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Kidneys for sale? Sherine Hamdy discusses her new book on Egypt’s ethical debate over organ transplantation

How much is a kidney worth? According to Sherine Hamdy, a Brown University anthropologist, the going rate in Egypt circa 2006 was approximately $5000.

It might not sound like much, but in a country where poverty is high, organ traffickers are persuasive and poor preventative care raises demand—the choice is complicated.

Enter Islam into the equation and you’ve got what amounts to a series of puzzles, according to Hamdy.

Sherine Hamdy, Assistant Professor of Anthropoloy, Brown University

Hamdy set about tackling these in her new book, “Our Bodies Belong to God: Bioethics, Islam and Organ Transplants in Egypt.”

More than thirty Northwestern students and faculty trudged through several inches of snow Tuesday evening to hear about Hamdy’s research in a land known for its broiling sunshine, magnificent  pyramids and a growing underground industry—organ transplantation.

Egyptians are ambivalent on the subject of organ transplantation, Hamdy explained.

While Islamic leaders wield substantial influence, Egyptians also rely on their personal experiences to guide their religious conclusions on the subject.

Hamdy illustrated this through the experience of Dr. Kotb, a successful transplant surgeon who later renounced his profession as haraam, or forbidden, by his Islamic beliefs.

She speculated Kobt’s change of heart wasn’t a sudden religious epiphany, but a broadening of Kobt’s perspective.  As a doctor he was compelled to end his patients’ suffering.  Later he started to ask the larger questions.

The answers he found were disturbing.  He saw the sometimes devastating effects of organ transplant on living donors and the potential for exploitation of the poor—factors which likely influenced his views on the subject, Hamdy said.

But many Westerners and upper-class Egyptians continue to fault Islam as the road block to open dialogue on organ transplantation.

“It’s not about a religious constraint to potential benefits of the biotechnology, it’s about whether there actually are benefits to the biotechnology that outweigh the costs,” she said.

The situation worsened in 2006 when the World Health Organization flagged Egypt as having one of the highest rates of organ trafficking in the world, Hamdy said.

This led to a government crackdown on organ transplantations, pushing the practice further underground and stilting conversations of creating a commercial market.

“Talk of regulating the market is so taboo that the dialogue is closed,” Hamdy said.

Although initially uncomfortable with commercializing organ transplantation, Hamdy said she advocates acknowledging the market to make it less hostile.

Hamdy’s words resonated with Northwestern anthropology and global health student Tamon Oshimo, 22.

“She mentioned something that most people agree with, that you can’t have an absolutist stance, but I like that she had a compelling argument for it as well.”

Hamdy was also hopeful.  She turned attention to Mansoura, a devout Muslim city 77 miles north of Cairo, which boasts the most effective kidney center in the nation and completes 80 transplants each year.

“If the medical rates get better, then the market might change,” she said.

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HIV in Nigeria

There are 22.4 million people in Nigeria living with HIV, said a Fogarty scholar at a campus lecture Friday on the state of HIV in Nigeria.

And though 750,000 affected people require antiviral therapy, only 198,000 people were treated last year—about 10 percent.  “This is an area that really bothers me,” said Ifeyinwa Rita Onwuatuelo, who is a visiting Nigerian scholar on a Fogarty scholarship conducting research with the Center for Global Health.

Onwuatuelo has worked since 2004 in the field of HIV/AIDS and is currently working as the Care & Support Officer at the Program Office of AIDS Prevention Initiative in Nigeria in Abuja.

Unlike the transmission of the HIV virus in the U.S., which is mainly a result of same-gender sex, 80-95 percent of the cases in Nigeria are passed on through heterosexual intercourse. 15-30 percent are passed on to unborn babies through mothers during pregnancy.

One of the key factors driving the rapid transmission rate is an overarching belief that individuals aren’t at risk for infection, which leads to less caution in making sexual decisions.  “People think ‘I cannot get it, only other people do,’” Onwuatuelo said, which is erroneous and furthers the current cycle.

Some contributing issues include inter-generational sex, sex with multiple partners, inefficient services to treat sexually transmitted infections and poverty.  Another major problem is the stigma and discrimination that comes along with an HIV diagnosis, which can deter people from seeking treatment or telling others about their diagnosis.

“This is one of the biggest issues,” she said.  “We need to do more to educate people so the cycle can stop.”

Developing countries such as Nigeria are 19 times more likely to be infected with HIV than the general population. And the virus has a major impact on society and its institutions—“HIV places a major burden on families economically, socially and psychologically,” she said.

It can cause families to reject infected members and cause issues in terms of family unity.  It can also affect a family’s economic status because diagnosed individuals might not be able to work, Onwuateleuo added. And 2.23 million children are orphaned because of AIDS in Nigeria, a number that is still growing.

Churches and community organizations may also reject people who have been diagnosed.  “Religions may discriminate against the faithful [who have been infected] as sinners,“ she said, which isolates infected people who need a support system more than ever.

Some of the treatment and prevention strategies the government and NGOS are employing are HIV counseling and sexual education testing, promoting the use of condoms and increasing media campaigns and public awareness.  These types of services need to be increased, she said, along with access to antiviral treatments drugs.

But with the efforts of the Nigerian government, the U.S. government and organizations such as the Bill Gates Foundation, access to treatment and prevention programs continue to grow.  With a continued push for early diagnosis and treatment, education and awareness programs and more preventative strategies, HIV can be managed, Onwuatuelo stressed.

“Attitudes are gradually changing,” she said. “But it’s not just a one day thing.  We have to continue fighting.”

