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#033 - 👩‍⚕️ Dr. Perri Klass MD


Perri Klass on the incubator podcast

Join us this week for an inspiring discussion with pediatrician and author Dr. Perri Klass.


Perri Klass is Professor of Journalism and Pediatrics at New York University and Co-Director of NYU Florence. She attended Harvard Medical School and completed her residency in pediatrics at Children’s Hospital, Boston. She writes the weekly column, “The Checkup,” for the New York Times Science Section. She has written extensively about medicine, children, literacy, and knitting. Her new book, A Good Time to Be Born: How Science and Public Health Gave Children a Future, is an account of how victories over infant and child mortality have changed the world. She began writing about medicine and about medical training when she was a medical student; her accounts were collected in her two books, A Not Entirely Benign Procedure: Four Years as a Medical Student, and Baby Doctor: A Pediatrician’s Training, which were originally published in 1987 and 1992, and were reissued as classics of the genre in updated editions in 2010. Her most recent book of medical journalism is Treatment Kind and Fair: Letters to a Young Doctor. Her medical journalism has appeared in a wide variety of publications, including The Washington Post, The Wall Street Journal, The New Yorker, The New England Journal of Medicine, and Harvard Medicine. Her other nonfiction includes Every Mother is a Daughter: the Neverending Quest for Success, Inner Peace, and a Really Clean Kitchen, which she coauthored with her mother, Sheila Solomon Klass, and Quirky Kids: Understanding and Supporting Your Child With Developmental Differences, which she coauthored with Eileen Costello, M.D., the second edition of which was published by the American Academy of Pediatrics in February 2021.



Perri is the National Medical Director of Reach Out and Read, a national program which promotes early literacy through pediatric primary care, with guidance about reading aloud for parents and children’s books provided at routine well child visits. She ran the National Center from its inception through 2006, during which time the program grew from a single site to a national program with thousands of sites serving millions of children; the program now reaches 4.8 million children a year, 80% of whom are growing up in poverty. Through her work with Reach Out and Read, Perri has been able to integrate her commitment to the health care of young children with her love of the written word. In an essay on the program, she wrote, "When I think about children growing up in homes without books, I have the same visceral reaction as I have when I think of children in homes without milk or food or heat: It cannot be, it must not be. It stunts them and deprives them before they've had a fair chance."



She has received numerous awards for her work as a pediatrician and educator including the 2007 American Academy of Pediatrics Education Award, which recognizes her educational contributions that have had a broad and positive impact on the health and well-being of children; the 2006 Women’s National Book Association Award; and the 2011 Alvarez Award from the American Medical Writers Association. In 2016 the American Academy of Pediatrics honored her with The Arnold P. Gold Foundation Humanism in Medicine Award, citing the impact that she has made through her writing, service as an educator, and leadership in promoting early literacy through Reach Out and Read. In April 2021 Perri was elected to the American Academy of Arts and Sciences.


You can contact Dr. Perri Klass at perri.klass@nyu.edu

Find out more about Perri at www.perriklass.com


Grab your copy of A GOOD TIME TO BE BORN right here 👇





 

The transcript of today's episode can be found below 👇


SUMMARY KEYWORDS

children, babies, book, people, pandemic, parents, child, writing, good, talk, communities, safe, infant mortality, great, vaccine, polio, care, inequities, families, infant

SPEAKERS

Ben, Perri Klass, Daphna


Daphna 00:00



Ben 00:39

Welcome Hello, everybody, welcome back to the podcast Daphna. How you feeling today?


Daphna 00:53

I'm good. We were just saying it's a rainy day here in Florida. It's a perfect day to be recording books. That's right. Talk about books, and some excitement this week. The week that we're recording is that our littles will get to be vaccinated, which actually is interesting considering our guests today.


Ben 01:14

I think that's absolutely right. I have my I have actually my booster shot scheduled today and my daughter is now I added her to the schedule. So we're gonna go get our our jabs today. So that's exciting. without much ado, let's introduce our guests today we have the pleasure of having with us Dr. Perry class. She is a professor of journalism and pediatrics at New York University and she's the co director of NYU Florence. She attended Harvard Medical School and completed her residency in pediatrics at the Children's Hospital in Boston. She writes the weekly column, the checkup for the New York Times science section, she has written extensively about medicine, children literacy and getting a new book, a good time to be born. How Science and Public Health give children a future is an account of how victories over infant and child mortality have changed the world. She has written multiple books and her medical journalism has appeared in a wide variety of publications, including the Washington Post, The Wall Street Journal, The New Yorker, the New England Journal of Medicine, and Harvard medicine, areas National Medical Director have reached out and read, which we are all familiar with. She has received numerous awards. Harry, thank you so much for being on with us.


Perri Klass 02:16

What a pleasure, and congratulations on your daughter's vaccination.


Daphna 02:23

They're pretty excited.


Ben 02:25

Well, Harry, I guess, you published the book that we're discussing today, a good time to be born in October of 2020. And I wanted to start for the listeners who have not had a chance and the pleasure to grab their copy of the book. Can you tell us briefly what the book is about?


