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Is Circumcision the Best Way to Prevent HIV in Africa?

Robert Bailey, Professor of Epidemiology, University of Illinois at Chicago

Circumcision is the most effective and promising tool that currently exists to prevent the spread of heterosexually acquired HIV infection in developing countries, an international health consultant and medical researcher said at a global health lecture on campus Wednesday afternoon.

The lecture, entitled “The Cutting Edge of HIV Prevention in Africa,” was the first of the Global Health Lecture Series and was cosponsored by the School of Public Health, Feinberg School of Medicine, International Program Development, and the Center for Civic Engagement.

Though there are several prevention tools such as behavior modification programs to promote using condoms or abstaining from sex, “The only truly evidence-based strategy that we have is male circumcision,” said Robert Bailey, who is also a professor of epidemiology at the University of Illinois at Chicago, a research associate at the Field Museum and co-director of the Chicago Center for AIDS Research. Other methods of prevention either don’t have the research to showcase their efficacy or have been found unsuccessful, he said, and a vaccine will not likely be invented soon.

But with 34 million people worldwide infected with HIV and 68 percent of those in Sub-Saharan Africa, preventive measures must be taken immediately. 5,000 men are newly infected each day in Africa, a number that health care professionals must slow down, Bailey said to the audience of 30 students, professors and community members who gathered in the Program of African Studies building on campus to hear him speak.

“We cannot treat our way out of this epidemic,” he said. “But we must find ways to prevent it from spreading.

One of those ways is clear, he said: The simple, cost-effective surgery of circumcision has been clinically proven to be both consistent and powerful in preventing HIV. According to evidence from three randomized controlled trials undertaken in Kisumu, Kenya, Rakai District, Uganda and Orange Farm, South Africa, uncircumcised men are two and a half times more likely to contract the HIV virus than those who are circumcised. Plus, unlike daily pills or other therapies, “once you’re circumcised you’re circumcised for the rest of your life,” he said, which makes it a one-time, inexpensive treatment (it costs about $50) that has lasting benefits.

After seeing the striking results of the clinical trials, The World Health Organization and UNAID threw in their endorsement in 2007, recommending that male circumcision now be recognized as an important intervention to reduce the risk of HIV.

But surgery alone is not the solution and must be performed in conjunction with other preventative treatments, Bailey cautioned. He is currently leading efforts funded by the Bill and Melinda Gates Foundation and the U.S. Government to implement a comprehensive package of HIV prevention services that includes male circumcision along with other tools such as couples counseling and sexually transmitted infection diagnosis in western Kenya.

Not only is circumcision effective in preventing the spread of HIV, it is also helpful in reducing sexually transmitted infections, genital herpes, genital ulcers and cervical cancer in women, among other things. And through implementing this comprehensive circumcision program, health care professionals will also have the opportunity to reach out and educate men and women on HIV and improve the health care infrastructure in Africa.

Bailey and his team have already performed 140,000 circumcisions in Kenya during the last 14 months and hope to perform 900,000 over the next 10 years. “My goal since 1994 when I first got into this was to show that [circumcision] is effective and implement it,” he said. “And now it’s happening.”

For more information on the Global Health Lecture Series, please visit http://globalhealthportal.northwestern.edu/news-and-events/events-archive.

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Learning through Field Experience: Northwestern’s Program in Public Health Open House and Poster Session

The Feinberg School of Medicine hosts Northwestern’s Program in Public Health under the Department of Preventative Medicine. A few undergraduate students gathered in a room with Maureen Moran, the associate director of the program and a current MPH student to discuss the admission process as well as details of the program. Within the program, there are several different degree options—freestanding MPH, combined MPH/MD, combined MPH/PHD or Master of Science in Epidemiology and Biostatistics. Many students with varying degree paths take classes together which proves for a diverse set of interests in the classroom. For those students who are enrolled in the freestanding MPH program, it is a part time program so many students continue their healthcare related job during the day and then take classes at night. Some of the classes that are offered are Behavior, Science and Health, Introduction to Biostatistics, Environmental Health Sciences and Introduction to Epidemiology.

