The city really is downtown. You have lots of bars, dance clubs, to places with really great views, like the View House, and nice rooftop decks, like the Tavern. Denver's just great for those chef-driven, owned restaurant concepts that you really could pick from about 20 or 30. We have about 92 beers on tap here at Falling Rock. If you're interested in craft beer, Denver is definitely the destination of the United States. Stoic and Genuine is my newest restaurant in Denver Union Station. I love the renovation inside the station itself. It's an incredible transformation of that historic building. They really took care to bring back that era of what it looked like as a train station. So all light rail, buses, and even Amtrak will be coming out of there. It's our pathway to DIA, which takes you to the world. Some of the great places downtown are these historic hotels. One is the Brown Palace, the other is the Oxford Hotel. Also in our neighborhood is the Tired Cover, which is one of the most amazing bookstores. You just have that really fun boutique feel when you walk in. Just the volume that we have here that makes downtown Denver special. There's really a lot of activity for shopping, too. Larimer Square gives you that kind of feeling like Rockefeller Center might in New York. It's the only historic block that still has all the historic buildings. Larimer Square has some really fun little boutiques that I think you can get some unique gifts. I always take people to Rock Mount Ranch Wear. They're attributed with popularizing the snap front western shirt. From rock stars to ranchers, it's people who are looking for something quintessentially Colorado. If I had one word for downtown Denver, it'd be exciting. Active. Historic but emerging. Very funky, be very artsy. It's kind of the heart of this city. It's also a melting pot of our Denver culture. So if you're coming down here, you're getting a real sense of Denver. It's just a constant stream of unexpected surprises here. The downtown Denver area is unique here, there's just so much more to do. There's plenty of historic sites, brand new businesses, museums, and cultural events happening every month. Denver is an extremely active city. It's an excellent place to try just about anything. People have come down here both to live and to play. It's full of shops, restaurants. It's really made it an enjoyable place to hang out. The changes to the downtown area are amazing, from Larimer Square into 16th Street Mall. 16th Street Mall is a really diverse area, each block is a little bit different and unique. I really enjoy the Denver Pavilions, which has an open air concept that combines outdoors New Jersey, Colorado, but also a very urban feel. There's the Hard Rock Cafe, Jazz at Jack's. You can also catch a film at the United Artists Theater. I stopped by the iHeart Denver store in the Denver Pavilions. You can find a real gambit, gift items, fine art pieces, prints, t-shirts, and jewelry, all made by local designers, artists, or creative minded businesses. Denver has a public art ordinance that allocates 1% of any new capital improvement project to public art. So when you're walking around downtown, you will see a large piece or some sort of art installation in almost every building and plaza. 14th Street in the Convention Center area has been revitalized just recently. The Denver Performing Arts Complex is one of the largest in the country. It takes up four city blocks. You can catch the symphony, the opera, the ballet. It really runs the gamut of popular music to classical. Then you can go a little farther down and hit the MCA. They're just very unique, very innovative with their shows. One of the nicest features about Lodo is the scale. Downtown Denver, in general, is extremely walkable. You look at where Careers Field is, even to the Pepsi Center. Lodo is also very bike friendly. We've had one of the first electronic bike share systems. B-cycle stations, you can get on one, you can use it all over town. The heart of the city really is downtown. You have lots of bars, dance clubs, to places with really great views like the View House. And nice rooftop decks, like the Tavern. Denver's just great for those chef-driven, owned restaurant concepts that you really could pick from about 20 or 30. We have about 92 beers on tap here at Falling Rock. If you're interested in craft beer, Denver is definitely the destination of the United States. Stoic & Genuine is my newest restaurant in Denver Union Station. I love the renovation inside the station itself. It's an incredible transformation of that historic building. They really took care to bring back that era of what it looked like as a train station. So all light rail, buses, and even Amtrak will be coming out of there. It's our pathway to DIA, which takes you to the world. Some of the great places downtown are these historic hotels. One is the Brown Palace, the other is the Oxford Hotel. Also in our neighborhood is the Tattered Cover, which is one of the most amazing bookstores. You just have that really fun, boutique feel when you walk in. It's just the volume that we have here that makes downtown Denver special. There's really a lot of activity for shopping, too. Larimer Square gives you that kind of feeling like Rockefeller Center might in New York. It's the only historic block that still has all the historic buildings. Larimer Square has some really fun little boutiques that I think you can get some unique gifts. I always take people to Rockmount Ranchwear. They're attributed with popularizing the snap front western shirt. From rock stars to ranchers, it's people who are looking for something quintessentially Colorado. If I had one word for downtown Denver, it would be exciting. Active. Historic but emerging. Very funky, very artsy. It's kind of the heart of this city. It's also a melting pot of our Denver culture, so if you're coming down here, you're getting a real sense of Denver. It's just a constant stream of unexpected surprises here. ♪♪♪ Good morning, everyone, and welcome to Public Health Topics and Rural Populations. I'm Dr. Amy Rogers, and we'll be moderating the talk for today, which will examine the growing concern of unvalidated environmental testing with specific focus on environmental testing and autism spectrum disorder in children and how to advance the women, peace, and security policy framework by developing programs preventing neglected tropical diseases. To go over a few how-tos for the conference, you'll notice on the right-hand side of your screen, you'll see a chat function box. On the top of that box, you'll see a chart icon, and if you click on that, that's where you can post your questions for our speakers. You can also chat with each other using the chat function, and we encourage you to look at the questions being posted, and you can either up or like those questions to help us gauge which questions to ask our speakers at the end of the talk. We'll save the questions for the end of the talk, but you may see us answer a few questions by typing the answers throughout the talk. So to briefly introduce our two wonderful speakers