Adriana welcomes Dr. Oluwafemi Adeagbo from the University of Iowa’s Department of Community and Behavioral Health for a wide-ranging discussion about HIV stigma, social determinants of health, medical ethics, health disparities, and more.
Hello everyone and welcome back to From the Front Row. We are joined today Dr. Adeagbo, an assistant professor here at our very own college of public health here at Iowa. Dr. Adeagbo is an applied social scientist with extensive research experience working collaboratively with local and international institutions on HIV related research in the United States, South Africa, Nigeria and most recently, Zambia.
Recently, Dr. Adeagbo has developed additional research interest in bioethics and non-communicable diseases. My name is Adriana Kotchkoski and if it’s your first time with us here today, welcome. We’re a student run podcast that talks about major issues in public health and how they’re relevant to anyone both inside and outside the field of public health. So before we get into the topic of today’s episode, can you tell us a little bit about your background?
Yeah. Thank you very much Adriana, and a good morning to you and your listeners. Yes, my name is Adeagbo Oluwafemi [inaudible 00:01:06] and I’m an assistant professor of [inaudible 00:01:12] Community and Behavioral Health there at the College of Public Health at the University of Iowa. Yes, that’s who I am.
Now we’re so happy to have you here today. So what brought you to the College of Public Health here at Iowa?
What [inaudible 00:01:31] I don’t know if [inaudible 00:01:32] here mention, but prior to my current position here I was a research fellow at the University of South Carolina, under the school of public health.
Yeah. Is there anything that you especially liked about Iowa from North Carolina or just work that brought you here?
Yeah, thank you for the question. I was being somewhere else, right? But when I visited Iowa, I just love the people who work under me, from the driver, to the faculty members that I met, and also the environmentals of people the university introduced to me, which was really heartwarming for me, it melted my heart when I go back. So, about the love [inaudible 00:02:24] about the weather. I also read about it and I was somewhat scared, but one of my colleagues is said then, “Oh, there is no bad weather, only bad clothing.” I was like, “Okay. That’s not bad.” And that makes a lot of sense to me. And I just made a decision.
So, the environment, beautiful environment. We love nature, green is everywhere. It was good when I visited, and I just made up my mind, I was like, “Okay, let’s try Iowa.” That means let me experience the access to school, compared to South Carolina. I only saw snow once in South Carolina.
Really? Well, you’re in for a treat for an Iowa winter. It’ll get really nice when the leaves change but then you might be thinking twice about the Iowa adventure.
No, I experienced it this year. So, yeah, I joined the University last year.
Oh. Good. Yes. Can you tell us about your research experience in different countries? I know you spent time in the United States, South Africa, Nigeria, and Zambia. So, how have these different experiences really shaped your perspective on global health?
Yeah, thank you very much for you question. I think I’ll start from South Africa because I conducted most of my past studies in South Africa. I studied there as well. So, I’ll start from there. I lived most of my life in South Africa. I don’t know how much you know about South Africa. As of 2021, South Africa had 60.1 million people. And so the population, and there are 13.7% HIV prevalence rates, and that gives you an estimated 8.2 million people living with HIV in 2021. That’s slightly more than 4 million people were on antiretroviral therapy, which is HIV treatment.
Also, South Africa runs the largest HIV programs in the world, because of the prevalence of HIV there, everyone wants to conduct studies there. And for me, my journey into HIV research is of quite funny, and I will start talking about it. So, I conducted research in both rural and urban areas trying to improve people’s, house calls, especially in old people and men in South Africa.
Staying in Johannesburg, just like Chika had read, you don’t really know much, you thought you knew a lot about HIV because I was privileged to work with one of the largest HIV institutes in the world, [inaudible 00:05:19] and I learned a lot from them and stayed in Johannesburg all my life, studied in Johannesburg. I told, man, this is it. I got this position and I started questioning myself because I got another position in the province with the highest number of people living with HIV in South Africa till today.
