Before I begin my pediatric-focused comments, I must acknowledge the Native Hawaiian people as the original stewards of this land. We honor their enduring connection to these islands during our stay here. I also recognize the beauty, rich cultural heritage, and history of this place, and I remain deeply grateful for this award, the opportunity to return, and the many experiences I’ve had here over the past 30 years. However, as only a guest, this island has become our haven of happiness and healing for me and my family. As such, I will continue to respect and support the rights and voices of this community in the pursuit of health equity. Mahalo.This award holds meaning for me because of Dr David Nichols’ lasting impact on the Johns Hopkins School of Medicine. He was the architect of the Genes to Society curriculum and the visionary behind the Armstrong Education Building at the Johns Hopkins School of Medicine. I had the privilege of teaching clinical skills and advising nearly 80 medical students in that space as part of the Colleges Advisory Program and later served as the faculty leader for Taussig College. I first met Dr Nichols when he sat at my orientation table with other year 1 students in my first macromolecule. His warm presence and approachable educational style, even as an executive leader, made a memorable impression on both me and my students. He remains an aspirational figure for our learning community and has left an indelible mark on the institution.I am grateful to the Society for Adolescent Health and Medicine and the American Academy of Pediatrics, whose members have welcomed me as a leader and enabled me to grow in a space supported by 10s of 1000s of pediatric and adolescent health professionals worldwide. Finally, I thank the American Pediatric Society for recognizing me at a time when I am at a crossroads, challenging the limits of what academic medicine can achieve. We must ensure that research continues to drive progress and build a future workforce composed of culturally attuned health professionals from diverse backgrounds who can foster healing environments for children, adolescents, and young adults.I sincerely appreciate my Johns Hopkins family: people like Drs Allison Agwu, Harolyn Belcher, Mychelle Farmer, Vanya Jones, and Pamela Matson, true queens who inspire confidence, collaborate on science and training programs, and fix my crown without ever pointing out that it was askew. I am also thankful for partners in service like Drs Danielle Dooley and Jaqueline Douge, who have become friends as we persevered, despite organizational challenges, to advance child health in a complex world.My academic and advocacy efforts have grown under the careful guidance of remarkable mentors, colleagues, and sponsors, individuals who identified opportunities for me and nurtured my evolving ideas. This interdisciplinary group has been steadfast, planted like trees offering shade on a hot southern day. I especially thank Dr Peter Rowe for embracing his identity as an Adolescent Medicine physician, for nominating me, and for being the calm, kind-hearted, visionary colleague that every academic team needs.The last time I was here in Hawai‘i, in 2019, my personal and professional life was vastly different. That year marked the publication of the American Academy of Pediatrics policy statement on the impact of racism on child and adolescent health. While in Hawai‘i, I participated in interviews about that work, which followed the identity-charged El Paso shootings. While downloads and citations conferred academic currency, the true reward of the work came just days ago when the El Paso community achieved some measure of justice and closure. Still, much work remains to create positive social ecologies for youth across the United States, where they live, learn, and play. I am reminded that this work started through a professional collaboration with specifically Drs Renée Jenkins, Janie Ward, Michael Lindsey, and Joseph Wright, who joined me on a listening tour across pediatric organizations to better understand the impact of racism on children and adolescent health through the pediatrician’s lens. Our first listening workshop was held at the Pediatric Academic Societies Meeting in Baltimore. It was there that I realized that change would need to occur within our organizations before we could begin to create changes in practice and when the idea of a policy statement was born.Today, I will utilize a model from the Centers for Disease Control and Prevention (CDC) to examine health equity, focusing on how inequities in an individual’s social-ecological context throughout the life course impact preventable health outcomes in both childhood and adulthood.1 I am most influenced by work examining these effects on the reproductive life course of female patients beginning in infancy and how identity shapes experiences within the health care system.I have no controversial recommendations today, but I remain firmly committed to the belief that achieving health equity requires honoring our core values. As such, we must protect the research enterprise to continue innovating at the forefront of clinical medicine. We must move past documenting disparities and instead embed data-driven solutions into health delivery systems with the same operational efficiency found in nonteaching institutions.We must begin early by cultivating future health professionals who possess not only academic strength but also curiosity, empathy, and communication skills necessary for building relationships. They must also be committed to ensuring equitable access to care for all. Finally, we must also support financial models that enable the recruitment and retention of outstanding faculty and stabilize the social safety net for young people.Change, even for a single disease, is often slow. I have spent much of my career advocating for the recognition of sexually transmitted infections (STIs) as pediatric conditions requiring appropriate care. I cannot pass up this opportunity to say again: This is our work.When I arrived at Johns Hopkins, I intended to focus on improving the quality of life in adolescents with polycystic ovary syndrome. Then, 1 patient altered my path. A cognitively challenged yet highly social adolescent girl returned to our clinic weeks after being diagnosed with pelvic inflammatory disease (PID), having taken none of the prescribed medications. PID, caused by infections such as Neisseria gonorrhoeae and Chlamydia trachomatis, increases the risk of ectopic pregnancy, tubal infertility, and chronic pelvic pain if left untreated. I was stunned that she had been discharged home alone in the middle of the night from the pediatric emergency department, given inadequate medication, and handed a blank discharge sheet. She should have been hospitalized for an inability to manage