that are still not clear. The rate fell from around 120 for males and 100 for females at the beginning of Federation to below 60 in the late 1920s. Both male and female rates have remained below 10 since 1986, and the overall rate was 5 in 1998. This compares well with other developed countries. Population data on Indigenous infant mortality have only been available since the 1970s, although Thompson noted that the Northern Territory in the 1960s reported rates of around 150 per 1,000 live births. The best estimates are around 70-80 in the 1970s falling to around 25 in 1980s (Thomson 1991). In 1994-96 it was 18.6, still much higher than that for non-Indigenous infants. Deaths from all causes, particularly from SIDS and respiratory system diseases, are much more common in Indigenous infants. Poor socioeconomic circumstances and living conditions, higher rates of teenage fertility and of low birthweight babies, all contribute to this higher rate (see graphs C6.3 and C6.4). The children born in conditions which result in higher infant mortality are likely to have poorer health throughout their lives. Low birth weight and other early problems may well relate to many of the diseases seen in higher frequency among Indigenous adults such as cardiovascular disease, diabetes and renal failure (Mathews 1997). The components of infant mortality-neonatal and postneonatal deaths Neonatal deaths are those infant deaths occurring in the first 28 days of life, while postneonatal deaths are those occurring from 1 month to 1 year. The factors responsible for the decline in infant mortality varied according to the age at which an infant died and across different time periods throughout the 20th century. Early in the century, over 50% of infant deaths were postneonatal. It was dominated by gastroenteritis and other infections, and thus these rates fell rapidly in response to major public health interventions and improved social conditions. By the 1930s, less than a third of infant deaths were postneonatal and these rates, still dominated by infectious diseases, responded further in the 1940s and 1950s as mass vaccination and antibiotics became available. As graph C6.5 shows, by the 1990s the postneonatal death rate was 2.1 per 1,000 live births (now only 38% of all infant deaths) with very few from infections. Three causes accounted for nearly 80% of postneonatal deaths at the turn of this century-SIDS, birth defects and perinatal conditions. While their causes on the whole are unknown, they differ markedly from the adverse social conditions in infancy which caused so many babies to die in 1901-1920. The modern causal pathways to postneonatal death start early in development, and while some may still be socially related, they are complex and preventive solutions are not currently obvious. Neonatal mortality has always been influenced by pregnancy complications and fetal growth and development. Thus its reduction had to await new methods to treat the end-stage complications in the neonate, as primary prevention was not possible in ignorance of causality. Most neonatal deaths occurred in the first days of life and this pattern is still seen today. Neonatal mortality rates have fallen steadily from the 1920s as better knowledge resulted in effective treatments for high risk pregnancies, obstetric care in labour and, particularly since 1970s, neonatal care of preterm and low birthweight babies.As graph C6.5 also shows, in the late 1990s the neonatal mortality rate was under 4 per 1,000 live births (now 62% of infant deaths); 60% of these occurred on the day of birth. Most were due to extreme prematurity and poor fetal growth, congenital malformations and complications of pregnancy. Thus the challenges facing us to further reduce neonatal mortality are similar to those for postneonatal deaths. Both demand research into the many causes of preterm birth, intra-uterine growth restriction and developmental anomalies. As most children born with these problems today do not die, but have significant morbidity and disabilities, knowledge leading to prevention is of considerable importance. While neonatal mortality in certain low gestation and birthweight categories has been used in the past to evaluate the quality of newborn intensive care, this is no longer a reasonable index. Recently in Australia, there has been a tendency in the media to use infant mortality, as well as mortality at older ages, to judge the appropriate levels of expenditure on medical, particularly hospital, services. This is inappropriate as the antecedents and major contributors to these rates today have little to do with hospital services. As in 1901, the causal pathways to infants dying in the 1990s commenced well before hospital services have any influence. Preventive solutions thus lie elsewhere and demand investment in research in early causal pathways. Deaths in childhood The death rates in children (1-4 and 5-14 years) have always been far lower than those among infants and are now very low in Australian children (only 14 deaths occur in every 100,000 5-14 year olds) (graph C6.1). However the major causal grouping, i.e. childhood accidents, poisoning and violence (nearly 50% of all deaths), is of public health importance as these are potentially avoidable. The commonest causes of accidental death in children are motor vehicle accidents, drowning and inhalation of foreign bodies. Decreases in accidental deaths due to traffic accidents and drowning in the 1980s and 1990s followed legislation to restrain young children in cars and to make swimming pool fencing compulsory. Changes in Western Australia which have relaxed the policing of swimming pool fencing have resulted in increases in child drowning in that State recently (Eastough and Gibson 1999; Silva, Palandri et al. 1999). Children in poorer families and in Indigenous families are more likely to have accidents than those in other families. Other causes of childhood deaths include congenital anomalies (particularly those of the heart and nervous system, and chromosomal defects such as Downs Syndrome) and cancers. Medical science has made significant contributions to falls in all these causes of death by more accurate diagnosis, improved surgical techniques and chemotherapy. Causes of death in teenagers The causes of death in older children (5-14 years) and teenagers (15-19 years) were dominated in the early part of the century by infectious diseases. And particularly among males, accidental and violent death has always been an important contributor. The most common causes of death in the age group 15-19 years in the 1990s were accidents and suicides. The most worrying trend in all of those shown in this article is the increasing rate of suicides in young Australian males. 