Perri Klass 02:41

The book is about the decline and fall of infant and child mortality. And especially, I guess, I would say, the change in expecting anticipating that a pretty significant number of babies and children are going to die rich family's poor families, city country, and that that's just the way it is. And that was still an expectation when my grandmother was having her children who were my parents, which would be 100 years ago in the 1920s in New York City. And at that time, in the 1920s. If you went around the table, and there were a group of parents sitting there, a good number of them would have lost a child, they would have lost a sibling growing up the next door neighbor, it wouldn't be far away wouldn't be the least bit unimaginable though it would be just as tragic as it would be today. And over the course of the 20th century, I trained in pediatrics in the 1980s. When I trained in pediatrics, the watchword of our profession was children are not supposed to die, babies are not supposed to die. If there's a child, we can say that either we have failed to make the world sufficiently safe. You know, we need legislation, we need car seats, we need walls to make things safe. Or we as a profession, pediatrics, it's a problem we haven't solved yet. But that means it should be on the list of problems we're going to solve. And I wanted to write about that what what went into that change medically. That, you know, in the 1980s, we could be talking about pretty much all the things which might kill children as things we should be able to prevent or solve or cure. I want to talk about what it meant medically, but I also wanted to sort of think about what it meant culturally and emotionally to go from a world in which almost everybody lived with the fear of losing a child and sometimes the reality to a world where it becomes the thing that should not happen, which is true for all of us in our training and in our in our workplaces.


Ben 04:53

Yeah, it's interesting. You mentioned that because i i My mother's middle name is actually the name of cousin Have hers that passed away in infancy. And I feel like these scars are there in many of our I mean, my family as well. And she died. I think it's funny because she she's not funny, but she died of pneumonia. When I asked my grandmother I said, What did she die of? She's like, Oh pneumonia, which didn't make it seems like so tragic. But yet you're right. It is it was there. And I guess, I guess the follow up questions I have to that is, how did we forget so quickly, it seems like this has completely vanished. This scar that's that, as you describe in the book is something that is so traumatic for every family. It seems like your book is a reminder of this. And you would think why do we need to be reminded this is so traumatic? How can we've already forgotten about this? This is difficult time?


Perri Klass 05:44

Well, I think you're right, I think we don't as parents, it's not something we necessarily want to remember and what to think about. And that's what what I think is a pity about this is I think that as a species as humans, this may be the greatest thing we've ever done. From being a species where you could anticipate that maybe one in three kids wanted 10 Kids one in seven, you know that it would be a common thing. Just, it wasn't a single campaign. I mean, in the book, I talk about a lot of inspirational single campaigns against polio, or against sudden infant death syndrome. But this wasn't one campaign. This is a bunch of different science and a bunch of different public policy and public health and hygiene. But it's it's all kinds of different people at different times. But what it does, is it lets us imagine a world and we're not there yet. And there, there are still inequities and problems. But it lets us imagine a world in which as a parent, you can have three children, and think about watching all three of them grow up, instead of looking at the children that you love around the table and wondering which ones of them will be safe. And if something bad comes through, if it's a bad year for scarlet fever, or a bad year for diphtheria, maybe all of them are gonna get sick. And you'll wonder how they do.


Ben 07:09

So frightening.


Daphna 07:11

Yeah, you actually you cover a lot of ground in this book, just just the titles of the chapters just so our listeners know, literary echoes of child mortality, child death and Civil War America, mother's milk, educating mothers, diphtheria, Scarlet Fever, polio, the incubator shows which we have talked about on the podcast, measles and chickenpox, and safe to sleep. So a lot, a lot of advances that that you cover. And I don't want our listeners to think that your book indicates that, that we're not losing children, right? Because you talk about that extensively, also, and how parental perspective over the loss of a child has has changed across generations. This is a little deeper than we usually like to go in the first 10 minutes. But I thought, you know, it's such an important, I was so captivated by your discussions about parental grief. And, and you know, before we didn't talk about it, because it was so common, and now we're still not talking about it. And it's kind of taboo in our in our society when we're when we're losing children. And so how can we, you know, support parents during their grief during that time? Well, I


Perri Klass 08:30

think that's a really interesting question. And again, just because I, I hope people will read my book, I have to say, I think it's actually a really happy story. I bring it up. As I say, I think this is amazing that we did this as human beings, we did this, for the most the people who depend on us, for our children. But I also think that nowadays, losing a child was always an incredibly tragic experience. If anyone comes along and says to you, oh, they knew that the children might die and they didn't love them. Same way. That's not I don't think that's true. When you actually read the poems and the diary entries. Of course, they loved them. They knew they might not always be able to keep them and they had to deal with that. But it wasn't a lonely experience. There were cut there were books being published every book that was an advice for for mothers, dealt with it, if you know, probably your your sister or your cousin or your brother had also been through it. So there was at least some companionship in this tragedy. And one of the things which happens I think, to parents nowadays is this has become kind of the unthinkable unmentionable tragedy if you go around that same table. Nowadays at a I don't know potluck or gathering back when we had gatherings and potlucks with World loud it. It would be hard for a parent to say Oh, We have three children, but one of them is no longer alive, that's become something which is become, you really have to think about how you're going to introduce it into conversation, people have no way to kind of move on from it. And I think one of the results is that parents who do face those tragedies ended up feeling very much alone, very isolated. And there have been people writing about parental grief, who have speculated that, that loneliness, that feeling that, you know, once upon a time, we think, you know, you would have had a picture of that child on the wall, you might have had that child's hair in a locket, people would have recognized the signals, and there would at least have been some kind of company in your group.


Ben 10:52

I think what's interesting is that you, you publish the book in October of 2020. And obviously, this, the book is exceptionally well researched, I'm assuming you started working on the book, way before the COVID 19 pandemic started. And then this happens, and I'm curious, the COVID pandemic hit us directly around what stage of your writing slash publishing process.