Yes, and I started thinking about HIV, “Am I going to contract HIV? What’s going to happen to me?” Because I was given the tour, rural, this is not rural, I’m talking deep rural area. And I took up the challenge. I love challenges. And I said to my partner, “Ajola, have you thought about it?” I was like, “Let me try.” And I thought about it. I said, “Vicky, I’ll do it.” I went into a rural at the epicenter of HIV, and I started looking at the social aspect of HIV, other than the medical aspect of things, and starting looking at what are the drivers of HIV, especially amongst young women, because still today, despite all these programs in the South Africa, although we still have over 200, 000 new HIV infections every year in South Africa.
So I started asking questions and I conducted a lot of research with young people that I mentioned earlier. And one of the things that we tried to explore was the concept of blessee and blesser. I don’t know how much you know about the blessee and the blesser. So the blessee usually is a young woman, deprived young woman, mostly black women, disadvantaged in terms of financial resources. And some of the things they probably need like this one, like, “Oh, I want iPhone 15.” And then we have this older male with the money to buy the iPhone 15 for these younger people. They will buy.
The sexual transaction, there’s power imbalances there, right? The man, oftentimes they don’t use condom. And the younger is less likely to negotiate success in that context. And that brings us to what we call social instinct theory, that say the more resources you have, the more power you have in a relationship and to make decision as well. So we discovered, when we conducted the final genetics of HIV, discover that this young woman would take some of these material resources, financial resources from the older male, will give them sexual transactions. They might contract HIV from that instance, and they will go back to have sex with their boyfriend, the younger male.
And some of those boys, they don’t like using condoms. And so this cycle continues of HIV transmission. And you start asking questions, start thinking about this, the socioeconomic aspect of things, the gender aspect of things, and how do we do this? And also, we still have been… So the dynamic of condom use is also very interesting because there’s a lot of programs in South Africa where you can access free condoms, even in rural areas as well.
But I conducted a lot of research with young males and older males in South Africa, and so what they will tell you is that condoms give them rashes. And at some point, there’s also an issue of fatalism, well, something will kill a man, whether it’s HIV or something, it will kill a man.
Also, we noticed alcohol and drug abuse in taverns. And in these taverns, there’s a lot of transactional sex going on too. And oftentimes, they don’t negotiate success because people are actually drunk and they have sex without condoms-
They aren’t thinking about it.
… and things about this cycle of HIV. And also, my research in South Africa also shows that people are actually more afraid of HIV. It’s not really HIV testing or treatment in particular, it’s HIV identity.
Yeah, so the stigma associated with that?
Exactly. The stigma. And it gives them that everyone is afraid of the HIV identity. And especially male. And some men do not want to lose their social status because if found to be HIV positive, some of the stigma in the community is very, very, rife. And some even people, young people and men, they don’t go to the clinics because if you go to, if you go to a certain place in the clinic, the building within the clinic, people know that you actually agree for HIV testing, treatments or whatever. And the stigma, even the person that’s going to attend to you is a member of community, people don’t trust them. It’s usually with trust and all of it.
Yes, complicated. And for men too, living with HIV and not on antiretroviral therapy, issue of waiting time. Some people, they usually are at the clinic in the morning, and they will leave at 4:00 p.m. they wouldn’t want to do that because they really need to provide for their family.
There was a study we conducted recently, and we were like, we offer financial incentive to everyone to test for HIV, and if you find to be positive, there are double financial incentive for you to remain to treatment, and we will facilitate your [inaudible 00:11:05], we would help you with transportation, if you don’t have transport, all of those things. People didn’t lean, especially men, they didn’t lean to care. And we went back to them after 30 days or 40 days, and said, “Why not?” They’re like, “Well, I have a lot of problems than HIV, food insecurity. What do you want? I don’t have balanced diet. I don’t have money to eat balanced diet.”
And I’ve heard from people that when you take these medications, you have bad dreams, even the side effects of things. And put together, if you look at everything, it tells you that poverty is a major time in that way, and we don’t usually talk about it much in my blue bios plans this semester, I will share some lights on poverty as a determinants of health, for people to see how it connects to every aspect of our life. So, that’s my South African study.
So, in Nigeria too, Nigerian population is over 220 million, right? And an estimated 1.9 million people were living with HIV last year in Nigeria. And also the issue of HIV disclosure and stigma is rife in Nigeria, because this kind of support you get if you disclose your HIV status, people will technically move away from you, including your family members. They won’t use the same spoon as you. In fact, you might even get physically abused because of your HIV status.
