Thinking Globally: HIV Center Expands Its International Research Portfolio

In the confusing early years after the first emergence of AIDS, it was not at all clear that the new syndrome afflicting homosexuals, injecting drug users, hemophiliacs, and others in the great cities of North America and Europe had much relevance for the rest of the world. Faced with endemic poverty and weak public health systems, many developing countries had other pressing priorities, even as researchers in the US and other parts of the developed world were focused on the health crisis on their own doorsteps.

Yet even early on, those who thought carefully about the new epidemic soon realized that there was no reason to expect that AIDS would be confined to gay men or heroin users any more than it would be contained by the boundaries of any country or culture.

Viruses recognize no borders, and human behavior shows some remarkable consistencies around the globe. And so, from the earliest days, the fate of AIDS in any one part of the world was clearly bound to AIDS everywhere.

This reality is part of the reason that international work has been a fundamental component of the HIV Center's mission from its earliest days. When the Center was founded in 1987, the demands of the epidemic in the United States in general and in New York City in particular were so great that most of the early research was domestically focused. Recognizing the need and value of an international perspective, however, HIV Center Director, Dr. Anke Ehrhardt, and her Columbia colleague and Center Co-Director, Dr. Zena Stein, established the HIV Center's International Program under Dr. Stein's leadership.

Pioneers in South Africa

Dr. Stein, who is today Co-Director Emerita of the HIV Center, had a long and illustrious history, along with her husband Dr. Mervyn Susser, of promoting public health in South Africa and opposing the apartheid regime. These strong personal connections led to durable linkages between the HIV Center and southern Africa, particularly the nations of South Africa and Namibia.

Among the earliest of these was support by the HIV Center for documentation of the epidemic in the rural Rakai district of Uganda. The Center was also an important co-sponsor of a 1990 conference in Mozambique that is now recognized as one of the first concerted efforts to organize a public health response to HIV in Sub-Saharan Africa.

To Dr. Stein, this undertaking also underscored the need to understand the context within which HIV was spreading in Africa – not simply the virological and immunological components, but also the social and political ones such as the legacy of colonialism and malign influence of apartheid. Thus, from early on, the HIV Center's interdisciplinary research perspectives have included sociology, anthropology, and public policy.

"The detailed studies we have conducted on the female condom, for instance, recognize that it's not just about one woman and one bit of health education," says Dr. Stein. "Studies have to include the government, the state, the clinic, the men, and the client – the whole context. That's why we have put a major emphasis on ethnography, so that we can understand exactly what is happening in difficult situations." Similar considerations have propelled research on the development of microbicides to prevent HIV infection and on managing the risks of transmission to infants during breastfeeding.

International Training Stage

Perhaps the most enduring link between the HIV Center and southern Africa has been the Fogarty Fellowship Program established in 1990 at Columbia to train public health practitioners from South Africa. Among the earliest trainees were Drs. Quarraisha Abdool Karim and Salim Abdool Karim, who continue an affiliation with the Fogarty Program and with Columbia today. "Quarraisha and Salim started a grassroots movement that was the underlying movement that Mandela inherited when the government changed in 1994," notes Dr. Stein.

But the Karims have not been the only HIV Center alumni to influence the course of AIDS in South Africa. "Today, people have a way of saying that almost all of the epidemiology in southern Africa has been spearheaded by our graduates, and some of the new leaders there have been trained by our graduates."

The Value of True Partnerships

Sustained linkages of this sort reflect one of the guiding principles of the Center's international work: the development of long-term institutional connections. All too often, researchers from the developed world engage in what derisively has been termed "parachute research," dropping into a new setting with little depth of understanding, extracting information, and then leaving with the data and offering little or nothing to local communities in return.

The HIV Center has consistently sought to apply the reverse of this approach, choosing to work in a limited number of settings but to establish long-term working institutional relationships that can outlast changes in individual investigators and survive specific research grants.

Crucially, this approach also promotes development of in-country expertise among indigenous populations, providing training opportunities and building research capacity in the developing countries themselves.

Research in Latin America

This approach has also been in evidence in the HIV Center's link to Latin America. Early research in this region included study of HIV transmission in the Dominican Republic and development and evaluation of community efforts to prevent HIV in rural Puerto Rico, as well as determinants of risk among Latino immigrants in New York.

The Center's ability to develop sustained linkages to Latin America was strengthened in 1997 with the arrival of Dr. Richard Parker, an anthropologist who was then leading the Brazilian Inter-disciplinary AIDS Association (ABIA) in Rio de Janeiro. Today, Dr. Parker is the Chair of the Department of Sociomedical Sciences at the Columbia Mailman School of Public Health and the Director of the HIV Center's International Core, which provides expert advice to international research projects and advances the Center's global agenda.

Established in 2002, the International Core represents an expansion of the original, smaller International Program and thus reflects the Center's increasing emphasis on the global epidemic. The Core's multidisciplinary faculty serve as a resource for the development of initiatives by HIV Center researchers working with local investigators and institutions. They also assist Center investigators in formulating comparative analyses – based on cross-national and cross-cultural research findings – of key theoretical and topical issues relevant to the global response to HIV/AIDS.

"If you want to be meaningful in terms of making a contribution to the fight against the global epidemic, you have to be working globally – there's just no way around it," says Dr. Parker. "The way that the HIV Center's work has evolved is that there are still many meaningful projects that take place in the US, but we expand our work internationally, trying to respond to the challenges created by the epidemic around the world."

Dr. Parker believes that, moving forward, the HIV Center is well placed to address the global challenges. The Center's position in New York puts it at a point of intersection for many different processes of social and cultural contact, since New York is a center of international relations and a center of migratory flows back and forth to different parts of the world. Likewise, Columbia is a major international university with an extensive health portfolio that is likely to contribute to the Center's work.

"The setting is helpful and if anything should push us to prioritize new and creative
work on global AIDS issues in the future," he adds. A hallmark of that work should continue to be the avoidance of "parachute research" in favor of longer, more sustained connections such as those Dr. Parker has helped to forge with ABIA and with universities in Sao Paolo and Rio de Janeiro. The Center's motives, he stresses, should not only be to conduct studies and to help build capacity in developing nations, but also to benefit from their experience.

"We ought to be trying to learn from the developing world. In fact, if you look at where the epidemic is going in this country, it is with marginalized populations with limited access to resources, populations that are in many ways similar to those that are being hit in larger numbers in the developing world," adds Parker.

"What you have are pockets of poverty and misery that exist as much in places like the South Bronx as in the shantytowns outside of Johannesburg or Sao Paolo. So, for instance, many of the lessons learned in doing prevention work through liberation pedagogy in Brazil can teach us things that we can use very effectively in the US. We should always be thinking about a bi-directional transfer, where we have as much to learn as we have to teach."