'External' causes of death include accidents (injury and poisoning), suicides and homicides. All other causes of deaths have shown marked falls over the century since Federation. This group of causes was high among all male children in the early 1900s. The rates for children have fallen steadily whereas those for teenage males rose to a peak in the mid 1970s before falling in 1990s to levels just below those in 1907 (graph C6.6). For females the rates are lower and the pattern is different: high rates in the 0-4 year old girls in the early decades of the 20th century with steady falls in both child age groups over time. Among teenage girls the rate was steady until an increase similar to that for males (but at a much lower rate) was observed from 1955 to 1985, with falling rates since then (graph C6.7). In 1998 it was the same as in 1907! Much of the increase and decrease in these rates is explained by accidents, and recently by road accidents. The fall in recent times reflects successful legislation (seatbelts, drink driving) and public education programs to avoid accidents of all kinds, including work safety, particularly aimed at young people. These death rates are markers for the high rate of injuries sustained in accidents resulting in serious and often permanent trauma and disability. Accidents remain a huge cost to Australian society. Graphs C6.8 and C6.9 show the increasing rates of suicide in Australian males aged 15-19 years; rates for females are much lower but may also be increasing. In 1907 fewer than 5 per 100,000 male teenagers took their own lives in spite of the difficulties of the times. From 1973-74 the male rate has climbed and is now around 20. The rate for females is more variable due to the small numbers, hovering between 2 and 6 per 100,000. Deaths from suicide have been more common in males than those from motor vehicle accidents since 1990, due to increases in suicide and falls in the accidental deaths. Beneath these death rates lie much larger numbers of children and young people with severe depression and other mental health problems. While female suicide rates are much lower, more females attempt suicide than males (Zubrick, Silburn et al. 1995). The significant social changes in families, the increasing level of child and adolescent mental health problems, the increased availability and use of addictive drugs and alcohol, the ready availability of guns and other means of suicide, and possibly other factors as well, have all contributed to these rising rates of mental health morbidities. Indigenous teenagers have particularly high rates (Youth Suicide Advisory Committee 1998). REASONS FOR THE DECLINE IN CHILD MORTALITY SINCE FEDERATION Better living conditions and enhanced public health awareness The decline in mortality in infants and children since Federation is obvious, the reasons for it less so. Caldwell (Caldwell 1999) quoted Alfred Marshall (1890) who attributed mortality declines in the 19th century to “the growth of temperance, of medical knowledge, of sanitation and of general cleanliness”. Thomas McKeown in the UK (McKeown 1979) and Douglas Gordon in Australia (Gordon 1976) both suggested that changes in living conditions, particularly better nutrition (which would have increased host resistance to infection) and improved hygiene (reducing contact with infecting organisms) played a more important role than improved medical knowledge. This was in the first few decades of the 20th century when falls in deaths in infancy and childhood were due mainly to fewer children dying from gastroenteritis, respiratory and other infections (Lancaster 1956a; Lancaster 1956b). Evidence for improved nutrition comes from the observed increase in the mean height and weight of school children (Cumpston 1989). Thus children grew taller and, one imagines, healthier and more capable of resisting infections than their earlier born, less well fed and shorter parents. As these young women entered the child bearing age, they would have been more likely to have healthy pregnancies. Armstrong (1939) described the early infant welfare activities in NSW which were the “first developed in the Southern hemisphere, and derived from and modelled upon the operation of similar activities in England and France". He wrote about the policies and legislation for improving maternal and child health (MCH), driven by a commitment to reduce the Australian “infantile mortality rate (which) was greater than that of London and as high as in most of the world's great cities". His aim was somewhat delayed as his energies were diverted into an outbreak of plague in Sydney at the turn of the century! The main intervention was to encourage mothers to breastfeed, with many supports to enable this to happen, including trained health workers visiting all new mothers. “Each day the clinic obtained from the district registrar a list of the births in the district, and these were all visited” (Armstrong 1939). His slogan was: “There is no feeding equal to breast feeding”. He was convinced from his international observations that breastfeeding was the most important protection from gastroenteritis which killed so many infants. His own investigations in Sydney showed that the mortality among infants under 3 months of age from diarrhoeal diseases was between 10 and 15 times as great among those artificially fed as among those entirely breastfed. Armstrong maintained that breastfeeding was the most important influence on infant mortality from the early 1900s to 1914 (table C6.10). However, he also acknowledged both improved sanitation and “the great wave of social betterment which spread over Australia after Federation, and which expressed itself in rising wages and industrial expansion with greatly improved conditions of living” (Armstrong 1939).
Mothers were educated about infant welfare, particularly the importance of breastfeeding, personal hygiene and clean environments. Mothers of sick children were advised to seek medical help and public hospitals treated children free. Special hospitals for sick babies, most with gastroenteritis, were also established, such as the Lady Edeline Hospital for Babies at 'Greycliff' in Vaucluse. Infant welfare clinics and the home visitor program expanded to postgraduate training for nurses in baby health (infant welfare) at 'Tresillian centres', which sprang up all over the country and were the beginning of community child health in Australia. As MCH improved over the century, breastfeeding became less vital for survival. And artificial feeding was less worrying because special infant formulas became available and the water to make them up was clean. Milk became safer as pasteurisation was introduced in the 1930s. While data on the prevalence of breast feeding at the time of discharge from the hospital of birth are fragmentary, it is recorded that only 40-45% of mothers were initiating breastfeeding in 1970s, a fall from over 50% in 1950s and much lower than the 90% in Armstrong’s day. Hospital staff were less educated about the importance of breastfeeding, and perhaps there was an influence of it not being fashionable as well! Following intensive community campaigns to reeducate women about breastfeeding, there has been a steady upward trend with recent figures in the 1990s of around 76% of new mothers initiating breastfeeding, with over 50% still fully breastfeeding at 3 months (Jain 1996). Maternal education and child health The seminal work of Australian social demographer Caldwell and his colleagues at ANU has described the important effect of parental, particularly maternal, educational level on improved outcome for a child. Even when controlling for family income and access to health services, a child’s chance of survival improves with higher levels of parental education, the relationship with maternal educational level being the strongest (Caldwell 1999). Similar associations are seen with morbidity as well (Silburn, Zubrick et al. 1996). An educated mother is one who is more rational, able to be informed about ways to improve child health, is likely to breastfeed and immunise her child, seek help early if the child is sick and follow instructions in terms of health care. Along with higher levels of education in the first 50 years since 1900 would have come an increasing knowledge about, and belief in, modern medical science and what it could deliver for health. “Educated people for most of the time up to the present have been more likely to use soap, to isolate family members with infectious diseases, to guard their children from danger, to use safe water or to boil it, to boil milk for babies use, to accept immunisation for their children, to take sick children for medical treatment and to follow the prescribed course of treatment" (Caldwell 1999). More recently more women being educated reflects female empowerment, which has been associated with greater control over