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"Michael, you are sitting up beautifully", "David, I love the way you put your hand up to ask a question" and "Now Anthony, you are ready to come back to the les= son now". Six year old Anthony had been taken from the room after throwing himself to the floor, crying and shouting trying to disrupt the lesson. This behaviour has always helped h= im to get attention, in his old school. So Anthony would be taken out of the class quietly and he could rejoin when he calmed down. This is a very typical scenario wh= en you are a teacher dealing with some of the most disturbed and chaotic infant-ag= ed children.

A centre in Kingsmead in Derby, is the only pupil referral unit for infant school children in Britain. The Centre costs 3 million pounds = per year to run, and supports 114 children who attend regular schools around the city. The Kingsmead children,= most of whom have been statemented for special education behavioural needs are supported by a team of specially trained educational and care officers.

Most of these children come to the Centre for four afternoons each week because their behavioural problems are= so severe that they cannot cope with full-time education in an ordinary school. Despite their age mos= t have been excluded for violence in the class, throwing furniture,swearing at and abusing teachers or other children. It can hence be seen how disruptive this would be in a normal class. One child has never been to school because of a history of disruptive behaviour in his nurseries. The head of the Centre said that t= he work done in this unit is vital because if children with problems at this tender age were excluded and no other school will take them, they are refer= red to a special school and it is very hard to get back into mainstream.He also adds that these children are effectively toddlers who cannot collaborate wi= th other children and their play is very self-centred. The Centre's job is to encourage t= hem to understand that they are real people and have true feelings and that they a= re valued by us adults

Nearly all children sent to the Cen= tre have suffered major trauma in their short lives. One 5 year old child had been in a= 19 foster homes already. Such children cannot be expected to sit down and foll= ow a National Curriculum when their lives are in chaos.One of the children will scratch herself until she bleeds, if disciplined. The teachers in the unit have lear= ned to sit still with folded arms, as a response, rather than leaping forward with tissues. Another child may st= ab himself with a pencil for attention if the teacher would praise another chi= ld, he would then cry out "Ow, it hurts, I'm bleeding! I don't like doing = this work!”.This is a typical response and often to ‘ignore’ helps.

The Centre has a large classroom decorated with the children's work. The room is sectioned into reading area, play area. The work done here is very structured and the staff's aim is to bring consistency into the children's lives. The general rule is that when staff say something it will happen including a punishment for bad behaviour= ; it happens.

The children arrive around <= st1:time Minute=3D"0" Hour=3D"12">12 noon and are immediately subject to a routine.&= nbsp; The session ends at 3pm with a drink and a biscuit

It is vitally important to have this early intervention. Any infant or Nursery Teacher can identify a child who = is going to have problems but if you can break the cycle of violence and disruption at this age then you have a better chance of having a positive effect on their educational and life chances. WE also can avoid some of the problems that re-surge in adolescence causing disruption and teenagers excl= uded from school or society. We should be more aware of the problems in very you= ng children and methods of tackling them. This unit works in partnership with = the regular schools and helps to avoid the devastating effect one child can hav= e on a general class. One little child was seen to be very quiet and withdrawn in the unit and was building something with bricks. The child's parents had di= ed recently when asked what he was building, the child replied "A safe ho= use where monsters can't come".

We have similar children at Youth Support House. Paul was a 4 year old boy who had a series of emotional problems, he was a damaged child with unacceptable behavioural patterns. He= had a very unstable home and was separated from his natural mother and put into foster care until re-united for a short period with his mother at Youth Sup= port House giving both mother and child help in terms of education,counselling a= nd therapy. Eventually Paul retu= rned to foster care due to mother’s rejection.Paul lacked love, security a= nd above all consistency. His behaviour continued to be disruptive and abusive, physically and verbally. Will he now continue to slide towards a disturbed = and insecure school life and adolescence?

My own experience in the last twenty five years is of working with an organisation= in Israel know as the Youth Alliah devoted entirely to the resolution of probl= ems and educational advancement of adolescent immigrants to Israel. We have established what we call youth villages - that is young people living in residential settings which provide both the education opportunities and also social and educational advancement as such.

In th= e last eleven years we had the rather unique experience of Ethiopian adolescents, immigrants from rural Ethiopia, into the modern western techno= logical society of Israel and in the last 5 years we have= been working with adolescents from the former soviet union. We have to realise t= hat many immigrants from Russia actually come from the eastern states which hav= e a very distinctive cultural pattern of their own.So this has resulted in the = need particularly in my own work for me to become not only a physician partly a psychologist or psychiatrist for which I have had the opportunity of traini= ng but also to become knowledgeable in health anthropology. I wish to emphasise that word because as Bob Blum indicated in his talk that is particularly important we need toconsider ethnic minorities existing all over the world.=

All over Europe,or middle east, we cannot work with ethnic minorit= ies without understanding their culture of the environment in which they grew up.The subject is deprivation so let us just list what happens when a young person moves into a different society -what deprivation occurs. The most im= portant one is the loss of a role model. Parents who come as adults into a new soci= ety have difficulty coping with their own adjustment and they have great diffic= ulty in providing an adequate, positive role model for their young people-not the young children, but the adolescents.

Another thing they lose is the knowledge they have of being able t= o do things in their own environment. The new system is entirely different, the language, the experiences-imagine you are a fifteen year old Ethiopian and you have never been to a doctor in your life.You come to Israel and after three months you have a cough, you go to a doctor and he examines you and gives you a little note and he indicates down a corridor to another room where someone in a wh= ite coat summons you into a darkened room and tells you to take off your shirt,= put your arms around some metallic monster and tells you to stop breathing and = then runs out of the room! He thin= ks it’s crazy, there’s no logic in that. One of the things I empha= sise is the lack of cultural logic to fit the events.There are many obvious thin= gs like housing and jobs and lack of food. Another important issue cultural bereavement - the mourning for loss of culture was brought to the fore by a Marius Isenbrook an Australian psychiatrist who had worked in Cambodia. So how do people who have lost something react? There are three reactions - one is idealisation - we speak well of someone who has just died and think of the marvellous things he did= and so when you are in another country and you begin to experience difficulties= - you can imagine how much better it was in your own ‘lost’ cultu= re. We hear how Russia and = Ethiopia was so much better from these p= eople - idealising what they have lost.

