The public health burden caused by cardiovascular disease (CVD) continues to adversely affect individuals in terms of cost, life expectancy, medical, pharmaceutical and hospital care. This burden has been excessive in the case of African Americans. The objective of this paper is to chronicle the procedures and processes that were implemented in the development of the Jackson Heart Study Coordinating Center. The Jackson Heart Study (JHS) is a population-based investigation of traditional and emerging risk factors that predict progression to CVD among African Americans. In response to the struggle against CVD, the Jackson Heart Study has convened a professional, technical, and administrative staff with specific competence in the operation of a coordinating center to handle the wide variety of areas related to CVD studies. The Jackson Heart Study Coordinating Center (JHSCC) was created to assure validity of the JHS findings and provide the resources necessary to meet comprehensive statistical needs ; data management , and administrative support. The JHSCC began with a commitment to support study functions in order to increase participant recruitment, retention and safety, meet regulatory requirements, prepare progress reports, and facilitate effective communication with the community and between all JHS centers. The JHSCC facilitates the efforts of the JHS scientists through the development and implementation of the study protocol. The efforts of the JHSCC have resulted in the successful preparation of scientific reports and manuscripts for publication and presentation of study findings and results. In summary, the JHSCC has emerged as an effective research mechanism that serves as the driving force behind the Jackson Heart Study activities. The JHS is a study of the characteristics of cardiovascular disease (CVD) in African Americans in Mississippi, examining traditional and emerging risk factors that predict progression to clinically detected CVD. The objective of this paper is to chronicle the procedures and processes that were implemented in the development of the Jackson Heart Study Coordinating Center. In recent times, CVD has been documented as a major cause of death in the United States. Approximately 64 million people in the United States have some form of CVD . The pubAs part of its role in the three institution partnership that comprises the Jackson Heart Study, Jackson State University was entrusted with the task of developing and managing the Jackson Heart Study Coordinating Center (JHSCC). The activities of the JHSCC were designed to provide opportunities for scientists to participate in ventures that would eventually lead to a reduction in the disparities in health care and health services that are now prevalent in Mississippi . Among aThe JHSCC collaborates with the National Heart, Lung, and Blood Institute (NHLBI) that has a field office located on site at the Jackson Medical Mall, Jackson, Mississippi; and the National Center on Minority Health and Health Disparities (NCMHD). The NHLBI Field Site Office team participates in surveillance activities, manuscript development and publication and presentation activities. These activities are fundamental to maintaining the scientific rigor and productivity of the study, and the JHSCC benefits immensely from the continuous involvement of the NHLBI and its Field Center staff.2.Jackson Heart Study researchers are studying a sample of 5,301 men and women aged 21 years or older who were recruited from the tri-county area of Hinds, Madison and Rankin counties in the Jackson Metropolitan Area. The cohort comprised 3,394 females and 1,907 males. Each participant receives an extensive physical examination and interview to obtain data on coronary status and function, standard coronary risk factors, socio-demographic factors, lifestyle factors, and psychosocial factors. Selected examinations and interview questions are repeated allowing the scientific investigators to comprehensively study the progression of CVD. Blood samples are analyzed and stored for future studies. DNA is extracted and stored for study of candidate genes and possibly, genome-wide scanning. Participants are monitored annually for identification and characterization of CVD events. In order to successfully undertake the enormous task of examining CVD in African Americans, the Jackson Heart Study comprises a professional, technical, and administrative staff with specific competence in the operation of a coordinating center to handle the wide variety of areas related to CVD studies.2.1.Jackson State University was funded beginning October 15, 1997 to develop plans for the provision of the typical functions of a coordinating center for the Jackson Heart Study (JHS) utilizing The University of North Carolina at Chapel Hill, through its established Coordinating Center, provided consultation to the planning committee. The primary mission was to assure validity of the JHS findings and provide the resources and expertise necessary to meet comprehensive statistical needs ; data management , and administrative support. The JHSCC also participated in activities that supported participant recruitment and retention through the Community Partnership Office which maintains collaborative enduring relationships with community groups and leads the efforts to provide community public health education, and to apprise the community periodically of JHS study by delivering progress reports. Several individuals played key roles in the early stages of the JHSCC to plan, develop, maintain, and monitor the effective management of the JHSCC activities. They are the following:Robert Garrison, Principal Investigator Coordinating Center, with responsibility for the overall direction, administration and scientific aspects of the coordinating center, was the representative of the Coordinating Center on the steering committee. He was later replaced by Daniel Sarpong in that capacity. In addition, Dr. Sarpong participated in policies and procedures development, training, data management activities, cost control, staff management, and report writing, and developed SAS programs for statistical data analysis.Mary Lou Gutierrez-Mohamed, Coordinating Center Coordinator, had primary responsibility for the coordination of the Coordinating Center programmatic activities and participated in the development of the manual of operations, OMB protocols, quality assurance and control, training, data collection, recruitment and retention surveys, and reports development.Gail Hughes, Co-Principal Investigator and Assistant Director, assisted the Principal Investigator in the planning and implementation of all the tasks of the Coordinating Center. She was involved in protocol development issues, sub-studies, ancillary studies, and statistical analysis of data.Joseph Cameron, Community Mobilization Director, provided overall programmatic direction to the Jackson Heart Study Community Mobilization effort, focus group planning and implementation, media outreach and community surveillance. He participated in the recruitment and retention efforts. He was later replaced by Donna Antoine LaVigne, and this department was renamed the Community Partnership for Awareness Education with Dr. Antoine-LaVigne coordinating the community mobilization-implementation plans, marketing efforts, workshops, conferences, focus groups and public relations.Pramod Anugu, Systems Analyst, provided database system and application support to the study. He designed, implemented, and maintained the systems for regular analysis and dissemination of data; he prepared data-driven reports, maintained and updated the web-sites and the communication systems (LAN etc.).Gregory Wilson served as Senior SAS Analyst/Programmer, responsible for preparing the consolidated database, implementing the data management procedures and programming for transfer and import of exam center, laboratory, and reading center data into the consolidated database. He was also responsible for overall statistical computing programming for the study.Clifton Addison, Statistical Programmer/Clinic Liaison participated in statistical computing programming for the study, OMB protocols, quality assurance and control, manuscript development and training. As Clinic Liaison, he was responsible for training and certification of Exam Center staff in preparation for the participants’ exam visits.Brenda Campbell-Jenkins, Research Associate had responsibility for the collection of research materials, preparation of paper forms, question-by-question instructions, and OMB protocols. She served as the Coordinator of the Publications and Presentations Subcommittee and the Ancillary Subcommittee. She also assisted in the QC monitoring of exam clinic through reviewing forms, re-certification documentation, and other standard QC procedures. She maintained detailed and organized records of procedures and served as the repository for all JHS research related information.Lavon Young, Data Entry Assistant/Information Processing Specialist, with responsibility for forms development, preparation of screen layouts for the DMS, and routine data checks, assisted in monitoring retention and follow-up of the cohort through weekly reports in the early stages of the study. She was responsible for formulating, planning and coordinating the layout and typesetting for various documents using advanced software applications.Danita Graham, Contracts Administrator, with primary responsibility for the coordination of the Coordinating Center programmatic activities, as well as the fiscal management of the study, coordinated all purchases for the Jackson Heart Study, communicated with reading centers, sub-contractors, and consultants on all contracts management issues; she tracked expenditures and developed all in-house financial reports for the Coordinating Center, as well as the ancillary administrative budget for Jackson Heart Study.Clara Fortner, Senior Program Coordinator, coordinated, facilitated, and managed activities of the Project Director Office and held overall administrative responsibility for the management of the JHS offices. She supervised all clerical staff and student assistants, developed personnel and steering committee reports, oversaw travel logistics for meetings of