[Susan Swedo]

Q #1 – Dr. Burdick describes qualities of effective programming and global collaboration. What barriers exist to expansion of faculty development programming in LMIC (low and middle income) settings?
Dr. Burdick mentions three challenges – aligning the programming with local needs, developing persistent dependency on external faculty, and distrust of “outsiders”. In addition, I think that a major barrier might be the tension between the reactive nature of clinical medicine and the proactive nature of faculty development. Clinicians are trained to react to the patient in front of them – observe, evaluate, deduce a diagnosis and treat accordingly. This focus on reacting to the “here and now” stands in stark contrast to the long-term investment required in faculty development. Busy clinicians often view the time spent learning new techniques as “wasted” because current methodologies are “good enough”. As mentioned in the article, academic clinicians are reluctant to invest time in a “faculty development” project because it isn’t publishable, doesn’t directly contribute to patient care, and often has been initiated as a top-down effort to solve a problem of which they’re unaware. Finally, there are no financial incentives to these projects. The participants are rewarded with “reputational benefit” of being a “giver” and “the value of giving is apparent when returns are measured in breadth of impact. This is especially true in education capacity building, where each participant may reach hundreds of students. When participants’ faculty development facilitation skills are strengthened, they may influence hundreds of teachers, who in turn will reach many hundreds more students.” (Burdick quoting Adam Grant in Give and Take.) While this a laudable end result, it seems too esoteric to convince “midcareer faculty” in a busy teaching hospital to carve out time from patient care, research, administrative duties and current teaching assignments to take on the responsibilities of being part of a ”global community of educators”. Instead, it seems more practical to approach faculty development in the way Burdick describes under “Projects that work” – help participants identify local problems in their healthcare delivery system and teach them how to solve them by working through the process together. Even then, I would suggest enrolling senior faculty in the program, rather than midcareer faculty who are simultaneously struggling to deliver high quality clinical care and to achieve scientific independence (tenure in some institutions). The senior faculty would have more time to devote to the project and at least in theory, be in a position of greater power and influence so that they could ensure that the project’s improvements are adopted by trainees and junior faculty.

Q #2 – Which habit of exemplary clinical teaching is translatable to education in LMIC (Low and middle income settings)? Can you provide an example of effective implementation from your own experience?
I think that all 8 of the habits suggested by Dr. Reilly are translatable to education in LMIC. Physician educators have to both “TALK the talk” and “WALK the walk” if we want our students and trainees to become the kind of doctors that we would want to deliver our care. One of the best teachers I ever had was a general surgeon when I was a third year medical student. I had no interest in doing surgery, but he was so passionate about his profession and so compassionate with his patients, that he made me want to learn. Further, he was masterful at the first point, “Think out loud”. He shared his observations, explained the rationale behind choosing a particular surgical approach – or suturing methods, and encouraged us to ask questions. Having him share the questions he’d asked himself made it much easier for us to ask questions of him and then generalize the information from that specific patient to the general condition. Another reason for teachers to verbalize observations and thought processes is to teach critical thinking skills – the deductive and inductive processes that go into establishing the differential diagnoses and then narrowing those to the most likely “working diagnosis” are not instinctive, but can be learned when teachers “think out loud”.
“Keep it simple” goes hand-in-hand with thinking out loud. When a person really knows their craft, they can explain it in a way that even a third grader can understand it – those who depend on acronyms, long complicated explanations and obscure references are not only bad teachers, they’re probably bad doctors because they haven’t taken their (egg)head knowledge and translated it into clinical care. Our internal medicine professor belonged to this group. He rewarded the students who could quote a semi-relevant statistic/finding from this week’s NEJM, but had no tolerance for those of us who wanted to know why the fact was relevant to this patient and how we were to develop a treatment plan. THe patients were even more clueless at the end of rounds than I was — fortunately, the nurses had enough experience to act as translators for the patients and for me. The final bullets – “Link learning to caring” and “Kindle kindness” are particularly important when teaching in LMIC as they require us to be culturally sensitive, humble, and respectful in both our teaching and clinical care. I loved the example that Dr. Reilly gave of the doctor who noticed the patient’s sweat-soaked gown and changed it – and fluffed the patient’s pillow. It is those small acts of kindness that are needed to teach compassion and kindness to others. Had the physician merely told the nurse “I noticed that this patient’s gown is damp – change it”, the lesson would have been quite different.
In summary, I believe that each one of the 8 bullet points is translatable to a LMIC setting because they are all based on the premise that outstanding clinical teachers are not only knowledgeable clinicians and gifted teachers, but also empathic and compassionate human beings.