their own lives and better health for them and their children. This is particularly pertinent to today’s Indigenous families in Australia. Education is now so widespread that its continued importance to child health and care is often taken for granted. Changing concepts about death Caldwell (1999) developed a theory of 'health transition' to explain the changes taking place in traditional societies and communities with high mortality and high fertility to the low levels of both as countries develop. Mortality declined through improved public health, social and behavioural changes, and the use of medical and other technology. A change in the way death is viewed culturally has driven this commitment to survival, with death being viewed as the worst of all possible outcomes (Simons 1989). In eras with high mortality rates, death was not regarded as unusual, whereas as the capacity to survive became possible, there was a strong commitment to reducing risks and to avoid death. Income, material wellbeing and mortality There is a clear ecological relationship between material wellbeing, measured by income or disposable household income for families with children, and their health status. The extent to which one influenced the other and how more income translated into better outcomes is not known. More disposable income for families resulted in better food, clothes, education and better housing-all of which have been associated with improved child mortality and morbidity. Fertility, family size and overcrowding As the fertility of women decreased, the average number of births for women less than 45 years old fell from around 7 before 1900 to 3 in 1920s (Williams 1989). This meant fewer children to look after, less crowding in housing and better provision of those things essential for good health for the children. In 1920s and 1930s there were still many living in crowded and poor industrial areas of large cities and in poor rural areas in inadequate housing and conditions, and unemployment made it hard for families, even those of smaller size, to provide for their children. Advances in medical science Throughout the century, scientific discoveries started to impact upon health and medical services. Before World War II few vaccines were available, the most significant for children being diphtheria and tetanus antitoxoid. Pertussis, polio and other viral vaccines soon followed. The impact of polio on deaths in young children and teenagers is shown in graph C6.11; the graph does not show the large numbers of young people permanently paralysed due to this virus. The effect of vaccination was dramatic (Ada and Isaacs 2000). Infectious deaths fell before widespread vaccination was implemented. However, since the 1950s, mass vaccination has been the single most effective public health measure to reduce the occurrence of infections, to reduce child deaths and to improve child health (Ada and Isaacs 2000). There continue to be success stories with new and effective infant vaccines. In 1980s Haemophilus influenzae (Hib) was the most serious infection in young children (graph 6.12). Invasive Hib disease (meningitis, septicaemia) had a high case fatality, particularly among Indigenous infants, and left many surviving children with severe intellectual and physical disabilities (Hanna 1992). Parents' fear of polio in the 1950s and of meningitis in the 1990s resulted in high levels of participation in these vaccination programs. As the incidence and severity of infections has fallen, parents have become apathetic about vaccination and some actively oppose it. Because of its very effectiveness, vaccination is regarded by a significant proportion of the community as unnecessary or dangerous. Yet its success to prevent disease depends upon high rates of participation. Current rates of vaccination in Australian children are less than those in Viet Nam; this is another public health challenge for us in the 21st century. Sulphonamides to treat infections were introduced in early 1940 and penicillin, dramatically effective against Streptococcal infections including bacterial meningitis, became available immediately after World War II. Other antibiotics followed, and the death and complication rates of all bacterial infections fell markedly (Williams 1989). However the excessive use of antibiotics has resulted in increasing numbers of organisms resistant to their effects. This situation is extremely worrying and makes the case for primary prevention even more powerful. From 1945 until 2000, with infectious disease rates very low, and other public health measures almost taken for granted, medical care began its revolutionary impact on illness and death. Children were to be beneficiaries of new knowledge in biomedical science as well as from the specialisation in paediatric care. The sciences of physiology, biochemistry and pathology blossomed throughout the 20th century, following fast on the tracks of bacteriology. Knowledge about how the body worked and how diseases were caused meant that diagnosis became accurate and treatments more focused and effective. X-rays, surgery and anaesthesia, fluid and electrolyte metabolism, chemotherapy and other drugs such as those for epilepsy, pain relief and many disorders, have been so effective that many now believe that everything can be cured or will be very soon. Public health, once centre stage and still vital, is often ignored. CHILD ILLNESSES IN THE 20th CENTURY Morbidity and disability While death rates in the early decades of 20th century probably reflected the occurrence of illness reasonably well, the rarity of death among children now means that death rates do not reflect the burden of illness and disability affecting our children and youth. Morbidity data for all Australian children are available via surveys, such as the National Health Survey, and from data collated by AIHW. And some States, such as WA, have good record-linked and special survey data to describe the recent pattern of child and adolescent morbidity (Stanley, Read et al. 1997). The rise of complex disease - the challenge of the late 20th century Improvements in social and economic circumstances in Australia have changed the face of child health. Similar to other developed countries, we have observed increases in 'complex' diseases in the cohorts of children born in the last three decades. Suicide and mental health morbidities have been described already and appear to be related to the social changes in our communities. The increased rates of cerebral palsy in very preterm and low birthweight survivors following the introduction of intensive care are an unwelcome outcome of effective technologies aimed at reducing deaths (Stanley, Blair et al. 2000). Two other examples are asthma and juvenile diabetes, both of which have increased considerably. They head a list of complex disorders which have taken over from infectious diseases as the most serious threats to the health of our young people. A review of population data and national health surveys (Bauman 1993) showed an increase in asthma symptoms, such as recent and cumulative wheeze and diagnosed asthma between the 1970s and 1990s (graph C6.13). C6.13 TRENDS IN CUMULATIVE LIFETIME WHEEZE PREVALENCE IN PRIMARY SCHOOL CHILDREN Asthma is now the leading cause of hospital admission in children and is costly to treat. It was the leading problem (present in nearly 20% of children aged 4-16 years) reported in the WA Child Health Survey in 1992 (Zubrick, Silburn et al. 1995). While some of this increase may be due to changes in diagnosis and more awareness, research is now concentrating on the variable and complex causal pathways to this major allergic disease in relatively healthy communities. Insulin dependent diabetes mellitus has also increased. In 0-14 year old Western Australian children the rate rose