5/4/22 – Margaret K. Hostetter, MD - Death at an Early Age

Transcript

• 00:00Uh, I'm pleased to welcome all of
• 00:03you to our grand rounds and our
• 00:06special grand rounds this week,
• 00:09which is an endowed lectureship in
• 00:12conjunction with our research forum
• 00:14and one of our highlights of our
• 00:17Centennial celebration this year.
• 00:24Some upcoming events next week.
• 00:27Mark Mercurio will be speaking
• 00:29at grand Rounds on justice,
• 00:31moral status and the NICU patient.
• 00:33And on May 18th,
• 00:36another uh Centennial event
• 00:37will be the Paul S Goldstein MD.
• 00:40Lectureship and we have.
• 00:45One of our former trainees coming Lori Cohen.
• 00:52This is a reminder that we're in
• 00:54the we in the midst of our 10th
• 00:57annual Pediatric Research Forum.
• 00:59Today it goes through two.
• 01:00After this it goes through 2:00
• 01:02o'clock and then tomorrow we have
• 01:04another virtual session from 11:00
• 01:05to 12:55 and it's a spectacular
• 01:09group of trainees giving giving
• 01:12presentations on their research.
• 01:15It really is impressive group.
• 01:20I also want to remind you that
• 01:23tomorrow from three to five we have
• 01:26our library exhibit opening reception
• 01:28in the medical Historical library
• 01:30and this is our Centennial event.
• 01:33Sort of tracing key aspects of
• 01:37the history of the department
• 01:39so please do come out and.
• 01:43Join us for some food and beverage
• 01:45and a chance to gather,
• 01:46uh and also to come see the great event.
• 01:51The great.
• 01:55Exhibit that Kai Shulman and Jen
• 01:58DeSantis and others have put together.
• 02:05And then one of our final events of
• 02:09the year is our congenital cardiology
• 02:12congenital heart disease symposium
• 02:15that's coming up on June 3rd.
• 02:18Change of heart, Yale and the
• 02:20evolution of congenital cardiac care.
• 02:21So that will be in person at the
• 02:24TAC auditorium from 9 to one.
• 02:26There's online registration and I
• 02:28encourage you to participate if you can.
• 02:31It should be.
• 02:31It looks like a great session.
• 02:36There is no commercial support for
• 02:38this grand rounds and there are no
• 02:41conflicts that have been found.
• 02:45And you'll get seeing me for this.
• 02:47You just text 29724 to the CME number there,
• 02:52and this will also be placed in the chat.
• 02:57Throughout the meeting and you'll have a
• 03:00chance to to see it then and please put
• 03:03questions in the Q&A at the end of the zoom.
• 03:10So today is our Grover Powers lecture
• 03:12and just who was Grover Powers?
• 03:14Well, you can see here this
• 03:16stately photo of Grover Powers,
• 03:18who was the chair of Pediatrics
• 03:20from 1926 to 1951.
• 03:22He was the second chair of Pediatrics.
• 03:27He actually was on the original
• 03:29faculty when it was started in 1921,
• 03:32when Edwards Park came to Yale from Hopkins
• 03:35and brought a number of his colleagues.
• 03:37From Hopkins to found the
• 03:39Department of Pediatrics at Yale,
• 03:42Grover Powers is really recognized
• 03:43as one of the most influential
• 03:46figures in American Pediatrics.
• 03:48Mainly for his clinical prowess,
• 03:50his personality and his teaching skills,
• 03:53and he has he attracted a star
• 03:56studded roster of faculty.
• 03:57Some of the names there you may
• 04:00recognize from various textbooks
• 04:02and from Seminole contributions
• 04:04that they made to Pediatrics.
• 04:06And so there was a an endowment
• 04:10started in his honor and this
• 04:12is what we use for supporting
• 04:15this lectureship every year.
• 04:22And it's my pleasure to introduce to my
• 04:26friend and colleague Peggy Hostetter,
• 04:28who will be giving today's lecture
• 04:31and just a brief background on Peggy.
• 04:34For those who don't know her,
• 04:37Peggy originally hailed from Ohio.
• 04:40That hot political battleground state
• 04:43graduating from Denison University,
• 04:46summa *** laude and Phi Beta Kappa.
• 04:48She started her career actually
• 04:51in Graduate School in English
• 04:53literature and in Houston,
• 04:55TX, and then decided to.
• 04:58To pursue medicine as a career where she
• 05:04matriculated at Houston's Baylor College
• 05:07of Medicine and graduated in 1975.
• 05:11AOA, she completed her internship
• 05:13and residency in Pediatrics at the
• 05:15Boston Children's Hospitals and a
• 05:18Combined Fellowship in infectious
• 05:20diseases at Boston Children's.
• 05:22The Peter Bent Brigham Hospital
• 05:24and Beth Israel.
• 05:26She spent two years as an instructor
• 05:28at Boston Children's and then moved
• 05:31to the University of Minnesota where
• 05:33she really established a stellar track
• 05:35record and meteoric rise as a faculty
• 05:38member to be over 16 years to become
• 05:41the American Legion Heart Research Professor,
• 05:44which is an endowed chair,
• 05:45chief of the section of Pediatric
• 05:48Infectious Diseases and vice Chair for
• 05:50research in the Department of Pediatrics.
• 05:54Joe Warshaw,
• 05:55one of our legendary chairs.
• 05:59Knew of Peggy's great accomplishments
• 06:02and leadership and so she
• 06:05he recruited her in 1988.
• 06:07To Yale in the Department of
• 06:10Pediatrics where she was tasked
• 06:12with establishing and leading the
• 06:14Yale Child Health Research Center.
• 06:17That's where I got to know Peggy as
• 06:20a junior faculty member with a lab at
• 06:23the Child Health Research Center and
• 06:26it was such a great time to be in that area.
• 06:30Working with Peggy and developing a number of
• 06:33other along with a number of other faculty.
• 06:36Our research careers.
