john cutler’s quiet legacy: sexual health and personal choices willard cates, jr., md, mph family...

John Cutler’s Quiet Legacy:Sexual Health and Personal Choices

Willard Cates, Jr., MD, MPHFamily Health International

John C. Cutler Annual Lecture University of Pittsburgh

Graduate School of Public Health November 27, 2007

SRH Colleagues at Pittsburgh• 1970’s – John Cutler

– Bunt Singh– Lew Kuller

• 1980’s – Ron Valdiserri– Rick Sweet

• 1990’s – Sharon Hillier– Roberta Ness– Mitch Creinin– Harold Weisenfeld

• 2000’s – Don Burke– Ron Stall– John Mellors– Ian McGowan

Overview

• John’s Public Health Career

• A Global Population Challenge

• His Reproductive Health Response– Public health and legal abortion– Microbicides as a concept

• HIV as the Global Issue

• A Sexual Health Approach

John Cutler’s Legacy

• Public Health

• Family Planning

• STD/HIV

• Sexual Health

John’s Career

• 1941 – Case Western Reserve - MD

• 1942-1967 – USPHS

– VD Research Laboratory– PAHO– Polio

• 1967-1993 – University of Pittsburgh

– Population Division– Training global obstetricians– Global Health

America in the 60s

• Ozzie and Harriett families

• Contraception and abortion illegal

• Oral contraception/IUDs unavailable

• Family planning programs unfunded

• Venereal disease marginalized

World Population, 1950-2100

0

2

4

6

8

10

1950 2000 2050 2100

Developing World

Po

pu

lati

on

siz

e (i

n b

illio

ns)

Asia

Africa

Latin America

Year

Source: Bongaarts (1994)

Factors Affecting Population Growth

0

2

4

6

8

10

12

1900 1950 2000 2050 2100

Causes of population growth

(1) Unwanted fertility

(2) High desired family size

(3) Population momentum

Year

10.2

8.3

7.3

4.5

Po

pu

lati

on

siz

e (i

n b

illi o

ns )

Source: Bongaarts (1994)

America in the 70s

• Make love, not war

• Abortion becomes legal

• Contraception widely available

• Title X family planning funds

• Gonorrhea control funds

Legal and Illegal Abortions in the US, 1969 to 1980

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980

Reported legalEstimated illegal

Source: Cates (1982)

Ab

ort

ion

s (m

illi

on

s)

Maternal Mortality and Abortion Mortality in the US, 1940-1980

Source: US Vital Statistics, National Center for Health Statistics

Abortion Morbidity - JPSA

• Partnership of Population Council and CDC

• Cohort study of abortion procedures and complications

• >230,000 procedures performed from 1970-1978

• 66 participating facilities, including the University of Pittsburgh

Abortion Morbidity – Key Findings

• 57 original contributions

• Suction curettage safer than sharp curettage

• Non-hospital procedures safe

• Dilatation and evacuation after 12 weeks gestation safer than intra-amniotic instillation

Trends in Abortion Procedures, 1972-1994

0

10

20

30

40

50

60

70

80

90

100

1972 1980 1990 1998

Per

cen

t D

istr

ibu

tio

n

Sharp Curettage

Vacuum Aspiration

Source: CDC Annual Abortion Surveillance Summaries

The Trimester Threshold – 1975

Actual distribution(with delay for instillation)

Projected distribution(without delay)

Increase in earlier abortions if no delay

Decrease in later abortions if no delay

Menstrual weeks’ gestation

Ab

ort

ion

s (

% o

f to

tal

0123456789

10111213141516

10 11 12 13 14 15 16 17 18 19 20

D&E Safer than Instillation

Effect of D&E on Women’s Health

• Since 1977, more than 1.8 million women have been spared instillation

• Earlier procedures

• Safer procedures

• More convenient

• Less costly

• Less emotionally traumatic

Abortion and Public Health - Conclusion

• Availability of safer, legal abortion had a major impact on women’s health and public health

• However, abortion had a negligible effect on population change

• Data do NOT address society’s moral problem with this topic

Enter THE Virus

“Anyone who has the least ability to look into the future can already see the potential for this disease being much worse than anything mankind has seen before.”

Ward CatesNewsweek, August 12, 1985

Total Number of AIDS Cases – 12,067

America in the ’80s and ’90s

• HIV/AIDS as domestic/global priority

• New PH Issues – Tobacco, Injuries, Chronic Diseases, Mental Health

• Increasing emphasis on women’s health

• Incorporation of HIV into RH mission – Cairo ICPD, 1994

Spermicides as Microbicides

Source: Advances in Planned Parenthood. Vol 12 #1, Amsterdam Excerpta Medica, 1977:45-56