staff, sub-contractors, boards, and committees. She also served as the recording secretary of the steering committee.Planning a study of this magnitude with a partnership among three institutions was an organizational challenge that required an atmosphere of cooperation among the institutions in the planning phase. During this planning phase, the principal activities included designing the survey instruments, developing a sampling plan and examination components; creating manuals of operations and training of staff. It also included pre-testing all data collection forms; implementing procedures for processing data and specimens; performing quality control and data analysis, and obtaining Office of Management and Budget (OMB) study clearance.2.2.The JHSCC plays a major role in instrument design, data collection, quality control monitoring, data processing, and statistical analysis in order to document procedures. The leadership at the coordinating center is committed to direct the study through the following sub-committees: Quality Assurance, Publications, Community Mobilization, Operations, Imaging, Laboratory, and Morbidity and Mortality. The JHSCC Director is responsible for maintaining the management structure of the coordinating center and assuring cooperation of all institutional investigators and staff to achieve the goals of the study. He is assisted by a staff of biostatisticians, data analysts, research associates, research assistants, and additional support staff. Participant reports, including summaries of participants’ clinic visits, data quality and timeliness reports, safety reports, inventory information, follow-up status summaries, and reports of unusual problems, are provided by the JHSCC to the entire JHS team.The JHSCC works in conjunction with the Jackson Heart Study Steering Committee to develop, implement, and monitor procedures to insure confidentiality and privacy in all the data collection stations as well as within the JHSCC. Details about the Jackson Heart Study Steering Committee are chronicled elsewhere. The responsibility for the protection of participants is an integral component of the operational procedures. The JHSCC is committed to ensuring the strictest level of confidentiality by discussing and monitoring procedures during hiring, re-certification, and limiting access, and protecting machine readable data with encryption. The JHSCC plays a major role in protocol development and oversight, instrument design, data collection, quality control monitoring, data processing, and statistical analysis in order to document procedures. Furthermore, it acquires and manages subcontracts for Reading Centers and related activities, cohort recruitment through community mobilization and administrative support.2.3.The JHSCC facilitates and coordinates the development of the forms, assures uniform implementation of the study protocol and coordinates the maintenance of the Manuals of Operations, providing expert guidance and dependable direction. Manuals of Operations are distributed to all study investigators, and are also located on a study-specific Web Site maintained by the JHSCC. These manuals serve as the main reference for central training of staff, and as a refresher course for staff prior to completing re-certification exercises. The protocols include the Examination Center Operations, Follow-up of health status, and Data and Specimen Collection and Transmittal. The quality assurance and quality control manual includes training and certification requirements, site visit and data audit methods, and procedures for replicate data collection. These documents provide detailed written standard operating procedures that govern the data collection, processing, storage and transmittal, quality assurance, and publication necessary for implementation of the scientific objectives and methods of the study protocols.The JHSCC guides the development, integration, and production of all Manuals of Operation, under the direction of the Steering Committee, including a detailed set of question-by-question instructions (QXQs) for each of the interview instruments for the target groups. Protocol development, staff training, and pilot testing were performed in the first 18 months of the study. The first examination took place over a four year period, from September 2000 to April 2004. It was followed by a second examination period beginning in September 2005 that ended in December 2008. A third examination period began in February 2009. Participants are contacted every 9 to 12 months throughout the study to assess clinical morbidity and mortality. Data analysis began in the last few months of 2004, and this focus will continue for the rest of the study and beyond.2.4.A database management program was developed with an overriding emphasis on ensuring system efficiency and system security. The JHSCC used a uniform approach to security across computer systems and databases. The guidelines required that proper authorization be identified as the first step in the creation of an account. Also included, as part of the security process, was the development of a standard convention for usernames and passwords. In addition, specific procedures were outlined and documented for JHS data management and data protection .During the planning phase of the JHS, systems were developed for examination data, administrative data, follow up data, and the event or surveillance data. Comprehensive data management is provided throughout all phases of data collection. A highly skilled team is on staff to design and develop computer applications for data collection, and to execute plans for central data acquisition, management, analysis, quality control measures, the recruitment and retention tracking system, and surveillance protocols. These staff members also possess expertise in the methods used to coordinate and manage this complex epidemiological study which include recruitment, clinic visits, networks, laboratories, reading centers, and follow-up of participants. Their responsibilities also include assisting in organizing protocol and procedures and monitoring recruitment and follow-up of study participants.Although the JHSCC started out using paper data collection systems, the transition was soon made to a commercial data management system that was customized over the first two years of operation. This completely electronic data entry and data management system uses commercial customized software or commercial database management system (DBMS) such as Oracle, Oracle Clinical or Clintrial4 and applications developed by the systems analysts. A tested data backup system has been integrated and regular backups are done. Each PC is connected to a central server for administrative and communications functions with standardized, secure e-mail and scheduling software for both the JHSCC and the Exam Center (EC). Communication between the Exam Center (EC) and JHSCC can be done using e-mail and other electronic means. Paper communication and FAX communication are also available means of communication. A secure dial-up capability is provided as a backup to direct internet connection for authorized JHSCC and EC personnel, and all systems are protected from power failure by means of uninterruptible power supplies.The JHSCC supports a Jackson Heart Study public web site and maintains secure web and file transfer protocol (ftp) sites for controlled information transfer and releases of data residing on the fast, high volume server. The JHSCC also maintains an effective intranet through the use of the secure web pages and secure ftp sites. The public web site publishes general news and technical information approved for public use.The JHSCC has developed documentation and training programs for all data collection software, instruments, and forms used by the Exam Center (EC) personnel. The system includes procedures for regular sampling inspection of intermediate and final data products for comparison to source information, and data correction and feedback to the EC and reading centers, when data quality problems are encountered. When data are being entered and electronically sent to the database, the staff conducts range checking and database consistency checking, and arranges site visits to observe data collection quality. As a contingency plan, backup systems using paper forms are provided in situations where computer system failures interrupt data collection. This system also includes an analysis management protocol with procedures for tracking data analysis requests, archiving analysis results and programs and error checking and verification of analyses. Data quality is optimized by the data entry, management and reporting system that is resistant to data error and data loss.2.5.An important function of the JHSCC is the evaluation of the suitability of medical and scientific expertise in cardiovascular medicine and the management of contracts and contractual arrangements with consultants specializing in analysis and interpretation of special JHS investigations. The JHSCC works with the NHLBI staff and the examination center to establish the framework for the subcontracts, the selection criteria, and solicitations, in accordance with NHLBI guidelines. This JHSCC oversees all budgets, in addition to contracts with the central processing unit for supplies at Jackson State University, a Central Laboratory, and Reading Centers including carotid ultrasound, electrocardiography (ECG), echocardiogram (ECHO), pulmonary function, diet and other special core center operations. A detailed work plan for each subcontractor is compiled indicating how each aspect of the work is to be accomplished. The JHSCC maintains information on how each sub-contractor’s project is to be organized and staffed, along with the management of important events or tasks with the objective of monitoring their operations to ensure that their proposed scope of work is completed in a timely and cost-effective manner. The details of the reading centers operations are chronicled elsewhere .The JHSCC purchases, distributes, and maintains all mechanical and electronic equipment related to computer hardware and software and clinic furnishings that can not be provided by the JHS centers. Such hardware includes workstations, file