• 06:38In 2002,
• 06:39Peggy became chair of the Department
• 06:42of Pediatrics and the Gene
• 06:44McClain Wallace Professor,
• 06:45which is an endowed chair,
• 06:47and she is the first woman
• 06:49chair of Pediatrics at Yale.
• 06:53She remained until 2010 when
• 06:55she was recruited to Cincinnati
• 06:58Children's and subsequently became
• 07:00the first female chair there,
• 07:03leading up the Department of Pediatrics
• 07:05and directing the Cincinnati
• 07:06Children's Research Foundation,
• 07:08which she did so for 10 years and
• 07:11leading and growing that institution.
• 07:14And retire left that position in 2020
• 07:17and she now currently serves as editor
• 07:20in chief of current opinion in Pediatrics.
• 07:24I will also say she has reengaged with
• 07:27our department and is supporting and
• 07:31working with our infectious disease
• 07:33group and mentoring fellows and serving
• 07:37as an advisor and to Elijah Paintsil.
• 07:41Peggy is nationally known.
• 07:42I won't go through all of her
• 07:44wonderful accomplishments,
• 07:45but certainly as a top notch researcher
• 07:49in the areas of infectious disease,
• 07:52especially with pneumococcus
• 07:54and Candida albicans.
• 07:56She has been previously elected
• 07:58as the president for the Society
• 08:00of Pediatric Research,
• 08:01as well as the American Pediatric Society.
• 08:05She's received many awards for
• 08:06her research on strep pneumo and
• 08:08can't get the albicans from the
• 08:10Society for Pediatric Research.
• 08:12The American Academy of Pediatrics
• 08:14and other private foundations.
• 08:16She's a member of the American
• 08:19Society for Clinical Investigation,
• 08:20the Association of American
• 08:22for American Physicians,
• 08:23and the National Academy of Medicine.
• 08:26And she now lives in New York City with
• 08:29four lovely grandchildren and two children.
• 08:33So with that, Peggy.
• 08:34Welcome back to Yale.
• 08:35It's so great to see you and we look
• 08:37forward to hearing your lecture.
• 08:55Well, I'm tremendously grateful to you,
• 08:59Cliff, and to Panina and to your
• 09:03committee for selecting me as this
• 09:06year's Grover Powers lecturer.
• 09:09It's a great opportunity to highlight
• 09:12some of Doctor Power's enormous
• 09:15contributions to Pediatrics and to
• 09:18celebrate the 100th anniversary
• 09:21of this outstanding department.
• 09:23So our objectives for the talk
• 09:26today are to understand the
• 09:28historical eras in the development
• 09:31of the discipline of Pediatrics.
• 09:34To recognize the interplay between
• 09:37childhood deaths in three novels and
• 09:42subsequent improvement in Children's Health.
• 09:45And to be ready to take action
• 09:49against the newest threats in
• 09:51the fight for Children's Health.
• 09:55So our focus is Pediatrics.
• 09:59But where did that term come from?
• 10:04It originated really with none
• 10:06other than Sir William Osler,
• 10:09who in the pages of the Boston Medical and
• 10:12Surgical Journal in 1880 differentiated
• 10:15physicians associated with diseases
• 10:18of children from other physicians.
• 10:21This led in 1904 to the New England Journal,
• 10:25starting a progress in Pediatrics section.
• 10:30And in 1954, the New England Journal
• 10:34accorded Pediatrics its very own section,
• 10:37which has unfortunately
• 10:40subsequently been curtailed.
• 10:42But much of what I'm going to discuss today.
• 10:51Problem here.
• 10:56Much of what I'm going to discuss
• 10:59today can be found in this New England
• 11:03Journal article from April 2012.
• 11:05It was one of the 200th anniversary issues,
• 11:09and I was invited by the journals editors
• 11:13to write a history of Pediatrics based on
• 11:16publications in the New England Journal.
• 11:20Over the preceding 200 years.
• 11:22So from 1812. To 2012 so in the article
• 11:29I delimited somewhat arbitrarily,
• 11:324 eras of Pediatrics.
• 11:36See it here from 1812 to 1880.
• 11:41Fix it. From 1880 to 1930.
• 11:48Prevent it from 1930 to 1980 and
• 11:53disseminate it from 1980 to 2012.
• 11:58And then Tim Schwartz,
• 12:01who is a conceptual artist in Los Angeles,
• 12:04developed an algorithm to track
• 12:07New England Journal publications
• 12:09with the words Pediatrics or
• 12:12pediatric in any given year.
• 12:15And so, interestingly,
• 12:16you can see that pediatric publications
• 12:20peak at around 14% of New England Journal
• 12:24articles in 1920 to 1930 or thereabouts,
• 12:28and we're going to use.
• 12:29This graph repeatedly as we talk
• 12:33about the evolution of Pediatrics.
• 12:36But it's really only fair to begin about
• 12:39200 years before the journal's first issue.
• 12:43Back when the deaths of infants
• 12:46and children were an expected part
• 12:48of life in the 1600s to the 1800s,
• 12:52child death is the natural order.
• 12:56Indeed, one of the first to recognize.
• 13:02The Evanescence of childhood was
• 13:05the Chinese emperor. Kang C.
• 13:10He was the 2nd ruler of the Qing dynasty.
• 13:13He ascended the throne at age 7 in
• 13:171661 and ruled for the next 61 years.
• 13:21Among his many accomplishments,
• 13:23he wrote poetry, quelled, rebellion,
• 13:26reorganized the state bureaucracy
• 13:29and sired 56 children from 30
• 13:33consorts as beautifully described in
• 13:36the biography by Jonathan Spence,
• 13:38whom you will know as Yale.
• 13:40Sterling Professor of History and
• 13:43who died recently last December.
• 13:46Kinsey had advanced insights
• 13:49into children's development.
• 13:53I'm going to take this quote from the
• 13:56book from infancy until around 10.
• 13:58The child may move according
• 14:01to natural principles,
• 14:02but for the rest of his life it is
• 14:05training and habits that direct him.
