رونوشت کامل Ep. 111: Driving Change for Children: Insights from AAP’s Mark Del Monte

death for HIV was 24 months, even for kids. The armamentarium of drugs was not what it is now. I saw unbelievably sad and tragic things happening all the time, but what I also saw during that period were moments of incredible courage and astonishing grace where humanity shows its best in the midst of the worst circumstances. Those kinds of things stick with you and give you energy to keep going. Those formative experiences that I had in my first five years of practice right out of law school and the people that I met there, and the inner strength and fortitude that they had to persevere despite unbelievably difficult challenges in their lives have given me, I think, a set of background focus that has really been wonderful tools in my toolbox for my whole life, and I'll be grateful to them forever. It was an incredible period of vital work. It was hard, but as a young lawyer, you felt like you were making a big difference and you were doing something that mattered to people. It was a tough time and an exciting time. Carol Vassar, podcast host/producer: How did it set the stage for your future career? How has it influenced the work you're doing today? Mark Del Monte, American Academy of Pediatrics: It was always about children. Especially in the rearview mirror. Five or 10 years into my career, I thought, "Hmm, I've always been working for kids. I guess maybe this is going to be on kids for me." It wasn't something I realized early on. But advocacy for children, whether it was one at a time doing those legal services in the community or later on from a policy perspective advocating... I moved to Washington in 2001 to be a lobbyist for children. So, from direct services or from a policy perspective and advocacy, it was always about advancing the cause of child health and making things better for children. Now, I've been at the academy for 20 years, so that has been a very consistent part of that for this whole time. Children need a voice. They are 20% of the population but 100% percent of the future. It's a population that, in many ways, is utterly dependent on those of us who are not children to take care of them one at a time or take care of them as a group. And the mechanisms to do that are in healthcare or in education or in law, and public policy. So all of us have a role to play in that, and I've been lucky to have a part. Carol Vassar, podcast host/producer: Let's bring it up to today. What do you see are the pressing issues both here in the US and worldwide in terms of children's health? I'm sure there are numerous. Mark Del Monte, American Academy of Pediatrics: They're very numerous, yeah. Unfortunately, there are too numerous, I think. Let's start in the United States. You ask globally, but we can start in the United States. In terms of what the academy especially has been focused on, I think everyone can agree that we're having a terrible crisis in mental health that we don't fully understand, but we're definitely having to deal with a double-digit increase in suicidal thinking among children under 10. It's hard to even internalize what is going on for kids that even our youngest children, all the way up to young adults, are in such despair that they would be thinking these thoughts. Why are they feeling so isolated and alone? And why do they have the ready mechanisms to hurt themselves that so many of them are able to do that, that firearms are now a leading cause of death in children in the United States? We got work to do here. Mental health and behavioral health is so top of mind. We have to put the fire out. We have to stop the number of children who are harming themselves. We've got to work on that on that end of the spectrum. But then we got to go all the way back and begin at the beginning in children's development, and how do we build more resiliency and how do we work on healthy emotional development and early relational health so that children are growing up in this society feeling like they have some strength and some grit and some ability to respond to all the difficulties. I think that's our work. We worry about children's physical development from little babies all the way up to young adults so that they grow up healthy physically. We're worried about that on a number of levels, but we also need to focus in the same way on their healthy mental and emotional development, I think. And then they're growing up in a world that people are concerned about the climate. Of course, climate change and mental health are interrelated because we hear so many kids who are worried about growing up in a world that's on fire. I think we have to deal with these things as adults. We have to take good care of the kids. We have to think about the world they're growing up in. So those are two of them. I think the third one I would name is this healthcare system that we have in the US is not built for children, and we need to really reimagine. If you and I sat together right now and got a clean sheet of paper out and designed a healthcare system that was built around children and families, how would it look different than the system we have today? I think it might look a lot different than the system we have today. Carol Vassar, podcast host/producer: What would it look like in your estimation? What would your dream healthcare system for kids be? Mark Del Monte, American Academy of Pediatrics: We know that so much of what builds lifelong health and well-being for children does not just happen in the clinical space. It happens in their communities and in their families. And so, how do we think about all of the structures and community systems that children are interacting with? How do we build those systems around the child and their families? So, how do we strengthen safe, stable, nurturing relationships around the kids? How do we make sure that we're promoting healthy, physical, and mental development? What are the systems at school? What are the support systems around that? How does