servers, laser printers and network components, such as wiring, hubs and connectors. The laboratories and reading centers will receive a stand-alone workstation on which to run the inventory and, if necessary, a data management system. The JHSCC is also responsible for developing, in conjunction with the laboratories and reading centers, a schedule for calibration and maintenance of the equipment. The JHSCC assembles and monitors the information on equipment calibration and maintenance for inclusion in the quality assurance reports.2.6.Staff of the JHSCC created a community mobilization plan to develop partnerships within the community and enhance methods for fostering recruitment and cohort retention in the JHS. Community mobilization, though not a traditional function of a coordinating center, was helpful in facilitating access to a stable population of African Americans from which the cohort was derived. The community mobilization arm of the JHSCC is titled the “Community Partnership for Awareness Education”. This component makes JHSCC unique compared to other Data Coordinating Centers. Among its main functions are addressing factors that may influence people to participate in long-term research studies, promoting ongoing community support for the Jackson Heart Study, and disseminating information about CVD risk factors to the community. The community mobilization plan undergoes periodic modification to adapt to specific needs of the study and the community, and much of this is executed through a comprehensive community involvement plan that includes the development and implementation of an extensive media campaign. The Community Partnership Subcommittee functions as the oversight advisory committee for this division of the JHSCC and is composed of JHS staff along with representation from the community. This subcommittee meets regularly to monitor progress of the JHS mobilization activities, evaluate JHS directions and achievements regarding recruitment/retention, and to make recommendations for improvements. Barriers and facilitators to African Americans’ participation in research were documented by the planning committee prior to implementation of the JHS.Knowledge about older African Americans and their involvement and influence in recruitment are essential to understanding recruitment success and pitfalls in ethnic minority research . Most Af2.7.The Coordinating Center provides the scientific leadership committees with accurate and timely reports on study progress. Performance reports, including participant accrual summaries, data quality and timeliness reports, safety reports, inventory information, follow-up status summaries, and reports of unusual problems, are provided to all JHS components. The Coordinating Center provides administrative support for the meetings of the JHS Steering Committee and all JHS subcommittees, and conference calls. Annual meetings of the NHLBI/JHS Observational Study Monitoring Board (OSMB) are arranged and managed as part of the administrative support provided by the JHSCC. The Coordinating Center also provides audiovisual equipment, and makes special arrangements to facilitate the successful culmination of proceedings.2.8.The Research Support Unit is responsible for providing technical support, as well as training and support for the rest of the JHS departments. Because of the overwhelming nature of research, the Research Support Unit was established to facilitate accessibility, problem solving and project development for beginning researchers and seasoned professionals alike. These staff members are dedicated to assisting interested individuals or groups with understanding and implementing Jackson Heart Study protocol and procedures, and meeting deadlines for deliverables. This unit’s primary goal is to support and assist policy and practice. The Research Support Unit of the JHSCC also facilitates entry and editing of data from the examination site and reading centers; follows up on missing or erroneous data; does quality control monitoring through data checks and monitoring visits; prepares reports on study progress and coordinates and monitors interim contact with study participants by the examination center.Several mechanisms have been developed to monitor quality control. The JHSCC provides documentation, training and user support along with regular assessment by observing exams and interviews in which direct entry is taking place. The JHSCC establishes staff training and certification procedures, internal quality control programs and data quality procedures. A schedule has been developed for periodic re-certification, calibration of equipment, and pretest of procedures. Protocols have been developed to monitor through direct observation , quantitative monitoring (random repeat measurement of inter- and intra-staff), reporting results , and action on results .The JHSCC is designated as the repository of all JHS data; responsible for preparation and dissemination of QC reports using tabulated data, summary statistics, and identifying specific QC problems. The JHSCC developed the Quality Control Protocol, and provides operational support for the quality control committee, through the maintenance of central logs of data quality problems and solutions. Data quality is assured by providing training and pre-testing, performance monitoring, quality control and online documentation. Quality Control is an ongoing monitoring process to detect deviations from protocol standards and procedures. Such monitoring activities take place at identified points during data collection and processing.2.9.The JHSCC has responsibility for developing and implementing pre-testing procedures. These procedures are developed for each component of data collection and field tested, and a detailed evaluation is provided to the Steering Committee (SC). The Biostatistics Unit possesses vast knowledge and understanding of scientific issues related to the study rationale and design, including the importance of the research questions and hypotheses, knowledge of CVD, and understanding of state-of-the-art analysis methods. Statisticians in the Biostatistics department possess expertise related to study design and analytical methods. This group takes the leadership in preparation of scientific reports and manuscripts for peer-reviewed publication. The JHSCC Biostatics Unit provides statistical analytical support for all JHS investigators and collaborators at other institutions.3.3.1.The investigators and staff of the JHSCC have demonstrated the capacity and the personal and technical expertise to design, organize, and efficiently execute data management and analysis and related responsibilities for a large-scale epidemiological study. Jackson State University has succeeded in establishing a functioning Coordinating Center capable of carrying out the epidemiological, biostatistical, data base management and data storage center resource functions for the Jackson Heart Study (JHS). The JHSCC has demonstrated the leadership and ability to coordinate statistical, medical, data management, and the fiscal/administrative expertise to provide leadership for the operation of a first-class Coordinating Center. The JHSCC continues to meet some very important objectives; to assist medical professionals in their research, understanding, analyses and dissemination of CVD discoveries; to report findings and circulate information to the community in an appropriate, relevant and culturally sensitive manner with the ultimate goal of improving the quality of life.The development and implementation of the JHSCC has led to the opening of several opportunities for public health students to engage in hands-on research training. The Jackson Heart Study research training opportunities include research projects that can lead to Masters theses or doctoral dissertations. In addition, the JHSCC regularly engages students from local and national colleges/universities in research assistantships and summer internships to prepare them for careers in the medical and public health fields. Through the development and successful implementation of the JHSCC, the Jackson Heart Study continually seeks to fulfill its obligation for capacity building in the African-American community.


Almost 40 years ago, in 1969, the Cuyahoga River caught fire as it flowed through Akron and Cleveland, Ohio. Although it was not the only river to burn, the image of this burning river—the terrible wronging of nature—became a symbol of the urgency for a transformation of environmental policy for the environmental movement of the 1970s, driving the creation of the U.S. Environmental Protection Agency (EPA) and the rapid passage of major new environmental laws and regulations.Staphylococcus aureus), and the return of highly pathogenic avian influenza , SARS (severe acute respiratory syndrome), MRSA (methicillin-resistant nfluenza . To paranfluenza , we haveSalmonella, Clostridium, enteroviruses, hepatitis A virus, Cryptosporidium, and Giardia. These are among the most common causes of infectious disease in the United States. In the rivers and streams flowing through Baltimore to the Inner Harbor of the Chesapeake Bay, researchers at Johns Hopkins University have found the same dangerous brew of disease-causing organisms. We carried out a study of urban anglers—people who fish in the urban watershed of Baltimore—and reported that, although some fish have elevated levels of polychlorinated biphenyls or mercury, anglers are at immediate risk of infection by Cryptosporidium merely by handling caught fish and crabs (Although the Cuyahoga River doesn’t burn, it is still in critical condition, filled with viruses, bacteria, and microparasites . The fisnd crabs .The modern environmental movement began with a long overdue call to action concerning pesticides and other industrial chemicals . AlthougThese are environmental health issues of the highest priority. The National Institute of Environmental Health Sciences has a critical role in improving our knowledge on the role of the environment in the emergence and dispersion of infectious pathogens and human disease, including ecologic cycling of pathogens, the regulation of reservoirs of antimicrobial resistance, and the persistence of pathogens in soils and other media.