Perri Klass 11:15

Um, the book was already pretty complete, I did go back. And, you know, put in some references to what was happening in the pandemic, I wanted to point out that, you know, the pandemic should be a reminder of our vulnerability, it should be a reminder, please of the miracle of vaccination, and you know, how that may be one of the cleverest things humans have ever figured out. But it should also be in this is one of the things I'm trying to argue with the book, it should be a reminder of how connected we are. Because to me, one of the things that I kept realizing in the book is you don't actually keep children safe by walling off your house, this house will be safe, my child will be safe. You keep children safe by saying how do we keep everybody in the community safe? How do we keep everybody in the city safe? How do we keep the country? How do we keep the world safe? And that's, and COVID has been such a reminder of that for all of us. We don't you have to think about it as making the community, the country, the world, the school safe for all the children. But I would point out that in July, the Director of the CDC was testifying before a Senate committee and was asked by a senator about whether children who are not usually the ones who get most severely sick with COVID should really be vaccinated. And she said, and I quote, I think we fall into the flawed thinking of saying that only 400 of these 600,000 deaths from COVID have been in children, meaning that people acted like that number, which was right at the time was small. And what she said was, children are not supposed to die. So 400 is a huge amount. And I think this book for me is about how we got to the place where we all agree, children are not supposed to die, it is the thing that is not supposed to happen. And I thought that, you know, in this pandemic, if we could hold on to all of the science and advocacy, and public health and communal thinking that got us to the place where we can understand that children are not supposed to die, we would have what we need to deal with this pandemic.


Ben 13:43

And I think this is I was gonna say this is one of the most significant messages of your book, which is that we've taken for granted, right, these vaccination campaigns, and we've taken for granted that we don't see polio anymore in our children. And, and we forgot that this is what it took. And now there's vaccine hesitancy, and people are questioning every vaccine. But your book comes at such a crucial time to remind people, this is what was at stake, and the pictures, there's also pictures in the book that are so good to remind us of what children did have to go through when they were afflicted with all your left area. This this is this is frightening. So I think this is where your book somehow the timing is perfect. I mean, I'm not sure if it felt like that when you were in the process of releasing the book saying God damn discovered 19 pandemic is hitting, but I do think for me when I was reading it when it came out, it provided a lot of historical evidence that helped me deal with the COVID 19 pandemic and embrace what science was doing at the time to fend off the pandemic in both adults and children.


Perri Klass 14:53

I'm so glad I'm so glad to hear that. I mean, I think when you talk about these diseases, we of course in PDF Do we still learn? Right? I mean, I've never seen that theory. But I studied dip theory. And I, you know, at some point in my life, I could pass on microbiology exam or dip theory. And, you know, I know it's, it's, it's what it is. But I think that, you know, this, this pandemic has reminded us more generally that we're vulnerable that things can, you know, surprise us in terms of our relation relationship to the microbes around us? And but it should also end the story of the pandemic, it should remind us that were actually pretty smart.


Daphna 15:39

Yes. Right. Yeah, that's exactly what what I was going to see to echo what Ben said is that when I was reading the book, I just thought how, how apropos of what is happening, and especially in the discussion around our mitigation strategies is how far we've really come and how different this pandemic is, from previous you know, pandemics and how fortunate though our children are going through something difficult, how fortunate, at least in this country, in my community, my daughter, and in my home, my daughter was able to have so many luxuries while being locked away, you know, at home. And she participated in one of the vaccine trials, and I was thinking of how many other families had to had to be part of experimental things, either volunteered or not, and we can talk about that in a little bit, to get us where we are today. So it really helped me put things in perspective. So I thank you for that.


Ben 16:49

I wanted to go back to what Daphna is just mentioning, obviously, because today, we talk about inequities in medicine. And we tend to leave the narrative that people with means are less subjected to illnesses. And if you are poor, and in a more complex social context, you're more at risk of certain diseases, which is true. But what I think the book is doing very well is that when it comes to pandemic, you do go through stories of people being faced with these afflictions, from all social statuses, right? I think you talk about people who, unfortunately, were still living at a time of slavery, all the way to physicians, Mark Twain, and the President of the United States who were all affected equally with child mortality. And, and I think that that is quite something that we tend to forget. Because today, people may say, Well, you know, I'll protect my kids, and we'll be fine. But this is not how, unfortunately, that viruses and bugs work. So I'm wondering if, if, what was your mindset when you wrote about these inequities, this lack of inequity, I guess, throughout time when it came to viruses and, and illnesses in general? Well,


Perri Klass 18:03

I mean, it's always been, for the most part better to be rich than for better to be, you know, in, in the group that's in power. Now, that's not 100% True, in the sense that, for example, one of the most important factors in whether babies lived or died, has always been whether they were breastfed. And there were situations in history when you are not necessarily more likely to be breastfed. If you are a child of somebody very well to do, you may be more likely to be consigned to care, you know, so but for the most part, I mean, when we think about what really helps children, it's better to be well fed, it's better to be well nourished and to be angry that but But what is also true is that up until the probably early middle of the 20th century, nobody was safe. And that's one of the reasons that I talk in the book about some of the very rich, very powerful people about royalty about all the presidents who lost children. It's a sort of shorthand way of saying, even if you were the most powerful person in the United States, even if you could have the best doctors in the world standing by it didn't matter because nobody could do anything about diphtheria, polio and scarlet fever. And in so in that sense, having health care, it might help but it also might not help. And although there were plenty of inequities, and we see that very powerfully with the different infant and child mortality rates between the black population and the white population in the United States, where you've got inequities that go clearly back into the 19th century that reflect the real really terrible conditions in which many black children were growing up, those rates come down very decidedly across the 20th century. But there's still a disparity, the infant mortality rate among African American babies in this country, we know is still double what it is among white infants. And so on the one hand, you need to note how many babies are surviving how much progress has been made. But on the other hand, you need to say, but we have not corrected the the inequity, there is still a disparity here. And it's it's affecting a smaller group of babies, because the rates have come down, but it is still, you know, kind of a glaring disparity and something that you have to figure out and address.


