Public use of the Internet for health information is increasing but its effect on health care is unclear. We studied physicians' experience of patients looking for health information on the Internet and their perceptions of the impact of this information on the physician-patient relationship, health care, and workload.Cross-sectional survey of a nationally-representative sample of United States physicians .Eighty-five percent of respondents had experienced a patient bringing Internet information to a visit. The quality of information was important: accurate, relevant information benefited, while inaccurate or irrelevant information harmed health care, health outcomes, and the physician-patient relationship. However, the physician's feeling that the patient was challenging his or her authority was the most consistent predictor of a perceived deterioration in the physician-patient relationship , in the quality of health care , or health outcomes . Thirty-eight percent of physicians believed that the patient bringing in information made the visit less time efficient, particularly if the patient wanted something inappropriate , or the physician felt challenged .The quality of information on the Internet is paramount: accurate relevant information is beneficial, while inaccurate information is harmful. Physicians appear to acquiesce to clinically-inappropriate requests generated by information from the Internet, either for fear of damaging the physician-patient relationship or because of the negative effect on time efficiency of not doing so. A minority of physicians feels challenged by patients bringing health information to the visit; reasons for this require further research. An increasing proportion of the public is using the Internet for health information . This isWe surveyed a nationally-representative sample of physicians about their experience with patients bringing health information from the Internet to office visits. Our aims were to determine physicians' perceptions of the effects of patients bringing health information from the Internet on the physician-patient relationship; time efficiency of the visit; quality of care received by the patient; and patient's health outcomes.Two thousand physicians were randomly selected from the national list of physicians provided by the Medical Marketing Service, Inc (MMS). The Medical Marketing Service list is based on the national database of the American Medical Association (AMA) which includes both members and nonmembers of the American Medical Association, and is updated weekly. The American Medical Association database contains over 650000 physicians, and is the most-complete list of physicians available in the United States. Physicians who currently spent over 20 hours a week on direct patient care were included in the survey. The sample was stratified by specialty: primary care, medical specialty, or surgical specialty. Primary care included family practice, general practice, internal medicine, and pediatrics. Ob-Gyn was classified as a surgical specialty.The questionnaire was developed following literature review and focus-group discussions. It was pretested to ensure that the instrument was easy to complete, all areas of interest were covered, and no questions were ambiguous. It consisted of closed-end questions, took approximately 12 minutes to complete, and was in 3 parts. The entire sample received Part 1 of the questionnaire, which elicited general information about views on health information on the Internet and direct-to-consumer advertising (DTCA). Questions included general views on accuracy and effects of such information, and personal use of the Internet at work. Part 2 was sent to a random 50% of the sample, and requested information about the last time a patient brought in information from the Internet. "Last-time" methodology was used to minimize recall bias. Areas explored were the relevance and accuracy of the information, physicians' perceptions of why the patient had brought the information, physicians' responses to the patient, and their views about the impact on health care, health outcomes, and the physician-patient relationship. The other 50% of the sample received a different Part 2, which explored these same areas but with regard to the last time a patient brought in information from direct-to-consumer advertising. The direct-to-consumer advertising data are presented elsewhere . Part 3 Data collection was undertaken between November 2000 and February 2001. The questionnaire was mailed to the selected physicians with a check for US $35 as a token of appreciation for completing the questionnaire. Up to 3 reminders were sent and additional telephone contact made with nonresponders. Of the original 2000 physicians sent the survey, 38 were ineligible because they were deceased, retired, or no longer in practice; and 1050 physicians completed the questionnaire (response rate 53%). Of these, 515 received the Internet version of the questionnaire, and 535 the direct-to-consumer advertising version.Data were weighted to represent the national population of physicians in the Medical Marketing Service database who spend 20 or more hours per week on direct patient care, using the Medical Marketing Service variables mentioned above. As can be seen in The analytic approach focused on evaluating univariate and multivariate relationships with 4 clinically-important outcomes — change in physician-patient relationship; time efficiency; quality of care; and patient health outcome — each of which was assessed on a 3-point scale (improved vs no difference vs worsened). All the demographic, workload, and practice variables listed in Although several of the workload and practice characteristics were assessed as continuous variables , most were highly skewed, so medians and interquartile ranges are reported for these data. These variables were split at the 75th percentile for analysis of univariate relationships to test for the influence of these factors. This split was chosen over a median split to maximize the opportunity for an effect to be visible.P< .20 were analyzed using a stepwise multiple-logistic regression procedure to determine the "most-important" correlates, where importance is defined solely by statistical criteria. Each analysis went through several iterations, with each new iteration employing successively more-stringent statistical criteria for inclusion in the model. Each iteration included consideration of a model yielded by a forward-stepwise procedure and a model yielded by a backward-stepwise procedure. Final models include all correlates with a significant ( P< .05) or near-significant (.05 < P<.10) likelihood ratio test while still achieving adequate fit, operationalized as P> .20 on the Hosmer-Lemeshow goodness-of-fit test.Separately for each outcome variable, correlates with chi-square statistics achieving P values and standard errors were undertaken. We used the SVYTAB procedure in STATA to obtain the Rao and Scott F-test P-values [As all data were weighted (except where specified), the appropriate procedures to correct P-values , and theThe characteristics of the respondents before and after weighting are presented in Sixty-one percent  of all respondents used the Internet in their own practice. In this group, the most-frequent uses were to obtain scientific information such as articles or guidelines  or to e-mail colleagues . Obtaining clinical information about patients, such as lab results , and e-mailing patients  were much less common uses of the Internet by physicians.Overall, respondents were positive about the recent increase in health information on the Internet, with 75%  of the total sample thinking that it was a good or very-good thing. Only 15%  believed that it was a bad thing, and the remainder were neutral. Similarly, most physicians  stated that they had encouraged patients to look for information, although only 35%  had referred patients to Web sites..                Eighty-five percent  of all respondents had experienced an occasion when a patient brought information from the Internet to a visit. For most physicians this is still a relatively-rare event; 59%  of respondents stated that less than one fifth of their patients had done this. 87%  of physicians perceived their patients as being concerned about the quality of information on the Internet, and 84%  of respondents rated their patients as only fair or poor  at appraising the quality of information on a Web site A random subsample (n = 519) was asked about the last time a patient had brought in health information on the Internet to a consultation and 430 reported that a patient had done so. The remaining data are from these 430 respondents.Most respondents believed that the last time a patient had brought in health information from the Internet, the information had been very  or somewhat  relevant to that patient's problems and very  or somewhat  accurate.Respondents perceived that the majority of these patients  had brought them the information because they wanted the physician's opinion on it. Physicians reported that patients sometimes also wanted a change in medication , a test , or a referral to a specialist .Physicians usually did what the patient wanted, either completely  or partially . Univariate associations are shown in On multivariate analysis, only 3 factors independently predicted not doing what the patient wanted. Thinking that the patient's request was not appropriate for their health was the most important factor , followed by thinking the information that the patient brought in was not accurate  and the type of specialty the physician was in. Medical specialists were more likely than primary care physicians and surgical specialists not to do what the patient wanted .Most physicians believed that the patient bringing information to the visit had had a beneficial  or neutral  effect on the physician-patient relationship. Univariate associations are shown in Multivariate analysis yielded 4 factors that were independently associated with a worsening of the physician-patient relationship. The physician feeling that the patient was challenging their authority was the strongest predictor  followed by the physician believing that the patient's request was not appropriate for their health . Not feeling that the patient was taking responsibility for their health was independently associated with a worsening of the physician-patient relationship , as was not doing what the patient wanted .Thirty-eight percent  of physicians believed that the effect of the patient bringing information to the consultation harmed their time efficiency while only 16%  believed that it had helped it. Univariate associations are shown in Multivariate analysis showed that many of these factors were independently associated. Physicians trained in the United States were more likely than physicians trained overseas to feel that time efficiency was worsened . Other independently-associated workload factors were not having enough time to discuss the information  and seeing over 100 patients per week . The physician thinking that the request was not appropriate for the patients health , feeling that the patient was challenging their authority , or not thinking that the patient was taking responsibility for their health  were also independently associated with worsened time efficiency.Most physicians believed that the information made no difference to the quality of care the patient received . More physicians believed that it had been beneficial  than deleterious  . LogistiSeventy-five percent  of physicians believed that the information had made no difference to the patient's health outcome, 21%  believed that it had improved the health outcome, and only 4%  believed that it had been deleterious . On multThis is the first large nationally-representative sample of physicians to study physician perceptions of the impact of health information on the Internet on quality of health care, health outcomes, health service utilization, and the physician-patient relationship that we could find by searching MEDLINE. We found evidence of both good and bad effects. Our findings have implications for practicing clinicians, policy makers, and researchers.Physicians believed that patients bringing in accurate, relevant online information is beneficial and welcomed it. Conversely, physicians believed that inaccurate or irrelevant information harms the quality of care, health outcomes, time efficiency, and the physician-patient relationship. Thus improving the accuracy and relevance of online information available to patients may improve outcomes of interest to health care providers, payers, and consumers. The policy challenge is how to improve the quality of online health information, given the large number of health-related Web sites and the ease with which sites can be updated. Suggestions include "kitemarks"  for quality Web sites, codes of conduct for development and content of Web sites, market forces, directing users to trusted Web sites, filters, rating instruments for users, and public education in evaluating the quality of online information - 14. TheUS physicians may feel in a quandary when patients request an inappropriate clinical intervention that they learned about online. Ethically, physicians should refuse inappropriate requests in order to avoid harming the patient and to use health service resources prudently. However, previous studies have suggested that refusing patient requests will reduce patient satisfaction ,19. PhysSeventeen percent of physicians felt that patients were challenging their authority during the visit. This reaction was strongly associated with harms to the physician-patient relationship, quality of care, health outcomes, and time efficiency. Our study cannot determine why physicians feel challenged. Some physicians may be having difficulty adjusting to a more-equal relationship, where the patient has greater access to medical information . AlternaAlthough our response rate is only moderate at 53%, it compares well to other surveys of Internet use by physicians. Because our sample was representative of all US physicians in terms of age, gender, specialty, location of practice, and practice income our results are likely to generalize to all US physicians. In contrast, previous surveys have examined specific branches of medicine , used coAs with all cross-sectional studies, we cannot determine causality, nor do we have objective data on whether patient requests were truly inappropriate or on quality of care or health outcomes. However, our measures are plausible because physicians address the appropriateness of care and outcomes daily on a professional basis. Patient perceptions of these consultations may have been different, but our results from a population survey of public perceptions of the effects of health information on the Internet are not dissimilar .Health care organizations, payers, and providers have a strong interest in ensuring both that health information on the Internet is accurate and that physicians have the necessary skills to respond to patients who bring in such information. Vigorous leadership in these areas will be needed if the effect of the Internet on medicine is to be truly beneficial.