Neglected tropical diseases (NTDs) exist and persist for social and economic reasons that enable the vectors and pathogens to take advantage of changes in the behavioral and physical environment. Persistent poverty at household, community, and national levels, and inequalities within and between sectors, contribute to the perpetuation and re-emergence of NTDs. Changes in production and habitat affect the physical environment, so that agricultural development, mining and forestry, rapid industrialization, and urbanization all result in changes in human uses of the environment, exposure to vectors, and vulnerability to infection. Concurrently, political instability and lack of resources limit the capacity of governments to manage environments, control disease transmission, and ensure an effective health system. Social, cultural, economic, and political factors interact and influence government capacity and individual willingness to reduce the risks of infection and transmission, and to recognize and treat disease. Understanding the dynamic interaction of diverse factors in varying contexts is a complex task, yet critical for successful health promotion, disease prevention, and disease control. Many of the research techniques and tools needed for this purpose are available in the applied social sciences. In this article we use this term broadly, and so include behavioral, population and economic social sciences, social and cultural epidemiology, and the multiple disciplines of public health, health services, and health policy and planning. These latter fields, informed by foundational social science theory and methods, include health promotion, health communication, and heath education.Social science health researchers have attended particularly to HIV/AIDS, and more recently to malaria and tuberculosis (TB), reflecting the prevalence and resistance to control of these diseases and their emphasis in the United Nations Millenium Development Goals. Other infectious diseases, by default, have slipped into a “neglected” category. These include most “tropical” diseases, such as Chagas disease, dengue, human African trypanosomiasis, leishmaniasis, leprosy, lymphatic filariasis, schistosomiasis, and onchocerciasis. The inclusion of these diverse diseases as “neglected” refers not only to their status relative to HIV, TB, and malaria. Their neglect reflects their epidemiology: they are prevalent among the poorest and most marginalized of the world's population. More than 70% of countries and territories affected by NTDs are low-income and lower middle-income countries, and 100% of low-income countries are affected by at least five NTDs In recent years, however, NTDs have received increasing international interest, partly in response to promising advances in drug development. Concerted efforts are being made also to promote innovative public health approaches such as integrated delivery of multiple interventions The focus of this review was established at an expert consultation in which we participated, hosted by TDR on April 23–24, 2007. The experts convened to examine the current status of applied social science research in tropical disease control, identify ongoing challenges, and develop a strategy to mainstream gender and the social sciences within TDR. Priority areas for the review were based on consensus panel discussion. Literature reviewed was identified through MeSH heading searches in Web of Science, PubMed, and Scopus using various combinations of terms including social science, tropical diseases, neglected diseases, gender, and poverty. The review also drew on research funded by TDR and work conducted by TDR-trained scientists, represented both in peer-reviewed journals and in grey literature. Our aim was to inform developments in the identified key areas, and reflecting this aim, we have not sought to cover comprehensively all social science research in tropical and neglected diseases. In addition, we do not necessarily reflect the views of WHO, nor specifically those of TDR.The research themes and priorities for social research on NTDs reflect evolving approaches and discourses in international public health and the specific public health challenges of the era. In the early 1950s, well before the international health community would coin the term “neglected tropical diseases,” public health practitioners involved in infectious disease control programs had developed a keen interest in applied social science research. Considerable work began to focus on understanding reasons for adverse reactions to vertical infectious disease control efforts In the 1970s, primary health care, community participation, and support for horizontal health care systems emerged as important concepts and tools to address health inequalities. TDR was established as a joint special program of the United Nations Development Programme (UNDP), the World Bank, and WHO  to counteract the neglect in research and development efforts for tools to combat infectious diseases among the poor TDR funded a significant number of young scholars for higher degrees as well as an expanding number of research projects through the Research Strengthening Group and the Steering Committee on Social and Economic Research, and after 1994, through various initiatives and task forces on applied field research Over the decades, a considerable sub-literature on social sciences in infectious diseases and their control has emerged, including chapters in textbooks of tropical medicine In the mid 1990s, “upstream” issues such as globalization, equity, gender, and human rights gained increasing prominence in international health. In 2000, a new TDR Steering Committee on Social, Economic, and Behavioural Research (SEB) was established with the mandate to build on, promote, and support social research identifying constraints in, and opportunities for, infectious disease control and prevention in resource-poor settings. Emphasis was placed on elucidating social, cultural, economic, health-systems, and policy-related factors, and proposing strategic solutions to barriers in disease control and public health. In contrast to the work of the earlier committees, attention now was placed on social research that would address large-scale, “transnational” issues and challenges in relation to infectious diseases and their control. Researchers were encouraged, in this context, to attend to the societal and economic impact of globalization as well as specific disease and health-systems factors The research programs and related training of social scientists have consolidated the role of social sciences in the tropical disease agenda, particularly with respect to a stronger evidence base on the social determinants of health, on potential areas for interventions, and on preliminary developments in the area of implementation research. However, major challenges remain in understanding the complex interactions of community, household, personal, and governmental factors that maintain health and produce disease, and in finding effective ways to address these issues at various political levels.As reflected in the bibliography, the social science and applied health literature on infectious diseases of poverty is substantial, but uneven across diseases, themes, regions, and institutions. There is, for example, greater attention to communities who are vulnerable to disease, and less to institutions involved in disease prevention and control. Below, we draw attention to what we regard now as the most urgent and emerging research questions.Continued research is needed on the implementation of interventions and control programs to ensure a critical evidence base to inform the effective, sustained, and embedded adoption of interventions by communities Increased urbanization is partly driven by economic changes, but also by environmental and climate change, resulting in changed patterns of land use and residence, and changes in vector habitat and behavior. Global warming has both direct and indirect effects on the distribution and prevalence of NTDs, highlighting the need for further research on the links between society, environment, agriculture, and human health, and the relationship of these factors to the control of neglected vector-borne diseases such as dengue Notwithstanding growing attention to health programs, health services, and access to care, research is still required to explore how access to health services is conditioned by poverty and inequality, as shaped by structural and political-economic factors . In an emerging research agenda, there is a need to move to explore practical ways to disrupt disease transmission and enhance accessibility of care. Because of changes in land use, climate, and population demographics, and subsequent changes in the distribution of NTDs and continuing risk of drug resistance, there is a need too for ongoing research on the maintenance of disease control in areas of low prevalence. This will enable monitoring and prevent resurgence, without the need for resource-intensive programs. The various roles of the not-for-profit sector, industries, and civil society need further exploration. There are also continuing questions regarding government and population interactions, governance and government institutions The research on gender has almost without exception focused on issues affecting women with a disregard for how gender affects the disease experience of men. The fluid nature of the concept of gender and its dynamic interaction with other determinants of vulnerability, such as socioeconomic status, ethnicity, and age, also remain poorly understood. Our understanding of the significance of and interactions between gender differences and other social and economic variables is sparse, and little work has been conducted to apply our current knowledge from gender studies to the development of gendered policy and practice across all aspects of the health sector, including human resources and capacity building. These issues need to be understood within a broader political and environmental context that takes into account issues such as inequality, political instability and violence, displacement, and globalization New biomedical priority areas need to be enhanced by social science research. Innovative vector control interventions and new drugs and diagnostics need to be considered in terms of their introduction, acceptability, and adherence, and the integration of such innovations as a component of community-based interventions. Research needs to be undertaken on the acceptability and utilization of drugs in multi-intervention approaches for disease control , including in relation to the acceptability and affordability of new approaches and new drug regimes. People in endemic areas frequently have multiple infections; however, limited work has been undertaken on the social implications of this. Other areas requiring greater attention include decision-making regarding treatment, the impact of complex treatments, particularly when a person has more than one communicable and/or non-communicable disease, willingness to carry the cost of treatment for recurrent infections, and attitudes towards side effects.Research needs to be continued on the supply and distribution of drugs, including in relation to the proliferation of counterfeit drugs, the failure or inability to adhere to prescribed treatment regimes, the illegal circulation of drugs, and other questions on the use of pharmaceuticals and the roles of the private sector TDR's social research activities address both basic social science and implementation research issues, including most recently research on community-directed interventions for major health problems in Africa The hierarchical structure of personnel within the health sector in many disease-endemic countries stems from a colonial legacy that privileges the knowledge and contributions of biomedically trained personnel, and fails to appreciate fully the importance of engaging with a range of health professionals, such as lay providers, volunteer workers, and traditional specialists, to enhance the effectiveness of behavioral, household, and community-based interventions While social scientists need to engage in research related to health policy, administration, and management, in countries where NTDs are endemic, there are still few applied social scientists working on health-related questions, and a limited understanding within the health sector of the contributions that they might make. Further, for non-medically trained health service personnel engaged in research and in the design and delivery of programs, there is usually a limited career trajectory: social scientists are typically employed at levels not commensurate with their qualifications, without opportunities to utilize their specialized skills. This lack of recognition serves as a disincentive for those with the capacity to return to or remain within the health sector, contributes to their dissatisfaction in improving health services, limits the quality of applied social science research, and inhibits the translation of relevant social science findings into practice.The research themes that we believe to be of key importance in the years to come fall into two broad areas. One relates to globalization and its impacts: global warming and changes in the epidemiology of disease, urbanization, anthropogenic environmental change, and the availability, cost, and distribution of drugs. The other area relates to the control of disease, and in this context, to community participation, government–community partnerships, PPPs, health services research, and strategies for control of both single diseases and multiple infectious diseases. It will take time to nurture and strengthen new areas of research, not least if they are breaking new ground and are conceptually difficult; it will also take time, and is always complex, to sustain the small group of researchers working in these fields in endemic countries. Strategies and resource allocation need to be based on long-term outcomes.NTDs are referred to often as diseases of poverty, but implicit in the use of the term poverty is the tight inter-relationship of poverty and inequality. This reference to poverty extends to include individuals, households, communities, and countries. It refers to the individuals and households affected by infectious diseases, the effects of continuing, untreated infection, and the impoverishment that occurs as a direct result of disease and the high costs of health care. It refers to the material circumstances of communities at risk—in poor, isolated, and ill-served rural areas and in the sub-standard conditions of urban slums and squatter settlements. It acknowledges, too, the difficulties faced by countries too poor to provide the infrastructure, human resources, and services that reduce the toll of such infections, and that are crippled by international debt and economic disadvantage in ways that are echoed in the incidence and prevalence of diseases. A social science perspective on diseases of poverty is critical to ensure that equity remains an underlying principle in policy development, research, advocacy/dialogue, legislation, resource allocation, planning, implementation, and monitoring of programs and projects.Social research has drawn attention to the difficulties in ensuring effective and sustained interventions for NTDs in both urban and rural communities, and in environments that have been disrupted by war, resettlement, and migration.Gender has a major impact on the distribution of disease, risks of transmission, and diagnosis and patterns of care. However, the links between gender differences and other social and economic variables, such as socioeconomic status, ethnicity, and age, are poorly understood.Social research on community diagnosis, treatment, and control highlights the importance of community participation for the successful introduction, acceptability, and adherence of innovative vector control interventions and new drugs and diagnostics.


