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Valedictory – why pediatric otolaryngology is important. This title, assigned to me, tells us semantically and syntactically several things: that this is both a leave taking and a commencement; and that there is no real question as to the importance of pediatric otolaryngology: but that perhaps there is a need to elucidate its importance, and that I will try to do so, with particular focus on certain dimensions of our specialty that I feel have a particular importance today.

Speaking generally, the importance of medicine can be thought of in terms of two branches – the effect on the individual patient and the impact that these cumulative individual outcomes have on society. A consideration of the development of pediatric otolaryngology during the last quarter century tells much of these two interrelated areas of effect, individual, and society. Let us look at an early pediatric otolaryngologic symposium, held in London from 4 to 8 November 1974 and entitled "Advanced Course in Pediatric Otolaryngology." (Fig. 1) There were 4 days of lectures and clinic visits for 20 participants and a foreign auditor. Many of the topics presented in 1974 are similar to what has been discussed here in Oxford these past 4 days; the differences, qualitative and quantitative, are illuminating. In 1974, there was no discussion of otitis media with effusion, Waldeyer's ring, sleep apnea, swallowing, antenatal diagnosis and treatment, cochlear implants, HIV, genetics, ethics, neither of genetics nor of academic otolaryngology. Conversely in 2002, there have been only a few presentations on acute laryngeal infections (acute epiglottis is now a rare entity), tracheobronchitis, or intensive care and endoscopic anesthesia (these are now standard care). Of great interest is the amount of program devoted to language. There were two sessions in 1974. Now, in 2002, there were eight, and in addition some of the work presented in the nine sessions on the deaf child, the eight sessions on OME and in one of the OSA sessions pertained to language.

Robert Pracy, in the opening lecture of the 1974 symposium, said (Fig. 2),

Mr. Pracy set the stage for the specialty to transcend its anatomical territory so as to care for the effects that otolaryngological diseases have on the person as a whole, not just as a biological specimen, and to encompass the heretofore not considered medical/biological area of language and communication.

The importance of the care given by the pediatric otolaryngologist to the individual child encompasses the traditional purposes of medicine, such as to avert life-threatening illness. Our field has its special focus on interventions that preserve, restore, and/or improve hearing, speech, voice, gustation, olfaction, deglutition, respiration, appearances, etc. The patient will say: "Thank you, I can, hear better, smell, better, taste better, breathe better, sleep better, look better ..."

All of these are incremental to the quality of life of the patient and makes the practice of pediatric otolaryngology of special consequence in society where the individual is valued. They justify the resources needed for the practice of the discipline. They support the achievement of each child's potential, fulfilling Mr. Pracy's admonition.

Each patient is a part of a society, and the totality of the care given with the resultant preservation, restoration, and/or improvement in function is value added to that society. The value added dimension of pediatric otolaryngology has a critical importance because it enhances communication – language – through the vehicles of hearing, voice, and speech. This critical importance is manifest in two ways.

The first relates to the economic bases of our society – the way in which people make their livelihoods; this has undergone fundamental change during the last half of the 20th century [1]. In earlier periods, we depended largely on manual labor. Today, we depend upon communication skills: hearing, voice, speech, and language. This revolutionary change in "making a living" is reflected in the labor statistics of the United States [2]. At the beginning of the century, at least 80% of America's labor force was primarily employed in tasks dependent upon manual skills (Fig. 3). Only 20% – the white-collar segment – performed work that was based upon their communication abilities. At midcentury, 63% of the nation was employed in farming, and blue-collar occupations and those holding white-collar jobs dependent upon communication skills had almost doubled to 38%. By the end of the century, 62% of the labor force made their livelihood on skills based upon their communication abilities, and many of the remaining 37%, although defined as farming and blue collar, are dependent upon their communication abilities to function well in the present communication society, including to effectively fulfil their "manual" jobs.

