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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

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
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
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
John Cutler’s Legacy
  • Public Health
  • Family Planning
  • STD/HIV
  • Sexual Health
john s career
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
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
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)

factors affecting population growth
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)

america in the 70s
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
Legal and Illegal Abortions in the US, 1969 to 1980

Abortions (millions)

Source: Cates (1982)

maternal mortality and abortion mortality in the us 1940 1980
Maternal Mortality and Abortion Mortality in the US, 1940-1980

Source: US Vital Statistics, National Center for Health Statistics

abortion morbidity jpsa
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
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
Trends in Abortion Procedures, 1972-1994

Source: CDC Annual Abortion Surveillance Summaries

the trimester threshold 1975
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

effect of d e on women s health
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
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
slide20
“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

america in the 80s and 90s
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
Spermicides as Microbicides

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

spermicides as microbicides the nonoxynol 9 story
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
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
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

topical microbicides lessons from n 9 hiv trials
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
reanalysis of cameroon n 9 observational study
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)

observational analysis two n 9 studies in cameroon sex workers
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)
observational vs experimental analysis same n 9 study of cameroon sex workers
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)
america in the new millennium
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
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)

projected world population 1950 2050
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

world fertility rates 1950 2050
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

six countries account for half the growth
Six Countries Account for Half the Growth
  • India - 21%
  • China - 12%
  • Pakistan - 5%
  • Bangladesh
  • Nigeria
  • USA

4%

Source: UN Population Division

hiv prevalence nov 2007
HIV Prevalence - Nov 2007

Total: 33.2 million

Source: UNAIDS (2007)

south africa with and without aids 1980 2050
South Africa With and Without AIDS, 1980-2050

Without AIDS

With AIDS

Source: UN Population Division

life expectancy without with aids 2010
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

population and environment 2007
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
How to Proceed?
  • A vision for Sexual Health
underlying foundation 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
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)

healthy sex components
Healthy Sex – Components
  • Consensual
  • Equitable
  • Honest
  • Mutually pleasurable
  • Protected

Source: SEICUS, WHO (2006)

john s sexual health legacy
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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