Recent clinical trials in Africa found that male circumcision reduces the risk of acquiring HIV from heterosexual sex--what are the implications of these studies for the United States? Three randomized, controlled clinical trials in South Africa, Kenya, and Uganda were recently unblinded early because interim analyses concluded that circumcision of HIV-negative adult males reduced their risk for acquiring HIV infection through penile–vaginal sex . In eachIt is now clear that male circumcision can be efficacious for men in reducing their risk of HIV acquisition through sex with women . Some exThe results of any trial must be interpreted with the caution that inference not be extended to populations differing from the study participants in important ways. The HIV epidemics in Africa are substantially different from the US epidemic. Generalized HIV epidemics exist in many areas of Africa, and the population prevalence of HIV among adult Kenyans, Ugandans, and South Africans ranges from 6%–19% . The pre+ T cells, and macrophages [The association between circumcision and reduced risk for HIV acquisition is biologically plausible: the foreskin contains high concentrations of superficial Langerhans cells, CD4rophages —all targrophages ,13. In arophages , and mayrophages .Epidemic differences are important because, on a population basis, the impact of circumcision as an intervention to prevent HIV infection among men who have sex with women will depend on the likelihood of HIV exposure among such men in the US—and, therefore, on the prevalence of HIV among their female sex partners. A recent analysis of data from sexually transmitted disease clinics in Baltimore evaluated the association of male circumcision and risk of prevalent HIV infection in two ways—first, evaluating all male attendees at the clinics, and second, restricting the analysis to males who were known to have been exposed to HIV heterosexually  . The resMost sexual transmission of HIV in the US occurs through male–male sex , most ofFew studies provide evidence as to whether circumcision may protect against HIV infection among MSM. In a vaccine preparedness cohort of MSM followed from 1995 to 1997, circumcision was significantly associated with a decreased risk for HIV seroconversion , controlling for number of male sex partners and unprotected sex with an HIV-positive partner . While fhttp://www.who.int/entity/hiv/mediacentre/MCrecommendations_en.pdf [In March 2007, the World Health Organization and the Joint United Nations Programme on HIV/AIDS held a technical consultation on male circumcision and issued a summary document providing conclusions and recommendations relating to policy and programming on male circumcision and HIV prevention . The docs_en.pdf .In the African countries where circumcision has been demonstrated to be efficacious, the predominant HIV subtypes are A, C, and D; it is likely that some recombinant strains were also represented in the Kenya and Uganda trials. In the US, subtype B predominates. Despite the theoretical possibility that subtype differences in either vaginal shedding of HIV or affinity to HIV receptors  could modify the effectiveness of circumcision as an HIV prevention intervention, the consistent findings of the African trials argue that this is unlikely. For example, despite differences in vaginal shedding between subtype C and subtypes A and D , the effPublic health recommendations will likely have the largest impact in populations where circumcision has been rare. Non-religious male circumcision was introduced to the US in the late 1800s , and by Data from another hospital discharge survey, the National Inpatient Sample, present a slightly different picture . In thatData from the National Health and Nutrition Examination Surveys from 1999 to 2004 indicated that the overall prevalence of circumcision among adult males in the US was 79% and varied by race/ethnicity . The prevalence of circumcision decreased among US-born men from the 1970s to the 1980s . AlthougThe ability of investigators to fully enroll three trials of adult circumcision  in AfricThe American Academy of Pediatrics changed from a less conclusive stance on circumcision in 1989 , which cCircumcision may have a role for the prevention of HIV transmission in the US. However, because of the many differences between the underlying HIV epidemics in Africa and the US, differences in the prevalence of male circumcision in Africa and the US, and the considerable gaps in knowledge that exist regarding the potential impact of circumcision on HIV transmission by male–male sex, the extent of this role on a population basis is unknown. Further, the already high prevalence of circumcision among US men suggests some limitations in the potential impact of circumcision at a population level.Based on the data from the three African clinical trials, it is likely that circumcision will decrease the probability of a man acquiring HIV via penile–vaginal sex with an HIV-infected woman in the US. Until public health recommendations are available for the US, some sexually active men may consider circumcision as an additional HIV prevention measure, but should do so only in consultation with their physician or health care provider, and with a clear understanding of the costs and risks of circumcision and the need to continue use of other, proven prevention measures . Men who choose to be circumcised should also be counseled about the importance of refraining from sexual intercourse following circumcision, until wound healing is complete .To consider the possible impact of public health recommendations for male circumcision, we must also take into account HIV incidence in high-risk groups, as well as adoption of other protective behaviors, such as condom use. For example, HIV incidence among US MSM recruited in community- and venue-based samples was, on average, about 1.9% annually , and 36%In order to understand the potential for male circumcision as an HIV prevention approach in the US, we believe that there are important questions that should be answered. These include questions that can be answered by basic science, by modeling, by surveys of acceptability, by considering ethical issues, and, perhaps, by clinical trials in the US. For example, it is important to understand more fully the differences in shedding of HIV by rectal versus vaginal mucosa. Modeling may provide important information on (1) the impact on the US epidemic from increasing male circumcision rates, and (2) the cost–benefit ratio of circumcision among newborns, or among adult men with high risk of exposure to HIV through sex. Cost–benefit models may be limited by lack of definitive transmission parameters in US populations and should therefore be conducted with appropriate sensitivity analyses. Surveys may increase our understanding of the acceptability of adult male circumcision among groups of uncircumcised adult males in the US for whom circumcision might be recommended , and of barriers and facilitators to acceptance of adult male circumcision, were it recommended as an HIV prevention strategy. Given recent trial results and international consensus that male circumcision is efficacious, it is important to consider ethical questions about whether equipoise exists for a US MSM trial, and about how to implement trials or programs of male circumcision in the context of complex cultural and religious views about circumcision . EvaluatFurther, recommendations about circumcision in newborns or high-risk adults for the prevention of HIV infection cannot be made without a more comprehensive discussion of other, documented disease prevention benefits and risks of circumcision. Benefits include reduction in acquisition of sexually transmitted genital ulcer disease, infant urinary tract infections, penile cancer, and cervical cancer in female sex partners ,40–43. Ahttp://www.cdc.gov/hiv/).To address these scientific and policy questions with a broad group of stakeholders, the US Centers for Disease Control and Prevention convened a consultation in April 2007 to gain diverse input about the public health research agenda and to develop public health recommendations about the role of male circumcision for prevention of HIV in the US. The summary of the outcomes of the consultation will be made available later in 2007, via the Centers' Division of HIV/AIDS Prevention Web site (


Because of the paucity of effective evidence-based therapies for children with recurrent abdominal pain, we evaluated the therapeutic effect of guided imagery, a well-studied self-regulation technique.22 children, aged 5 – 18 years, were randomized to learn either breathing exercises alone or guided imagery with progressive muscle relaxation. Both groups had 4-weekly sessions with a therapist. Children reported the numbers of days with pain, the pain intensity, and missed activities due to abdominal pain using a daily pain diary collected at baseline and during the intervention. Monthly phone calls to the children reported the number of days with pain and the number of days of missed activities experienced during the month of and month following the intervention. Children with ≤ 4 days of pain/month and no missed activities due to pain were defined as being healed. Depression, anxiety, and somatization were measured in both children and parents at baseline.At baseline the children who received guided imagery had more days of pain during the preceding month . There were no differences in the intensity of painful episodes or any baseline psychological factors between the two groups. Children who learned guided imagery with progressive muscle relaxation had significantly greater decrease in the number of days with pain than those learning breathing exercises alone after one , and two  months and significantly greater decrease in days with missed activities at one  and two (95% vs. 77%. P = 0.05) months. During the two months of follow-up, more children who had learned guided imagery met the threshold of ≤ 4 day of pain each month and no missed activities  than children who learned only the breathing exercises.The therapeutic efficacy of guided imagery with progressive muscle relaxation found in this study is consistent with our present understanding of the pathophysiology of recurrent abdominal pain in children. Although unfamiliar to many pediatricians, guided imagery is a simple, noninvasive therapy with potential benefit for treating children with RAP. Chronic pain is a significant problem in the pediatric population . One of Recent systematic reviews of the treatments for functional gastrointestinal disorders in children found weak evidence for the effectiveness of very few therapies -12. Two In attempts to understand the nature of functional gastrointestinal disorders researchers have focused on the functioning of the enteric nervous system (ENS). The ENS acts as a local minibrain producing the same neuropeptides and neurotransmitters found in the central nervous system (CNS) . These aBecause of these recent findings, our current understanding of functional gastrointestinal disorders has moved from a biomechanical model towards one with a biopsychosocial emphasis . This unGuided imagery is one form of self-regulation therapy. During the process, a state of