from around 12 per 100,000 (in 1985-91) to 22 in more recent years (Kelly, Russell et al. 1994). Many other centres are now reporting similar increases. Both asthma and diabetes are lifelong illnesses with significant morbidity and need for complex treatments. Primary prevention, as with all these complex problems, is obviously the way forward, but will only come from further research into causes. Population data on disability in childhood are not readily available, but suggest increases in both incidence and prevalence of several impairments across the range of severity. Some of this is clearly related to increased survival of high risk newborns and of children with established disability (Blair and Shean 1996). The proportion of children aged 0-14 years with intellectual disability has fallen from 1970 to 1990. Antenatal diagnosis and termination of affected Down Syndrome and Fragile X affected fetuses, newborn screening for phenylketonuria and congenital hypothyroidism, and vaccination against congenital rubella and Hib, have been the main contributors; improved social conditions may also have contributed. Increases in autism, behaviour problems and learning disabilities in children have been reported over the 1980s and 1990s (Alessandri, Leonard et al. 1997); it is not clear the extent to which these are all true rises or due in part to parental concerns and changing fashions in diagnosis. LIFESTYLE RISK FACTORS FOR POOR HEALTH Tobacco and alcohol Smoking and alcohol abuse are recognised as the leading drug problems in Australia, and influence deaths and illness at all ages. Due to clever advertising by cigarette companies internationally, and peer pressure, children and teenagers are starting to experiment with these drugs at earlier and earlier ages. Once addicted they put themselves at increased risk of smoking related illnesses such as cancer, heart disease, stroke and those risks associated with alcohol such as accidents, unsafe sex, suicide and mental illness. Regular nationwide surveys of school children document recent levels of tobacco and alcohol use in Australia (Hill, White et al. 1999). Between a quarter and a third of 15 year old males and a third of females admit to smoking in the past week (table C6.14). There is little improvement over time, most of it in males (Hill, White et al. 1993; Hill, White et al. 1995).
Table C6.15 shows, by age and gender, the proportions of school children classifying themselves as drinkers. By 14 years of age, over half of the boys and girls have started drinking, some on a regular basis. The dramatic increase in females smoking and drinking over the last 50 years has been a major social change. Such behaviour in women was unusual in the early and middle years of last century; now we are faced with the prospect of more young girls smoking and as many drinking alcohol as young boys. With the knowledge about the effects of these on the future health of both boys and girls and for girls, on that of their babies, this is a major public health concern. Australia has been a leader in legislation and health education to reduce cigarette smoking levels in the community. Legislation banning cigarette advertising of any kind was introduced earlier in Australia than in other countries. Recent laws have banned smoking in work and public places, but novel ways need to be found to counteract the clever subliminal advertising of cigarette companies (Daube 2000). Similarly legislation and education about drinking and driving seems to have impacted on accident rates in young people. Obesity, poor physical fitness In the last 20 years, concern has been expressed nationally about the increasing levels of obesity and lack of physical fitness in children and adolescents in Australia (O'Connor and Eden 2000). Two studies (Wake, Lazarus et al. 1999; Lynch, Wang et al. 2000) reported temporal increases in Body Mass Index (BMI, a measure of weight for height) in both Sydney and Melbourne children from age 7 to 18 years, with about 25% of children being overweight. Researchers blame the sedentary lifestyles and diets of children; the intake of fruit and vegetables and of physical activity decreases throughout adolescence (Wake, Lazarus et al. 1999). At the other extreme, there is an epidemic of eating disorders and weight concerns with a desire for thinness among girls, and increasingly among boys as well. Over 30% of 8-12 year old girls have already tried to lose weight (Rolland, Farnill et al. 1997). The longer-term effects of poor adolescent growth are now starting to be described, particularly on bones and on mental health. IMPORTANCE OF SOCIAL FACTORS IN CHILD HEALTH Family structure and interactions, employment and incomes There have been changes in our communities that have had a profound effect on child and adolescent health and wellbeing. The marriage rate reflects the prevailing economic and social conditions. It increased in times of prosperity such as the early 1900s, rose before each world war, fell during it and rose again after it, and fell in times of adversity such as in the 1930s during the Depression. It rose again around the time of the Viet Nam war. Over the last 20 years marriage rates have fallen, and age at first marriage and age at first birth have increased dramatically (graph C6.16). In contrast divorce rates rose in the 1970s, stabilised in the 1980s and have increased slightly through the 1990s. Coincident with the fall in marriage rates, there has been an increase in de facto relationships, which have become more socially acceptable in the last 20 years, even if children are involved. The proportion of births which are ex-nuptial has risen from around 6% in 1901 to 29% in 1998 (graph C6.17); at least half of these births are to women in de facto relationships. The median age at first marriage was around 27 years for males and 24 for females in the 1920s, remained high during the 1930s Depression years and fell dramatically after 1940. It continued to fall until around 1975 when, associated with marked changes in the professional and social development of women, age at marriage increased again to levels similar or even higher than those seen in 1920s. Age of mothers at first birth closely mirrors the trend for age of mothers at first marriage (graphs C6.18 and C6.19). Late in the 19th century the fertility rate was falling; it picked up again as the new century progressed, falling rapidly after the 1929 Depression. Fertility increased to 3 babies per woman in 1947 and peaked at 3.6 in 1961-during this period (1947-61) 3 million babies were born in what has been referred to as the baby boom! The widespread introduction of the contraceptive pill gave women easier and more sure control over their fertility, which fell along with changes in desired family size. Since the 1970s fertility has declined to its lowest rate ever. An increasing part of this fall is contributed by women who decide to remain childless; in the 1990s 27% of women did not have any children. Of those who do, 40% will have 2 children, the most common family size, and only 12% of women would have one child. While there is under-registration or recognition of Indigenous births, some data are available. During the 1960s Indigenous women had a total fertility rate of around 6 babies per woman, which fell during 1970s to about 3 and in the 1990s to 2.4. The age distribution of births is very different for Indigenous mothers compared with non-Indigenous, with many more teenage births (graph C6.3). Divorce and effects on child health and welfare Until 1940 the level of divorce in Australia was negligible, with less than 2 per 1,000 married women. By 1947 when marriages in haste before the war had started to be tested, the rate had risen to around 5. After a decline in the 1950s, divorces started to increase in the 1960s and climbed sharply in 1976, following the introduction of the Family Law Act and 'no-fault' divorce. This allowed only one ground for divorce-an irretrievable breakdown in the marriage measured by the separation of the spouses for at least one year. Divorce rates have been consistently higher in the 1980s and 1990s than at any time before 1975. The most common themes associated with marital breakdown are listed here because of the impact they are likely to have had on children before the divorce occurred:
Most of these factors have a negative effect on the care and mental health of children (Zubrick, Silburn et al. 1995; Silburn, Zubrick et al. 1996), and suggest that community support systems may be less available than in the past. The proportion of children involved in divorces has risen slightly, from around 9.7 per 1,000 children aged less than 18 in 1988 to 10.9 in 1998; the number of children involved in divorce each year increased from 44,400 to 51,600. After separation, children of all ages were more likely to live with their mother than their father, but could have regular contact with the other parent. The ABS Family Characteristics Survey of 1997 found that there were 978,000 children living with only one natural parent; most (88%) lived with their mother in either one-parent (68%) or in step or blended families (20%). Remarriage rates increased after the 1976 divorce peak and have declined slightly since then. Fathers were more likely to remarry than mothers. Many studies have observed the detrimental effects of divorce and single parenthood on child health and wellbeing (Fergusson, Horwood et al. 1981; Fergusson 1984; Zubrick, Silburn et al. 1995). The data suggest that children in single parent families fare less well socially, educationally and physically than children in two parent families (adopted as well as natural). Single parents are more likely to be young, poor, and have low educational levels and other social risk factors. Thus the critical issue is not necessarily how many parents a child has but the social and environmental context in which the single parent family operates (Fergusson 1984). Also problems can be exacerbated if the parent remarries or enters into a new situation with a blended family. The costs to Australia of family breakdowns were assessed at about $3b per year, through legal and social support schemes, and when all indirect costs and the personal and emotional trauma to children is added to these figures, the cost to the nation is enormous. Data from the WA Child Health Survey (Zubrick, Silburn et al. 1995) suggested that three factors worked to protect children from higher levels of mental health morbidity: two parent family structures (compared with one); higher parental incomes (why is not fully understood and needs more research); and the presence of excellent or good relationships between adult caregiver and another adult. Rates of mental health morbidity were highest when adult relationships were rated poor or fair.
Coincident with these changes in families and communities, the incidence of child abuse-physical, emotional and sexual-is thought to have risen over the last three decades. However the data are incomplete as much goes unrecorded even in those States with mandatory reporting of abuse. Data from the Australian Institute of Health and Welfare show increases in abuse and neglect up to 1994-95, with small falls in later years (table C6.20). All paediatric hospitals now have teams of highly skilled professionals to diagnose and manage these children and their families. In the majority of cases the perpetrator is a close family member or friend. The tragedy of this is illustrated by the proportions of post-neonatally acquired cerebral palsy due to non-accidental injury in WA children, which rose from 3.4% to 14.9% between 1956-75 and 1980-92 (Stanley, Blair et al. 2000). Deaths and cerebral palsy are the 'tip of the iceberg' of damaged children; prevention will need research to identify the best ways to avoid unwanted pregnancies, help young parents, avoid isolation of single parents and provide social support. Employment Apart from the periods of unemployment in the depressions and recessions of the 20th century, the most significant influences in employment impacting on children have been increases in women working (see Characteristics of the labour force in the Labour chapter, and graphs C6.21a, C6.21b and C6.22). The increase in women working has decreased the availability of the 'volunteer' community workforce, so important for schools, care of the aged and other activities. More of this may now need to be provided by local government (see later). Poverty, child health and social security The levels of poverty and disadvantage around 1900 were a powerful influence on the low levels of child health and high death rates of that time. As Australia has grown and developed over the century, the changes have mainly been towards significant improvement. However, as we move into the new millennium, increasing levels of inequity in social and health status are worrying. One in six of the developed world's children live in relative poverty, i.e. below the national poverty line in their country (UNICEF 2000). Australia ranks 15th of the 23 'rich' countries listed, with 12.6% of its children living in households with incomes below 50% of the national median. Sweden had the least (2.6%), and countries with higher levels than Australia included Poland, Canada, UK and USA. Many European countries had lower relative poverty rates than Australia (graph C6.23). Of enormous importance to child health is the marked increase in the number of low-income families dependent on benefits because of unemployment or sole parenthood and of the increasing numbers of children in relative poverty.
Many more Indigenous families are living in relative poverty than non-Indigenous families (table C6.24), and some are living in real deprivation. The overall poverty rate among Indigenous families is almost three times that among non-Indigenous families; half of all Indigenous children were living in poverty in 1986 and the same pattern is seen for both groups, i.e. increased risk of poverty with sole parents and unemployed parents. At the end of the 20th century, these social changes in families, as well as those mentioned above, have implications for social security and child health (Cass 1986). Economic and social attitudes have driven the decrease in size of Australian families, and the increases in sole parent families and in the workforce participation rate of women with children. Future directions for reform include family income support, redistributing income to all families with children to improve and maintain their position. Australia needs to reassess the value which it places on children, and focus on the concept of shared parental and community obligation (Clinton 1996). Those making policy about family income support need to recognise the increased costs which parents bear, particularly those with young or disabled children, those with large families, and those who are sole parents and/or who are on low incomes (Cass 1986). Schools, preschool and education During the 19th century, the church dominated education, initially only available to selected groups. By 1900 education was firmly established on a non-sectarian basis in all States, and by 1910-20 governments also developed technical and high schools. Distance and transport influenced Australian education, and correspondence schools date back to 1914. Use was quickly made of radio, and the pedal wireless was introduced soon after, along with the Flying Doctor service (Gandevia 1978). Preschool education and the kindergarten movement started in NSW in 1895, and were in all States by 1910. Twenty years later Lady Gowrie preschool centres supported