• 14:08Once he is taught to discriminate
• 14:12between alternatives.
• 14:13But despite the sort of wealth and
• 14:15protection of the emperor's court,
• 14:17he was really one of the first to adopt
• 14:21smallpox vaccination throughout his nation.
• 14:23The health of his beloved children was little
• 14:26better than that of the poorest peasant.
• 14:29So from the roster of birth in his
• 14:32book and Jonathan Spence's book,
• 14:34I compiled the following table
• 14:37of his 56 royal progeny.
• 14:40There were 28 deaths for mortality rate.
• 14:44About 50%.
• 14:45Mortality rate for his daughters in
• 14:48Pink was twelve out of 20 or 60%.
• 14:52For his sons in blue.
• 14:5616 out of 36 or 44%.
• 14:59As shown in the box graph,
• 15:02eight children 4 girls and four boys
• 15:06died before their first birthday
• 15:09and another ten of his children,
• 15:114 girls and six boys died
• 15:14before the age of four.
• 15:18So indeed,
• 15:19the mortality rate in the Royal Court was
• 15:22no different than from what was observed
• 15:26everywhere everywhere else in the 1700s.
• 15:28One in eight children died in the
• 15:31first year of life and three of
• 15:34ten were dead by the age of 10,
• 15:37and the causes virtually every
• 15:39infectious diseases known at the time.
• 15:42Diphtheria, whooping cough,
• 15:44tuberculosis, dysentery,
• 15:45cholera typhus, typhoid fever,
• 15:47chicken pox, measles, scarlet fever,
• 15:49smallpox, plague and rickets.
• 15:51And you can say rickets.
• 15:53That's certainly not an infectious disease,
• 15:55but we now know that vitamin D
• 15:58plays a major role in an 8.
• 16:00Community,
• 16:00so yes,
• 16:01you can die from rickets.
• 16:10Today it seems almost incomprehensible that
• 16:13diphtheria was a leading cause of death,
• 16:16and yet in the diphtheria outbreak
• 16:18that began in New England in 1935,
• 16:22a single index case in Kingston NH
• 16:25spread the pestilence north to Kittery,
• 16:29ME, and then South to Boston,
• 16:32where through the Boston Post
• 16:34Rd and you can see it here in
• 16:37Red going South from Boston.
• 16:39And then West it came to New Haven.
• 16:43The Boston Post Rd as a vector of pestilence,
• 16:47so think about that the next
• 16:49time you're driving to the mall.
• 16:51Of the 5000 fatalities,
• 16:5480% were children with a peak
• 16:57death rate in New Haven in 1739.
• 17:03There are three tombstones
• 17:05in the Grove St Cemetery
• 17:07in New Haven, Hervey,
• 17:09aged 3 years, eight months.
• 17:12Mary, aged 4 years eight months.
• 17:16Maggie, aged one year, eight months.
• 17:19They all died within 5 days.
• 17:22And the tombstone off to
• 17:24the right is their mothers.
• 17:26A tragedy to be sure.
• 17:29But the belief at the time was that
• 17:31there's nothing you can do about it.
• 17:33Death in childhood is the law of nature.
• 17:39So that brings us to our first
• 17:42era in Pediatrics 1812 to 1880.
• 17:46See it there were no New England
• 17:50Journal articles mentioning Pediatrics
• 17:51during that time. Remember,
• 17:53Osler didn't even coin the term until 1880,
• 17:56so there's just a little blip here.
• 17:59But by the middle of the 19th century,
• 18:02a youthful death was viewed as a tragedy.
• 18:07And this sudden change in perception.
• 18:10See it originated,
• 18:12not with medical fact, but with fiction.
• 18:17Now why children died didn't really
• 18:20change diarrhea, fevers, croup,
• 18:23scarlet fever, pertussis cholera,
• 18:26and phantom measles, smallpox.
• 18:29But the portrayal of childhood
• 18:32death did change.
• 18:36Before the middle of the 19th century,
• 18:38youthful death in a novel was extremely rare,
• 18:42and when it occurred,
• 18:44it was ascribed to a character flaw.
• 18:46Good case in point,
• 18:48Catherine Earnshaw heroin of
• 18:51Wuthering Heights by Emily Bronte.
• 18:53Catherine is fiery,
• 18:55tempestuous rushing about the stormy Moors
• 18:58because of her fervid love for Heathcliff.
• 19:00Here's a quote, oh I'm burning.
• 19:03I wish I were out of doors.
• 19:05Why does my blood rush into a hell of tumult?
• 19:07Get those words.
• 19:09I'm sure I should be myself where I once
• 19:12among the Heather on those hills. Yikes,
• 19:15is it any surprise that Catherine contracts
• 19:19brain fever and dies within 10 pages?
• 19:22After all, her brain is fevered.
• 19:25This is death by character flaw.
• 19:28The fatal flaw of unbridled passion.
• 19:32But then came the novel that
• 19:35provoked a transformation.
• 19:36Charles Dickens Bleak House
• 19:39serialized between 1852 and 1853,
• 19:43the novel harnessed public
• 19:46Sympathy for children and
• 19:48dramatically reformed perception.
• 19:51Now, in Bleak House there are a multitude
• 19:54of characters of all social strata,
• 19:56but the most sympathetic is the Orphan Joe.
• 20:00He's around 9 to 10 years of age.
• 20:03He's a little St sweeper who
• 20:05Burrows in the tenements of London.
• 20:07The picture here is an illustration
• 20:09from an early edition of Bleak House,
• 20:12and it is drawn first hand from real life.
• 20:17As a blameless victim trapped by poverty,
• 20:20Joe contracts smallpox.
• 20:22Although the disease is
• 20:23not named in the novel,
• 20:26and he then infects the middle
• 20:28class heroine Esther Summerson,
• 20:30who is disfigured by the later
• 20:32in the book by the disease.
• 20:34Social class is not protective.