Daphna 20:53

Yeah, it um, you know, we like you mentioned that childhood mortality across the world, but even in our country here in the United States is we know is still related in many things along socio economic lines, citizenship, and race. And it actually almost feels that throughout our improvements in medicine, that we may actually have widened the health gap between certain certain groups of people. Because it did go from a time where everybody was at risk to now it seems like you know, certain populations are more at risk, given our how our, our society is functioning, I was hoping you might be able to speak to that.


Perri Klass 21:35

So when we looked at, when we look at the persistent disparities, both in maternal mortality, and in infant mortality, most of what we're looking at, and that is most of the infant and child mortality that we're looking at nowadays, in this country, and in most other relatively rich countries, it's going to be infant mortality, and most of the infant mortality is going to be perinatal mortality, right, you know that better than I do. So an awful lot of what we're looking at just in terms of what still kills children in this country, a great deal of it is going to be prematurity going to be complications of pregnancy. So when you I mean, I could ask you when you want to prevent that when you want to stop it. We're talking about primary care health care for girls and women as they're growing up health care for people when they're pregnant, support while you're pregnant. Prevention of prematurity, superb health care at delivery, we're talking about places where we need a really strong system that provides preventive primary care, and that takes care of you when you're pregnant. And that's probably the place that you would absolutely start if you will certainly in trying to correct disparities, it would be the care, the primary care before you're pregnant, the primary care while you're pregnant, the obstetrical care, the care around delivery. And then of course, as children get older in this society, because we got these great vaccines, because nobody should be dying of pneumonia, because nobody's got the theory. So then we have to look at the other things which which turn up and there are also disparities in children's exposure to accidents in drowning, and you have to look at how you can make the world safer for all children again, and you know, the safer you make it around issues like drowning, which is a


Ben 23:46

preventable, super preventable,


Perri Klass 23:48

preventable, you proud? I mean, you're in Florida, you tell me what what do you what do you do to make it safer for for a little kids around drowning?


Ben 23:57

Well, I think it's, it's always the expectation of just the, in my, in my experience, the biggest issue has always been right, and you fence around your pool and not assume that the door to the pool is going to be locked all the time. Right. And, and people say, Oh, it doesn't look as nice. It's like, Yeah, but I mean, do you have you considered the what if, and, and people just don't have that type of foresight. And I think this is something that in the book I was riveted by is when you go through these stories, sometimes dating more than 100 years ago, and you have these people who put their finger directly on an issue that we're still struggling with today. And, and talking about inequities. I mean, I like you mentioned Georgia, Georgia, Newman's book from 1906 writes infant mortality, and he's sort of the first one to look at, at infant mortality and child mortality through statistics. And and in his book, he says, under some of the worst external conditions in the world, the evil is absent, it is difficult to escape the conclusion that this loss of infinite life is in some way intimately related to the social life of the people. And he writes Was that in 1906? And we're 2021. And we're just scratching the surface. And, and so I think this is really, really cool. But I'm wondering, what was your feeling when this is just one example. There's so many examples throughout the book, where people who have practiced medicine or who have looked at the infant mortality and childhood mortality really pinpointed something that was so astute. And yet, we haven't solved these issues. What are your thoughts on that? I mean, how do you feel about that? Is it frustrating?


Perri Klass 25:30

No, well, because we've made so much progress, because you've made so much progress. And we complain that our infant mortality numbers in this country are not where they should be. They're not as good as they are in some other wealthy countries. But that's what does that mean, we're losing, we're losing six, seven children out of every 1000 live births. That's too many. That's tragic. But we were in my grandmother's day losing more than 100 of those children. So I think we have to be able to celebrate the progress without losing sight of the fact that it's not a complete, it's not a completed project. And there are ways and I mean, I think, as I think you were saying, what you see over and over again, is that this is this is not one heroic scientist in a laboratory. This is public health. This is infrastructure, this is primary care, this is the whole medical profession, this is the legislature, this is saying that the children belong to all of us, and they should be safe and they should be properly cared for. And, you know, again, I think that's a good model for the moment of the pandemic as well. Yeah,


Daphna 26:49

I think you did a beautiful job really, actually, of bringing so many instances to the forefront of how much of especially in our line of work, how much of modern kind of maternal fetal medicine is dictated by the work done on oppressed groups, like slaves, in particular surgical procedures performed on enslaved mothers and babies. And I think, as the discussions around even race in this country are, have been very prevalent in the in the last few years, I think it's a good, a good reminder about how, you know, larger debt of gratitude is owed to those families for the lives of all of our children that are being saved today. And I think that's not something that's being taught in school in medical schools, and is is a part of the on going and equities that we're seeing, for example, in vaccination rates in regards to the the COVID pandemic, and people, you know, being willing to have access to care. And there's so much history there. And I think that you did a really good job of educating people on why that why it's important to know that history and that it's, it's still a problem for us today, because it is impacting care.