for today, first is Dr. Jasmine Bodia, who is a preventive medicine resident at the Mount Sinai Hospital in New York. She's a board-certified pediatrician who completed her residency at Newark Beth Israel Medical Center in New Jersey. She went to St. George's University in Grenada, West Indies, and received a master's in health sciences and environmental health sciences from the Bloomberg School of Public Health, and she'll be talking on environmental testing in children, specifically looking at autism spectrum disorder. Our next speaker will be Lieutenant Colonel Chelsea Payne, who is the command preventive medicine physician at the United States Africa Command. She's a board-certified in public health and general preventive medicine, as well as family medicine. Dr. Payne oversees public health for deployed forces across 53 nation area responsibility, and she works with interagency organizations to direct medical research, immunization policy, and pharmaceutical development. She also leads AFRICOM's infectious disease engagement, the African Partner Outbreak Response Alliance, which brings together military, Ministry of Health, and Ministry of Defense representatives from 26 nations to prevent and respond to disease outbreaks. I hope you enjoy our talks. We encourage you to use the chat function and ask a lot of questions of our speakers. And right now, I'm going to turn it over to Jasmine to start her presentation. Thank you. Hi, everyone. Thank you, Dr. Rogers, for hosting this session. My name is Dr. Jasmine Bhatia. I am a preventive medicine resident with a background in pediatrics, and I'm currently at the Icahn School of Medicine in Mount Sinai, which is home to the Region 2 Pesu. So I'm just going to get started here. OK, these are learning objectives for my talk. And just to give you guys some context, so at Mount Sinai, this is the home of the Region 2 Pesu, which covers New York, New Jersey, Puerto Rico, and the U.S. Virgin Islands. I'll be referring to the Pesu, but it's also it stands for Pediatric Environmental Health Specialty Units. And this is a national network of experts who deal with the prevention, diagnosis, management, and treatment of health issues that arise from environmental exposures in the pediatric population. And so as part of my training, I participate in some of their clinical work, as well as their research. And so we're going to start with a case presentation. This is a patient that was referred to us. The name and the details were changed to protect this child's identity, as well as to provide a representative case of some of the patients that we deal with. Anna is a 10-year-old female with a history of constipation, speech, and expressive language delay, diagnosed with high-functioning autism spectrum disorder. Her integrative medicine functional Ayurvedic doctor ordered several urine environmental panels to explain Anna's recent difficulties with concentrating on schoolwork. Her mother brought these results to the EPA, who referred her to the Region 2 Pesu for lab interpretation and exploration of possible environmental causes to explain the worsening of autism symptoms. Results showed elevated levels of flame retardants, gasoline byproducts, and pesticides. So as you can see from some of her medications, she's taking a couple of supplements, as well as multivitamin. She receives a couple of therapies. She sees GI for her constipation. She previously saw her developmental pediatrician about seven years ago. She's an only child. Her father works in construction, and her mother is a homemaker. I'll refer back to this case during my presentation. So we know that autism spectrum disorders are increasing. And it's unclear whether the increase of autism spectrum in the past decades is a result of a real increase in autism or whether these increases are reflective of the expansion of the autism diagnosis. Perhaps there's an increase in awareness leading to more diagnoses. We're not totally sure. It's also unclear at this time which environmental exposures might play a part in the increase of autism spectrum disorders and if they play a part in the development of autism. Here in this red box, I just have a clipping from a web page that really plays to the unknown that exists regarding these environmental exposures. This is just one of the many examples out on the web that sort of plays on what we don't know and especially targets families who may have autistic children. And the word toxin seems to be a particularly prominent word that seems to really resonate with many of our families. And so there's no single identified cause of autism, and we now accept that it's likely multifactorial. Recent research in the field of environmental health has started to focus on the exposome, which, according to the NIH and NIOSH, can be defined as the measure of all the exposures of an individual in a lifetime and how these exposures relate to health. At my own institution at Mount Sinai, Dr. Manish Arora has been studying biomarkers that utilize baby and permanent teeth to reconstruct the timing of exposure to various harmful chemicals and essential nutrients and the biological response to these environmental factors. Teeth have previously been used to estimate long-term cumulative exposures to metals, but recently developed lab techniques are now able to precisely sample tooth layers that correspond to specific life stages. This research has the potential to really reconstruct the whole exposome from prenatal to childhood. And so environmental tests are now widely available, and these are the top. These are probably the most common ones that we see. And so here's one from glyphosate, which is a well-known pollutant known as Roundup. The next one here is a mycotoxins report. And the last one here is a hair analysis. And so these are some of the top ones that we see, and we'll go through them on the next slide. And so many of these environmental tests are currently being researched, excuse me, as part of the exposome to determine if they can be utilized in the diagnosis of autism. But the key thing to really remember here is that no definitive links have been made for diagnostic purposes of autism, but perhaps there will be utility in the future for uses as diagnostic aids, as seen with Dr. Aurora's work. The other thing to keep in mind with these tests is that a few of them can be medically relevant to autism spectrum children, but that they should not be used to diagnose autism. These labs may offer standard testing, which when indicated, kids with autism should absolutely undergo. So the first group of tests here are urine tests. And these are usually really popular because they're convenient to collect. There's non-invasive and there's usually a lot of it. So provocation urine testing is an inappropriate environmental test that measures urinary excretion of metals after the patient has been given a chelating agent such as Suxamer or DMSA. And these tests don't offer a diagnostic value for autism, and there are no validated ranges for these results. And this is really the main thing with these tests and that I can kind