[Susan Swedo]

Barry — I agree with your comments in response to both questions. Lack of personal responsibility is a major barrier to effective HIV prevention. In addition to the reasons you mentioned, I think that fear plays a huge part in the “refusal” to get HIV testing. People who have had unprotected sexual encounters realize that they’ve made themselves vulnerable and are afraid to find out they’re HIV positive because they assume that means they already have AIDS. I think that education campaigns should discuss the differences between HIV positivity and the disease of AIDS, and emphasize the importance of starting ART therapy early. The campaign could emphasize that being HIV+ isn’t the problem – the problem is being HIV+ and not taking medications that can decrease your viral load to the point where your disease isn’t progressing (and where you won’t be infectious – unfortunately, as we saw with mask-wearing during COVID-19, protecting others doesn’t seem to be sufficient motivation to encourage someone to use a condom, much less take twice a day medications.)
Your comments about MTCT made me wonder about the 10% of children who are HIV positive without having been infected during pregnancy, labor/delivery or by breastfeeding. Since they didn’t get HIV from their mothers, they had to have acquired the infection through sexual activity – and since they’re still children, even if “consensual”, it meets the definition of sexual abuse. Premature sexual activity and full-blown sexual abuse is a major problem worldwide. You mentioned your time in Malawi – one of my daughters was there as a CDC EIS Fellow and looked at adverse childhood experiences in 595 girls and women (ages 13 – 24 yrs) who had ever had sex; 232 (39%) reported that they had experienced forced sexual initiation, often accompanied by physical and emotional abuse. Nearly 40% of the young women had been virgins when they were raped – if the sexual assault left them with an HIV infection, they were at risk of developing AIDS through no fault of their own. No amount of education of counseling about the ABCs of HIV control would have helped them prevent the infection. Only systematic, cultural changes in the way women are valued and treated, and children are treasured and protected will reduce HIV transmission in these cases.

[Susan Swedo]

Question #2: Why, in your judgment, is pediatric HIV control lagging behind that of adults and what should be undertaken to reverse this status?
I appreciated the thoughtful comments of my classmates and agree that there are many factors negatively impacting HIV control in children — of these, I think the greatest barrier is probably the overwhelming need to deal with life-threatening acute illnesses and conditions. When children are dying from measles, diarrhea and severe malnutrition, it’s hard to pay attention to an HIV infection that won’t become problematic for 3 – 5 years. Aside from the public stigma associated with HIV infections, there is also the mom’s shame and guilt for having given her child this fatal illness (even if she acquired HIV through a forced sexual encounter). While her child looks healthy, she’s able to deny the truth of the illness and understandably, may choose to ignore the child’s HIV infection (if it’s even known), until it’s too late to intervene successfully.
I think there is an additional issue that compounds the problem – the macroeconomics of pediatric healthcare. Throughout modern history, childhood illnesses and disabling conditions have received less government research funding and less therapeutic development by pharmaceutical industries then adult diseases of similar severity and import. As one of my colleagues would say, “Children are always going to be ignored by the government and private industry – they can’t vote, they don’t pay taxes, and their allowances are too small to pay for fancy drugs.” While both frivolous and harsh, there is truth in the comment. Investment in pediatric diseases has never reached levels comparable to those of adult diseases with similar morbidity, mortality and DALYs lost. Despite this, great progress was made in finding ways to decrease MTCT – in some countries, to nearly zero! Dissemination of that knowledge and implementation of those practices will require major investments in pediatric healthcare, maternal education and services provision. We must also strive to ensure that any treatment gains that are made for HIV infection and AIDS in adults are immediately translated into similarly efficacious pediatric treatments — one simple way to do this is to reinstate/reinforce regulations requiring pharmaceutical companies seeking FDA approval of a new medication/therapeutic intervention to begin pediatric trials as soon as the Phase IIIA adult trials are completed. We may also need to continue using the COVID-19 model of buying licenses for key drugs/tests/vaccines with federal funds to ensure that they remain available at no/low cost.