• 20:39And as Joe dies comforted by
• 20:42Esther and the physician,
• 20:44Alan Woodcourt, Dickens intones dead.
• 20:49Dead, your majesty.
• 20:52Dead,
• 20:53my Lords and gentlemen.
• 20:56Dead right reverence and wrong
• 20:59reverence of every order.
• 21:02Dead men and women born with
• 21:05heavenly compassion in your hearts
• 21:08and dying thus around us every day.
• 21:15Those last words and dying
• 21:18thus around us every day.
• 21:21Some of you may know is,
• 21:22as Cliff mentioned,
• 21:23that in 1971 I was in Graduate
• 21:26School studying the Victorian novel
• 21:28when I decided to go to medical
• 21:30school and it was this very passage.
• 21:33These very words that propelled me out
• 21:36of the library and into organic chemistry.
• 21:40And Dickens contemporary readers
• 21:42felt exactly the same way.
• 21:44They recognized the reality behind the
• 21:48fiction and in that same year 1853,
• 21:51the British Parliament mandated smallpox
• 21:54vaccination within three months of
• 21:57birth for all children born after
• 22:00August 1st and just three years later,
• 22:02the British Parliament for bad work
• 22:05for any child under 9 and prescribed
• 22:09a maximum of 60 hours of work
• 22:12per week for children overnight.
• 22:15At the time, this was incredibly enlightened.
• 22:20So yes, you full death is a tragedy.
• 22:24A similar death occurs on our side
• 22:26of the Atlantic in little women,
• 22:29although from a different cause
• 22:31and in a different social class.
• 22:34Beth, the third of the four March sisters,
• 22:37and I'll bet every woman in this
• 22:40room can name Meg, Joe, Beth,
• 22:42and Amy Beth contracts scarlet fever
• 22:45when she's caring for an impoverished
• 22:48infant and then later in the book
• 22:52dies from rheumatic heart disease.
• 22:55Like Joe Beth's characterized
• 22:57as pure and angelic,
• 23:00like the little St sweeper,
• 23:01there's no character flaw here,
• 23:04so again, the issue is environmental,
• 23:08but inexorable.
• 23:09And as Beth says in the book,
• 23:13it's like the Tide Joe,
• 23:15when it turns it goes slowly,
• 23:17but it can't be stopped.
• 23:20And then later, as Beth had hoped,
• 23:22the tide went out easily and in the
• 23:25dark hour before dawn on the bosom,
• 23:28where she had drawn her first breath,
• 23:30she quietly drew her last.
• 23:33So indeed it was no secret that at the time.
• 23:39In Beth Louisa May Alcott was
• 23:42portraying the death of her own sister,
• 23:44Lizzie, who also died in her
• 23:4720s from rheumatic fever.
• 23:49And deaths of blameless children
• 23:51were everywhere at that time.
• 23:53Edvard Munch's sister,
• 23:55Johann died of TB at age 16,
• 23:59and even three of Lincoln Son
• 24:01one from TB at age 18 months.
• 24:04He's not in this picture and two
• 24:07shown here in the White House from
• 24:10TB and typhoid at ages 11 and 18.
• 24:13So if famous writers and artists and
• 24:16even presidents of the United States.
• 24:19They're not immune to the tragedy
• 24:21of childhood death.
• 24:22Then we are all susceptible
• 24:25and something must be done.
• 24:27And of course,
• 24:29the final insight that catapults
• 24:31us from fiction to fact.
• 24:33Pasteurs germ theory in the mid 1860s,
• 24:36which addressed the mysteries
• 24:39of causality and transmission.
• 24:41I like this quote, gentlemen.
• 24:43It is the microbes who will
• 24:45have the last word.
• 24:47That's a good one for section chiefs meeting.
• 24:50So now the old order is completely upended.
• 24:54Prior to 1852, the victim was the problem.
• 24:57A poor beginning predicted a poor end,
• 25:01and the same trajectory could
• 25:03be accelerated by the N8
• 25:05susceptibility due to a character flaw.
• 25:08Nothing can be done.
• 25:12But Bleak house and little women and
• 25:15pastor made the public recognize
• 25:17that the victim is not the problem.
• 25:19The environment is the problem,
• 25:22and social class is not protective.
• 25:25Therefore, we are all potentially
• 25:28susceptible and something must be done.
• 25:32So yes, back to the impact of Pediatrics.
• 25:35We see it and now we must fix it.
• 25:38It's a new era.
• 25:40Mentions of Pediatrics skyrocket in
• 25:43the New England Journal and childhood
• 25:46death is not the natural order.
• 25:49And so I'll,
• 25:50although the deaths of children under
• 25:535 from pneumonia and influenza to
• 25:56verticular osis enteritis with diarrhea.
• 25:58Still represented.
• 25:5930% of all US deaths.
• 26:03We began to confront the causes
• 26:05of childhood death that we can fix
• 26:08first by focusing on sanitation.
• 26:11Here's another quote from the New
• 26:15England Journal sanitary reform as a
• 26:18means of reducing our infant mortality.
• 26:20Demands our earnest attention.
• 26:24That's from Jay O Webster in 1873,
• 26:28and what he was talking about was cholera.
• 26:31In Phantom or summer gastroenteritis.
• 26:35It was particularly deadly in the
• 26:37tenements of New York and Boston,
• 26:40with a 20% mortality.
• 26:43Breastfeeding had declined.
• 26:45Poor women were now working in
• 26:48factories and cows milk powder
• 26:50as a breast milk substitute
• 26:53was completely unstandardized.
• 26:56On top of that,
• 26:58most water sources were were
• 27:00completely contaminated.
• 27:02But three pioneers took up the challenge
• 27:04on the left there and the hat.
• 27:06We see Abraham Jacoby,
• 27:08who was the founder of the
• 27:10American Pediatric Society.
• 27:13And really the first to establish
• 27:16a department of Pediatrics in
• 27:18the US at Mount Sinai.
