UCSF Making An Impact Around The World - UCSF Safe Motherhood Program

Fighting HIV/AIDS“It’s their Donna Summer moment.But there’s absolutely no reason forthem to repeat the horror of the earlyepidemic in the United States.”Henry Raymond flew at least 150,000 miles last yearby peers and social networks, which is based onfor work. That’s not surprising: One of his main jobssnowball sampling, but controls for bias. Whicheveris tackling HIV in developing countries and applyingstrategy is used, it must be standardized to getwhat has been learned in San Francisco over threeconsistent results.decades.“We’re sharing tools to get really important data from“Much of the image of Africa and HIV is a mother andbaby,” says Raymond, “But we need to documentvery hard-to-reach populations in settings that arethat there are men having sex with men in Africandifficult to work in,” says Raymond, DrPH, MPH, ancountries. When I first went to Uganda in 2004, gayassistant professor of epidemiology and biostatisticsmen said, ‘There’s no HIV among us.’ A gay guy seesat UCSF. “There’s a responsibility. We have thisa young heterosexual couple on a billboard and says,expertise, and we should export it.”‘That’s not my problem.’ There are no data to say, ‘It isRaymond, who also works for the San Franciscomy problem.’”Department of Public Health, says the “San FranciscoIf workers in health sectors are armed with data, itmodel,” now ubiquitous in the AIDS world, meanshelps them make arguments for services for thesedeveloping partnerships among all key partieshidden but high-risk groups.to work on a problem, and the assumption thatcommunities know themselves and their needs best.Partnerships between government and academia arealso crucial, he adds, such as UCSF’s collaborationwith the San Francisco Department of Public Health,epitomized by San Francisco General Hospital, whosephysicians are UCSF faculty.In his global health work, Raymond is concentratingon three high-risk groups: men who have sex withmen, injection drug users and female sex workers.One approach used in San Francisco involves goingto venues where members of the group can be foundand doing time-location sampling. Another strategyis respondent-driven sampling, based on recruitment9In many parts of the world, communities of gay menare finding themselves. “In China, there are lots ofcities with nightclubs, and the disco music is playing,and, literally, the disco ball is spinning,” he says. “It’slike 1979 in San Francisco. It’s their Donna Summermoment. But there’s absolutely no reason for them torepeat the horror of the early epidemic in the UnitedStates.”Raymond says that one of the goals of his work is tohelp build capacity and skills locally and encouragepeople to keep the work going after he leaves. “I sayto my collaborators, ‘I hope the next time I come hereis as a tourist.’”9

Fighting HIV/AIDS“All this money has gone intotreatment, but we need to knowwho gets treated and what theirhealth outcomes are.”“The cross-cultural practice of medicine is interestingto know who gets treated and what their healthworked in California, New York City, China and Eastoutcomes are,” Geng says. “That may seem obvious,Africa. “But one thing I’ve learned is that peoplebut it’s not at all self-evident how you find them.”are not that different. They want to be treated withrespect—especially when they’re asking for help. Itdoesn’t matter if you’re Donald Trump or an illiteratemother of seven in Uganda. That’s something publichealth needs to pay more attention to.”Geng, an assistant professor of medicine at UCSF,is the son of Chinese immigrants and grew up in an10academic family in Davis, California. He’d always beenattracted to medicine because it was “ultimatelypractical.” First he went to acupuncture school butwas disappointed, despite its “ideological appeal.”Then he entered medical school at ColumbiaUniversity. While he was working in a Manhattanemergency room, a man came in with symptoms of amassive heart attack. “They saved his life,” he recalls.“I’ll never forget that experience. I knew at thatmoment I’d picked the right profession.”In recent years Geng has been studying “loss tofollow-up,” a problem pervasive in antiretroviral10“All this money has gone into treatment, but we needbeyond description,” says Elvin Geng, MD, who hastreatment programs in Africa for people with AIDSand HIV. These “lost” patients have disengaged fromcare, for a variety of reasons.Explanations fall into three categories. Structuralreasons are tied to the economic conditions of life,such as a washed-out road. Then there’s servicedelivery, which amounts to having satisfied patientsmotivated to return. Finally, there are psychosocialfactors, such as depression.It’s impossible to determine what happens toeveryone, but it is possible to apply basic epidemiological principles in sampling and learn a lot. “NateSilver knew Obama was going to win the election,even though he didn’t talk to every American,because he was able to look at the polls and figureout their biases and summarize them,” Geng says.“What we’re doing is essentially very similar.”He clicks on a video that he shot with his mobilephone from a motorbike in Uganda. He and the driver,Hassan, were looking for patients they’d identified ina sample of those who had not come back fortreatment. Hassan, a peer educator at an HIV clinic,knows the society, culture and geography extremelywell and knows how to find people without revealingwhere he works or why he’s looking.“I like to call him the ascertainer,” Geng says. “Wewant him to ascertain what happened to the patients.Words matter. We’ve used the word ‘tracking,’ but Idon’t like that word.”Geng and Hassan usually get a good reception. Still,Geng wondered if Hassan was a unique case. So, hegot a grant to repeat the approach in 14 clinics inUganda, Tanzania and Kenya. “The short answer is yes,there are Hassans everywhere,” he says. “They’reabsolutely critical. Human relationships are everything.”