MPH Poster Presentation

The most intriguing part of the evening was the Master in Public Health 2010 Field Experience Poster Presentation. MPH students gathered around posters displaying elaborate research projects. Students spent about 200 hours doing service in the community with an organization of their choice and this was their opportunity to present their research. The field experience helps MPH students achieve interdisciplinary public health knowledge, which is important to the Northwestern curriculum. One student, Lauren Slubowski, a MPH/PHD student worked with the Student Health Force, a public health initiative aimed at improving the health and success of high school students through education, skill-building, and career development. Lauren said that the children’s health education, awareness and interest grew tremendously throughout the year. Laura Phillips, another student interviewed HIV-positive patients about smoking cessation in the Lending Hands for Life program at Humboldt Park’s Erie Family Health Center. She found that the HIV patients knew that smoking was bad for their health but had no great incentive to stop because of their current condition. Overall, I was impressed with the variety of research topics and the student’s continued dedication to their community organizations.

Click here for a photo slideshow of the poster presentations.

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Community Engaged Research: A Potent Strategy for Promoting Health Public Policy

I attended a lecture recently by Meredith Minkler, a professor at UC Berkeley’s School of Public Health. This event was sponsored by Northwestern University’s Alliance for Research in Chicagoland Communities (ARCC) and the Community Engaged Research Center. Professor Minkler spoke of her experience in community engaged research and its affects on promoting healthy public policy. Community Based Participatory Research (CBPR), her specialty, encompasses several principles, one being asset based community development (ABCD). This principle involves building on pre-existing strengths and assets of a community. Other principles include co-learning between partners to begin the power sharing process, creating a balance between research and action and a commitment to sustainability. With her background in policy, Professor Minkler also took us through the stages of the policy process. The first step she explained is defining the problem, second is setting the agenda, third is constructing policy alternatives, fourth is deciding on the policy to pursue, fifth is implementing the policy and fifth is evaluation. By creating policy hand in hand with CBPR principles, you not only empower the community with co-learning and creating opportunities for partners to learn skills in leadership, strategic planning, management and negotiation but also create sustainable change in the community.

This concept is demonstrated in the example Meredith Minkler gives on the food desert in San Francisco’s  Bayview/Hunter’s Point neighborhood. Professor Minkler and her policy team defined the problem as the lack of access to healthy food for the residents of the Bayview/Hunter’s Point. Nearly 25% of the residents ate fast food daily and in order to get to the closest supermarket, residents had to take 3 buses.  However, they noted there were neighborhood stores already in existence but their shelves were mostly stocked with tobacco and alcohol. This is an example of asset based community development. When constructing policy alternatives, Minkler and her team reviewed municipal ordinances but decided on creating the Good Neighbor Program. This policy program gave local stores store branding, free marketing, city recognition, discounts on energy efficient appliances if they agreed to devote 10%+ of shelf space to healthy foods and to reduce outdoor tobacco advertisements. By giving them the tools to succeed, the Bayview/Hunter’s point neighborhood had tremendous success. All Good Neighborhood Program stores had an increase in produce sales, decrease in tobacco and alcohol and an increase in overall profits.

With capacity focused partnering, policy makers will see the community as possessing assets on which to build resources and as a result, a high level of mutual respect and trust in the community will be gained. Minkler interpreted Community Based Participatory Research as a kind of street science necessary for policy making. She ended her presentation with a quote from colleague, Jason Corburn,. “When CBPR identifies hazards, highlights previously ignored questions, provides hard to gather data, involves difficult to reach populations, and expands the possibilities for intervention alternatives and success, science and democracy are improved.”