[Susan Swedo]

Question #1: From your perspective, what are the largest remaining barriers against worldwide HIV control?
I think that the biggest remaining barriers to controlling HIV are human nature and the nature of the disease — specifically, the fact that the initial HIV infection comes from a (hopefully) pleasurable encounter and the infection remains asymptomatic for 8 years or longer.
As we learned in Lesson 2, at least one-half of HIV control is dependent on changing behaviors to decrease risk of transmission. The NIMH and other institutions have spent millions on research to determine what is the most effective strategy for increasing the number of people who know the basics of HIV tranmission and how to prevent becoming infected and practice safe sex. Of the behavioral interventions tested, the best outcomes were reported with intensive messaging about the ABC’s of HIV control — Abstain. Be faithful (and if not…) Be tested. and Condomize (correctly and consistently). Unfortunately, B and C contradict A and immediately raise questions about feasibility and utility of any of the advice. I have further concerns that control measures which depend on abstinence as a cornerstone will fail. As an example, we can recall the laughable futility of Nancy Reagan’s “Just Say No!” campaign against drug use, or the continually rising rates of teen pregnancies, despite early and repeated educational messages touting abstinence as the only 100% safe contraceptive method. And those campaigns were aimed at problems with immediate consequences of the behavior — with HIV/AIDS, the threat doesn’t become real for 8 – 10 years. This extended time lag is particularly problematic for teens, as they often complete pubertal sexual development before they’ve fully transitioned cognitively from concrete operations to abstract thinking. Until teens are able to truly understand “if–then” statements, and grasp the complex nature of time, there is no way that they can/will decide to abstain from something pleasurable today just to avoid something that may or may not harm them when they’re “old” (like in their 20’s – 30’s.) In addition, many of the youth still have magical thinking, so they honestly believe that wanting something to be true will make it so – they don’t want to get HIV/AIDS, so they simply believe that they won’t. As a vivid example, I can recall a 15 year old homosexual male who came to my clinic in Chicago in the late 1980’s for treatment of an STI (his third). As I talked with him about the importance of practicing safe sex to prevent another STI or the newly discovered threat of an HIV infection, he mumbled, “Well if I get HIV, you’ll just treat it like you did the gonorrhea and syphilis and I’ll be fine.” I explained that wasn’t possible because there weren’t any treatments, much less a cure for HIV and that it always led to AIDS and eventually, death. I told him the only way he could be sure he’d be safe is if he abstained from sex with new partners – he said, “That’s not happening, try again.” So I told him that he had to use a condom “all the time, every time” and he said, “Sure Doc, whatever you say” and bolted from the exam room. A few months later, he was back with another STI, and I tried again to educate him about HIV and the dangers of an incurable disease like AIDS. This time, he interrupted me sooner by saying, “You can save the speech, Doc, I’m not going to get HIV. But even if I do, it won’t turn into AIDS because they will have found a cure by then.” I replied, “Possible, but not likely. If you get HIV now, you need to know that you’re likely to get AIDS and it will kill you. Not tomorrow, but definitely in the next 10 years or so.” “Well then, I definitely don’t have to worry about it — 10 years is like forever from now. I’ll be so old by then, that if AIDS didn’t kill me, I’d die anyway from a heart attack or something (at 25!)”
That conversation occurred more than 35 years ago and we still don’t have a cure for HIV/AIDS, nor have we figured out how to protect youth from themselves. Even in Uganda, the best example of behavioral interventions, prevalence rates remained at 6 – 8% of the adult population – that’s too high for an infection with a 100% mortality rate. Perhaps it’s time to treat HIV as an infectious disease, rather than an STI, and AIDS as a pandemic of greater important than COVID-19. At the least, we need to rebalance the HIV prevention equation and depend less on behavioral strategies and more on expanding surveillance and monitoring, with routine, mass testing offered at regular intervals, and free treatment provided to all those who are HIV positive (ideally with long-acting compounds that didn’t require twice a day dosing).