Perri Klass 28:11

It's important for those reasons, it's important to be to acknowledge and to be grateful to people who either deliberately and heroically and there are a lot of heroic stories. And some of the many of those stories actually come out of the more marginalized groups. I mean, there are so as I said, this isn't one campaign. So that's why, you know, when you start thinking about, I don't know, tuberculosis in the black community, you come across these heroic, early African American nurses who were trained in, went to work in Philadelphia, and went to work in New York, in the black community, bringing down what had been terribly high rates of tuberculosis, and of death. And then you look at some of the doctors working in the hospital where I work in Bellevue, and you have the children's chest clinic, which is mostly children from the tenements from the Lower East Side. And you look at the writings of the doctors who are working there in the first half of the 20th century, and they have nothing to offer. They're writing it all down, they're recording it all. They're looking what happens to these children, but they don't have a therapy, and then they have a therapy. And then you know, the someone this is the you get the first couple of drugs and to actually sort of see the writing and the research and hear the voices of the people who had been caring for these children and losing them. And now suddenly, if that have something to offer, it helps you I think, understand all the different contributions which include those families, those parents, those children, who came from the most disenfranchised groups and who were not Always consenting to what they were doing on, it needs to be recognized as part of this remarkable achievement.


Ben 30:11

I think this leads us to the topic of neonatology. Right because I think in neonatology, we do have this conflict of we often very frequently within the history of neonatology things come up and suddenly we do have something to offer. And sometimes it's not. The ramifications of applying these therapies can feel a bit conflicting. I think in the book, you talk about William Silverman, who was obviously this famous neonatologist from Columbia. And I think he in one of his essays that you quote from 1992, he talks about a baby in the NICU, and about like this very medically complex child that they were able to save and he says the baby was presented at Grand Rounds as a triumph of mechanism guided treatment, and I was made to feel like a hero. The parents were asking about the long term prognosis and the baby's future, the longer the baby lived, the more angry the parents became at the thought that I a young, childless household, childless house officer, with no personal experience in grieving a normal child, much less one with might be disabled, now held in my hands, an important determinant, the fate of this family, first of all, William Silverman's essays are so good. But this is so true, right? We do have sometimes things to offer, and yet at the expense sometimes of long term outcomes. And so I think this is this is very interesting. How do we as physician, do you think negotiate the immediate relief, and the delayed gratification or sometimes delayed terror of disability in the future? Especially when it comes to your intelligence?


Perri Klass 31:41

Well, I mean, I thought that I think that's a really good question. Because as I say, we now the diseases which used to kill the the, you know, cholera infantum, the diarrhea which used to kill the eight 910 12 month olds, the dip theory, the whooping cough, the diseases which used to, tragically horribly kill the two year olds and three year olds with a five year old, those are mostly prevented now by vaccine. No, no, you know, pneumonia is treatable with antibiotics, even if, even if it's not prevented by the vaccine. So the great majority of the infant more of the child mortality in the world right now is infant mortality. And the majority of the infant mortality, again, is perinatal. So it is it's your stuff. And, and but again, you know, let's start with the good news, right, Silverman was writing about in the 50s, when even babies who by our standards nowadays would only be not, they would not be very low birth weight, they would


Ben 32:51

know like 1200 grams, you know, that those types of patients,


Perri Klass 32:55

they would be, you know, they would be, you know, maybe six weeks preterm eight weeks preterm, when those babies would kind of be basically left to die, right, there will be nothing that can be done from what we've come a very long way. In terms of I mean, there are an awful lot of people out there practicing medicine with us, listen to this podcast, who would probably started out life with a little extra help. And so I think, you know, let's, let's talk about the fact that oxygen in the delivery room, I talk in the book about the fact that I trained at Children's Hospital, the hospital were 20 years before by training, the child of the President of the United States, the child of John and Jacqueline Kennedy had died at the age of three days, Patrick, again, for I think, five weeks early, five pounds. Um, because in the early 1960s, there was no way to ventilate a premature baby, son of the President or not. And so I think so first, let's say let's, you know, look at all of the people who are walking around who are you know, living their lives, because people figured out how to help those babies through but then and you guys should really be the ones answering this not me. Then let's talk about the question of how you practice each of these new advances and how you learn to do it and what happens to those kids in the transitional zone because it's a couple headed one, what do you think?


Ben 34:41

So I think I rely on William Silverman. I was reading his book on ROP and I think he talks about the experience that parents gave after the epidemic of ROP and going back to these parents and says What would have made a difference when it came to us not really knowing what we were doing? And the parents said, All we wanted was honesty. If you told us, we don't know, we would have been fine with it. And we would have trusted you that you're making the best decision for a child. But remaining honest was the key and not pretending that you knew something you didn't. So I think this is my moral compass when it comes to that. I think, go ahead,


Daphna 35:16

we've been talking a lot about, you know, talking to parents and talking to adults born preterm or children born preterm, and really cataloging what, what their lives look like, to better, you know, and it's important that we do that to better inform how we provide our anticipatory guidance, especially when we don't know for sure the range of outcomes is is broad, and and helping decide at this point that that, you know, certain things are acceptable for some families and not for others. And I think, you know, at least in these last few months, some of the articles that we've been reviewing on our show, are very pertinent to this conversation. I didn't mean to interrupt you, Ben. But I just thought that was so you know, interesting when we think about long term outcome.


Ben 36:10

No, and the book is so good for that, because you go through the historical milestones, and you see what we've we as a community used to do, and you see how, like you said, the class you have far we've come, there's this quote from from the section on on neonatology where it says midwifery and obstetrics through the ages had recommended a variety of techniques for simulating newborn babies who did not immediately read or cry from giving forms of mouth to mouth breathing, putting a little wine in the baby's mouth, placing the baby in a lukewarm bath to more strenuous endeavors, including administering enemas, burning the baby's feet with a hot iron and swinging the bat vigorously. So you read those things. And you're like, Oh, we're not doing too.


