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

John Cutler’s Quiet Legacy: Sexual Health and Personal Choices. Willard Cates, Jr., MD, MPH Family 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

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

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  1. John Cutler’s Quiet Legacy:Sexual Health and Personal Choices Willard Cates, Jr., MD, MPH Family Health International John C. Cutler Annual Lecture University of Pittsburgh Graduate School of Public Health November 27, 2007

  2. 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

  3. 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

  4. John Cutler’s Legacy • Public Health • Family Planning • STD/HIV • Sexual Health

  5. 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

  6. America in the 60s • Ozzie and Harriett families • Contraception and abortion illegal • Oral contraception/IUDs unavailable • Family planning programs unfunded • Venereal disease marginalized

  7. World Population, 1950-2100 Developing World 10 Asia 8 6 Population size (in billions) 4 Africa 2 Latin America 0 1950 2000 2050 2100 Year Source: Bongaarts (1994)

  8. Factors Affecting Population Growth Causes of population growth 12 10.2 (1) Unwanted fertility 10 8.3 (2) High desired family size 8 7.3 (3) Population momentum 6 Population size (in billions) 4.5 4 2 0 1950 2000 2050 2100 1900 Year Source: Bongaarts (1994)

  9. America in the 70s • Make love, not war • Abortion becomes legal • Contraception widely available • Title X family planning funds • Gonorrhea control funds

  10. Legal and Illegal Abortions in the US, 1969 to 1980 Abortions (millions) Source: Cates (1982)

  11. Maternal Mortality and Abortion Mortality in the US, 1940-1980 Source: US Vital Statistics, National Center for Health Statistics

  12. 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

  13. 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

  14. Trends in Abortion Procedures, 1972-1994 Source: CDC Annual Abortion Surveillance Summaries

  15. The Trimester Threshold – 1975 16 15 14 13 Actual distribution (with delay for instillation) 12 11 10 9 Abortions (% of total 8 Projected distribution (without delay) 7 6 Decrease in later abortions if no delay 5 4 3 Increase in earlier abortions if no delay 2 1 0 10 11 12 13 14 15 16 17 18 19 20 Menstrual weeks’ gestation

  16. D&E Safer than Instillation

  17. 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

  18. 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

  19. Enter THE Virus

  20. “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 Cates Newsweek, August 12, 1985 Total Number of AIDS Cases – 12,067

  21. 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

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

  23. Spermicides as Microbicides -The Nonoxynol-9 Story • In vitro success – Anti-sperm membrane – Anti-microbial membranes • FDA approval • Long contraceptive history

  24. 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

  25. 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 1.0 Film N-9 Film 595 48 6.7 1.01 (0.68-1.52) Source: Roddy, NEJM 1998

  26. 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

  27. Reanalysis of Cameroon N-9 Observational Study • Data Source: Coital diaries from sex workers • Measure: Efficacy per sexual episode • Result: Condoms 92% (79-100%) • N-9 Suppositories 100% (43-100%) Sources: Zekeng (1993), Wittkowski (1998)

  28. Observational Analysis Two N-9 Studies in Cameroon Sex Workers • ZekengRoddy • Analysis Observational Observational • Rates of HIV: • Inconsistent 16.3 15.6 • Consistent 3.5 5.0 • Rate Ratios 0.2 (0.1-0.7) 0.3(0.1-0.7) • Sources: Zekeng (1993), Roddy (1998)

  29. Observational vs. Experimental Analysis Same N-9 Study of Cameroon Sex Workers • Roddy Roddy • Analysis Observational Experimental • Rates of HIV: • Inconsist 15.6 Placebo 4.3 • Consistent 5.0 N-9 5.3 • Rate Ratios 0.3 (0.1-0.7) 1.2 (0.7-2.1) • Source: Roddy (1998)

  30. America in the New Millennium • HIV as THE global health priority • Global warming/the environment as a global emergency • Population growth a major factor

  31. 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)

  32. Projected World Population, 1950-2050 14000000 Constant = 12.8 B 12000000 High = 10.6 B 10000000 Medium = 8.9 B 8000000 Low = 7.3 B 6000000 4000000 2000000 0 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Source: UN Population Division

  33. 7 6 5 Least developed regions 4 Less developed regions 3 2 More developed regions 1 0 1970-1975 2020-2025 2030-2035 1960-1965 1975-1980 1985-1900 2010-2015 2040-2045 1950-1955 1990-1995 2000-2005 World Fertility Rates, 1950-2050 Source: UN Population Division

  34. Six Countries Account for Half the Growth • India - 21% • China - 12% • Pakistan - 5% • Bangladesh • Nigeria • USA 4% Source: UN Population Division

  35. HIV Prevalence - Nov 2007 Total: 33.2 million Source: UNAIDS (2007)

  36. South Africa With and Without AIDS, 1980-2050 Without AIDS With AIDS Source: UN Population Division

  37. Life Expectancy Without/With AIDS, 2010 Without AIDSWith AIDS Botswana 68.1 39.7 South Africa 66.6 47.7 Zimbabwe 67.6 33.1 Source: UN Population Division

  38. 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)

  39. How to Proceed? • A vision for Sexual Health

  40. Underlying Foundation for Sexual Health • “Absence of Disease” • – Old Millennium • – Negative Message • Healthy Sex • – New Millennium • – Positive Message

  41. 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)

  42. Healthy Sex – Components • Consensual • Equitable • Honest • Mutually pleasurable • Protected Source: SEICUS, WHO (2006)

  43. John’s Sexual Health Legacy • 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!!

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