by Commonwealth grants commenced, and in 1938 the Australian Association of Preschool Child Development was formed. After 1900 the public health concern for infant welfare expanded to preschool and school aged children. School Medical Services were operating in all States by 1920. Education was given about personal hygiene, cleanliness, physical education and fresh air, good food and healthy thoughts. School doctors and nurses inspected children for spinal curvature, visual defects, dental caries and other abnormalities. Science and domestic economics were taught to girls to enable them to be good mothers. This commitment to improved conditions, healthy environments and educating future mothers certainly contributed to the early declines in child mortality in Australia. However there was obviously a difference of opinion between the public health advocates in schools and the teachers, highlighted in a quote from J.W. Springthorpe who, in 1914, attributed the decline in the physique and health of the current generation to “teacherdom which neglected the bodies, which never qualified itself to impart the knowledge of protection from health and disease …. the same teacherdom is with us now, resisting the medical inspection of schoolchildren… prattling of child-soul gardens, and manufacturing child-body cess-pools; spending years in teaching how to model baby-elephants in plasticine, and never an hour on how to use a toothbrush; dawdling over book-learnt nature study, in dark, overcrowded classrooms, redolent with the air-sewage of unwashed children” (quoted in Gandevia 1978). This commitment to school health reflected the medical feeling of the time about the close relationship between environment, health and disease (both mental and physical), and a rapidly growing interest in preventive medicine. Screening and surveillance of school children and the provision of preventive services through schools continues today. The WA Child Health Survey identified that 20% of 12-16 year olds had a significant mental health problem (table C6.25).
Thus one in five teenage school children will have a mental health problem and most will not seek or receive treatment. The implications for school health services is that this level of morbidity demands a preventive approach, aimed at reaching large numbers of children and adolescents. In addition to the detection and surveillance of disabilities in school children and giving them health education, there is a huge unmet need to provide preventive strategies-both in and out of school. Infancy and early childhood are critical times for the social and physical development of the child, and his/her resiliency and success as an adult. By the age of 4-5 years, when most Australian children are about to start school, the stage for good or bad health and educational outcomes has been set. Research around parenting and its impact on this early period has also highlighted how important it is for that child’s own capacity as a parent. This research must be considered when designing appropriate interventions-the earlier the better if we wish to make real differences to child development and adult competencies. This research also suggests that any activities that undermine parents, or interfere with their capacity to be good and loving parents and to create a nurturing environment for their child, should be avoided at all costs. The policy of removing half-caste Indigenous children from their families was certainly devastating to generations of children and families, and it continues to have effects on today's parents and families (Human Rights and Equal Opportunity Commission 1997). THE ROLE OF HEALTH AND MEDICAL RESEARCH - SOME CASE STUDIES ILLUSTRATING THE ADVANCES IN THE 20th CENTURY The special case of neural tube defects Birth defects (congenital malformations) are now one of the commonest reasons for deaths in early infancy and childhood, for hospitalisations, for other care of and disabilities in children. Little is known about the causes of most malformations, which limits our capacity to prevent them. One of the most common burdensome birth defects results from failure of closure of the developing neural tube in the developing embryo. The resulting defects of anencephaly, spina bifida and encephalocoele, collectively called neural tube defects, cause death or often lifelong disability. Antenatal diagnosis (ultrasound and blood tests) followed by offering termination to mothers of affected fetuses was the only 'preventive' strategy. Research throughout the 1980s, in Australia as well as internationally, elucidated the protective effect of a maternal diet rich in or supplemented by folate, a B vitamin, found commonly in leafy green vegetables (Bower and Stanley 1996). The impact of increasing maternal folate around the time of conception in WA is shown in graph C6.26. The special case of SIDS Sudden infant death syndrome (SIDS) or cot death was not a classifiable ICD cause of death until the 1970s. Graph C6.27 shows the Australian SIDS rates from 1979 to 1997. The rate peaked in the late 1980s in males to above 2.5 per 1,000 live births and was 1.5 for females. Australian research from Tasmania, published in 1989 (Dwyer, Ponsonby et al. 1991) clearly demonstrated the risk of laying babies on their tummies to sleep. Other risks including wrapping the baby up too warmly, smoking and not breastfeeding. A major education campaign to 'Reduce the risks' was run in the early 1990s, which resulted in a dramatic reduction of the rates to around 0.5 per 1,000. The rate of SIDS in Indigenous babies (graph C6.28) was higher than in Caucasian babies and even after the campaign, has remained high (Alessandri, Read et al. 1996). Possibly other causal pathways to SIDS may be more important in these infants. The special case of preterm births and NICU The increasing survival of very preterm infants with more and more expensive neonatal intensive care, but with worrying levels of disability, has been debated and questioned internationally. In the US this has been referred to as the perinatal paradox: “the basic incongruity in American perinatal care lies in our superb ability to care for the individual patient and our dismal failure to address the problems of the larger society” (Rosenblatt 1989). The rates of death in smaller and smaller preterm neonates have fallen since the introduction of neonatal intensive care, and the rates of motor disability such as severe cerebral palsy have risen in the survivors (Stanley, Blair et al. 2000). This is also illustrated in graph C6.29. Meanwhile the proportion of all births born preterm has not changed, suggesting that our efforts have been concentrated on treating the sick preterm newborns rather than on trying to increase the numbers born at term. We must put as much effort into researching the causal pathways to preterm births and other causes of low birth weight as we have into the biomedical research that has had such a wonderful effect on their survival. The special case of childhood leukaemia Cancer as a cause of mortality and morbidity has always been low in children. Mortality increased from 1907 to the 1950s probably reflecting better ascertainment and more children surviving infancy rather than a real increase in incidence. The falls from around the 1950s, to the 1990s are due to more effective therapy. As yet we do not know how to avoid cancers in children. The rates for deaths due to leukaemia are shown in graph C6.30. There are several important points to make about the reasons for the substantial improvements in cancer survival shown in graph C6.31. One is a wonderful lesson of the demonstration of the importance of randomised controlled trials to ascertain better clinical practice. Another is the multidisciplinary teamwork needed for both research to identify better