Yeah, we conducted a study amongst almost 4 000 people in 2021, we were presenting to Nigerian government last year, and people lost their jobs because of their HIV disclosure, when they disclosed their HIV status. Especially women that have disclosed to their partner, they got beaten mercilessly, and so on. Their family disowned them. So there’s, on it, issue around stigma. Even with South Africans, Nigerians around HIV, even Zambia. The President of Zambia declared that Zambia is a Christian country, right? And in 1996, it was entrenched in the Zambian constitution that it is a Christian country.
And it gives [inaudible 00:13:23] a day, the population is slightly above 20 million population. With 11.1 HIV prevalent rates among adult, 15 to 59 years, that gives you around 4.2 million people. But it’s was 14.6 percent prevalence rates in children. And so it was still high too. So going back to the constitution, the Declaration of Christianity. As Zambia as a Christian country, and this is established by their 1996 constitution.
This does not mean that they do not have other religious, traditions in the country, is just a wing of enacting his power, right? And these actually have a serious impacts on the way the clinicians treat the sexual gender minorities in the country because they believe what homosexuality is foreign. And some of these guys will go to the clinic for siblings, and imagine one clinician coming out and say, “Oh, one of them is here.” Kind of thing.
The stigma is also right. And this also I’ll link into the United States now, my research and oftentimes you always think, “Oh, United State have already…” Some of these countries, they do not have a lot of money for the IELTS kit 16, right. And also when it is present, the issue of vaccines is a problem, right? And also transportation, all of those things and our food insecurity. In United State, you would think with the level of HIV education and everything that there won’t be this problem. But it’s a lie.
When you go to the US South, you see them. I did some research in South Carolina. HIV stigma is also getting right, especially in rural areas. And also there is another issue of representation. People like me, especially among sexual and gender minorities, we do not have people that represent the group, a lot of people that represent the group within the health care system, especially in rural areas.
And also, is your race plays an important role too, and poverty is also a key factor. Yes, US has more health plan compared to others, [inaudible 00:15:55], and you would think, “Okay, there won’t be a problem.” But healthiness also affects our lifestyle. How we behave in terms of our health behaviors. Other than HIV, US has more than a million people that were living with HIV. Half of them currently living with HIV in the US.
Lifestyle also brings about the issue of non-communicable diseases, right? Your diabetes, other chronic diseases. So if you look at it generally, income determines the healthcare that you accept in the US. How do you assess it? It’s availability also enables. So poverty, you’re looking at the US, which is high income country, right? And some of these lower and middle income countries I’ve talked about, you’ll see that they have something in common, stigma, poverty, can spite the availability of one. And this has really shaped the global health perspective when we talk about health disparities and inequities, right? Because it’s for what’s at present, high income countries and lower middle income countries.
And also the issue of how race, socioeconomic status, availability, and location of health services impacts population health outcomes. And to reduce health disparities and in headwinds, which need to understand what health resources have in different contexts. And how do we allocate health resources equitably? Also, we should ask ourselves this question, can the population mostly in need of such resources assess them easily, right? And is the service issued same time?
So these are the questions we need to start, and these are the kind of questions that I actually said in my global health research, to say, is this all about NMIC? What about the United States? How do we access services, whether in the US, whether in South Africa, or in Zambia, or in Nigeria? So, yeah, so this has really helped me and shaped my global perspective about health related research, especially, HIV.
You can really hear your passion and why you chose to really focus your research on this, and it’s so unique. And I really see that stigma really sits at the center of so many of these issues, which is disappointing that I really hope that really find a way to reduce and bridge that. So, how do you see the role of interdisciplinary and collaboration and addressing complex public health challenges, such as those related to HIV/AIDS as well as noncommunicable diseases?
Well, thank you very much for the question. Now we’re talking about interdisciplinary, multidisciplinary, which I think it’s very important. I will quickly talk about my background, because I have a very interesting background, and I think we also have some students or aspiring public health researchers out there to know that you can bring… it doesn’t matter where you’re coming from, you can be useful in public health research.