Employment that is voice dependent accounts currently for 34% of all workers [3]. In urban areas, such as New York City, at least 87.5% of the work force is dependent upon communication skills. Farmers now have become farm managers, spending a significant portion of their time working indoors with information coming in. Today the cows are bar coded and the agricultural engineer, a.k.a., the farmer, carries out market analysis and works fundamentally as a manager. Factory workers guide robots as automation has created dark areas of factories with no human workers: factory output continues to rise, and a quarter of a million manufacturing jobs are lost each year [2, 4]. The computer now carries out design and personal allocations. The trucking industry needs an estimated 80,000 new drivers by 2008 [5]; these drivers need a degree of physical strength and prowess – even though hydraulics are doing most of the lifting – but most importantly, they require logistic skills to conduct inventories, routings, and flow analyses from the computers in their cabs. Bureau of Labor [6] projections for the year 2005 indicate that United States employment will increase by 17.7 million jobs, of which at least 92% (16.2 million) of these new jobs will be based on communication skills (Fig. 4).

As the economic basis of our society shifts, so does our definition of what is required for fitness. In the communication age of the 21st century, society will direct its resources to a strategy of preventive medicine and medical care that will optimize the health – the communication fitness – of its population, and this is the province of pediatric otolaryngology.

The diseases of communication – hearing loss, voice and speech disorders, and, on the most essential and significant level, language disorders – heretofore have not been recognized as a substantial public health issue. There are no precise figures as to the prevalence of these disorders, but the data provide a conservative estimate of prevalence for hearing impairment of 5%, voice and speech disorders 3%, and language disorders less than 7%. The overall prevalence of communication disorders (CDs) may be between 5% and 10% of the population.

Among those with hearing and speech disorders, in the United States, the unemployment rate is estimated at 43.3%, compared with 29.5% for the same working age population without such disabilities (Fig. 5) [6, 7, 8]. Those with speech disorders, although the fewest in number, have the greatest rates of unemployment: 67.4% for those who have difficulty in speaking understandably, and 75.6% unemployed for those who are unable to speak understandably. The relationship between an increased incidence of CDs and lower social class has been identified. In the United Kingdom, men with a hearing or a speech handicap were found more frequently in the lowest classes – class III manual and classes IV and V. They also were more likely to be out of the labor force – three times greater for hearing and eight times greater for speech than the controls. The women appear to be less affected, but there were fewer in the highest class – class I – than the unimpaired population. The Women showed a twofold (hearing impaired) and threefold (speech impaired) increase in the out-of-the-labor-force group.¹ A similar trend is found in the US in that low incomes were more frequently found in those affected by hearing or speech impairments than in the nonaffected population. A total of 43.7% of those affected by speech problems were found in the lowest income group – more than 1.5 times greater than the normal controls.

The incomes of the hearing impaired were 40–45% of the non-CD population, while in contrast, the incomes of people with disabilities of all kinds was 85% that of the population without disabilities (Fig. 6). A similar economic disadvantage of persons with CDs is noted when comparing their unemployment rate of 43.3% to the unemployment rate of 25.9% for those with nonsevere disabilities. This tendency is also noted in the income group study that shows that 21.4–43.7% of persons with CDs are in the lowest income group compared with 19.3% of those with what Kruse [9] defines as nonsevere disabilities. These data show that a CD, in our current social context, is a disabling condition when economic levels are used as the outcome.

An estimate of the lost income to the US as result of the lower income, underemployment for workers is approximately $45 billion/year and from unemployment $80 billion, for a total loss of $125 billion/year (Fig. 7). Added to this are the medical, habilitative, and special education costs for the care of CDs [10]. These are estimated from $32 billion (5% prevalence) to $64 billion (10% prevalence). The combined cost of CDs to the US economy is between $157 and $189 billion/year, which is 2.5–3.0% of the predicted GNP for the US. These data indicate the significant loss to the US economy represented by CDs.