drugs and to implement best practice. Australian children have benefited from participating in these international research groups. C6.31 SURVIVAL OF CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKAEMIA, Children's Cancer Group Studies, USA Source: Bleyer 1997. Cumpston-the father of public health in Australia Improvements in MCH and Australia’s commitment to public health in the early 20th century is inextricably entwined with the career of J.H.L. Cumpston. Cumpston (1880-1954) was Australia’s first Commonwealth Director-General of Health. A medical graduate from Melbourne and working in the Melbourne Hospital in 1903, he was influenced by the numbers of cases of preventable infectious and parasitic diseases he saw (such as typhoid and hydatids). He set about training himself overseas (UK, France, India) for a career in preventive medicine, “the medicine of the future” as he called it. How right he was. He oversaw the most spectacular falls in mortality and morbidity ever seen in Australia. With J.S.C. Elkington and R.W. (later Sir Raphael) Cilento, he played the most significant role in the improvements in public health in the first fifty years after Federation. These changes and the ideology which drove them (social, economic and hygienic improvements aimed at “the physical efficiency of the population”) were similar to that in Britain and America at the time. Essential to this movement was an expert bureaucracy to research, create and administer policy: Federation and the income divide between the States and the Commonwealth led to the growth of both State and Commonwealth bureaucracies (discussed later) and, as importantly, legislation to improve public health. Other essential ingredients for the success of the public health movement was a competent and independent (from State) group of medical practitioners, devoted to the care of the sick, but willing to accept State interventions for both public health improvements and care (the latter of course on their terms). The Labor party of the 1920s was committed to collective responsibility and equitable access with respect to public health. The conservative parties emphasised individual responsibility more, so a reformist Labor Party was also helpful to Cumpston's aims. Also of course, the explosion in knowledge in the sciences underpinning medicine and public health was to play a major role. The theory of 'miasmas' in public health had led to major environmental changes such as sanitation, fresh water and better living conditions, which started to have an impact on reducing illness and death from infections in the late 19th century. Throughout the early 20th century, as bacteriology developed, knowledge grew of the role of organisms in disease, and the focus of public health shifted to identifying disease in individuals and control by isolation (quarantine), which opened the way to mass vaccination. Cumpston’s contribution can be divided into three phases since 1901. The first, from 1901 to WWI, focused on disease prevention and control in individuals, and in groups of signal importance to the productive and reproductive needs of the community (the 'physical efficiency' referred to earlier)-i.e. mothers and children and, to a lesser extent, the workforce. The second phase, from WWI to 1930s, resulted in a Commonwealth Department of Health promotion of national public health via 'cooperative Federalism' (see discussion in the next section). His last phase, from the 1930s to the end of WWII, concerned the creation of a national health service, which did not come to fruition before he died in 1954. His and Cilento’s dream was for a national health service which was state financed, allowed universal access, integrated the usually separate areas of preventive and curative medical practice, but did not get rid of private medicine. This sounds an almost perfect world! M.J. Lewis (1989) edited Cumpston's 1928 writings (Cumpston 1989) and noted: “he was well read in the history of English public health. In appreciating the importance of the political and socio-economic context of public health, he was also well informed about the history of Australia’s political and social mores and institutions”. His writing has been described as “historically oriented epidemiology”, and he acknowledged that this approach was crucial to the understanding of future crises. While Cumpston concentrated on infectious diseases, which was logical given the prevailing epidemiology of his day, a public health approach is equally crucial to today's epidemics of complex diseases and psychosocial morbidities. They are calling out for a modern day Cumpston. Governments and child health in the 20th century Politics and health systems are integrally related, as legislation and government funding have been influential in the overall approach, strategies and management of health care as well as influencing the roles of the different professions in its provision. Knowledge of the political system remains important if people are to be effective in influencing child health policy and allocation of resources. As a researcher dedicated to improving child health I feel that it is vital to ensure that good research in child health gets funded and that it is used to improve services. Given how much we now know about the relationship of income, employment, child care provision, family support, educational level and housing to the general health and welfare of our children, government policies at all levels-Commonwealth, State/Territory and local-are important. Federal system How has the unique Australian Federal system influenced the delivery of health care and other policies affecting children? Federalism, the constitutional division of power between the Commonwealth and State Governments, has affected all aspects of Australian life. Throughout the 20th century, there has been an increase in the power of the Commonwealth Government, but the States have also become increasingly independent, with resulting multiplying and complex inter-governmental arrangements which have not always served the health care system well. As mentioned earlier, Cumpston, as our first Commonwealth Director-General of Health, was a strong supporter of social medicine and convinced that unemployment, poor housing and inadequate social security were detrimental to health (Gillespie 1991). The era of infectious disease public health broadened under his influence, in the first few decades since 1900, to include the new knowledge of physiology and biochemistry which underpinned the nutritional solutions to prevent and treat diseases such as pellagra and anaemia. Cumpston and others responded to the new public health by replacing the ineffective Federal Health Council with a stronger and more independent National Health and Medical Research Council (NH&MRC) in 1937. This was both to fund the nation's fledgling medical research and to drive decision making in the States about public health. Medical care (hospitals and private practice) was kept closely within the medical profession and within State jurisdictions. Attempts to bring in national health insurance were strongly opposed by doctors and other groups. Initial funding for the NH&MRC came from the Commonwealth Jubilee Fund Appeal for Maternal Welfare and Lord Nuffield’s Gift for Crippled Children. By 1938 the allocation was £30,000 (Gillespie 1991). The council was dominated by the Heads of State Health Departments and chaired by Cumpston who said, “preventive health is the centre of the NH&MRC’s program leading to a widespread national campaign which will ensure complete and adequate supervision of an intelligent kind over the bodily health of infants, pre-school children and school children, over the physical culture of the school child and over the diet of the community” (quoted in Gillespie 1991). W. Hughes as Federal Minister of Health from 1934 to 1937 actively promoted the concept that Australia had to “populate or perish”. Thus maternal and infant welfare was a top priority. Lady Gowrie centres were established to train mothers in the care and instruction of the preschool child. They also provided samples of children for surveys of nutrition and growth! NH&MRC had both nutrition and physical fitness as its major national thrust in the 1930s. Malnutrition was of major concern, with mention of rickets in urban slums and goitre in rural areas as well as the rapid deterioration of the health of Indigenous people in contact with whites (Gandevia 1978). The main activities of the NH&MRC were dominated by the political program of national hygiene and, as the threat of war deepened, the NH&MRC launched a national fitness campaign. They strongly influenced physical education in schools with the aim of producing “a race of strong, virile, stalwart individuals who would provide an invincible bulwark for defence at times of crisis or emergency…” (Gillespie 1991). Thus it seems that a major reason for growing healthy children was to ensure they could fight in a war! The Commonwealth became increasingly dominant due to the 'power of the purse'; in 1926 the Loan Council helped to ensure dominance with grants to the States, and in 1933 the Commonwealth Grants Commission was established to continue and expand the trend. However Australia throughout the last century was a nation of States, and continues to function with very few truly national organisations or institutions in the health area. The supposedly ideal model of Federalism is one in which each level of government acts independently of the other. This does not exist in practice: working for and representing the same groups means overlap and one impinging on the other. Modern transport and technology means that communications and collaborations between States are facilitated, resulting in more uniform legislation across Australia including policies relating to children, families and health. However, Canberra makes and enforces social and some health policy with varying degrees of “cooperation, conflict and competition with the states. There has been frequent duplication, bureaucratic rivalry, buck passing and lack of accountability” (Rydon 1995). Attempts by several Labor governments to implement a national health service were opposed by doctors, and so a system of universal health insurance was not signed up by all States until 1975 when Medibank was created. This, to satisfy the doctors, retained the concept of fee-for-service for general and specialist practitioners, with salaried staff in public hospitals (which were free) and in community health. The complexities of State-Commonwealth services funding and control remain today, with little hope of any great simplification of government roles. Some would say that this situation is a considerable impediment to effective health policy in Australia. Public health and local government Local government has played a crucially important role in preventive maternal and child health over the last 100 years. While local government has been mentioned in a somewhat derogatory manner as dealing with ”roads, rates and rubbish or ditches, dunnies and drains” (Smith 1995), in the late 19th and early 20th centuries the role of ensuring a safe and healthy environment was paramount. The fall in infant and child mortality, as mentioned earlier, was in major part initially a result of improved hygiene. Infant welfare was the first human (rather than property) service in which local government became involved, establishing Baby Health centres or Infant Welfare clinics staffed by nurses. These focused on keeping children healthy with advice to, and support for, parents. This movement commenced at the beginning of the 20th century, aimed at reducing infectious diseases and improving the nutritional and physical condition of children, and was one of the most successful public health initiatives, being the forerunner of our current child and family health services. Immunisation clinics were almost totally run by local government until relatively recently, when there has been a shift to State and Commonwealth funding of specific programs (such as the 1998-89 measles vaccination campaign), with increasing use of State government personnel and of local general practitioners. The role of local government in public health could become as important in the 21st century as it was at the beginning of the last century. Public health again is being perceived as requiring an intersectoral response with the development of healthy public policy, involving work, education, town planning and community services as well as health. Thus local government programs and facilities, which might lure children to exercise, watch less TV and participate in activities which build self-esteem, could be powerful in improving child and adolescent health in 2000 and beyond. Local government might also be best placed to provide support for high-risk families such as safe, cheap, enriched childcare or parenting programs. “The close relationship between Local government and public health in Australia is seen in their origins and historical development. The new understanding of health, rather than simply illness, may require a further examination of this relationship and the development of a new framework” (Smith 1995). Perhaps the only area where local government has failed public health has been in the provision of basic services to Indigenous communities. In many of these, particularly in remote areas, conditions are reminiscent of 19th century poverty with the resulting disease patterns described earlier. Summary As we begin a new century, certain problems in child and adolescent health are presenting us with a set of challenges similar to those of the social and environmental situations in 1901. Coincident with the changes in our modern society in family life, in employment and in the economy, and the inequalities in wealth which have occurred particularly over the past four decades, we are observing epidemics of mental health problems such as suicides, risk taking behaviours, depression and eating disorders in our young people. As families break down and reform, we are seeing increases in violence against and abuse of children, which resonates with the abuse of children 100 years ago. More and more young people are seduced to watch television, sit at computers, eat and drink unhealthily, smoke cigarettes, drink alcohol excessively and drive dangerously, and so we have the adverse effects of these lifestyles to combat as well. Issues in relation to poverty and child health have not left Australia’s shores in the new century either, in spite of us being one of the most developed countries in the world. Many Indigenous families with children are living in conditions of real deprivation, not unlike those in the 19th and beginning of the 20th century. Their rates of death and illness are higher than those of non-Indigenous children, although there have been improvements recently. This is a uniquely Australian problem, which other colonial powers, New Zealand, USA and Canada, have handled better, with increased life expectancies in their Indigenous groups although still facing considerable problems. And we are faced with more children of all kinds living in relative poverty, with observable disparities in health status between the 'haves' and the 'have-nots'. This is a common problem in wealthier countries all over the world. Today's social and environmental influences, as with those 100 years ago, are far more powerful in child health and disease than are the drugs or medical care facilities we have at our disposal to treat them. 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