When I was a medical student 50 years ago, the only antibiotics available were sulfonamides, and although vaccines for diphtheria, tetanus, and pertussis were used in selected populations of infants, they were largely experimental and not available to most infants. No antibiotic treatment was effective for tuberculosis, and arsenicals and bismuth were still used for congenital syphilis. Nothing could be done for viral diseases, and viral culture techniques on chicken embryos were only recently developed. Nutritional deficiencies and helminthiasis were common conditions underlying infectious diseases in rural Tennessee. Leukemia patients were sent home to die in the bosom of their families. The first ductus and tracheoesophageal fistulas were surgically corrected during those years. Diarrhea was the scourge of the second summer, and babies died like flies. Polio was every parent's worst fear, and tank respirator units were the best available for neuromuscular respiratory failure. Bulbar disease was almost invariably fatal. Rheumatic fever killed more children between the ages of 5 and 13 years than any other disease. Premature babies were left alone with a hands-off policy and, unless they were reasonably mature or small-for-dates, died of hyaline membrane disease, asphyxia, infection, or intraventricular hemorrhage. Erythroblastotic patients developed severe anemia or kernicterus as exchange transfusions had not yet been used. Many small premature infants or infants with severe anomalies were declared unsalvageable and left to die in the delivery room.

What a fantastic 50 years it has been. Each of these conditions has been either susceptible to successful preventive measures such as vaccines, to treatment regimens such as antibiotics, to surgical correction or to nutritional and broad public health environmental changes. Even cancer and leukemia in childhood are treatable with reasonable chances of cure. In my area of interest, premature infants are surviving at extreme levels of immaturity, and hyaline membrane disease is amenable to both preventive and treatment measures.

Why aren't we elated with the potential for healthy and happy lives that our children should now face? It is because a series of new conditions have substituted themselves for the old diseases as quickly as they have been eradicated or brought under control.

Let us look at the scoreboard according to the 1996 Children's Defense Fund publication (Table 1).

Table 1 Every day in America*

Perhaps the most frightening of these is the expression of childhood violence, particularly among male youths, who kill and maim and torture each other and others, seemingly without conscience or any sense of identity with their victims as human beings. Although much of this violence appears as random acts, some is drug-related, or gang-related influenced by peer pressure. Our culture is obsessed with violence. Our children from all backgrounds are exposed to its most graphic forms in movies and television, and some must live with its reality on a daily basis, where participation may be easier than fear of reprisal. As Eldridge Cleaver observed in the 1960s,“Violence is as American as apple pie.”

Another, although perhaps in subtle ways, related problem is that of teenage pregnancy, which is part of a far more pervasive pattern of unintended pregnancy afflicting American women throughout their childbearing years. Many of these childmothers ignore contraceptive practices in a wish, perhaps unconscious, to have something or someone in their life to love and by whom to be loved. They ignore the inevitable end of their schooling, the lack of opportunity to learn job skills, the loss of their girlhood years with the responsibilities of motherhood, and, all too often, the loss of their boyfriend when pregnancy becomes apparent. This dead end street may be repeated time and again, and new boyfriends and fathers feel little responsibility for other men's children. Many of these children are neglected, abused, even killed by parents or surrogates whose emotions are unbridled and violent toward the helpless.

How long are we, as a society going to tolerate these new diseases against which we seem to have no vaccines, no antibiotics, and no surgery, with only prison for violence and abortion or welfare for the results of unwanted pregnancy? It is clear that many parents, in all social and ethnic backgrounds and at all economic levels, have failed their children and have lost control over their values and over their future. We pediatricians have given only lip service to the solution of these problems which are destroying our children and, as they become adults, now threaten the entire society in which we live. Who will save our children? Who, indeed, if not we, their advocates. We must demand solutions which are realistic and which must begin with the beginning of life. Every child has the right to be a wanted child. We must prevent that unwanted pregnancy which becomes an unwanted and unloved child, and from which cascades the self-perpetuating cycle of neglect, mental and physical abuse, violence toward children, and, inevitably, violenceby children. We have lost at least two generations of young people which cannot be resurrected. They are lost to drugs and alcohol abuse, to lack of education and joblessness, greed and hate, and probable incarceration, as most legislators believe prison is the answer to youthful violence and withholding financial aid is the answer to adolescent pregnancy. Having lost these children we now must protect the rest of society from their violent actions, but this is no solution for the next generation. Our veneer of civilized and moral behavior is very thin; its concepts are introduced to children by precept and by example. Only strong, positive intervention at the earliest age can change the patterns of behavior which result in this tragic loss of health, education, future, and, in many instances, loss of life from violence or suicide. These abnormal patterns of behavior are learned as accepted norms, from parents and caregivers, from peers, and, eventually, from society. The first years of life are crucial and cannot be recapitulated.

Overriding both these related problems of children killing children and of children having children is poverty, poverty of a minimal standard of living, poverty of affection, poverty of educational and job opportunities, poverty of adequate health care and, worst of all, poverty of spirit. In 1995, 15.3 million children in America, or 1 in 5, were living below the poverty line.

Who better than pediatricians can argue the case for and, if necessary, demand this intervention in the national interest. Politicians, legislators at local, state, and national levels have knee-jerk responses for complex social problems, and it is easy for them to persuade an electorate that short-term answers, such as building more prisons or putting adolescent mothers to work for a minimum wage without adequate day care is an answer. We as pediatricians must be vocal and active in a massive pro-children's movement which must convince law-makers and bureaucrats alike that health, both physical and emotional, and hope of a better future must be assured, beginning with the very young, if we are to reverse this enormous loss of future national potential, our children. As Marion Edelman has stated, democracy is not a spectator sport. Who will save our children? It is we who must, or we will surely be held accountable for their future loss, and the future of our democracy will reap the whirlwind.