deep relaxation is induced using progressive muscle relaxation (PMR) which allows the subject to then be guided in actively creating images that facilitate resolution of certain problems. This differs from hypnosis in that the child, through imagery, creates his own solution to the problem rather than the therapist offering suggestions for change. This process is felt to be especially effective in children because of their ability to have creative, active imaginations with a high degree of suggestibility . We consThis makes guided imagery a potentially ideal modality for treating children with functional gastrointestinal disorders. With physical relaxation and behavior modification through imagery, there may be regulation of gastrointestinal motility and an increase in the visceral pain threshold in these children. Because of our success with this technique during a pilot study , we condThe methodology of this study was based on the guidelines outlined by an international panel of experts that convened for the design, conduct, and analysis of treatments trials in functional gastrointestinal disorders (Rome II) . AdditioChildren 5–18 years of age were recruited from pediatric gastroenterologists within the University of Arizona Department of Pediatrics and general pediatricians throughout the greater Tucson metropolitan area. Inclusion criteria included a history of at least 3 episodes of abdominal pain over the previous 3 months severe enough to affect their normal activity. All participants had a complete history and physical performed by their pediatrician or pediatric gastroenterologist and had a minimal laboratory evaluation including a complete blood count, sedimentation rate, and urinalysis. All other diagnostic tests were performed at the discretion of the treating physician. Participants were required to be stable on any current medications they were taking and asked not to add, delete, or change the dosing of any medication for the duration of the study. Participants were required to be English-speaking. Exclusion criteria were unwillingness to participate, chronic documented gastrointestinal disease, cognitive-developmental delay or major dissociative disorder as determined by history as the latter two are contraindications for doing guided imagery. The Institutional Review Board of the University of Arizona approved this study. Informed consent and assent for participation were obtained from the parents and children, respectively.Daily pain diaries were obtained at baseline by the child for at least 2 weeks prior to the start of the intervention and during the first month of the intervention. These were used to record the number of days with pain and to rate the intensity of pain experienced. To rate the intensity children used the FACES scale  of 0–6 fBaseline questionnaires to obtain symptom and psychological measures were completed both by the child and the parent. These included, for the child, the Bowel Symptom Questionnaire (BSQ) adapted from Talley's instrument for use in children , Child DOur hypothesis was that guided imagery with progressive muscle relaxation would be superior to breathing techniques alone for managing the symptoms of functional gastrointestinal disorders, therefore subjects were randomized to receive either breathing techniques alone or guided imagery with PMR. Two randomized tables were used depending on the source of the referral–pediatric gastroenterologist or general pediatrician–and further stratified by age, grouped age 5 < 12 and = 12 to 18. Random assignment was made in groups of four by drawing tokens out of a hat by the biostatistics core group assisting with this study. This randomization list was given only to the therapists teaching the breathing techniques and guided imagery and was concealed until the intervention was assigned. No other member of the research team was aware of the group assignments. All treatments, regardless of the group, were referred to as "relaxation techniques", which allowed blinding of the research associate collecting outcomes and some degree of masking of subjects not previously aware of these therapies.For those randomized to receive guided imagery, four sessions were done on a weekly basis. During the first session, which lasted about 1 hour, participants were instructed on progressive muscle relaxation which led into the guided imagery. Once achieving relaxation, subjects were asked to invite an image to come to mind that represented their pain. They were encouraged to describe the image in detail using all the senses as the more detailed the image is sensed, the more potential the pain reliever it could be. Once this image was established, they were then asked to invite a second image to come that would get rid of the pain (first image). An audiotape of the relaxation and imagery was sent with the subject to practice at home twice daily. Three follow up sessions, which lasted 20–30 minutes, were done to assess competence, to assess compliance with daily practice, and for reinstruction and reinforcement. No psychotherapy or further counseling occurred during these sessions.The control group was designed to mimic the intervention in order to control for the therapist's time and attention. Those randomized to receive the breathing techniques also met weekly with the therapist for 4 sessions. During the first session of approximately 1 hour, subjects were instructed on 3 breathing techniques that facilitate relaxation: abdominal breathing, "breathing in fives" , and "bubble breathing" . After practicing these techniques to achieve relaxation, an audiotape was made for subjects to take with them to practice at home twice daily, repeating each of the three exercises 5 times apiece. At each of the 4 sessions, subjects were evaluated for their competence in performing these exercises to achieve relaxation. In the 3 follow up sessions that lasted approximately 20–30 minutes, assessment of compliance of practice, and if needed, reinstruction of the techniques was performed.Pain outcomes measured were number of days with pain per month, mean pain intensity per pain episode, and the number of days with a missed activity due to abdominal pain per month. However, since the Rome II expert panel recommended that the primary outcome measure be the percentage of subjects meeting a predetermined clinical outcome, we used as our primary outcome the percentage of children who had ≤ 4 days with pain and no missed activities during the previous month . The terAll analyses were compared using Chi-square or Student's t-test after transformation of non-normally distributed continuous variables when appropriate. An alpha of < 0.05, two-sided, was considered statistically significant. Because families were asked to continue to complete pain diaries until they received the intervention, the number of actual days of completed diaries varied among subjects, ranging from 14 to 43 days. Therefore, the number of days with pain and number of days with missed activities were standardized to 30 days, allowing the presentation of number of days during the "previous month" at baseline.Between July 2000 and June 2002, 31 children were assessed for eligibility. All met inclusion criteria, however 4 refused to participate. [Figure Baseline characteristics of the final study population are summarized in Table Table Figure The primary finding from this study was that children suffering from RAP who learned guided imagery with progressive muscle relaxation were much more likely to improve and ultimately be healed than children learning breathing techniques alone. In addition, the greater therapeutic effect of guided imagery with PMR was sustained after termination of the intervention and occurred in spite of the children in this group who entered with more frequent complaints of abdominal pain.Since Apley's description of recurrent abdominal pain in school-aged children in the 1950s, physicians and researchers have sought treatments for functional gastrointestinal disorders using the model most prevalent in the medical system–that of a biomechanical approach. Unfortunately, this approach has not led to effective therapies as evidenced by the recent evidence-based review of pharmaceutical therapies by the Cochrane Collaboration . This reAs our knowledge of the brain-gut interaction has grown, researchers and physicians have utilized the mind-body techniques as effective therapy for functional gastrointestinal disorders. Gastrointestinal symptoms have improved with the use of hypnosis and relaxation training in adults with IBS ,53. In aIn our protocol we specifically encouraged the participants to create their own image that represented their pain and a second image that would take their pain away. One young adolescent participant very vividly described a large, red, hot, immovable boulder to represent his pain. As his solution, he imagined first a trickle of rain, then a more forceful rain, and eventually, torrents of rain. The rain initially bounced off the hot rock, but then eventually cooled it–changing its color to a dull brown–broke the boulder into small pieces, and then washed it completely away. Most participants had no problem creating their own images at the first session and showed competence in doing this technique on their own.There are four potential limitations of this study. First, all children did not have the same diagnostic evaluation, which might have differed between general pediatricians and pediatric gastroenterologists. However, we previously found no differences between children referred from generalists and specialists . Our useIt is not surprising that a mind-body therapy, such as guided imagery, is effective for RAP as functional gastrointestinal disorders are theorized to be the result of a dysregulation of the brain-gut neuroenteric system, much like anovulatory bleeding is a dysregulation of the hypothalamic-pitutary-ovarian system . Our stuGuided imagery techniques along with progressive muscle relaxation is more effective than breathing and relaxation techniques for reducing pain episodes and missed activities in children with RAP. The response to guided imagery in this group of children with RAP was rapid, sustained, clinically effective and not associated with any apparent side effects.This study is relevant to pediatrics as recurrent abdominal pain is a common complaint in children with very few treatments that have been found to be efficacious in the recent systematic reviews. Guided imagery is one type of self-regulation technique that has been beneficial in treating other pain syndromes and now found, in this study, to be beneficial in treating recurrent abdominal pain. Use of this type of therapy early in the course of the evaluation and treatment of RAP may reduce not only the number of days with pain with subsequent return to regular activities, but also reduce health care costs by decreasing the use of medical services.The author(s) declare that they have no competing interests.JW participated in study coordination and execution, and drafting of the manuscriptDS conceived the study and participated in its design and coordinationSA conceived the study and participated in its design and coordinationCM participated in study design, coordination, and executionAC participated in study design, coordination, and executionTB participated in study design, performed statistical analysis, and drafting of the manuscriptAll authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


