Kal Dana” (“the year-long sore”), as it is known locally, not only leaves a disfiguring scar on your face, but permanently changes your perception of your own self . As she grew older, multiple other lesions appeared on her arms and face (the exposed parts of the body). She described this as a period of grief for her, when her parents started isolating her from the rest of the siblings to prevent further spread.She belonged to a poor family; her father, the sole breadwinner of the family, is a cattle rearer. She acquired her first lesion at the age of 12; from thereon she was socially excluded and not allowed to go to the local No treatment was acquired, due to the afflicting poverty and lack of resources of the region. But the scar had a deeper impact on this woman, as she is still unmarried in a community where early marriages are common. She describes her fate as, “I will probably get married to a limp or mentally disabled in a year or so; at least that is what happened to all the other girls who had these marks.”Globally, this disfiguring disease affects 1 to 1.5 million people. Approximately 90% of these infections occur in Afghanistan, Pakistan, Syria, Saudi Arabia, Algeria, Islamic Republic of Iran, Brazil, and Peru With women and children being particularly affected by this marring disease, cutaneous leishmaniasis (CL) is now a major public health issue with considerable stigma associated with it Leishmania parasite L. major, L. tropica, and L. aethiopica in the “Old World”; and L. infantum, L. braziliensis, L. (V) peruviana, and L. (V) guyanensis in the “New World.” In Pakistan and Afghanistan, the most commonly reported species have been L. tropicaTransmitted by the bite of the 2–3 mm-long sandfly , the disPLoS Neglected Tropical Diseases, some of the so-called neglected tropical diseases not only cause “health and economic” effects but also result in “horrific social stigma” As rightly pointed out by Peter J. Hotez in his recent editorial in n  =  86] and “sharing meals and household goods” [n  =  26]). The study also indicated that “affected people are excluded from communal life” A study conducted in five of the 14 districts of Kabul, the capital of Afghanistan, showed that many erroneous beliefs exist about CL, e.g., that “the disease can be transmitted by person-to-person physical contact” .As seen in the scenario presented, unaffected people tend to isolate affected people during the course of active lesions. Such lesions are a source of apprehension and even disgust. This indeed leaves a very strong impact on the individual as the scar lasts for years , not only will the stigmatization of people with CL continue, but other problems, such as stigmatization and isolation of people with HIV or those who are addicted to drugs, will continue to prosper. As suggested by Reithinger and colleagues, a disease-specific health education strategy would have to be developed, thoroughly tested, and then implemented Posters and public health messages need to be everywhere in the country. Local general practitioners and other health care professionals should come forward and play an active role in educating the public. With media now available almost everywhere in the country and in every language, this media platform should be used more effectively to increase public awareness of diseases. School-based education should not be forgotten—it is equally if not more important to educate the youth to reduce the burden of stigma of CL and other diseases However, it should be remembered that extensive literature on attempts to reduce stigma in other disease states has shown that knowledge/education alone is not enough. A multifaceted approach is what is needed, including increasing contact between people affected by CL and the community. The preventive and even the management programs should be at the level of the community, as such community-based programs would help “eliminate the social stigma in the patients' families” along with “educating the community” about CL Finally, socioeconomic development has to coincide with all these measures. Many neglected tropical diseases, especially some of the infectious diseases, were eliminated in the West long before effective treatment regimens were in place, mainly owing to socioeconomic development With respect to stigma associated with CL and other diseases, it is very unfortunate that with effective diagnosis, treatment, and prevention strategies available, the disease still affects thousands across the country. The stigma further compounds the morbidity of the disease and leads to unfortunate psychological and social consequences like in the case of the woman from Chaman. We sincerely hope that this will improve in the very near future.Globally, 1 to 1.5 million people are affected by marring cutaneous leishmaniasis, especially women and children.In Pakistan, CL is endemic and the incidence is rising, with the condition being far worse in neighboring war-torn Afghanistan.The marring and disfigurement that lead to social stigmatization are a cause for concern. Educating the public is key to removing the disease's stigma.Disease-specific health education programs need to be coupled with other preventive and management programs in endemic countries.


The Lancet: Should global mean temperatures rise an additional 5–6°C, “more than a billion people could be dispersed in environmental mass migration. . . . An additional 2 billion would be water stressed while billions more would face hunger or starvation. The risk of armed conflict would rise. Public health systems around the world would be damaged, some to the point of collapse.”Consider the floods, plagues, famines, and other calamities we can expect from climate change, and an apocalyptic prophecy might come to mind, perhaps rightfully so. An expert panel convened to assess risks from climate change put it this way in the 16 May 2009 issue of Alarming scenarios like this have fueled efforts to lower heat-trapping greenhouse gas emissions and limit future impacts [see “Climate Change Abatement Strategies: Which Way Is the Wind Blowing?” p. A296 this issue]. But more recently, scientists have acknowledged that some degree of global warming is now inevitable. “Climate change models tell us that even if we blocked all emissions now, the amounts of greenhouse gases already in the atmosphere would raise global temperatures by an additional 2°C by 2100,” says Robert Corell, vice president of the John Heinz III Center for Science, Economics, and Environment, in Washington, DC. In light of this probability, Corell says, mitigation has begun sharing the global policy stage with a new challenge: how to adapt to climate change that is already under way.Adaptation refers to the measures humans can take to minimize damage from climate change—for instance, by protecting infrastructure and communities against flooding, erosion, and extreme weather, or by preparing for changes in precipitation that result in too little—or too much—rain to sustain traditional crops.Adapting to climate change’s anticipated health problems is a more recent concern, says Kristie Ebi, a Virginia-based independent consultant on health issues related to climate change. U.S. officials in particular have been slow to consider health adaptation, she says, both because of funding shortages in this area and because climate-related health problems in this country aren’t yet as acute as they are elsewhere in the world.Other regions have not been as fortunate. In Europe, for instance, an unprecedented heat wave in the summer of 2003 killed more than 52,000 people and contributed to heightened wildfire activity and crop failure. Sustained high temperatures across the northern portion of the continent surprised and confounded countries accustomed to milder summers.Health problems attributed to climate change are expected to increase worldwide in the coming decades, Ebi says, not just as a downstream consequence of flooding, drought, forest fires, and other area-specific outcomes of climate change, but also from increasing heat stress, the spread of vector-borne pathogens into new territory, and increased exposure to allergens and air pollutants such as ozone, which is formed by heat-driven reactions involving smog and sunlight.Climate change won’t unleash new health effects so much as it will intensify existing problems, says Jonathan Patz, an associate professor of environmental health at the University of Wisconsin–Madison. “[A warming climate] isn’t going to dramatically alter the types of illnesses we’re dealing with. We’re dealing with them today, and global warming will affect them all.”Because climate change will affect different regions in different ways, adaptation is chiefly a local concern. But adaptation poses difficult challenges, given the paucity of information on projected impacts at local levels. The global models that scientists use to predict air temperature, precipitation, and other climate variables can’t yet achieve spatial resolutions better than 150–350 km, according to Cynthia Rosenzweig, director of the Climate Impacts Group at the Goddard Institute for Space Studies and an advisor to New York City’s adaptation program. However, mountain ranges and other topographic features can influence the local atmosphere at much finer scales, leaving decision makers unsure what to expect in specific areas.Given data shortages, local health impacts are hard to predict, Ebi says. “When I speak at congressional hearings on Capitol Hill, committee members invariably ask me what sorts of health effects they can expect in their own districts,” she says. “And I tell them, ‘Without the detailed studies that we need, I just don’t have the data to tell you.’ We have some detailed projections of how ozone might change in New York and some limited projections in California, but that’s it. The same applies to allergens and diarrheal diseases from food- and waterborne pathogens, which are sensitive to changes in temperature and precipitation. How can cities prepare for adaptation when they can’t estimate the size of the impact?”EHP, Ebi and colleagues concluded that federal extramural funding for research directly studying the human health effects of climate change was less than $3 million annually, an amount they called “inadequate to address the real risks that climate change poses for U.S. populations.”In the June 2009 issue of Now, with communities and states asking the federal government for help with climate change adaptation planning, Ebi says, the federal government’s involvement in adaptation appears to be growing. The Centers for Disease Control and Prevention (CDC), for instance, through the National Center for Environmental Health, has been coordinating workshops for local, state, and city health departments with the aim of helping these entities understand potential health effects related to climate change, especially among the most vulnerable populations, and how to address them. The CDC also received $7.5 million in new funding to study climate change and public health for fiscal year 2009.The U.S. Environmental Protection Agency (EPA) Climate Change Science Program has investigated a number of adaptation strategies targeting human health. They include more surveillance and training to address the spread of vectorborne diseases such as malaria and dengue fever. They also include optimal land use designs—such as more use of undeveloped “green space” and shade trees—to help keep city-dwellers cool as well as better weather advisories to warn of acute temperature extremes. According to the EPA, government officials can plan for alternative water supplies and engineers can protect aquifers from saltwater intrusion. Coastal dikes can protect against rising sea levels and storm surges. And in some cases, populations and vulnerable infrastructure can be relocated away from threatened coastlines altogether.A key point, says Patz, is that mitigation and adaptation strategies can have mutual health benefits. As an example, he points to a shift toward replacing pavement with green space, which he asserts can cut energy use and help lower local temperatures in the summer. City dwellers live in “urban heat islands,” Patz explains, where black asphalt in parking lots and roads can