The next reaction is denial - I can’t believe this has happe= ned, I can’t believe this person died and so they cannot believe that fore= ver they are not going to be in Russia or <= st1:place>Ethiopia or <= st1:place>Turkey for instance. Perhaps this is temporary and we will go back.

The third reaction anger - what the hell are we doing here - why d= id I get into this situation? A particular example comes from the work that I was doing with sexual counselling of the disabled - one young man was accidenta= lly shot by a fellow soldier in the spine and developed a paraplegia and his mo= st immediate and intense desire was to know can I be fertile? Do I have sperm - well we took him into the spinal injury clinic three times to check the res= ults of his fertility tests,eventually I told him that he had an infection follo= wing the injury and he had practically no sperm at all - and he looked at me and said ‘One of these days you are going to get it from me - I’ll = see that you get ‘fixed’ for what you have just told me’. Wel= l we all know of the bad messenger - he who brought bad tidings - they killed the messenger in medieval times because he brought the message to the king. The Army is destroyed - so kill the messenger. We as doctors have to relate to people we are often the bad messengers - we tell them they have TB, that th= ey have malaria and so they are angry with us - we have to understand when the= y do not co-operate, when they are angry - that is a kind of reaction.

Another response is to wait for miracles - wait till tomorrow and everything will be marvellous -sure Ill get over my tuberculosis - give me a week and I’ll be finished with that. So miraculous expectations as su= ch. Bob Blum has mentioned the importance of a belief system in common - which = is one of the few things that the Ethiopians and the Israelis have - a common belief system - this can work in two ways. An example of people who were involved in the holocaust - they can come out of such an experience complet= ely disillusioned with the concept of a superior being - how could there be a superior being in care of us Jewish people and allow six million to be destroyed - on the other hand there are those who come through the same experience and say - how can it be that I have come through all this and survived when so many others did not - there must be a superior being that allowed me to survive. It can work both ways from that point of view. So wh= at do adolescent immigrants bring with them into the new country - the new environment. One thing they bring is their bodies. We had a very interesting presentation at our health and culture conference - a physician from Norway who deals with immigrants from = a number of cultures. She felt that since they bring their bodies - the development = of those bodies was a very important feature - so body building for the adoles= cent males is important to them - comparing who has bigger triceps and seeing who has the ‘better’ body. We as doctors work with their bodies - so care of these bodies is something we should be encouraging. For an Ethiopian girl - it is very important for the girls to braid their hair - this is par= t of their body image - also one should understand that they do not consider themselves black but dark brown - a joke in Israel is of two Ethiopian girls who see two Yemenite girls in the street and say - gee these Scandinavian g= irls are beautiful So everything is relative.

One problem with image is that whenever we have a new wave of immigrants from one part of the world or another - many of the officials ca= nnot understand the names in Ethiopian or another tongue - so they give them new names - the only thing you have with you is the name you brought with you -= now that is lost too.

They bring with them notions - certain notions about the world - f= or example - there was a refusal to have blood taken for clinical investigatio= n - and if you look at anthropology you will see that their notion is that the amount of blood you have is a constant and does not replace itself so why should somebody take ten ccs of blood from you - if someone took ten dollars out of your bank account you would object. Local therapy was given in the villages - if you had a swollen foot you were given a poultice.Where is the logic in putting something in your mouth to cure a swollen foot<= /span>

Tradition in Ethiopia forbids marriage up to the seve= nth generation. The extended family would keep a trace on who these relatives w= ere so you might find you cannot marry your boyfriend - though you may be 14 and pregnant because you discover he is only three generations apart. You must accept this tradition or be rejected by the family.

Let us go on to some clinical considerations. A very strong reacti= on to a problem is psychosomatic illness - for example stomach pain from a pro= blem - in Iraq it was more ‘I can’t breatheR= 17; so a lot of asthmatic illness - others may say ‘it hurts my heart’= - so chest pains. For Ethiopians it is the stomach - they have a saying, ‘the stomach is larger than the world’ in other words you swall= ow the problem. Eventually there may be an abdominal problem. There may be pse= udo psychiatric symptoms - perhaps almost looking schizophrenic, very vague, lo= sing interest - we worked with an adolescent psychiatrist who did not immediately put people on medication right away because they were in an ambulant situat= ion. Give them a week in the place and you discover what is called an adjustment reaction - when people are reacting too much they need time out and everyth= ing will settle down. They may begin to act in a confused state but medication = is not the answer. You just need someone from their own culture to come in - no doctors, no medication, just someone who has been here a year and can ident= ify with what they are going through.

Of course there are psychiatric problems - but most are pseudo-psychiatric. If you have someone in this state, you put them on medication, they don’t cooperate, then you have to restrain them. You have created a dreadful situation. Where can you go with them after they ha= ve had 3 months treatment and are in this sort of state? There’s nowhere= to go- you are classified as an Ethiopian,an adolescent, a psychotic - that’s it! Then there are problems such as suicide -taking up negative aspects of your new society - what happens when you learn a new language? T= he first things you learn are the swear words - and so they want to go into smoking, sexual patterns - things that make them seem more Israeli.

