Health systems delivery systems can be divided into two broad categories: National Health Services (NHS) on the one hand and Social Security (based) Health care systems (SSH) on the other hand. Existing literature is inconclusive about which system performs best. In this paper we would like to improve the evidence-base for discussion about pros and cons of NHS-systems versus SSH-system for health outcomes, expenditure and population satisfaction.In this study we used time series data for 17 European countries, that were characterized as either NHS or SSH country. We used the following performance indicators: For health outcome: overall mortality rate, infant mortality rate and life expectancy at birth. For health care costs: health care expenditure per capita in pppUS$ and health expenditure as percentage of GDP. Time series dated from 1970 until 2003 or 2004, depending on availability. Sources were OECD health data base 2006 and WHO health for all database 2006. For satisfaction we used the Eurobarometer studies from 1996, 1998 and 1999.SSH systems perform slightly better on overall mortality rates and life expectancy (after 1980). For infant mortality the rates converged between the two types of systems and since 1980 no differences ceased to exist.SSH systems are more expensive and NHS systems have a better cost containment. Inhabitants of countries with SSH-systems are on average substantially more satisfied than those in NHS countries.We concluded that the question 'which type of system performs best' can be answered empirically as far as health outcomes, health care expenditures and patient satisfaction are concerned. Whether this selection of indicators covers all or even most relevant aspects of health system comparison remains to be seen. Perhaps further and more conclusive research into health system related differences in, for instance, equity should be completed before the leading question of this paper can be answered. We do think, however, that this study can form a base for a policy debate on the pros and cons of the existing health care systems in Europe. In the domain of health systems research it is not uncommon to divide health systems, or, to be more precise, health care delivery systems into two broad categories: National Health Services (NHS) on the one hand and Social Security (based) Health care systems (SSH) on the other hand, often dubbed after their founding fathers Beveridge (NHS) and Bismarck (SSH) -7.The inclusion of a country's system into one of the two categories is mainly based on the way the systems are funded  but these funding differences also correlate with differences in the way the systems are organised  European health care systems.Many aspects of both categories of systems have been studied and described -21, but This is not the case, however: the question, in its primitive or in a more sophisticated (that is: by specifying the criteria of comparison) form has rarely been posed and, if so, the answer was mostly inconclusive.In spite of this general lack of discussion, some authors touched the subject. Firstly, a decade ago, in 1996, Javier Elola (Spain) published in the International Journal of Health Services a paper comparing NHS- and SSH-systems on: health outcomes, health care costs and expenditures and population satisfaction . Using 1Secondly, about a decade later, Saltman and Figueras  devote ith century, to their social security roots Anyway, Elola's paper did not leave a trace in the health systems literature, although it would have formed a very good base for a serious policy discussion about the most desirable direction health care systems should move.So, we dispose of two sources, a decade apart, in which NHS-systems are compared to SSH-systems. The oldest study seems to yield clear cut results: NHS-systems are cheaper and are better in cost control, and SSH-systems seem to have  a stronger public support. There is no difference in health outcomes. The results are valid for 1992. The most recent study concludes firstly that the two types of system do not seem to differ in health outcomes, but that this depends on the indicators used and that there probably is a trade off between health care costs and population satisfaction, but due to a low number of observations (caused by a subdivision of the groups) and a confusingly high number of indicators, the conclusion remains tentative.In this paper we would like to improve the evidence-base for discussion about pros and cons of NHS-systems versus SSH-systems by adopting Elola's approach using a set of well accepted general performance indicators and testing the robustness of Elola's findings by using time series data instead of a single point in time.We have the following research questions:1) Are there indeed no systematic differences in health outcome between NHS- and SSH-systems over a longer period in time (1970–2003)?2) Do NHS-systems indeed spend less on health care as % of GDP and per capita and are they better in cost control over the same period in time?3) Is, indeed, the population in SSH-systems more positive about its health care system than in NHS-systems?4) If differences exist, do they converge over time?In this study we restrict ourselves to the Western European countries, where the systems exist over a longer time period and time series analysis is possible. In the study period 1970–2003) some transitions from one system to another have taken place. Greece (1983), Italy (1978), Portugal (1979) and Spain (1986) changed from a SSH system to a NHS system. We deviate from the Saltman and Figueras study in the sense that we excluded Israel (as non-European country) in our study. This results in the following countries  and the evaluation of the system by the population (satisfaction).health outcome we used overall mortality rate , infant mortality rate, and life expectancy at birth.For cost of a country's health care system can be expressed as the cost per head of the population. To compare the costs between countries, these costs are expressed in ppp US$ (power purchasing parities US$). Besides this, the share of health care costs in the total GDP is used. We used both the absolute share as well as the change in share (indexed for the year 2000 = 100).The satisfaction the satisfaction of the population with the health care system as a whole was used for the years 1996, 1998 and 1999.For For each indicator, we used time series from 1970 until 2003 or 2004, depending on the availability of the data.The health indicators are retrieved from the WHO- Health For All database  and OECD health data files 2006 .The economic indicators are based on the OECD health data files.Satisfaction with the health care system is based on the indicators that Saltman and Figueras used. Satisfaction data were available for the following countries: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxembourg, Netherlands, Portugal, Spain, Sweden, United Kingdom. Data for 1996, 1998 and 1999 are based on the results of questions concerning the satisfaction with the (organisation) of the health services in the countries concerned from the Eurobarometer studies (Eurobarometer 44.3 (1996), 49 (1998), and 52.1 (1999)).For each indicator, time series will be displayed for each country, with (unweighted) averages calculated for each system and we will discuss the differences between these averages.Ethical approval was not required for this study.Mortality rates were declining over the years irrespective of the health care system. However, there is no convergence: the range between minimum and maximum mortality rates hardly changed. There is a small difference in average mortality rates between NHS and SSH, in favour of the SSH. The SSH had on average over the years a 5% lower mortality rate see Fig. .There has been a clear converging trend in infant mortality rates. Differences between countries became rapidly smaller over the years. We found that until 1982, NHS had lower rates and from 1983 until 1998, SSH had a (on average 6%) lower infant mortality rate, although the differences were much smaller compared to the previous period. From 1999 until 2004, the differences between NHS and SSH become negligible , in the later years (1980–2002) SSH had a slightly higher life expectancy (about 0.5 years) see Fig. .The expenditure per capita showed a diverging trend. In SSH systems, the expenditure on health per capita has become increasingly higher compared to NHS-systems see Fig. .The share of health care expenditures in GDP is increasing in the 1970s for both systems and in the 1980s, cost containment methods seem to be effective in both systems, since the share of health care expenditure is more or less constant. From 1993, we see an increase again for the SSH systems, the NHS-systems follow at a lower pace see Fig. . Over tiThe satisfaction with the health care system of the population in SSH-countries is much higher compared to NHS countries see Fig. . In SSH Our first research question concerned differences in health outcome between NHS and SSH systems over time. Our study revealed a strong improvement in life expectancy and a reduction in infant mortality regardless of the system. In our time series, since the 1980s, SSH systems showed slightly favourable mortality rates compared to NHS systems, a persistent difference that continued to exist over time. Also for the life expectancy at birth, SSH systems persistently performed better than NHS systems since the 1980s, although the differences are small. Infant mortality rates showed a converging trend without any difference between both systems since the beginning of the 1980s. Therefore, the conclusion of both Elola and Figueras et al, based on cross sectional data, that there were no differences in health outcomes between NHS and SSH systems is not fully supported by our study.Our second research question concerned the differences in health care expenditure. The costs of NHS systems are persistently lower compared to SSH systems over time both in terms of health expenditure per capita and as percentage of GDP . So, both Elola's and Figueras and Saltman's conclusion that NHS systems perform better in controlling costs is supported by our study.The third research question was: is the population in SSH systems more positive about its health care system than in NHS systems. Elola's conclusion that SSH systems receive greater public support is also supported by our study.The last research question concerned a possible convergence of the systems over time. The results of our study show that, except for infant mortality rates, this convergence did not take place yet. This is not in line with the hypothesis of Elola, who argued that health care reforms were directed towards convergence between both systems.Of course this study has several limitations, that we would like to discuss here. Firstly we will address the pitfalls of international comparative research, secondly the effect of the small numbers of countries and thirdly the consideration whether we used the right set of outcome indicators.International comparison of health data is severely hampered by differences in national definitions and differences in national methods of data collection ,25,26. MDue to the small numbers of countries it is possible that a country with extreme