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Research Update from Global Health Student Sarah Cohick on the Ugandan Hydrocephalus Project

Sarah Cohick with a patient from a pediatric neurosurgery hospital in Mbale, Uganda

By Student Guest Blogger:
Sarah Cohick

Biomedical Engineering
McCormick School of Engineering and Applied Science 2012

Research Topic: Ugandan Hydrocephalus Project

Research Location: Mbale, Uganda

Research Update: I am in Mbale, Uganda with a fellow Northwestern student, Emily Laning, working at a pediatric neurosurgery hospital. Most of the patients are infants with hydrocephalus or spina bifida. The hospital sees about 900 of these cases a year. While spina bifida is a condition children are born with, the majority of the hydrocephalus cases are post-infectious, meaning they acquire the disease after birth from an infection, typically meningitis. After a recent research project’s results were analyzed, it was found that 50% of the patients who leave the hospital healthy after a successful surgery end up expiring or being in life-threatening states because of ignorance and neglect by the parents. Our project involves developing a post-operative education program for the parents so that they understand their role in the necessary care for the child; this ranges from preventing pressure sores from accumulating on the paraplegic child to simply knowing the symptoms that indicate the child should go back to the hospital.  Much neglect stems from the stigmas that the culture has put on these conditions, so the education also heavily emphasizes the value of the children and the incredibly bright futures they have. Many villages and communities will say that if the parents take the child to this hospital, CURE Children’s Hospital, they are wasting their money as the child is not a value to society or even a curse.

After collecting data from past patient files and current patients in the ward at the hospital, Emily and I have created an assessment to determine the level of knowledge the parents have about the condition of their child, the necessary care to be given at home, and how they will respond to any negativity that may come from their families and communities with regards to their child. The results from this assessment show the social workers and nurses of the hospital where the parents may need more education. Next week we will begin administering the assessment and collecting data to edit the form. In this process, we are also trying to edit a form created by a Yale medical student who was here a few months ago. His form evaluates quality of life of returning patients, specifically those treated for hydrocephalus. These results combined with those of the assessment will help us start an outline for an education program the hospital will start for the parents. Patients are here an average of 6-10 days and the program will be a cycle of educational lectures or activities that will prepare the parents for discharge and being successful when they go home.

As we went through the patient files to acquire information about past patients from the ten years this hospital has been running, we found that the hard copy, non-electronic system is extremely unorganized and difficult to navigate. Emily and I have looked through the forms that the different departments give to the patients and have eliminated redundant questions, added key, unasked questions, and created a plan to consolidate the forms in one central file instead of each department having their own file for the patient. We have a meeting set up for next week with the heads of each department to present our plan and hear what we should keep about the plan and what needs to be adjusted. A computerized system is something that the CUREInternational headquarters in the U.S. would love to start, but the current infrastructure will not support an immediate shift in that direction. However, Emily and I have been asked to make some sort of outlined plan of what would need to happen to make that shift and what the projected time frame would look like. Either way, having a more organized filing system will make the switch much smoother.

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Public Health and the Linguistic Barrier for the Spanish-Speaking Population in the United States

By Student Guest Blogger:
David Leander
Class of 2010, Weinberg College of Arts & Sciences
Materials Science, Economics, and Spanish; Global Health Studies and Classical Studies

During my 45-minute drive from Evanston to the Plaza Family Medical Clinic in Pilsen, I became aware of the change of scenery that materialized seamlessly–realizing the familiar microcosm that morphed within a few blocks.  The Chicagoland streets transformed into the calles I remembered from my study abroad experience in Mexico City.  Street vendors, Latino supermercados, and of course, the language lined the streets.  In the clinic, I waited in the hallway to the examination rooms before approaching a patient–in hand with a 15-page survey, subject compensation, IRB forms.  As an unfamiliar face to subjects both as a member of the clinic and as a native Spanish-speaker, my entrance to the examination room was a strange intrusion on both fronts.  Initially awkward, I explained my research project to the patients.  I gained their trust and our conversation about pharmacies and the language barrier began.