of bring up with most of the tests on this slide. Chelation for purposes other than evidence-based treatment for lead or other heavy metal exposure should really be done under the guidance of a toxicologist. And furthermore, unnecessary chelation can have side effects on children as it's not a completely benign medication. Urine metal panels claim to test for a variety of metals such as arsenic, cadmium, cobalt, lead, mercury, thallium, and zinc, along with many others. And porphyrin tests. So these may be appropriate in the setting of a suspected porphyria. However, it's no longer used for lead testing and blood sampling would really be the means of obtaining this lab and not urine. Again, I just want to emphasize it's not diagnostic for autism. And mycotoxins. So this is a really common one that we get. Mycotoxins are metabolites produced by mold under certain conditions, and they are a really common source of concern for families. All fungi are capable of producing mycotoxins and they're present in all of us due to the food we eat in our environment. Mycotoxins such as aflatoxin are known to cause disease. However, it's important to keep in mind that our food supply is tightly regulated and monitored for aflatoxin in the United States. And there's no approved test for mycotoxins. While it's an area of investigation, there's been no definitive link. And there's really no evidence to support testing beyond children with severe asthma and allergies. And so, some of the common unapproved tests you might see are serum tests for antibodies to mycotoxin and fungus-specific IgA and IgM. And again, there's no diagnostic value for autism. Moving right along here, hair and nail analysis also has the same appeal of urine testing. It's easy to obtain, non-invasive, and readily available. But these can lead to spurious and misleading results as they don't accurately reflect the levels inside the body and can't be correlated with blood. We're really only now developing the technology such as with Dr. Arora's research to analyze these biomarkers, but it really should just be used as a diagnostic aid at the moment and it's not validated for clinical use. There's a lot of exciting research in the field that looks promising, and perhaps these tests might be available in the future. And then wrapping up here, so these non-metal chemical profiles test for pollutants such as acrolein, styrene, MTBE, and are usually analyzed by blood or urine samples. While many of these have been studied, no definitive links have been made to autism. Furthermore, many of these compounds are commonly present in Americans as seen in data from NHANES. Elevated levels of certain pollutants is concerning, and here at the PACE, we do help families lower their exposure to chemicals that appear elevated. However, again, it must be emphasized that these tests are unvalidated, often have no reference ranges in children, and do not lead to evidence-based treatments. And so they should not be used in diagnosis of autism. Some other available tests are adrenal stress profiles, which purport to test the HPA, the hypothalamic pituitary adrenal axis, and they test for DHEA and cortisol through typically through saliva. But these adrenal disorders and HPA axis disorders should really be done under the guidance of an endocrinologist and are, again, not linked to autism. Stool testing is also becoming more common, and this really looks at the different types of bacteria in the stool through quantitative PCR. Is it normal flora? Is it pathogenic? Are there parasites? And the idea here is that dysbiosis, which is an imbalance in the guts bacteria, can lead to a number of disorders. And while dysbiosis and SIBO, which is small intestinal bacterial overgrowth, are recognized entities, no links have been made to autism. That being said, children who are suspected to have an intestinal parasite should absolutely undergo testing for that. And then finally, organic acids is sort of a broad term, and it does have clinical use in diagnosing a range of disorders, such as inborn errors of metabolism or diabetic ketoacidosis. However, their utility doesn't really extend past these metabolic disorders. Again, no definitive links have been made, and testing for organic acids should be really done under the guidance of a specialist, such as an endocrinologist or a geneticist or a metabolism expert. And so the limitations of these commonly available tests, they're not validated by the FDA. Many of these tests are CLIA-approved labs, but it's important to keep in mind that CLIA regulations don't address the clinical validity of testing. And to be clear, validity refers to the accuracy with which a test identifies, measures, or predicts a patient's clinical status. FDA clearance or approval of a test provides assurance that the test has adequate analytical and clinical validation, and that it's safe and effective. Again, these commonly available tests might be inaccurate and not reflect body burden, such as with hair testing. There's no clinical reference ranges available. They might be potentially dangerous to obtain, and they're not clinically relevant. And many of the environmental exposures in the aforementioned tests may potentially play a part in autism, but the research is just really not there yet. And so without reliable testing that can lead to evidence-driven treatments, we can't recommend subjecting our children to this testing. And in pediatrics, we're very choosy about when to do testing, especially when it won't lead to a change in management. So children with autism should ideally be diagnosed quickly and referred to appropriate evidence-driven therapies. And so when some of our families get these test results, there's often a really high level of anxiety because there's something that is too high or too low, and these tests look scary. And that really worries the family, and the mental health sequelae cannot be overstated. Parents experience high levels of stress after getting these results. Many of them are losing sleep over this. They throw out many of their own belongings, many of their child's belongings. They change their child's diet drastically. And it really does take a toll on families and their routine, and it can be really significant. It can also lead to unnecessary lab collections, stress with needle sticks for the child, unnecessary family expenditures. These tests can cost hundreds of dollars, and because many of them are available direct to the consumer, parents can just readily pay for it. And the key thing is we just don't want families pursuing further workup with invalidated testing as it may not give them the answers that they're looking for. And we don't want it to lead to potentially dangerous and unimproved treatments and detoxification regimens. And so when can environmental testing be indicated? Well, especially as is the case with lead, there's mandatory testing. You want to continue to assess risk, especially in children who are older who have autism. And any child that's between a certain age should definitely receive screening. Lead should always be considered in