Philosophy, Ethics and Humanities in Medicine (PEHM) responds to these realities by providing a forum for deep discussion of the philosophical bases of science and medicine, so as to attempt to depict 1) the intensity and complexity of the intersection of philosophy and ethics; 2) how this intersection is revealed in research and therapeutics, and 3) how philosophical premises might ground ethical analyses and approaches that are necessary for sound medical care. Simply put, the vision and mission of PEHM is to generate thought and reflection upon the richness of the situations and relationships that are intrinsic to medicine.In an accompanying interview, Prof. Edmund Pellegrino reflects upon a life in medicine and bioethics, and offers his perspectives on the current and future state of these fields. Professor Pellegrino reiterates his oft-cited view of the inextricability of philosophy, ethics and the humanities in science and clinical medicine. This intertwinement must be acknowledged and regarded in any consideration of the nature and extent of the myriad possibilities and problems that can and will arise in medicine, and in the moral decisions mandated by its circumstances. in medicine is important, as it communicates an appreciation for ethics and humanitarian concern(s) as essential to each and all of the dimensions that contribute to and constitute medicine as a profession and practice. The papers appearing in PEHM illustrate this, and also seek to inform, educate, and at times, provoke debate and controversy. This year has seen a fine complement of papers: some re-examining longstanding questions and constructs of medicine [The notion of philosophy, ethics and humanities medicine -3; othermedicine -10, and medicine -14 Certamedicine , that havide infra), as both commentary upon the ongoing discussion of the issue at hand - and Prof. Papadimos' paper.Each and all of these themes are relevant - and controversial - in light of recent healthcare reforms and the changing climate of healthcare provision. There is some question as to whether Aristotle actually endorsed healthcare as a right, and Prof. Pellegrino  has raised this point by noting specific citations from Annas, Long, Miller, Schofield, et al.  The readPellegrino calls for "...broader conversation...about the whether any classical foundation exists for the right to healthcare", and recently, John K. Hall and Mark V. Boswell have asserted that while physicians - and, might I add, patients - may like to think of healthcare as a human right, ethics and law do not provide clear support for this position . As thesBut it is important to bear in mind that legislators do not render patient care, clinicians do, and I urge that we view this task scopiously, so as to obtain an enhanced appreciation for the professional responsibilities for healthcare that arise from what the most current scientific findings - and the humanities - reveal about health, disease and illness. This may provide deeper insight to why and how the realties - and philosophy and ethics - of medicine should inform healthcare policy. Toward these ends, it might be meaningful to reflect upon the teachings of the past. Aristotle's depiction of the interdependence of science, practical wisdom, philosophy, ethics, and politics is just as relevant today as it was centuries ago . It speaAs Aristotle recognized, a healthy citizenry makes for a stronger republic. But achieving such goals is reliant, at least in part, upon responsibilities borne by the "strong"  to mitigate the plight of the weak . Yet, whatever the system of medical care may turn out to be, it will be enacted in an increasingly technophilic milieu that is steeped in - and influenced by - a market mindset that is quick to commoditize resources, services and goods. To ethically navigate this socio-economic landscape, clinicians might do well to heed Aristotle's call for virtue and temperance, for despite the fact that technology has dramatically enhanced the quality of health and healthcare, the imprudent use of any technology - old or new- can be problematic, if not  erroneous -22. The This decision remains the province of the clinician, in concert with individual patients' needs and values. Yet, the latitude to make such decisions - and provide such care - must be enabled by guidelines, policy and law. Medicine - as profession and practice - does not occur in a socio-political vacuum, and as David Nash has stated, it is important to understand "...the political, educational and economic forces that are helping shape the future practice of medicine..." . To do sPEHM can facilitate such positive change by providing a forum for intellectual reflection and discussion that gives rise to fresh ideas and directions that are required if meaningfully sound progress - if not true paradigmatic shift - are to occur. Thus, in some small way, our work together in this journal might contribute to the preservation of something old and valuable  as we forge ahead and shape a new, viable -and better - medicine for the future.Clinicians, philosophers, ethicists, and policy-makers must be well-informed of the facts, circumstances, needs and values of involved agents, and the contingencies, exigencies and potential consequences that are both intrinsic to medicine, and that could be affected by guidelines and reforms. That such policy reforms have been posed reveals an awareness of changing problems and current inadequacies within the systems and conduct of medicine, and an expanding conventional wisdom that has identified the need for health care to "work better" -26. My h


Communities of practice and social-professional networks are generally considered to enhance workplace experience and enable organizational success. However, despite the remarkable growth in interest in the role of collaborating structures in a range of industries, there is a paucity of empirical research to support this view. Nor is there a convincing model for their systematic evaluation, despite the significant potential benefits in answering the core question: how well do groups of professionals work together and how could they be organised to work together more effectively? This research project will produce a rigorous evaluation methodology and deliver supporting tools for the benefit of researchers, policymakers, practitioners and consumers within the health system and other sectors. Given the prevalence and importance of communities of practice and social networks, and the extent of investments in them, this project represents a scientific innovation of national and international significance.Working in four conceptual phases the project will employ a combination of qualitative and quantitative methods to develop, design, field-test, refine and finalise an evaluation framework. Once available the framework will be used to evaluate simulated, and then later existing, health care communities of practice and social-professional networks to assess their effectiveness in achieving desired outcomes. Peak stakeholder groups have agreed to involve a wide range of members and participant organisations, and will facilitate access to various policy, managerial and clinical networks.Given its scope and size, the project represents a valuable opportunity to achieve breakthroughs at two levels; firstly, by introducing novel and innovative aims and methods into the social research process and, secondly, through the resulting evaluation framework and tools. We anticipate valuable outcomes in the improved understanding of organisational performance and delivery of care. The project's wider appeal lies in transferring this understanding to other health jurisdictions and to other industries and sectors, both nationally and internationally. This means not merely publishing the results, but contextually interpreting them, and translating them to advance the knowledge base and enable widespread institutional and organisational application. Scholars within the health , aviatioCommunities of practice can be defined as "groups of people who share a concern, a set of problems, or passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis" . Social These kinds of clustered relationships abound in health care and other industries. They can be naturally-occurring  or mandated  . They caCommunities of practice ,22 and sAt the same time, potentially negative consequences have been noted. Wenger and colleagues argue that communities of practice can encourage the hoarding of information to the detriment of others, curtail improvement and progress, and create in-group and out-group rivalries . BuchanaAlthough interest in communities of practice and social networks in industry settings has grown remarkably, no convincing model for their systematic evaluation has eventuated. Many authoritative commentators agree that analytic evaluation methods and tools are lacking -34. ThusClinicians, like other professionals, work best when they are allowed to flourish in groupings of their own interests and preference, are empowered ... and nurtured and influenced by their peers rather than controlled by others"  will employ new approaches.We will inform our work using theories on teams , inter-pThis is a comprehensive effort to execute a rigorous evaluation methodology, and deliver tools for the benefit of researchers, policymakers, practitioners and consumers. We have the opportunity to achieve both meaningful and transferable advances in the knowledge base of the discipline and to incorporate novel and innovative aims and concepts into the project design. Through the support of key stakeholders within the Australian health system, we will have access to a wide range of workplace communities and networks, including hundreds of clinicians, to test