Good to go. >> Hi Sophia, I'm so grateful to you being able to join our students on our MOOC on global adolescent health today. Just by wave introduction to our students, Professor Zulfiqar Bhutta is the Robert Harding chair in global child health at the hospital for sick children in Toronto in Canada where he's co-director of The Sick Kids Center for Global Child Health and the founding director of The Center of Excellence in women's and child health at the Aga Khan University in Pakistan where he is originally from. So he holds really too many high level appointments in various global agencies, too many for me to mention really today, but a very imminent figure in the field of child and adolescent health. With training in neonatology Zulfi has really made a remarkable contribution to the field of paternal and child health and his research interests include newborn and child survival, maternal and child under nutrition and micronutrient deficiencies. And really Zulfi this is often where I'd like to start because as a long standing researcher in maternal and child health, why is it that you've more recently become interested in the field of adolescent health? >> That's a great question, Susan. One of the questions should have been perhaps, why didn't you take on adolescent health earlier? [LAUGH] >> [LAUGH] >> So the honest answer for that is that you know as we embarked on this journey around maternal newborn and child survival and have made progress over the last decade and a half. It's also become clear that a number of things that you can achieve in early childhood or after birth are very limited by the health of the child that principally starts during pregnancy. And a lot of the factors that influence health outcomes have their antecedence in the later part of childhood than the adolescent period has been broadly neglected in global health, which is my area, for a very long time. We neither have the numbers from geographies like lower middle income countries, we have very little data on epidemiology distribution and burden of disease and more importantly these poor adolescent boys and girls are principally what newborn health was like about 15 years ago when newborns were orphaned between obstetricians and paediatricians. And today adolescents in many low and middle income countries are neither children nor their adults and as results they have systems and public policy votes don't know to deal with them. And that's been a real challenge in influencing global policies in my own areas of interest, malnutrition. It's very evident that you truly cannot do much about malnutrition during pregnancy because you're very limited in terms of impact. And to really effect both outcomes, you've got to start before birth. Preconceptions, so to say, enhanced the interest in that period whereby current global burden figures. Close to around a quarter of all births take place in that age group. So in my own learning on this, so the first step in my own journey around understanding of adolescent health has been In trying to educate myself first, and understanding what the global dimensions of this are, where are the gaps? And also importantly, where are the potential strategies for interventions where we could make a difference? So I've given you a long winded answer as to why someone like me who's so steeped in maternal child survival has becoming interested in adolescent health and the honest answer for that is because it's important. It's neglected. And for people like myself, this is the frontier where we potentially can make a difference not only in terms of birth outcomes and health for adolescent boys and girls but potentially across generations so there is a huge intergenerational impact that may emerge from interventions that are targeted for adolescents. >> As you know, many of the, if you like, the notion of trying to promote health capital in our adolescents is due to the benefits for adolescents themselves, the benefits for those adolescents as adults and also in terms of the benefits intergenerationally, which is what we're really talking about here and obviously in a Country like Pakistan, where so many women enter pregnancy stunted, malnourished with micronutrient deficiencies, the preconception agenda around nutrition is pretty clear. But when you talk about preconceptual health, are you primarily referring to that as the nutritional aspects or is that something more broadly that you're really thinking about because I suppose really the question here is to what extent is preconception health agenda the same as adolescent health agenda or not? >> Well, there are quite significant overlaps. But let me paraphrase by saying we are also very careful as we understand these issues. That one should not look at adolescent girls in particular from a reproductive health lens. These girls have their lives and they are useful members of society in their own right. They have huge issues that are broader than reproductive sexual health and functions. To give you an example in our own data from rural Pakistan, the prevalence of depressive disorders, even mental health issues that are broader than just depression, is significantly high among girls, and especially where there are issues of empowerment. There is a very close nexus between gender issues, issues of societal value of rights, and things that eventually will have health consequences, but will have consequences that are not just restricted to adolescent boys and girls that go way beyond it. The other big thing is that there is such a big portion of our society now, the youth bunch that people talk about is also a huge risk and problem and some of us work in very, let's say, conflict effected geographies. Are we painfully aware of the fact that because adolescent needs, healths and rights have been ignored is probably one of the underlying factors why we have so much problems with behaviours, with violence being permeated in a particular society. So absolutely our lens for adolescent health wellbeing. It is very broad, it's not just through a reproductive health lens, but there is a need to do something about girls entering pregnancy today, just because of the numbers. But it certainly isn't the only problem that we have to contend with. I think that's a lovely way of highlighting the scope of adolescent health issues. But it is interesting because the language of preconception health in the nutrition field, I think sometimes risks being conflated with adolescent health. And yet obviously the way most people think about preconception influences, that means we're only primarily talking about 50% of the population, and as you've alluded to that notion of focusing on girls purely in terms of their reproductive capacity is one that I think many young women and, perhaps, older women among us, would find somewhat challenging. I know your daughter has has some particular reflections on this herself, a while ago you had shared with me some of her comments. And I wonder whether your daughter would be enable you to share some of her reflections with our students. Well she would if she was here it would be much more adequately then I would but she is very young and she is a medical student now but when she was just an adolescent in terms of hearing my own views and reading it's not the stuff, but all reflections on this were quite straight forward. For her, if we did not talk to adolescents as individuals in their own rights who had every bit as much right to access to education, to happiness, as she put it. And to life as we saw it in it's broader dimension. She felt that we shouldn't be delving in this area without speaking to adolescents taking into account what their own views were. So in her words, which paraphrased was, nothing for us without us. And that is clearly true that in the dialog around what we need to do for adolescents, what we need to do for the benefit of adolescents this is not something that incredibly comes to healthcare professionals readily. We've got to bring in the voice of the youngsters who view their health, development, education, and rights needs much more broadly than healthcare professionals do now. Now, fortunately they have people like yourself who are experts and have spent a lifetime in this but many people in the development field, Susan, are not necessarily aware of the broader dimensions of adolescent health. And we face this all the time as we try and integrate adolescent health within our existing strategies. In that people, as you said, conflate a lot of the rights and a lot of the issues that relate to adolescents to really narrow focused objectives around things that they understand and are comfortable with. So, one of the reasons why the entire field fascinates me also is that I do know is that there is a lot to be done but it needs to be done properly and needs to be done with a much wider lens of adolescent health, education, the social determinants of adolescent health than we have done so far. >> Well, Zulfi, I think you've provided a lovely rationale for why we've put so much effort into developing this MOOC, in terms of, as you know the lack of training opportunities in so many parts of the world in terms of those who are wanting to be influential in terms of improving the health and well being of children and young people. But for whom an understanding of adolescents hasn't been being readily available. So that's what we're certainly trying to address in this MOOC, and we'd very much like to thank you for joining our students today and for sharing some of those thoughts with us, and we wish you well in your own future endeavours. Thanks very much. >> Best wishes, Susan. Thank you.
