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PATH:Catalyst for Global Health
by Tera Schreiber

As women in Seattle, we take a lot of health care services for granted. We have easy access to vaccines and contraception. We can give birth in sanitary settings with highly trained doctors, nurses or midwives, and resources are readily available to help us prevent and treat sexually transmitted diseases. While all of these advantages seem routine to us, PATH, an international nonprofit organization headquartered at the base of the Ballard bridge, is all too aware that these are luxuries frequently denied to women in many parts of the world. Its mission is to change this by developing sustainable and culturally relevant strategies to break the cycle of poor health around the globe.

PATH, which stands for Program for Appropriate Technology in Health, got its start in 1977 as the Program for the Introduction and Adaptation of Contraceptive Technology. This small organization was founded by Drs. Gordon Perkin, Gordon Duncan and Richard Mahoney, medical and technology experts and pioneers in public health who believed that people in developing countries also deserved to benefit from advances in contraceptive technology. Thirty years later, PATH has more than 500 staff members and 28 offices in 18 countries, a program budget of over $168 million, and a mission to improve the basic health of people throughout the world.

Much of PATH’s work grows out of its early interest in reproductive health, and the prevention of sexually transmitted disease and ensuring safe childbirth in areas with little access to health is a priority. But PATH also has a commitment to assuring that its projects are culturally acceptable to the people it seeks to serve. Nearly half of PATH’s staff members come from developing countries, which means that natives of the regions PATH provides medical technologies to help ensure that the technologies it introduces are culturally competent. Likewise, PATH continuously tests its innovations and seeks feedback about its work to assure that its products and services work for those who will be using them.

MICROBICIDES

One of PATH’s programs, The Global Campaign for Microbicides, endeavors to increase the awareness, support and development of microbicides to fight HIV and other sexually transmitted diseases. Microbicides are compounds that can be formulated into a number of different products such as gels, creams, suppositories, sponges or rings to protect against sexually transmitted infections including HIV, and they are regarded as one of the most promising new technologies to address the HIV/AIDS pandemic. Because they are protective agents that don’t require the cooperation of a partner, microbicides could vastly increase the power of women around the world to protect themselves against diseases like HIV. What’s more, the goal is to produce microbicides both with and without contraceptive components to allow women to use the product whether or not they wish to become pregnant.

What difference would microbicides make for women in developing nations? Anna Forbes, deputy director of the Global Campaign for Microbicides, says, “Mathematical modeling has shown that with a 60 percent efficacy of microbicides, if microbicides are introduced in 75 high risk countries, if microbicides [are] picked up by only 20 percent of the women with access to health care, and if those women use them only 50 percent of the time when they are not using condoms, we could prevent 2.5 million HIV infections in just three years.”

Because of the potential of microbicides to save so many lives, PATH helped introduce the Microbicide Development Act of 2007 in Congress. If adopted, the act would establish a dedicated microbicide research and development branch at the National Institutes of Health and strengthen microbicide research activity at the United States Agency for International Development and the Centers for Disease Control and Prevention. Forbes hopes that women in the United States will help advocate for microbicide research by contacting their legislative representatives to encourage passage of the act. “Imagine what it would be like to sleep with someone you know is at risk or positive for HIV, and have no way to protect yourself and no way to refuse sex. Having a tool to prevent HIV transmission to these otherwise powerless women is extraordinarily powerful.”

PATH is also focused on overcoming one of the problems with traditional condoms. Although they are a highly effective tool for both contraception and prevention of sexually transmitted diseases, a woman must rely on her partner’s willingness to use one, and in many parts of the world, a woman doesn’t have the power to demand or even request that her partner use a condom.

“One of the biggest problems that women who live in poverty have is the inability to insist that a partner use a condom,” explains Forbes. “The less social and economic power you have, the less power you have in the bedroom. Many women simply cannot insist on a condom because they cannot risk being abandoned by their husbands and communities.”

To make matters worse, women are biologically more susceptible to transmission of HIV. As a result, the HIV/AIDS pandemic hits women in developing nations particularly hard. In sub-Saharan Africa, well over half of all new HIV infections occur in women. Data suggests that the vast majority of HIV infections happen with women who have only one partner.

Although female condoms exist, they have traditionally been expensive and more difficult to use than the male condom. PATH is now working on a more convenient and inexpensive female condom that can be provided to women all over the world, increasing their ability to have control over their own health. To assure the cultural acceptability of the product in the developing world, prototypes were tested with populations that varied widely in physical and cultural needs, including those in Thailand, Mexico, and South Africa.