and refine our models. The overarching aims, phases, objectives, methods and outcomes in the approach are depicted in Figure The methodology is conceptualised in four major phases, matched to the aims and objectives and commensurate with the research approach. Each phase has two components, and involves a little over a year's work to achieve the project's objectives.The project will produce an evaluation framework founded on empirically-grounded evaluation principles. Initially we will drill further into the literature and derive from this assessment a set of fundamental, working evaluation principles. Work feeding into this process includes seminal contributions by Wenger and colleagues ,22,30 anSecondly, armed with the initial framework, we will design a preliminary evaluation model. There are many evaluation types , but ourThirdly, in phase 2, we aim to test the model and tools across a focused sample of communities of practice and social-professional networks. Peak Australian stakeholder groups have agreed to involve a wide range of members and participant organisations in this study. These include networks or communities of clinicians identified by the National Institute of Clinical Studies, accreditation surveyors of the Australian Council on Healthcare Standards, managerial members of the Australian College of Health Service Executives and clinical, managerial and policy groups associated with the Clinical Excellence Commission. We will identify, in conjunction with these stakeholder partners, representative samples of differing types of communities of practices and social-professional networks  and enrol them in our study. We aim to make comparisons between groups and across group types.The testing component will yield experience which will, fourthly, enable us to refine the tools, including their validity and reliability. Differing approaches to examine validity and reliability will be taken. Work on the reliability of social network data is important, and optimum outcomes can be achieved by re-applying social network questionnaires and comparing consistency of results -58. We hPhase 3 involves two components: fifthly, simulating the systems dynamics  of commuHaving derived the refined evaluation framework, model and tools we will seventhly apply them on a large scale to a sample of communities of practice and social networks identified across Australia, covering the public and private sectors, in order to achieve a sample broadly representative of the health care system. In this phase we will gather sufficient data on communities of practice and social-professional networks to assess their value, and judge the extent to which they contribute to work satisfaction, motivation, recruitment and retention, performance, resilience, safety and renewal. We will test the results and calibrate them against the predictive simulation data drawn from phase 3.This leads to our eighth component - a review of the research outcomes to interpret results and make final observations on the findings. We will use an arm's length, expert panel to triangulate judgements. Such a process further strengthens project outcomes, closing the feedback loop and helping to determine whether communities of practice and social-professional networks realise the results intended for them.This protocol provides a conceptual framework and research design for evaluating hard-to-research social science manifestations which are key determinants of health systems performance. A multi-methods, phased research design is important and innovative, and has been matched to the phenomena under investigation. This represents a bold approach to creating and then testing an evaluation model.Investigating and evaluating complex organisational constructs such as communities of practice and social-professional networks is challenging. Conducting research in naturalistic settings, examining behavioural and attitudinal factors in context, is a key strength. The research design recognises this, and applies a complex systems approach to the examination of complex systems phenomena. Repeated, staged testing of progress with the model introduces validity, reliability and rigour. Incorporating measures of organisational performance in the design increases the potential for robust correlations. Having undertaken extensive literature analyses of both communities of practice and social-professional networks, we have laid a sound platform to aid understanding and provide theoretical and empirical building blocks to our research studies.Objective measures are hard to achieve in social science research, as is generalisability, thus we have incorporated triangulation techniques in our design and seek transferability of findings rather than strict generalisability. Nevertheless, our results by definition will fall short of the gold standard, and will not produce level 1 evidence. Balancing this limitation is the reality that a strict test of this kind cannot be applied against research in this mould. Thus, other safeguards, including seeking data from multiple sources and assessing the extent to which they converge or diverge, constitute an effective, alternative approach.This is a large, comprehensive research project which will deliver outcomes both specifically relevant to health systems and transferable to the large number of organisations, systems and sectors which are affected by the effectiveness, or otherwise, of communities of practice and social-professional networks. In developing a rigorous evaluation methodology and delivering tools for researchers, policymakers, practitioners and consumers, the research project also demonstrates innovation and tests novel approaches in design. By interpreting and translating results for applications both within and beyond the health system, the project will advance understanding of how professionals work together, and how to optimise this interaction to improve organisational effectiveness and service delivery.The authors declare that they have no competing interests.JB and JIW designed the study, phases, protocol and instruments, and wrote the manuscript. GR, FC, JP and JW are members of the research team, and commented on an earlier draft of the manuscript. DB, SH, CH and BJ are industry partners, are members of the expert advisory committee, and provided input into the initial conceptualisation of the project. JC, NC, AG and LB-M commented on an earlier draft of the manuscript, and are members of the expert advisory committee. DD commented on an earlier draft of the manuscript and developed the ethics application, and steered it through the approval process. All authors approved the final version of the manuscript.The pre-publication history for this paper can be accessed here:


Sir,The World Health Organization (WHO) defines palliative care as the active total care of the patient, whose disease is not responsive to curative treatment. Control of pain, other symptoms, and the psychological, social, and spiritual problems are paramount. The goal of palliative treatment is the achievement of the best possible quality of life (QOL) for patients and their families. PalliatiCommunity need and the role of palliative care - As per the WHO figures, around one million new cases of cancer are diagnosed each year. About one-third of the patients are being treated for cancer and three-fourth is in terminal stages, and have pain. There is a need to increase the awareness among the community with regard to palliative care and its role at the end stage of any chronic illness. Greater awareness of palliative care should make it easier for professionals to combine active treatment and a supportive approach. People with disabling, progressive illnesses expect active care, but they also seek comfort, control, and dignity. The barriers to effective communication about emotional and end-of-life issues are well recognized.Palliative care: Indian scenario - The message of palliative care has become a movement in several parts of India in a short span of time. The past two decades have seen palpable changes in the mindset of healthcare providers, and policy makers with respect to the urgency of providing palliative care. Every ho


Communication theory and techniques, aided by the electronic revolution, provide new opportunities and challenges for the effective transfer of laboratory, epidemiologic, surveillance, and other public health data to the public who funds them. We review the applicability of communication theory, particularly the audience-source-message-channel meta-model, to emerging infectious disease issues. Emergence of new infectious organisms, microbial resistance to therapeutic drugs, and increased emphasis on prevention have expanded the role of communication as a vital component of public health practice. In the absence of cure, as in AIDS and many other public health problems, an effectively crafted and disseminated prevention message is the key control measure. Applying communication theory to disease prevention messages can increase the effectiveness of the messages and improve public health.


The aetiologic fractions due to smoking and chewing tobacco have been quantified for the first time, for cancers of the oral cavity, oropharynx, hypopharynx, larynx and oesophagus. The overall aetiologic fractions due to smoking and/or chewing tobacco have been found to be 70% for cancer of the oral cavity, 84% for the oropharynx, and about 75% for the hypopharynx and larynx. In cancer of the oesophagus, however, the fraction is only 50%, showing that another factor or factors play an equal role in the aetiology of cancer of this site. At each of the sites studied, it was found that the two factors, smoking and chewing, acted synergistically, though in varying degrees.