values influences the results strongly. In our study this could have been the case with Portugal. The health indicators in Portugal were inferior to all other countries, although a spectacular improvement could be observed over time. From 1985 onwards, Portugal is performing at a comparable level with other relatively low performing countries in our study, but before 1985, Portugal was performing worse. Portugal had a SSH until 1978 and a NHS from 1979. Portugal's switch might have influenced the average of both groups considerably, that is to say until 1985. Elola excluded Portugal from the analyses because he argued that although Portugal formally had changed towards an NHS the practical implementation was incomplete: parts of the SSH system continued to exist. However, the same could be concluded for Greece, where also parts of the SSH system continued to exist after the formal change towards a NHS system. Since none of the countries in our study have a pure NHS or SSH system anyway and formulating criteria for including and excluding a country into one of both systems will be always disputable, we decided to opt for the formal introduction of the law concerning the organisation of the health care system as criterion for classifying the country's health care system . The excThe health indicators used in this study are relatively basic indicators. The advantage of these basic indicators is that their definition is relatively stable over time and among countries. A more sophisticated health indicator is the (recently introduced) Health Adjusted Life Expectancy (HALE).We analysed the differences in HALE between the two groups; SSH countries had a slightly higher Health Adjusted Life Expectancy than NHS countries. HALE data were however only available for a short period of time (1999–2002) and have also been subject to a change in definition in those years . So, forThe stronger public support of SSH-systems is a result that has been found in several studies now ,23,29. DAlthough health outcomes may be influenced by financial and organisational opportunities within the medical world, this will not be the only contributing factor. For instance, life style factors  contribute largely to health outcomes. However, transforming life style factors into more healthy habits can be reached more effectively outside the health care system.One might argue that the indicators selected in this study do not cover all relevant criteria in health care systems analysis. Equity, for instance, is an overall criterion that forms the corner stone of the National Health Service. Comparing NHS and SSH systems without taking into account the concept of equity might be considered as not completely fair. The point is, however: what is equity and is it an unequivocal concept?Equity in health care can be described as follows: those with equal needs should be equally treated and those with greater needs should receive greater attention and more resources . MayberrWe think that our study can form a base for a policy debate on the pros and cons of the existing health care systems in Europe as far as health outcomes, health care expenditures and patient satisfaction are concerned. For the issue of equity firstly a discussion is needed on what indicators are relevant and secondly, more research is needed into these indicators. The debate on 'which system is best' should take place at national level and at European level. The big challenge is to reconcile organisational restrictions like waiting lists and gate-keeping with consumer preferences. Countries that combine high satisfaction rates with organisational restrictions  could form examples for their neighbours. Further more, the results of our study could contribute to the discussion for the choice of health care systems in countries that are in the process of implementing  health care insurance, like middle income countries or the newly independent states of the former Russian Federation.GDP Gross Domestic ProductNHS National Health ServicesSSH Social Security Health care systemThe author(s) declare that they have no competing interests.JvdZ initiated the study and drafted the manuscript. MK participated in the design of the study, the analyses of the data and helped to draft the manuscript. Both authors read and approved the final manuscriptThe pre-publication history for this paper can be accessed here:


This paper examines two topics in Japanese medical ethics: non-disclosure of medical information by Japanese physicians, and the history of human rights abuses by Japanese physicians during World War II. These contrasting issues show how culture shapes our view of ethically appropriate behavior in medicine. An understanding of cultural context reveals that certain practices, such as withholding diagnostic information from patients, may represent ethical behavior in that context. In contrast, nonconsensual human experimentation designed to harm the patient is inherently unethical irrespective of cultural context. Attempts to define moral consensus in bioethics, and to distinguish between acceptable and unacceptable variation across different cultural contexts, remain central challenges in articulating international, culturally sensitive norms in medical ethics. This paper examines two quite different topics in Japanese medical ethics: non-disclosure of medical information by Japanese physicians, and the history of human rights abuses by Japanese physicians during World War II. An analysis of these contrasting issues shows how culture shapes our view of ethically appropriate behavior in medicine. A grasp of cultural context reveals that certain practices, such as withholding diagnostic information from patients, may represent ethical behavior in that context. In contrast, nonconsensual human experimentation designed to harm the patient is inherently unethical irrespective of cultural context. The attempt to define moral consensus in bioethics, and to distinguish between acceptable and unacceptable variation across different cultural contexts, remain central challenges in articulating international, culturally sensitive norms in medical ethics.The non-disclosure of medical information by Japanese physicians is the most widely discussed topic in Japanese medical ethics, with more than 3000 articles published on this subject within a five year period . Up untiStarting in the late 1980's and continuing today, Japanese physicians' practices regarding disclosure have been changing, with disclosure becoming more common, though not as prevalent as in the US. For instance, in a 1992 study of Japanese physicians, only 13% reported that they usually communicated cancer diagnoses to their patients . More reMany factors contribute to the shift in disclosure practices in Japan. A widely reported medical malpractice case drew national attention to the potential for increased risk to patients because of nondisclosure. The case involved a nurse who was evaluated for abdominal pain in 1983 . Her docJapanese society has devoted significant resources to the debate on disclosure practices. Two important official groups were convened and developed contrasting sets of recommendations in 1989 and 1990. The Government Task Force on Terminal Care was an appointed group including both physicians and non-physicians. It recommended that disclosure of cancer diagnoses be increased, though not without assessing four patient-related factors: psychological stability; decisional capacity; positive relationships between providers, family and patient; and available supports for the patient . In contThe Japanese government supports efforts to increase disclosure by way of a 1996 Ministry of Health regulation, revised in 1997, that permits physicians to bill the Japanese national health system specifically for documented disclosure of the patient's diagnosis and treatment plan . In a naDying in a Japanese Hospital  didn't say a word to me or to the nurses for 24 hours after that. No matter how many times we spoke to her, she turned away and kept silent. Did she lose her speech because she was so shocked with knowing the truth? Or did she lose her speech because she was enraged with knowing how people she had trusted had betrayed her? and failed to act as an ethical physician by disclosing the patient's diagnosis is palpable.When the patient's oldest son visited the hospital later that day, he attacked the doctor for breaking a promise to the family and telling his mother the truth. Dr. Yamazaki's pain in this encounter, and his sense of having tried The tone of the bioethics literature on nondisclosure in Japan can be harshly judgmental. Various articles attribute nondisclosure exclusively to the arrogance and paternalism of Japanese physicians ,6,7. Thoishin denshin, the Japanese term for non-verbal communication, which is viewed as appropriate and effective in many circumstances, particularly highly emotional ones [However, differences in social status between doctors and patients surely do not explain why Emperor Hirohito, who had been revered as a living god, fell ill from cancer in 1988, and did not have his diagnosis explicitly revealed to him . It is wnal ones . Such inThose unfamiliar with Japanese culture may see only the overt behavior, non-disclosure, and rush to the judgment that Japanese patients are treated disrespectfully by their physicians. However, knowledge of Japan's cultural context reveals that the ethical propriety of disclosure practices is more nuanced than is captured in some of the bioethics literature. For instance, when Japanese physicians practice nondisclosure, they generally do not conceal medical information from all concerned parties. Families, rather than patients, are often informed about diagnoses; decisions about whether or not to tell the patient are left to family members, who often decide against disclosure ,4,7,12. Is the idea of "family autonomy" a contradiction in terms? At first glance, an arrangement that precludes independent individual action seems inconsistent with autonomy. However, for individuals who prize group identity and welfare then a choice reached by consensus may be the best expression of the individual's values. From this perspective, we might say that individuals can express autonomy by delegating authority to the family.Surveys of Japanese views on disclosure reveal interesting anomalies. In the 1990s, surveys reported that a large percentage of Japanese wanted to know their own diagnosis but would not want a family member informed. Fetters describes this as the "cancer disclosure paradox" . He arguomakase describes the practice of placing oneself in the care of a professional [omakase.Both taking care of others and allowing others to take care, including by making decisions, is accepted in a variety of Japanese cultural contexts. For instance, the concept of essional . In a meMedical anthropologist Susan Long argues that the shift toward disclosure reflects the dissolution of a shared moral consensus among Japanese physicians, families and patients . CurrentLong addresses the interplay of disclosure and autonomy in offering a culturally sensitive analysis of Japanese practices . She queA number of authors have criticized Western and particularly American bioethicists who place excessive value in individual autonomy . Indeed,should behave as Western bioethicists would like them to do, and that their physicians ought to impose autonomy-based relationships upon them. Some authors suggest that physicians need only inquire of patients about their desires for information, and then proceed accordingly. However, this practice stems from Western assumptions about the benefit of frank discussion. In a model where it is assumed that many important things will not and must not be spoken, the invitation to frank discussion may itself be an affront [Patients who wish for disclosure and shared decision-making should have physicians who respect their wishes. However, the practice of limited medical disclosure remains common across most of the world today . Nondisc affront .more ethical than traditional practices? Perhaps this shift merely documents that Japanese practices are coalescing with Western ones, in a manner that does not prove the intrinsic worth of one practice versus another. Indeed, some bioethicists argue for an approach to disclosure that attempts to balance respect for cultural differences while encouraging shared decision-making when patients choose it [Japanese medical practices regarding disclosure are shifting. More and more Japanese patients and physicians expect and value candid discussion of medical information . Yet doehoose it . It remaIn sum, full disclosure does not rise to the level of a universal norm. It was not the accepted standard in medicine for the past thousands of years, and is not currently the standard in most of the world. Nondisclosure is ethically appropriate for some patients, partly because of culturally shaped norms. Fuller disclosure is best for other patients because of their individual culturally shaped preferences.A practice may be culturally accepted, yet still ethically unacceptable to others outside that culture. Practices like female circumcision arguably fall into this category. However, nondisclosure of medical information, when conforming to cultural expectations and benefiting the patient, need not be unethical. Other practices are not ethically permissible, and cannot be made so by any degree of cultural sensitivity. Egregious human rights abuses can not be understood as ethical regardless of context, as we shall see in the review of Japanese physician participation in biological warfare experiments during World War II.Japanese physicians during World War II undertook biological warfare research that perpetrated significant abuse of human subjects. These acts cannot be understood as consistent with some different standard of medical ethics; they profoundly violated the standards of medical ethics even in that time and place. Indeed, the lead physician and researcher in Japan's biological warfare efforts, Shiro Ishii, addressed this dilemma in welcoming new staff members, acknowledging that their work was "completely opposite" to the physician's ethical obligation to cure disease . A revieCrimes by Japanese physicians were not publicized as were those by Nazi physicians, nor were Japanese physicians tried in the Tokyo War Crimes trials. For the most part, these acts have only gradually come to light in the decades after the war, due to the work of a handful of Japanese and other historians ,25. SignJapanese physicians and scientists undertook a massive program of biological warfare during WWII. A focus of this activity was a facility known as Unit 731, whose headquarters near Harbin, China, ultimately grew to encompass about 100 buildings, was under the direction of Shiro Ishii . ResearcResearch aimed at prevention of disease produced innovations at Unit 731, but at the cost of human life. Under Dr. Ishii's direction, researchers invented a portable water filtration system that allowed Japanese soldiers to protect their water supply while in contested areas or makeshift camps. Researchers studying frostbite gained knowledge about treatment by means of cruel experiments. They tied up prisoners in subzero temperature until severely frostbitten, then subjected the prisoners to various experiments, either to study potential treatments or to understand the physiology of freezing; prisoners died both due to frostbite and due to the experimental treatments . PrincipResearch was conducted on sexually transmitted disease, always the scourge of armies. Unit 731 staff members reported witnessing forced sex acts by infected prisoners, including Korean comfort women. Former staff of Unit 731 have testified that vivisection was a common means of studying disease processes .Unit 731 conducted substantial research into biological warfare, a violation of existing treaty obligations. Such research focused on methods of disseminating disease agents such as cholera, bubonic plague, and malaria. Indeed, residents in the area of Harbin, China, reported outbreaks of bubonic plague for decades after the war; these outbreaks were the subject of a lawsuit of Chinese citizens against the Japanese government . Unit 73Japanese physicians do not appear to have planned a wholesale program of genocide as did the Nazis. Nonetheless, war crimes in the form of the horrific abuse of human subjects did occur and were known at the end of the war. Why then were these crimes, similar to those of the Nazi physicians, not publicized by trials like those at Nuremberg? A number of factors contributed to protect the secrecy of these crimes and their perpetrators. As the war neared its end, Unit 731 was dismantled with orders to preserve secrecy; there were no survivors among those incarcerated at Unit 731. Research records were destroyed, remaining prisoners were executed, and bodies were burned to destroy evidence.However, not all evidence of Unit 731 was successfully suppressed. A few photographs remain, including photographs of bodies stacked and awaiting incineration. Likewise, some documents, including hundreds of autopsy reports of murdered research subjects, survived the attempt to destroy evidence . FurtherMost of the senior staff of Unit 731, including Dr. Ishii, returned to Japan as the war ended. These highly ranked staff members came under the exclusive jurisdiction of US military forces at the end of the war. America, already at the start of the Cold War, was reluctant to share secrets of biological warfare with its erstwhile allies, the Soviets and the Chinese. American military authorities chose not to include Dr. Ishii or any other participant in medical atrocities in the public war crimes trials in Tokyo, apparently in the hope of acquiring and maintaining the secrecy of valuable information from research into biological warfare . Such a Tanaka and other authors carefully weigh the issue of why Japanese physicians were willing to grossly abuse human subjects in the pursuit of research . DrawingThis paper examines two contrasting issues in Japanese medical ethics. The first section analyzes the workaday issue of how physicians share information with patients, and argues that a range of practices may suit ethical norms in different cultural contexts. The second topic, the gross abuse of human subjects during wartime, is one that fewer physicians will directly confront. However, the collaboration of physicians in the abuse of prisoners of war does recur.Non-disclosure of medical information to patients can constitute an ethical practice when certain conditions apply. First, the overt and credible intent of the physician in withholding information must be to benefit the patient. Withholding diagnostic information to protect a third party, for instance to conceal medical error, does not meet criteria for ethical behavior. Second, the patient must also view this practice as beneficial. Ascertaining the patient's view is inherently difficult when medical practices cannot be frankly discussed. However, either through the patient's expressed views or the family's interpretation of those views, patients in the past and to a lesser extent today indicate that they view the withholding of certain types of medical information as beneficial. Third, the patient must at least tacitly agree to the practice of withholding information in the current instance. In a culture where such practices are the norm, physicians may have greater confidence in family statements about the patient's beliefs. However, members of a culture may accept a practice as applied to others but not to themselves. In the current climate of change, careful assessment of beliefs with both patients and families provide an ethical foundation for selecting the best approach to disclosure.By contrast, the abuse of research subjects as documented in Unit 731 can never be ethical. Research, unlike medical treatment, poses an inherent ethical challenge, in that it is never only in the patient's interest, but always brings with it potentially competing claims, such as the good of other patients in the future. Consent is important for ethical treatment, yet even more critical in the ethical practice of research, as noted in various codes of research ethics. In the case of Unit 731, no pretense of consent was made; the subjects were held as prisoners without rights, whether they were civilians or combatants, adults or children. Neither was there any pretense of benefit to the subject; the overt goal was to use the lives of these subjects in order to gain benefit for others. No recorded attempt was made to preserve the life or minimize the suffering of the victims. It is possible, though far from certain, that a cultural standard in Japan during WWII may have supported such abuse of prisoners. Japanese citizens and soldiers made enormous sacrifices to support the war, even to the point of committing suicide. However, it is not enough for a standard to exist in a culture for it to serve as the basis of an ethical practice; it must at a minimum be accepted by those to whom it is applied in the specific instance. Since no prisoner of Unit 731 was there voluntarily, none can be said to have accepted the role of subhuman research material.Contemporary emphasis on cultural sensitivity and cultural competence enriches bioethics by broadening the understanding of ethical practices internationally. A greater awareness of practices around the world leads to modesty in asserting the ethical universality of certain practices, such as modes of communicating medical information. Many aspects of medical practice are deeply shaped by culture; the meaning of illness, the nature of healing, and styles of communication between doctor, patient, and family are all bound by culture and language. Yet it is important to distinguish between cultural competency and cultural relativism. Understanding the context of a time and place may permit us to discern ethical principles behind behaviors that at first strike us as merely wrong. However, other behaviors will remain ethically unacceptable regardless of our grasp of the cultural context. Indeed, the rational for some behaviors may elude understanding, irrespective of efforts to place motives within a context. Behavior during wartime, either by physicians or others, can fall to a level of barbarism that defies acceptance or understanding. The tragedy is that the capacity for egregious behavior under extraordinary circumstances exists in a wide range of cultures and peoples, our own included.


Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management.We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.This case highlights the importance of early aggressive debridement to healthy tissue limits, the consideration of a rare underlying cause, and the scope for plastic surgical reconstruction in order that aggressive initial surgery can be adequately performed. Necrotising Fasciitis is a life threatening soft tissue infection which requires aggressive, early surgical management. The precise aetiology of necrotising fasciitis is unclear in many cases. We present a rare case of a retroperitoneal perforation of a carcinoma of the caecum presenting as a necrotising fasciitis of the anterior abdominal wall.A 52 year old male presented with a one week history of discomfort and swelling in the right iliac fossa, and 12 hours of skin erythema which was rapidly progressing. Within 2 hours of assessment, the cellulitis was noted to have spread outside the boundaries marked on admission. He was hypotensive, tachycardic, febrile and noted to have an elevated white cell count.On examination of the area there was diffuse oedema of the skin with marked erythema and heat in the area of skin from the right loin to groin across to midline. Subcutaneous crepitus was present. A lateral abdominal X-Ray revealed free gas within the subcutaneous tissues Fig. .A presumed diagnosis of necrotising fasciitis was made and the patient commenced on intravenous antibiotics, resuscitated with intravenous fluids, and taken immediately to the operating theatre.Extensive debridement of the affected cutaneous, subcutaneous tissue, and muscle was performed and pus noted to extend to the right loin area. Histology and bacteriology confirmed a diagnosis of necrotising fasciitis, with a β-haemolytic group streptococcus cultured. Exploration revealed a retroperitoneal abscess arising as a result of a perforation of a caecal carcinoma. The caecum was resected and a right hemicolectomy performed, with a large defect resulting in the anterior abdominal wall from the extensive debridement Fig. .The patient was admitted to the intensive care unit for inotropic support and management of sepsis, and 2 days later proceeded to have a rectus femoris myocutaneous flap fashioned to close the defect in the abdominal wall. He made a good post-operative recovery, with adequate skin closure on the abdominal wall Fig. , and wasRetroperitoneal, or psoas, abscess is an unusual problem, which has insidious and occult characteristic. There ath century BC[Conversely, necrotising fasciitis is a soft tissue infection associated with high morbidity and mortality. Necrotientury BC. A rapidentury BC. Wilson entury BC.Necrotising fasciitis is rare within the UK with an estimated at 500 new cases each year, however this is difficult to confirm, as different eponyms are given to describe the same condition, as outlined above. The aetThe cornerstone of management of necrotising fasciitis is recognised as being aggressive surgical debridement and intensive support, whilst other severe soft tissue infections do not necessarily require the same amount of aggressive debridement. Therefore it is important that clinicians are able to differentiate between the two.Necrotising fasciitis should be considered in those patients who have rapidly progressing cellulitis, and palpable subcutaneous crepitus, in association with tachycardia, hypotension, neutropenia or neutrophilia, and hyponatraemia.Adjuvant diagnostic tools for necrotising fasciitis include CT scanning and plain radiography. In thisThe finding of necrotising fasciitis of the anterior abdominal wall associated with a carcinomatous perforation of the colon is rare, having only previously been described with perforation of a sigmoid colon carcinoma directly adherent to the anterior abdominal wall. In addiThis case illustrates that the principles of management should be two-fold; 1) To rapidly and unequivocally control infection and sepsis through extensive radical debridement of necrotic tissue and; 2) Identify and treat any underlying condition giving rise to the infection, in this case removing the caecal tumour.Intravenous antibiotics should be started promptly and modified when sensitivities return. However, it is essential to ensure that adequate necrotic material is removed at the first opportunity to reduce the risk of further progression, regardless of the defect that will remain. Defects may be closed using a variety of techniques, including split skin grafts, Vacuum Assisted Closure (VAC) therapy, and flaEarly recognition of important signs of necrotising fasciitis is essential to effective management of this condition, and clinicians assessing patients with rapidly progressive cellulitis should be aware of these vital features.In cases presenting with necrotising fasciitis there should be consideration given to an underlying cause for the infection.Aggressive surgical management is the cornerstone to management of this condition, and is the key to survival for these patients. This case demonstrates that extensive debridement can be performed with resulting large defects, which can be adequately closed at a later time, and therefore this should not be thought of as a barrier to adequate surgical debridement and definitive treatment.The author(s) declare that they have no competing interests.All authors have read and approved the final version of the manuscript.CM was involved in the conception for the idea for the report, and was involved with the diagnosis, operative, and post-operative management of the patient. He is responsible for preparation of the manuscript for submissionGMcA was responsible for up to date literature review, re-writing of manuscript prior to submission, gaining of consent for use of images, and management of the patient.MR was responsible for ward care of the patient, review, and re-writing of manuscript prior to submission.SS was the senior consultant Plastic Surgeon responsible for the patients operative management and post-operative care and was involved in review and alteration of the manuscript prior to submission.RM was the Senior Consultant General Surgeon involved with operative and post-operative management of the patient and was responsible for critical review of the manuscript prior to submission.The pre-publication history for this paper can be accessed here:


This study examined the relationship between life satisfaction among medical students and a basic model of personality, stress and coping. Previous studies have shown relatively high levels of distress, such as symptoms of depression and suicidal thoughts in medical undergraduates. However despite the increased focus on positive psychological health and well-being during the past decades, only a few studies have focused on life satisfaction and coping in medical students. This is the first longitudinal study which has identified predictors of sustained high levels of life satisfaction among medical students.This longitudinal, nationwide questionnaire study examined the course of life satisfaction during medical school, compared the level of satisfaction of medical students with that of other university students, and identified resilience factors. T-tests were used to compare means of life satisfaction between and within the population groups. K-means cluster analyses were applied to identify subgroups among the medical students. Analysis of Variance (ANOVA) and logistic regression analyses were used to compare the subgroups.Life satisfaction decreased during medical school. Medical students were as satisfied as other students in the first year of study, but reported less satisfaction in their graduation year. Medical students who sustained high levels of life satisfaction perceived medical school as interfering less with their social and personal life, and were less likely to use emotion focused coping, such as wishful thinking, than their peers.Medical schools should encourage students to spend adequate time on their social and personal lives and emphasise the importance of health-promoting coping strategies. To be a student in medical school may be stressful -3. PreviThe main purpose of this study was to examine the relationship between life satisfaction among medical students and a basic model of personality, stress and coping ,16. PersA recent study from our group  followedAgainst this background we have analysed data from a longitudinal, nationwide study of Norwegian students entering medical school in 1993 (n = 421) and compared them with two samples of non medical students. The medical students were assessed three times: at medical school entry, at mid curriculum (third year) and in the graduating semester (sixth year). The objectives of this study were: (I) to describe the course of life satisfaction in medical school students; (II) to compare the level of life satisfaction among medical students with that of other university students; and (III) to identify resilient medical students and assess whether these students differ from their peers in regards to personality, stress and coping.All students entering medical school at the four Norwegian universities in 1993 were invited to participate. Data were collected by mail in their first, third, and final (sixth) year and were anonymous. Out of the initial pool of 421 students, 375 responded to the baseline assessment ), 302 participated in the second assessment ) and 287 took part in the final year assessment ). A total of 236 students responded on all three occasions ), constituting the longitudinal sample to be investigated. We used the longitudinal sample in order to analyse the course of life satisfaction throughout medical school, but used all responses from the first and last assessments to compare the level of life satisfaction of medical students with that of other university students. The study was conducted according to the guidelines and with the approval of the regional ethical committees and the National Data Inspectorate in Norway.The two samples used for comparison were obtained from a nationwide, cross-sectional study on quality of life from 1996 . The incLife satisfaction was assessed on a 7-point Likert scale using a global one-item measure  with alternatives ranging from (1) very dissatisfied, to (7) very satisfied. This item has been used in several other studies, such as the Canadian Community Health Survey  and the In order to identify subgroups based on the course of life satisfaction in medical school, we applied cluster analysis to the reported levels of life satisfaction in the longitudinal sample.Personality was measured at baseline, using three out of four traits from the 36-item version of the Basic Character Inventory (BCI), a questionnaire constructed by Lazare, Klerman and Armor  and modiStress factors linked to medical school were measured in the middle and final years, using eight items from the 13-item Perceived Medical School Stress (PMSS) instrument, developed by Vitaliano et al. . The PMSThe coping strategies of the medical students were measured in their middle year, using the 42-item Ways of Coping Checklist (WCCL) , with a Table We used t-tests to compare means of life satisfaction between and within the population groups. In order to identify the subgroups we applied K-means cluster analyses. To compare the subgroups, we made use of Analysis of Variance (ANOVA) and logistic regression analyses.The mean values of life satisfaction among the medical students in the longitudinal sample were 5.7 (SD = 1.0) in the first year, 5.3 (SD = 1.1) in the third year, and 5.3 (SD = 1.2) in the final year. A paired samples t-test showed there was a statistically significant reduction in life satisfaction from baseline to the middle year (t (df) = 5.2 (235), p < .01), but no statistically significant change during the last three years. This applied to both genders. The 139 students who responded to the first assessment, but then dropped out and did not respond to the second and third assessments, reported a lower level of life satisfaction  when entering medical school than those who constituted the longitudinal sample . An independent samples t-test showed this difference to be significant (t (df) = -2.3 (373), p = .02).On entering medical school, the level of life satisfaction among the medical students in the cross-sectional sample  was not significantly different from that of other university students of the same age  (t (df) = 1.0 (438), p = .32). In their final year, however, the level of life satisfaction among the medical students  was significantly lower than among other students in the same age group  (t (df) = -2.8 (327.7), p = .01). This applied to both genders.First, we ran an analysis with three clusters and found one group with increasing life satisfaction (n = 44), one with decreasing life satisfaction (n = 67) and one group with stable high life satisfaction n = 