SAFER CHILDBIRTH

Every year, about 57 million women worldwide give birth without the help of a trained health worker. These births often take place in settings where the risk of infection is high, and hundreds of thousands of women and babies die each year from birth-related infections. To address this issue, PATH helped develop sanitary birth kits in Bangladesh, Egypt and Nepal. Most kits contain a small bar of soap for washing hands, a plastic sheet to serve as a sterile surface to catch the baby, clean string for tying the umbilical cord, a new razor blade for cutting the cord, and pictorial instructions that illustrate the sequence of birth events. These kits are intended to help even untrained people safely assist women giving birth.

True to their commitment to ensure the cultural competency of products they introduce, PATH workers sought feedback to evaluate the birth kits. They learned that in Nepal, umbilical cords were still being cut with a coin for good luck, despite the instructions to use the hygienic razor blade. Out of respect for this custom, kits produced in Nepal now contain a plastic rupee for sanitary cord-cutting. Follow-up research in the areas where the kits are distributed indicates that women and babies are less likely to develop infections when the birth kits are used.

Another problem for birthing women in the developing world is the risk of postpartum hemorrhage. While United States health care providers have easy access to drugs and technology that stop hemorrhage, that is not the case in developing nations. “Midwives fear hemorrhage,” says Vivien Tsu, Ph.D., senior program officer in PATH’s reproductive health and maternal/child health divisions, “because they can watch a mother die in a matter of hours and have nothing they can do about it.”

Fortunately, a growing body of research indicates that giving the mother the drug oxytocin as part of the management of third stage labor (after the baby is born and before delivery of the placenta) helps the uterus contract and reduces the risk of hemorrhage. Most women in the developing world give birth at home or in a small health center, and midwives in these settings are not accustomed to using oxytocin. PATH workers realized that a pre-filled injector, which it had originally developed for administering vaccines, could make delivery of oxytocin easier.

In an Indonesian study performed by PATH, midwives reported that the pre-filled injector was effective. “The Indonesian midwives found it made a difference for them,” explains Tsu. “With our study, they delivered about 2,200 women. There were about 50 women that the attending midwives felt were bleeding enough that they needed a second dose. Not one of those women needed to go to a hospital.”

Excited about the outcomes in Indonesia, PATH organized a study in Vietnam comparing a district that used active management of the third stage of labor with oxytocin to the existing standard of care that involved treating women only if bleeding problems arose. The study found that active management with oxytocin resulted in a 40 percent reduction in the incidence of postpartum hemorrhage. Cost savings were realized because the treatments for a major hemorrhage include expensive and complicated procedures like blood transfusion or surgery. Other studies have shown 40 to 60 percent reductions in the incidence of postpartum hemorrhage with the use of oxytocin. These important advancements have made childbirth safer for women around the world.

CERVICAL CANCER VACCINE

PATH has been involved in the development of the vaccine for cervical cancer for the past two decades, not so much with the intention of vaccinating women in the U.S., but with an eye toward vaccinating women who do not have access to regular screenings through a Pap smear. Cervical cancer is the leading cause of cancer death for women in the developing world. There are half a million new cases around the world each year and more than a quarter of a million women die from cervical cancer annually. A disproportionate number of those deaths occur in developing countries.

Before the existence of the vaccine, PATH started work on screening programs in the developing world. “We found that very little screening was happening,” says Tsu. “Sometimes a capital city would have a family planning clinic and would offer Pap smears for women who were coming there. Essentially, a small group of women were being repeatedly screened, but the rest got nothing. Or we found that it would take months to get tests, and labs were unable to reliably get results to women. Telephones and mail are just not feasible options in these areas.”

In Peru, PATH studied what had been done to Paps the previous year. They found that only about one quarter of the women who had an abnormal Pap which indicated the need for treatment actually received the treatment. “That meant that three quarters of these women were not taken care of!” exclaims Tsu. “Essentially they were using a model that didn’t work within their infrastructure.”

Learning from these obstacles, PATH worked to develop low-cost screening procedures that deliver immediate results. First, PATH introduced a new approach to screening called visual inspection that involves the simple process of swabbing the cervix with vinegar and looking for the change in appearance that occurs in any abnormal tissue that has been swabbed.