render summer heat virtually intolerable. “Transportation accounts for one-third of the world’s oil consumption,” Patz says. “So, by building shaded bike and walking trails, we have a great opportunity to make ourselves less dependent on cars while also reducing the number of Americans who don’t get recommended levels of exercise.”Public Health Climate Change Adaptation Strategy, currently in draft form, officials wrote that they will “promote community resilience and reduce vulnerability to climate change” chiefly by “altering the built environment with more urban residential density, bike trails, and parks designed to lessen effects from urban heat islands.” Other measures described in the strategy include expanding community and school gardens, educating health care providers about climate change, conducting health assessments of proposed mitigation and adaptation responses, and strengthening local emergency response for climate impacts.In California’s As for whether any of these strategic elements are being funded, Linda Rudolph, deputy director in the California Department of Public Health, says, “We’re in the same boat as any other state struggling with budget woes, doing the best we can within existing programs. That said, when you look at the breadth and scope of the likely impact of climate change, you can’t escape from the broad nature of the threat. Climate change threatens our food, water, shelter, and the basic components on which we depend for survival.”California is one of dozens of states, counties, and cities in the United States, most of them coastal, that have been drafting their own adaptation strategies. Another is New York City, where Mayor Michael Bloomberg has taken a lead role in this area. Rosenzweig says roughly 40 agencies—both public and private—are involved in the New York City adaptation effort. An important activity, Rosenzweig says, has been to estimate the city’s vulnerability to sea-level rise, which is potentially the most damaging climate-related change facing New York.To project the local rise in sea level, Rosenzweig and her colleagues calculated two scenarios: one that does not account for rapid ice melting in polar regions and one that does. With the former analysis, she says, New York City faces a 2-foot sea-level rise by 2080. In the latter, that figure doubles to 4 feet over the same duration, enough to threaten some of the city’s most crucial infrastructure, including JFK and La Guardia airports, which were built on drained coastal wetlands. Asked how these scenario depictions could guide future policies, Rosenzweig says, “Engineering designs in New York were built to accommodate a hundred-year flood. But with sea-level rise, we’re going to have to rethink this. We’ve found that low-lying areas of the city face an ever-increasing risk of coastal flooding. ”Rosenzweig concedes that model projections aren’t perfect. Scientists have generally relied on global climate model simulations, she explains, which have a longer history of use and provide more robust predictions than those generated by regional models developed chiefly for studies of weather on shorter time frames. New York City’s scenarios were derived by linking global and regional models using evolving techniques to align the different models’ parameters.“Regional climate models have resolutions of fifteen to fifty kilometers, but these are used mainly in a research mode,” Rosenzweig says. “As regional climate modeling and computer power improves, the more detailed information can be incorporated into decision making. But the key lesson is: Don’t wait for the perfect model! There is ample information coming from the global climate models to begin to plan regional adaptation strategies now. Adaptation is a process, and it’s going to evolve through time.”Along those lines, adaptation across the board relies on “the tools of day-to-day governance,” says Lara Whitely Binder, an outreach specialist with the University of Washington’s Climate Impacts Group, which studies climate change in the Pacific Northwest. This is unlike mitigation, she explains, which is more generally concerned with new energy infrastructure and technology. “Adaptation is about using fee setting, conservation planning, bond issuances, infrastructure upgrades, and other things that are already in the governance toolbox,” she says. “But it’s also about using them in a way that’s appropriate for climate change.”Informing Decisions in a Changing Climate, National Research Council panelists proposed that federal leadership is essential in this area. One initiative highlighted by the National Research Council is the Regional Integrated Sciences and Assessments (RISA) program developed by the National Oceanic and Atmospheric Administration, through which university-based scientists help decision makers evaluate local impacts and response options. The University of Washington Climate Impacts Group is one of nine RISA programs now in existence.What local policy makers addressing adaptation need, the National Research Council recently concluded, is information to make sound decisions. In a report released 12 March 2009, Corell likens the RISA programs to the cooperative extension system. “We put cooperative extensions between the scientist and the farmer so that one can learn from the other,” he says. “Cooperative extensions aren’t run by any one agency, and similarly many agencies can provide decision support for adaptation depending on the expertise that’s needed.”On the global front, Bo Lim, a technical advisor on climate change adaptation with the United Nations Development Programme (UNDP), says that program’s adaptation budget jumped from $15 million in 2006 to $200 million in 2009. Lim says many developing countries are particularly hard-pressed to adapt because of their poverty and geographic vulnerability to the effects of climate change . These countries will no longer negotiate on mitigation without more financing for adaptation from wealthier countries, she says.Most of the UNDP’s adaptation resources are going to Africa, the small island nations, and several countries in Latin America. But Lim points out that the allocations aren’t equitably distributed chiefly because funding decisions aren’t based on indices of vulnerability or human development. Because countries have been unable to agree on such frameworks, the money tends to go to countries that know how to work the system, she admits, “and the fastest ones get the money first.” What’s more, of the $200 million allocated annually to adaptation, only $10 million goes exclusively to health programs to combat threats such as heat stress and vectorborne disease transmission, she adds. The rest goes for technical assistance in food security and agricultural production.To access adaptation funding, countries have to show that the primary driver for the problem is climate change and not underlying societal phenomena such as failing health systems. “We’re really looking for technical evidence of climate impacts,” Lim explains.The crucial need, Lim adds, is that adaptation occur within a framework for sustainable development. “For us, adaptation has to be aligned with UNDP’s corporate mission, which is to alleviate poverty among the poorest one billion people on the planet,” she says. “So, from our view, we’re looking at how we can create, support, and build national institutions that can respond to climate change. You need decentralization and clear budgeting, which are really bread-and-butter practices for good governance.”Adaptation to environmental stressors is not a new concept, but it’s taken on a new shade of meaning as climate change awareness has grown. “[We’re going to have] climate impacts for many decades to come,” says Lim. “This means that adaptation today is no longer tomorrow’s choice, but today’s imperative.”


Student views of new curricula can shape training outcomes. This qualitative study elicited student opinions of CAM instruction to examine and distill best strategies.49 second, third and fourth year students participated in focus groups using a predefined question route. Interviews were audio taped and transcribed.Students successfully differentiated CAM curricula from other academic content and were supportive of a longitudinal integrated approach. They had positive disposition toward CAM use for themselves but this did not necessarily translate into patient recommendations. They agreed that goals of the CAM curriculum should center on awareness of patient use and evidence and information relevant to clinical practice. They advocated a case-based, hands-on, experiential strategy vs lectures. Students proposed greater institutional commitment to strengthen curricular effectiveness. The majority did not intend to practice CAM modalities but valued skills to assess them. Patient-centeredness was recognized. As training progressed, students exhibited a growing tendency to evaluate CAM efficacy, and therefore value, exclusively according to evidence.In-depth student input allowed examination of the effectiveness of a CAM curriculum, permitting improvement and assessment of program effectiveness. The increasing popularity and use of complementary and alternative medicine (CAM) therapies and integrative medicine7910147Information is emerging about student health professionals’ attitudes about CAM,To assess CAM curriculum program effectiveness, we conducted a focus group study of second, third and fourth year medical students in a medical school in which CAM teaching was introduced and integrated into existing courses within all four years of the curriculum. We had previously demonstrated as a baseline needs assessment an overall positive attitude toward CAM instruction in three consecutive cohorts of students using a validated survey instrument, the CAM Health Beliefs Questionnaire or CHBQ.11Focus groups have been defined as a particular form of group interview intended to take advantage of group dynamics by stimulating conversation among participants.31Setting - The study was conducted in one California medical school with a class size of 92 students annually. Class demographics have been stable over the previous 4 years, with 50% female, 45 to 50% white, 30 to 40% Asian and 10 to 15% other ethnicities. The curriculum in years 1 and 2 comprised basic science teaching in traditional topics and a longitudinal two-year organ-based Doctoring course consisting of standardized patient (SP) cases in year 1 followed by patient encounters in community preceptors’ practices in the second year, culminating in a clinical skills examination at the end of year 2. From 2000 to 2003, additions were progressively made in CAM teaching, to include, by 2004, the following components of required CAM teaching  that included patient health beliefs and diversity teaching within their materials.In addition to required experiences, students had the option of participating in a 15 hour elective in year 1 and a four-week community practice-based elective with CAM practitioners in year 4. Ten to thirty percent of students took part in these experiences in any given year.Subjects and recruitment - 47 students participated in 8 focus groups that targeted 2nd (MS2), 3rd (MS3), and 4th (MS4) years of training; 2 third year female students were interviewed together as a “mini-group” for a total of 49 students. Participant breakdown by year and gender is summarized in Table All focus groups were audio-taped with participants’ permission. Audio-tapes were later transcribed in their entirety by a research assistant. In addition, the research assistant took field notes during the groups, including observations of group process, and recorded keywords, sentence fragments, and summaries of basic ideas/concepts. The research team reviewed all these sources in formulating conclusions. The researchers consisted of two family physicians, both with expertise in cultural competence and CAM curriculum development,3839Focus group structure - The researcher (JS) with extensive previous focus group experience examining cultural issues relevant to medical education developed a preliminary version of the focus group question schedule. A second researcher (DL) with expertise in CAM and curriculum development, a third researcher, a CAM practitioner