• 27:20To the right, we have Nathan Strauss,
• 27:24a New York merchant who opened free milk
• 27:28clinics in 1901 and then at the bottom.
• 27:32We have Sarah Josephine Baker,
• 27:35the first head of the New York
• 27:37Department of Public Health,
• 27:39whose educational campaigns among the
• 27:42poor reduce deaths from cholera and
• 27:45phantom by 50% from 1901 to 1917.
• 27:52Others, like the photographer,
• 27:55Jacob Reese,
• 27:56called attention to the dangers of
• 27:59child labor and the poverty of St children.
• 28:03It was hard to ignore his evidence.
• 28:07So the special needs of children
• 28:10and what we owe to them sparked
• 28:14the rise of children's hospitals.
• 28:18Chat in 1855. Boston in 1869.
• 28:24Plenty of cows in the front yard,
• 28:27Cincinnati and others in the 1880s
• 28:31and grew over Powers consolidated the
• 28:35Department of Pediatrics at Yale in 1933.
• 28:41So now.
• 28:43These accomplishments of the fixed era.
• 28:47With the prelude to another paradigm shift.
• 28:51Why fix it if we can prevent it?
• 28:56So from 1930 to 1980,
• 28:58this was the vaccine era.
• 29:01Protection of children is our responsibility.
• 29:05Beginning in the 30s with the
• 29:08pertussis vaccine developed by Pearl,
• 29:10Kendrick and Gertrude elderly
• 29:13in Grand Rapids, MI.
• 29:16And the results were absolutely incredible
• 29:20over 75 years from 19 from 1875 to 1950,
• 29:28diphtheria completely disappeared.
• 29:31Indeed, you know vaccines conquered
• 29:34a host of infectious diseases.
• 29:37Measles,
• 29:37shown in green down at the bottom,
• 29:40whooping cough in orange,
• 29:42diphtheria in the dark,
• 29:44blue, influenza,
• 29:46spiking obviously in 1918, in the brown.
• 29:50Even scarlet fever, typhoid fever and
• 29:54tuberculosis shown in the Aqua color.
• 29:57For which there were no vaccines
• 30:00declined because of improved sanitation,
• 30:03and ultimately the invention of antibiotics.
• 30:08So now we're in our last era
• 30:11disseminated and we are on fire.
• 30:14Just get the word out around the globe.
• 30:16We know what's best for children
• 30:19and we can get it to them.
• 30:21Share the best for Children's Health.
• 30:25If you were a pediatric infectious
• 30:27disease specialist in 1980, like me,
• 30:30you were on top of the world.
• 30:34We had vaccines.
• 30:35We had new diagnostic techniques.
• 30:38We had a plethora of antibiotics
• 30:40and no resistance.
• 30:42And then in 1982 we had HIV.
• 30:49In the early years of the battle against HIV,
• 30:53children had some of the
• 30:55highest rates of death.
• 30:57We didn't understand at the outset
• 30:59that a child's immune system,
• 31:01particularly in infancy,
• 31:02had fewer CD 4 positive
• 31:05T cells than an adults.
• 31:07So we initiated prophylaxis for
• 31:11opportunistic infections too late.
• 31:13We had one antiviral agent,
• 31:15AZT,
• 31:16and it was terrible and there was great
• 31:22prejudice against the HIV infected.
• 31:25But as with the diphtheria epidemic of 1735.
• 31:30New Haven and Connecticut had some of
• 31:33the worst mortality figures for children,
• 31:37but this did not deter Warren
• 31:39Andyman here at Yale.
• 31:41He and colleagues like Lisa Ferlino had
• 31:45recognized the plight of HIV infected
• 31:49children in New Haven and launched
• 31:52the Pediatric AIDS Care program in 1987.
• 31:56Now in New Haven,
• 31:59women represented 20% of all HIV
• 32:03patients versus only 8% nationwide.
• 32:07That meant an extremely high incidence of
• 32:11children infected from maternal transmission.
• 32:15As you can see here,
• 32:16that was the highest in the nation.
• 32:18Connecticut actually ranked first
• 32:20among all the states in the
• 32:22incidence of HIV in children.
• 32:25These little babies were in Yale,
• 32:27New Haven Hospital for months
• 32:29because their parents were dead
• 32:32and no one would adopt them.
• 32:34But with untiring and far reaching efforts,
• 32:38Warren and his colleagues reduced
• 32:41that transmission rate from 20%.
• 32:44In 1987 to 0% in just nine years,
• 32:50and there have been no new
• 32:54pediatric HIV cases in New Haven.
• 32:58From that time on.
• 33:01Another remarkable Yale contribution.
• 33:04But even with the most
• 33:07dedicated efforts nationwide,
• 33:09the childhood death rate from HIV marched
• 33:13ever higher to a peak in 1993 to 1995.
• 33:19And in many ways,
• 33:21the social prejudice against these
• 33:24children was even harder to combat.
• 33:28And now the third novel in
• 33:31the 90s makes a difference.
• 33:34Other women's children by
• 33:36Perry class herself,
• 33:38a pediatrician at Boston
• 33:40City Hospital doctor class,
• 33:42told the story of of an HIV infected
• 33:45little boy and the female physician
• 33:48who cares for him until he dies.
• 33:51And once again the Union of Science,
• 33:55the novel and public opinion.
• 33:58Began to turn the tide.
• 34:00Deaths began to decline and
• 34:04people embraced these children.
• 34:07And the contributions continue.
• 34:11Disseminated here is a list
• 34:14of recent New England Journal
• 34:16publications with authors,
• 34:17some now deceased from Yale's
• 34:20Department of Pediatrics.
• 34:22I certainly hope I didn't miss
• 34:24anybody in this recent recap.
• 34:27Congratulations. Yes, congratulations.
• 34:31Global child mortality has decreased
• 34:37elevenfold from 1800. To 2017
• 34:44but global childhood mortality is
• 34:48still astounding in its excess.