Daphna 36:51

Well, I thought it was funny. Just your conversation about car seats, right? What what a major innovation for for families. And I was just struck because I was already a pediatrician, I was a third year pediatric resident when my daughter was born. And we took her downstairs at the hospital and the security guard and the Circle Drive caught me YouTubing how to put her in the car seat, put the car seat in the car, but I hadn't figured out how to loosen the seat at all. And so, you know, here we are just a few generations removed from where there were no car seats to where I was able to find in a matter of seconds on my phone how to work this new this device purchase does keep my daughter safe.


Perri Klass 37:39

But I'm old enough to remember when it became law that even taking a baby home from the hospital. You know, you had to have you couldn't do it without a car seat. And I and to remember, people older than me, like my parents generation sort of thing. Really, aren't you guys carrying this a little far? And I'm just like, No, no, this is this is this is safer this way. And but it's not, it's not that far away. The idea that that this was acceptable risk. And I guess what I would argue is that one of the reasons that these risks became so clear and so clearly on the agenda of what has to be addressed is because all those other deaths stop. Yeah. And then all you if you start looking at what is still killing children, car accidents are on the top of the list. You know, you if if you look at like what are the top 10 causes of death in childhood, and you see that the that say childhood malignancy is up at the top of the list. That doesn't mean that more and more and more children are dying of cancer, it means that nobody is dying of pneumonia, diphtheria, polio. And now the thing that you've got to address is accidental death, or is oncology.


Ben 39:05

And you mentioned that with the transition that the March of Dimes had to go through right because of the fact that they were initially the March of Dimes for polio went out went away and now they had to rebrand themselves and so they had to focus on the next thing on the list.


Daphna 39:20

I thought it was neat to how many how many things even in the newborn nursery today when you know occasionally covering the newborn nursery that it's still like you said in the in the proximal generations on you know, the breastfeeding the back to sleep, the car seats, you know, so many things are really just in the last two decades, even where the grandparents and the you know, are trying to are trying to battle with a new mommy and daddy about what the plan should be for the baby.


Perri Klass 39:52

I had two children my first two children I was sent home from the hospital with instructions that you should always put them to sleep on their stomach because it's safe. For. And then the third child, we had the evidence and they said, they put him to sleep on his back. And that will prevent sudden death. And Freeman like on his back, that will look very good. Of course, that was right. That was true. That was evidence that was a change that and of course, you can sleep on his back. And I was going to be telling people to put their babies down on their backs, too. But I think that it does change. And it changed. And I think we can learn a lot from those successful campaigns. The Baptist sleep campaign was a campaign, which really reached out to people in different communities, people in the in, say, faith leaders in communities, because they were trying to bring down the rates of sudden infant death syndrome in the black community, among indigenous peoples, and they they really, there's a lot of interesting history about, you know, asking, not telling, going to communities and saying, Who is the right messenger? How can we communicate this? Look, let's look at the risks left. And that's still I think, going on in many communities in terms of trying to address this in a way that works for the communities that you're trying to help.


Daphna 41:28

That it's the book spoke to me as a neonatologist because of exactly what you're saying is that some of those major campaigns started just as grassroots or as parents who saw that this is a problem that we need to fix. And when I think about things that still lead to mortality in in the neonatal unit, right, the, you know, propagation of breast milk, are we able to have good prenatal nutrition so that the babies aren't born exceedingly small? Are we able to have good maternal access to care? So babies aren't born exceedingly early? You know, I think, what, what is my obligation, you know, as a neonatologist to help, right to help reach out to the communities where that's really where we need the impact is, is really in the communities. Because the the technological and medical advances, they're pushing the limits, but we need to, how can I get back engaged with my communities to to make change, like the campaigns that have been most successful in history?


Ben 42:37

I think I felt like I knew some of the stories that were mentioned in the book. And I some of them, I didn't know as much detail as you presented them. But the one that I got exposed to was the one of Dr. Josephine Baker. So growing up in France, for me, Josephine Baker was the entertainer who then took part in the French Resistance. So I was like, Is that the same person, but it's not. And she was a physician that figured it all out, she was so bright, and and, and she, I mean, you spend quite a significant amount of time going through her story in the book, and it's just so good. And her quotes and her assessment of, of public health in New York City is just so onpoint. I mean, some of the things I wrote down with when she writes that the way to keep people from dying from disease, it struck me suddenly was to keep them from falling ill. And it's like, Oh, my God, this is again, happening in the early 1900s. And then going back to what you were saying earlier, when she really identified that people who were wealthy who had access to wet nurses, and all these other techniques were probably not better off than people who were just promoting breastfeeding. She says sometimes, it really looked as if a baby brought up in a dingy tenements room had a better chance to survive its first year given reasonable care than a baby born with a silver spoon in his mouth and taken care of by trainers, who knew all the latest hygenic answers. How pertinent and how accurate is that? How did you stumble upon her story? I mean, how did you? How did you find her?