and educator (WN) with curricular expertise, and the research assistant reviewed and modified this question route  reviewed each group transcript separately and noted key words, phrases, and major themes, both in response to the specific questions asked and as they spontaneously emerged from student comments.3042Data triangulation was achieved through multiple data sources. Investigator triangulation occurred because of the incorporation of different disciplinary perspectives into the data analysis. Member checking was conducted at the end of each focus group by checking our perceptions of the main points of the session with participants.Overall, we concluded that we elicited a broad range of student opinions about CAM. After each group, the lead facilitator (JS) and the research assistant (SP) noted the presence of comments representing skepticism, enthusiastic endorsement, and neutrality (open-mindedness). In addition, post-hoc review of the transcripts confirmed that opinions of students regarding the CAM curriculum spanned the spectrum from highly positive to skeptical in most groups. The views tended to be similar within preclinical and clinical student groups. We were able to achieve theoretical saturation  of the data in both preclinical and clinical years. Whenever student perceptions diverged consistently by year, these findings are reported separately.CAM content in the curriculum - Both preclinical and clinical students reported curricular exposure to information about acupuncture, diet and exercise, herbal remedies, and spirituality (meditation and prayer). Art and music therapy and cupping were consistently mentioned in the pediatric clerkship, and moxibustion on the OB-Gyn clerkship. Students reported rare or no exposure to chiropractic, manipulation, energy therapies, massage, aryuveda, and homeopathic remedies. Predictably, clinical students mentioned exposure to a greater number of modalities.Methods of presentation of CAM material - Almost all second and third year students mentioned a particular evidence-based lecture on the cardiovascular benefits of acupuncture and that acupuncture was integrated into physiology lectures. They were also aware of a CAM first year elective and of CAM being integrated into a required first year standardized patient interview. Students repeatedly mentioned integration of CAM topics on the family medicine third-year clerkship. Some students also mentioned a CAM website, a CAM interest group, and a CAM weekend conference. Efforts to include CAM on other required clerkships such as psychiatry, OB-Gyn, and medicine and other CAM-related lectures were infrequently mentioned.Other sources for learning about CAM - All students frequently reported learning about CAM through personal experience from family  and also self-initiated personal experience and friends. Other less frequently mentioned sources of information included the media and CAM-related websites. Clinical students sometimes mentioned learning about CAM from patients. The large majority of students from all years had some or a fair amount of exposure/experience with CAM. “My parents are Korean so they do a lot of alternative medicine. They do all the acupuncture; they do all the herbal medicines.” (MS3) “I get acupuncture every once in awhile and that cupping thing. And I drink like this herbal tea…but it's really nasty-tasting.” (MS2)Personal use of CAM - Both second year and third or fourth year students tended to mention having tried such CAM modalities as herbals/teas, massage, chiropractic, exercise, and various nutritional interventions. Occasionally students were personally familiar with cupping, homeopathic or Chinese medicine, acupuncture, yoga, and meditation. Students never mentioned going to healers, homeopathy, or energy healing. “My mom is Indian and has a million concoctions and she throws them in milk or something gross and I have to drink it. So I do that all the time.” (MS3) “I used to use prayer to stay healthy. Sometimes I do massage, I do chiropractic. I've also gone to the flax and fish oil guy.” (MS2)Belief in CAM efficacy - Among second year students, the most widely endorsed response was that CAM efficacy is highly variable, depending on the situation, the individual, and the type of modality being considered. Acupuncture was generally perceived as selectively effective for some conditions. There was more ambivalence about herbals. A minority across all years felt CAM was not at all effective. The majority of students were open to being persuaded of efficacy, and many felt positive about certain practices (such as acupuncture), but not others. Those who were open often recounted strongly positive personal anecdotes. A few, however, had become more skeptical about CAM because they believed that CAM was ‘not research-based’. “We're all about statistics and p-values, and all that other stuff. In order to use it in a western society, any type of eastern whatever… any type of CAM, I think you have to standardize it to the system that we're used to. Otherwise it's not really going to be valid” (MS2).Clinical students expressed a wide range of opinion in terms of perceived efficacy of CAM. Some students adopted the position that if people believed in it, it generally does some good. Some argued that what we consider CAM is equal to western medicine but has not been validated by western norms. However, on the negative side, students expressed the concern that CAM is not necessarily benign, but we know very little about it. These students worried that people use CAM uncritically and that much more evidence is needed. “I don't know whether if it's actually the treatment that helps or just the placebo effect. But I think it's helpful.” (MS2) “I think what happens is that it works so well for some people, it becomes evidence to other people that it works. Where really it's not evidence, it's a story.” (MS2)What constitutes evidence of efficacy - Discussing the issue of efficacy led us to ask about what kind of “evidence” was convincing to students. In the second year, there were some hard-liners: “If it's EBM-proven, then it transforms into real medicine.” Others put stock in “3,000 years of history,” for example, in the case of Chinese medicine. Testimonials of individual patients or friends and family seemed very compelling to preclinical students. They also expressed the view that patients “don't need” evidence if CAM is part of their culture. Some students were also willing to accept the “placebo effect” if the product had a positive outcome for the patient: “..…if it is something that's already in place in a patient's environment, you don't really need the evidence.” (MS2) “If (sic) this is the stuff they always do, and they're positive about it, I think that that makes it work better for them.” (MS3) “I think just for the placebo effect, it's very effective.” (MS3) “So you hear stories like that and it's really powerful, more so than any trial or study could be.” (MS3)Among third and fourth year students, many, especially 4th year students, wanted “proof”, defined as clinical trials. This need for evidence was much stronger than among the second years. A few accepted the “proof” of historicity; another handful was influenced by personal anecdote. Some students suggested that, as an academic community, we need to be more open to creative ways of assessing efficacy other than the randomized clinical trial. On the whole, while open to the potential efficacy of CAM, these students were frustrated that there is not a lot of research being conducted and were focused on the potential risk of harm to patients in the absence of evidence. “We're not an alternative, a naturopathic school. We can't just talk… the way it's presented needs to be in a scientific manner … the way it's presented is too touchy-feely for me. It's too, ‘This is wonderful.”… where is the evidence?” (MS3) “…if I want to believe in something there has to be good evidence-based, statistical significance to what people are using…” (MS3)Several students in both preclinical and clinical groups, although more so in the second year groups, discussed that evidence-based medicine (EBM) as a gold standard for efficacy might have limitations. Some regarded EBM as Truth with a capital t, but others recognized it as a culture-bound phenomenon. Third and fourth years were more intent on “wanting to know the science” behind CAM if it is presented in the curriculum . “…if you can incorporate CAM… and have those numbers to back it up, have some kind of evidence, because it's one thing to just say, ‘Well, I've heard that there's something called this, people take it when they're experiencing this’ but if you can back that up with numbers, it speaks a lot more…” (MS2)Goals of CAM curriculum - Most students felt that the primary goal of the curriculum was awareness, to make students aware of CAM's existence: “It's out there and your patient might use it.” Both preclinical and clinical students frequently mentioned that the purpose of the curriculum was simply to get them to ask their patients about CAM: “…you need to be able to recognize that it exists and to be able to ask about it.” (MS3)A smaller number of students mentioned goals of relating to patients using CAM practices with sensitivity and respect, transmission of (very limited) knowledge about CAM, influencing attitudes in a positive direction, and giving students tools to learn more. Particularly in the clinical years, students emphasized that the goal was not to learn to practice CAM or to know about all modalities. “The goal is to increase awareness of the treatments patients might be using. Awareness includes acceptance. Be wary of potential harms of CAM and also aware of the benefits.” (MS3)A handful of students in both preclinical and clinical years had a skeptical view of the curriculum goals, labeling it as “just going through the motions” with “no real commitment”. These students wanted a more rigorous, in-depth curriculum. On the other hand, several students expressed the view that allopathic schools should not be in the business of educating doctors to “practice” CAM and that most allopathic physicians don't want to be “CAM practitioners.”Attitudes toward CAM - Some students perceived one of the goals of the CAM curriculum to be improving students’ attitudes toward CAM. However, the majority believed CAM was presented in an “objective,” “scientific” way, not leaning toward either excessive endorsement or negativity, and they liked this approach. Fourth years were more likely than students in other years to say that participating in the curriculum made them feel more comfortable with CAM and about recommending it to their patients.Least useful aspects of CAM curriculum - Opinions were divided among second year students, with some stating lectures were not memorable, while others thought lectures presented useful, “scientific” information. A standardized patient interview integrating CAM was judged by some students as too challenging and insufficiently educational, while others thought it served its purpose of preparing students for patients who use CAM. Exercises to interview and then discuss actual patients using CAM were also evaluated as not useful because of the difficulty in finding such patients. Preclinical students also requested more hands-on exposure: “I think you always learn a little bit more when you do something that's more interactive, more hands on. I would have liked to have more of an experience with various types of alternative medicine.” (MS2)Clinical students complained that the curriculum provided inadequate understanding of what herbal remedies are for and how each one is used; “diet and exercise” prescriptions were encouraged without any meaningful understanding of nutrition or how to effectively counsel about weight loss; reflective discussion groups often seemed redundant; material was superficial and not well connected to clinical practice; written assignments seemed like busywork; and the curriculum overall was repetitive. A few clinical students noted that there was a prevalent feeling among most (other) students that CAM was just a “nuisance.” Overall, students preferred cases and demonstrations to lectures. “I feel like there's a discontinuity between