Elvin Geng, MDAssistant Professor of Medicine1111

1212Suellen Miller, PhD, RN, CNM, MHAProfessor of Obstetrics, Gynecology and Reproductive Sciences;Director of the Safe Motherhood Program at the Bixby Centerfor Global Reproductive Health

Promoting women’s health“Maternal mortality is a gross violation of human rights. Whatis needed is political will for girls’ and women’s lives to matter.”In 1987, Suellen Miller was a nurse-midwife with adone case studies in Pakistan on the first-aid device.booming practice that reflected her longtimeThe two then did research in Egypt and Nigeria withcommitment to the women’s health movement. Shepromising results, and Miller has since conducteddecided to take her first vacation in six years andother studies.bring her 10-year-old daughter along. The trip’simpact was monumental.“In Nepal I saw horrific conditions under which womenOne of the goals of their research, says Miller, was toprove efficacy in order to get the NASG included inthe World Health Organization (WHO) guidelines.were giving birth,” says Miller, PhD, RN, CNM, MHA. “ItIn late 2012, they met that objective when WHOcompletely turned my life around.”recommended the device for first aid for postpartumNow she is a clinical researcher dedicated to reducingmaternal mortality all over the world. Miller, a UCSFprofessor of obstetrics, gynecology and reproductivesciences, is director of the Safe Motherhood Programat the Bixby Center for Global Reproductive Health.Its LifeWrap project takes up much of her time.“We don’t think about childbirth as being alife-threatening thing,” says Miller. “But in somecountries there are even sayings about it. Whenfriends hear a woman is pregnant, they might say,‘You have one foot in the grave.’ ”Globally about 358,000 women die each year, oftenat home, from complications related to pregnancyand childbirth. To prevent this, LifeWrap advocatesthe use of a non-pneumatic anti-shock garment(NASG), made of neoprene and Velcro and similarto the lower half of a wetsuit cut into segments. Thehemorrhage. More companies are now making thegarment, which ranges in price from 60 to 300. Atleast 14 countries are using it, and Miller is reachingout to ministers of health, hospital directors andleaders of professional associations.At this point she has worked in at least 30 countriesin Asia, Africa, the Caribbean and Latin America. Shespent a few months on a ship in the middle of thePacific, providing medical care to the Marshall Islands,and went back and forth to Tibet for five years on aproject on the prevention of postpartum hemorrhage.Whenever she is in Africa, Miller tries to visit big-catreserves, and her Facebook picture shows her witha cheetah in South Africa. The daughter she took toNepal now runs a nanny agency in New York, andMiller has two granddaughters.The self-proclaimed “very doting” grandmother ispressure created by compression sends blood to thea passionate advocate and sought-after expert whoheart and brain and slows blood loss, buying timedoes not shy away from political undercurrents inuntil mothers can get care.“When I first heard about it, I really pooh-poohed thewhole idea,” Miller says. “I was very cynical andskeptical. This thing just sounded ridiculous. It wastoo simple and too easy.”But she changed her mind in 2003 after reading anarticle by Paul Hensleigh, a Stanford doctor who had13the women’s health field. She provided technicalguidance to Christy Turlington Burns’ 2010documentary “No Woman, No Cry,” and in November2012 she gave a TEDxSF talk called “Stop the Bleeding.”“Maternal mortality is a gross violation of humanrights,” said Miller in her TedxSF talk. “What is neededis political will for girls’ and women’s lives to matter.”13