the pediatrician and the healthcare system fit into that? Luckily, most kids are well. That's good. 80% of kids grow up and are well, but what about the 20% of kids who have a chronic disease or those 3 or 5% of kids who have really complex medical conditions? What do we do about them and building out that healthcare system? What's the subspecialty workforce that we need for them? What is the really complex care system that we need for those kids? But for the most kids who are well and most kids who are now Medicaid eligible, that means they're growing up in families that are poor or near poor. So they need housing supports and transportation supports and all those things that are going to help them get through their lives. Carol Vassar, podcast host/producer: Food. Mark Del Monte, American Academy of Pediatrics: Food, all the social drivers of health. We know those things are huge. And so if we could build a system that supports that, you're going to help kids do just fine. Carol Vassar, podcast host/producer: AAP does a lot of policy work. You came to Washington to do policy work, you said in 2001. What is AAP's role in policy for that future state of healthcare and for the pediatricians that you serve? Mark Del Monte, American Academy of Pediatrics: AAP, from its very beginning, has been about advocacy. Actually, it was founded in advocacy in the early days. In fact, we are 94 years old. We're thinking about our 100th anniversary in a few years here. It was founded in 1930 by a group of pediatricians who really believed that the collective strength of an organized group of pediatricians could really change the world for kids. They were thinking about excellence in clinical care certainly, but they were also thinking about child labor and infectious diseases. There were no child labor laws. There was no kind of child welfare as a concept, or public health was kind of emerging even as a concept. So, they were thinking about social drivers at that time, even though there were no terms for that. S,o AAP has always been about working outside the clinic. We have a big Washington office working at all levels of government in DC. All of our state chapters are working in their state capitals to drive policy for kids. Whether that's making sure that the federal government is making appropriate investments in necessary programs for kids, and that's from legislation to appropriations, or whether they're solving problems. One of the things that we've been working on a lot recently is drug shortages. This is driving families crazy. If you can't get a medicine for your child, and you're driving from pharmacy to pharmacy to pharmacy, you're not only interrupting the care for your child, you're interrupting your own job, you're interrupting your own life to worry about your child. So we think that in addition to the 67,000 members who are doing great care every day, our job is to work at the systems level and at the policy level to try to make things better for kids. Carol Vassar, podcast host/producer: What are some recent policy wins for AAP and ultimately that would benefit children? Mark Del Monte, American Academy of Pediatrics: Yeah, very good. We have had some really nice advances recently. I love to talk about this, and thanks for asking, because when we have a success on Capitol Hill, or we have a policy success within the administration, it's almost never on the news because it's not controversial, or it's not about people fighting. There is a bill in the United States Congress right now called the Kids Online Safety Act, K-O-S-A, KOSA. This bill is a real good piece of legislation. It's been hard work to get it going. It has the chance to put guardrails around social media platforms for kids. This is something everyone agrees about. And it passed the United States Senate 91 to 3. I'll say that again, just in case you missed it. Carol Vassar, podcast host/producer: 91 to 3; that sounds very bipartisan to me. Mark Del Monte, American Academy of Pediatrics: It sounds amazing. When have you ever heard of anything passing 91 to 3? Carol Vassar, podcast host/producer: Not recently. Mark Del Monte, American Academy of Pediatrics: It's impossible in this Congress. Nobody believes that's happening. It didn't get on the news, and it's not a big deal because it's not a fight. We like to win. We don't need a lot of spotlight. We don't need a lot of news coverage, but we like to move the ball. It passed a House committee as well and is moving through the House. Even in this election year, we may get a bipartisan, bicameral piece of legislation that has real meaning for children to the White House for signature in the most contentious election year ever, and that's a wonderful thing. And I wish more people knew about it, but that's the world that we live in. Carol Vassar, podcast host/producer: Well, they'll hear about it on our podcast. Mark Del Monte, American Academy of Pediatrics: Wonderful. Carol Vassar, podcast host/producer: As we sit here, we're at HLTH today, we're in Las Vegas, we are hearing so much about new technologies that are bearing fruit within the healthcare system, especially AI. As AAP has a huge role in advocacy in policy, what role does the organization play in ensuring that AI is used as a force for good, especially for kids? Mark Del Monte, American Academy of Pediatrics: Yeah, this is so important. AI is sort of as exciting as it is sort of anxiety inducing in equal measures, I think, right now. We are thinking about AI in three work streams, essentially, at AAP. One is clinically. I think there is tremendous promise in AI systems to reduce the unnecessary administrative burden of clinical medicine. So if some equivalent of AI Alexa is listening in the background and charting and coding and all the things that it could be doing that the clinician no longer has to do, and it's reliable and sound, what an amazing thing, if that's just going on in the background, and it gives an

opportunity for the clinician to do what the clinician is trained to do and wants to do, which is actually engage with the family. Look mom or dad or caregiver in the eye, look child in the eye; oh, what a way to reduce burnout and all the things we worry about. You could actually get back to being the doctor. So, there is a real promise in clinical medicine if we get that right. Now, we have to get it right. It can't be just another thing where the EMR got away from us and it made jobs harder. So we have to make sure to stay focused on the clinical aspect of that in a way to work with those companies and the people who are thinking about that to stay clinically focused in the development of it. That's number one. Number two is the training and education of clinicians. There's a real opportunity here, I think, to innovate around the way that we teach people how to take care of children, and that could be really exciting if we can get that right. Young learners today are learning in a different way than before, and so let's adapt and be innovative about that. And then third, this is the one that worries me the most. There's the