What can we as physicians do to help these people, to improve their health situation. First is to avoid being judgemental - we always have a tendency to consider people from different backgrounds who are not coping as inferior somehow.Talk about class differences - there is always that -they = may not be able to use the toilet - have come straight out of the countryside a= nd have never seen flush toilets. My reaction to that is that if we took you a qualified physician and left you in an Ethiopian village and you had to find your way through a forest or a jungle for ten kilometers - how the hell wou= ld you cope? So they don’t know what they don’t need to know we ne= ed to give them information. We have another example - we use young people to teach hygiene to the older immigrants - these are sixteen year olds who have been 2 or 3 years in the country. One of the stories that someone obviously= had quite a severe infection of the skin and this young person said, didn’= ;t you go to the doctor- yes I went to the doctor - and what did he do - he ga= ve me a little note - what did you do with it - I hung it around my neck.He assumed it must be an amulet - nobody seemed to think he needed to be told = -you use this note to get medication and then you use the medication in this way= .. Another point is to go beyond the initial complaint - we all know an adoles= cent will come with a pain in their ear when they really want to ask you about something else.They throw you= the question just as they go out the door - by the way I think I’m pregna= nt! One could say so right at the beginning - so it’s important to have a little check list to go through. The name - that’s important - what is your name and what does your name mean - it only takes two seconds to ask t= hat question but already you have personal contact and have broken a barrier wi= th that young person. Doctors never have time, but it’s a question of how you use that time where you put the priorities.

Using a few words in their own language is very powerful - Harry Belafonte was performing for 20,000 people in the local park there and he s= aid ‘le- itra -ot’ which means see you again , and the whole crowd = went crazy. President Kennedy walks into the 100,000 people out here in <= st1:country-region>Germany and says ‘Ich bin ein Berliner’ - nonsense! but they remember him 30 years later that he we= nt there and said ‘I am a Berliner’. When our prime minister was assassinated President Clinton spoke on TV and he said ‘Shalom ha ber= e’ Farewell friend - three words - what did we get three thousand stickers in Israel saying those three words - stuck on walls, on food every sort of thi= ng - amazing to use these words to make such a connection with somebody.

Another thing I like is to keep communication going - not close the case -say ‘if you feel bad come back, or you can always write to me’ something to keep the door open. It’s amazing how people remember, come back ten years later and say - remember you said if I needed= you I could come back - I didn’t need you , but I remember you said that.=

Lastly a find of way to work with other staff - multidisciplinary - using social workers and other disciplines makes life much easier. The indi= rect method can be useful - I have a friend who had this problem. Rather than -I think you have this vaginal discharge because you had sex - one could use an indirect approach - you know last month I had someone come in who had the s= ame problem as you and it turned out to be caused by having sex - do you think = that might be the case for you too? An indirect way of leading into the question= .

In health education we often use movies to help - and one we often show when looking at adjustment is called ‘Victor’about a Mexic= an kid in California trying to be organised and in Israel we say -well could t= his happen here? Two little stories to show what could be done.A girl of sixteen managed a record for Israel,she gave birth at the youth vil= lage two years running quite unexpectedly because she was wearing the voluminous typ= e of dress that wear and she came to medical attention because she denied having= sex at all a psycho -social problem. What was the first thing she needed?- to a= void getting pregnant again whatever the reasons so we arranged an adolescent gynaecologist from a private clinic to have an IUD inserted.Now she got the message- I am now protected. First pregnancy resulted within the family the second by a driver on the last bus station on the way home - both cases of sexual abuse and she cannot talk about these events. She had a period of anorexia nervosa and during treatment she had her IUD checked regularly, she attempted suicide. Two years later she is rehabilitated working in the army=

Another Ethiopian girl kept vomiting- not exactly bulimic but she = was making herself quite ill. She refused psychiatric admission she had gone wi= th a group of Israeli adolescents to visit some holocaust sites in Europe, where youth are taken to help = them understand something of their history. This seemed to awaken a problem for her,the youth village would not take her - she was considered too ill and difficult to handle. So I tried the use of metaphors- instead of vomiting o= ut all this food- why not vomit out your problem. That caught on with her and every time she came she would say that she was helping to vomit out the pro= blem and she started to eat the food. I continued the ritual of weighing her - w= hen people are in bereavement it is important to continue with the ritual as a = form of therapy. Now she’s doing well in school and is very bright I use t= he metaphor of the sun being out and everything rosy and happy - but then a cl= oud might come and block out the sun and everything may seem dark and depressin= g - but the sun is still there behind the cloud even though we can’t see = it and it will come out again. So when working with ethnic minorities I stress again how important it is to be a medical anthropologist, speaking in terms they understand

I don’t know how many have be= en to Vancouver - your impression probably is that of a beautiful city in a marvellous sett= ing with a fair degree of affluence in the society. Even then despite those features we have our population of young people who are less well served by society or in greater ne= ed and I will talk briefly about them this morning. I will share an anecdote but indicate that material I present is population based information not about individual patients or scenarios. It is important to recognise that adolesc= ent health care is based on population as well as individual cases and we cannot focus on one to the detriment of the other. When thinking of population bas= ed approaches we need to think how that translates into action, programmes benefiting somebody other than ourselves to give a paper or publish in a journal. We have just appoint= ed a Children’s Commissioner under mandate from the Justice Dept. One thing they are mandated to do is review all deaths of children & adolescents = in the province, they were only looking at deaths of young people under the ca= re of the state when they realised they should be looking at them all.