Allopathic practitioners in India are outnumbered by practitioners of traditional Indian medicine and homeopathy (TIMH), which is used by up to two-thirds of its population to help meet primary health care needs, particularly in rural areas. India has an estimated 2.5 million HIV infected persons. However, little is known about TIMH use, safety or efficacy in HIV/AIDS management in India, which has one of the largest indigenous medical systems in the world. The purpose of this review was to assess the quality of peer-reviewed, published literature on TIMH for HIV/AIDS care and treatment.Of 206 original articles reviewed, 21 laboratory studies, 17 clinical studies, and 6 previous reviews of the literature were identified that covered at least one system of TIMH, which includes Ayurveda, Unani medicine, Siddha medicine, homeopathy, yoga and naturopathy. Most studies examined either Ayurvedic or homeopathic treatments. Only 4 of these studies were randomized controlled trials, and only 10 were published in MEDLINE-indexed journals. Overall, the studies reported positive effects and even "cure" and reversal of HIV infection, but frequent methodological flaws call into question their internal and external validity. Common reasons for poor quality included small sample sizes, high drop-out rates, design flaws such as selection of inappropriate or weak outcome measures, flaws in statistical analysis, and reporting flaws such as lack of details on products and their standardization, poor or no description of randomization, and incomplete reporting of study results.This review exposes a broad gap between the widespread use of TIMH therapies for HIV/AIDS, and the dearth of high-quality data supporting their effectiveness and safety. In light of the suboptimal effectiveness of vaccines, barrier methods and behavior change strategies for prevention of HIV infection and the cost and side effects of antiretroviral therapy (ART) for its treatment, it is both important and urgent to develop and implement a rigorous research agenda to investigate the potential risks and benefits of TIMH and to identify its role in the management of HIV/AIDS and associated illnesses in India. The Indian health system has perhaps the world's largest community-based indigenous system of medicine, and it includes Ayurveda, Unani medicine, Siddha medicine, yoga and naturopathy.  These foIndia has a long history of traditional medicine that is well established and integrated within the overall medical structure of the country. ,9 In facTo address some of these issues, the Indian government established the Department of Indian Systems of Medicine and Homeopathy in 1995 and later renamed it the Department of Ayurveda, Yoga-Naturopathy, Unani, Siddha and Homoeopathy (AYUSH), which is part of the Ministry of Health and Family Welfare. The mission of AYUSH includes: a) an initiative for integrating AYUSH with modern, allopathic medicine; b) attention to standardization of compounds and quality control; c) assessing and standardizing TIMH education in institutions around India that teach TIMH; d) improving the availability of raw material that will be used in the manufacturing of TIMH compounds; and e) prioritizing research on TIMH. The Indian Government has also established a Central Council for Research in each of these core areas, as well as separate Directorates of AYUSH in 18 Indian States. Not all TIMH is perceived equally in India. For example, yoga and healthy diet – which are often incorporated into the Ayurveda, yoga and naturopathy traditions – are considered beneficial by both TIMH and allopathic providers. However, many of the Ayurvedic herbal preparations and homeopathic treatments for conditions such as tuberculosis and HIV are discouraged by allopathic organizations such as the Indian Medical Association, or in allopathic medical schools, since data are lacking to support the use of such treatments.  Use of TCaraka Samhita and Sushruta Samhita, which are the primary texts on Ayurvedic medicine, describe eight branches of Ayurvedic medicine: internal medicine, surgery, treatment of head and neck disease, toxicology, psychiatry, sexual vitality, rejuvenation and care of the elderly, and gynecology, obstetrics and pediatrics. . Only studies in English were reviewed. Bibliographies of review and other relevant articles were searched for relevant Indian literature, as well as a bibliography of Indian medicine  and sevein vivo, in vitro and in clinical studies. Abstracts from the initial electronic searches were searched to select studies that met the following inclusion criteria: English-language, peer-reviewed literature, published after the first case reported of HIV in India in 1986 through October 2008. Randomized controlled trials, experimental studies, observational studies, descriptive studies, and reviews of HIV and TIMH were included, while ethnographic literature was excluded.We examined studies focused on the impact of TIMH on HIV/AIDS Two reviewers (MF and CC) independently screened the titles and abstracts of all of the literature collected through the searches. If both reviewers agreed that the abstract was relevant, the full article was accessed and a second phase of screening was conducted. All studies passing these screening phases were included in the full descriptive review.Of 206 original articles reviewed, 36 were relevant and met the inclusion criteria described above. These 36 articles contained 38 relevant studies, 21 laboratory and 17 clinical. The majority of articles were excluded because they were not based on actual research studies, were not in English, or were surveys of TIMH usage. A bibliography of all included studies can be found in Additional File A total of 6 previous reviews of the literature were identified that covered at least one system of TIMH. The review by Vermani and Garg  on TIMH This literature review identified 38 individual studies  that are relevant to TIMH and HIV/AIDS. Most studied Ayurvedic herbs and homeopathic preparations, and none of the articles reviewed addressed naturopathy or Unani medicine.Gossypium spp.), Phyllanthus niruri, curcumin (Curcuma longa), and neem (Azadirachta indica). Many studies used a controlled experimental model, with uninfected or mock infected cells as the controls. Almost all of these studies reported positive effects on HIV infection rates; however, many of these studies had significant methodological flaws, lacked information about product standardization, and had insufficient outcome measures and reporting.Since the goal of this review was to assess the quality of published literature on TIMH for HIV/AIDS treatment and care, our main focus was on clinical research. However, 21 laboratory studies met the inclusion criteria and are summarized in Additional File Boxus sempervirens),  should be replicated to determine whether these initial positive effects can be confirmed and whether future research is justified. Future studies would benefit from larger samples, stronger designs, and clearer descriptions of populations, controls and intervention components under study. Imperative for reliability and validity is greater care in analysis and reporting of results.Due to their methodological shortcomings, studies included in this review that reported positive effects [such as those of Boxwood (virens),  Andrograculata),  neem (Azindica),  and the Significant roadblocks to achieving these research goals exist. A broad spectrum of TIMH practices is currently in use, but there is limited availability of scientific information on which to build testable hypotheses. It is difficult to fit non-Western clinical practices that are often individualized for each patient into the Western, reductionist scientific model. Finally, there is a general lack of scientific expertise or a research culture within the TIMH practice community and a weak TIMH clinical perspective in the scientific community. The majority of TIMH research has been conducted outside the traditional setting in which the therapy was created and is practiced, which seriously limits the model validity and generalizability of research findings.  To overcAs previously stated, TIMH providers outnumber allopathic providers in India and serve as the primary method for delivering primary care for a majority of India's population. Across the socioeconomic spectrum, private medical facilities are the preferred source of care ,77. IndiWhile it would be imprudent to promote use of TIMH in place of allopathic medicines for HIV/AIDS, we propose that consideration be given by the Indian Medical Association to recognizing TIMH providers and to training them in providing coordinated care  to the millions of HIV infected patients for whom they already provide care. Furthermore, we propose that a sound, evidence-based model of integrative HIV/AIDS care that is based on enhanced cross-training and collaboration between TIMH and allopathic practitioners and solid safety and effectiveness data, has the potential for improving health outcomes among HIV positive individuals in India.In summary, this review exposes a broad gap between the current widespread use of TIMH therapies for HIV/AIDS in India, and the research base supporting their effectiveness, efficacy and safety. The therapeutic effects of TIMH for HIV/AIDS cannot be established based on the current literature; most studies published to date in the English-language literature lack sufficient clarity and rigor of reporting to assess reliably and quantitatively the quality of results. The lack of high-quality evidence highlights the need for rigorous investigation of both whole systems of TIMH, as well as individual therapies. In light of the suboptimal effectiveness of vaccines, ART, barrier methods and behavior change strategies for prevention and cure of HIV infection, it is both important and urgent to develop a collaborative research agenda that uses rigorous methodologies to investigate, evaluate and better understand the role of TIMH in managing HIV/AIDS and associated illnesses in India.The authors declare that they have no competing interests.MF participated in the conception and design, acquisition of data, analysis and interpretation, drafting and critical revision of the manuscript, material support and supervisionCC participated in the conception and design, acquisition of data, analysis and interpretation, drafting and critical revision of the manuscript, material support and supervisionDQ participated in analysis and interpretation of data, drafting the manuscript, and material support.WBJ participated in the conception and design, analysis and interpretation of data, critical revision of the manuscript, obtaining funding and supervision.AG participated in the conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript, administrative support and supervision.AA participated in the conception and design, analysis and interpretation of data, critical revision of the manuscript, and supervision.IC participated in the conception and design, analysis and interpretation of data, drafting of the manuscript, critical revision of the manuscript and supervision.Bibliography of included studies.Click here for fileSummaries and critiques of included studies.Click here for fileTable of laboratory studies.Click here for fileTable of clinical studies.Click here for file