• 34:525.2 million childhood
• 34:55deaths worldwide in 2019.
• 34:58And the different shades
• 35:00of red on this graph.
• 35:03And in fact, this whole talk.
• 35:06Really focuses our sites on disparities.
• 35:12We overcame the disparity that
• 35:14saw a child as essentially
• 35:17worthless compared to an adult.
• 35:20We conquered at least in wealthier
• 35:23nations the disparities that
• 35:26dictated death by infection.
• 35:28If the gross domestic product per
• 35:32capita is greater than 20,000.
• 35:36Our children now die from accidents,
• 35:40guns and suicide.
• 35:43While on the opposite side of this slide,
• 35:46just as in the novels of Dickens.
• 35:49Children in economically disadvantaged
• 35:52countries die from infections.
• 35:59And even in this country,
• 36:01in the age of COVID,
• 36:03we must be vigilant for the
• 36:05disparities and health systems,
• 36:07the disadvantaged, some,
• 36:09and not others. Of a
• 36:131341 deaths from COVID in children
• 36:16age 0 to 18, recently tabulated
• 36:18by the CDC in March of 2022,
• 36:22the age adjusted risk of
• 36:25death in American Indian,
• 36:27Hispanic, Native, Hawaiian,
• 36:29and black children is twice
• 36:31that of white children.
• 36:36And with Miss C, Whether you read
• 36:39the earliest report in the New
• 36:41England Journal in June of 2020,
• 36:43or a multitude of subsequent publications,
• 36:46you know that Black and Hispanic children
• 36:50account for more than 60% of cases.
• 36:56So I'll conclude this
• 36:58talk with one last book.
• 37:01Jonathan Kozol's death at an early age.
• 37:05Yes, I took the title of this talk from his
• 37:09book and it is unfortunately not an official,
• 37:13but rather the appalling indictment
• 37:15of the Boston Public School system.
• 37:18Published in 1967,
• 37:20I saw it first hand when I was a resident.
• 37:24I was the school doctor in a
• 37:27Roxbury elementary school in 1977.
• 37:29And over the past 55 years since
• 37:34the publication of Cosal's book,
• 37:36Our Educational Systems have not yet
• 37:39found an answer that includes everyone.
• 37:43When we talk about death at an early age,
• 37:46we must consider not only
• 37:49infectious diseases,
• 37:50but the slow suffocation of a life.
• 37:53When the educational system fails.
• 37:56As Kozal himself has said.
• 38:00I don't know if anything I write will endure,
• 38:04but I do try to write it as a narrative
• 38:07that will not only challenge,
• 38:10but also entice the reader
• 38:13into the lives of children.
• 38:16The writers whom we've discussed today
• 38:19and your Yale colleagues past and present,
• 38:22the people whom we applaud from our hearts,
• 38:26have been enticed into the lives of children
• 38:29and have revolutionized their future.
• 38:33Child death is no longer accepted as a given.
• 38:37Novels and science helped to
• 38:40drive this change in perception.
• 38:44But even today,
• 38:45children must be pushed to the
• 38:48forefront of public consciousness
• 38:50both globally and locally.
• 38:52Can we see it? Fix it.
• 38:56Prevent it, disseminate it.
• 38:59These children are looking to us to do it.
• 39:04Grover Powers would tell
• 39:05us that we have to do it,
• 39:08and I have every conviction that we can.
• 39:13Thank you.
• 39:17Peggy, thank you. That was an
• 39:20amazing tour to force and combining.
• 39:24Obviously your your
• 39:26experience with literature.
• 39:29It was just so moving and you
• 39:33know to me also made me rediscover
• 39:36during you know your presentation.
• 39:39Just how important a child's life is.
• 39:43And so you know just a couple of questions.
• 39:47So, so first of all, feel free everybody
• 39:50to pose questions into the Q&A.
• 39:52But in terms of the larger
• 39:55perception of children,
• 39:57I go back to that graph that you
• 40:00presented from the New England
• 40:02Journal and the percentage of
• 40:04articles on children just.
• 40:05Decreasing,
• 40:06do you think that there's also
• 40:08a perception on the part of the
• 40:12larger community of medicine that
• 40:14children perhaps are not as important
• 40:16as adults or given less weight?
• 40:20Well, I think that's a terrific question.
• 40:24You know our search strategy that Tim
• 40:29Schwartz so kindly put into effect,
• 40:32looked only at the words
• 40:34Pediatrics and Pediatrics.
• 40:36We didn't look at the words children or
• 40:39childhood we might have seen an upswing
• 40:43in those later eras if we had been
• 40:47more inclusive in our search term, but.
• 40:50I think you raised a very important point.
• 40:54What if indeed there is a falling
• 40:58off of articles about children?
• 41:01You know it maybe that the pendulum
• 41:04has now swung in the opposite
• 41:06direction and people are saying, well,
• 41:09Gee, children are pretty healthy.
• 41:12You know they're not a lot of
• 41:15articles that need to be written,
• 41:18and that could be 1 explanation.
• 41:20Another explanation could be that
• 41:23the pediatric section which the
• 41:26New England Journal, for example,
• 41:28inaugurated in 1954 and then discontinued,
• 41:32has left a void other than our
• 41:37pediatric journals.
• 41:39Which are, you know,
• 41:41doing an excellent job of trying to fill it,
• 41:44and thirdly, I think.
• 41:49We do have to again worry that with
• 41:53all of the how should we say with
• 41:57all of the attentions that the
• 42:00pandemic has brought to the deaths.
• 42:04For example of productive adults
• 42:06and senior adults,
• 42:08the relatively the very small number
• 42:11of childhood deaths has again
• 42:14focused attention elsewhere, so yes,
• 42:17that's why I really wanted to give.
• 42:20Umm,
• 42:21an exhortation that I knew this
• 42:24department would be so great at carrying out.
• 42:28It's time to start pushing children
• 42:29to the front of the line again.
• 42:32Yeah, totally agreed.