Promoting women’s health“Sometimes it’s these experiences of visiting an individualpatient or research participant at their home or farm thatare more powerful than all the data in the world.”It often seems as if Craig Cohen, MD, MPH isTo remain connected to the patients and programeverywhere doing everything, all at the same time.staff, Cohen often visits program sites during hisHe’s involved in a vast number of programs at UCSFfrequent trips to Kenya. In addition to building localthat take him from hospitals and boardrooms in Sancapacity to take care of people living with HIV, FACESFrancisco to remote villages in Kenya.serves as the foundation for a growing list of aboutCohen, a professor in UCSF’s Department ofObstetrics, Gynecology & Reproductive Sciences, isan attending physician in the women’s clinic at SanFrancisco General Hospital, as well as the co-directorof the University of California-wide Women’s Health& Empowerment Center of Expertise. He has a32-page resume that details his career as a physician,researcher, mentor and administrator. What it can’tconvey is his passion and commitment to improving14and treatment, as well as the intersection of HIVand reproductive health, such as family planningand cervical cancer prevention. These studies aresupported by a variety of donors including the USNational Institutes of Health, Center for DiseaseControl and Prevention, the Bill & Melinda GatesFoundation, and private philanthropists.“One thing UCSF brings to the table is academic rigor,”people’s lives, specifically those living in some of thesays Cohen, speaking by phone from Nairobi. “Butpoorest conditions in sub-Saharan Africa.sometimes it’s these experiences of visiting an“If you really want to do global health research, youshould spend real time on the ground,” says Cohen,who lived and worked in Kenya from 1994 to 2002and returns frequently.Cohen is founding director of Family AIDS Care &Education Services (FACES), a collaborative partnership between UCSF and Kenya Medical ResearchInstitute (KEMRI) funded by the US President’sEmergency Plan for AIDS Relief (PEPFAR). FACEShas grown significantly since it began in 2004 and1420 research projects, most focused on HIV preventionindividual patient or research participant at theirhome or farm that are more powerful than all thedata in the world.”He describes a program he leads with Bukusi andDr. Sheri Weiser at UCSF called Shamba Maisha,which is Swahili for “farm life.” It’s an agriculturalintervention, mixed with microfinance and financialliteracy training, to improve the health and well-beingof people and their families affected by HIV in Kenya.Last year Cohen went to see an older woman namedsupports 130 health facilities run by the ministry ofMary. In 2007 she joined Shamba Maisha, which con-health in western Kenya near and on the shores ofnected her with a loan to purchase a human-poweredLake Victoria, the area of Kenya hardest hit by thewater pump and agricultural inputs, and training as aHIV epidemic.way to grow food, address food insecurity and earnCohen likens the FACES program, which runs onapproximately 13 million a year, to a “medium-sizebusiness” with the aim of creating knowledge,training the next generation of researchers andincome. At that time, she was an impoverished widowliving in a hut and feeling tremendous stigmabecause of her HIV status.“Five years later, she was successful,” Cohen says. “Sheproviding care to HIV-affected families. The programhad graduated to a larger water pump, was irrigatingis built upon Cohen’s 19-year collaboration withtwo acres, making money and living in a brick house.Dr. Elizabeth Bukusi, Deputy Director for ResearchWith her new stature came respect. People who were& Training at KEMRI.once hesitant to interact with Mary now come to seekFACES focuses on HIV prevention, care andtreatment. It has drawn more than 131,000 patients,of which at least 61,000 have started lifesavingantiretroviral regimens.her advice. She is now viewed as one of the leadersof the community. Mary’s success tells me we are onthe right track, that implementing an interventionthat combines health and development to empowerwomen and men affected by HIV really does work.”

CRAIG COHEN, MD, MPHProfessor in Residence of Obstetrics, Gynecology andReproductive Sciences; Founding Director of FamilyAIDS Care and Education Services1515

Roland (Roly) Gosling, MRCPCH,FRCPath, PhDAssociate Professor of Epidemiology & Biostatistics;Lead of the Global Health Group’s Malaria Elimination Initiative1616