the initial workup for autism as it's known to cause neurocognitive impairments. Lead poisoning still unfortunately happens, but we do have medications that can lower the body burden but not reverse neurocognitive deficits. And I just want to mention that children with autism are at increased risk of lead poisoning due to pica behaviors and poor discriminatory cognitive recognition of edible versus inedible item. And that being said, there's no link between autism and lead. However, prompt recognition can avoid further effects on neurocognition as well as potentially avoid encephalopathy and death. Mercury is really only in certain situations. And I just wanted to mention that after controversies surrounding thimerosal, the FDA and the Institute of Medicine reviewed evidence that rejected a causal relationship between vaccines and autism and even went so far as to remove thimerosal from vaccines since 2001. And extensive reviews of literature continue to support no association between thimerosal and autism. And these are just a couple of more important points I just wanted to bring up. And so these are some of the common questions we get from parents. And what we really see here is just parents seeking answers and really just trying to advocate for their children and just wanting to know what else they can do to help them. And so the approach to the patients. So I just wanted to mention that the PESU is a wonderful resource for physicians who have encountered patients with these types of concerns. You want to take an environmental history, and I'll talk a little bit about that later on. You want to characterize the exposures of concern. Is there a completed route of exposure through inhalation, ingestion, or dermal absorption? You want to characterize the symptoms in relation to the exposures. Do the symptoms worsen or get better at certain times in specific places? You want to determine if there are tests available that will help accurately document the exposure. And then when considering the appropriate next step for your patient, you may want to consider getting your PESU involved to help guide management. And then also potentially referring them out to specialists to get other environmental testing. And so when you're trying to provide strategies for reducing exposures of concern, it's important to remember that even if there's no way to test for it, giving families strategies to reduce exposures actively can be empowering and reassuring, and I'll give you a way to do that later on. And so when taking an environmental history, these are just some of the things you want to keep in mind. I just wanted to mention that with children who have autism, you really want to keep their patient characteristics at the top of your mind. Do they have pica? What's their age? Do they use alternative medications, as was the case with our patients? And if you're looking for a resource, the National Environmental Education Foundation has a form that can help you take an environmental history, and it really draws on best practices and medical literature. And again, contacting your local PACE, you can help really with your families and help you deal with any environmental exposures of concern. And so it's important when you're addressing parental concerns to really build a strong rapport with them. They're really just trying to help their children. So thank them for bringing up the subject, be supportive of their desire to find treatments, explore issues with parental guilt, address their concerns about heavy metal, acknowledge that medicine doesn't offer any curative treatments, and uniformly recommend consultation with a developmental pediatrician. As we saw with our case, our patient really lapsed in her follow-up with a developmental pediatrician who can accurately document whatever deficits she may have, as well as hook her up with the appropriate therapies. And the key here is really just sort of getting them to the appropriate therapies and avoiding further harmful treatments. And so the challenge with children who have autism is that there's been no treatment shown to cure autism. However, several interventions have been studied for use, such as applied behavior analysis, social skills training, OT, PT, sensory integration therapy, and the use of assistive technology. Other approaches include the ones here, behavior approaches, medication, and complementary and alternative medication. And I bring that up because we really want to steer parents away from detoxified regimens that may be harmful to the child, such as infrared saunas and things of that nature, because there's no known treatment that can cure it, along with unnecessary and unvalidated testing come suggested treatments for spurious results. And in 2016, there was a Cochrane review that showed that there's no clinical trial evidence that pharmaceutical chelation is an effective treatment for autism. And this is really the key to helping families who are seeking unvalidated testing or who have already gotten it, is that we have to prevent harmful treatments on our children that haven't been shown to help them. And so going back to the case, and this has been seen with many of the cases referred to us, parents often end up seeking the help of various providers and community practitioners who may peddle supplements to them. And parents accept their advice simply because they cannot access treatments recommended to them by their doctors. And often the waiting list for ABA and other therapies are long. And parents who are just watching their child's neurocognition and behavior decline, they really feel a strong need to intervene to halt that progress. And so supplements, ayurvedic therapies can seem really tempting to them. And this is really unfortunate because sometimes they are heavily laden with lead. And so like the child we saw in our case presentation and with our other cases, they do sometimes end up with elevated lead levels and they do need environmental testing, they do need to be chelated, and they do need to be followed. And so what's the solution? The solution really is upstream. We need healthier environments for everyone. The NHANES environmental exposures report shows that we have really a full spectrum of environmental chemicals present in all of us. What policies can we make to make our environment safer and our products safer for our families and our children? There's a great example of this, which is the Child Safe Products Act, which through a great effort of the Region 2 PESU and its sister organizations was signed into law in 2020 and requires manufacturers to disclose the use of chemicals in children's products and the Department of Environmental Conservation to make this information public to consumers. Again, in 2016, there was a bipartisan update to the Toxic Substances Control Act, also known as TSCA, which was passed in Congress and gives the EPA important new ways to tackle toxic chemicals already used in our products. And while these steps are in the right direction, we still have a long way to go to prevent exposures on a population level. And now that we finally