teaching us what it is versus us actually being able to help our patients achieve what they want with it.” (MS3) “They let me go in and watch when they were doing it and the guy that was doing it explained it to me what he was doing and why and that was really helpful.” (MS2) “I think I learned what but I didn't learn how to transition that into practicing it or utilizing it in a practice setting.” (MS3)Most useful aspects of CAM curriculum - Students mentioned experiential aspects and direct exposure, as well as certain reading materials and lectures. A few students noted that the mere presence of CAM in the curriculum was useful because it sent an important message about its relevance in medical education. Fourth year students were more likely than any other year of students to do their own PubMed or other database searches.Suggestions for improving CAM curriculum - The most commonly mentioned suggestion among second year students was the need for a systematic overview of CAM information. Specifically, they wanted a single lecture providing a comprehensive overview of common (top 10) CAM practices, including definitions, examples, illustrative pictures, an identification of the most common uses of these practices, RCT-evidence of efficacy, and information about dangerous drug interactions and general harm: “..it would be more beneficial to me if I know what were the top ten supplements, the top ten maneuvers, and really more of the efficacy.” (MS3) However, a few students dissented, pointing out that “top 10” might vary from community to community or simply change, and argued that the curriculum shouldn't focus so much on content as on skills .By contrast, students in the clinical years stressed getting more practical training, including hands-on training, linking content information to clinical practice, and expanding field trips and community experiences that included observation of and interaction with practitioners and patients. They also suggested more training in how to integrate CAM with western medicine and specifically how to advise patients. Some students would have preferred more “useful” CAM, such as in-depth nutritional education as opposed to “far-out” CAM like aryuvedic because physicians make recommendations about these with most patients without being able to say more than “watch your diet,” or “get more exercise.” Many students also advocated for better content and better quality, not just “random smattering of very cursory lectures,” and a more useful and more efficient curriculum. Often, this seemed to be more teaching from scientific perspective, citing studies and evidence.Other suggestions included a CAM Day to expose students in an experiential way, CAM “tag-alongs”, list of community CAM resources, panels of patients and practitioners, opportunities to do research, and incorporating CAM into existing EBM assignments. Most of these ideas came from second year students.Structure of CAM curriculum - Required vs. elective: Students across all four years were reluctant to endorse more required CAM curriculum; most also did not see the need for additional electives, although a few did; a few thought it would be nice to have more optional CAM experiences. Among second year students, there was some sentiment that CAM should not be required at all because of resistance among their peers to attending lectures for any material not included on the US Medical Licensing Examination: “…we all focus on passing the boards. And anything that's not the exam… we don't really care about. It's so sad.” (MS2)Placement in curriculum - Second year students sometimes suggested that CAM be required in 3rd year so long as it didn't supplant anything “more important”. Clinical students tended to say their years were already too full for more CAM, but agreed that the 3rd/4th years were the best place for CAM because of the greater potential for clinical applications. Both preclinical and clinical students agreed CAM should be present in 1st year, but in a very limited way, perhaps as one overview lecture; in the 2nd year, it could be linked to specific diseases and conditions. In the clinical years, the large majority of CAM curriculum occurred during the family medicine clerkship, and students agreed this was an ideal placement for the material.Curricular integration - Students in both groups expressed the opinion that integration of CAM material in existing courses like Pharmacology, Topics in Medicine, Pathophysiology, and Biochemistry was desirable. Students wanted continuity and consistency: if they receive EBM validation of palmetto's efficacy in a family medicine CAM presentation, they would like the urologist on their urology rotation to be familiar with its use as well. Students differed about the extent to which such integration already existed. Students in the 3rd and 4th years emphasized that there wouldn't be so much resistance if CAM were presented as part of traditional courses, whether basic science curriculum or clinical clerkships.CAM instructors - Second year students were divided between thinking physicians with CAM expertise would make the best teachers versus actual CAM practitioners. Clinical students tended to favor physicians who knew about CAM. They were skeptical of both CAM practitioners and patient testimonials.Examinations and written assignments in CAM curriculum - The majority of students agreed that CAM was hard to test. Many believed that CAM should not be tested at all or that it should not be tested unless it could be presented factually. Most clinical students expressed a favorable opinion about CAM testing in an OSCE format. Written assignments about CAM were regarded with even less favor than testing.Intentions to use CAM in students’ own practice - Most second year students were open to the idea of making CAM-related referrals, but most did not intend to practice CAM themselves. Several students stated that they wouldn't recommend CAM as first line treatment, but they wouldn't object to their patients using a CAM modality so long as it wasn't harmful. A minority of students took the position that they would not use CAM in any way unless they learned more about it, especially from an evidence-based perspective. A handful of students intended to incorporate CAM into their practices: “I may not personally do acupuncture on my patients but if somebody wants to talk about it, I'll talk about it, and I will probably recommend vitamins and supplements. It's pretty much guaranteed that I'm going to involve nutrition, exercise, and spirituality.” (MS2) “…I won't tell them not to do it. As long as there's no harm to them from the herbal (sic) medication.” (MS3).Clinical students expressed more reservations. On the whole, they were willing to learn more about CAM, but they wanted to see EBM evidence about benefit and harm, otherwise they would not recommend it. They frequently mentioned wanting “proof.” Others were concerned that CAM could be exploitive of patients in terms of unnecessary expenditures and even outright quackery. Similar to second year students, even students who were open to CAM stressed it should be seen as supplementary, not alternative: western medicine should be tried first and only if it didn't work should patients then turn to CAM.reactive position regarding the role of CAM in their future practices: if patients want to use it and if there's no harm, they wouldn't recommend against it. A handful of students anticipated a more proactive role in relation to CAM, describing multidisciplinary practices that would incorporate an acupuncturist, naturopath, nutritionist, and massage. Overall the most common attitude was one of limited openness to some level of incorporation. They favored the idea of CAM presence in their practices in principle, but didn't feel they knew enough to take more than a passive stance regarding usage: “As long as I know it's safe, it won't hurt them; it's a natural product, that's fine. If it works or not, we'll leave it up to them.” (MS3)The majority of clinical students assumed a Overall, the majority of medical students valued the CAM curriculum and expressed appreciation that it was represented in the larger teaching program. This finding has been verified by findings of the 2007 AAMC Graduation Questionnaire, an exit survey completed by the entire graduating class and compared with other US and Canadian medical schools.Based on research assistant notes and facilitator observations, we believe students were comfortable and sincere in the sessions. They expressed themselves with vigor and passion and seemed to feel their opinions were taken seriously. Almost every group presented a significant diversity of opinions, both positive and negative, about the CAM curriculum.Thus, as has been shown in other focus group-based research about CAM in particularWe noted the tendency of some students to demean the content and process of the CAM curriculum. Students criticized the curriculum as repetitive and poorly organized. Phrases like “more systematic,” “more structured,” and “less anecdotal” seemed to be code words for “more scientific.” Along similar lines, students often recommended ideas, such as CAM web-site and resource links, or information about risks and adverse effects that were already provided in the curriculum, suggesting that they did not always pay careful attention to what they were being taught. Disturbingly, a small number of students admitted “making up” information to satisfy CAM assignments and justified this behavior by the triviality of the CAM curriculum as a whole. Many students also wondered whether CAM deserves serious consideration in the curriculum because there was insufficient “gold standard”  data to support its usage. Further, students became progressively narrower in what constituted “proof” of efficacy as they advanced through the educational system. Some questioned whether CAM belonged at all in the curriculum of an allopathic medical school.These behaviors suggest that the perceived low institutional status of CAM affects the perceptions of certain students, permitting them to regard CAM as unimportant compared to the rest of the curriculum. Ironically, given this critical perception of the CAM curriculum we identified in our focus groups, students overall had a high level of exposure to some form of CAM. For the majority, their familiarity came from parents or grandparents who were 1st or 2nd generation immigrants and regularly recommended CAM practices to them. This familial link produced an intriguing personal/professional conflict. Students seemed willing to use CAM on themselves without strict evidence but were reluctant to recommend it to patients. This suggests students may apply one set of values in their personal lives but another in their professional lives. It raises the question of whether students are applying a higher standard of care to their patients or whether they have concluded that in order to become physicians they must abandon other potential standards of evidence as soft and unscientific. Overall, the principle of nonmaleficence appeared to dominate students’ responses about the role of CAM in their own future practice.Our research suggests the following theoretical model for understanding the complex relationship between CAM education and the overall process of medical education. Most students reported bringing an open mind to learning about CAM modalities and interventions. On the whole, they were happy that it is part of the curriculum. If anything, they wished to have more in-depth exposure and training. But – and this is key – increasingly they wanted this exposure to be presented in scientific terms as they have been taught to understand them, i.e., evidence-based medicine. While students in all years supported CAM as part of an integrated curriculum in the pre-clinical years, this was because integration would make CAM appear more “scientific.” In the clinical years, students struggled to find a connection between clinical scientific practice and CAM and hoped integration would fill the gap. Information about CAM that did not conform to the bioscientific model was regarded as anecdotal and soft. A subset of students appeared to retain their enthusiasm for CAM, and continuing to apply broader standards of evaluation  to criteria of efficacy. This model is represented in Figure Strengths of our study include its in-depth approach to a broad spectrum of students by level and student opinion, the diverse perspectives of the researchers, and their expertise in this methodology. Our approach also permitted a cross-sectional and comprehensive look across 4 years of curriculum, an approach that can be generalized to assessment of other similarly presented curricula. The main limitation of the study is that it was conducted at one institution with its own unique integrated CAM curriculum, institutional culture and student demographics, and the particular findings may not generalize to other settings. Nonetheless, general principles emerged that inform curricular development and assessment of CAM instruction that can guide the process of curricular integration of not only CAM but other similar content.In summary, our focus group findings from 3 different classes of students at one school confirmed the positive attitudes toward CAM use previously demonstrated with the survey approach


The artist knew his own difficult nature. “[I have] one terrible, irreconcilable enemy,” he once admitted to Pierre-Auguste Renoir, “myself, of course.” From those who associated with him, Degas exacted an emotional toll. “There will be a dish cooked without butter for me. No flowers on the table, very little light …. You’ll shut up the cat, I know, and no one will bring a dog. And if there are women there, ask them not to put smells on themselves …. Scent, when there are things that smell so good! Such as toast, for example. And we shall sit down to table at exactly half-past seven.”“All his friends had to leave him,” Renoir reported, “I was one of the last to go, but even I couldn’t stay till the end.” Considered a misogynist by some, Degas counted among his friends Mary Cassatt, Berthe Morisot, and leading opera divas and ballerinas of his day. Accused of being a recluse, he denied it. “I am not a misanthrope, far from it, but it is sad to live surrounded by scoundrels.” Despite his uncompromising persona, he was respected by his peers, who were afraid of him, and was popular with art critics and buyers. “I was, or appeared to be, hard with everyone, owing to a sort of tendency towards roughness that originated in my doubts and my bad temper.”Born in Paris during the same decade as Édouard Manet, Paul Cézanne, and Claude Monet, Degas had many opportunities. His early years were privileged, though tinged by the melancholy that followed him all his life. “I was sulky with the whole world and with myself.” Under pressure he agreed to study law but soon abandoned the effort and pursued art with a fervor that convinced his father to support him, first at the Atelier Lamothe and École des Beaux-Arts and then independently in Italy, “the most extraordinary period of my life.”en plein air. “The gendarmes should shoot down all those easels cluttering up the countryside.”Degas’ early works were historical paintings in the classical tradition. Early in his training, he absorbed the methods of Auguste-Dominique Ingres, Eugène Delacroix, and Gustave Courbet and aspired to paint like Michelangelo and Raphael. But by the 1860s, he abandoned history for scenes of everyday life. While copying a Velásquez at the Louvre, he met Manet, who became his friend and brought him into the circle of impressionist painters. Though Degas exhibited with them often, he never identified himself with the movement. “What I do is the result of reflection and study of the great masters. Of inspiration, spontaneity, temperament I know nothing.” He was not interested in the transient effects of light on landscape. He preferred painting people and abhorred painting “Draw lines, young man, a great many lines,” Ingress once advised Degas, who took the comment to heart. “I always tried to urge my colleagues along the path of draftsmanship, which I consider a more fruitful field than that of color.” Always seeking perfection, he reworked every picture, even after it was sold, studying and repeating details until he had mastered and memorized them. Owners were known to chain his works to the wall. He experimented with many media, among them pastels, which he softened over steam into a paste and used over gouache and monotype prints. He disliked the shine of oil paints, so he removed the oil and applied with turpentine, often on paper rather than canvas.Absinthe, on this month’s cover, appears to be a genre scene. But it is a portrait of Degas’ friend Marcellin Desboutin, writer, artist, printmaker, and a regular at the Café de la Nouvelle-Athènes, a meeting place for the impressionists and others in the avant garde. “I did not go to either Oxford or Cambridge,” Irish art critic George Moore said about his education, “but I went to the Nouvelle-Athènes.” Against all convention, the focal point of the portrait is a woman seated at Desboutin’s side. She is Ellen Andrée, a model who posed often for Degas and Renoir and aspired to be a serious actress, “like Sarah Bernhardt … in Phèdre.”This painting of an unloving couple was called “the perfection of ugliness” by one critic and caused a stir when exhibited in London. “It is not a painting at all,” other critics said, “It is a novelette―a treatise against drink.” Desboutin, his elbow a wall between him and his companion, is detached, lost in thought. He is not even entirely in the picture―pipe, arm, and one leg cropped, eyes glaring off somewhere. She is precariously in center stage, her social status exposed. Pushed off one table, not quite at the next one, she sits in-between, as awkwardly positioned as her carafe.The painting’s architecture drives the story, framing it in fresh and innovative ways. The marble tables, zigzagging across the picture, create perspective by drawing the eyes to the figures barricaded behind them, whose reflections in the mirror suggest the presence of other patrons without actually showing any. Newspapers form a bridge between the tables. The artist’s signature seems a seal of approval.This nearly monochromatic snapshot lays bare human isolation in the midst of gaiety. Desputin’s drooping companion, propped up behind a glass of absinthe, represents women, many of them in Degas’ very neighborhood, caught in ill-fitting bohemianism, absinthe not withstanding, for as Oscar Wilde put it, “After the first glass, you see things as you wish they were. After the second, you see things as they are not. Finally, you see things as they really are, and that is the most horrible thing in the world.”en pointe, or washed and ironed clothes in substandard conditions for meager pay. They got sick and died young. But through their drab lives, fluffy costumes, or trappings of gaiety in busy venues, the artist’s penetrating eye captured for all to see not emotional isolation alone, which had marred his own life, but its many causes: poverty, social stigma, and underlying illnesses, not the least of them tuberculosis, rampant in his day.Degas’ women were often at a disadvantage, whether they sought solace in cafés, danced The costumes have changed and absinthe is no longer the drug of choice, but emotional isolation lives on as do its many causes. Therapies have curtailed tuberculosis in some parts of the world, despite the emergence of multidrug resistance, but pulmonary infections caused by nontuberculous mycobacteria are on the rise, prompting investigations and gathering of data to explore and identify what Ellen Andrée was not able to find in the bottom of the absinthe glass.


This is an international collaboration with journals from developed and developing countries. Some journals dedicate an entire issue to this subject, others publish a few papers, and still others only publish an editorial. Almost 1000 papers will be published in this Global Theme Issue.In this issue, the Journal of Medical Internet Research (JMIR) publishes five papers -5 which Amazingly, JMIR is the only Medline-indexed health informatics journal participating in this initiative.This is surprising, because the potential of ehealth to improve life expectancy, literacy, education, and standard of living  is significant, as illustrated by some papers in this issue.Access to information is often most difficult for those who need it most. The “inverse information law” was formulated in analogy to Tudor Hart’s “inverse care law”, which describes that access to health care is often most difficult for those populations who need it most.At the same time it is exactly poverty , lack of literacy and deficits in education that often prevents or limits the use and access to information and information technology in underdeveloped settings. Seven years ago, I proposed the now widely used term “inverse information law”  to charaThis paradox is also echoed in some of the papers we publish in this issue, but the papers published here also offer inspiration for how information technology may be used effectively in resource-poor settings.Hamish Fraser and colleagues have been deeply involved in deploying information systems in developing countries. In their paper , which iAnother clear example of the role of ehealth in addressing human development issues are telehealth programs, bridging gaps in health care between developed and underdeveloped regions. Patterson and colleagues present a telehealth program between one of the most developed countries in the world - Australia - and war-torn Middle Eastern countries such as Iraq and Afghanistan , and Valwithin a less developed country . Again, we find evidence for the inverse information law, as only 0.2% of requests came from remote areas, where access to health services is suboptimal. This is similar to previous observations from a similar project, where we observed that “we did not encounter any patient where physical disabilities, remoteness, or living in a medically underserved area appeared to be the reason for seeking information on the Internet and teleadvice.” [The teleconsultation project by Valenzuela and colleagues  is diffeadvice.” .Poverty and digital divide remain an issue in developed countries as well. The work of Kontos and colleagues  providesFinally, the paper by Hassan Masum and Peter Singer on visual dashboards  reminds Authors with relevant research who missed our call for papers are encouraged to submit their work to any regular JMIR issue – we remain very interested in this topic, particularly on how to improve the lives of those who have the least. After all, the open access model of this journal is also an example of how information technology can make the world a more equitable and better place, facilitating knowledge transfer to those who would otherwise not be able to access scientific and technical information.Gunther Eysenbach,Editor, JMIR                            http://www.jmir.org/2007/4/e35/(Note added on 13 Dec 2007) The following paper was added to the Poverty Theme Issue after publication of this editorial: McNeill LH, Puleo E, Bennett GG, Emmons KM. Exploring Social Contextual Correlates of Computer Ownership and Frequency of Use Among Urban, Low-Income, Public Housing Adult Residents. J Med Internet Res 2007;9(4):e35, URL:


Under the wide and starry sky,Dig the grave and let me lie. R. L. Stevenson, “Requiem”Mycobacterium tuberculosis now infects 1.9 billion people, nearly a third of the world’s population (nearly 2 million deaths each year). But human suffering is still difficult to quantify. For more than a century, readers have pondered the strange beginning to one of the most haunting poems in the English language, “Requiem.” Who has not wondered how a poet can seem to welcome his own death? Scotsman Robert Louis Stevenson died of a disease so poorly understood in his day that over a few decades its preferred name changed three times, from "phthisis" to "consumption" to "tuberculosis.” A century later, we have reliable scientific facts on this "old" poet-killing disease—we know for one that Two million deaths each year. How can we grasp such statistics of misery? Reduced to numbers stacked up in columns and cut up in pie charts, tuberculosis patients don’t seem like us. They live in faraway places, come from obscure cultures, speak incomprehensible languages, have disreputable comorbid disease, or exhibit antisocial behavior. They are “the other.” Maybe they do not even exist.past images will help fix the gazes of today’s victims, whose faces we do not seem to be able to see. To grasp the human suffering perpetrated by tuberculosis, we may need to recall the past when, incurable and incomprehensible, the disease had to be deciphered by metaphors—metaphors that changed as societal views of the disease changed over time. We may need to recall the lives of dying artists and the work they created and let art paint their faces, sculpt their shapes and contours, and compose leitmotivs. Perhaps such The arts  have always helped us understand, given us perspective, invoked compassion, and argued a purpose and meaning for life. We listened to the molto adagio of Barber’s string quartet (opus 11), and came together at President Roosevelt’s death. We read the poems of Walt Whitman and taught our children about the soldier's sacrifice. We studied the works of Petrarcha and Guillaume de Machaut and revisited the terror of Black Death, 700 years ago. Now, we must turn to art again to grasp human suffering because scientific knowledge of the disease seems to have displaced our interest in the patient. In his modest room, a 25-year-old "lapsed" medical student in 1820s Great Britain wakes from a sudden fevered sweat and finds a single drop of blood on the sheet. He has known many patients who spit such bright blood. “It’s arterial blood…that blood is my death warrant, I must die,” he confides to a friend. One of England’s greatest poets, the medical student John Keats, never wrote specifically about phthisis. But his life and his works became a metaphor for generations of patients, a metaphor that helped transform the physical disease phthisis” into its spiritual offspring, consumption. Keats’ life was defined by tuberculosis. At 14, he nursed his mother as she died of phthisis. A few years later he watched his brother die of phthisis, and by age 23, he had symptoms of this “hereditary ailment” himself. Yet, as the best remedies  failed, as his work was savaged by critics and his love was languishing (he could not marry because of the disease), Keats feverishly wrote his greatest poems: Ode to a Nightingale, Ode on a Grecian Urn, Ode on Melancholy. He died only months after he first spit blood. Autopsy found his lungs completely destroyed. He was 26. To be dead himself within the year, Percy Bysshe Shelley, another young poet with phthisis, compared Keats to “a pale flower by some sad maiden cherished,/And fed with true-love tears, instead of dew/The bloom, whose petals nipped before they blew/Died on the promise of the fruit, is waste;/The broken lily lies—the storm is overpast.”Shelley’s tribute expressed what would become the central metaphor of consumption in the 19th century, the idea that the phthisic body is consumed from within by its passions, “the bloom…Died on the promise of the fruit.” Shelley also likened Keats to an eagle that “outsoared the shadow of our night,” and “could scale Heaven, and could nourish in the sun’s domain.” These romantic notions contrasted sharply with the actual demise of tuberculosis patients, poets or not. As death neared, Keats himself contradicted his friend. In “On Seeing the Elgin Marbles” (published posthumously), Keats wrote, “My spirit is too weak—mortality/Weighs heavily upon me like unwilling sleep,/And each imagin’d pinnacle and steep/Of godlike hardship, tells me I must die/Like a sick Eagle looking at the sky.”In succeeding decades, Keats’ illness came to exemplify spes phthisica, a condition believed peculiar to consumptives in which physical wasting led to euphoric flowering of the passionate and creative aspects of the soul. The prosaic human, it was said, became poetic as the body expired from consumption, genius bursting forth from the fevered combustion of ordinary talent, the body burning so that the creative soul could be released. Keats’ great poetic output during his last year was considered a direct consequence of consumption. Spes phthisica, which sought to make sense of the senseless and give purpose to purposeless suffering and death, came to be viewed as a prerequisite for creative genius. French author Alexandre Dumas fils wrote, “It was the fashion to suffer from the lungs; everybody was consumptive, poets especially; it was good form to spit blood after any emotion that was at all sensational, and to die before reaching the age of thirty.” Dumas’ colleague, the poet Théophile Gautier, wrote, “…I could not have accepted as a lyrical poet anyone weighing more than ninety-nine pounds.” A subsequent alleged decline in the arts was even blamed on decline in tuberculosis incidence. In the 19th century, it seemed as if everyone was slowly dying of consumption. Without explanation, the good and the bad, the young and the old, all shared the consumptive fate. Consumption came to be viewed not in medical terms (medicine had little to offer anyway), but in popular terms, first as romantic redemption, then as reflection of societal ills. The consumptive prostitute, for example, could be a moral deviant redeemed by suffering and death. Redemption occurred not in the confessional, nor in the "last rites," but in consumption’s physical sacrifice. Alternatively, the prostitute could be merely a woman victimized by a corrupt society.Opera perhaps provides the most powerful examples of romantic redemption through tuberculosis. The pallor and wasting, the burning sunken eyes, the perspiration-anointed skin—all hallmarks of the disease—came to represent haunted feminine beauty, romantic passion, and fevered sexuality, notions reinforced by the excess of consumption deaths in young women. Of several operas that deal explicitly with consumption, three  show the evolution in thinking about the disease.Verdi’s La traviata [The Straying One] is based on La dame aux camélias [The Lady of the Camellias], Dumas’ tale chronicling the life of Parisian beauty Rose Alphonsine Plessis . Violetta, the heroine, is a courtesan whose loveliness is stereotypically enhanced and made unforgettable by progressive consumption. So strong was the expectation that women dying of consumption be beautiful ghosts that, at La traviata's 1853 premiere, the audience broke out laughing when Violetta, played by the ample soprano Fanny Salvini-Donatelli, was told she had only hours to live. The plot of La traviata develops around the consequences of Violetta’s scandalous past, which prevents her marriage to an honorable man whose family objects. In the libretto (by Francesco Maria Piave), Violetta links Alfredo’s acceptance to a cure for her consumption. Referring to their separation, she asks, “Do you know the fatal ill, That attacks my life—to kill? That already draws the end? And you’d part me from my friend!” Eventually realizing that redemption is possible only through death, Violetta withdraws to her former world to suffer and die for love: “If he knew the sacrifice Whereby love I atone—Knew that to my last breath I loved just him alone…." In taking her life, consumption also serves as a vehicle for atonement. Violetta dies redeemed in the eyes of Alfredo and his father, her labored breaths fading as she pleads: “Look at me! I breathe for you still.” Mycobacterium tuberculosis), Les contes d’Hoffmann [Tales of Hoffmann] exhibits an important shift in thinking about consumption. In Hoffmann, the beautiful consumptive Antonia is treated by the charlatan physician Dr. Miracle. At the time of Keats’ death, in 1821, little could be done to treat phthisis; the physician's role was in prognosis. By 1881, the “medicalization” of consumption was in full swing, with diets, nostrums, regimens, and activity lists . Produced only 28 years later  appealed to the opera’s audience because it absolved the patient from guilt or shame. Heredity as cause may have also appealed to the opera’s composer Jacques Offenbach—both he and his son were consumptive. The libretto (by Jules Barbier and Michel Carré) seems also to presage a new medical concept, a mycobacterial neurotoxin postulated as the cause of spes phthisica after Koch’s discovery. In Hoffmann, Dr. Miracle asks, “Well, this trouble she inherited From her mother? Still progressing. We’ll cure her.” As he forces her to sing, in what amounts to a musical exorcism, he notes, “The pulse is unequal and fast, bad symptom [sic]. Sing.” The ghost of Antonia’s mother, conjured by Dr. Miracle, calls to her, and she sings frantically, an artistic representation of her consumptive decline. Nearing death, she asks, “What ardor draws and devours me? I give way to a transport that maddens. What flame is it dazzles my eyes. A single moment to live, And my soul flies to Heaven.” Antonia is merely a victim, not burdened by sins that need to be atoned for. Unlike Violetta, she dies maddened by disease, without comprehending why and without making any moral choice.By 1896, the cause of consumption had been discovered. Tuberculosis or TB (as the disease was now known to everyone) had also been definitively linked to poverty and industrial blight, child labor, and sweatshops. A contagious disease and shameful indicator of class, it was no longer easily romanticized in conventional or artistic terms. Public health efforts to isolate the infected and control their behavior were everywhere. Giacomo Puccini’s La bohème (1896) presents tuberculosis as social commentary and features characters new to opera, street artists living with poverty and disease. The opera was fashioned from Bohemians of the Latin Quarter by Louis-Henri Murger, a young writer who also died of tuberculosis. The heroine, Mimì, is based on Murger’s friend Lucille Louvet. A poor seamstress portrayed as a fevered beauty whose allure is heightened by physical decline, Mimì loves a poor poet named Rodolfo. He first loves her in return but then abandons her, fearing he cannot provide for her and (possibly) fearing contagion. In the libretto (by Giuseppe Giacosa and Luigi Illica), Mimì tells Rodolfo, “My story is brief. I embroider silk and satin at home or outside. I love all things that have gentle magic, that talk of love, of spring…the things called poetry. Do you understand me? They call me Mimì. I don’t know why. I live all by myself and I eat alone. I look at the roofs and the sky. But when spring comes the sun’s first rays are mine. April’s first kiss is mine, is mine! A rose blooms in my vase, I breathe its perfume, petal by petal.” Later, in the winter cold, Mimì is reconciled with Rodolfo and dies beside him. In one of opera’s most enduring scenes, there is no attempt at metaphorical understanding. Mimì dies literally. No one is saved, no one is redeemed, and no larger point is made. Opera and tuberculosis have entered a new era, recognizable today, in which tragedy is seen as experiencing loss but is not understood in an artistic or philosophical sense. In the moments before her death, Rodolfo tells Mimì that she is “beautiful as the dawn.” “You’ve mistaken the image:” she corrects him, “You should have said, beautiful as the sunset.” Mimì dies surrounded by a philosopher, a poet, a painter, a musician, and a singer—the arts had become powerless against tuberculosis.Even though new, La bohème’s approach of pointing the finger at society as the cause of human suffering was not unprecedented. An earlier example from literature is Victor Hugo’s Les misérables [The Outcasts], published in 1862. In the novel, the hounded protagonist  finds redemption in the child of a dying woman (Fantine) who had been forced by poverty into prostitution. Like Mimì’s in La bohème, Fantine’s death from consumption is portrayed as a consequence of social ills. Society, Hugo says, victimizes good people by putting them in hopeless circumstances. Of Fantine’s death Hugo writes with a simple beauty that is eloquent even in translation. Like the “afterthought” the world had regarded the poor woman’s entire life, the paragraph describing her death is inserted almost randomly, in retrospect: “We all have one mother—the earth. Fantine was restored to this mother. [She] was buried in the common grave of the cemetery, which is for everybody and for all, and in which the poor are lost. Happily, God knows where to find the soul. Fantine was