Workers from PATH found that they could combine the visual screening procedure with a current method of treatment, cryotherapy, or the freezing of the abnormal tissue, and began training nurses to first perform the visual inspection and to follow up with immediate cryotherapy if the cervix looked abnormal.

As a result of this work, PATH became part of the Cervical Cancer Prevention Alliance. With a grant from the Bill & Melinda Gates Foundation in 1999, PATH and the Alliance embarked on a training program in several countries around the world. Hundreds of thousands of women have been screened as part of this project.

It’s no surprise that women in the United States don’t receive a vinegar swab to check for cervical cancer. Instead, we are all encouraged to have a regular Pap smear. While the visual screening process serves an important purpose where Paps are not practical or feasible, it is not as effective as a Pap smear. So PATH continues to try to improve the methods used in screening for cervical cancer.

PATH developed a simpler, faster, and more economical test for HPV, the virus that causes cervical cancer. The test in the United States currently costs $30 to $60 per test, a cost that is completely impractical in the developing world. Working with the same manufacturer of the test used in the United States, PATH developed one that takes only two and a half hours and costs less than $5 per test. The test can be performed with a sample that women take themselves, instead of requiring a provider with a speculum to do the test for them. “We realize this may not be quite as effective, but if it’s a lot more acceptable, we might reach many, many more women,” says Tsu. PATH is testing this product in the field right now.

At the same time, PATH is working to get the new cervical cancer vaccine into the developing world. “Our goal,” says Tsu, “is to help countries make decisions on whether the vaccine is the right thing for them. They have a lot of competing choices to make. The goal of our current project is to help countries gather information to make those choices.”

RESEARCHING VIOLENCE

In collaboration with the World Health Organization and the London School of Hygiene and Tropical Medicine, PATH began work on the first landmark study of violence against women in the developing world. The study involved more than 24,000 women from 15 to 49 years of age in 10 countries. The findings showed that not only does violence against women negatively affect their overall health, abuse is underreported and varies wildly in all settings. Researchers now hope to continue in this field to help answer questions including which factors increase a woman’s chance of being the victim
of violence and what can be done to prevent it.

One outcome of the research project was that it provided some measure of outreach and support for women suffering from abuse. A participant from Japan explained, “I did not know where I could go for help. Now I know where I can go. I was looking for such places.” PATH and the organizations that facilitated the study are now working to disseminate information and support regional initiatives that protect women who suffer from violence.

EDUCATION AND SUPPORT

Married adolescent girls face an increased risk of HIV compared to their unmarried counterparts. In rural parts of Western Kenya, girls commonly marry as early as 15. Adolescent girls often marry older husbands, many of whom have been exposed to HIV, and begin married life with little information about sexual and reproductive health.

Following current gender norms in the region, many husbands discourage their young wives from socializing with other women, or even leaving the house. Because many of the girls attend weekly church services, PATH has been working closely with local church leaders to establish married girls clubs where girls can receive information, advice and social support. The clubs offer young married girls an opportunity to be mentored by older married women and a place to discuss reproductive health, marital communication, condom use and HIV testing. PATH has also developed radio spots and street theater shows that encourage girls not to rush into marriage at a young age, and to make sure their partner is tested for HIV before becoming intimate.

MAKING A DIFFERENCE

PATH has certainly had a broad impact on the health of women in developing nations. Yet, with the multitude of health concerns around the world, it seems overwhelming to know where future work should begin. “When considering what new technologies to develop and introduce, we look at three things,” says Teresa Guillien, PATH’s senior communications associate. “We look for a demonstrated need. We consider whether we have the capability in-house and if we can offer an expertise in that area. And we ask whether there are resources to support the work.” Once a technology is developed, PATH employees seek partners, from those who can help them manufacture and distribute products, to those who can provide on-the-ground education and support to implement the technology.

Resources are the key to the kind of work that PATH does around the world. While PATH gets most of its funding from government and foundation sources, PATH still relies in large part on individual donors. Those who are interested in helping fund the strides made by PATH in providing accessible health care to the populations of the developing world can donate online or attend PATH”s education and fundraising events. PATH also offers community tours where members of the community can learn more about the technologies being developed and how these products are delivered to the people who need them. While it may seem that we are a world away from the women in developing nations, PATH is helping to make that world a little smaller, one technology at a time.

Tera Schreiber is a freelance writer in Seattle and former Executive Director of Great Starts Birth & Family Education. She frequently writes about health issues.

©2007 Caliope Publishing Company