shifted our focus to think about health disparities, how can we decrease or mitigate these certain exposures for our children in a community setting? As public health leaders, we need to advocate for these changes and how can we create primary prevention so that our environment is safer for everyone? And so here are some of our key messages. I just want to wrap up with some resources. So a great resource is the Prescriptions for Prevention. Our PESU is part of a larger network called NICE Check, which is composed of various organizations which has developed a tool for families called Prescriptions for Prevention, and this covers a variety of environmental health concerns. So each prescription educates families on environmental exposures and is designed to be comprehensive yet accessible and give actionable steps to families to reduce exposures of concern. So it's also available in Spanish as well. And here are some other resources for providers and family. Again, your PESU is a great place to start. NICE Check is the home of Prescriptions for Prevention. Project Tender is a collaboration of scientists who are working to develop policies to reduce chemicals linked to neurodevelopmental disorders. The Green Book, Pediatric Environmental Health, is a great resource. And Choosing Wisely has also released a recent report that's very helpful this week. So thank you so much for listening. That's all I have for you today. Here are my references. And thanks again. Jasmine, thank you so much for that wonderful talk. Again, if you have questions for Jasmine, feel free to post them in the chat or the question box on the right-hand side, and then she'll answer them at the end of the talk. We're now going to shift over to Dr. Chelsea Payne, who is going to talk about the Women's Security and Peace Initiative. Thank you. Dr. Payne? Thank you, Dr. Rogers, and thank you, Dr. Batia, for that excellent presentation. I appreciate the opportunity to be here today and discuss with you advancing women's peace and security by preventing neglected tropical diseases. As I mentioned earlier, I'm a family and preventive medicine physician, and most of my work right now focuses on the forest health protection of troops who are deployed to Africa. But in the past, I've worked for a considerable time as an international health specialist across Eastern Europe and into Africa. And during that time, a lot of my work focused on global health. And it was during that time that I first learned about the women's peace and security agenda, and later on was trained in how to incorporate it into health security activities. So the content of this presentation does not reflect the views of the United States government. It's just my views, and I have no relevant financial interest to disclose. This is an outline of the topics that I'm going to discuss today. I'll talk about the women's peace and security agenda. I'll talk about it in the context of conflict and humanitarian crisis. And then we'll spend some time going through different neglected tropical diseases and how they uniquely impact women and girls. I'll be incorporating themes related to the COVID-19 pandemic throughout my discussion. And then at the end, I'll talk about the sustainable development goals and some relevant conclusions and key recommendations. So these are the learning objectives of this presentation. We're going to try to understand women's peace and security and how the United States is incorporating WPS into security cooperation. We're going to review the intersecting domains of women's health and gender equality, particularly in the context of humanitarian crisis. We're going to discuss neglected tropical diseases and how women are uniquely and disproportionately impacted by several of these diseases. And we're going to examine health's multidimensional nature in the context of the UN's sustainable development goals. So the United Nations Security Council Resolution 1325 was published in the year 2000, and it was a landmark resolution on women, peace, and security, and it really highlighted the necessary role women have in resolving conflict and supporting sustainable peace negotiations. And that includes humanitarian response and post-conflict reconstruction efforts. Since that time, there are 92 countries that have developed national action plans for women, peace, and security, and numerous countries have continued to update their plans, including the United Kingdom, Canada, and the United States. In fact, the United States was the first country to pass legislation in 2017 mandating the promotion of women's meaningful participation, conflict resolution, and incorporation of WPS into all of its activities. And since that time, the U.S. strategy for WPS was published, along with numerous federal agencies, including the Department of Defense, the Department of State, and Homeland Security, all developing frameworks for how they're going to incorporate WPS into their various activities. So even though this was started about a decade ago, the last five years, we've really seen an acceleration in the policy and the documents to guide WPS activities. There's also been considerable progress made towards developing metrics to assess, monitor, and evaluate that progress. And that includes measuring how nations are doing on very abstract concepts to include things like justice and inclusion. And these resources include the Global Peace Index, Women, Peace, and Security Index, and the Gender and Equality Index. The most recent WPS Security Index was updated in 2020, and it really highlighted how women's security at home, particularly intimate partner violence and sexual violence, correlated with organizational violence and security in the country itself. It also broke down data at a subnational level to highlight disparities across nations. And there were significant disparities that were noted in India and Nigeria. So gender inclusion is a recognized pathway to support peace and stability, yet full participation of women through employment, through parliamentary representation, through financial inclusion really remains to be seen in many nations. While well-being is mentioned in many of these metrics I talked about, the actual physical and mental health of women is often not incorporated into those metrics. The most common metrics are things like mortality, maternal mortality, or adolescent fertility rates. But there are many other dimensions to health and well-being that impact a woman's ability to fully participate. And this includes disability. Neglected tropical diseases are one of the most common causes of disability in many developing countries. And so health is multidimensional. And by addressing neglected tropical diseases, we can support women, peace, and security and broader global health concepts such as the sustainable development goals. In terms of global health and humanitarian response, conflict is the main driver of humanitarian natural disasters being a second source. Women and girls are among the most vulnerable populations and they represent about two-thirds of casualties. The COVID-19 pandemic