[Casey Kernan]

Question #2: Why, in your judgment, is pediatric HIV control lagging behind that of adults and what should be undertaken to reverse this status?
Pediatric HIV control lags behind that of adults partly due to the lack of optimal ART. There are fewer available ART options today for children than there are adults. Not only are these current formulations more toxic to children, they can be difficult to administer. We need more research and funding in new safe, effective and easy to use ART formulations. Kids can also be rapid progressors and experience the ill effects of HIV/AIDS far quicker than their adult counterparts. We need to identify these children at risk earlier. This identification starts during preconception counseling and pre- and postnatal care. More comprehensive family-centered approaches can identify those at risk and help prevent further exposure and infection.

[Casey Kernan]

Question #1: From your perspective, what are the largest remaining barriers against worldwide HIV control?

During medical school I had the opportunity to do an LGBTQ rotation in Los Angeles. I was introduced to the HIV treatment cascade also referred to as the HIV care continuum. This represents a continuum of HIV care from the initial stage of getting tested to being able to suppress the virus through treatment. It can provide a framework to identify gaps in care. It starts with individuals living with HIV being tested and diagnosed. Of those that are diagnosed how many are linked to appropriate medical care, how many are retained in care, how many receive ART, how many are able to adhere to treatment and how many suppress the virus? With each step in the continuum, the number of people or percentage that progress along decreases as people are lost to care. I think the largest barriers for HIV suppression and ultimately eradication lie in the virus itself (immune evasion, development of resistance through mutation), the continuity of care and the stigma. Looking at this cascade within a community can help identify what resources are necessary to move those infected along this cascade. Reduction of stigma, education and widespread testing is key to placing those on the cascade in the first place. Prenatal care seems to be one important area where wide spreading testing should be focused.

[Casey Kernan]

Alice I enjoy reading your responses. You bring up many interesting points. Your example of Chagas disease in Bolivia really confirms the importance of prevention. These children being born to mothers and acquiring infection vertically is a challenging dilemma. I agree that there needs to be larger focus on identifying disease earlier, which can be challenging when it presents asymptomatically. Preconception counseling and prenatal care testing can identify women that are seropositive and their children should be tested early at the 1st month of life but also at 6 and 12 months of age. If treated early, the clinical response appears to be quite good. This close follow-up can help identify those that need treatment before it again is transmitted. While conceptually this seems pretty straightforward, improving access and databases to accomplish this is difficult.

[Casey Kernan]

Question #1: From your perspective, why are people living in poverty most likely to suffer from TB, and how should this fact influence efforts to control the disease?
Social determinants of health play a role in TB and poverty is very closely linked. It can become a self-fulfulling prophecy in some sense. TB is much more prevalent in areas where people are living in density and close quarters. Multi-generation families may need to live together to afford shelter. When one member gets TB it can be financially destabilizing for the rest (especially if they are carrying the financial weight of the family and need to leave the work force). These members may lack access to appropriate medical care, antibiotics that work and follow-up to insure compliance. The medications must be taken for months. Those in poor areas may lack the education and understanding to take their medications appropriately and prevent the disease in the first place.

Question #2: What, in your opinion, are two interventions that would be most effective against neglected tropical diseases?
I agree with the article about uni-dimensional strategies (mass drug administration) and their only temporary solution to management and eradication of NTD’s. We need to address these health concerns through funding of education, improving infrastructure and treating the underlying causes. Research and development funding for only medication is not a sustainable solution. Interventions that create stability and long-standing change include the community that lives and experiences these diseases daily. The first intervention I propose is increasing the role of community participation. We need to elect city leaders to be champions and experts about these diseases. This will mobilize community members, enhance understanding of transmission and create a sense of ownership to these problems. More people will start to understand the transmission of disease and it will slowly change behavior (ie. not allowing kids to swim in snail infested waters). This brings me to my second intervention which includes the provision of safe water, sanitation and hygiene. The communities should have water chiefs and be provided with the tools and resources to create clean water infrastructure. This empowerment and knowledge among the community itself will allow them to maintain this system and teach the importance to generations to come. This is especially important because the transmission of most NTDs is closely linked to poor water, sanitation and hygiene (schistosomiasis, trachoma, lymphatic filariasis).

