Oh yeah, that school thing...part four

For the final two courses of this year, I took a course in HIV/AIDS and another one in maternal/child health. The first one was directed by a very well-known physician and researcher whose credits include - among dozens of other more scholarly works - a mention in the back of John LeCarre's novel The Constant Gardener as a technical advisor on the novel.

The course opened with a viewing of the movie version of And the Band Played On, which is probably the most thorough account available of the early years of the AIDS epidemic in America. The book was written by a San Francisco Chronicle journalist named Randy Shilts, who died of AIDS no more than a few months before the first anti-retroviral drugs appeared on the market and forever changed the face of HIV from a death sentence into an unpleasant but treatable chronic condition. In the ensuing discussion, it was discussed that in one sense, the world is very lucky that the virus hit the gay community first - not to justify any of the vile hatred that was inflicted on homosexual men in the 1980s (and still today), but because the gay community was quite probably the only minority group in America who was vocal, well-organized, and politically committed enough to overcome the fatal inattention paid to the disease in the Reaganite era of small government and declining interest in public investment into health. Without the hard-fought battle to find a treatment when the president of the USA wouldn't even say the word AIDS on television, whole classes of anti-retroviral drugs we have today would probably not exist. And as the disease makes its inevitable shift from a condition of the well-traveled to a condition of poverty (with prevalence in some African nations running up to a jaw-dropping 20% in adults), it becomes ever-more clear that the world owes a debt of honor to the early AIDS victims on whose graves the struggle for attention and research and progress against the disease was built. Without them - especially activist groups like ACT UP and the Gay Men's Health Initiative - medical science and government agencies would probably still be twiddling their thumbs while the disease becomes Africa's top killer.

The course moved on from there through the various aspects of HIV & AIDS, from the disease pathology to its global epidemiology, from treatment challenges as the virus grows resistant to antiviral drugs to sociological approaches to reduces the stigma of HIV that so often hinders prevention and adequate treatment. One of the more original and amusing talks was given by a advertising executive who had taken up the cause of producing effective campaigns that use very slick and market-tested radio, television, and newsprint spots to bring public health messages into the media spotlight in developing nations. On the topic of leprosy - thought by some Hindus in India to be a duly deserved curse from the gods - one ad sent a leper to the house of the gods, who joked about how only a silly fool would think the disease was a god-given curse when they could get pills to cure it from the local health department. In another one, an attractive young woman asks the viewing audience if they think they might have also been intimate with the gentleman she contracted HIV from; at the end, she tells the viewers, "All I want to know is...did you give HIV to me, or did I give it to you?" Some of the ads threw interesting spins on homophobia - in one spot, an angry father tells his son's boyfriend to leave and never come back; just when you think you know the punch line, the father turns to his homosexual son and comforts him with reassurances that someday he will find a man who treats him well enough to be worthy of his love. Other than that, the most memorable ads were a series of condom promotions from various parts of Africa, which set up very steamy scenes between one beautiful woman and one hunky guy, which inevitably ended with hunky dude using a handy condom (always be prepared!) to fix quotidian problems such as a leak under the hood of a car.

Many of the presentations were similarly interesting, but the course leaned heavily on the lecture format to the exclusion of direct participation and discussion - and six hours a day of straight lecture is enough to put an audience to sleep no matter how interesting the topics. I also started to realize during this course that LSHTM as an institution seems to hold dominion over a finite and somewhat limited breadth of topics. And while I find all the areas covered to be rather interesting, toward the end of the year I started to get a feeling that I had heard it all somewhere before. Indeed, when I went back to look through the lectures from the fall, some of the speakers and hand-outs were indeed identical to those covered in this class. I suspect that is partly because my track - Control of Infectious Diseases - is somewhat narrower than other like Public Health in Developing Countries; I also understand that a balance has to be struck to cover the basic CID topics in the fall for those who don't take those particular classes in the spring. Nevertheless, a certain saturation point has been reached in what LSHTM has to offer.

That saturation point has also been reached for that enormous annoyance known as group work. Someone once said regarding group work that a group is only as strong as its weakest member. I disagree. I think a group is only as strong as its most anal-retentive member who is willing to stay up for hours just before the assignment is due to clean up the messes left by those inevitable weaker members.