has resulted in even greater need. According to the global humanitarian overview, extreme poverty is increasing for the first time in 22 years. Food security, access to education, as well as disease control programs that focus on diarrheal illness, immunizations, HIV, and tuberculosis have all been impacted. There are also psychosocial consequences, which we are still understanding better. Efforts to control neglected tropical diseases through mass drug administration programs have also been impacted. And women in humanitarian settings continue to have unmet needs for sexual and reproductive health and to experience gender-based violence. Fortunately, the World Health Organization has outlined a decision-making framework on how and when to proceed with programming. And that includes prioritization as well as using a COVID risk assessment matrix. And as COVID-19 vaccination becomes more available, there will be less need for restrictions and hopefully improved access to essential services in more countries. So, now I'm going to take you on a virtual trip to Botswana. This is a picture of Kasane, Botswana, which is in the northern Four Corners region where Botswana, Zambia, Zimbabwe, and Namibia all meet. And this is the Tobi River, and it's near a large national park there. And this area, as well as many other areas of Botswana, are known to be endemic with schistosomiasis. And this organism is transmitted by freshwater snails. It penetrates the skin and then migrates through a complex life cycle through the blood to different organs, and it can lead to chronic fevers, abdominal pain, fatigue, headaches. It can also impact fertility and even lead to bladder cancer. Women in many developing countries are more likely to perform household chores or agricultural work which requires them to wade in contaminated water, and they're more likely to become infected. This neglected tropical disease, like many others, can be controlled through mass drug administration programs. The World Health Organization recognizes 20 different neglected tropical diseases, and there are more than 1 billion people in about 150 countries at any given time who are infected with an NTD, and many people are infected for years. They predominantly infect people in low and middle income countries, and they tend to be in Southern Asia and Sub-Saharan Africa. Neglected tropical diseases are associated with inadequate work and living conditions, and the five most prevalent ones are highlighted here for you. We're going to go through a few of these and talk about how they uniquely will impact women in many developing countries. Well, there were more slides available. Neglected tropical diseases are estimated to cause about 26 million DALYs globally. DALYs are disability-adjusted life years, and it's a mathematical calculation that combines morbidity and mortality into one metric. One DALY represents one year of healthy life lost. The majority of this burden is from soil-transmitted ailments or parasitic worms. Hookworms, for instance, can lead to anemia, and anemia in pregnancy contributes to excessive blood loss during childbirth. According to the WHO, obstetric hemorrhage is the leading cause of maternal death worldwide. It accounts for about 27% of maternal deaths. Other consequences can include low infant birth weights. Also in children, it can impact cognitive development and stunt growth. There was a large study in Kenya that looked at school absenteeism, and they found that by going back and deworming adolescent girls over time, they could actually increase their scores on secondary education entrance exams and increase the likelihood that they would enroll and go on to secondary education. Eczema is the second organism on this list, and that is the most common and preventable cause of blindness worldwide. It's caused by a bacterium, and it's very contagious through contact with the secretions of an infected person. So nasal discharge, eye discharge, and a lot of preschool children are infected with it in developing countries. It can be endemic. And so women are a little more likely to be caring for those children, and they're more likely to become infected over and over again. In general, you have to get infected about 150 times before you start to develop blindness. So this is a chronic and reoccurring infection, which is very treatable through topical antibiotics and preventable by having clean water and sanitation. Another organism on this list is cutaneous leishmaniasis, which is caused by a parasite that's transmitted through sand flies. It can lead to skin ulcers and disfiguring facial scars. Significant symptoms are associated with it, and it can include depression, anxiety, and decreased quality of life. And then urogenital schistosomiasis I mentioned earlier in Botswana, that can actually also increase the risk of HIV infection, and it can have a threefold increased risk of vertical transmission from the mother to the child. Moving on through this list, the first one on here is lymphatic filariasis. This infection is actually a small, thread-like worm, which is spread by mosquitoes in different tropical regions. And these worms infect the human lymph system and can lead to pain and swelling in the arms, in the legs, and in the breast and genitalia. In some societies, there are cultural restrictions on examining women, and so women are actually more likely to be underdiagnosed and also undertreated. Social stigma can result from that. Sometimes a loss in jobs, a loss in wages, and even family abandonment has been documented. Women are more at risk for exclusion from treatment programs over time, because whenever they are pregnant or lactating, sometimes they're not included in the program, and then whenever those people come back, they might be pregnant again or lactating again. And if they're in a unique situation where perhaps they're an internally displaced person or a refugee, sometimes they are then excluded from the national or the host nation MDA program. It's also important to point out that women can have critical roles in surpassing social, behavioral, and structural barriers to medical treatment. In fact, the UN estimates that about 70% of healthcare and social workers internationally are women. As community-directed distributors of NTD medications in sub-Saharan Africa, women have been shown to be very patient, persistent, and committed as compared to male workers. Unpaid labor also contributes to leadership role and empowerment for these women. It's actually very important to pay them, because women spend three times as many hours in unpaid domestic work and care, care for children and care for the elderly, as compared to men, and that has only increased during the COVID-19 pandemic. So this contributes to a time poverty, which can also impact their ability to be active participants in their community and at a regional or a national level. The last thing I'm going to touch on is the Sustainable Development Goals. The Sustainable Development Goals really offer a blueprint towards a better future. There are 17 goals, and they're all interconnected in