Feature Reproductive Health: Collaborating for a Large-scale Impact by Johanna Van Hise Heart

Traditional birth attendants in rural Tanzania participate in a study aimed at preventing deaths from postpartum hemorrhage.

is to make this drug available and interdisciplinary network of colleagues affordable in the developing world, to tackle multi-layered international health conundrums and look for where 600 million women are opportunities to actively make a large- struggling to survive on two dollars scale difference. a day or less. Mobilizing an Interdisciplinary The industrialized West is insulated from Team Malcolm Potts, M.B., B.Chir., many of the tragic disparities in women’s Their professional connections arise from long careers working in the fields Ph.D., F.R.C.O.G., and Martha health prevalent in the world's developing nations. Women are dying needlessly of of family planning, population growth, Campbell, Ph.D., are acutely aware AIDS—especially those for whom socie- and AIDS prevention. Potts, holder of of a tremendous problem: women are tal status makes it difficult to negotiate the Fred H. Bixby Endowed Chair in bleeding to death. According to the the use of condoms. And upwards of Population and Family Planning and director of the School’s Bixby Program World Health Organization (WHO) 68,000 women are dying annually of complications from unsafe abortions. in Population, Family Planning & more than 130,000 women die each Maternal Health, is a British, Cambridge- year from postpartum hemorrhage— What can be done? Potts and Campbell trained obstetrician and reproductive sci- entist. In 1972 he introduced the manu- a condition for which there is actually have many good ideas. Both are inde- fatigable problem-solvers and collabo- al vacuum aspirator, a device that has a cure, a drug called misoprostol, a rators (and their collaboration extends become the preferred method around prostaglandin designed to treat gastric to their personal lives—the two recently the world for safe abortion and treat- ulcers that also contracts the uterus celebrated their tenth wedding anniver- ment of complications from incomplete abortions. Potts was the first medical and inhibits bleeding. The challenge sary). But more importantly, they are able to bring together a vast international Continued on page 6

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Reproductive Health: Collaborating for a Large-scale Impact, continued

director of the London-based Internat- Development (CEIHD). The center ional Planned Parenthood Federation promotes the use of entrepreneurial and CEO of Family Health International, methods to improve the health of fami- where he led the largest global program lies in developing countries. They create of AIDS prevention outside of the World financially sustainable systems, such as Health Organization. strategies to distribute off-patent drug products at modest prices, employing Recognizing the need to address the the skills and knowledge of local entre- quantitative aspects of family planning preneurs as partners and eventual owners and reproductive health in developing of the health-promoting enterprise. countries, Potts and adjunct professor Julia Walsh, M.D., D.T.P.H., founded Also in 2000, Campbell founded the the Bay Area International Group (BIG), nonprofit Venture Strategies for Health now known as the Berkeley International and Development, the board of which Opportunities for Group, in 1997. BIG brings together is, for the most part, populated by graduate students from a number of School-affiliated faculty members. Large-scale Change countries and across the disciplines of Venture Strategies was set up to work Challenge: Almost half the world’s popula- public health economics, medicine, and closely with the School, especially the tion lives on $2 a day or less. In parts of epidemiology, AIDS prevention, and Bixby Program and CEIHD. It strives to Africa, one-quarter of disposable income is business, to consider how money is best improve the health of large numbers of spent on health care. spent to achieve improved health in low-income people in developing coun- developing countries. “We know what it tries by combining scientific evidence Action: Ease the financial burden of health costs to provide contraceptives,” explains about tractable problems in health with care for the poor. Potts by way of illustration. “If we also opportunities inherent in existing market know what people are willing to pay, forces around the world. “Venture Challenge: One woman per a minute dies then we can work out the difference and Strategies was designed to work with the from pregnancy, childbirth, or abortion. what the international community School of Public Health at Berkeley to Ninety-nine percent of those deaths are in should be providing and what the gov- do the action side—which is much easier developing countries, and most of these take ernment should be providing.” for a nonprofit organization—based on place outside the hospital or clinic setting. the scientific evidence of the university,” Action: Make medical supplies and health Campbell, by contrast, is a political sci- explains Campbell. entist and health policy specialist, focus- care available for women experiencing post- ing on global population growth and “There are some things that the universi- partum hemorrhage and complications of economics of international health and ty can do best,” says Potts. “But there are unsafe abortion. family planning. Before joining the also things that a university would find School of Public Health as a lecturer, quite difficult to do.” Traditional birth Challenge: The population of the earth Campbell led the David and Lucile attendants are often illiterate and unable grows by one million more births than Packard Foundation’s population pro- to submit invoices related to a study. deaths every 110 hours. gram, where she came to recognize that African governments requesting a policy Action: Remove barriers to family planning. in many developing countries govern- meeting of experts to advise on drug ment health services are simply unable to approvals cannot wait for delays associat- Challenge: 116,000 new HIV/AIDS infections reach the poor and that many essential ed with the bureaucracy of obtaining occur every day. Half of these are among health needs are not being covered by travel funds. Venture Strategies’ nonprofit women, many of whom are not free to foreign assistance. nature allows it to respond quickly. choose when to have sex and cannot nego- Developing Effective Strategies tiate condom use, even when they suspect In 2000 Campbell and Nap Hosang, M.D., M.B.A., M.P.H., F.R.C.O.G., Just as Potts and Campbell bring together their partner may be HIV positive. who heads the School’s Interdisciplinary complementary skills and shared inter- Action: Identify an effective, affordable, Master’s in Public Health Program, ests, the Bixby Program, BIG, CEIHD, available microbicide women can use to established the School’s Center for and Venture Strategies combine their dif- protect themselves. Entrepreneurship in Health and ferent approaches to address certain