So I did philosophy in my honors, my undergrads, and I started developing interest in medical ethics. I think everyone believes philosophy is abstract. Yes, I agree, right? But it depends on how you see and how you apply it. And for my master’s, I did migration studies. And I started to look at the nexus between migration and health, and that was what sparked my interest. And in my peer leadership program, I intentionally looked at… that was in sociology, right? I intentionally looked at how resources, whether it’s financial resources, whether it’s race, gender, how these resources play an important role in decision making, in intimate relationships, which can also be linked to health.
And so look at all of these in general, and it’s really helps and you will see how interdisciplinary, how it plays important role in my own career, right? And I was still talking about how it could play more roles in global health. In March, 2005, so prior to 2005, the focus on some of these global health [inaudible 00:20:42] has been very medical in nature, right?
But in March 2005, World Health Organization established a commission on social determinants of health, right? It was established. And why was it established? Well, because they discovered that some of these issues, they are the social parts of them. And if we could address the social parts, talking about race, talking about gender, talking about stigma, anything, we would be able to address some of the health disparities that we see and also inequities. And that was why it was established.
And what is the role of interdisciplinary collaboration in this? Let’s take, for instance, environmental issues. Let’s talk about the type of [inaudible 00:21:32], one, environmental issues, and talking about your air pollution, right? Food or water contamination. Some of my colleagues doing research in water or in epidemiology will be useful here. We can come together and we can expert in environmental issues, and also behavioral aspect means is psychologists will be useful in looking at the excessive smoking, drug abuse amongst young people or everyone.
Also, biological determinants, where epidemiologists can also come in here, where we look at smallpox, measles, plagues, and issue of mental health too, cancer loss, psychology. So all of us, including clinicians, talking about pre and post prophylaxis, HIV treatment. And also, so it’s all about coming together to improve population results, which is our primary goal, though we all will bring our expertise together to be able to do that. So that’s right, interdisciplinary collaboration is very, very important.
You said that truly beautifully. It’s part of why I think our folks at College of Public Health is so nice. We have people from epidemiology, we have people focusing on policy, people focusing on environment. It’s so nice being able to come together with everyone’s expertise from different angles to look at a problem. So I definitely agree with what you’ve said. So I know from your bio, you’ve mentioned interest in bioethics and noncommunicable diseases. How do ethical considerations play a role in your research, and what are some emerging issues in non communicable disease prevention and management?
Oh, thank you very much for your question. And everything we do, it draws back to my philosophical background, right? Because a lot of it is about epistemology, ethics, and other things as well. And this is about morals, and ethics is key in global health research. I’ll give you an example. There are some ethical challenges in global public health now.
One of the [inaudible 00:23:51]. I don’t know if you know it. And the terms refers to exploitative research activities conducted by some researchers as well as short term relationships with research communities. Especially in low and middle income countries. And all we mean is, some people come into your community, gather the data and go elsewhere and start publishing the data the communities do not get a benefit to anything.
Yeah, when they don’t make sure it’s not… If it’s not sustainable, it doesn’t really help the community.
So, excellent. And that’s what we’re saying that such an approach is not only detrimental to communities involved, right? Well, it also arose that trust within the larger scientific community, and this is what I’ve been doing with some other colleagues, community engagement, we can’t leave out community engaged research perspective, is key to addressing these, is your helicopter research in global health.
And that’s been my interest. And also, it will also help us to magnify the void, to help magnify the voices of marginalized or underrepresented groups. And also, because we researchers on this team, we know it all. And I think community engage research, and our ability to be humble, cultural humility is important.
And also, and this community engage research will also help us to start flipping the narrative, to flip the narratives about what the expert is in the global health research, the community is the experts. Communities are experts of their knowledge. We’re hardly there to support, to learn and to engage with them, and to help magnify the voices and put it out there.
But oftentimes, we claim the knowledge and we take the glory. But I think it is unethical to do that. So in order to have a responsible research conduct, we should be able to involve community. Let them be the expert of their knowledge. Recently, I organized a panel session on community engaged research in global health. Some of the issues, and how to address them at the University of Oxford in the UK during the Oxford Global Health and Bioethics International Conference in June this year.