outpatient care, but no one saw her.When I shared my concern with a senior Adolescent Medicine faculty member, Dr Hoover Adger, he didn’t excuse it. He challenged me: “Are you just going to talk about it or do something about it?” So, in the true Johns Hopkins way, I submitted an institutional review board application and reviewed every medical record for adolescent patients younger than 21 years treated and billed for PID care at our institution and found systemic health equity issues that likely contributed to regional disparities.2That moment ignited a path of discovery, leading to quality-improvement projects, big data analysis, and clinical trials, all focused on enhancing care for adolescents with PID. Collaborating with Dr Monika Goyal, we confirmed this was not merely a local issue; nationwide, only 60 000 of 200 000 girls affected by PID annually were receiving guideline-based care.3Supported by the Thomas Wilson Foundation4 and the Robert Wood Johnson Foundation5 and mentors Drs Allen Walker (Pediatric Emergency Department) and Jonathan Ellen (Adolescent Medicine), I led a series of projects aimed at reforming PID care at Hopkins. While the CDC shifted national guidance in 1998—further bolstered by analyses from the PID Evaluation and Clinical Health (PEACH) Study that deemed inpatient care too costly for mild-to-moderate disease, even for adolescents—I knew differently. My patients were often managing their care alone, had poor medication adherence and low follow-up rates, and were at substantial risk for recurrence putting them at risk for ectopic pregnancy, tubal factor infertility, and chronic pelvic pain.8Through collaboration with Dr Catherine Haggerty, a PEACH coinvestigator, we reanalyzed PEACH data through an adolescent lens. At 7 years after treatment, 21% of patients had recurrent disease, 19% met infertility criteria, and 43% suffered from chronic pelvic pain. The adolescent subset was even more concerning, with a mean (SD) age of 18 (1.0) years, suggesting limited applicability to younger teenagers.9,10 I collaborated with colleagues, Drs Harold Lehmann and K. Davina Frick, in which we demonstrated that (1) clinicians were aligned on management according to strict CDC criteria but were more aligned on managing cases for adolescents with social vulnerability,11 (2) adolescents could identify the impact of social vulnerability on care and opted for hospitalization more often than clinicians in these scenarios, (3) parents underestimate the impact of PID on adolescents,12 and (4) adolescents and parents were willing to pay more for physician follow-up but were also open to having community health nurse visit as an alternative.13Determined to do better, I designed a cost-effective intervention: the Technology-Enhanced Community Health Nursing (TECH-N) study.14 Using behavioral change theory, text messaging, and a culturally responsive home-visiting nurse model, we improved short-term follow-up rates and reduced the recurrence of STIs. Foundational to this work is my collaboration with Dr Charlotte Gaydos, a bench scientist and former director of the Johns Hopkins International STD Laboratory, that enabled us to introduce and test the value of new technology and diagnostics to better optimize precision care for affected patients in our work.15–18 Participants in the TECH-N intervention group were 86-times more likely to receive recommended care.19 TECH-N has also proved both effective and cost-saving.20 We now aim to bring it into the community, leveraging stakeholder input, including from teenagers and parents, to ensure the intervention translates from bedside to community and back again. This next step is the final component necessary to complete the circle of trust we have with the individuals and communities who participate in the experimental phases of our research and the US taxpayers who have supported it.Globally, PID is even more common in areas with high STI prevalence and low socioeconomic status, historically accounting for 17% to 40% of gynecologic admissions.21 Over the past decade, I have also worked with teams at the University of Minnesota and Muhimbili University of Health and Allied Sciences in Dar es Salaam, Tanzania, to develop and evaluate an Afrocentric sexual and reproductive health curriculum for nursing, midwifery, and medical students.22–24 Using simulation-based education, we have proven its effectiveness,25 and we are expanding it across sub-Saharan Africa to have expanded the curriculum to respond to the sexual and reproductive health needs of individuals with disabilities.26 Ultimately, my dream is also to see effective interventions like TECH-N move into this international space where adolescent girls and young women also need them.We must continue planting seeds in academic medicine. One of my first advisees, Dr Kate Miele, is now an Obstetrician-Gynecologist and public health officer at the CDC. She is leading the development of new national guidance on PID and has invited me to the table. That seat is the product of years of data collection, advocacy, and innovation, all sparked by 1 patient’s unmet needs.Although the CDC protections for adolescents with PID were rolled back many years ago, my goal has always been to provide compelling evidence, from quality and safety data to analysis of large data sets and randomized clinical trials, to advocate for rebuilding better care. It is also through clinical training and workforce development that true innovation for health equity takes root and flourishes, such as through my long-term investment in leading the Society for Adolescent Health and Medicine Research and Mentoring Forum and the National Institutes of Health-funded Adolescent Health T32 Training Program at the Johns Hopkins School of Medicine.In closing, pediatricians must not be shocked and awed into paralysis by the challenges of our sociopolitical landscape. Years ago, I heard Dr Ben Hoffman speak on gun violence and have since adopted his call: “We must become more powerful on behalf of children and adolescents.” At this moment, we must recommit to our oath, not only in medical schools but in hospitals, communities, and on the national stage.If you find yourself struggling with inertia, think of my mother, Vivian Trent, pictured here (Figure 1) in Paris circa 1959, just 25 years old, before her civil rights were fully enshrined in law in the United States, traveling the world without any assurance of general safety. She returned home to join a movement aimed at creating change for her community and the generations to follow. I stand here because of her, and many of us have benefited from sacrifices by people like her. Let us all lean into our power to do meaningful work for children, adolescents, and emerging adults, thoughtfully, without hesitation, and together.
Maria Trent (Thu,) studied this question.