The case I want to talk about is of= an infant who died in foster care of sudden infant death syndrome - that case = is illustrative firstly because sudden death syndrome means the child was under six months of age. The child was born cocaine addicted and immediately plac= ed in foster care and it turned out this was the second infant death to this mother and had cocaine addiction. The first child of three is also in foster care alive not born cocaine addicted apprehended early on for neglect. The reason being that the youngsters mother was a hooker, an aboriginal working= in the province - remember our province if you travelled 1000 miles north you = are still in BC and the same East, only 3mill people in the province so we have quite a spread out population. When young people leave their reserves they = get onto the streets, especially young aboriginals. This mother and baby I revi= ew was l4 when she hit the streets, getting into all the street scene and l7 w= hen she killed herself. We are talking about a very young life associated with = an incredible amount of misery w= hich does not come through in the population based statistics. That is why I told you this story.

Let us look at two populations - ju= st under l6000 students in all regions and 110 kids who live on the streets in= Vancouver. This population is special, reviewed in December by us. The others are only there in summer or weekends. Almost the entire street youth population is i= n Vancouver, the media make it big but it is small. We divided youth into 9 groups of population based on very simple splits - if you carried a weapon you were violent - it didn’t mention whether you were the victim of a fight, carried a pocket knife, if you fought once in your lifetime - simply that y= ou were involved in violence. You can see students in school are largely non violent and street people are involved in violence in some way. Mostly grade 7-12, population of really young are much less so- they tend to be older youths. Males are a little more violent than females certainly in our provi= nce, a high proportion are Asian so you see the Asian population is high risk as= are aboriginal as opposed to others - not living at home, mother employed full time, could have given same information for fathers but usually the families are more well off of other groups. Interestingly the majority on the street said they did like school and a fair number were thinking of returning to scho= ol. Where did their income come from? They had jobs, we did a poll in 1993 and = the Govt have just changed the welfare system so that if you did not have 3 mon= ths proven residency you did not get welfare - some get money from families, a = fair chunk are involved in the drug scene and prostitution. That is for income, = not necessarily trading a place to live for sex. When we compared youngsters in school with those on the street it was interesting that with the exception = of cavities both groups had the same standards of general health. When you loo= ked at more specific areas of healthcare giving them labels you can see a higher incidence of TB, anaemia and more concern with acne as well as more allergi= es reported in street population. This may be part of the answer of why there = are complaints of respiratory problems because almost the entire street populat= ion are smokers and in both male and female it is a less common reported proble= m.

You can see from chart 95% of school attenders have never tried cocaine whereas the street kids are more likely = to use it, and similar findings were available for marijuana etc. Sexual activ= ity - basically the norm, this population remember being slightly older - but school attenders are less sexually active than the street population althou= gh interestingly the numbers are different to those presented earlier. When you look at partners over six months remember only a small proportion quoted prostituti= on as a way of gaining income wh= ereas school attenders have no partners or one. Certainly they practice monogamy. First of interest is self recorded levels of emotional distress during preceding three months and you will see high proportions of both males and females presented more as emotionally disturbed than school attenders.Perha= ps it was slightly more obvious as a gender gap in street population than scho= ol.

We believe this study is one of the= few based on population approach involving self reported physical and sexual ab= use but I am sure it is of no surprise we can confirm the biases. You can see t= he females on the street have a history of physical and sexual abuse, their li= ves are an experience of youth and the same applies to the males on the street having more physical abuse than any sub group which gives a sense of a population who are experiencing more abuse in a serious manner. Again there is the traditional gen= der gap but the street group have a higher incidence of having been involved in= or been attended to for violent or suicidal attempt so suicide is very much a piece of their life. They tend to get good medical care but mental health services are not so good so efforts are being made now to address this grou= p.

Remember first overhead of various groups of population there is another group - this is pure speculation and small piece of methodology. When we first presented this we left out the non violent g= roup which represented 5 or 6 kids but if you look at this group 100% heterosexu= als the higher proportion of groups in school 95% of them considered themselves heterosexuals, and this was based not only on practice but of the street pe= ople only 20% of them see themselves as heterosexuals and when we looked through= we stumbled upon what we think is a different group on the street - more likel= y to be suicidal, less likely to be violent, and we are not sure what that means= so we have a project working with the gay lesbian community looking at the iss= ue of suicide in the gay population. Another example of statisticians throwing this stuff out but from listening to the kids they are saying we have to lo= ok at this. We produced a report for release to the general population on stre= et people in a user friendly format,data is used for looking at marginalised a= dolescents to motivate programmes. My pitch is that when looking at adolescents whether street people, gay, aboriginal or kids with chronic illness we have to look= at population comparison and at what data tells us and how to get them involve= d in whatever the issue may be.

Nutritional issues affecting youth - deprivation poverty and neglect and I am bringing the other side of the coi= n. Numerous problems pertaining to adolescent and nutrition, nutritional needs= are greater at puberty than at any other time except infancy. Unfortunately less attention has been given to this despite long term consequences. Nutritional issues impinge not only on immediate need and development but lifestyle lea= ding to chronic disease such as cardiovascular disease, cancer and osteoporosis.=

In developing countries malnutritio= n is the major problem faced by adolescents and I would like to concentrate on t= he nutritional problems related to the disease of affluence, obesity, eating disorders and specific nutritional deficiency resulting from unbalanced die= t. These problems once seen only in the so called developed countries and increasingly is prevalent in developing countries due to the widespread adoption of western values and lifestyles. Although this issue is not so prevalent in developing countries as affluent countries, long term implicat= ions and the likelihood of their increase may lead to serious implications and merits effort in prevention. Unfortunately most doctors in nutrition are fr= om USA or Europe and little has been done on diet styles of teenagers in developing countries however much may be learned by studying the surveys do= ne in developed countries especially in low socio economic groups. =

Nutritional requirements in adolesc= ence -The major issues are relatively high fat and saturated fats recommended le= vel is 30% Recommended dietary allowance for adolescence in terms of energy requirements in females 47% before puberty and 40% after but few attain the= se levels. All nutritional needs are increasing during this period, and the ma= in deficiencies in this period are of calcium iron and Vit A.