[Casey Kernan]

Abigail, I totally agree with you. One of the biggest barriers to measles eradication is access. Access to primary care and pediatricians in research rich countries is a problem and access to vaccination programs in resource poor countries due to transportation, poverty, conflict and strive all contribute. The disease spreads very quick and we must make access to immunization easier for all.

[Casey Kernan]

Question #1: What system-wide changes, in your opinion, would most successfully increase world-wide food security?
World-wide food insecurity is complex and I believe that finding sustainable solutions requires identification of the underlying cause first, which is somewhat different for every nation. Causes like political instability, civil strife, poverty, population growth, inadequate education, poor health and climate change are some of the big contributors. Empowering local communities and improving the availability of food through improved agricultural practices while understanding the climate and resources available is key. Education about disease prevention and management, including proper sanitation and hygiene practices, improves and protects food so that it can be utilized and consumed without significant waste. We need creative policies that incentivize families to produce their own food and promote young children into agricultural fields. Here at home, I think we can do our part by reducing our intake of meat and dairy products, buying local and eliminating waste. Food hunger is a complex problem with changing variables. Most importantly we all need to recognize and do our part.

Question 2: What do you believe are the most substantial barriers to global measles elimination, and how can these be overcome?
As a practicing family medicine resident in the Pacific Northwest, I witness the mistrust and reluctance toward vaccination among parents, nearly monthly. With the spread of misinformation on the internet and stories that families hold onto, it can be very difficult to convince parents to vaccinate their children. Many of these parents have not witnessed or know the true severity of disease. We should learn from strategies that successfully eradicated polio in 1977; however, one substantial barrier is the characteristics that set measles apart from other infectious diseases. The basic R0 or reproductive rate for measles is very high, often >10. Coupled with increased global travel and it’s high infectivity rate, it will be more difficult to eradicate. Globally we must strengthen routine immunization and surveillance systems while supporting follow-up SIA’s to achieve immunity. Educating those in resource rich communities while supporting and improving immunization surveillance and SIA’s in resource poor areas is equally important. Widespread use of an oral measles vaccination could allow it to be administered more widespread and rely less on trained professionals and volunteers.

[Casey Kernan]

Hi everyone, my name is Casey Kernan. I am a 3rd year resident in a family medicine program on the Kitsap Peninsula in the Puget Sound. I grew up on a small farm in Oregon and initially wanted to be a veterinarian. Through college my love for animals continued to grow but I quickly learned that I enjoyed the connection and relationships that are built in primary care. During a global health outreach trip to rural Honduras, my passion for serving communities came to fruition. I quickly noticed illnesses that had long ago succumbed to modern medicine back home, yet continued here unopposed. I realized that the sustainable answer to their problems was not in treating the disease but in going after the cause. Causes which could often be addressed through quality education, sound infrastructure and clean water. With that realization in mind, I initiated a water brigade at Oregon State University, establishing a partner chapter that focused on providing access to clean water in Honduran communities. Collaborating with experts and community leaders, I led twelve students in implementing and constructing a clean and effective water system. Our work not only provided the communities with access to clean water, but naturally reinforced the communities commitment to preventative medicine.

My experiences in Honduras did allow me to recognize the impact of social, economic, environmental and political factors that create health disparities. After my global water brigade, I returned to Honduras for the third time with the same goal in mind, but guided by a new approach. Our mission this time focused on building public health infrastructure and empowering the rural Honduran communities. After these communities have received access to clean, sanitary water it is important that they have the tools, infrastructure and knowledge to maintain this vital resource. This time, our work was much more personable and we had the opportunity to work alongside the Lopez family, consisting of three generations. The relationship we developed over the short time we had spent with the family was remarkable. The genuine appreciation and thanks were quite apparent as the family embraced us with hugs, tears and prayers upon our departure. Through experiential training my goal is to experience this connection again, far from home with children, families and those at death’s doorstep. This human connection drives me and reminds me why I have chosen medicine as a career. Ultimately, my goal is to continue my practice here in the PNW and use it as a home base for adventures and global work abroad.

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