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