Understanding current diet habits of adolescents is important in order to identify problem areas and suggest correction. In Western society adolescents have greater freedom and increas= ing buying power for snacks and beverages. They can do that without parents hel= p. With decreasing parental supervision of nutrition and diet the path is set = for unhealthy eating pattern which contribute to disorders, skipping meals, breakfast, snacking is common and reported in 80% of adolescents. Junk food tends to be high in saturated fats, cholesterol and sodium.

TV and computer games account for a substantial amount of daily routine of teenagers. This sedentary activity coupled with snacking in response to advertising leads to a cycle of poor nutrition setting a lifetime habit leading to long term problems detrimenta= l to health. Slimming is the ultimate response to glamorous multi million dollar advertising programme of weight loss products and globalisation of communication internet and western ideas is like= ly to be adopted by non western society with similar results. Our research study included a study of the report by Susan McNab “Report on the Dietary practice of black and white girls 9-10 years old over a 5 year period” They took 5379 kids, finding skipping meals, snack food, use of fast foods = were common. Black girls were most likely to report any of those behaviours. The reason was unclear. May have been related to behaviour and differing percep= tion of weight by the different social and ethnic groups. This study highlighted= the difficulty in generalising about diet practices of socio economic and ethnic groups without taking into consideration cultural differences. <= /span>

Little is known of eating habits of developing countries and because of lack of information it would be useful = to assume that habits are related to adolescents in poor socioeconomic groups = in developed countries rather than high socioeconomic groups. It is revealing = to look at changes in morbidity in cardiovascular disease among African Americ= an populations over the past decade, relating diet to atheroschlerosis which has risen dramatically.=

Recently Johnson studied the intake= of diet of adolescents between 11-18. Deficiency in calcium, Vit A & B were common as well as over use= of saturated fats and sodium. African American from poor socioeconomic groups = were most at risk. This is not confined to the USA, in England 80% of children a= ged 12-13 in a poor area of London were in excess of ll% of total dietary intak= e, 25% of the girl’s calcium intake was below recommended level and 30% ate no vegetables.

A report from Korea gives an insight into dietary trends in developing countries. Population of= Seoul rose from 2.5 mill 1960 to 10 mill 1990, economic change created a gap betw= een low and high income groups in dietary practice. Meat fish and dairy produce increased six fold in high income group compared with low income, more than= 30% of calorie intake coming from fats and 20% in poor group. Also lower income group suffer from anaemia and malnutrition. In the higher income groups cardiovascular problems have increased in Korea accentuating the potential danger of adopting western diets and creating new problems of over-nutrition of wealthy in parallel with malnutrition of the poor.

In developing countries diet practi= ce means insufficient calorie intake - for example a study done in street food= by Nigerians in 1995 showed that all major food groups were represented in str= eet food - 50% of mineral and vitamin needs and 25% of daily energy needs indicating that contrary to the situation with snack and fast food in developing countries street food has good nutritional content and contribut= es to good dietary intake by teenagers in Nigeria. Unfortunately the study did= not analyse fat content.

Obesity and anorexia - eating disor= ders where calorie ingested is in discord with amount needed resulting in energy imbalance. Reports from US National Health & Nutritional Examination Service showed 22% prevalence of obesity in 12-17yr olds between 1963 and 1= 991. In 95 cases there is no medical aetiology and 75% persist to adulthood. Sev= eral factors are relevant- increased availability of high calorie foods out of h= ome leading to decreased levels of activity in front of computers leads to increasing obesity, leading to medical and psycho social complications lead= ing to bulimia and hypertension causing cardiac disease and ill health. Long te= rm morbidity and mortality of obese adolescents was studied in a 55year follow= up of 550 students at Harvard showing increased mortality in all types of cardiovascular disease. The same group in 1993 studied social problems show= ed a lower academic achievement in overweight adolescents, lower income and decreased likelihood of marriage in male and females. Obese adolescents far= ed less well than adolescents with chronic medical conditions.Contribution of genes & parental size is unclear.

Data is available for developing countries from a study of a poor neighbourhood in San Paolo Brazil investigating prevalence of obesity and malnutrition found a rate of 21% obesity in girls and 8.8% in boys whilst malnutrition was 12.6% in girls and 15.5 in boys in the poorest society. It is difficult to assess the social implications in developing countries but it is clear that cultural differen= ces will affect the way that people react to differences in weight - in parts of the black community in America slight overweight in girls is preferred to underweight for ulterior reasons - it may give the appearance of strength a= nd the idea of beauty in the subculture. In a 1994 study British and Uganda students were compared with their rating of the female figure ranging from anorectic to obese. The most striking difference was the fact that whilst British students found the slimmer figure more attractive, Ugandans found under-weight less attractive and rated the obese figure most attractive. Su= ch data may hinder preventive measures in anorexia and bulimia and obesity. Conditions thought to be extinct in developing countries are becoming more prevalent with increasing awareness of the medical community and also secon= dary to the influence of western culture on adolescent societies with exposure to international media.