The Latino population is predicted to become the largest minority group in the United States.  As a consequence, in terms of a public health perspective, the problem of language concordance presents itself as a serious concern.  In particular, several studies document that pharmacies in the United States lack the capability to provide Spanish-speakers with translated materials.  Related, medication errors represent significant costs that affect the healthcare industry–many of which occur in outpatient situations.  Thus, it is imperative that pharmacies focus on providing customers language appropriate materials.

My study, in conjunction with the Feinberg School of Medicine’s Health Literacy and Learning Program, investigated this issue from the perspective of the customers themselves.  I was linked with ACCESS Community Network, which is a large community healthcare provider in Chicago–specifically, I recruited subjects at the Plaza Medical Center on Cermak in Chicago’s Pilsen community.  While patients waited to see their primary healthcare provider, I would survey them regarding their behavior with prescription medicines when the language barrier is present.  All subjects were 18-70 years old, taking at least 1 prescription medicine, and a Spanish-speaker.  I conducted all surveys (15-20 minutes with 33 questions) exclusively in Spanish.  Overall, I spoke with 35 subjects.

The principal results of my study concurred with previous studies that indicated that pharmacies lacked translation capabilities.  48% of subjects did not receive full translation services (information pamphlet, prescription label, and advice from pharmacist) and 20% did not receive any translation services.  Moreover, I found a discord between patient needs and preferences.  As rationally economic consumers, subjects reported that price (and proxies of price such as location and convenience) dominated their decision in choosing  a pharmacy.  On the other hand, in terms of patient needs, subjects reported that they thought that pharmacies could improve services by offering bilingual services.  Thus, this difference represents a challenge for pharmacies and their customers.  Furthermore, delving into subjects’ behavior, I found that a significant percentage (43%) used translators (children, spouses, or non-pharmacy employees).  None of these translators however are suitable for providing safe and efficient delivery of pharmaceutical medicines.  As well, of those subjects that received translations, it was reported that these translations may not be fully digestable for patient use.  Demographically, the subjects I surveyed had a range of years of education of 0 to 18 years, with a median of 7 years.  Therefore, another issue involved is that of providing comprehensible, target-appropriate materials to deliver safe information.

David Leander at Undergraduate Symposium

I presented this information at the 2010 Undergraduate Research Symposium.  In terms of how this has affected my future career, I just started full-time work at Epic two weeks ago.  Epic is a healthcare software company in Verona, WI and I hope to help find ways to diminish the language barrier in healthcare delivery.  Beyond this scope, I am interested in a future in the medical and/or healthcare field.  This experience gave me the once in a lifetime opportunity to develop, execute, and analyze my own research topic as an undergraduate in the public health sphere.  This project would not have been possible without the support of the Mabie family, to whom I am deeply thankful–their generous support provided me everything I needed to carry out this project.  As well, I would like to thank the ACCESS staff who assisted me in this project.  Lastly, I would like to thank the amazing faculty that guided me through this experience: Stacy Bailey, director of the Health Literacy and Learning Program, aided me in developing a survey battery and connecting with the ACCESS clinic; Professor Beth Barden was essential to helping me develop my research proposal and application; and Profesora Elisa Baena served as my advisor for my Spanish 399 Independent Study, which I took as a capstone project for my senior year as a Spanish major.

A particularly memorable experience that I had outside of the research perspective was when I saw one woman who I interviewed a month later in the waiting room.  She asked me how my project was going and she actually told the people around her in the room about my study.  Incredulously, they looked at me, a South Korean native, and wondered who would ask them questions.  ”Él” (him), she would say, pointing at me, to which I would respond: “Si, hablo español.  ¿Ud. puede hablar conmigo mientras está esperando para el doctor?”  (Yes, I speak Spanish.  Would you be able to speak with me while you wait for the doctor?).  Because of this action, a referral of sorts, I was socially validated and was extremely successful that day recruiting patients.  This experience was not only important training as a research experience, but also in understanding the social aspect of healthcare.  With language especially, trust and competency are essential.

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