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AMPATH: An Academic Partnership Changing Kenya

Counterpart relationships, a community-based approach and a focus on care above all else is what makes AMPATH a success story.

The program, which is a partnership between Moi University School of Medicine and Moi Teaching and Referral Hospital in Eldoret, Kenya, and a consortium of U.S. medical schools led by Indiana University, is one of Africa’s most comprehensive HIV treatment and control centers.  But though it is a multi-million dollar organization supported by some of the world’s most brilliant minds, those involved say its success all boils down to good relationships.

“Everything we do is based on mutual trust and respect, and counterpart relationships [with the Kenyans],” said Megan Miller, director of development and communications for AMPATH, at a campus lecture Tuesday afternoon. Miller was at Northwestern on November 10th, as part of the Global Health Lecture Series.

The organization began 20 years when four Indiana University doctors decided they wanted to forge a relationship with Moi University School of Medicine in western Kenya.  The idea was to help train health care leaders in Kenya, while at the same time giving IU medical students the opportunity to have an international health experience.

But when in the late 1990’s southern Africa’s number of HIV cases skyrocketed, Dr. Joe Mamlin, one of the founders of the program who had already spent a year on the ground, decided something must be done. “Joe said if we don’t start treating this then we just need to pack up and leave,” Miller said.

So they formed AMPATH, or Academic Model for Prevention and Treatment of HIV/AIDS, which has now been changed to Academic Model Providing Access to Healthcare to reflect its ever-expanding range of activities.  Starting with just 60 patients, the program is now the recipient of a $65 million grant, and is a partner with the U.S. government in AIDS relief and the World Food Program.

It also boasts a growing list of accomplishments, including: operating 25 full-time clinics and more than 30 satellite clinics, a state-of-the-art electronic medical record system, a brand new mother and baby hospital that delivers 10,000 babies a year, over $41 million in research grants, a legal aid center, a Family Sustainability Initiative to help provide families with food, jobs and training, and feeding more than 30,000 people a day, to name a few.

And the work has only just begun, with the organization expanding its scope to include areas such as primary care and chronic disease management, as well as programs to ensure water safety.  But those involved always keep in mind every program must be a partnership with the community. “We will not start any initiative unless it can be run by Kenyan leaders,” Miller said.

So why expand so quickly into so many various arenas?  Miller said it was a matter of necessity.  “We realized really quickly that treating and preventing HIV is a comprehensive project that needs to be looked at holistically,” she said. “If someone is starving, HIV treatment isn’t going to work.”

But though the organization continues to expand at a rapid rate, the initial community-based model has not changed: care always comes first.  “If you put care first, everything else follows,” Miller said. “That’s our motto.”

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How to improve Reproductive Health in Africa

Comprehensive, sustainable efforts must be taken in Sub-Saharan Africa to improve women’s reproductive and overall health, said the associate director for the Center for Global Health at Northwestern’s Feinberg School of Medicine at a campus lecture Wednesday.

Carolyn Baer

With 600,000 mothers lost annually to pregnancy-related causes and 80 percent of these deaths occurring in Sub-Saharan Africa, this is an important issue to address, said Carolyn Baer, who has worked with organizations such as the Centers for Disease Control and the Peace Corps program.  21.1 million AIDS orphans have died in Africa and 4.2 million unsafe abortions occur in Sub-Saharan African each year, she said.

It is important to remind the public this is an issue that affects everyone, Baer added. “Reproductive health is not just a woman’s issue,” she said.  “It is a husband’s issue, a son’s’ issue, a father’s issue, a community’s issue.”

The best ways to ensure a higher rate of survival is to invest in the education of boys and girls, train health care workers, end harmful practices, expand access to birth control methods, make abortion legal, safe and accessible, and improve and expand access to obstetric care, she said.

She focused specifically on four steps that can be taken within communities to address reproductive health: Safe motherhood services, prevention of rape and violence, provision of family planning, and prevention and treatment of sexually transmitted diseases. Safe motherhood services include providing prenatal care, ensuring clean and safe delivery and then offering postnatal services.

“It is that first 24 hours during labor that is the most critical,” Baer explained.

Communities can also establish a referral system to get a woman in labor from home to a health care facility quickly.   “Clean delivery kits” which include items such as soap, clean latex gloves and a plastic sheet, are another easy and doable precaution and can easily be gathered in local environments.

“Simple steps can yield big benefits,” Baer said.

Sexual and gender-based violence within communities is another important area that needs to be addressed. But it is important to work within communities to see what they consider to be the biggest issues of violence instead of imposing a preconceived agenda on them, she cautioned.  Once definitions and concerns have been established, it is possible to put together medical services, including psychological support and counseling, as well as provide emergency contraception, Baer said.

“A lot of people are so shamed and the stigma is so great, a lot of people don’t want to talk about it,” she explained. “Communities need to figure out how to help.”

Improving family planning services means making contraceptives readily available and accessible, as well as offering patients a choice of which type is best for their lifestyle.  Health care workers must also ensure confidentiality, she said.

“Gender relations needs to be considered,” she said. “And people need to be empowered to choose what works for them.”

Because in Sub-Saharan Africa access to laboratory equipment is limited, The UN recommends diagnosis of STIs be done using a syndromic approach, she said.  Syndromic means asking what the patient’s symptoms are such as fever, swollen belly, etc and diagnosing according to those signs and symptoms.

“Treatment protocol based on syndromic case management should be prepared and adopted,” Baer said.  “And the most effective drugs should be used at first encounter.”

All of these steps should be taken when possible to ensure better reproductive health in Sub-Saharan Africa, Baer said.  “Healthy families and communities need healthy moms,” she said.

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