terms of achieving the same endpoint of a better world for all people. Sustainable Development Goal 5 focuses on gender equality. Sustainable Development Goal 3 focuses on good health and well-being. It talks about infectious disease prevention, the well-being of maternal health, and as well as clean water and sanitation and the prevention of diseases that are caused by contaminated water. Sustainable Development Goal 1 focuses on having no poverty in the world, and Sustainable Development Goal 6 focuses on sanitation and building infrastructure for that. So all of these goals are interconnected, and it's by recognizing how these different aspects are interrelated that we can address the underlying and upstream causes of things like inequality and disease in our populations. So in conclusion, I just want to say that expansion of women in security and peace operations really begins with addressing the prime factors that impede their meaningful participation. In many countries, that's actually disease, like neglected tropical diseases, and by focusing on these, we can better position them to be active participants in their communities. Equality is a very important metric, and it should be part of how we are measuring and monitoring well-being, as well as how we're measuring and monitoring the well-being of women in countries and helping to propagate things like the Women, Peace, and Security Agenda. The five most common neglected tropical diseases that I mentioned can all be controlled through mass drug administration programs, and it's actually very cost-effective, because for every dollar invested in MDAs, there's a net benefit that has been about $27 from 2011 through 2020, and that's expected to rise to $42 from 2021 through 2030. So the key points of my talk are that neglected tropical diseases disproportionately impact women. Addressing neglected tropical diseases is an integral part of meeting the Sustainable Development Goals. Gender impacts of the COVID-19 pandemic must be considered in response plans and reconstruction packages, and sustainable development is really founded on human rights, and it can address inequalities in gender and health. So thank you so much for the opportunity to speak today. If you'd like more information on neglected tropical diseases and Women, Peace, and Security, I'd encourage you to go to the London School of Economics page. They have a large section on WPS, and you can find an article I published in 2019 on this topic. Thank you. Thank you, Dr. Payne. Really appreciate everyone. Two really great presentations. Really appreciate it. We have a few questions that have been posted. The first question looks like it's for Jasmine. Is it standard practice for physicians to talk about environmental testing at the time of autism spectrum disorder diagnosis so parents understand the pros and cons? Probably this is also, is it more that, you know, where in the process do physicians usually talk to their patients about this? Thank you. That's a great question. So I would say that it's typically not a standard of practice to talk about environmental testing. I do know that, you know, you would want to maybe consider lead poisoning if the child is at risk after doing a risk assessment. However, I would argue that it might be a reasonable route for a provider to discuss with the family as, you know, you may want to get a sense of whether or not the family would be interested in pursuing this testing and potentially therapies. So it might be good to sort of establish rapport with the family, really get a sense if they're sort of interested in, you know, pursuing further testing or if they're okay with the result. I mean, getting a diagnosis can be very, for some, you know, parents deal with it in many different ways. So some parents are unsatisfied with the diagnosis. Some of them are like, thank you, I, you know, I finally know what's going on. And so it might be good to sort of get a sense of what the family, if the family is interested in potentially pursuing, and it would absolutely be relevant to sort of discuss with them what, you know, what concerns they have, if any. Going back to sort of when I was talking about, you know, approaches to the patients, you really want to, you know, using those points might be really helpful. So, you know, thanking them for bringing up the subject and really sort of just, you know, trying to provide them with best next steps. And if they do have environmental concerns, it might, you know, that might be a good way to sort of just approach them, say, you know, do you have any environmental concerns? And that might be a good sort of segue into talking about them. And of course, if they have environmental concerns that you can't necessarily answer, they can always talk to someone at the Pediatric Environmental Health Unit for your specific location. And that actually is a great segue into the next question, which is about Choosing Wisely, which is a really wonderful resource that is a tool to promote sort of conversations between clinicians and their patients. And Choosing Wisely just came out with these recommendations, like literally this week. So I didn't get a chance to update my PowerPoint, but, you know, it's a really wonderful starting place. And it really echoes a lot of the things I talked about in my presentation. And I really highly encourage people to use that as a starting place for having these conversations with families, should they have any environmental concerns. Thank you. Dr. Payne, there's a question for you, which is, let's see here, oh, what impact has climate change had on neglected tropical disease incidents in the recent years? So climate change that might increase the temperature in certain regions could lead to longer growing seasons. It could also lead to more of the vectors which are known to transmit neglected tropical diseases. And so if you are in a country, many developing countries don't have a good control program or eradication system for many of those vectors. And so if you have more of them in the environment, or you have a longer season where it's warmer, you're going to have people at risk for longer periods of time. And then I would just highlight too, which isn't necessarily related to climate change, but just another factor is that we have sort of a world that has become much more interconnected. And we've seen this with emerging infectious diseases, like Ebola and COVID, where just how interconnected our different countries are with migration, with travel. It allows illnesses to spread much quicker and much easier than it might have 50 years ago even. Thank you. Dr. Jasmine? Oh, go ahead, ma'am. Go ahead. Well, there's a question at the bottom that is addressing the cost to treat, but I can't see the whole question. Yeah, here, we'll go right to it because it's somewhat related. And it says, can Dr. Payne discuss what it might cost to treat neglected tropical diseases? And what are the obstacles for high income countries to fund these cures or treatments? So again, most neglected tropical diseases are diseases of poverty. They're diseases