125). After performing analysis of variance (ANOVA) of the explanatory variables and the three clusters, it became evident that the stable life satisfaction group differed from the changing life satisfaction groups. These fluctuating groups showed many similarities regarding personality, perception of medical school stress and coping strategies. At first we considered the students with increasing life satisfaction as being adaptive and expected them to stand out when compared with other students. However, the similarities between the students with increasing and decreasing life satisfaction, and the differences between these and the ones with stable high life satisfaction, forced us to interpret these findings as indicating that there were really only two true subgroups; one with sustained high life satisfaction, and one with fluctuating levels. We therefore ran a second analysis with two clusters, and found a stable group (n = 149) and a group with fluctuating levels of life satisfaction (n = 87). Since our main interest was describing the resilient students, we decided to employ the two-cluster solution, with one stable and one labile group, and applied logistic regression analysis to identify predictors of stability versus fluctuation. Table 5. After The two groups were compared in a personality, stress and coping model in order to see if they differed in the personality traits vulnerability, intensity and control (BCI), whether they had different levels of academic worries or perceived medical school as interfering more or less with their social and personal life (PMSS), and what type of coping strategies they used, such as being problem focused, seeking social support or focusing on emotions like wishful thinking (WCCL). The crude and adjusted associations between the explanatory variables and the two subgroups are shown in table The level of life satisfaction among the medical students decreased from their first to their third year in medical school, and remained at this lower level until graduation. The comparison analyses showed that the medical students were as satisfied as other students when starting their studies of medicine, but reported a lower level than the comparison group in their final year. Furthermore, stable high levels of life satisfaction in medical school corresponded to low levels of stress in the form of one's perception of social and personal renunciations, and by low levels of wishful thinking as a way of coping.How do we explain the decrease in life satisfaction during the first years in medical school? We do not know the level of life satisfaction among the students before they embarked on their studies of medicine. It is possible that they reported higher levels of satisfaction than they normally would due to the fact that they had recently been accepted to medical school, which has Norway's highest admission requirements and that they simply returned to their normal level of satisfaction by the third year in medical school. However, the fact that medical students were as satisfied as other students when entering medical school, but less satisfied at graduation, contradicts this explanation, and indicates that the reduction in life satisfaction may have been caused by factors specific to medical school. It may be that the medical students did not adapt to their studies as well as other students. Although some studies have found that pharmacy students , graduatThe main aim of this study was to identify resilient medical students and find out if these students differed from their peers in personality, perceived stress, and coping strategies. We succeeded in finding a subgroup of students with stable high levels of life satisfaction. Compared to the group with fluctuating levels of life satisfaction, the stable students differed with respect to both perceived stress and coping abilities.Our study found that low scores on the PMSS – social and personal renunciations item predicted stable high life satisfaction, even when susceptible personality traits were controlled for. This indicates that students in the stable group perceived medical school as interfering far less with their social and personal life than did students with fluctuating levels of life satisfaction. The ability to find enough energy to spend on several of life's domains, while maintaining a balance between them may be crucial for experiencing stable high life satisfaction. This finding is supported by previous studies which have shown that socializing decreased in medical school , that inIn the univariate analysis, low levels of academic worries corresponded to stable high life satisfaction. Although this effect did not remain statistically significant in the adjusted model, this finding may still indicate that perceived cognitive abilities are important for life satisfaction among medical students.As expected, we found that a low level of passive, emotion focused coping, such as wishful thinking, was associated with stable high life satisfaction. Other studies support the harmful effect of emotion focused coping among medical students ,38. StudWe found that personality traits did not predict stable high life satisfaction when we controlled for other coping variables. A low level of vulnerability predicted stable high levels of life satisfaction in the univariate analysis, but this effect seemed to be channelled through wishful thinking in the adjusted model. The role of personality and dispositional variables has been emphasised in several other life satisfaction studies ,17. HoweWhile other studies have found that female medical students report more stress  and lessThe major strength of this study is that it is a longitudinal study, following a nationwide cohort of medical students throughout their entire study period. Medical education in Norway consists of six years of education at the university, followed by one and a half years of compulsory residency. Although this is different from, for example the United States, our findings may be generalised beyond Norway, at least within the European system of training. High levels of stress are reported in several countries ,12,36,37What can be done to increase resilience in medical students and ensure that future students are enabled to maintain stable, high levels of life satisfaction throughout medical school? The results of this study stress the importance of making time for personal and social life while in medical school, and the advantage of avoiding the use of passive, emotion focused coping, such as wishful thinking.Findings from another study, which revealed that many medical students felt guilty for spending time on social activities and personal well-being even though they recognised the importance of doing so , may indA review article on stress management in medical education found that participation in such programs gave promising results, but concluded that the studies had many limitations and that further research on stress reducing intervention in medical school is needed .In conclusion, this study shows that life satisfaction decreased somewhat during medical school. The medical students were initially as satisfied as other students, but the level of life satisfaction in their final year was lower than that of other comparable students. Medical students who sustained high levels of life satisfaction perceived medical school as interfering less with their social and personal life, and made less use of passive, emotion focused coping, such as wishful thinking, than did their peers. Medical schools should encourage students to try to achieve a balance between schoolwork and their social and personal lives, and emphasise the importance of healthy coping strategies, for instance, by providing stress management courses.The author(s) declare that they have no competing interests.KK acted as the principal investigator, RT was involved in designing the study, analysing the data and writing the paper, AF was involved in analyzing the data and writing the paper, EH was involved in designing the study and writing the paper, TG contributed to the interpretation of data and drafting of the manuscript, NTG was involved in initiating and designing the study and was responsible for collection of the data, PV and OE initiated and designed the study and supervised the collection of data, and were involved in writing the paper. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


More than 80% of African Americans in Oregon reside in the Portland metropolitan area; African Americans comprise 1.7% of the state's population. Although relatively small, the African American population in the state experiences substantial health disparities. The African American Health Coalition, Inc was developed to implement initiatives that would reduce these disparities and to promote increased communication and trust between the African American community and local institutions and organizations. One of these initiatives is an annual Wellness Week featuring an African American Wellness Village. The Wellness Village uses a model of cultural sensitivity to provide access to free health screenings, links between health care organizations and African American community members, and health education and information.The African American Health Coalition, Inc obtained a Racial and Ethnic Approaches to Community Health (REACH) 2010 grant to sustain this programming. The Wellness Village is supported by five major sponsors; annual attendance has ranged from 700 to 900 participants. The African American Health Coalition's evaluation of the event indicates that more than 50% of respondents identify the Wellness Village as the only place that they receive health screenings. Participants with access to screenings elsewhere report that a culturally sensitive environment that inspires trust is the reason they prefer the screenings offered at the Wellness Village.Culturally sensitive health fairs such as the Wellness Village may play an important role in bringing preventive health screenings to African American communities. Collaboration between black and white health care providers is critical in this effort. Partnerships must be built at multiple levels, including institutions to provide financial resources and in-kind donations, community members to assist with outreach and recruitment, and health care professionals to conduct screenings and services. The African American community in Portland, Ore, is clearly defined and is centralized in the Portland Metropolitan Statistical Area (MSA), which is located in the northwestern part of the state. The MSA encompasses the city of Portland, the largest city in the state, and surrounding suburbs in Multnomah, Washington, and Clackamas counties. More than 40% of the state's population and 80% of African Americans living in Oregon reside in the Portland MSA. Of the four million Oregonians in 2005, 68,000 were African American .In Oregon, 20.2% of African Americans do not have health insurance, whereas only approximately 14% of the state population is uninsured . A disparity also exists in cardiovascular health. Although the picture of cardiovascular disease (CVD) for African Americans is bleak nationwide, in Oregon the data are even more striking. For example, from 1996 to 2000, African Americans in Oregon had a higher stroke death rate than the national stroke death rate for African Americans  ,5. AfricReport of the Secretary's Task Force on Black and Minority Health  was founded by volunteers in 1989 to call attention to such health disparities, develop initiatives to reduce them, and increase the trust of Portland's African American community in local health authorities and health care systems. One of AAHC's initiatives is the African American Wellness Village, held annually as part of African American Wellness Week. Introduced in 1996, the Wellness Village is a health fair that offers health screenings and health promotion information for African Americans in a culturally sensitive environment. The Wellness Village provides a trusted source of information for participants and the opportunity to communicate with health care providers in a comfortable setting.The African American experience in Portland is rooted in displacement and intergenerational mistrust of local authorities and health care systems. This mistrust affects the way in which the African American community views its hospitals, doctors, health care systems, and local authorities. Oregon's original constitution contained an exclusion law prohibiting African Americans from permanent residency. In the 1860s, African Americans who migrated to Oregon faced widespread prejudice and intolerance and were forced to live in a small area of land along the Columbia River .During World War II, an influx of African Americans arrived to work in the ship yards . This miIn 1970, a major health care system approached Albina community homeowners, offering to purchase