Perri Klass 44:01

Well, she I was interested in she's the first head of kind of the New York office that's concerned with child health, which is the first such office in the United States, and becomes a model. So I was first interested just in how that had come to be. And then she wrote this autobiography. She wrote it in 1939. And when you pick it up, she's just such a great character. She says exactly what's on her mind. Right? He's not particularly interested in making herself out to be the heroine. She's sort of willing to, which is not always true of the great pioneers. They don't always tell you and then I did this, but it was a mistake. And then I did that was a bad idea. And she's because she's doing this New York and because it's the early 20th century, she's working in the tenements that are full of all of the newly arrived immigrants and Yeah, I mean, so for example, she tells this really funny story about how they're sending home all the children from school who have any kind of communicable condition. And that includes ringworm, and that includes the headlights, and that includes impetigo and various skin conditions. And so those children are being sent home with what she says in their families or conditions that people don't make so much of a fuss about that, you know, a lot of people. And so then they send the children home, and then the truant officers from a different city Bureau, come around to the houses demanding to know why the children aren't in school. And she writes, you know, she says it also, very reasonably, they conclude that they've come to a crazy country, in which say, one group of officials to send your children home from school for no particular reason, and they pay another group of around and tell you, the children. And you know, she had a certain amount, she had a sort of sense of humor, and an ability to see how things look from the other side. And I just, I just loved her voice. And I, I liked the way she wasn't telling a narrative member, she's working before antibiotics. She's working at a moment when she does, she doesn't have a lot of magic in her pocket, in terms of therapies. So she's really talking about what you can do with education, public health, hygiene, breastfeeding. And so that was it was a, because otherwise, you know, it'd be you don't want it to just become a narrative of neurotic lab discoveries, even though those are important, because the truth is that cleaning up the water supply pasteurizing milk, encouraging breastfeeding, that's going to save an awful lot of babies. And now let's talk about what it takes to get to a dip theory, a vaccine or a polio vaccine. But let's not forget those, you know, amazing public health nurses going door to door, helping people who are having problems with breastfeeding, making sure that when the weather gets hot, and there are a lot of flies around that the diarrhea doesn't kill babies. So she was a good person to talk about that, because it was it was a you know, she didn't have penicillin streptomycin she, she didn't have the what will come later, she didn't have the miracles of later, neonatology. This is


Ben 47:31

where I think she's so brilliant is that many other physicians because there was no quote unquote, medications, then there's nothing we can do. But she was able to do this grant assessment and saying, Well, we may not have medications, but all these things have an impact. And, and I mean, again, the way you describe her in the book, she has this presence, even when she goes into the family's room. Again, she's a she's a, she's a woman being a physician in the in the early 20th century, all the stigma that is associated with that, and yet, it seems to not bother her at all. And she's just she's just so great. I mean, yes,


Daphna 48:04

model, I'm trying to envision the working in the unit with no antibiotics all of a sudden am it's just a feel terror, honestly. But I wonder if the pendulum has swung too far, right. And we we cut doctors came from, you know, meeting people in their homes, and treating people in their homes and understanding what their home lives are like, to now we've swung so far that we really have lost sight of what's even going on at home and how it affects care. And I just wonder what, what there is to do about that?


Perri Klass 48:46

I don't know. But it is it is it's interesting. And it you know, it speaks to some other things that we sometimes get wrong in medicine in that we all know that frequently. If you after an interaction between doctor and patient, if you interview the doctor and you say what do you think you said, and then you interview the patient and you say, What did you hear? It's not always the same where you know, we sometimes come out of interactions with patients thinking Well, I I explained this and I explained that and I explained this but sometimes the only person who understood the explanation was the person giving it right.


Ben 49:26

As we are getting close to the end of the of this interview, I cannot help but feel you would have made a great neonatologists and I'm wondering what happened what happened there?


Perri Klass 49:36

I actually I love toddlers I like I like the moment you know, if we all find a moment in, in children that we really identify with somehow I really identify with two year olds and three year olds.


Daphna 49:55

Bless your heart.


Perri Klass 49:58

But I mean, you know you could have some I'm saying that about adolescence, you could have someone's, but I mean, I just I just I, I, I there's something about the way that they navigate the world and maneuver with their, with their parents and their siblings. But I also I don't I don't think I don't think I'm an intensivist. I mean, I tried. I worked at it for a long time, but I don't think I don't think I don't think I have the temperament. I'm so glad there are people who do.


Ben 50:29

Fair enough. Fair enough. I guess my last question is, the stories are great, but some of them sort of demystify some of the great so for example, for me, when you mentioned that Virginia Apgar was carrying this like eight week old fetus, it's like, oh my god, Virginia, Apgar fell from grace, when I was when I read the story. And and I'm wondering, what, what are your thoughts on that?


Perri Klass 50:56

Well, I think I think, I think these doctors are great characters. And I think some of them get where they get, partly because they see things at a slightly different slant. I didn't mean that story to demystify, or I meant to tell it as a story of, you know, how as as you're saying, as things change with more times, and people begin to pay more attention to fetal development and to the prevention of congenital anomalies. But it's again, it's a very different moment than the moment that we know and what she does, I mean, she's, she's a great character from the time she invents the, you know, Apgar test on the napkin. And what she says about it that, you know, basically, I'm making people look at the baby.


Ben 51:47

And so that was so that's so critical. You mentioned that in the book saying that the I forgot who you're quoting that that says that about her that her biggest contribution. I think it's Dr. Stanley James, that you quote where he says, she made people look at the baby, which people were dismissing outright, especially in the first few minutes of like, yeah, so this is this is this was great. And again, I think it's the demystifying is not necessarily such a bad thing, either. Because we tend sometimes to put people on a pedestal and think we cannot reach their level. But once we see their human side, we can maybe relate more and feel like we also can follow in their footsteps of contribution to medicine. Alright, I'm sorry.