[Susan Swedo]

Question #2: What, in your opinion, are two interventions that would be most effective against neglected tropical diseases?
The “Blue Marble health” NTDs in wealthy nations seem like an easy target for intervention. In wealthy nations like the United States, it is unacceptable for people to suffer from diseases of poverty. Free/low-cost healthcare should be provided to all who need it, regardless of immigration status. Currently, undocumented individuals are often afraid to seek medical care for fear of being deported/separated from family members. To overcome these fears, we should invest in education campaigns and outreach efforts that assure those needing services that they can be accessed without consequence. In-school clinics could provide vaccinations and other well-child care, and perhaps even serve as a “medical home” for families in need by offering OB/GYNE and family practice clinics. We should also increase efforts to ensure that “No Child Goes Hungry” by expanding the schools’ free meals programs to provide food during weekends and school holidays.
My second intervention suggestion may be unpopular, but I think that we should revisit the use of insecticides to eradicate insect vectors. Before DDT was banned in 1972 for having unwanted health and environmental effects, rates of malaria infection had decreased in regions where it was applied during and after the rainy season. In the five decades since the DDT ban, many new insecticides have been developed that are purported to have a safe and efficacious profile. Those insecticides should be thoroughly tested by independent groups to ensure that the claims are valid and then, the chemicals that meet or exceed rigorous safety standards should be licensed into the public domain (by governments of wealthier nations or philanthropic agencies) so they can be produced in quantities sufficient to permit low-cost acquisition by under-resourced nations. Regional insecticide spraying that effectively eliminates the insect vector should result in a dramatic decrease in disease rates, as the life-cycle of the infecting organism would be interrupted prior to infecting a human host.

[Susan Swedo]

I agree with your discussion comments on TB, Suzanne, and appreciated your thoughtful analysis of the impact of crowded living conditions on TB transmission. The extended duration between acquisition of a latent TB infection and active disease may play an additional role. While most report that latent infections are non-contagious, some authors have suggested that latent infections might be “minimally infective”. For families living together in a crowded home, the extended latency period would be sufficient to transmit even a “minimally infective” organism. Even if that doesn’t occur, the early stages of an active TB infection are likely to be missed, since the catarrhal phase of TB has symptoms identical to those of the common cold and other URIs. Family members could be exposed to an active infection for days or even weeks before a TB diagnosis is suspected. Identification of individuals with latent infection and then ongoing surveillance monitoring might be helpful in reducing the period of exposure and mitigate somewhat against the crowded living conditions.

[Susan Swedo]