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shared priorities. “What this close-knit circle of colleagues has in common,” “Misoprostol has been used often in hospitals by WHO, explains Campbell, “is attention to scale; attention to money and how it is spent but not in the field. And it is in the field where the in the field for most beneficial effect; good research; and a considerable maternal deaths occur—one woman a minute dies from amount of experience in most of the postpartum hemorrhage or unsafe abortion.” countries in the developing world.”

They begin with research to show that traditional birth attendants.“Misoprostol health after home births. Both meetings something works. Then, responding to has been used often in hospitals by focused on the reality that the drugs requests from medical leaders in devel- WHO,” says Potts of the study’s sig- used to control postpartum hemorrhage oping countries, they organize feasibility nificance, “but not in the field. And in hospitals require refrigeration and studies. “We ask ourselves, is there any- it is in the field where the maternal injections and are therefore not usable thing we can do where there isn’t a deaths occur—one woman a minute in rural areas where most deaths occur. health professional available to stop dies from postpartum hemorrhage or women from dying?” says Potts. The unsafe abortion.” “The goal of such meetings,” says answer in the case of postpartum hemor- Melodie Holden, M.S., M.P.H. ’05, who rhage is yes, the aforementioned wonder The next step is to identify the source of recently visited officials in the Tanzanian drug misoprostol, which is heat stable, needed products—in this case manufac- ministries of health, “is to clear the path low cost, and off patent. turers of misoprostol. Campbell, who for misoprostol to be available and has crossed the globe visiting nearly affordable to rural women.” One obsta- Ndola Prata, M.D., M.Sc., an Angolan every producer of the drug, has found cle she must overcome is that the drug is physician and medical demographer in producers in China and Egypt who are controversial because it can be used for the Bixby Program, has worked with already manufacturing the drug in great early-term abortion, which is illegal in African colleagues to demonstrate that quantity, but who would not be able to many developing countries. traditional birth attendants can use this do the work of exporting their drug to drug very effectively in resource-poor sub-Saharan Africa. CEIHD then pro- Other projects may hold promise for rural areas of Tanzania. First, she devel- vides assistance. In the past, for example, large-scale impact. Anke Hemmerling, oped a virtually cost-free method for CEIHD has arranged the technical work M.D., M.P.H. ’04, a gynecologist work- birth attendants to identify whether a of translating documentation into other ing with the Bixby Program, will be woman needs the drug. Prata found that languages (e.g., translating birth control running a cohort study at UC Berkeley 500 ml of blood, which is the standard pill instructions into Afghan languages) to examine the effects of lemon and trigger for saying that a woman is experi- or assembled information required by an lime juice on the vagina in the hope encing postpartum hemorrhage, soaks African country’s drug approval agency. that the juice may be safely used as a two kangas, the colorful, traditional gar- “If we open the door for a Chinese or spermicide and virucide. Since this ments worn by East African women. “So Egyptian or Indian manufacturer, they fruit is widely available and inexpensive the traditional birth attendants now have will undoubtedly supply the drug. But around the world, demonstration of its the power to diagnose a life-threatening we have to do the regulatory work for safety and effectiveness could hold situation,” explains Potts. them,” says Potts. promise of protection from HIV for millions of women. In another study, working with Godfrey Finally, comes consensus building— Mbaruku, M.D., Ph.D., in Kigoma, bringing together national-level decision- In the end, the complementary nature of Tanzania, Prata has assisted in showing makers to agree on the need to use the the School's sisterhood of entities con- for the first time that field use of miso- product to save women’s lives. At the cerned with women’s reproductive health prostol works after home births in rural request of the governments of Uganda creates a very powerful continuum of areas, far from hospitals. The number of and Kenya, Venture Strategies cospon- efforts. “We are responding to an agenda women referred to Dr. Mbaruku’s hospi- sored policy meetings on maternal that is set by colleagues around the tal was reduced by 90 percent, indicating mortality, highlighting the opportunity world,” explains Potts. “We bring essen- effective use of the medication by to use misoprostol to improve women’s tial skills to the equation.”

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