their property at below market value. Most community members had no experience with land development, so when approached with a cash offer, they sold their homes. Homeowners were also promised that a large health center would be built on the land, which would enhance the community's quality of life. This promise was not fulfilled, and many African American families and businesses were once again displaced.Since 1989, state and local health departments, researchers, and community groups have studied African American health conditions in Oregon and the African American community’s perceptions of its health care services . There aThe AAHC uses a model of cultural sensitivity as described by Resnicow et al  for the Health screenings are provided for free at the Wellness Village by 15 to 20 of the AAHC's collaborative partners. The screenings provided by our health care partners include the following: dental, by the Oregon Chapter of Lion's Club International; HIV and hepatitis C, by the Multnomah County Health Department; blood pressure, cholesterol, and diabetes, by the American Heart Association; and glaucoma, by Devers Eye Institute. The Oregon Immunization Program offers reduced-cost flu shots paid for by the AAHC for high-risk groups, including seniors and infants. Each health care partner is required to commit staff to be available for questions from community members the entire day of the event.The Wellness Village also offers cultural and educational programming. The opening ceremony includes a calling of the elders, libations, and African drumming. Child care is provided in the Children's Hut by volunteers and staff. The Wellness Village also provides a healthy soul-food cooking demonstration, and attendees receive food samples. Attendees learn how to add spices to soul food to enhance flavor but reduce the fat. Participants can also take salsa and African dance lessons, go for the afternoon Wellness Walk through the neighborhood, or enjoy the gospel choir. Door prizes are given away at the end of the event. Throughout the day, attendees can stroll among the health screening and education booths.Participants also receive information about year-round AAHC health promotion interventions supported by the Centers for Disease Control and Prevention's (CDC's) Racial and Ethnic Approaches to Community Health (REACH)Participants also receive information about year-round AAHC health promotion interventions supported by the Centers for Disease Control and Prevention's (CDC's) Racial and Ethnic Approaches to Community Health (REACH) 2010 initiative. The REACH 2010 initiative consists of four interventions: 1) Lookin' Tight Livin' Right, a beauty and barber shop intervention based on peer education that uses motivational interviewing and relationships among hair stylists to educate their clients about CVD; 2) Healthier Options to Living Longer Actively (HOLLA), a train-the-trainer model that uses students to deliver health education messages; 3) Wellness Within REACH, a partnership with parks and recreational facilities that provides access to free physical activity classes; and 4) Spice It Up, a partnership with the Oregon Food Bank to provide ethnic cooking classes to African American community members. The REACH 2010 program provides year-round access to health education that follows up on information that participants receive at the Wellness Village.In the early 1990s, the AAHC called attention to the Oregon Health Division's analysis, which found large health disparities for African Americans in Oregon. The AAHC alerted local media, and newspapers published data showing the disproportionately high infant mortality rates of African Americans. The newspaper coverage gained the attention of state decision makers and resulted in offers to collaborate. Partnerships with Legacy Health Systems, Kaiser Permanente, Providence Health System, Oregon Health & Science University, Eli Lilly and Co, and the state and county health departments provided funding and technical assistance for the first African American Wellness Village in 1996. Since then, the event has been held annually, and the original health care systems continue to provide financial support.The overwhelming community response to the first Wellness Village was the catalyst that led the coalition volunteers to see the need to build an infrastructure and become a nonprofit corporation. The first step of institutional capacity building was realized by the formation of the 501(c) in DecemThe Wellness Village is supported statewide. A proclamation in 1996 declared the third week in October "African American Wellness Week." The African American Wellness Village attracts partners who do not typically have connections to the African American community. The Wellness Village was initially funded with in-kind donations from coalition members and a major sponsorship from Kaiser Permanente. Since its early years, the Wellness Village has had five major sponsors who annually contribute $10,000 each: Legacy Health System, Oregon Health & Science University, Providence Health System, Kaiser Permanente, and Eli Lilly and Co. The Wellness Village was founded by a group of volunteers that included black health professionals and white advocates who united to fight the social injustice that is a factor in health disparities. The initial success of the Wellness Village was based on the community and the health care system's trust in the black health care professionals and their white colleagues, who opened doors and provided access to resources. These partnerships developed primarily through personal and business relationships forged by black health care professionals. The black health care professionals maintained respect and connections with local African Americans, while at the same time gaining recognition and credibility within the health care community, including from the original major sponsors and state and local health departments. In addition to the major sponsors, other partners contribute substantially to the village by offering donated resources for raffles, free screenings, and education. Exhibitors purchase tables for $200 each; they secure a table by filling out an application at least 3 months before the event. Each organization is required to define the resources and services to be offered. The AAHC carefully screens each application to avoid exploitation of the community and the participants. Exhibitors agree to report required data on the screenings they perform.The planning process for the Wellness Village begins in the first quarter of the year with the recruitment of an annual Wellness Village planning team. The planning team consists of representatives from each major sponsor; the AAHC management and Wellness Village coordinator; community members, including youths; staff members from local and state health care departments; and volunteer screeners. During this period, new sponsorships are identified and solicited, and program and recruitment materials are completed. During the second quarter, the planning team develops letters, flyers, and programs that will inform community members about the event. In the third quarter, the planning team finalizes the Wellness Village layout and event logistics and orders all of the needed supplies and equipment, including tables, props, T-shirts, and programs. All in-kind donations for raffles and prizes are solicited, and volunteers are recruited and trained. The fourth quarter is dedicated to community outreach through local contacts and the dissemination of flyers. The event timeline is the responsibility of the AAHC program coordinator, who records minutes, makes reminder calls, follows up with the planning team, and oversees the logistics.The Portland African American community is easily mobilized when approached by individuals whom they trust. Our methods for announcing the upcoming Wellness Village and recruiting participants include providing information to 22 exercise venues, using the AAHC Board and staff's social support networks, making presentations, and soliciting other social service agencies who also recruit participants through their constituencies. The African American community in Portland is tight-knit and is like a rural area in that word of mouth is a communications method often used . A mediaAverage attendance at the Wellness Village each year ranges from 700 to 900 community members. For the past 3 years, the AAHC has subcontracted with research evaluators who use surveys and observation to examine the impact of the Wellness Village. Between 2002 and 2004, 483 Wellness Village participants voluntarily completed a survey as they exited the village. Analyses of 4 years of data provide a rich view of the trends in participant needs and concerns. During the survey period, 66% to 78% of individuals completing surveys reported that the information received at the Wellness Village was "very helpful." Participants reported that they found information about nutrition, exercise, and healthy cooking most useful. Cooking demonstrations were added in response to these survey findings. Thirty percent to 50% of respondents also wanted or needed information about diabetes.Each year, most attendees receive free screenings for one or more health conditions. The most frequently used screenings include blood pressure, vision, and glaucoma. More than 50% of the survey respondents said that the Wellness Village was the only place they received screenings. Qualitative responses suggest that participants come to the Wellness Village for screenings because they trust the AAHC and because the services are free. When health problems are identified, participants are linked to community heath care resources by the screeners. Participants are encouraged to visit the onsite OHP screeners to determine whether they qualify for Medicaid support. For participants who do not qualify for OHP and cannot pay for services, the Wellness Village and AAHC education and support groups are crucial.The social aspects of the Wellness Village are very important, and many respondents commented on the community feeling of the event and on the friendliness of vendors and volunteers. Because so many people mentioned the social aspect of the Wellness Village, emphasis has been put on events such as church choir performances, African dancing, salsa dance lessons, and food tasting. Over the years, AAHC has responded to the community's feedback and added requested screenings, demonstrations, and exhibitors. The most effective mechanism for disseminating information about the Wellness Village has been word of mouth, with almost 40% of the respondents reporting that they had heard about the event from family or friends or at church.Although the Wellness Village is a very important event, it is only part of the overall AAHC effort to eliminate health disparities. People who come to the Wellness Village often learn about or are already involved in another AAHC program. Approximately one third of respondents to a survey in 2004 reported that they were involved in the free exercise program, and approximately one third reported that they had participated in the Wellness Walk.By conducting an annual event that African Americans can rely upon, the AAHC has sustained a culturally specific event that delivers health education, preventive screenings, and links to resources and referral information. The Wellness Village provides a connection to services for community members who otherwise would not learn about or receive those services. Although the screeners are not exclusively African American, they are introduced to the community by the AAHC as trusted gatekeepers. For some individuals, the Wellness Village is the only venue where they can obtain annual health screenings. It continues to be a major community event.One challenge of an annual event is to keep the volunteers, vendors, and staff engaged over time. The AAHC strategy includes personal contact and ongoing communication through newsletters, telephone calls, and involving our partners in other activities of the coalition. Direct feedback from vendors, volunteers, staff, and participants is used in the planning process for the next year. Because of the annual planning process, such an event requires a full-time staff to adhere to the time line.Because of budget cuts to the OHP, more participants are screened each year for whom there are no community services. The AAHC has no mechanism for tracking people who are screened at the Wellness Village to determine whether they have been linked to needed services. Continued development of community partnerships may alleviate this problem. Despite criticism, health fairs may play an important role in bringing preventive health services to the African American community . Confron