laid away in the darkness with bodies which had no name; she suffered the promiscuity of dust. She was thrown into the public pit. Her tomb was like her bed.” In the same romantic context is Hugo’s earlier novel Notre-Dame de Paris (1831), which featured the grotesque and deformed “hunchback” Quasimodo. In those days, the principal cause of severe spinal deformity was Pott’s disease, tuberculosis of the spine. What Hugo knew of this condition can only be speculated, but as a leading poet, he would unquestionably have been familiar with the life of one of England’s greatest poets, Alexander Pope (1688–1744), a hunchback severely deformed in childhood by Pott’s disease. Bent to a height of 4½ feet, at age 47, Pope famously described “this long disease, my life” in “An Epistle from Mr. Pope, to Dr. Arbuthnot.” Quasimodo’s physical “otherness” is Hugo’s device for insisting we recognize his humanity, without judgment, in all its dimensions, good and ill. Notre-Dame de Paris carries a simple message, one expunged from many films and operas made of the book. Hugo writes that long after the events depicted in the novel, workmen discovered two entwined skeletons, one of a young woman, the other of a man with a twisted spine. After La Esmeralda’s execution, the reader surmises, Quasimodo had gone to end his life beside the woman who had found him so repugnant. In death, his disfigurement and her beauty alike were dissolved in dust. All of Quasimodo’s actions, misunderstood by everyone else, are explained by love, as pure in the deformed, slow-witted bell-ringer as in the beautiful saint.Operatic and literary examples show the romantic transformation of tuberculosis. Only rarely in the period before Koch's discovery was the disease portrayed realistically in artistic works. The most powerful example of realistic portrayal may be Tolstoy's Anna Karénina (1877). Apparently based on Tolstoy's own brother Nikolai, the novel’s character Nikolai Levin suffers an agonizing and vividly depicted death. "A desire for his death was now felt by everyone who saw him; by the hotel servants and the proprietor…by Maria Nikolayevna, Levin, and Kitty. [I]n rare moments, when opium made him find momentary oblivion…[he] expressed what he felt more intensely in his heart than all the others: ‘Oh, if only it was all over!’ or ‘When will this end?’ There was no position in which he could lie without pain, there was not a moment in which he could forget…And that was why all his desires were merged into one—a desire to get rid of all the sufferings and their source, the body." Unlike the prostitute whose death provided Jean Valjean's redemption, Maria was rescued from prostitution by Nikolai and nursed him when he was abandoned. As Nikolai entered the long descent into suffering and death, Maria's love was his only human connection.At the beginning of this period, the stethoscope was invented and used to diagnose phthisis, and statistics were compiled by population-oriented proto-epidemiologists  and by clinical proto-epidemiologists . In the 1820s, contagion was beginning to coalesce into a modern concept, although it was not imagined in chronic conditions like phthisis. Science was beginning to understand the disease clinically and epidemiologically . It was left to the arts to make sense of misery and death in ways that turned otherwise senseless suffering into human dignity and hope, allowing consumption to reveal the innate worth even of prostitutes, the impoverished, and the socially outcast. At the end of the 19th century, romantic notions about tuberculosis were replaced by scientific ideas and products: vaccines and therapies, rest cures, tonics, lobectomies, pneumonectomies, thoracoplasties, “artificial” pneumothoracies, phrenic nerve crushings, plombage, pneumatic cabinet treatments, and antiseptic injections into the pleural spaces. Surgeons packed the pleural cavity with fat, paraffin, and even Ping-Pong balls. In contrast to the arts, science and medicine were unapologetically prosaic.Over a 70-year span, tuberculosis literally transformed Western society. Tuberculosis patients were excluded from many occupations. Married patients had to sleep in separate beds from uninfected spouses and were counseled to avoid sex and especially to not have children. Public health nurses visited door to door, sanatoria were built by the hundreds, and hospitals added tuberculosis wings. Cold water hydrotherapy, alcohol massages, and brisk rubdowns with coarse towels were prescribed. Millions of spittoons and cuspidors were placed in homes and public places. Patients’ bed linens were changed daily and were boiled and laundered separately. Handkerchiefs (for those who could afford them—cut-up pieces of muslin for the rest) were stuffed in pockets before leaving home, then disinfected or burned at night. Japanese “paper handkerchiefs” became popular, leading eventually to the modern “facial tissue.” Tuberculous women had to forego corsets and brassieres in favor of loose-fitting clothes. Life insurance policies added clauses canceling benefits for the tubercular, and hotels and landlords refused to serve them. Compulsory registration, immigration bans, and even interstate travel restrictions were debated. Suicides in towns with sanatoria increased. Prevention efforts were put in place. National antituberculosis programs were led by U.S. presidents. Ubiquitous “ad campaigns” featured catchy tunes some called “jingles.” Architects designed alcoves to hide concealed spittoons in middle-class homes. Babies were no longer allowed to play on the floor, and mothers were told not to kiss children on the mouth. Some churches abandoned the “common” communion cup. "TB" and “x-ray” became household words. Streets were watered down before sweeping to prevent aerosols. Long “trailing” dresses went out of fashion because they dragged on the ground and picked up potentially infectious dust. Store candies and bakery loaves had to be wrapped; public libraries and their books were regularly disinfected. In the late 1940s and early 1950s, a truck cycled through neighborhoods to administer chest x-rays, and schools provided “tine tests.” Patients sat in big sunrooms off hospital wards, semi-erect in lounge chairs, wrapped like mummies on an ocean cruise. Family members disappeared for long periods—off to sanatoria for “rest cures.” People bought Christmas Seals, and spoke in a slight hush when they mentioned “TB.” As a medical student in the 1960s, I remember the second patient I ever examined. Born in 1879, she had undergone a right phrenic nerve crush, sometime around 1910, surviving tuberculosis to the age of 90. The 1950s represented the cusp of a new era in which drug treatment would end tuberculosis visibility in industrialized countries. People still read Thomas Mann’s The Magic Mountain (1924), which was set in the real-life sanatorium in Davos, Switzerland, but less to learn about tuberculosis and more to understand the “Sanatorium Movement.” The modern tuberculosis era began around 1952 with antituberculosis chemotherapy, but more die of the disease today than in the 19th century. Medicine and public health have answers but lack the will to apply them. Tragedy now derives not from unknown evils out of our control but from known evils we do not control. Art is redemptive. Even in modern times, when artistic expression seems to have moved to other causes of human suffering, occasionally dramatic irony sneaks backstage to comment on the empty theater of tuberculosis progress. In 1967, a woman born in India, acclaimed a great actress in such roles as Anna Karénina and Scarlett O’Hara (Gone with the Wind), died of tuberculosis. Starring at the time in a long-running play, Vivian Hartley (stage name Vivian Leigh) began to experience cough, then fever. Within a few months she was dead. The accidental irony was pure “theater.” The play was Chekhov’s Ivanov. Vivian Leigh, a wealthy woman dying of tuberculosis, was starring in a play about a wealthy woman dying of tuberculosis, written by a wealthy physician dying of tuberculosis. One may imagine that when art fails to imitate life, life may have no recourse but to imitate art. In the early 1980s, I realized a boyhood dream, to climb an isolated peak called Mount Vaea, on the remote South Pacific island of Upolu, in what is now Western Samoa. Around that time, one of my patients, born on a Pacific island and admitted to my American hospital for tuberculosis, had walked up to the nursing station for some trivial purpose and in the middle of a conversation with the nurse, had suddenly opened his mouth to an explosion of arterial blood that shot across the room, overflowed like a waterfall to the linoleum floor, and caught him in its plumes as he sank downward and died—suffocated or drowned. A century earlier, in 1880, coughing blood and dying more slowly, Robert Louis Stevenson fled his consumptive sentence. He escaped to Davos, to rugged sea-swept Speyside, and to sunny Marseille. All the while, he worked on the great books we still read all over the world, Treasure Island, Kidnapped—novels of escape. Surviving a succession of hemorrhages, Stevenson climbed hills and sailed oceans, following the medical advice of his time. In New York, he stayed at Saranac Lake, America’s most famous sanatorium. In San Francisco, he was farther from home than he had ever been. Still the hemorrhages and wasting continued. Escaping ever farther, he went to Hawaii, lived in a grass hut, and told stories to the King and Queen. He went on to Sydney, Australia, where he had additional hemorrhages, and at last to Upolu. Tuberculosis nevertheless continued to consume him. He wrote every day, suffering sudden hemorrhages, waiting to be “weaned from the passion of life.” The doctors said it was a stroke that felled him in December 1894. The 44-year-old Stevenson was placed on a bed in the middle of the room. Family and friends beside him, his Samoan “family” kneeling in a circle all around, the great Tusitala, “teller of tales,” took a last breath. A council of chiefs was called, appointing 40 strong men to carry out Stevenson’s final wish. They carried his body up to the top of the highest mountain and buried him in the place he had chosen.Although I have visited the place several times—once dragging a famous epidemiologist barefoot up the mountain—it was the first time, 20 years ago, that I remember most clearly. I reflected then that in 1891, when Stevenson had escaped to Upolu, tuberculosis was still a disease of wealthy industrial nations. To run from it, Stevenson had to leave behind everything else in his life: family, friends, mother country, home, comfort. He fled to the very end of the earth. Now, more than a century later, tuberculosis has escaped to the places where its victims once sought refuge, the one-time colonies of Western nations. The disease destroys the poor and underprivileged as it once destroyed the wealthy—95% of cases and 98% of deaths occur in the developing world. Its ravages are worst in the Pacific Islands. I wonder if the victims, who are too often beyond the reach of Western cures, have their own operas, poems, or plays to explain their predicament. I wonder where they escape. Do their escapes, like Stevenson's, lead only to resignation and surrender? On top of Mount Vaea, at 1,500 feet, a small promontory shows the blue Pacific in a broad sweep. Facing “Magic Mountain” half a world away, you see a blue curtain above and below the horizon. At night, the sky is indeed wide and starry. The Southern Cross sparkles wildly, too low and too close to be celestial. The sarcophagus, placed at the highest point, is of white plaster, like the walls of the European hospitals and sanatoria Stevenson had fled. The plaque is of shiny brass, so that even in the moonlight, sometimes even in the tropical starlight alone, it is possible to read the words engraved on the side of the tomb. It is Stevenson’s “Requiem,” the poetry of his last resigned step in a long but unsuccessful flight. Under the wide and starry sky,Dig the grave and let me lie.Glad did I live and gladly die,And I laid me down with a will.This be the verse you grave for me:“Here he lies where he longed to be;Home is the sailor, home from the sea,And the hunter home from the hill.”