Spermicides as Microbicides -The Nonoxynol-9 Story

• In vitro success– Anti-sperm membrane– Anti-microbial membranes

• FDA approval

• Long contraceptive history

Evolution of N-9 Microbicidal Research

• Initial hopes against bacterial STD

• Observational findings

• Sponge protects from Gc, though hint of higher HIV risks

• Epithelial toxicity concerns

N-9 Film - Effect on HIV Acquisition

No. of HIV No. of HIV incidence RR women

infections 100 p-y (95% CI)

Placebo 575 46 6.6 1.0Film

N-9 Film 595 48 6.7 1.01 (0.68-1.52)

Source: Roddy, NEJM 1998

Topical Microbicides – Lessons from N-9 HIV Trials

• HIV incidence in trials compared to the community

• Value of RCT compared to observational designs

• Difficulties in etiologic reasoning between active arm and placebo

Data Source:Data Source:Coital diaries from sex workersCoital diaries from sex workers

Measure: Efficacy per sexual episodeMeasure: Efficacy per sexual episode

Result: CondomsResult: Condoms 92% (79-100%) 92% (79-100%)N-9 Suppositories N-9 Suppositories 100% (43-100%) 100% (43-100%)

Reanalysis of Cameroon N-9 Observational Study

Sources: Zekeng (1993), Wittkowski (1998)

ZekengZekeng RoddyRoddy

AnalysisAnalysis ObservationalObservational ObservationalObservational

Rates of HIV:Rates of HIV:InconsistentInconsistent 16.3 16.3 15.615.6ConsistentConsistent 3.5 3.5 5.0 5.0

Rate RatiosRate Ratios 0.2 (0.1-0.7) 0.2 (0.1-0.7) 0.3(0.1-0.7) 0.3(0.1-0.7)

Observational Analysis

Two N-9 Studies in Cameroon Sex Workers

Sources: Zekeng (1993), Roddy (1998)Sources: Zekeng (1993), Roddy (1998)

RoddyRoddy RoddyRoddy

AnalysisAnalysis ObservationalObservational ExperimentalExperimental

Rates of HIV:Rates of HIV:InconsistInconsist 15.615.6 PlaceboPlacebo 4.34.3ConsistentConsistent 5.0 5.0 N-9N-9 5.35.3

Rate RatiosRate Ratios 0.3 (0.1-0.7)0.3 (0.1-0.7) 1.2 (0.7-2.1)1.2 (0.7-2.1)

Observational vs. Experimental Analysis

Same N-9 Study of Cameroon Sex Workers

Source: Roddy (1998)

America in the New Millennium

• HIV as THE global health priority

• Global warming/the environment as a global emergency

• Population growth a major factor

World Population, 2007

• Population projections lowered substantially

• Half due to reduced fertility rates

• Half due to increased mortality from AIDS

• BUT global population will still rise by 2.5 billion persons

Source: UN Population Division (2007)

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Constant = 12.8 B

High = 10.6 B

Medium = 8.9 B

Low = 7.3 B

Source: UN Population Division

Projected World Population, 1950-2050

Source: UN Population Division

World Fertility Rates, 1950-2050

0

1

2

3

4

5

6

7

1950-19551960-1965

1970-19751975-1980

1985-19001990-1995

2000-20052010-2015

2020-20252030-2035

2040-2045

Least developed regions

Less developed regions

More developed regions

Six Countries Account for Half the Growth

• India - 21%

• China - 12%

• Pakistan - 5%

• Bangladesh

• Nigeria

• USA

Source: UN Population Division

4%

HIV Prevalence - Nov 2007HIV Prevalence - Nov 2007

Source: UNAIDS (2007)

Total: 33.2 million

South Africa With and Without AIDS, 1980-2050

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

1980 1990 2000 2010 2020 2030 2040 2050

Source: UN Population Division

With AIDS

Without AIDS

Life Expectancy Without/With AIDS, 2010

Without AIDS With AIDS

Botswana 68.1 39.7

South Africa 66.6 47.7

Zimbabwe 67.6 33.1

Source: UN Population Division

Population and Environment - 2007

• World is growing by 78M annually

• Levels of consumption increasing as disparities reduced

• Like HIV, the environment needs an infusion of billions to improve

• Unintended pregnancy the factor most amenable to interventions

• Strengthening RH services is crucial to slowing rates

Source: Speidel (2007)

How to Proceed?

• A vision for Sexual Health

Underlying Foundation for Sexual Health

• “Absence of Disease”

– Old Millennium

– Negative Message

• Healthy Sex– New Millennium

– Positive Message

Sexual Health – WHO Definition

The integration of the physical, emotional, intellectual, and social aspects of sexual well being in ways that are enriching and that enhance personality, communication and love.

Source: WHO (1990)

• Consensual

• Equitable

• Honest

• Mutually pleasurable

• Protected

Healthy Sex – Components

Source: SEICUS, WHO (2006)

• Sexual health is a vibrant field at University of Pittsburgh

• World class faculty making major contributions to global population and health issues

• Embracing new public health challenges, no matter how controversial

• John Cutler is smiling!!

John’s Sexual Health Legacy