Eliminating malaria“It’s becoming an emergency to get ridof malaria before we run out of tools.”Among infectious diseases, malaria is one of the mostnets and spraying houses with insecticide makelethal. It kills about 660,000 people a year.sense because mosquitoes often bite when people“I’ve seen kids dying of malaria in front of my ownare asleep.eyes,” says Roland (Roly) Gosling, lead of the MalariaIn low-transmission areas, however, infection happensElimination Initiative within the UCSF Global Healthoutdoors and can be related to behavior. “Are peopleGroup (GHG). “We work with 34 low-endemicout at night drinking beer in a bar, or working in thecountries with the goal of making those countriesforest or sleeping next to their fields?” Gosling asks.malaria free within the next 20 years.”“In these settings, traditional interventions don’t work.”Gosling, MRCPCH, FRCPath, PhD, believes eliminationIn the quest to find what does work, Gosling and hisis entirely possible. Unlike most people in the malariacolleagues are doing clinical trials this year offield, who focus on high-burden areas, he works onPrimaquine, using very low doses they hope will keepmoving from low to no transmission. “It’s becomingmosquitoes from getting infected with malariaan emergency to get rid of malaria before we runparasites. Primaquine is currently the only licensedout of tools,” he says. “Drug resistance is increasingdrug that can effectively kill mature infectious malariaamong malaria parasites, and insecticide resistance isgametocytes, and thus is viewed as an interventionrising among mosquitoes.”that could significantly drive down and disrupt ma-The Malaria Elimination Initiative works to bringcountries together into regional networks, such asthe 14-country Asia Pacific Malaria Eliminationmalaria, are taking place in Mali and Thailand.“These are two different ecological areas and prettyNetwork (APMEN), so that they can clear the lastunconnected,” Gosling says. “In Mali people haveremaining pockets of malaria. “These pockets tendnever used this drug, and the parasite will never haveto be complicated border areas with marginalizedbeen exposed to it. In Thailand, the standard treatmentpopulations,” says Gosling, who works closely withfor P. vivax malaria is Chloroquine plus Primaquine, soGHG Director Sir Richard Feachem and colleagues atwe expect P. falciparum would have been exposed inthe University of Queensland to coordinate APMEN.“People there have the worst access to healthcare.There is often conflict. Sometimes there are undocumented workers carrying out illegal activities. Theydon’t want to be found.”the past and might have developed some resistance.In both settings we need to know the right dose.”Gosling and his colleagues in the Malaria EliminationInitiative are using every tool at their disposal to helpthe 34 countries around the world that are strivingGosling, an associate professor of epidemiologyfor elimination. They are making great progress, butand biostatistics, grew up in London and trained aspeople continue to die, even in low-endemic countries.a medical doctor in Nottingham, the “home of RobinHood,” he notes. He enjoys living in hot climateswith palm trees and oceans; malaria work suits him.Tanzania, where he worked for six years, is a secondhome. He speaks Swahili and returns at least oncea year. Malaria transmission is high there; using bed17laria transmission. The trials, targeting P. falciparum“My colleague in Namibia, which is a low-transmissioncountry, called earlier today to tell me that a 15-yearold girl and 60-year-old man had died in the last twoweeks,” Gosling said. “Malaria is very real and it killspeople. And that’s why we should get rid of it.”17

Eliminating malaria“It’s very relevant for me to thinkabout spatial dimensions, themolecular genotypes of theparasites and the host’s response.I can put all these tools togetherto answer questions and findconnections between things.”Bryan Greenhouse is only 38 but figures he’ll betrying to create a ‘family tree’ of the parasites,” heworking on malaria research the rest of his life. Itssays. He envisions online maps that would show inbreadth and complexities fascinate him.“You can’t think about malaria and any one small pieceof it, because everything is so interrelated,” says18“Malaria doesn’t know where a political boundary is,”Greenhouse, MD. “It’s a lot more interesting than mostGreenhouse says. “If Swaziland wants to eliminatediseases because it involves people and mosquitoesmalaria and its neighbor Mozambique has a lot ofand communities.”malaria, Swaziland will need to help Mozambique.”His first encounter with malaria began 13 years ago,He is focusing on immunology, too, measuring humans’through sheer serendipity, when he was a medicalantibody responses to malaria parasites. He’d like tostudent at the University of Pennsylvania. He arriveddevelop a test to see how many times a person hasin Uganda for a four-month project, only to find thathad malaria and how long it’s been since the last time.it had fallen through. But he soon met Grant Dorsey,an infectious disease fellow from UCSF who put himto work on a malaria survey in the slums of Kampala.Four years later, Greenhouse came to UCSF, andDorsey, now an associate professor, is one of hisprimary mentors.“I really enjoy the fact that with malaria I don’t haveto be pigeonholed into a very small scientific field ofinquiry,” says Greenhouse, an assistant professor in18real time where cases are coming from and how theyare being transmitted.residence. “It’s very relevant for me to think aboutspatial dimensions, the molecular genotypes of theparasites, and the host’s response. I can put all thesetools together to answer questions and findconnections between things.”“It’s like cutting open a tree and looking at the rings togo back in time,” he says. “The idea is to do the samewith antibodies. You can say, ‘You’ve been exposed20 times in your life but not at all in the last two years,which means there used to be a lot of malaria herebut something has changed.’ You do that on acommunity level, and you can map spatially andtemporally what’s going on with malaria.”Greenhouse is also studying some fundamentalmechanisms for the development of natural immunity.“Prevention is really the way to go,” he says. “It allcomes down to money and effect

UCSF Global Health Sciences hosted 600 people at the Mission Bay campus for 7 Billion Well: Re-imagining Global Health. The day featured inspirational talks from scientists, authors, entrepreneurs, artists and others about how to improve 3 health around the world. GHS Executive Director Jaime Sepulveda spoke about vaccine justice; Gavin Yamey,