We had two group assignments for this course. One involved four teams of 25 people each arguing various aspect of HIV resource prioritization in a debate on the last day. The size of the group was the first problem, given how hard it is to get half a dozen people to meet at an agreed-upon time, much less a couple dozen. The second part of the problem is that with no appointed leader, most people just didn't show up and about ten of us ended up putting our part together the day before the presentation. Ours was as good (or bad) as any others, which indicated to me that we weren't the only team with these same problems.

The other group project consisted of writing a country profile together, then using that document to write individual plans for how one might use a given amount of funding to fight the AIDS problem in that nation. Largely because no time was allowed in class to complete this assignment (and also because the "country profile" was more like a book report than anything more original or useful), this was one of the most painful group projects out of a year of many painful group projects. I ended up putting together (ie. re-writing) a set of contributions that did not speak well for the literacy of the participants. One was not in complete sentences, just half-factoids in broken-up phrases. One was yanked wholesale from a website on South Africa, with just enough words changed around to make it borderline plagiarism rather than overt plagiarism. One was cited by highlighting each paragraph in a color to be matched to a color in the reference list; this left me scratching my head as to whether the paragraphs were original works or block quotes from one source or another. It took me one long weekend afternoon trying to sort all that out before I blew a gasket at the group via email and demanded that some of this stuff get fixed before I had to work with it. In the end, I coped with the short-comings by re-writing each paragraph then spot-checking for plagiarism by googling random phrases to make sure they would not show up in the software that universities now regularly employ to check for plagiarism. I know fairly certainly that this was not intentional on the part of the group members I worked with, which left it as either laziness or incompetence. The worst part of these experiences is usually the fact that by now most of the groups contain people who I am well acquainted with and otherwise like very much. I'm sure the unpleasant after-taste this left in my mouth was mutual from their end, but with very little patience left so close to the end of the year, I couldn't really bring myself to be apologetic.

The other class I chose to take was entirely outside the realm of infectious disease, and because of that it was a breath of fresh air. The course had some very lengthy and complicated name that was a dressed-up phrase for maternal/child health (MCH, as the parlance goes). Because there was very little overlap with infectious disease (aside from a few topics such as neonatal sepsis and vertical transmission of HIV from mother to child), the bulk of the information and the lecturers were refreshingly new to me.

Most striking about the course was the simple statistics they presented early on - the rates of maternal, infant, and childhood deaths in developing nations are ten-fold - sometimes even a hundred-fold - increased over the rates in nations like the UK. For a wealthy nation, the US doesn't score so hot either - far down the ranking in terms of industrialized regions, though still nowhere near the bottom-out rates in southeast Asia and sub-Saharan Africa. The causes of maternal mortality are particular tragic both in how preventable they are, and in their terrible impact on the dependent families these women leave behind when they die in birth. Hemorrhage, eclampsia, and a handful of conditions that are so routinely treated with total success in the developed world are still killers of moms and babies in areas where even low-tech birth interventions are unavailable.

One of the most disturbing elements brought up in lecture was the tight correlation between restrictive abortion laws and maternal mortality. In the 1990s, a morbid and tragic experiment in human behavior took place in Romania. For about a decade before the fall of communism in Europe, Romania's population was falling and strict laws were instituted against any and all abortions. During that same time, improvement in the care of birthing mothers dropped the maternal mortality rate from perinatal causes in Romania to the low level commonly associated with developed nations. But at the same time, the overall maternal mortality rate failed to budge at all, as it was propped up by the mortality experienced by women who died from unsafe abortions. A few years ago the abortion laws were lifted, and the all-cause maternal mortality sank within months to a level comparable with any wealthy nation. In other words, during the years of abortion restriction, the vast majority of the women who died due to pregnancy-related causes died because of unsafe abortion. All of which points to the ultimate lie of the anti-abortion contingent, for whom "pro-life" only applies to fetuses in utero, and not the adult women who carry them. Access to safe abortions IS a pro-life stance, if one considers the life of the woman as part of the equation.