India enjoyed early initial successes in vaccine development and indigenous production of vaccines in the public sector. But the country now faces a growing gap between the demand for and supply of essential vaccines. Vaccines are important preventive medicines for primary health care, and are a critical component of a nation's health security. Although international agencies such as the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) promote global immunisation drives and policies, the success of an immunisation programme in any country depends more upon local realities and national policies . This isdisease surveillancepathogen variationsincidence levels that qualify for mass vaccinationdevelopment and/or procurement of vaccineschoice of technologieschoice of selective vs. universal vaccination (even among childhood vaccines)logistics, cost-benefit analyses, and resource mobilisationThe current Indian market for vaccines is estimated to be about US$260 million . India iThe history of vaccine research and production in India is almost as old as the history of vaccines themselves. During the latter half of the 19th century, when institutions for vaccine development and production were taking root in the Western world , the BriHaffkine's development of the world's first plague vaccine in 1897 , later named the Haffkine Institute) and Manson's development of an indigenous cholera vaccine at Kolkata during the same period bear testimony to the benefits of the early institutionalisation of vaccine research and development in India . Soon, IHowever, the benefits of this early institutionalisation did not last long. The policies of the colonial government ensured that Indian scientists were not a significant part of this intellectual legacy. By the time Indians inherited the leadership of the above institutions in the early 20th century, research and technological innovation were sidelined as demands for routine vaccine production took priority . By the What were the factors that led to the stagnation in vaccine development efforts between the time of Haffkine's success and India's independence? These included the pressures of routine production and service functions, financial constraints, lack of institutional mechanisms to foster and link up research and technology development, and the absence of an interdisciplinary approach. All these factors posed a threat to India's vaccine development efforts .One year after its independence in 1947, India became a member country of the WHO and eagerly aligned itself to the policies of the WHO and UNICEF. Many new Indian institutions were established with partial support from international organisations during the period 1950–1970.However, after independence, it took three decades for India to articulate its first official policy for childhood vaccination, a policy that was in alignment with the WHO's policy of “Health for All by 2000” . The WHO's policy recommended universal immunisation of all children to reduce child mortality under its Expanded Programme of Immunization (EPI). In line with Health for All by 2000, in 1978 India introduced six childhood vaccines  in its EPI. Measles vaccine was added much later, in 1985, when the Indian government launched the Universal Immunization Programme (UIP) and a mission to achieve immunisation coverage of all children and pregnant women by the1990s.Vaccine requirements for India's EPI have been met mainly through the public-sector vaccine institutions, as was the case in most parts of the world until the 1980s. However, the Indian public sector failed to introduce new technologies of production  or to expand production to become self-reliant in producing oral polio vaccine (OPV) or the measles vaccine . Thus, eIn some cases, indigenously manufactured vaccines were stopped in favour of imported vaccines. For example, the Pasteur Institute of India in Coonoor indigenously produced polio vaccine during the period 1967–1977 with the help of seed virus from Dr. A. B. Sabin (who developed OPV) and with the approval of the WHO. However, the Indian government discouraged its production in 1977, alleging that one of the batches was virulent, and since then OPV has become one of India's major imports . SubsequIn 1987, the Union  government's Department of Biotechnology established a new public sector unit, Bharat Immunologicals and Biologicals Corporation Ltd.  with technology transferred from the Institute of Poliomyelitis and Viral Encephalitis . The first phase of production was based on repackaging OPV imported in bulk from Russia. The aim was for OPV production to be completely indigenised in the second phase, within five years. However, the first phase continued (with imports) until the year 2000, when such importation supplied 70 million doses of OPV to UNICEF and earned a net profit of Rs 8 million. Yet, in 2000, the government declared Bharat Immunologicals and Biologicals a sick unit , and its revival remains uncertain.It is strange that there is no published analysis as to why OPV production in the Indian public sector has failed repeatedly while Panacea Biotec, an Indian private sector firm, has recently secured a comfortable position as a WHO pre-qualified supplier of OPV for UNICEF. Panacea repackages its OPV from imported bulk OPV obtained from Biopharma  and Chiron . Some argue that even though India always had an effective indigenous injectable polio vaccine (IPV), OPV was recommended in developing countries because international organizations were trying to find new markets for United States multinational corporations (since market demand for OPV ceased to exist in the US and other developed countries by the end of the 20th century) .The failure of the Indian public sector in vaccine production was not limited to OPV. In 1984, the government took over Bengal Immunity Ltd. , a loss-making private company, and revived it so that it could supply TT, DT, DPT and other products to the government. But within a decade, the government declared that the company was financially unviable and eventually closed it. Similarly, in 1989, the Union government's Department of Biotechnology established a new public sector unit, Indian Vaccine Corporation Ltd. (IVCOL) at Gurgaon, for the indigenous production of measles vaccine with technology transferred from Institut Merieux, a public sector company based in Lyons, France. However, the technology transfer never materialised, as the private sector took over the French public sector firm and denied the technology transfer to IVCOL [The inability of the Indian public sector to recover from its mounting failures to achieve self-sufficiency and self-reliance in primary vaccines is also related to the liberalisation and globalisation of the Indian economy. It is not a coincidence that these failures and closures, and the preference for imports (while paying lip service to self-reliance), happened after the Indian government liberalised its economy in 1991 as prescribed by the International Monetary Fund and the World Bank. It is no longer fashionable to produce vaccines in the public sector in India, let alone to try and revive failing public sector units, even if essential vaccines are not available from the private sector.http://www.unicef.org/supply/index_vaccine_security.html).One of the main reasons for the growing gap in demand for and supply of primary vaccines in India is that while public sector production is on the decline , vaccinehttp://www.unicef.org/publications/index_4442.html).Shortages of primary vaccines in developing countries began to emerge in the late 1990s. These shortages were due to the introduction of new, more sophisticated, more expensive vaccines in industrialised country markets, leading to manufacturers phasing out the production of the traditional, less expensive vaccines used in developing countries. Between 1998 and 2001, ten out of 14 major manufacturers partially or totally stopped production of traditional vaccines. Eight of these firms were the main suppliers of vaccines to UNICEF. Of these eight, six were involved in mergers between larger pharmaceutical companies. The overall outcome of these developments is that the availability of primary vaccines to UNICEF has dramatically decreased, while the prices have increased  of India's current human vaccine market is mainly attributed to the new, high-priced vaccines  such as Many western countries have included several other new vaccines  in their regular immunisation programmes . These tThere is another serious contradiction that grips the global drug and vaccine industry. For curative medicine, the pharmaceutical industry places increasing emphasis on the use of genomics and bioinformatics to move toward customised medicine to suit different populations. And yet in vaccines, the tendency is to move toward a “one vaccine fits all” regime. This would be fine if the vaccines were specifically designed for universal use, but there was no attempt to conclusively establish that the imported vaccines actually suited the Indian strains of the pathogens before they were adopted. Doubts over suitability that have subsequently emerged have not been adequately addressed. With the decline of epidemiology and disease surveillance in India, and the main emphasis being on the statistics of vaccine “coverage” rather than the immune protection achieved, it seems that spending money on vaccines is more important than actual disease prevention. If these trends continue unabated, they will lead to serious distortions in the vaccination programmes of India and other developing countries facing a similar situation.India enjoyed the advantages of early initial successes in vaccine R&D and indigenous production in the public sector, but the country is increasingly unable to cope with the growing gap in the demand and supply of UIP vaccines . The avaThe first and foremost element in this strategy must be the decisive intervention of the Indian government to meet the shortfall in the UIP vaccines. This may be done either by strengthening the public sector wherever possible, or by taking suitable (and transparent) measures to encourage the indigenous private sector on a case-by-case basis to make safe and effective vaccines available at affordable prices. The suitability of imported vaccines to deal with Indian pathogenic strains also needs to be conclusively established wherever necessary. The health security of a nation of India's size cannot be left to the vagaries of global market forces. With a strong will and a small amount of planning, the current situation in India can be reversed, and India can even play a major role in meeting the global shortfall in the vaccines procured by UNICEF.Secondly, India needs to strengthen epidemiology and revive the collapsing disease surveillance system. This would help to decide between universal or selective immunisation based on unequivocal scientific evidence, as well as to respond to the changing disease prevalence scenario on the ground, which may call for a move from universal to selective immunisation or vice versa. Some diseases may not need vaccinating against at all, and may be better controlled by other strategies, such as better sanitation, vector control, quarantine, and curative medicines. National immunisation programmes must be led by scientifically established public health needs and not by the mere availability of a vaccine in the market.Thirdly, a strong emphasis on in-house R&D is needed in order to ensure that our production technologies are in tune with the times, and to negotiate strategic partnerships with outside scientists or institutions and companies.Last but not least, the Indian government should actively encourage independent policy research, cost-benefit studies, and wider national consultations on various aspects of vaccination and public health so that it can take more informed decisions on such matters.