In 1994 an Egyptian screening for eating disorders in secondary schoolgirls in Cairo -11.4% scored positive for abnormal eating patterns and 1.7% were victims of bulimia. In a screening of girls in found a 1.10% rate of abnormal eating disorders, much higher than expected = from an earlier study and similar to the levels expected of a western country. Attitude towards eating and diet was dependant on country of origin of immigrants. Mothers emigrating from Europe rated as having greater weight concerns than those from the east Asia or Africa - this shows the effect of acculturation on eating disorders -adapting to western values and eating habits girls exposed themselves to obesity, eating disorders.Similar problems were appearing in developing countries

Calcium deficiency - Calcium is essential for bone formation about 40% of the bone mass is laid down during adolescence.Long term consequence of low intake during this period include osteoporosis and low bone mass. Replacing milk as a source of calcium and increased use of carbonated drinks aggravates this deficiency.Calcium phosphorous balance is also adversely affected. Normally milk and milk prod= ucts account for 50% of the calcium intake at this age - studies have shown that= 40% of adolescents may be deficient in calcium intake and intake decreases with time. Girls suffering from anorexia have a high risk of osteoporosis. Iron deficiency is most likely to occur during peak growth and be made worse by blood loss during menstruation.Daily need increases from 12mg to 15mg during peak growth and up to 30 mg during pregnancy. Iron deficiency is one of the most important dietary problems in developing countries -as well as develop= ed - it is worse in pregnant and vegetarians In Rajistan India 74% of 10-14yr gi= rls had iron deficiency anaemia and a high level of malnutrition. These problems are compounded by the high needs of pregnancy.

Despite importance of dietary needs= in adolescence only recently have deficiencies in this area been researched and recommendations formulated.Less is known about the nutritional status of teenagers in developing countries. We are seeing diseases of affluence in developed countries becoming prevalent in developing countries and poorer communities hand in hand with adoption of western diet and values. We are seeing the spread of obesity, anorexia and bulimia and poor eating habits of the west becoming prevalent in developing countries thus aggravating defici= ency diseases such as iron deficiency anaemia and diseases of malnutrition found previously in the poor.

The Simon International English-Spa= nish Dictionary gives these definitions for the following words: deprivation: privacio= n (privation); carencia (lack); perdida (loss) deprive: privar (to dispose of); despojar (to divest) despojar: to strip= ; to rob.Something has been taken away something has been robbed. It keeps being taken away and robbed The same thing happens with the word neglect, translated into Spani= sh as despamparo. Lack of protection. The second version of deprive refers to dignity.

This the basis on which I will make= the following consideration about youth in Latin America. Let us study what neglect consists of, by going thr= ough different situations that are closely connected with each other.=

= POVERTYlevels of poverty in Latin America are those of a Third World Country -or a developing country, whichever you prefer. Adjustment policies and ill-distribution= of public expenses and wealth, tend to increase the irritating social inequalities, showing no signs of a reversion of this process. The information provided by the mo= st wide-ranging sources only confirm what is already known to all.The prospect= is even gloomier when we analyse the lack of functional, well-grounded alternatives to modify the system. The "death" of the ideologies, although liable to be argued abo= ut, leads to a certain quiet and passivity, which forecasts no good for the fut= ure.

Together with material poverty, it = is possible to observe the settling in of an affective poverty. Endeavours made to ov= ercome the economical problem have their inevitable side effects upon the family, whose members must multiply their work efforts. The number of families capa= ble of subsistence based upon the income of only one member is steadily decreas= ing. This is an important unbalancing factor in the structure of the traditional family tipping into crisis.

= NUTRITION Malnutrition levels are continuous= ly and permanently increasing. Those concerned the most are the children, origin a= nd end-point of the already typical vicious cycle of poverty. Forty thousand deaths per day due to malnutrition and illness that are avoidable. This fact, by itself, is significant. It comes from th= e Cumbre Mundial de la Infancia (World <= /i>Summit for Infancy).

= EDUCATION = One of the main characteristics of present society is the high degree of competitiveness. Education perform= s here an essential role. Education = means knowledge, and knowledge means power. As an antithesis, we can state that lack of education in itself lead= s to marginal situations.

We would be facing what has been ca= lled cultural malnutrition.   In three Latin American countries we have found that:-

= * In Argentina 88 % of the population complete the primary education; 26 % of this group complete the secondary education while 2 % of this last group finish studie= s at the University.

= * In Costa Rica the same thing happens with the 34.4 %; 21.3 % and 9 % respectively. While = in Brazil only 17 % complete the primary education; 8 % of this group finish secondary education, and only 1.8% of this small group accomplish University studies.=

These figures provide partial information, since they refer to quantity and not quality. What is profitab= le is high technology, and it goes without saying that our countries can only = have access to borrowed technology, if <= /i>and when it is allowed to them.

100 MILLION CHILDREN aged 6-11 are without school education Another figure provided by the (World Summit for Infancy).

= HEALTH Latin America= is a replica of what happens world-wide in other developing countries. Comprehensive medicine is preventi= ve and interdisciplinary, and that is not easy to achieve in areas which lack resources. The share of the a= lready scant budgets intended for Health turn out insufficient, and the requiremen= ts of a society with educational and nutritional deficiencies are greater.

= Reproductive health: unwanted pregnancy, abortion and AIDS; the inappropriate use of drugs, accidents and/or violence.&n= bsp; Pathologies that go beyond merely biological facts, due to their hig= hly psychological and social implications.&nbs= p; All social groups are affected, but each with characteristics of its own.

= Unwanted pregnancy: and its consequence, abortion, imp= ly a higher death rate in areas of fewer resources.

= AIDS: as it is correctly said, affects poore= r, younger and more female sub= jects every day.

And as to drugs, Latin American countries were traditionally considered as producers, or countries in which drugs were "in transit".Nowadays, unfortunately, drugs have reached our countries to stay. The decrea= se in the price of many substances has extended the use of drugs to the most vari= ed circles.    When considering the topic of drugs, several regional, social and cultural connotations must be taken into consideration and respected, since they bri= ng forth consequences on health quite different to those expected, when regard= ed from another point of view. Accide= nts, formerly patrimony of developed countries, show an important increase in Latin America. Argentina reaches the sad number of 30 deaths per day, due to traffic accidents, over= a total population of thirty five million.&n= bsp; The higher speeds of modern vehicles do not match deficient road infrastructure. The connection accidents-alcohol is the same here as in other societies. Teenagers and youths are a large proportion of injured

Latin America bears an important share in another report of the Summit World. 150 MILLION children in the world suffer from deficient health conditions.