So this is the way we’re trying to do that. And in terms of emerging issues in NCDs, if you look at current data, these are the causes, the major causes of death globally now. When we look at the leading causes of death, 1 to 10, I think 8 of 10 will be non communicable disease, and an estimated 41 million people die annually from non communicable disease. And that is 74% global deaths. And this is an issue.
And I’ve shown, that some [inaudible 00:27:13] prevention and treatment interventions, right? But there’s still a gates of research on NCDs care and delivery approaches, cost effectiveness and larger implementation research, especially in low and middle income countries. My colleagues and I, College of Medicine in South Africa, recently published a scoping review protocol of this. And we’re currently working on a scoping review and also of research, your potential research on these in LMIC. So thank you. I was able to answer the question?
Oh, thank you so much. This is a question that could hopefully help any aspiring students who want to come college of public health, or just generally, but what advice do you have for aspiring public health researchers, especially those interested in addressing health disparities in approving population health and research resource and screen settings?
Oh, thank you. Thank you very much. Advice, I’ll start with the practice, right? They’re learning. My advice would be one, if you aspire to address disparities, rural people, you want to improve population health and resource [inaudible 00:28:39], you should learn both theories and practice from school, and learn the application of some of the concepts in public health, global, how you apply them in practice, which I think it’s very, very important.
Yeah. It’s difficult, but they are very helpful just to learn all of those. And also, it is okay to be empathetic and reflective because oftentimes, we ignore our privileges. Especially when we go to a country like South Africa. Going to South Africa, seeing some of these young people drinking alcohol in the morning, vibing to music in the tavern, and we know that there’s high rate of HIV infections amongst them, we can easily judge people doing drugs, but we need to understand where they’re coming from, what led them to that? So that’s where the empathy comes in.
And also we should recognize our own privileges in order for us to understand other people’s background. So that is very, very important. And also you must learn about the community. I lived here for some time to understand the community better. If I lived in that rural community for over three years that I spoke about. It was a difficult time, I had lived in the city all my life. All my life. I was born in the city. I had lived in the city all my life. It was difficult for me.
But then I appreciated what it means to wake up in the morning, get into my kitchen, take two loaves of bread, make some nice tea. Some people couldn’t afford that. Even sometimes on the field, I bought people food. So it’s all kids need that because cultural immunity, it’s so important. And coming back to our research, you want to be a researcher, you need to understand the community, and you need to understand that the community needs tailored interventions, just because something had worked in the United States doesn’t mean it’s going to work… Something that had worked in rural Iowa doesn’t mean it’s going to work in rural South Africa.
So part of it could work, but how do we adapt it and make it more culturally acceptable in other countries? And lastly, which I think the most important. And this is the driving factor for me too, is that, they must have a moral commitment to social justice. When you have a moral commitment to social justice, irrespective of the challenges that you face in your exploration of global health, or the way that would keep them gonna. And talk about social justice, we’re talking about how do we close the gap in health disparities, right? And then the health inequity, how do we allocate resources according to needs and not wants? And this will also go into an issue around policy. So the moral commitment to social justice is very important. And it’s a driving factor for everything that I’m doing in global.
I think like what you’ve said, the community needs to get that drive. Information has to be tailored to community. That’s so profound. I’ve heard so many stories throughout my undergrad about how so many people have such amazing intention. They really want to help a community and they go in with what they think the community needs. And then stories about how that backfire is… and that feels like such a simple thing to say, but community. The needs of the community, that really needs to… interventions need to be tailored towards that. Each community is so different and so unique. The community members need to be asked about what they feel that their needs are, especially not those from outside researchers. It’s about the community.
Your research covers a wide array of factors including class, race, gender, education, violence, substance abuse, employment status. So how do these factors intersect and influence individual health outcomes?
Yeah, well, thank you for the question. You notice that I’ve been talking about some of my research in different countries. Now for these, I’ll limit to South Africa. I just want to give you a scenario of a young man, right? Young high school that will accidentally or intentionally impregnated someone. In that context, he drops out of school because it needs to provide for the job, because definitely… and this is basically what already been living in poverty, and the education we know this is an edge, and when he drop out of school.