Since the stage of cancer detection generally predicts future mortality rates, a key cancer control strategy is to increase the proportion of cancers found in the early stage. This study compared stage of detection for members of rural and urban communities to determine whether disparities were present.The California Cancer Registry (CCR), a total population based cancer registry, was used to examine the proportion of early stage presentation for patients with breast, melanoma, and colon cancer from 1988 to 2003. Cancer stage at time of detection for these cancers was compared for rural and urban areas.In patients with breast cancer, there were significantly more patients presenting at early stage in 2003 compared to 1988, but no difference in the percentage of patients presenting with early stage disease between rural and urban dwellers. There were no differences in incidence in early stage cancer incidence between these groups for melanoma patients, as well. In colorectal cancer in 1988, significantly more patients presented with early stage disease in the urban areas . However, over time the rural patients were diagnosed with early stage disease with the same frequency in 2003 as 1988.This analysis demonstrates that people in rural and urban areas have their breast, melanoma or colorectal cancers diagnosed at similar stages. Health care administrators may take this information into account in future strategic planning. Addressing identified pockets of health disparities within various population sub-groups has become a major focus among leading cancer organizations as they work toward achieving their cancer control goals ,2. ReseaPrevious studies have identified significant disparities in stages of diagnosis between people living in rural and urban areas, with a greater incidence of late stage diagnosis generally found in rural areas 11]. Thi. Thi11].While these factors are reported to contribute to a higher rate of late stage cancer detection in rural versus urban areas, a study by McElroy found no significant difference in early detection of cancer between urban and rural communities . He attrIn 1988, cancer was made a mandatory reportable disease in California. The California Cancer Registry (CCR) became the repository for the data. New cases are reported by physicians, health facilities, laboratories, and death certificates, and there are penalties for failure to report cases. The actual abstracting of cases is done by certified Cancer Abstracters. Ten Regional Cancer Registries were set up to act as the first-level receiving facility and to provide quality assurance, coordination of reports from multiple sources for the same patient, provide technical help to those reporting cases, and then to report the data to the central registry in Sacramento. At this level, there is further quality assurance, elimination of duplicate entries, clearance with death certificates, and mutual referral of reports of patients actually residing in other states and countries. The CCR is certified by the North American Association of Central Cancer Registries (NAACCR) and currently the entire state is part of NCI's Surveillance, Epidemiology, and End Results Program (SEER). California has the largest population of any single total population-based registry in the world.With California's very large population (36 million in 2003), CCR is the total population-based registry encompassing the largest population in the world, and probably, the most diverse. Sixteen years of data , with all patient, physician, and institutional identification removed, are available to researchers.The data set includes demographics of the patient, features of the tumor such as stage and histology, and follow-up information. The data are made available to qualified researchers on a CD. Intercensal population data developed by the California Department of Finance have been supplied by the CCR.There are no uniformly accepted definitions of "rural" and "urban" for registry data. We have chosen the one used by the California Rural Health Commission , using cUsing the above definitions of "rural" and "urban", all of the cases which had the years of diagnosis and Summary Stage of breast cancer, colorectal cancer, and cutaneous malignant melanoma from the years 1988 through 2003 were studied. For each type of cancer, data were tabulated by years of diagnosis and "early" versus "late" stage, using the "EpiInfo6" (CDC and WHO) software. As noted above, there are multiple levels of quality assurance, and the standards of the North American Association of Central Cancer Registries (NAACCR) are all met or exceeded. The tissue diagnoses of the original pathologists are accepted because central review would be a fiscal and operational impossibility. It should be remembered that the patient's therapy is based on the diagnosis by the local pathologist.Early" stage is defined as a Summary Stage of carcinoma-in-situ or localized tumor, and "late" stage is a Summary Stage of regional or distant disease. Summary Stages are rigorously defined by the NCI's Surveillance, Epidemiology, and End Results Program (SEER), the American Joint Commission on Cancer, and the American College of Surgeons. The definitions of stages differ from one primary site to another. While for clinical purposes it might be preferable to use the TNM System, there are no TNM staging data for the earlier years of CCR for all sites and thus not possible to use the TNM system. Moreover, to allow comparison with earlier registry data as well as data from other registries, the Summary Stage is more useful. When the data exist, cross- tabulations of Summary Stage "localized" against "T1N0M0" show a correlation of over 90%. We do not have data on Breslow stage. Staging data are not available for every case. Finally, while the CCR has information about ethnicity, there are not enough numbers in the non-white rural population to draw any meaningful conclusions to include in this manuscript. Because this study used the above data, it was exempt from the usual methods of Ethical Approval.Using the above definitions of rural and urban, the 28 rural counties were compared to the two urban counties with the greatest population density. Between 1988 and 2003 there were 59,615 total breast cancers in the registry and 19,428 were in rural patients and 40,187 were in urban patients. There were significantly more patients presenting at early summary stage in 2003 compared to 1988 . However, there was no difference in percentage of patients presenting with early summary stage disease between rural and urban dwellers. For example, in 2003, 70% of urban patients presented with early summary stage disease and 69% of urban patients were diagnosed with early summary stage breast cancer. . However, over time the rural patients were diagnosed with early summary stage disease with the same frequency and in 2003, there was no difference in percentage of patients with early summary stage disease  on the incidence of early stage melanoma. Van Durme et al. examined the database from the State of Florida and found that lower median educational attainment but not rural verses urban residence increased the risk of presenting with late-stage disease . This stLastly, this study did find, like other previous investigators, that there were more locally advanced cancers in rural areas for colorectal cancer in the early period which may reflect less availability of practitioners and technology for screening. However, in the last few years that trend has reversed and there is no difference in incidence of early stage cancers for colorectal cancer as well. Other recent investigators have found that socio-economic status is a more important determinant of early stage disease than rural or urban residence. For example, recent publications concerning these issues in Florida found that socioeconomic status predicted advanced stage disease, but not rural residence and Koka et al. found that in North Dakota distance from a tertiary care center did not seem to be a barrier to early diagnosis of colorectal cancer,21.At present in California, the California Cancer Registry data demonstrate that people in rural and urban areas have their cancers diagnosed at comparable stages. Health care administrators may take this information into account in future strategic planning.The author(s) declare that we have no competing interests.SLB originated the idea for the manuscript and wrote the majority of the article. RB, CS and AT researched the literature and helped write the background material. GS assembled the team, organized its meetings and assisted in the preparation of the manuscript. SS analyzed the data from the CCR database wrote the methods section and assisted in the preparation of the manuscript.The pre-publication history for this paper can be accessed here:


This paper discusses how Mozambique coped with the health system needs in terms of specialized doctors since independence, in a troubled context of war, lack of financial resources and modifying settings of foreign aid. The Ministry of Health (MOH) managed to make up for its severe scarcity of specialist MDs especially through contracting expatriate technical assistance. Different scenarios, partnerships and contract schemes that have evolved since independence are briefly described, as well as self-reliance option possibility and implications. Lessons learned about donor initiatives aimed at contracting specialists from other developing countries are singled out. The issue of obtaining expertise and knowledge in the global market as cheap as possible is stressed, and realistic figures of cost planning are highlighted, as determined by the overall health system necessities and budget limitations. Shortly after independence 1975), the mass repatriation of the Portuguese cadres working in the Health System left the MOH with the urgent need of finding specialized medical doctors (MD) for its referral hospitals. In 1972 there were 289 MDs in the country 975, the , most ofThe health sector in Mozambique is heavily dependent on external financial support (about 60% of the budget in 2004), while donors are progressively dropping financial mechanisms aimed at particular health programs or sectors for a broader policy of budget support. Dependence could increase with the expected worsening of the AIDS epidemic. The new AIDS program in Mozambique, aimed at rapidly expanding the access to ARV treatment for AIDS-patients, will create more demand for MDs, in a country where the estimated number of HIV-positive people presently amounts to 1 400 000. The total salary bill is increasing because of the growth of the entire health workforce (to cope with the new demand brought by AIDS) and because of a faster increase of graduated and middle level cadres [More than 90% of the health system is made up of a multitude of minuscule health centres and posts with very basic resources, and managed by elementary and basic level health personnel. In spite of figures of MD per capita in Mozambique being among the lowest in the world, work load for MDs and specialists working in the country's few sizeable hospitals does not look particularly high, at least not higher than what may be found in other sub-Saharan African Countries. ,6.Table Table Most specialists hired through the pooling mechanism are senior cadres with a long in-country experience, working out of the capital, which puts their cost relatively high, but rewards the health system with higher reliability. The number of doctors paid by this scheme oscillated between 50 and 60 annually, from 1996 to March 2000, the year in which donors withdrew their support from MD pooling . It was Pooling was unanimously considered a simple and successful initiative. Its dismissal was blamed, among others, 'on strained communication between the MOH and financers, lack of consensus between donors, poor coordination inside the MOH, unclear roles of involved parties and unrealistic expectations about the quick replacement of foreign physicians with national ones' .The MOH and the Swiss Development Cooperation (SDC) have agreed a 'topping up' for national specialized MDs since 1997. It allows the MOH to have senior national cadres in all referral hospitals, with tasks of enforcing therapeutic and procedural national norms, coordination, supervision and teaching. Between 11 and 15 national specialists were contracted annually under this scheme until 2002. Currently their number is increasing. By topping up, national specialists could gradually replace expatriate ones contracted by the previous pooling agreement. A Sector Wide Approach (SWAp) financial scheme replaced the SDC as topping up financer in 2004; more posts are expected to be filled (25) by the gradually increasing number of newly trained specialists.Direct Government agreements offer the advantage of lower transactional costs compared to individual contracts. On the side of Mozambique the only duty is to identify the needed specialities and to map the vacancies nationwide. However, it implies a very centralized process, where the headquarters makes a national plan and contracts the MD on behalf of every hospital involved. This approach seems at odds with the public sector reforms undertaken in Mozambique, directed to allow more autonomy in fund and resource management at lower levels of decision making. As elsewhere in health management, it is difficult to define a fair trade-off between efficiency gains and a sound management built on local capacity. Moreover, as in other African countries , almost Most doctors under this scheme come from developing countries, had been previously contracted under a GBA, and are continuing on an individual basis after their first contract terms came to an end. A very small fraction is made up of Portuguese doctors who remained in Mozambique after independence, or by MD catholic priests willing to work within the NHS.In sum, a kind of osmosis exists between the different categories of expatriate specialists. Part of those contracted through bilateral agreements, after fulfilling their terms, manage to remain in Mozambique, shifting to 'ex-pooling' mechanisms or other kinds of individual contracts and/or, in some cases, to private practice. Thus, through a process of selection between expatriate specialists and a group of long-term residents, culturally and socially integrated MDs emerged as a structural and considerable component of the medical workforce in Mozambique.Table Local Technical Assistance (TA) in Africa is becoming increasingly expensive . At leasIn Mozambique, it is the limited availability of medical specialists which puts salaries relatively high. Moreover, their scarce number means a profitable market for the suppliers, because the demand for better, individual services is constantly increasing among the growing urban bourgeoisie.As in many other countries , most MoAt present, the availability of newly trained national specialists is increasing, notwithstanding the shortage of young MDs and the scarcity of training hospital capacity for all but the most basic specialities. The State Medical School (UEM) has trained MDs at a discouragingly low pace. On average, from 1975 to 2003, 22 MDs were trained annually in Mozambique. Drop-out rates have been astonishingly high, as well as unit training costs. This was ascribed to many difficulties such as poor high school preparation, lack of books and bibliography, erratic follow-up by tutors in the teaching at Maputo central hospital and insufficient financial support. Students are also unsatisfied with the burden of lecturing and quality of teaching .A curricular reform is now under way together with the hiring of new lecturers (mainly from Cuba), and in the next three years these figures are expected to rise to 50–60 MD/year. Figures will still grow to an average of 120 MD trained per annum after 2007, when a new, private University in the central town of Beira, a recent institution functioning since 2001, will begin to yield its first graduates.Between 1991 and 2002, the average annual output of specialized Mozambican MDs inside and outside the country has been only 7. In 2003, 21 new MDs completed their post-graduation, and 70 more are expected to be trained between 2004 and 2007.The salary gap between nationals and expatriates for vacancies outside the capital was already being closed by the topping-up scheme. Eventually, no substantial savings from the substitution of foreign MDs with national MDs should be expected. The international oversupply of MDs  floods the global market with a large supply of well-trained, disciplined and relatively cheap specialized cadres, who could be hired for reasonable salaries to work in countries where lack of MDs is still severe. It has been argued that "self-reliance is not the ultimate objective, in a world where all countries are competing for intellectual capital on a global basis, and when foreign aid is as much about knowledge as it is about money" .Although medical students originate from all the country's provinces, once they are admitted by the State University, their expectation is to obtain a job in the capital city. This is the first of many 'pull factors' which will maintain the high concentration of MDs in Maputo, to where they will return once their two-year term of mandatory rural employment as junior doctors is completed . In factThe national political option to carry out a public sector decentralization policy could give rise to more individual contracts of national or expatriate MDs but, as it has been observed, decentralization has often remained a discourse, with civil service reform having been announced several times, but never really having materialized . It shouExpatriate MD contracting in Mozambique has been a history of effective policy and also a rare example of sound pragmatism which prevailed against old-fashioned nationalist wishful thinking. The way a pooling mechanism supported by the donor community funded the salaries of high level expatriate medical cadres directly chosen by the recipient country, has been a positive, noteworthy experience. Allopathic medicine speaks the same language everywhere. Universally, medical universities offer remarkably homogeneous curricula; doctors update their knowledge through the same basket of international medical literature. In the global market the medical profession is rather easy to sell and purchase. When expatriate doctors learn the immigration country's language and health system rules, their integration is quickly achieved. For ordinary referral hospitals posts, lack of sophisticated diagnostic devices and expensive drugs make specialists from other developing countries more suitable to the local situation than their first-world counterparts, who are used to working in a more 'professional' environment, with technical support and at a cost too distant from what they could find in Mozambique. In global terms, a redistribution of the medical workforce, acting on economical incentives – from countries where it is excessive to countries where it is still scarce – makes sense and should be encouraged. In the end, at least in Mozambique, expatriate specialists do not cost significantly more than national ones. Increasing budget support by the donors should enable governments to recruit specialized MDs from countries where expertise is reasonably cheap, such as Cuba, the former Soviet Union, China and India. Thus, as a little contribution to alleviate the enormous health problems of Africa, a pattern of "poor"-to-"poor" cooperation, may be encouraged, supported financially by the wealthy North – a system that has proven to have been cost-effective in Mozambique.The two different kinds of contracts for specialized MDs , proved to be equally useful, offering balancing advantages to the health system. In the future, real willingness to decentralise responsibilities and competences, improvement in management capacity and cost considerations would be the factors favouring individual instead of collective contracting mechanisms for employment of expatriate MDs.From a Mozambican perspective, a sustained increase of specialised MDs in the public sector outside the capital district would be fully meaningful only if it were in line with an upgrading of the health system as a whole , and/or if these cadres were more thoroughly employed in activities of training and supervision. In the first case, the critical health policy issue would be about how and where to direct major investments financed from the scarce resources available. In the second one, an efficient way of coordinating activities of systemic supervision, on-the-job training of the supervised cadres and initial training must be found, which means for the most differentiate referral units to take responsibility for the medical care provided in all the health facilities within their catchment area. Otherwise, it would be nonsensical to hire expensive, well-qualified health cadres without adequately using their skills. A more balanced distribution, based on work load comparisons between hospitals of the same level, could also be useful in improving efficiency. Finally, the option of improving high-quality health services must be weighed up against the needs of expanding a primary health network which, at the moment, barely gives access to 50% of the population.The author worked as a technical advisor to the Human Resources Directorate, in the Ministry of Health of Mozambique from 2000 to 2004.Ferruccio Vio is entirely responsible for the final manuscript. The views expressed in the paper are those of the author only and do not necessarily represent the view of the Ministry of Health.