= THE TRANSCULTURAL PROCESS The problem brought about by the transcultural process has an important impact upon the health of our teenagers and youths. The migration in search of sources= of employment, both towards the interior of the countries as to neighbouring countries, is greater every day. The migrat= ion from outer rural areas to the city originates belts of poverty: slums (villas miserias), favelas.

The communication media encourage a desire to acquire consumer go= ods and life styles unattainable for the majority of the population. The "American Dream" is = also exported into Latin America, and if it can be considered frustrating in North American society itself, little can be said of what happens "South of the border".

= VIOLENCE From all I have said so far derives one the main problems in the health of teenagers and youths: VIOLENCE.   Our societies are more and more violent every day. As paediatrician I deal with recur= ring consultations from kindergartens. The reason, the child does not know how to defend himself. Children = that have been brought up with affection in moderating homes (containing homes) = face from the beginning of their socialisation violent components for which they= are not prepared. It is as if the= re were no room for a healthy, non-aggressive child in the present society. Violence reveals itself in many wa= ys: right from handling a gun, down to an irresponsible practice of sexuality, = or high-speed driving.

= CHALLENGES FOR THIRD MILLENNIUM On the threshold of the third millennium, it is right to consider the various challenges that our Latin American society is due to face. Whereas human life upon this earth is computed in "thousands of years", machines= as we know them hardly date back two hund= red years. Development of science and the technology of the century about to end match those of no other period in the history of humanity. Therefore, t= he integration of human factors wi= th the progress that has been achieved= is far from being ideal. Teenage= rs of today will play the leading roles of the next millennium. Post-industrial society is already being forged by high technology. Automation is replacing many jobs,= with unemployment as its main outcome. These advances, fruit of complex and costly investigations, will keep growing. As a paradox, our agro-exporting countries will find their incomes relatively diminished, in terms on exchan= ge with technology-exporting countries. The consumer society will not weaken its pressure; it will be increased as a result of its necessity to place its goods. The breach between what is offered= and the possibilities of acquiring it will grow larger, and this will lead to logical negative consequences. Development in communication media will keep "shrinking" the world. This takes place at dizzying speed. Nothing happening in the world can= be ignored by the international community.&nb= sp; This aspect will act as an important counterpart to the differences between rich and poor countries. Nations will no longer be able to regard what happens in any other country as something beyond their concern.= True leadership will be based on the ability to foresee and circum -= vent problems. Otherwise the solution will only lead to increased individual, regional and international violence.

This world-wide tendency to go back= to village kind of life will have a s= trong impact on ECOLOGY. Man is no = longer a lonely inhabitant of the planet. Large human (settlements) produce harmful effects of Nature. The balance is in danger. The heat= ing of the atmosphere, the melting of the polar ice, the green-house effect, the nuclear waste, and so on, are only some aspects of what is really happening. Development of new vaccines will increase the preventive aspects -immunisat= ion against HIV is to be expected. Health costs will be greater and greater. Who will be able to pay for them? We can immunise against hepatitis A or B but the cost rises beyond $1= 00. This is what high technology offers to a population with a yearly income of $300 per head. Genetic manipulation= will create ethical dilemmas of increasing difficulty

= PREPARING FOR THE MILENNIUM The magnitude of the facts so far = may produce a paralysis or immobility fruit of panic;or on the contrary may act= as motivator for change. The development of humanity must engender natural optimism. Very few years ago, the planet was on the verge of destruction. Nuclear armament had reached such an extent that it could annihilate life on Earth completely. When the fate of mankind rested on the push of a detonato= r,solutions formerly unimagined,came to mind. We professionals dealing with teens by vi= rtue of our closeness to youth are responsible for their future and that of huma= nity. In answer our concern is to strive for:-

= *comprehensive education suited to future demands. Informati= on grows so fast that encyclopaedic approaches must be left aside, with the certainty that however hard he strives, man will only be able to learn a ti= ny proportion of available knowledge.Creative potential must be stimulated, in= a continuous educational process.

= *adequate NUTRITION answering the needs of young peopl= e and their idio-syncrasies. We cannot solve the problem of malnutrition of large populations but can achieve positive results by making better use of scarce resources.

* individual responsibility for own health and that of those around him. It is essential t= hat man should value himself adequately in both respect and dignity. On this ba= sis, all efforts should be directed to primary prevention,on individual and community levels.

= * ECOLOGY in many communities, y= oung people have a stronger conscience than adults. Humbly acknowledging this reality, we must contribute our experience and knowledge to it.<= /span>

= *An important contribution to health of youth has been provided studies on RESILIENCE.In the make up of the resilient being we find an important working tool. It is not a closed proce= ss but is open to the reality and present of the individual and society in whi= ch they are immersed

* development of SPIRITUALITY Throughout history man has given transcendental importance to spirituality. Professionals entrenched in west= ern philosophy (dissociation of body and soul)maybe due to over emphasis on individuality have largely excluded the spiritual from health practice.