To reach Dr. Narcis Kabatereine's office at the Vector Control Division (VCD) of Uganda's Ministry of Health in Kampala, you must first walk through a room full of lab technicians who are studiously looking down microscopes.The atmosphere of quiet diligence is set by the softly spoken Dr. Kabatereine  himself,Dr. Kabatereine manages the ministry's Bilharzia and Worm Control Programme and chairs the Neglected Tropical Disease (NTD) Secretariat in the VCD. Without fanfare, he has steadily built a career as both an academic and a highly trusted technical expert whose advice on tropical disease control is greatly in demand across Africa. Rwanda, Mozambique, Tanzania, and southern Sudan have all called on him to help guide their NTD control efforts. Dr. Simon Brooker of KEMRI/Wellcome Trust in Nairobi, Kenya, calls him “the unsung hero of NTDs.”Dr. Kabatereine's office gives a snapshot of his wide-ranging research, consultancies, and advocacy. There are files and papers everywhere. A box on the shelf is labeled “10% Kato Katz Slides,” used in the diagnosis of schistosomiasis. His bulletin board is plastered with newspaper clippings—one striking headline reads “Bilharzia Threatens Hundreds in Uganda.” There's a calendar from the Carter Center. And there are photos on almost every inch of his walls, including one of his PhD graduation ceremony on March 28, 2001, at the Danish Bilharziasis Laboratory (DBL) in Copenhagen.As a child, he says, “I just loved insects, wondering how the social insects managed to work together—bees, termites and ants.” He followed his fascination at Makerere University in Kampala, where, for his bachelor's degree in zoology and botany, he did a dissertation in entomology while at the same time gaining a diploma in education. During his degree, he says, “my interest in insects increased when I realized that many were vectors of disease.”That realization led him to join the VCD in 1980. At that time, he says, there were documents showing that schistosomiasis was a problem in north western Uganda “but no one was working on it.” In 1982, he did a 4-month course at the DBL called “Fresh water snails of Africa and schistosomiasis control.” He later did a master's degree in medical entomology at Nairobi University in Kenya, with a focus on tsetse flies and trypanosomiasis control. But when it came to choosing a topic for his doctorate, he says, he chose “snails and schistosomiasis, a disease that was then more neglected than trypanosomiasis.”S.mansoni both in North Western Uganda and in a remote fishing community on Lake Albert.Throughout this time, he was becoming steadily more senior at the VCD, eventually becoming the division's Principal Entomologist in 2007. He was devoting much of his life to understanding and controlling Uganda's enormous burden of schistosomiasis and intestinal worms. His studies included the epidemiology of these parasitic diseases in Kampala, and the transmission of I ask him to tell me which of his many achievements gives him the greatest pride. “I managed to map out the magnitude of the problem due to schistosomiasis and soil transmitted helminthiasis in Uganda,” he says, “and initiated a national control programme for the diseases.” He also succeeded in including these neglected conditions in the country's Health Sector Strategic Plan. He is proud of having convinced the government and external donors that mass drug administration (MDA) to control these worms was necessary. Through Uganda's MDA campaign, he says, “we have successfully reduced morbidity due to schistosomiasis and soil transmitted helminthiasis.” Since the late stages of schistosomiasis are deadly, he believes the campaign has also saved many lives.“Appearances with Narcis can be deceptive,” says Dr. Brooker. “To some who do not know him well, he seems happy and grateful to have donors interested in NTD control in Uganda. With time, you realize that long before donors arrived, he had identified what was required to develop an effective and sustainable helminth control programme in Uganda. He then strategically set about to put those pieces in place, identifying which collaborators could support each area.”Dr. Jan Kolaczinski, Senior Specialist for NTDs at the Malaria Consortium in Kampala, who works closely with Dr. Kabatereine, says that “one of the key character attributes of Narcis is he genuinely wants to do good for his country—he's not a career person.” This attribute is echoed by Dr. Brooker: “At times, Narcis can be very firm with his staff, especially when they haven't done something just right,” he says, “yet when working with him on school surveys, you see a real gentleness in how he is with children, and a genuine concern for their well-being and to rid them of worms. What Narcis does comes from the heart.”Dr. Kolackzinski talks highly of Dr. Kabatereine's willingness to share data, to speak frankly at stakeholder meetings, to collaborate with all sorts of people, and to willingly assist other African countries with their NTD control efforts. The Malaria Consortium is currently working with the Government of Southern Sudan on the integrated mapping and control of NTDs, and Dr. Kabatereine has been acting as an adviser. “The team of technicians that Narcis sent to southern Sudan to work with us worked like clockwork,” says Dr. Kolackzinski. “They did all the lab tests for mapping and trained the Sudanese surveyors. They were genuinely committed to training others.” Dr. Kolackzinski credits Narcis's leadership for the technicians' disciplined approach. “Narcis is a useful coach for other African countries,” says Dr. Kolackzinski, “especially for schistosomiasis and soil-transmitted helminths.”I get a strong sense of Dr. Kabatereine's willingness to speak frankly about controversial issues when I ask him about Uganda's recent move towards integrated control of NTDs, which is being supported by funding from the U.S. Agency for International Development (USAID). Current strategies for controlling several different NTDs, says Dr. Kabatereine, are very similar—they all involve training community medicine distributors (CMDs) and schoolteachers to deliver MDA. So it makes great sense to try and integrate these strategies, he says, and deliver multiple interventions at once. “Reaching the communities themselves within a single period—it's an idea that's quite salient.” Uganda is integrating the control of five diseases: schistosomiasis, soil-transmitted helminths, onchocerciasis, trachoma, and lymphatic filariasis. “None of us want to go back to vertical programs,” he says. “We all want to prove that integration works.”Nevertheless, he is critical of the way in which USAID has set up a parallel structure, largely outside of the Ministry of Health, to manage the integration. The development agency is channeling funding through the research organization RTI International and Dr. Kabatereine feels that the ministry and the national health system have been sidelined. He worries what will happen when the USAID funding ends—how will integration be sustained if it was never run by the ministry in the first place? “We need strong government involvement in the running,” he says.Earlier in the day, I had met with Dr. Ambrose Onapa, RTI International's Programme Manager for NTDs, whose office is just down the hallway. He explains that RTI International is providing the funding required by the districts and the ministry of health for implementation of the integrated control program, and is also providing personnel to manage the funds. Implementation is facilitated by an NTD Secretariat at VCD, made up of himself and the individual program managers for each different NTD. Dr. Kabatereine chairs this Secretariat.“Our role as secretariat is unclear,” says Dr. Kabatereine. “I feel we should be coordinating the program.” In the future, he believes that donors should make sure that the ministry of health has a strong say in the management of integrated control. “Integration isn't easy. It should go directly through the health systems,” he says. He is concerned that CMDs are required to deliver many interventions at once, yet most have little formal education and find it hard to grasp the instructions in the thick integrated training manuals. If this in turn leads to less time spent educating the community about the nature of NTDs, the success of the integrated program could be jeopardized.Rumors have been going around in the communities, he says, that the medicines are a form of birth control, and such rumors threaten coverage levels. He fears that the problem arises when the CMDs don't give people enough information. He points me to a 2008 social science study on NTDs in North West Uganda, by Melissa Parker and colleagues, which found that adults were increasingly rejecting MDAs through fear of side effects, local beliefs about worms, and inadequate health education It is rare for public health professionals to be willing to go on the record in criticizing a donor-funded program. My interview with Dr. Kabatereine was part of a fellowship in global health reporting that took me to southern Sudan, Uganda, and Kenya So I make double sure that Dr. Kabatereine is happy to be quoted with his concerns about the RTI International program. He confirms that he is. “I don't know what impact I'll face,” he says, but “the story must be told.” He wants to lay out the challenges of integration, not because the idea itself is flawed but because “all these challenges are manageable. We can solve all of these.”He shares with me an idea that he thinks would go some way to addressing these challenges. The USAID/RTI program is supporting seven African countries to scale up integrated control of NTDs As our interview ends, he throws out other ideas that he believes would have an impact on Uganda's NTD burden, such as developing anti-parasitic drug formulations specifically for children. Instead of giving children crushed albendazole/mebendazole tablets mixed with dirty water, he says, a practice that can transmit disease, “we should advocate to develop syrups.” And money should be given to health educators at the district level, he argues, to show videos in schools and churches to educate the community about NTDs and their control.“I hope one day I will succeed with these ideas,” says Dr. Kabatereine. From what I have learned of him, I feel confident he will be a forceful and vocal champion for his suggestions.


To the Editor:Biological Psychiatry, Tyrka et al.  and one referred to maltreatment at any time (2008). The specific questions asked were the following: “As a child, were you ever a victim of physical abuse?” “As a child, were you ever a victim of sexual abuse?” “Have you ever been physically abused?” “Have you ever been emotionally abused?” “Have you ever been sexually abused?”The possible answers were Yes, No, or no answer. We only considered subjects that gave a consistent answer to the physical abuse or the sexual abuse questions in both questionnaires. We felt it further strengthened our phenotype to have corroborative data at two time points.Mean leukocyte telomere length was derived from the mean of the terminal restriction fragment length by using the Southern blot method on DNA extracted from peripheral leukocytes, as described elsewhere . Each DNThere is no significant difference in telomere length between people who have been abused and those who have not been abused , Table 1When we looked at individuals who had answered the maltreatment in childhood questionnaire alone, we had a much larger sample size. With 123 cases and 1751 control subjects, there remains no significant difference in the mean telomere length between those subjects who had suffered sexual abuse and those who had not. The mean telomere length in this group is identical in cases and control subjects. This result was unchanged when possible confounders  were included in the linear model.et al. (We have failed to replicate the findings of Tyrka et al. , despiteet al. .et al. (The questionnaires to assess abuse used by Tyrka et al.  and Twinet al. (Many different environmental factors are known to reduce telomeres, such as cigarette smoking, obesity, lack of exercise, and social class, as well as genes . With a et al. , rather