Spatial epidemiology is the description and analysis of geographic variations in disease with respect to demographic, environmental, behavioral, socioeconomic, genetic, and infectious risk factors. We focus on small-area analyses, encompassing disease mapping, geographic correlation studies, disease clusters, and clustering. Advances in geographic information systems, statistical methodology, and availability of high-resolution, geographically referenced health and environmental quality data have created unprecedented new opportunities to investigate environmental and other factors in explaining local geographic variations in disease. They also present new challenges. Problems include the large random component that may predominate disease rates across small areas. Though this can be dealt with appropriately using Bayesian statistics to provide smooth estimates of disease risks, sensitivity to detect areas at high risk is limited when expected numbers of cases are small. Potential biases and confounding, particularly due to socioeconomic factors, and a detailed understanding of data quality are important. Data errors can result in large apparent disease excess in a locality. Disease cluster reports often arise nonsystematically because of media, physician, or public concern. One ready means of investigating such concerns is the replication of analyses in different areas based on routine data, as is done in the United Kingdom through the Small Area Health Statistics Unit . In the future, developments in exposure modeling and mapping, enhanced study designs, and new methods of surveillance of large health databases promise to improve our ability to understand the complex relationships of environment to health. Spatial epidemiology is the description and analysis of geographically indexed health data with respect to demographic, environmental, behavioral, socioeconomic, genetic, and infectious risk factors. It is part of a long tradition of geographic analyses dating back to the 1800s when maps of disease rates in different countries began to emerge to characterize the spread and possible causes of outbreaks of infectious diseases such as yellow fever and cholera . Over thRecent advances in data availability and analytic methods have created new opportunities for investigators to improve on the traditional reporting of disease at national or regional scale by studying variations in disease occurrence rates at a local  scale . Such inWe note that an in-depth and individual-based approach might investigate how individuals interact with their environment and how these interactions affect health. This could address, for example, why people with higher incomes take more leisure-time exercise. Is it because they have a local environment more enticing, have the financial resources to engage in specific activities, have jobs that afford them more leisure time, or pursue more leisure-time activities for other reasons? Such questions may have an important spatial component. However, we see these as second-order issues beyond the scope of this article.We now briefly consider the analytic framework for carrying out spatial analyses and the types of studies commonly undertaken. We then focus on a number of challenges that face the practitioner of spatial epidemiology, including issues of data availability and quality, confidentiality, exposure assessment, exposure mapping, and study design.p-dioxin (TCDD) from the Seveso accident in northern Italy , and the statistical models used are often similar. Each of the above main types of inquiry is now considered in turn.As noted earlier, disease maps have a long history. A survey in 1991 identified 49 international, national, and regional disease atlases . An earli is estimated by the standardized mortality (or morbidity) ratio (SMRi), calculated as Oi /Ei, where Oi is the observed number of deaths or incident cases of disease in the area (assumed to follow an independent Poisson distribution). Ei is the expected number of cases . The SMR thus defined is based on indirect standardization. Some authors advocate direct standardization, as it involves adjustment to a common standard  ratios (SMRs) for geographic areas such as countries, counties, or districts. The rate in area standard . In our Although disease maps have both visual and intuitive appeal, caution is required in interpretation, as apparent patterns can be created or lost artifactually depending on how the mapped variable is depicted  and the geographic scale or resolution. The choice of colors for displaying data can also affect interpretation . Maps ofWhen constructing maps, users must select both the size of units and the method to aggregate units to highlight the features of interest. Homogeneity within aggregate groups is important for meaningful interpretation. Different scales and different aggregation strategies can lead to different but equally valid maps that emphasize different features of the data. In the geography literature, this is called the modifiable area unit problem . AlthougVariation in rates across the map may reflect differences in the quality of data, for example, in the diagnosis, classification, or reporting of disease , rather Ei and small populations will have large variability in the estimated rates. As these sparsely populated areas are often bigger than densely populated areas (because the administrative geography depends on population size), they tend to dominate the map visually even though they produce the least-precise risk estimates .Recent focus on small-area mapping studies, where typically the unit of analysis has a population of 5,000 or less , introduces an extra source of variability into the map because of random variation. Typically, sparsely populated areas with few (or zero) cases can generate extreme values of the SMR, as the variance of the SMR is inversely related to stimates . Methodsstimates  have beeAlthough map smoothing on average produce a more stable and realistic map, an important issue is the extent to which disease excesses in any truly high-risk areas  might be smoothed away. The degree of smoothing will determine the tradeoff between high sensitivity (truly high-risk areas correctly identified) and high specificity (areas without excess risk correctly identified). This tradeoff is important, as a sensitive but nonspecific measure will generate many false positive findings, whereas a specific but nonsensitive measure will miss areas with high risk. In geographic correlation studies, the aim is to examine geographic variations across population groups in exposure to environmental variables , socioeconomic and demographic measures (such as race and income), or lifestyle factors (such as smoking and diet) in relation to health outcomes measured on a geographic (ecologic) scale. This approach often takes advantage of data that are routinely available and can be used to investigate natural experiments where the exposure has a physical basis  . In addiThe development of the first cancer mortality atlases in the United States in the mid-1970s , 1976 shGeographic correlation studies are also carried out at a more local or small-area scale, where the problem of ecologic bias may be lessened as the analysis is closer to the level of the individual. For example, One important issue merits brief mention here. Informal geographic correlation studies  are often conducted by non-scientists in their own communities or neighborhoods out of personal concern. When one suspects a local disease excess, or when oneself, a family member or friend is stricken with cancer, one often asks “Why? What did I or they do wrong? What is it about where I live or where I work that caused this tragedy?” This concern may cause one to seek an explanation or to consider local industries or sources of environmental pollution as the putative cause. In this process, an informal geographic correlation is being undertaken, insofar as the health event and putative environmental exposure have been juxtaposed. Most such evaluations do not provide useful etiologic clues, as neither the underlying variability in disease rates nor the post hoc nature of the association with sources of environmental pollution are properly accounted for.Investigation of disease clusters and disease incidence near a point source usually assumes that the background risk surface is flat, against which a peak at the pollution source is being tested. If this is not the case and the background surface is bumpy, that is, there are peaks and troughs in the risk surface, this may indicate generalized or broad-scale clustering of the disease.  This tendency for disease cases to occur in a nonrandom spatial pattern relative to the pattern of the noncases has a more robust statistical formulation than the investigation of disease clusters per se and may give clues as to etiology . For exaPutative disease clusters may come to light because of media reports or be brought to the attention of the authorities by concerned individuals; as noted, often the apparent cluster will become linked with a local source of environmental pollution . In geneThe term disease cluster is poorly defined but implies an excess of cases above some background rate bounded in time and space. These boundaries may be ill-defined, and so-called boundary shrinkage may occur, accentuating the apparent risk by focusing the investigation tightly on the cases making up the cluster.The more narrowly the underlying population is defined, the less will be the number of expected cases, the greater will be the estimate of the excess rate, and often the more profound will be the statistical significance. Despite the inherent problems, the local public health department may find itself compelled to respond, if only to allay public anxiety . UsuallyDetailed checking of the cases. This is an essential step, as the putative cluster may involve a disparate group of diagnoses, some double-counting (duplicate records) may occur, and some cases may be erroneously reported. One also must verify the location (or geocode) of each case, which can be difficult in some locales.Definition of the boundaries in time and space so that a population denominator, by age and sex, can be constructed . Although accuracy is important, it is hard to validate the population data outside the census years, particularly as the areas get smaller.Estimation of the expected numbers of cases based on age- and sex-specific background rates .Calculation of the SMR for the area.p < 0.05) assuming a Poisson distribution for the occurrence of cases.Assessment of statistical significance , as such methods are not part of the routine armory of the public health specialist . In the Once a link between a putative disease cluster and a local source of environmental pollution has been put forward, it is extremely difficult to confirm or refute it without recourse to external data . Because an informal process of data comparison (akin to multiple testing) has taken place  in similar-sized localities elsewhere across the country, statistical testing in a formal sense is rendered invalid . Only diLocal concerns about a disease cluster in a particular area must be sympathetically and sensitively handled but will not usually lead to formal study or any new etiologic insight . Indeed,Occasionally it will be necessary to carry out more detailed inquiry. Investigations have adopted either the case–control e.g.,  or smalla priori concerns about a source of environmental pollution rather than in response to a claim of disease excess in a particular area, the statistical framework is again more robust, as a hypothesis can be set up and tested in the usual way. Investigation may involve a number of or all such sources in the region or country. This increases statistical power and overcomes the problem of selection where one site, or a few sites, are chosen for study, perhaps because of suspicion of disease excess in the vicinity. However, it makes the possibly unrealistic assumption that the sources are similar with respect to their potential to cause environmental health problems, and high risk around one or two sources (which may have high levels of toxic releases into the environment) may be masked. In the United Kingdom, national studies undertaken a priori include cancer incidence near municipal incinerators , they do give a valuable answer to the public health question “If I live near polluting source X, am I (on average) at increased risk of disease?” and may indicate avenues for further inquiry such as studies of pathways of environmental exposure, biomarker studies, or case–control studies.Surveillance, or the systematic routine collection and analysis of health outcome data for disease prevention and control purposes , can be Proactive surveillance systems have been effective for disease prevention and control when applied to infectious disease outbreaks, occupational exposures and disease , and advData quality issues are again important, as detecting apparent local clusters of disease may merely indicate areas with higher-quality data registration or perhaps areas of poor data quality where there are many duplicate registrations. Specificity is also a major issue, as, given the size of the database, the range of diseases, different age and sex strata, myriad definitions of areas of various sizes and configuration, and so forth, many false-positive clusters are bound to occur. For a surveillance program to be efficient and effective, researchers must provide methods for discrimination of true alarms, false alarms , and those situations that are less clear or equivocal, so that health department officials would not be obliged to follow up all apparent aberrations. One possible approach is to survey potential local sources of risk for the specific disease in question as is done currently for many cluster reports and respond only if there is an independent source of confirmatory or consistent environmental evidence. For those disease excesses for which there is a plausible, nonenvironmental explanation, clear and thoughtful communication to concerned communities based on solid scientific evidence could help dispel their urgent concerns.For these reasons, in common with most public health departments, we do not currently advocate carrying out surveillance for chronic disease excesses as a matter of public health practice. We believe that this type of surveillance should not be put into practice until such time as the underlying data and methodologies provide a robust framework to support this activity, as would be the requirement for screening for other public health concerns. Nonetheless, we believe that development and evaluation of surveillance approaches is an important and priority area for future research on disease clusters.http://www.cdc.gov/nceh/tracking).To carry out small-area studies using routine data sources, the basic data need to be made available, with high quality, and the inclusion of a geographically referenced code, such as the postcode in the United Kingdom or the census block or block group in the United States. Data should include (at the least) cancer registration as well as mortality, natality, and population data. Although natality and mortality data are a statutory requirement in developed countries, not all countries (including the United States) have a national cancer registry, reducing the ability to carry out studies of environmental health problems. In the United States, the Centers for Disease Control and Prevention (CDC) has established a program in environmental public health tracking, one component of which funds states to develop additional registries of health outcomes, such as asthma, for assessment of possible environmental etiologies  are likely. In contrast, for spatial epidemiologic studies that rely on routine data sources, it is usually not possible to carry out detailed validation studies of the database. However, some assessment of the basic quality of the routine data is essential to inform their use in spatial analyses, and some limited validation of the cases might be undertaken . As alreOne type of relevant data not readily available in the United States or the United Kingdom is the history of residential locations. For longer-latency health outcomes, such as cancer incidence and many types of mortality, knowing the residential history of an individual would be far more useful for reconstructing exposure histories than his/her location/residence at time of diagnosis or death. Even for natality data, it has been shown in small studies in both the United States and the United Kingdom that between 20 and 25% of women change residences between date of conception and delivery . HoweverIn contrast, the Scandinavian countries maintain historical registries of residences, and these have proved invaluable, as in the example already noted of constructing exposure histories to low-frequency electromagnetic fields from overhead power lines . In the In the future, the increasing use and availability of computerization in medical care means that large new databases of morbidity, linked to individuals, may become available. Examples include general practitioner consultations in the United Kingdom, whereas in the United States there is particular interest in syndromic surveillance e.g., . The quaThe current climate of legislation in the United States and the European Union is providing greater recognition of the rights of individuals to confidentiality of personal data, including health data, and the need for consent for medical investigations. In 2003, the United States brought into force the Privacy Rule  arising In addition, with the recent increase in availability of fine-scaled, geocoded data, there is a new concern about the confidentiality of blocks, neighborhoods, and communities. The ability to acquire data and map high rates of adverse outcomes, clusters, or areas with high levels of pollutants can cause concern and outrage and possibly influence property values. Yet, rules and principles of good practices for analysts and others are still in the formative stages. Providing researchers access to these data is necessary for this field of research to progress, but implementing appropriate controls for confidentiality and protection of data is essential to maintain the trust and support of the public.The quality of the exposure data has been regarded as the Achilles heel of environmental epidemiology. This holds true for spatial epidemiology, where distance is often used as a proxy for exposure to environmental pollutants, or some other geographic measure is used, for example, plume modeling . AlthougSuch approaches may provide valid first-order approximations to group or population exposure but may not capture individual exposure well nor allow for individual variations in absorption and susceptibility. Poorly measured exposure data can produce differential errors leading to systematic bias or result in random errors or imprecision, which (unless corrected) typically lead to bias toward no effect . More geequating environmental exposure  with biologic  doseequating current exposure with past exposureequating modeled estimates of exposure (including distance-based measures) with true exposureequating exposure at a point  with total personal exposure, that is, exposure integrated over the course of daily activities as the individual moves through the exposure fieldequating group exposure and group exposure–disease relationships with individual exposure and relationships at the individual level, that is, ecologic fallacy .An important issue in geographic analyses is the extent that the population of the areal unit is homogenous, both with respect to the environmental exposure under investigation and potential confounders. Within-unit variability in these factors could lead to bias in risk estimates . RecentlIn the future, developments in exposure biomarkers  and moleOne of the opportunities presented by GIS technology is the adaptation of traditional study designs to the spatial context. For example, one of the most vexing problems for epidemiologists occurs when both the disease and environmental exposure under investigation are rare. Both the case–control and the cohort approach are likely to be costly and/or difficult because of issues of representativeness and sample size. As an alternative, hybrid designs have been used: the nested case–control  or the cGIS technology may offer a more efficient and cost-effective solution, at least for exposures that can be readily characterized geographically . With thIn a demonstration project, a cohort of children with a far higher likelihood of being exposed to high levels of magnetic fields was identified using a geographically defined population living within 0.5 miles of a high-voltage electric power transmission line , 1997. BAdvances in GIS and statistical methodology together with the availability of high-resolution, geographically referenced health databases present unprecedented new opportunities to investigate the environmental, social, and behavioral factors underlying geographic variations in disease rates at small-area scale. Such studies must be guided by good questions, excellent statistical methodology, and sound epidemiologic principles, including taking proper account of problems of data quality and the potential for bias and confounding. Spatial epidemiologic studies will become increasingly common in the future, both because of the instant visual appeal and wide availability of the new geographic techniques, and the desire for cleaner and healthier environments. With ongoing improvements in the data and methodologies, these studies will play an increasingly important role in our understanding of the complex relationships between environment and health.