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?
Others already have discussed the many socioeconomic factors that increase the risk of TB for people living in poverty – poor sanitation, crowded living conditions, lack of education (resulting in increased risk of HIV transmission, among others), and malnutrition, untreated systemic diseases and other conditions that suppress immune function. I agree that all of these are important and should be addressed as long-term solutions.
However, I believe that aggressive action must be taken to help those who are currently suffering and to ensure that the 2 BILLION people with latent TB never have to suffer the morbidity and mortality of active infections. The current strategies and “social policy solutions” aren’t working. Despite the lofty goals of the 2015 WHO report and the implementation plans developed at the 2018 UN High-Level Meeting on Tuberculosis, the rate of TB cases and deaths has continued to rise, particularly among children and youth – there were 1.1 million pediatric TB cases in 2020; the year previously, there were 230,000 pediatric deaths from tuberculosis – higher than any of the previous three years. The number of TB cases and deaths is thought to have risen further during the COVID pandemic, as public health resources were diverted and access to routine pediatric care was limited or completely denied. And were those diverted resources needed to respond to a new life-threatening pediatric illness? The reported data would suggest that they were not, as most pediatric cases were asymptomatic or exhibited only mild URI symptoms. In fact, less than 0.4% of COVID deaths occurred in individuals under 20 years of age – in the 2.5 years of the pandemic, there were 16,000 pediatric deaths reported to be “associated with COVID” yielding an annual global death rate of 6,400 youth (3,010 were ages 0-9 years; data from UNICEF website for period ending September 2022). Throughout this period, the risk of a child dying from TB was at least 36 times greater than their risk of death from COVID. When adults are factored into the statistics, the ratio reverses, but the gap narrows significantly, with approximately twice as many COVID deaths (3 million) as TB deaths (1.5 million) reported globally in 2020. Spending on TB research that year totaled $915 Million, while more than $104 Billion had been spent in the first 11 months on research and development of COVID test kits, vaccines and therapeutics (114 times as much as TB).
As we know, the huge investment in SARS-CoV-2 research paid off, with brand new vaccines and antiviral therapies being invented, tested and released in record-breaking time. Much of the research funding was provided by the U.S. Federal government and they continued to spend hundreds of billions (nearly 2 trillion?) dollars to subsidize anti-COVID efforts by providing free testing and low/no-cost therapeutics to U.S. citizens, as well as subsidizing wages, rent and healthcare, and providing “stimulus funds” to millions of Americans. To the credit of the U.S. government, they also sent millions of vaccines to poorer nations – I’m jaded enough to think that it was done only to decrease the number of imported COVID cases, but would like to hope that there was at least some global responsibility at play. If so, we should demand that our government leaders make a similar investment in the eradication of tuberculosis. The logistical lessons have already been learned, the funds have already been authorized, and the R&D contracts are still in place, so I propose that we turn the “COVID machinery” towards the development of pre-/post-TB exposure vaccines, point-of-care testing and effective, short-course therapeutics for tuberculosis (ideally also including drugs to eradicate latent infections). With a concerted effort, I am confident that we could deliver these life-saving products in the next 18-24 months and finally have the tools needed to conquer a disease that has plagued the world’s poor for generations. (Resources: CDC and WHO websites and “Worrying lack of funding for tuberculosis” by Priya Venkatesan, http://www.thelancet.com/infection, Vol 22, March 2022.)

[Susan Swedo]

Joao – I fully agree with your thoughtful comments and suggestions. Beautifully stated!

[Susan Swedo]

Suzanne – I agree with you completely that vaccine refusal is a huge problem in the United States and Europe and appreciated your suggestion that education could reverse the problem, as well as empowering parents in under-resourced countries with knowledge about how to protect their child from the morbidity and mortality associated with measles.

[Susan Swedo]