• 42:33I mean, I just I think about NIH
• 42:36funding in terms of Pediatrics.
• 42:38I think about, you know,
• 42:40on the adult side,
• 42:41how the increase in terms of the number
• 42:45of adults over the age of 65 and the
• 42:49population swing will give less, I guess.
• 42:54Support to issues that affect
• 42:56children and funding to
• 42:58research that affects children.
• 43:01I think you're absolutely right.
• 43:02And of course, you know in the political
• 43:05arena probably the most important
• 43:07lesson is children don't vote.
• 43:11Peggy, Peggy, and by the way,
• 43:13I hope that you're looking at all
• 43:15the strings of commendations and how
• 43:18amazing this this session has been.
• 43:22A question from Mustafa Akoka.
• 43:25It's all starting with Peggy,
• 43:26so good to see you again.
• 43:29If we're in the dissemination era now,
• 43:31what era is next?
• 43:32Where do you think the future
• 43:34is going for Pediatrics?
• 43:37Oh, and that's a wonderful question.
• 43:40I mean, obviously my graph stopped in
• 43:432012 and that was ten years ago and I
• 43:46really do have to think because of so
• 43:49many of the reasons that canina mentioned,
• 43:53you know, just just look.
• 43:55For example, you know at the economics
• 43:59of medicine as to how reimbursement for
• 44:03children's care compares to reimbursement
• 44:05for adult care even for the same.
• 44:08Procedure I think for the last 10 years
• 44:12we've been perhaps in an era of abeyance,
• 44:16and I think it's time to start
• 44:20the race again.
• 44:21You know, I've I've often thought
• 44:22who's going to be the next Dickens.
• 44:24That's what we need right now and I
• 44:28don't know who that is going to be.
• 44:32That's a good point.
• 44:33I was thinking the same.
• 44:34What's the next novel
• 44:35that needs to be written?
• 44:37What is it need to address?
• 44:42I think it needs to address, you know,
• 44:45some of the themes that have been
• 44:48beautifully done by Dickens,
• 44:50and particularly by
• 44:51Perry's class disparities.
• 44:53Because I think if we say that all
• 44:57children are somewhat disadvantaged by
• 45:00not being able to vote, for example,
• 45:03and by not being able to earn income.
• 45:08Then there are particular groups of
• 45:11children who are even more disadvantaged.
• 45:14And so I think that next novel
• 45:17really needs to emphasize some of
• 45:20the disparities that are really
• 45:23causing some groups of children
• 45:25to suffer more than others.
• 45:29Thank you Peggy. And so while
• 45:31we're waiting for that next Nob,
• 45:34what what can we do? As you know,
• 45:40individual pediatricians or
• 45:42alternatively as a department.
• 45:46What what recommendations can you give?
• 45:49Yeah, so I. I certainly don't have.
• 45:54A prescription pad,
• 45:55but I think on the individual
• 45:58sense I've become more and more
• 46:02convinced of the importance of.
• 46:05Education you know, for the most part,
• 46:07children are wonderfully healthy
• 46:09and they're going to be spending.
• 46:11We hope a lot more time learning in school
• 46:14than in a hospital or a doctor's office.
• 46:17And so can we as pediatricians facilitate.
• 46:24Medical care in the schools.
• 46:27School based health centers.
• 46:29I know you have some Yale.
• 46:31We had some at Cincinnati and those school
• 46:34based health centers when I toured them
• 46:37in Cincinnati were really remarkable.
• 46:39They had the best vaccination
• 46:41rates of any districts in town.
• 46:43Their asthma admission rates were the
• 46:46lowest even compared to some of the
• 46:48high income districts in Cincinnati
• 46:50and that was because the medical
• 46:52care was right there in the schools.
• 46:54So that's one thing I've also become
• 46:57convinced of the importance of reading,
• 47:00and I know Jeff Gruen gave a wonderful
• 47:03grand rounds just a short while ago,
• 47:06you know.
• 47:07And I was preparing for this talk.
• 47:09I looked up some of the numbers about
• 47:12illiteracy in the United States.
• 47:14We are about ranked in.
• 47:17There are 70 to 80 countries who have a
• 47:20better literacy rate among adults that we do.
• 47:23We have 14% of adults who are judged
• 47:27functionally illiterate and so one
• 47:29of the things I'm gearing up to do is
• 47:32to join one of the reading tutoring
• 47:35programs here in New York City to see
• 47:37if I can be of any help with little
• 47:40children who might be struggling with that.
• 47:43So I think there are several things.
• 47:46I've named just a few that that might
• 47:49be helpful as we try to put an end
• 47:52to that era of abeyance and get back
• 47:56into an era that's more active and
• 47:59driven by Pediatrics and pediatric
• 48:03organizations that are conscious of
• 48:05what needs to be done for children.
• 48:08Thank you and the question for Mel Friedman.
• 48:11Wonderful presentation, Peggy.
• 48:12So good to have you back at Yale.
• 48:15Would you share what current literature
• 48:17you're reading now and what's inspiring you?
• 48:21Ah, OK, well you know I always have
• 48:25to dip back into the 19th century.
• 48:30So recently I restarted Jane Eyre
• 48:33and for those of you who may not
• 48:37have read that novel in a long time,
• 48:39and that would be me as well.
• 48:42You know the first several chapters
• 48:45talk about her life as an orphan at
• 48:49a really barbaric school and it is.
• 48:52It was so scary I had to stop.
• 48:55I thought to myself how did I
• 48:57read this when I was 18 and not,
• 48:59you know and not be able to handle it.
• 49:01Now another reading,
• 49:03another book that I'm reading is called
• 49:07whatever it takes and this is by Paul tough.
• 49:12And it's the story of Jeffrey Canada
• 49:14and he he recently hit the newspaper
• 49:18because his Harlem children's zone got
• 49:21$100 million from Michael Bloomberg,
• 49:23as did Eva Moskowitz's success Academy,
• 49:25and these are two great charter
• 49:28school systems in New York City,
• 49:30Harlem Children's Zone.