Daphna 52:31

No, I I, to that point about the storytelling about certain, you know, care, historical characters, I really loved how you discussed, the early pioneers in neonatology and the incubator shows, that's something that we've talked about on on the show, and they can be seen in a negative light, they get a bad rap, but they certainly are the pioneers of modern neonatal neonatology. So I appreciate that you alluded to that. I also really loved your stories of mothers and parents and how people are working together. I think that we can learn something from the value of like you call it mutual motherhood that we saw in the abolitionist movement. And I wonder in this time, where, you know, we think social media is connecting people, it's probably doing the opposite, right? It's so in some ways, dividing people. How can we, you know, connect parents who share experiences of parenthood, kind of to cross lines and continue improving care for infants and children?


Perri Klass 53:41

Oh, I think that's such a good question. I wish I knew the answer. I think that, that, you know, parenthood ought to be one of the things which connects people. It's one of those experiences which a nobody is ready for it, you know, we hit too, you know, and there are so many pieces of it, which you really only understand after you've gone through it from the joys and the vulnerabilities to the frustrations to the absolutely important rule that being the parent of one child is different from being the parent of another which may be you know, the the the saying the temperament was invented by the first person who had a second child, you know, in order to be in order to connect us. And I don't know so much of what gets written and talked about with regard to parents and parenting and parenthood is actually critical, hypercritical, everything you do. It sometimes seems there are people ready, ready to disapprove. I feel that when I write about parenting, the world is full of people who want to write in and say, parents today. They're completely neglectful. They're busy on theirs. cell phones while their children run wild, and then there's another group writing into, say, parents today they're hovering their children, everybody, you know, and it's like, are they doing everything wrong? Can Can that be? So anyway, all I mean is that I There ought to be a way for social media for all the possible ways of communicating to help parents feel connected and supported and reassured and helped. And I don't think that always happens. I wish I knew how to make it happen.


Ben 55:31

And I think you quote Dr. Benjamin Spock a lot through the book. And he has and he has that ability to say exactly that where he says don't like about childcare saying, Don't take too seriously what all the neighbors say, Don't be overwhelmed by what the experts say bringing up your child won't be a complicated job. If you take it easy. Trust your own instincts and follow the directions that your doctors give you. It's exactly what you're saying.


Perri Klass 55:55

Well, he The thing about Dr. Spock, is that he had that message of reassurance right, that famous first line, trust yourself, you know, more than you think you do. That doesn't always seem to be the message that parents are getting from a lot of places where they look for information to date, I'm afraid, I would say that the message is not only don't trust yourself, it's often don't trust your doctor, don't trust your Mother, don't trust anyone in the world. That's a very hard message because parenthood is is anxious.


Daphna 56:31

You know, I think that's something that we can even use in the unit. I just told them mother yesterday, you're here and you know your baby better than any of us. And if you know, if you're worried that I'm worried if you feel like she's doing better today than I feel like she's doing better today. And I think that's a powerful gift that we can we can give to our to our parents, especially those of us in the NICU where parents feel really, so out of control, parenting already feels out of control. And then and then a NICU admission makes it even harder hill to climb. I think I know we're running out of time. And I know we're in the midst of COVID vaccination. But I wonder what you think will be the next major milestone in protecting infant and child health?


Perri Klass 57:19

Well, I mean, as you say, we're at the moment of another vaccination. I don't want to use the word miracle, but we're at the moment of another vaccination milestone in terms of COVID vaccination. And I think we all hope that what we've learned with the development of COVID vaccines with about the of this technology is actually going to open doors in terms of future vaccine, you know, protection. I don't know what's going to be the first or the next. But I've heard a lot of stubborn vaccination problems discussed as possibly, you know, could we get to that universal flu vaccine where we don't have to vaccinate children every year? Because we, you know, get to be could well, what will be your fantasy to protect even premature children from RSV infection, you know, is wildly delightful. Are we going to have new technologies that will make safe vaccines possible, effective vaccines, vaccines that we need to deliver really early? So


Ben 58:35

my last question for you, Perry is, what's the next book about? If there's, if you have if you have an export plan? I'm sure you do.


Perri Klass 58:45

I'm, I'm interested in writing. I'm, and I hope it will eventually be a book. I'm interested in writing about how different societies solve the phenomenon of foster care of abandonment of children whose families are not able to care for them and how that plays out kind of from a pediatric point of view. But thinking that now,


Ben 59:11

this is so cool. All right. Thank you. Well, thank you for sharing that with us. And thank you for being on the show. It was


Perri Klass 59:17

the time flew by, didn't it? Thank you so much. And thanks for your patience with me.


Ben 59:23

Yeah, no, no, no, no, our pleasures, the end for everybody listening. Please pick up Perry classes book, a good time to be born, how science and public health gave children a future. And this was such a great book. It was like you say in the book, the triumph of sweet over better. I love that quote. So thank you for everything.


Perri Klass 59:41

Thank you.


Ben 59:43

Thank you for listening to this week's episode of the incubator. If you liked this episode, please leave us a review on Apple podcast or the Apple podcast website. You can find other episodes of the show on Apple podcasts, Spotify, Google podcasts, or the podcast app of your choice. We would love to hear from you so feel free to send us Questions, comments or suggestions to our email address the queue podcast@gmail.com. You can also message the show on Instagram or Twitter at NICU podcast. Personally, I am on Twitter at Dr. Nikhil, spelled Dr. NICU and Dafna is at Dr. Dafna. MD. Thanks again for listening and see you next time. This podcast is intended to be purely for entertainment and informational purposes and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner. Thank you

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