In any case, this class also had its own fair share of group work, and strangely enough, this was perhaps the smoothest and most productive group project of the year, as well as being the last one. This was probably because ample in-class time was dedicated to the project, so there was less stress of having to stack the project on top of all the other class commitments. I chose the group that was looking at ways of reducing maternal mortality from hemorrhage.

In wealthy settings, when a woman shows signs of post-partum hemorrhage, a quick shot of a drug called pitocin is administered. This is the synthetic version of the hormone oxytocin, which causes the uterine contractions that drive labor. In a direct intramuscular dose, pitocin cause the uterus to contract tightly (and nearly instantaneously), stopping most of the bleeding that kills women who experience this problem. It's fairly painless with few side effects, and usually the mom & baby go home with no further effects. But pitocin is expensive by third-world standards, it requires administration with a needle, and it has to be kept cold and away from sunlight if it is to keep for very long. In nations where most births occur outside of hospitals with no skilled attendants, pitocin is hardly a practical way to slow the death rate from post-partum hemorrhage, and so the mortality rate from this complication remains unacceptable high.

At the moment, two different interventions are being considered to reduce mortality in regions where pitocin isn't available. The first is a strange looking apparatus called a non-pneumatic anti-shock garment. It's mostly a big piece of fitted neoprene that is wrapped around the legs and belly of the woman in shock and cinched tight with velcro straps. This pressure on the lower limbs and the belly can both slow the bleeding from the uterus and drive the remaining blood out of the limbs (which don't particularly need it on an immediate basis) and back toward the heart, brain, and kidneys, which can't live without it. There are tales from Africa (even documented in the literature) of women coming into hospital with no pulse and no signs of consciousness who literally come back to life after being wrapped up into one of these garments. There are downsides though - the outfit is a little expensive for a poor community to invest in (about $150, though it can be re-used a few dozen times), and for women who give birth way out in the sticks, there probably isn't enough time to get them to a clinic that might have one of these things before they bleed out. Some people even think that investing in these sorts of things is a way of slowing progress toward investment in the gold standard treatment, which is still pitocin.

The other intervention is a drug called misoprostol, a synthetic prostaglandin that contracts the uterus much like pitocin. It works more slowly, but has the big advantage that it comes in the form of a pill so no needles are needed. And, the pill can last for years if it's kept in the kind of air-sealed packet that lots of over-the-counter medications come in. Women can take the pills on their own at home after the birth to prevent any problems that might come on, or the pills can be given just as the problem starts to keep it from getting worse. Some trials have returned good results when community health workers hand out the pills to anyone who might be pregnant (both those who show up at a pre-natal clinic and those who the health workers find out in the rural areas who never make it to a prenatal clinic at all), with strict instructions about how and when to take them. This intervention shows great promise because it can work in rural regions where most women give birth far away from medical facilities - ie. the same regions that are most difficult to place other interventions in. The downside of this is that because the same drug can also be used quite successfully to induce first- and second-term abortions, there is a large contingent of politically active people out there who do not want it distributed anywhere. Again, this sort of stance shows what the "pro-life" slogan really means: the anti-abortion people are willing to sacrifice the lives of birthing women - women who are trying to carry their babies to term and raise healthy families - in order to restrict other women from having access to a pill which not only induces abortion, but shows far safer outcomes than illegal abortions. Because of this problem, the drug has never been tested or formally registered for any obstetrical use, so optimal dosing regimens have not been firmly established. In fact, misoprostol was invented as an ulcer drug, and there is some concern that because there are many better ulcer medications available now, the companies that make this product will cease to market it at all.

On the last day of class we presented this information and our hypothetical recommendations that this be implemented in several African countries alongside studies to make sure that this approach was producing good results for the investment required. Of course, we were immediately shot down by one of the instructors - an attending physician who has worked extensively in African crises from outbreaks of Ebola to outbreaks of civil war - who asked us, "What about the second twin?" We puzzled over this for a moment, then realized what he meant: where pre-natal care is minimal, it's often not known whether a woman is carry a singlet or more babies until the birth gets going - and a substance taken routinely to contract the uterus after birth would certain clamp down on the blood supply to any remaining babies in the womb - twins or triplets. Back to the drawing board for us, eh?!

And so ended my last class at LSHTM. Now all there is to look forward to is exams!