At least, I’m talking about black male now, in terms of race, of gender, talking about educational status and employment status. Someone without much education cannot attract high paying jobs. They do many jobs just to sustain them and the child. And we see a lot of these in rural South Africa, not only for the male, also for the females, they drop out of school. But it’s very common among the male, they drop out of school, and the female, because of the stigma attached to teenage pregnancy, they drop out of schools too, and that limits their potential.
And for them to come back, it’s always difficult. I have some of these guys who worked with me as research assistant, and in South Africa, I think. And some of them before, it takes only less than 1% of them to go back to school to change their life. And they continue to [inaudible 00:35:13] in poverty. And this affect also their health outcome. But this is the same young man and young girl who will do anything to make money.
And a blesser could come in to meet a young female. “Well, I can give you some money to take care of you, I’m not using condom and I’m having sex with you. I give 600 a month.” She would do it. And also someone who lives in poverty, definitely the of health outcomes. And some of these guys, even the availability of health services is very far from where they live to get money for transportation to access health services. And these are more quality health services is also difficult. So put everything together, it’s affects their health outcomes.
And also another example is that I will give is intimate partner’s bodies. I think that is very rife in South Africa. And South Africa has one of the highest femicide rates in the world. And if you look at that, a lot of research has shown that women, who experience violence, were eight times more likely to contract HIV when compared to women who are not.
So you see how some of these factors play an important role in terms of gender, or educational attainment, substance use too. Under the influence of alcohol, drug, sex without condom, definitely exposing yourself to some STIs. HIV is is going to come soon. All of these things, they have a role to play, people [inaudible 00:37:02].
Yeah, how they build upon each other and really increase someone’s risk, especially [inaudible 00:37:16]. So to round it out, what is one thing you thought you knew, but were later wrong about? And this could be truly about anything.
Well, probably, I’ll still go back to me living in Johannesburg, or rural Kwa-Zulu Natal. I thought I knew a lot about HIV when I was in UNS, because I worked with a lot of clinicians. And while in Jo’burg, I was working in different provinces too, I was doing research in different provinces. But I was staying in Johannesburg, but I traveled to different provinces. But I knew a lot about HIV, and South Africa’s socioeconomic status and how that plays, some of these factors that I mentioned, how the people [inaudible 00:38:08], I thought I had it figured out [inaudible 00:38:12] for over three years of my life. I could easily tell you that more than 50% of my colleagues, some of my colleagues that I work with in the past were actually living with HIV, and I didn’t even know.
And I thought I knew a lot about HIV where I was coming. And so I got this [inaudible 00:38:32], a lot of social factors, a lot of social determinants of some of these diseases, including non communicable diseases as well. And like I say, I mentioned poverty is at the center of it all. And even if you look at the gaps in income in the United States, people who are earning the most, [inaudible 00:38:54] 1%. And the bottom, the life expectancy in between them, it’s a lot, probably over 10 years. And that tells you a lot. And that also plays a lot of role in people’s health outcomes. And in life, everything that goes on, the access, everything around the island.
So I think if we can start shedding more light on poverty, because it plays a significant role in the primary prevention, secondary prevention, and tertiary prevention. And yeah, it plays an important role. If you start shedding more light on how it’s created health disparity too, disparity in income is associated with health disparity.
Equities, even if there are resources in case of United States, right? We have the resources readily available, but how are those resources allocated? Who will have access to them? Well, how many people have access to them? So how are people treated within this healthcare system too is your stigma. So it is a lot to some of them. So I thought I knew a lot about HIV, but when I got to the rural area, I was like, okay. It’s hard to relearn everything completely.
How different every community is, even HIV is not the same with every community [inaudible 00:40:31], that’s a community. The effects of poverty, the effect of how resources are allocated. That’s so important, necessary to look at. So I just want to say thank you so much Dr. Adeagbo, well, for spending time this a rainy morning, talking with me. I really appreciate it. And your experience and your passion, it really shows. So this was Adriana and this is From the Front Row.
That’s it for our episode this week. Big thank you to both Dr. Adeagbo and to Adriana for joining us on this episode today. This episode was hosted and written by Adriana and edited and produced by Lauren Lavin. You can learn more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud.
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