With the background of these considerations, it is significant to consider that throughout the US economy, there is a need for skilled workers. It has been estimated that the shortages of skilled workers – primarily those with communication skills – will cause a 5% drop in the growth rate of the GNP over the next 5 years. The amelioration of CDs would go a long way in meeting this demand for skilled workers, adding to the US GNP and increasing the fitness for survival in the communication age of the 21st century.

Two nations with demographics different from the US when viewed from the point of view of these economic trends in relation to CDs show a similar picture, the Netherlands and the Philippines. In the Netherlands the current age distribution and the predicted changes over the next 50 years indicate that in 1997, 62% of the population was between 20 and 64 years of age – defined as the work force (Fig. 8). By the mid-21st century, the number of people in the labor force defined as between ages 20 and 64 years will be reduced to 53% of the population. Each 'worker' in 1997, supported 1.6% of the population – i.e., a worker between the ages of 20 and 64 supported all those who were younger than 20 and older than 64 years of age. In 2050, as there will be a 9% decrease in workers; thus, each worker will now have to support 1.9% of the total population. This suggests that there will a 16% increase in the productivity required of each worker to maintain the current economic standard of living for the Netherlands. The economic value of each newborn to the society will increase 16%. Thus, the Netherlands can ill afford to have 5–10 % of their working population with CDs that result in underemployment, unemployment, and a lack of communicationally skilled workers.

The Philippines presents a different demography; it is a nation of young people and is undergoing a dramatic shift from a manual to a communication-based economy (Fig. 9). From 1980 to 1994, agricultural and industrial jobs decreased, and employment in the service sector increased by 14%. A comparison of rates of the change to communication-based employment shows that the Philippines fall between the most accelerated (urban New York City) and the United States as a whole. The phenomenon of the change of the economic basis for society is not confined to postindustrial nations but is evident in many societies, including the Philippines; a similar situation is noted for Asia and the Pacific by the International Labor Organization report on human resources.

The Philippines has a young and rapidly growing population. The Philippine working population, ages 20–64, is predicted to increase 60% (29 million more) by 2040. Using the prevalence estimates for communication disorders, one would expect between 3.4 and 6.7 million Philippine workers with significant and economically disabling communication disorder in 2040. The magnitude of these numbers and their social and economic consequences compel a major public health initiative to prevent this outcome. It is the pediatric otolaryngologists who have the important task of ameliorating these diseases and enabling the potential of the population so that the society may prosper.

There is another important societal benefit that accrues from the practice of pediatric otolaryngology that has only begun to receive appropriate recognition. Juvenile crime is one of the most tragic and destructive aspects of society. It represents the waste of human beings and augments a dangerous form of social disintegration. The causes of juvenile crime are multiple and interrelated. Communication disorders has high prevalence and incidence in this population. Between 30% and 40% of young offenders have significant hearing loss [11]. Prospective studies from the United Kingdom have shown that otitis media is correlated with antisocial behavior [12]. Children with speech and/or language disorders are four times as likely to have a psychiatric disorder as others, and girls may be a greater risk [13]. Language disorders have been identified in 14–22% of incarcerated adolescents [14, 15]. The incidence of inadequate language skills among incarcerated children may be twice that found in the general population [16]. A negative correlation is found between early language devolvement and criminality [17]: the more retarded the language development, the higher the incidence of crime. It appears that lower language competency leads to both decreased understanding and inadequate expression that, in turn, diminishes the ability to resolve conflicts in the verbal mode. The alternative, especially for those children with inadequate social resources, is violent physical action whose consequence is a crime. Appropriate pediatric otolaryngic treatment for communications disorders in this population should foster greater achievement of individual potential as well as the prevention of violence.

Pediatric otolaryngology, fulfilling the traditional medical role of care of the individual, goes beyond the individual in its beneficial role since the sum of its effects are value added to the economy and the enhancement of social integrity. Its importance, already recognized, will be augmented, and resources will be made available to allow the development of maximal communication skills for every child. Our work as pediatric otolaryngologists has just begun – it will be of interest for the valedictorian of 2030 to compare the two symposia. We now commence with our new knowledge on our journey to 2030.