where people have really unsafe living and working conditions. So the best way would be to honestly prevent them from occurring. And that would require infrastructure and investment in the country to have a proper sanitation system, to have clean water piped into homes like you have in more developed countries. But we have other ways of going in and doing things like the Mass Drug Administration programs. But those are not perfect solutions because, again, you can have people who are not included in those programs. And then you also have cost limitations. If it's not something the country is able to invest in themselves, it could be based on a donor. And then for that program to become more sustaining, then it may have to be sort of racked and stacked against other programming. In general, it costs cents to treat a person. But when you have a whole nation of people or millions of people at risk, it's more cost effective over time to prevent those diseases from happening by investing in the infrastructure, the growth of that country into a more sustainable and peaceful society. Thank you so much, Dr. Payne. There's another question for Jasmine. What do you recommend that physicians and patients discuss about environmental exposures and possibly testing during pregnancy? Thank you, that's a great question. I'll just start out with maybe talking about sort of like the stuff that maybe we don't really think about our environmental exposures, but really are. So exposure to secondhand smoke, we know, can have a huge impact on the growing fetus. So things like that are really important to keep in mind. Is the pregnant mom, is she at risk for lead exposure? That's something else that's super important and that you may want to test for as well. During my own pregnancy, I did my training in Newark and during the time that I was pregnant, there was a concern about lead in the Newark supply. And so I absolutely brought that up to my provider and she tested me and thank goodness everything was okay. But so things like that, that we kind of take for granted are definitely a great place to start. So another great example is, does the patient, does the pregnant mom, does she drink well water? Is that something that she's concerned about as well? And so these common things are certainly important to address since we know that they do have an impact on the baby and of course on the mom. And so those are, that's typically a great place to start. For the more exotic things like phthalates and PFAS, I do recommend checking out prescriptions for prevention, which might be a really helpful resource for families and pregnant moms who have these concerns as well. But it's not something that pregnant moms immediately think of. And I would encourage you to sort of focus on the things that we know are very important and that we know are very common, such as secondhand smoke, lead, and those kinds of things. Great question. So that answers the current questions that are out there. I'm going to hand it over to our speakers if they have any other final comments or if they've thought of anything with regards to some of these questions coming up. And Dr. Payne, I actually want to ask a little bit about, as we see nations struggle with the COVID vaccine rollout, do you feel like this is going to really start taking away from any efforts we're doing towards neglected tropical diseases or other immunization campaigns? And how do we really balance when you have limited resources and you have to choose one or the other, the COVID-19 vaccine versus some of these programs that we have in some of these developing countries? Thanks for that interesting question. I appreciate it. I want to say first that I think that a lot of programming has already had to start making those difficult decisions early on in the pandemic. The DHAP program, Defense HIV Prevention Program, was one of the earliest and only sites in many African countries that could offer testing for COVID-19. It was using the same machine that they would potentially be running tests for their HIV patients on, but they had to sort of divert resources and supplies towards COVID-19 to respond to that. Since then, there have been other supplies that have stood up, but early on there were those limitations. And there have also been other limitations in terms of being able to see patients. And they've had to work around that with longer prescriptions, with virtual encounters, and with the restrictions and movement even going sometimes into the communities to try to meet patients. And so a lot of challenges with this pandemic. And I don't see it quickly going away on the continent, unfortunately, without more vaccine becoming available and more people becoming eligible for those vaccines. So those are not easy choices. Some of the choices initially, you know, result revolved around the safety of the health care workers who were going in and trying to still deliver vaccinations and trying to prioritize those programs, you know, things like polio eradication and being able to reach those populations and needs. So they're not easy choices and it all costs money, unfortunately. And so I think that looking at risk assessments for individual countries, where they're at with the pandemic and what are their individual needs, and then working with those countries to understand what they want and what they prioritize is also important because ultimately things like the vaccination is still elective for people and bringing in a large effort to vaccinate a population that doesn't want to be vaccinated also isn't going to help. So difficult choices and we'll continue to make them and we'll continue to do our best to meet people's needs. Thank you so much. We do have a little over a minute left if either of our presenters have any final comments. But again, I want to thank you both for such wonderful presentations and all the hard work you've been doing this past year on these topics. Definitely, you know, I feel like topics that are often overlooked and populations that are overlooked. And so, again, just want a great, great job. Do you have any final comments for the for the audience? Well, I just want to thank the audience for listening to both of our presentations. You know, they might seem like very different topics when you're talking about gender equality. You're talking about neglected tropical diseases. How are these related? You might also think about that in the context of autism and environmental exposures. But I think there's so many intersecting domains with health, with animal health, with climate, with where we live and how and how we work that are important. And that's becoming more and more evident and how we can address our underlying needs. Absolutely. Thank you so much. Well, I hope you all enjoy the rest of the conference. Don't forget to fill out your survey and for the CME. Thank you so much. Have a wonderful rest of your day. Thank you.

Women's Peace and Security

neglected tropical diseases

role of women

conflicts

peace

schistosomiasis

lymphatic filariasis

ectoparasitosis

health disparities

climate change