This paper critically discusses two previous studies concerned with predictions of HIV/AIDS in the United States and Japan during the early 1990s. Although the study in the US applied a historical theory, assuming normal distribution for the epidemic curve, the underlying infection process was not taken into account. In the Japan case, the true HIV incidence was estimated using the coverage ratio of previously diagnosed/undiagnosed HIV infections among AIDS cases, the assumptions of which were not supported by a firm theoretical understanding. At least partly because of failure to account for underlying mechanisms of the disease and its transmission, both studies failed to yield appropriate predictions of the future AIDS incidence. Further, in the Japan case, the importance of consistent surveillance data was not sufficiently emphasized or openly discussed and, because of this, revision of the AIDS reporting system has made it difficult to determine the total number of AIDS cases and apply a backcalculation method. Other widely accepted approaches can also fail to provide perfect predictions. Nevertheless, wrong policy direction could arise if we ignore important assumptions, methods and input data required to answer specific questions. The present paper highlights the need for appropriate assessment of specific modeling purposes and explicit listing of essential information as well as possible solutions to aid relevant policy formulation. Although numerous mathematical and statistical approaches have been proposed to predict the future course of infectious diseases, various assumptions are required to account for the intrinsic and extrinsic dynamics of disease spread -3, and cBefore entering into discussion on the details of the case studies, two widely accepted models of HIV/AIDS epidemiology are briefly discussed. Whereas there is no single best method for AIDS prediction, these two approaches, both of which were initially proposed during the late 1980s, are widely employed -10.The first approach is based on a mathematical model that explores the population dynamics of HIV/AIDS ,11. The The second model, referred to as backcalculation, is a more statistically motivated approach to estimating HIV prevalence -10. BackNeither the US nor Japan case studies used the above methods, and further, whereas the above two approaches account for underlying mechanisms of the disease, the two case studies focused almost entirely on extrapolation of the epidemic curve.The approach employed in the US case study assumed a normally distributed epidemic curve . The undAs the Japan case study, the series of studies by the Working Group on prediction of HIV-infected cases and AIDS patients, organized by the Ministry of Health, Labor and Welfare (MHLW), Japan, are discussed -31. FromHu, Hd, Au, and Ad are the cumulative number of unreported and reported HIV infections and unreported and reported AIDS cases, respectively. The ratio has been revised several times, but the most recent studies adopt an estimate of 1/5.1 (reported/unreported), because approximately 19.6% of the AIDS cases reported up until the mid-1990s were previously diagnosed as being infected with HIV [where with HIV ,32.The ratio should be implicitly assumed to be independent of time. Using the estimated HIV prevalence based on this ratio, it is assumed that HIV-infected individuals develop AIDS according to a fixed incubation period distribution that follows Weibull distribution -30. BaseAs shown in Fig. The original study did not take into account the reason behind the assumption of a normal curve ,35. Non-Figs. A number of professionals immediately and sharply criticized the US projection ,33,36,37Some publications, which did not follow the widely discussed theoretical concepts, investigated the original study as an accepted theory or extended the discussion concerning predictability. Shortly after publication of the original study and more recently ,40, the In Japan, the Committee of AIDS Trends, formed by MHLW, expressed their standpoint with respect to interpretation of such estimations as follows : "BecausThe Japan case study also indirectly influenced the AIDS notification method. Prior to revision of the surveillance system in 1999, HIV/AIDS notifications among Japanese nationals were classified into one of three categories: (1) HIV infection, (2) AIDS without a previous diagnosis of HIV infection (= 'First Report'), and (3) AIDS with a previous HIV diagnosis (= 'Second Report'). Since implementation of the Law Concerning the Prevention of Infectious Diseases and Medical Care in 1999, replacing the previous law for HIV/AIDS in Japan, it has become difficult to link individuals initially categorized as (1) and later as (3) due to the altered administrative system . MoreoveThe two case studies discussed here employed rather different approaches compared to widely accepted methods. In the US, experts in relevant fields criticized the original study and the flawed prediction has become relatively well known, at least among specialists. Although there were few public health impacts (including the data collection method), a few non-experts, who seem not to recognize the importance of intrinsic dynamics, continue to reference and extend the original theory. Moreover, the predictions obtained based on the original Japan case study have been largely adopted as official, and unfortunately, only one study has so far criticized the technical flaw . The folIt should be accentuated that intrinsic dynamics are one of the most important factors offering valid and sound answers to the specific question addressed by the model  . TransmiIt should be emphasized that even if a model has good predictability it does not necessarily mean it's a good model for prediction. It should also be noted that good models are essentially accompanied by valid basic assumptions of the spread of disease and pay close attention to the input parameters; the widely accepted approaches take particular care to heed this point. As in the above two case studies, the majority of flawed predictions employ simple extrapolation of an epidemic curve, the most uncertain component of modeling, frequently focusing on the predicted value itself or simple residual variance alone.One of the biggest challenges facing modelers and policy makers is how to communicate and share these points effectively . Many reThe criticisms presented here do not blame the authors of the presented case studies, but rather attempt to give general suggestions for improvement. As a possible remedy for modeling frameworks, to make them truly useful for policy making, I suggest the following potential solutions. These apply not only to the above discussed extreme cases in the US and Japan but also to most quantitative models.The model structure depends on investigation of a specific question. Even if based on valid assumptions, it must be remembered that models may not provide any insights other than their main purpose. Thus, what can and cannot be learned from each study must be explicitly documented for the reader to assess. If more than two quantitative approaches are applied to the same data, the purposes and information obtained could be different. It is not uncommon for various approaches to be applied to the same data, with the generated findings enhancing our understanding of the validity of the assumptions made. Thus, where possible, various approaches that differ from each other in their purposes should be applied to the same data.As discussed above, the validity of estimations and/or predictions largely depends on the assumptions made. Thus, it would be very useful if all publications documented the assumptions, limitations and input parameters in an explicit manner . AltMost modeling frameworks are accompanied by a certain number of unrealistic assumptions. Despite efforts to make a model as realistic as possible, it is often the case that the data is limited, e.g., as a result of future improvements in treatments or behavioral changes. It should be noted, however, that incorporation of numerous details is not necessarily a remedy for inappropriate description of the reality. Depending on the question being addressed, an accurate yet simplistic model may be desirable; a simple model often better reflecting the reality than complex simulations . In lineModelers should fully understand the intrinsic dynamics of the disease and/or work closely with specialists who can offer detailed disease information. Since it is not uncommon for the findings of a model to be misinterpreted (as in the above case studies), it is crucial that modelers, policy makers, and clinicians work together when creating and utilizing such models. Through such practice, modeling experts should share their knowledge in assessing the validity of a model and translating the implications for policy makers. Further, if public health officials are unable to assess the findings of model-based predictions, modelers should be on hand for consultation. These experts should also employ their knowledge to disease monitoring systems.The present study critically discussed two predictions of AIDS incidence with the aim of understanding how such estimates are interpreted by the general public and exploring possible improvements in policy making. It should be emphasized that ignoring how a disease spreads, and related assumptions, as well as neglecting key input information could lead to wrong policy direction. The need for appropriate assessment of specific modeling purposes, and explicit listing of assumptions, limitations and parameter inputs as well as possible solutions to aid relevant policy formulation was therefore highlighted.The author(s) declare that they have no competing interests.HN carried out paper reviews, proposed the study, performed mathematical analyses and drafted the manuscript. The author has read and approved the final manuscript.Additional methods. Mathematical details are provided in pdf format.Click here for file


The BioGeomancer Project provides a toolkit to georeference data and specimens collected for natural history collections, a crucial task if the potential of these specimens is to be fully realized. Over the past 250 years, biologists who were interested in describing and understanding patterns of biological diversity have gone into the field to observe and collect species. Conservation of the specimens and data collected through these explorations has produced an irreplaceable archive of life on Earth . Today, http://www.gbif.net). Many of these records have never before been electronically accessible, let alone from a single point of access that uses sophisticated protocols to directly retrieve information from primary data custodians. The third grand challenge, and the focus of this article, is to further increase the value of these species-occurrence records by converting the textual descriptions of places where data and specimens were collected  into their corresponding geographic coordinates—to georeference them.There are three main challenges to the effective use of specimens in natural history collections and of related observation data, such as bird counts. The first challenge is to capture the information associated with specimens, such as species name and the day and locality of collection, in computer databases. The name of an organism and the location in which it occurs are information elements most widely used by consumers of biodiversity data—including researchers, educators, natural resource managers, and the general public. The second challenge is to make this information, housed in many hundreds of separate institutes, easily accessible via the Internet. Through a large number of digitization and computer application development efforts, these challenges have been partially overcome, as is illustrated by the nearly 100 million species-occurrence records that are currently available through the Global Biodiversity Information Facility  tools. Empirical evidence suggests that a large fraction of available georeferences are in error , yet forIn summary, the current situation for georeferencing is characterized by the following major shortcomings: (i) The process is slow—an average of several minutes per locality. (ii) With a few exceptions, the accuracy and precision of the assigned coordinates is unknown. (iii) A large fraction of available coordinates are demonstrably inconsistent with the rest of the locality information. (iv) The materials and methods used are poorly documented. (v) Many localities are georeferenced many times over—but not likely with the same results.The BioGeomancer Project is an international collaborative effort to build a Web-based automated georeferencing toolkit that addresses all of the shortcomings listed above. The BioGeomancer toolkit is being developed by a coalition that includes individuals with expertise in manual and semi-automated georeferencing, GIS, collection management, software engineering, protocol standards, and data standards. The toolkit provides dramatic improvements over existing common practice by: (i) increasing the rate at which locations can be georeferenced (at least 5-fold) by focusing on automated methods and batch processing; (ii) estimating the uncertainty associated with the coordinates of each record; (iii) testing for errors and assuring consistency; (iv) enhancing the value of the data by defining and applying documented data standards; and (v) providing essential information about the data processing steps so that the results can be tested, replicated, and easily improved upon. By creating freely available georeferencing tools backed by high-quality digital geospatial data, BioGeomancer removes the cost of acquiring these resources at individual institutions and provides a standard mechanism for accomplishing a core biodiversity data management task.BioGeomancer provides a set of tools that are necessary and sufficient to complete all the tasks that would otherwise be accomplished manually  in a gazetteer and using the information found there along with offsets and the semantics of the locality. The program estimates the spatial uncertainty of a georeference , taking http://www.biogeomancer.org.BioGeomancer initially supports the interpretation of localities in English, Spanish, and Portuguese, although in the future, we hope to add capabilities for other languages by further developing the language-specific component needed to interpret locality descriptions. BioGeomancer is accessible at