child safety aspect of this, and we're not talking about this enough. There are things out there; your AI Best Friend that speaks to you in your mother's voice. There is no guardrails at the moment around what is happening in the child health, child safety space around this, and we need to be very concerned about that as people who care about children. So we're trying to work with the companies to figure out how to put some boundaries around what's happening, because the innovators are going so fast that parents don't understand what's happening, people who care about kids can't keep up with it, and the kids are there. So we got to slow down, and we got to think about that one faster than we are right now. So those are the three work streams that we're thinking about. Carol Vassar, podcast host/producer: And policy always lags behind. You've been in Washington for over 20 years. Is there any way to speed that up in this area? AI is moving so quickly. Mark Del Monte, American Academy of Pediatrics: I hope so. I hope so. It's like an aphorism that policy always lags behind. People know this. Science is always in advance of clinical medicine. Policy is always behind the advances in science. There's some real risks here, and as I said, I'm worried about the child health piece of this, the child safety piece of this, and so we need to get all the stakeholders working faster to think about that. And that includes the innovators. They have a stake in this too. Nobody wants to hurt children. We have to presume that everybody's doing the right thing for the right reason that everyone has good motives. We want to put out there that we are here to partner with you, that the child health experts want to be at the table to help you figure this out. The government has a role to play. They don't have any authority at the moment, but if Congress is willing and the regulators can get there, we think there's some stuff that we can do together, but the time is right now, we don't have much time to waste here. Carol Vassar, podcast host/producer: What's on the horizon for AAP in terms of policy around anything? Mark Del Monte, American Academy of Pediatrics: Yeah. I think a couple of big priorities for us. As I said, we are continuing to try to innovate around mental health. We need to build a different kind of infrastructure. We're worried about environmental health. That's been a big focus for us. We continue to try to think about all of our work through an equity lens to make sure that no child is getting left behind for any reason and no child is not getting access to the treatment and care that they need. And then the workforce and pediatrics, that we have sufficient workforce on all fronts, and that's a very complicated thing. Fundamentally, the way that pediatric healthcare is financed is through Medicaid these days. My grandparents get one program, one big Medicare program. It's a big national program. Kids get dozens and dozens and dozens of Medicaid programs. And where you live really depends on what kind of care you get, and we don't think that's right. So, if Medicaid is going to be the primary payer for children now and into the future, we really have to think about a healthcare system in which Medicaid is the primary payer. That's okay if that's what it is, but then we got to think if the whole thing is built on that chassis, we better have a pretty good chassis there. So, we have ideas about how to improve the Medicaid program and think about that so that a child doesn't get vastly different things depending on where they live. I think from a federal policy perspective, we're going to be working really hard on that because if the Medicaid program is stable and strong, then there's a lot of positive benefits that flow out throughout the system. And luckily, there's smart people thinking about this, doing really good experiments all around the country, thinking about social drivers and incorporating the kind of clean sheet of paper process we were talking about earlier. What if you added things that made health outcomes not just what happens in the hospital but what happens in the community? And so if we can do some of those experiments and really start to reform the system, people get very excited. Carol Vassar, podcast host/producer: Final word: what would you say to legislators and policymakers, in addition to what you just said, to kind of bring them around to this concern that children's health is the future's health? Mark Del Monte, American Academy of Pediatrics: Yeah. At AAP, we've been saying for a long time, "Children are not just small adults. If every new legislator orientation day, we get in front of them to say, "Children are not just small adults. You have to build children's programs for children, you cannot retrofit adults programs and put children into them. Children require unique and different things." And so if you start every idea with a child in mind, you'll get it right for the adults later. But we always have to begin looking at children first. And if, for every policy proposal that ever comes in front of a legislator's desk, the first question they ask is, "How does this affect the children?" they'll get everything else right. Carol Vassar, podcast host/producer: This has been fabulous. Mark Del Monte with the American Academy of Pediatrics. Thank you for joining us on the Well Beyond Medicine Podcast. Mark Del Monte, American Academy of Pediatrics: Thank you for having me. This is great. MUSIC: Well beyond medicine. Carol Vassar, podcast host/producer: Mark Del Monte is the CEO and Executive Vice President of the American Academy of Pediatrics. We thank him for taking time to talk with us while at HLTH 2024, and we thank you for listening. Don't forget to check out our video version of this podcast on the Nemours YouTube page via the link in the show notes for this episode. More video podcasts from HLTH in Las Vegas are on the way, including our next episode when we talk with Dr. Ashwin Vasan, who recently completed his tenure heading up one of the largest public health agencies in the world: the New York City Department of Health and Mental Hygiene. Don't miss it. In fact, visit our website, nemourswellbeyond.org, and subscribe to the podcast. That way, you'll never miss an episode. That's nemourswellbeyond.org.  The podcast team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, Steve Savino, and Sebastian Reilla. I'm Carol Vassar, and until next time, remember, we can change children's health for good well beyond medicine. MUSIC: Let's go-o-o well beyond medicine.