• 49:32Dedicated entirely to the children of Harlem,
• 49:36but the book, whatever it takes,
• 49:38talks about Jeffrey Canada
• 49:41starting her own children's zone.
• 49:43Back in the early 70s and the
• 49:47difficulties he went through,
• 49:49it's very honest about,
• 49:50and he's very honest about the mistakes
• 49:53he made and then the tremendous
• 49:55success that eventually was his.
• 49:58And then I'm also reading another book.
• 50:01Called the wide Sargasso Sea,
• 50:04which is by Gene Reese,
• 50:07RH YS,
• 50:08which is it's a novel and it's the
• 50:13story of a young woman who becomes
• 50:16the wife of Mr Rochester from Jane
• 50:20Eyre and she is from a Caribbean
• 50:23nation and it talks really then
• 50:26about the disparities again between
• 50:28a man and a woman between a.
• 50:32Gentleman from England and
• 50:33a woman from the Caribbean,
• 50:35and of course, as we all know,
• 50:37Mr Rochester eventually puts
• 50:39her in the attic in Jane Eyre,
• 50:42and so not a great outcome, but this book.
• 50:46This novel was developed as
• 50:47the prelude to Jane Eyre,
• 50:49so all those are the those are
• 50:50the three I'm reading right now.
• 50:54OK, and and I just wrote in the chat.
• 50:57Just, you know, Peggy wonderful
• 50:58talk and this is so true.
• 51:00Children don't load, it's the AP is
• 51:03said vote for children even better.
• 51:05Perhaps we should form a new
• 51:07political party children first.
• 51:09We should tweet right up
• 51:10EDS and make some noise.
• 51:12Hashtag children first. Wow.
• 51:16That's a great idea. I mean I, I think.
• 51:21I think it's going to take that kind
• 51:24of activism to get us back into
• 51:27a more active era in Pediatrics.
• 51:31That's great and cheap
• 51:33deep actually wrote one.
• 51:35Then hopefully I'll get this one right,
• 51:38but obviously so great to see you.
• 51:39Thanks for your wonderful talk.
• 51:41And as you know Judy is mid peace
• 51:44because of improved survival to adulthood
• 51:47in children with chronic disease.
• 51:48This of childhood.
• 51:50Is it possible that landmark trials
• 51:52are being done in adult first
• 51:54with follow up studies and kids?
• 51:56Take cystic fibrosis as an example.
• 52:01Yeah so.
• 52:04Hmm. Was your question JD?
• 52:08Was it more the idea that you
• 52:10know we always do the trials and
• 52:12adults 1st and then we move to
• 52:15children and sometimes that can be
• 52:17very quick or relatively quick.
• 52:19As with the COVID vaccines.
• 52:22Or sometimes it can take a very
• 52:24long time was was that the question
• 52:28or I I might have actually missed?
• 52:31What you wanted me to address?
• 52:34No worries, I think that that's I think
• 52:36that's fair enough to address Peggy.
• 52:38I think it'll be hard to
• 52:40get some clarification,
• 52:41so I if you address that,
• 52:42that would be great. OK,
• 52:45well you know, I think again, you know.
• 52:49Protection of children is our responsibility.
• 52:51That was certainly a theme of
• 52:54the vaccine era starting in the
• 52:561930s and and some people since my
• 52:58middle name is Kendrick have asked,
• 53:01was I related to Pearl Kendrick
• 53:03who developed the diphtheria toxin?
• 53:04I wish I were, but I'm not.
• 53:07So I think protection of children
• 53:09and I'm not a clinical trialist,
• 53:13but I think that's one of the reasons.
• 53:15Why? Clinical trials in children are
• 53:20approached with such great care.
• 53:23I think the downside of that if
• 53:25if one could even call it that is
• 53:29that that sometimes then postpones
• 53:31that trial or hampers its start.
• 53:36I think we saw in the pandemic
• 53:38that a child a very effective
• 53:41children's trial of a vaccine,
• 53:44can occur right on the
• 53:46heels of the adult trials.
• 53:47But we haven't seen that
• 53:49with some other diseases.
• 53:51So yes, JP, I think it's an important point.
• 53:55There may be.
• 53:58Lot of time lost between the
• 54:01adult trial and translation to
• 54:03children who have the same disease.
• 54:06Great and it looks like JD actually
• 54:09appreciated your response,
• 54:10but you must have hit the right.
• 54:13The right response on that one.
• 54:16But thank you so much,
• 54:18Peggy really appreciate you sharing
• 54:22your very wide perspective.
• 54:25You know, especially from
• 54:28the literary standpoint.
• 54:30With that assault and kind of
• 54:32putting us into history and the
• 54:35history of childhood health,
• 54:37so you know,
• 54:38thank you so much for agreeing to
• 54:42be our group of powers lecture.
• 54:46Well, thank you planning and I just want
• 54:49to say to the department being with
• 54:51you for those years 1998 through 2010.
• 54:54Some of the happiest pediatric
• 54:56times of my life.
• 54:58You are a tremendous group of
• 55:02highly dedicated pediatric
• 55:04professionals and I congratulate
• 55:06you on your 100th anniversary.
• 55:08Thank you Peggy.
• 55:09We congratulate you on your semi
• 55:12retirement already looking for ways to
• 55:14integrate you more into the department.
• 55:17Maybe if you take a break from your from
• 55:20your reading sessions would certainly
• 55:22love to have you back to share your
• 55:26expertise and perspective and for
• 55:28everybody else Please remember we have
• 55:31pediatric research forum starting at
• 55:331:15 till about 2:00 o'clock and it'll do it.
• 55:37The session is.
• 55:38The heart and soul of the matter.
• 55:40It'll be moderated by Tina
• 55:42Brechner and Jason Greenberg.
• 55:44As so, please join us and
• 55:46Peggy thank you again.
• 55:47Really just an absolute tour to force.
• 55:51Bye bye alright take care.