Question #2 – What are the most substantial barriers to global measles elimination and how can these be overcome?
The primary barrier to eliminating measles globally is the high infectivity of the morbillivirus. Each infected person is estimated to infect 12-18 people, with more than 90% of unvaccinated people becoming ill after a single exposure. The transmission rate for measles is even higher than that of SARS-CoV-2 (COVID19). In addition, the period of infectivity begins four days before a rash occurs and continues for at least four days afterwards – malnourished individuals have longer periods of transmission because of their decreased capacity for viral containment. This means that a single infected child could infect an entire school or village before anyone even knows that they are ill. Containment of the viral outbreak depends on case-based surveillance, and the WHO has invested heavily in improving these strategies.
The second barrier is linked to the first — because measles is so highly infectious, more than 95% of the population must be adequately vaccinated in order to prevent person-to-person spread. To be adequately vaccinated, a person must have received two doses of the live attenuated vaccine (separated by at least one month.) National campaigns typically focus on infant vaccination, as young children have the greatest morbidity and mortality from measles, with the first dose given at 9 months and the second at 15-18 months. Additionally, supplementary immunization activities (SIAs) are carried out to ensure that children born since the last mass vaccination campaign will receive their vaccines, and to vaccinate older individuals who were missed in previous vaccination efforts. In some WHO regions, such as the Americas, these strategies were effective in eliminating measles – but only for a brief period. As soon as vaccination rates waned, as happened in Venezuela, case rates surged to the point where measles is once again endemic in that country, and exportation of the virus to neighboring countries.
Ignorance about the benefits of the measles vaccine, and vaccine resistance are additional barriers. In the United States, for example, many people (even physicians) have never seen a case of measles and are completely unaware that it can be a life-threatening/life-altering illness. Thus, they have little motivation to vaccinate their child and protect them from measles, but are required to give “written informed consent” for their child to receive the injection.
Unfortunately, the AAP’s standard consent form has only a sentence or two about the utility and effectiveness of the vaccine, and several paragraphs presenting all of the potential adverse effects. As a pediatrician, I often had parents who were willing to have their child vaccinated until they read the consent form – they then refused and it took great effort to convince them of the necessity (and safety) of the vaccine. The solution to this seems simple – rewrite the consent form to highlight the benefits of vaccination or, preferably, make MMR vaccinations mandatory so that parents aren’t required to give consent.
Vaccine resistance in the US and Europe, particularly in England, began rising just as Gavi, the Vaccine Alliance, was ramping up efforts to bring measles vaccines to under-resourced countries. Much of the resistance was linked to Andy Wakefield’s fraudulent data about an association between the MMR and the onset of autism. Dr. Wakefield is credited with reducing England’s infant vaccination rate from 95+% to less than 75%, resulting in nationwide outbreaks of measles in the UK and their first measles deaths in years. Dr. Wakefield traveled to the US frequently to espouse his theories, and our vaccination rates also fell with the return of measles cases, hospitalizations and deaths. It is hard to imagine a strategy that would be effective against such evil lies, but perhaps we could reintroduce vaccination education into the elementary schools so that children grew up knowing about the life-saving benefits of vaccines.
The final barrier is the enormity of the task. The MMWR report was heartening in its discussion of regional and global cooperation to eradicate measles, but there are still huge numbers of people to be reached. Thus, to eliminate measles worldwide, we must “maintain political commitment, and secure substantial, sustained investments” (MMWR Report Summary, p. 1329). In short, we must do even more of what’s worked well so far.

[Susan Swedo]

Question #1 – What system-wide changes, in your opinion, would most successfully increase world-wide food security?
The Lancet Commentary states, “the food system–encompassing the production, processing, marketing, and purchase of food…appears to be struggling to deliver nutritious and healthy diets in an equitable manner.” Thus, the changes required to successfully increase world-wide food security must address each component of the food supply chain – productivity, processing, distribution and access/cost.
Productivity — Fertilizer application is the best means of increasing productivity. Between COVID-enforced industrial shutdowns and the Russian invasion of Ukraine, the fertilizer supply chain has been severely disrupted and costs have risen to the point where even U.S. farmers cannot afford to purchase adequate supplies of fertilizer (if they can even find it!) International cooperation will be needed to ensure the uninterrupted production and supply of fertilizer. The U.N. has also suggested that richer nations should help poorer countries to acquire fertilizer at no-/low-cost for distribution to their local farmers.
Processing — Jose Graziano Da Silva writes “The truth is that the way we produce, process, distribute, and consume our food is profligate. Roughly one third of all the food produced in the world for human consumption every year — approximately 1.3 billion tonnes — is lost or wasted. Industrialized and developing countries squander roughly the same quantities of food — respectively, 670 and 630 million tonnes.” (https://www.un.org/en/chronicle/article/feeding-world-sustainably) I found it interesting that developing countries also have food wastage, presumably because of spoilage. Finding better means of storing and transporting food from farm to table would increase the available food by 1/3 – enough to address current shortages and begin to close the gap between food production and the growing world population.
Distribution — War and civil unrest are major factors that interfere with food production, distribution and access. Warring parties often destroy each others resources, including food supplies and the means of distributing them. Intentional starvation has even been used as a weapon by some unscrupulous leaders (e.g., South Sudan, Syria, Yemen). Well-coordinated international humanitarian efforts could alleviate the problem in the short-term, but for lasting benefits to be realized, there must be international agreement that disruptions of the food supply chain are unacceptable – perhaps by making such actions “war crimes” that would be prosecuted and penalized in an international court.
Access/cost — Increasing production can help lower food costs and increase availability of affordable foodstuffs. To accomplish this, nations should share knowledge and coordinate agricultural efforts to maximize the production of healthy, life-sustaining foods (e.g. protein-rich grains). Until that can happen, nations of plenty should share with those in need, through in-kind donations, release of food from emergency stockpiles, etc. Even when global food production is optimized, regional droughts or insect infestations may produce local shortages, so I would recommend that an international “food crisis response team” be created that can quickly and efficiently respond to such needs. A tiny tariff on international agricultural sales could provide the necessary resources without further raising food costs.