Congenital syphilis is recognized as a substantial public health problem in Sub-Saharan Africa. The aim of this study was to determine the prevalence of syphilis among antenatal care attendees in Botswana and to contribute to knowledge about the challenges facing the syphilis-screening programme.In a cross-sectional study, 703 antenatal care attendees at 13 health facilities in Gaborone, Botswana were interviewed and examined. Venous blood samples were collected for the identification of syphilis infection. The antenatal records were used to obtain information on any screening, diagnosis and treatment of syphilis that had been done earlier in the current pregnancy.Active syphilis was found in 32 (5%) of the attendees. Among 546 women coming for a repeat antenatal care visit, 71 (13%) had not been screened for syphilis. Uptake late in pregnancy, delayed treatment and a high rate of seroconversion after testing were other identified obstacles to the effective prevention of congenital syphilis.Syphilis prevalence among pregnant women in Botswana remains high, and there is still much to be gained by improving the effectiveness of the syphilis screening and treatment programme. Earlier antenatal care attendance, rapid on-site testing, improved partner treatment and a repeat test late in pregnancy to manage incident cases are important goals for patients, health care workers and health authorities. Maternal syphilis has a severe impact on pregnancy outcome. Although antenatal syphilis screening has proven to be cheap and effective, syphilis during pregnancy continues to be a substantial problem in resource-poor settings . PublishIn Botswana, universal screening and treatment of syphilis in pregnancy is integrated in antenatal care. Blood is collected from all attendees at the first antenatal visit and analyzed with a non-treponemal syphilis test  at a centralized laboratory. According to the guidelines, high risk women should be retested at 34–36 weeks of gestation. All RPR/VDRL positive cases should be provided with education, risk reduction counselling and condoms. The treatment regimen is three doses of benzathine penicillin 2.4 million units at weekly intervals. Partner notification and treatment is not specifically recommended.The striking need for improved surveillance of syphilis and its consequences in developing countries has been emphasized,  and thisThe aim of this study was to determine the prevalence of syphilis among antenatal care attendees in Gaborone, Botswana; to contribute to increased knowledge of the implementation of the national syphilis screening programme; and to identify areas of concern in this and similar settings.Included in this study were 703 antenatal care attendees who visited 13 primary health care clinics in Gaborone, the capital of Botswana, between October 2000 and February 2001. Although 18 facilities in Gaborone provided antenatal care at that time, the 5 facilities with less than 600 antenatal care consultations during the previous year (range 10 to 570) were not included for practical reasons. A proportionate sample of attendees was recruited from each of the eligible clinics, based on the total load of antenatal care attendees at that clinic during the same period in the previous year. The clinics were visited one by one, and the attendees were consecutively invited to be included in the study. The number of patients per day was limited by either the total number of attendees at the clinic that day or by the number of specimens the laboratory could handle . In the majority of clinics, all attendees were included during the period of data collection; in the busiest clinics only a random sample of the attendees was included.All participants gave written, informed consent. The only exclusion criterion was the use of antibiotics in the two weeks prior to their visit. No woman declined to participate in the study, but 34 attendees were excluded – 32 because of treatment for vaginal discharge syndrome and 2 because they were on penicillin for syphilis.Treponema pallidum haemagglutination assay (TPHA).A structured interview was used to obtain information on socio-demographic factors, symptoms of any sexually transmitted infection (STI) and history of STI diagnosis and treatment earlier in the pregnancy. All eligible attendees underwent a genital examination by a medical doctor, and clinical signs from external and internal genitalia were recorded. For the attendees coming for a repeat visit, we recorded the gestational age when blood was drawn for the non-treponemal syphilis test, the test results and the treatment prescribed, all which is documented in the patient-held antenatal records. For study purposes, additional venous blood samples were collected from both new and repeat attendees. The maternal sera were tested at the National Health Laboratory with the RPR test and the specific Data were analyzed with the statistical package SPSS Version 11. The study was approved by the national committees for medical research ethics in Botswana and in Norway.The median age of the 703 antenatal care attendees was 25 years range 15–43). Other socio-demographic characteristics are described elsewhere . Eight w5–43. OthRPR titre and TPHA results in the study setting are shown in Table We do not have data on the exact incidence of syphilis during pregnancy, but among the 461 attendees who were RPR negative in the routine screening, 451 were retested in the study setting with both RPR and TPHA. Median 11 weeks later in their pregnancy, 16 (3.5%) of these 451 initially RPR negative women had active syphilis; 1 with high and 15 with low titres. Of the 16 women, 15 reported having had one partner the last 12 months, and 14 said that they had been in the relationship more than two years.Maternal syphilis remains a significant cause of adverse pregnancy outcome in Sub-Saharan Africa . AntenatTo prevent congenital syphilis, it is imperative to screen for syphilis early in pregnancy; but this remains a challenge. We found that the pregnant women who came for a first antenatal care visit had a median gestational age of 20 weeks. The repeat attendees had been tested at 19 weeks. Promotion of earlier attendance at antenatal care is a simple prevention strategy which should be advocated. The current practice of processing tests at centralized laboratories also results in delayed treatment; as described, it is takes more than a month before treatment is provided. To ensure immediate treatment, rapid diagnosis of syphilis can be introduced in the clinics, as recommended by the World Health Organization . BotswanThis study from Botswana also identifies several other operational difficulties within the syphilis screening programme. Of the 26 repeat attendees who were identified with active syphilis (RPR and TPHA positive) in our study, only five had been identified and treated with penicillin in routine antenatal care. Not all antenatal care attendees had been tested, and not all attendees with positive RPR results had been treated. None of the attendees in the study population had been routinely tested more than once. As many as 3.5% of the women who were RPR negative in the routine screening were RPR and TPHA positive when re-tested in the study after a median period of 11 weeks. All but one of these women was considered to be at low risk of infection. The women's initial TPHA status is not known, and some of them could have had old or untreated syphilis combined with an RPR seroconversion due to conditions other than syphilis. Nevertheless, the results indicate a high number of incident cases, and we recommend an urgent change in the retesting policy. A repeat test late in pregnancy for both low- and high-risk attendees should be clearly stated in the guidelines and communicated to the health workers.In the national STI management guidelines, partner notification and treatment is explicitly recommended for other STI syndromes, but not for RPR/VDRL positive cases. Botswana, like many other countries, relies on patient-based partner referral, with index patients informing their own contacts and referring them for treatment. To avoid reinfection of the patients and reduce the spread of syphilis, partners of RPR/VDRL positive antenatal care attendees should be treated. A patient-based contact tracing strategy should be the minimum strategy employed in the syphilis screening programme, and more intense efforts should be considered. It is known that partner notification and treatment can be improved by introducing combinations of provider and patient referral, and by explicit and thorough verbal health education .Our results indicate a need for improved coverage of the screening and improved adherence to treatment guidelines. However, it is a limitation of the study that we do not have information on why the guidelines are not followed. Data on the impact of maternal syphilis on pregnancy outcome are also lacking. A targeted approach to improving the syphilis screening programme requires that more knowledge be gathered about the specific problems, where they exist, and why. There is an obvious need to strengthen the routine data collection. In order to evaluate the screening programme continuously, each clinic can easily register and report the proportion of pregnant women who are tested and the proportion of test-positive women who are effectively treated. Studies on the quality of STI care in Botswana have shown that the clinics have adequate supplies of equipment and drugs, but that nurses' adherence to the guidelines is poor ,15. InfoThe study population is representative for antenatal care attendees in Gaborone, and the level of health care is supposed to be the same throughout the country. However, conditions such as communication, transport, educational level and standard of living are less favourable in the rural areas. To the best of our understanding, it is reasonable to expect the same or higher prevalence of syphilis, as well as the same or greater operational difficulties in the rest of the country. We also believe that the results of this study are of relevance to other developing countries.Syphilis remains a significant public health problem in many resource-poor settings. Lack of adequate antenatal care has been described as an important obstacle to the prevention of congenital syphilis globally, and available data show that this is also the case in Botswana. The prevalence of syphilis among pregnant women is high, and there is much to be gained by improving the effectiveness of the syphilis screening and treatment programme. We recommend promotion of earlier antenatal care attendance, rapid on-site testing, improved partner treatment and a repeat test late in pregnancy in order to manage incident cases. Increased commitment among both politicians and health care workers is necessary to reduce maternal syphilis and its consequences.RPR, rapid plasma regain; TPHA, treponema pallidum hemaglutin assay; STI, sexually transmitted infection; PMTCT, the prevention of mother-to-child transmission of HIV programmeThe author(s) declare that they have no competing interests.Maria Romoren contributed to the study design, was responsible for data collection and data analysis, and was the primary author of the manuscript. Mafizur Rahman contributed to the study design and to formal and organisational aspects of the study and approved the final manuscript.The pre-publication history for this paper can be accessed here: