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Trousseau: ’Man is born free, but, everywhere is in cha ins ’ 1
The wonderful, understated Nobel museum in Stockholm is moving on two levels: not unexpectedly, one is left in awe of the dedication and genius of the scientists whose work has been recognised. Even more moving, however, is the mark left by the commemoration of the lives of the peace prize recipients: Martin Luther King, Mikhail Gorbachev, Malala Yousafzai, Mairead Corrigan and Betty Williams to single out just a few. Grainy footage of the 1950s US South reminds us how far we have come or, alternatively, how far we seduce ourselves into believing we have come. This section resonates for longest, perhaps as Nobel would have wanted it, the prize a result of the guilt he felt at the destructive use to which his altruistic discovery of dynamite had been put.
Race and preterm delivery
Let’s begin with some facts: the infant mortality rate in the US exceeds that of most high income countries with non-Hispanic black infants in USA dying more than twice as often as non-Hispanic white infants a disparity essentially reflecting differences in preterm birth rates.
Heather Burris opens the account with a blistering evisceration of the component parts of the association between race and preterm delivery in the US, generalisable of course, dissecting those factors with genuine causal credentials. Genetic theories, the easy option for armchair observers, have now been largely rejected and the focus fallen on environment. The literature is as compelling as shaming and two broad groups of environmental exposures are scrutinised: the micro-environment over which a person has (some) control, the choice over whether to smoke for example (even here to some extent externally influenced) and the macro-environment over which a person is helpless. There is now robust observational evidence for the role of macro-environment factors in preterm delivery: pollutants (fine particulate matter such as PM 2.5, lead and phthalates) but, shamefully, a clear association with both life exposure to crime and racism in black women. Space restricts further expansion here, but this is my editor’s choice for the month and I urge you (in fact insist!) you read it.
Burris’ paper is put in historical context by Richard David who continues the rejection of the biological construct and argues the case for the social construct from post war social scientists to the work by Cooper and Hogue in the 1970s and 1980s. We seem at last to be acknowledging the elephant in the room but, as the gap is widening, have clearly had limited success in coaxing the beast out. See pages 931 and 929.
Fear of flying?
Though the association is a complex one peppered with confounders, effect modifiers and mediators, there is a relationship between the distance of referring hospital to the retrieving paediatric intensive care unit (PICU) and risk-adjusted mortality. The current UK recommendation is for a retrieval team (and not all PICUs have one) to arrive within 3 hours of accepting a referral. Some would argue this is insufficiently rigorous and, as PICU transfer demand is increasing in parallel with medical and societal changes the question is clinically and politically germane
King and colleagues as one spoke of the DEPICT project, make an assessment of the current geographical relationships between referring district general hospitals (DGHs) and PICU transport team times. Using location–allocation methods, they estimated the optimal allocation of DGHs to current paediatric intensive care retrieval team (PICRT) locations to minimise road journey time and the proportion of demand reachable within set times. At present, 98% of referrals can be met within 3 hours, 86% within 2 hours and 20% within 1 hour. Five hospitals (2%) were not reachable within 3 hours. Further analysis suggested that though the current PICRTs are reasonably placed, if there were any change in stringency of timing or increase in workload, then the current system would be insufficient. The answers might be practically complex but are objectively simple: equip more existing PICUs with transfer teams or transfer more children by air. In the UK, only 2% of all transfers are currently made by air, despite this being the norm in many other high income countries. The ‘UK is more compact argument’ doesn’t wash as this excellent paper amply demonstrates while gridlock on highways worsens and pristine helipads turn to rust. See page 962.
Consent in research
Chappuy and colleagues explore children’s perception of consent and the degree to which it is both informed and ‘consensual’ in a group of French children being offered participation in an early phase-controlled trial of a new oncological therapy.
37 children and 119 parents were interviewed and the participants’ understanding of informed consent and the decision-making process assessed. Most parents and children had an excellent understanding of what involvement in a trial entailed, but only a minority correctly understood the alternatives, the risks, the prospects of individual benefits and the purpose of the clinical trial. Most, and this is the real crux, felt they had no choice but to participate in the trial in order to have access to the new treatment. Roberts’ leading article on broader ethical aspects of research in children gets to the nub of this issue concluding that consent to research is an entirely different entity to consenting to an intervention (for example, acute surgery) where time is limited and that it should be a process rather. This means it is (as it should be) more complex and nuanced, such as full or partial withdrawal of consent and that children should be genuinely encouraged to say ‘wait’ …or ‘no’
Rousseau had an aphorism for this situation too: “I have never thought, for my part, that man's freedom consists in his being able to do whatever he wills, but that he should not, by any human power, be forced to do what is against his will.”2 What wisdom. See pages 947 and 936.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Commissioned; internally peer reviewed.
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