[Susan Swedo]

Hannah — I appreciated your suggestion of harnessing the power of genetic modifications to improve the ability of crops to tolerate increase heat. This is a practical solution that would improve food chain sustainability. However, I can anticipate protests and blockades from people who oppose “GMO foods” which could slow or stop the efforts. Of greater concern, the heat tolerant seeds may have lower productivity than other strains and using only them would further strain food production. To overcome these problems, perhaps we could use the power of “natural” selection and cross-breeding, just as Mendel did in his original genetic experiments on peas. Heat tolerance could be tested and the most heat resistant strains could be crossed with the most productive strains to create heat tolerant strains that would also produce high yield crops.
Interestingly, a similar technique of natural selection and cross-breeding is being used to address “bleaching” (death) of the coral reefs that has resulted from increased oceanic temperatures. Scientists from the Shedd Aquarium in Chicago and other institutions have developed techniques which allow them to rapidly test the heat tolerance of coral samples – those that are most heat resistant are then taken to the laboratory for cross-breeding with other heat resistant strains (to ensure adequate genetic diversity) and then sent to “coral nurseries” to propagate. In addition to providing evidence of feasibility of the strategy, the coral experiments serve as a reminder that the created strains must thrive in the environment in which they will live as scientists have discovered that miniscule differences in oceanic salinity prohibit transplantation of corals from the Florida Keys into the Great Barrier Reef. (Personal communication from Director of Coral Research, Shedd Aquarium, September 18, 2022)
For food-producing seeds, this would mean starting with seeds from grains, vegetables, etc that are native to the region where they will be planted and enhancing their heat resistance and productivity. It also will be important to ensure that local farmers can make a decent living if they plant these now heat-tolerant native crops, rather than ones that might bring bigger profits at market (e.g. willingness to plant enriched grains instead of coffee.)

[Susan Swedo]

Hello! I’m Sue Swedo
I graduated from Southern Illinois University School of Medicine in 1980 and completed a pediatrics residency at Children’s Memorial Hospital (Chicago) in 1983. For the next three years, I worked as a pediatric hospitalist at one of the NWU’s satellites, Evanston Hospital, providing coverage for the Peds ICU and NICU, as well as working in the Ambulatory Care Center and starting an adolescent medicine program. In 1986, we moved to the metro DC area and I started a research fellowship in the Child Psychiatry Branch of the National Institute of Mental Health (NIMH). I ended up staying at NIMH for my whole career, conducting clinical research on obsessive-compulsive disorder, autism spectrum disorder and other childhood neuropsychiatric conditions. I also volunteered in a pediatric free clinic in Arlington VA and served as the Medical Advisor for Jill’s House, a Christian respite care center for physically and intellectually disabled children. I retired from NIMH in 2019 and now have a small telehealth consultative practice and serve on the Scientific Advisory Boards of a number of advocacy/patient support groups.
Going forward, I would like to use my skills and experience to serve children and adolescents in under-resourced areas. I am taking this course to learn/relearn the diseases of poverty and become more knowledgeable about diagnosis and treatment of these disorders. I’m also very interested in learning more about community-wide health promotion and disease/death prevention. After completing the course, I hope to have a better understanding of my role in caring for impoverished youth — whether it’s in the field as a hands-on healthcare provider, on the internet as a medical educator, or in a team office, working to design and implement programs and policies that will improve recognition and treatment of pediatric mental illnesses in under-resourced areas.

[Author]

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