= * The doctor patient relationship is essentially a human meeting, a vital encounter-as such it must not be undervalued.Reduced to the intellectual mere transference of information, little benefit is obtained nor behaviour modified. One of the richest, captivating controversial personalities in our times, Teilhard de Chardin, describes the human being as not created, = but in the process of being created. T= here are few similarities between Stone Age cavemen and Modern Man. Today we wou= ld be ashamed of our ancestor. What characteristics will future man possess? I= f we work hard with dedication and passion for youth, we will have contributed without even knowing it, to take a step forward in human development.<= /o:p>

We need to consider basic definitio= ns. What we are talking about,how do we get information, to what use do we put that information What can we do for street children who are not just deprived, t= hey are marginalised and not just marginalised but criminalised. You have no ri= ght to go out there and collect any information at all about them unless you ask yourself the question what do street children get out of this research? I h= ave worked for the last ten years in Bello Horizonte where I have the clinica a= mor-for street children. has 140 million people. The state of Sao Paulo has 25 million and the city 13 mil= lion -its very modern and up to date any western business man would feel complet= ely at home there - but there is another = Brazil - a Brazil more like the we have heard about - from which Manny’s immigrants come from. <= /o:p>

My clients,the children of <= st1:country-region>Brazil are those who live love and sleep on the streets. My clientelle - they go around in bands together. There are children on the streets and children of= the streets. Children on the streets have a family of sorts to go back to at ni= ght - may spend the day on the street selling chewing gum-but he has a reference point, someone he might listen to who he respects. He is not my client, my clients are of the street. How many children? Any statistics you are given,= figures are probably wrong - it is a dynamic situation -there are those coming into= the pool and those going out- we do not know how many are on the streets at any given time.They come from poor neighbourhoods but they may bounce back and forth going back to another area or to a family when the police are putting= on pressure. Some have come from rural areas with their family and some may co= me on their own having left their family in the countryside. The longer they s= tay on the street the harder it is to go back they lose reference and become pa= rt of the street. They may come from another city - from Rio the death squads = are more active in Rio -our town is safer -drugs are more in evidence in Rio and cheaper and so when they find it more expensive here they will go back to R= io. The only people who care in general for these kids are church groups - many have no help from official sources. Until 1989 a child on the street would = be taken from the street to a government institution, by virtue of the fact that he was on the street but now they h= ave the same rights as adults so technically are allowed to be on the street - however if they are on the street and steal they can be arrested just like = an adult can. This is a radical change - you won’t find as many street k= ids in the government institutions now. Their role is being redefined.

When do you count the kids if you w= ant to find out how many - the best time is at night- but you will have trouble finding them - they are so well hidden, huddled together you can’t te= ll how many are there or differentiate adults from children - if you count in = the day they can get from one end of town to the other so fast- you can count t= hem two, three four times. A survey found that 400 children were on the street - but workers were giving them meal tickets and many attended several times,h= ad 3 or 4 meal tickets at least 60 of 400 had been through the survey three time= s.

How about their health - speaking in the physical, emotional and psychosocial sense. There are massive queues for health care - people sleep in the queues-health care is very poor for these people in . With regard to health care for the street kids - I bring the clinic half wa= y to them - but they have to come half way to me.There are many projects working with street chidlren - we work in Bello Horizonte together - there are more than 25 projects church projects, national street kids movement,city government projects and we all work together in an integrated way to deliver health ca= re as part of this integration. We have different goals for different kids and different goals for different steps this child is taking. The model is like= the twelve steps of Alcoholics anonymous - the first step is on the street. The goal when he is on the street- the Rua is simply - make friends with him see what his reality is like establish a trusting relationship -don’t make demands of him - you have no right to - you can’t set limits at this stage. But if he will come to my open house then I can offer him more - we = can set some limits at that stage - to come to the open house he has to abide by our opening hours - has to arrive without being under the influence of drugs an= d if he’s stolen something he’s not allowed to bring it in - these r= ules were made with the kids themselves. With regard to my medical care,on the street I could offer just first aid but in the open house I can offer a bro= ader range of medical interventions and work on medical needs - convincing him t= hat they are of importance.

When he has been able to come to the open house - we hope he will be able to step up to a residential project - there he will have to accept even more limits. In addition to stopping drug= s, he will have to keep regular hours, will have to study to prepare for a profession or job and medical care will have to change also - he will have = to learn to use the government system. He’s no longer on the street,he has to go to the health post = and learn to exercise rights of using the government system from which they were excluded when they were on the street.

Finally once they leave a residenti= al project where they have daily supervision they move on to a hostel -a bit l= ike a boarding house where they all have jobs and they share the rent and house= hold duties and the function of the clinica amor is to refer them on- whatever t= heir health needs are. Our motto is educating for life through health The clinic= is behind the open house. At the clinic they need to learn to wait-wait their = turn and not need instant gratification - like when they need something on the street and they will steal a watch - their records are also something which they can ‘own’ and they will be encouraged to be interested in their weight, height and share the information with the staff. Much of the information on the kids comes in their ‘check ups’ - they are pleased to be able to make an appointment, and attend for ‘their̵= 7; ‘check up’ - which is a sharing experience between the staff and the kids. The open house is run by the church - the church have no problem = with the legitimate use of condoms - they support AIDS prevention - the open hou= se has broken glass in the windows because these kids have very short fuses, a problem can easily cause them to flare, break glass - hit your friend over = the head with a chair - and many of the girls have babies. Body image is import= ant to them - but they have no way of seeing their bodies - we have a mirror in= the open house which they love to stand in front of - it has never been cracked! We do courses with t= he girls and sessions devoted to looking at being a girl on the street, being pregnant and being a mother.We teach hairdressing,sewing making things to s= ell in the market as an alternative to stealing. Success for me means that a gi= rl can get off the street have antenatal care and then come and see me with the baby. Another street boy became a street educator - he went round in a van = and made friends and encourage them to come in for care to a project. Street problems vary - in other cities prostitution is the norm, in our town the g= irls do not - it is not acceptable - they do not want to. In <= span lang=3DEN-GB style=3D'font-family:"Courier New";mso-bidi-font-family:"Time= s New Roman"'>Rio the kids go hungry - the police is a heavy presence - in our town they are = not hungry. Health care can be a bridge to these children - so that in the end = it is the kids themselves who benefit from our intervention.=