Rickettsia NomenclatureOn  Rickettsia sibirica infections in Spain and Portugal. The authors identify the agent both as a subspecies  was first discovered in the 1930s, and its etiologic agent, If, and when, the subspecies names are validated, they are likely to be adopted and routinely used in the literature. Rickettsial taxonomy continues to evolve, and future changes should be determined by critical scientific judgments and general consensus within the scientific community.Bartonella spp. diseases and Q fever.Dr Massung is chief of the Rickettsial Zoonoses Branch, Division of Viral and Rickettsial Diseases, National Center for Zoonotic, Vector-borne and Enteric Diseases, Centers for Disease Control and Prevention. His research interests include laboratory and epidemiologic investigations targeting the detection, prevention, and control of rickettsial and


This report on the health of Canadian women is intended to: (i) determine the extent to which currently available data can be used to provide gender-relevant insights into women's health; (ii) provide information to support the development of health policy, public health programs, and interventions aimed at improving the health of Canadian women; and (iii) serve as the basis for further indicator development. The report provides information and descriptive statistics on determinants of health, health status, and health outcomes for Canadian women. To the extent possible, each chapter presents new, gender-relevant information on a health condition or issue identified as important to women's health during national expert and stakeholder consultations in 1999. Where data or appropriate data are lacking, this is documented. Recommendations for change are made at the end of each chapter, accompanied by a discussion of the gaps in and policy implications of the findings.A number of jurisdictions have recognized the need for information on gender and health -4. In thIt is generally agreed that differences in health status and health outcomes between individuals-and between men and women-are determined by factors beyond biology. Global forces, including cultural, political, and ecological change, have a powerful effect on health. Against this global backdrop, a complex set of factors-such as socio-cultural and transition experiences, education, income, social status, housing, employment, health services, personal health practices, and the physical environment-comes into play. For example, in developed countries, cultural and economic shifts in attitude toward women's participation in the labour force and control over reproductive decisions have led many women to delay childbirth.The Women's Health Surveillance Report adopts the broad definition of women's health that provided the framework for the discussion on women and health at the Fourth World Conference on Women (the Beijing Conference), held in September 1995:Women's health involves women's emotional, social, cultural, spiritual and physical well-being and is determined by the social, political and economic context of women's lives as well as by biology. This broad definition recognizes the validity of women's life experiences and women's own beliefs and experiences of health. Every woman should be provided with the opportunity to achieve, sustain and maintain health as defined by that woman herself to her full potential. Further, this report attempts to take a gender-sensitive approach to health information where possible, taking into account the context of individual's lives . Its aim in part is to inform future gender-based analyses.The authors of individual chapters have made use of population data from large Canadian surveys and administrative databases. Data chosen for analysis depended largely on the availability of the databases at the time of chapter development. Although such data sources can provide interesting insights, they also have limitations. For example, while they usually include a breakdown of the data by sex, they often do not provide sufficient measures by which to explore the influence of gender as determined by the context of women's lives. For example, depression is a major cause of disability worldwide. In Canada, as in other developed countries, the prevalence of depression is the same among boys and girls. After puberty, however, women are about twice as likely as men to experience a depressive episode ,7. Tradi* The views expressed in this report do not necessarily represent the views of the Canadian Population Health Initiative, the Canadian Institute for Health Information or Health Canada.


Norman Bleehen came from an orthodox Jewish background and was much influenced by the great value both sides of his rabbinical family placed on academic achievement. He took pride in having studied and worked in internationally recognised centres of excellence at the universities of Oxford, London, Cambridge and Stanford.Born in Manchester in 1930, he grew up in London. In 1947, he won a scholarship to Exeter College Oxford to read Medicine, taking an additional year to do a BA in Physiology and Biochemistry. A Medical Research Council (MRC) studentship allowed him to study aspects of the action of insulin in the Biochemistry Department, for which he was awarded the Gotch Memorial prize. During his years in Oxford, he was President of the Oxford University Jewish Society and was influential in the Interuniversity Jewish Federation.In 1952, he began his clinical training at the Middlesex Hospital Medical School, qualifying in 1955. En route, he won prizes for forensic medicine, orthopaedic surgery, and radiology and radiotherapy. A house job in the radiotherapy department at the Middlesex set the direction of Norman's future career. He much impressed the then head, Professor (later Sir) Brian Windeyer. In 1957, he gained Membership of the Royal College of Physicians, before entering the Royal Army Medical Corps for his national service, initially at the British Military Hospital in Hanover and then, in 1958, in occupied Berlin. There the allied powers, Britain, the United States, France and Russia, shared responsibility, on a rotating monthly basis, for the War Criminals' gaol at Spandau. The only inmates were Baldur von Schirach, Albert Speer and, Hitler's ex-deputy, Rudolf Hess. When the British were mounting the guard, it was Norman's task to examine each inmate weekly, and to produce a report. As a committed Jew, he was deeply concerned about taking medical responsibility for these particular war criminals. Consulting his commanding officer brought the reminder: ‘This is the army, and that is your job’. But Berlin was not all duty; Norman was able to enjoy the city, especially the excellent opera.On demobilisation in 1959, Norman returned to the Middlesex Hospital. He was to specialise in radiotherapy and gain a Fellowship of the Royal College of Radiologists. In 1966, the MRC awarded him a Lilly travelling fellowship to Stanford University, where he worked in Professor Henry Kaplan's department, much acclaimed for its excellence in relating laboratory research to treating patients. This appealed to Norman's intellect and profoundly influenced his future professional life. He thoroughly enjoyed Stanford, telling tales of never-to-be-forgotten fishing trips. Although offered a faculty post there, he chose to return to the Middlesex, where Sir Brian Windeyer had suggested that he might ultimately succeed him. Initially, the Duchess of Bedford Research Fellow, in 1969 he was appointed Professor of Radiotherapy and head of the Academic Department of Radiotherapy. He began a laboratory-based research programme alongside his clinical work and started to build the team he would subsequently take to Cambridge. That summer he met Tirza Loeb, an attractive Israeli/Australian PhD student whom he married after a whirlwind romance. They lived in a beautiful modern house in Highgate, where walls of glass gave them maximum pleasure from their garden: a growing enthusiasm. There they extended generous hospitality and friendship to Norman's rapidly expanding circle of colleagues and friends from all over the world.In 1975, the MRC invited Norman to set up a clinical and research unit in Cambridge at Addenbrooke's Hospital. He became Director of the MRC Clinical Oncology and Radiotherapeutics Unit (CORU). Cambridge University created a Department of Clinical Oncology endowed by the Cancer Research Campaign (now Cancer Research UK), and he was elected its first Professor of Clinical Oncology and Radiotherapeutics in the same year. Under his direction, this developed into one of the country's leading academic oncology units, both clinically and scientifically.Clinically, his interests were the treatment of brain tumours, especially gliomas, and lung cancer, both challenging diseases where new treatments were needed to improve dismal prognoses. All novel cancer treatments must be tested for efficacy against the current best practise. At this time in the mid-1970s, national cancer clinical trials supported by the MRC were proliferating rapidly. The statistical and data management tasks associated with the good design and successful conduct of clinical trials are substantial, and as Chairman of the MRC Cancer Therapy Committee, Norman recognised the need for a dedicated MRC group to carry out these tasks. He proposed that a Cancer Trials Office (CTO) be set up within his Cambridge Unit. It was inaugurated in 1977, taking over responsibility for ongoing trials as well for as setting up new ones. The CTO was one of his major achievements; its success led the MRC to create an independent Cancer Trials Unit.The team Norman gathered at CORU worked on both fundamental tumour biology and the development and optimisation of radiotherapy and chemotherapy. His personal research interests were in the development and trial of drugs to increase the efficacy of radiotherapy, and in the use of heat to improve radiotherapy and chemotherapy. In the course of Phase I trials of radiosensitisers and chemosensitisers, and many other clinical studies, he trained a new generation of investigative clinical oncologists and radiotherapists: now influential consultants and professors in today's oncology. The research students and post-doctoral scientists of CORU, now scattered around the world, are senior academics or hold powerful positions in the pharmaceutical industry: a potent legacy of his unit and of his leadership. Norman displayed an enviable flair for choosing people who would work together productively in a strong atmosphere of camaraderie. He was always very supportive of his staff, and invariably delivered on his promises to them, a rare quality which was much valued.A substantial body of publications, in excess of 400, bear his name. Norman also took time to serve on numerous UK boards and committees, frequently as chairman, as well in range of international organisations, primarily in Europe. He represented the UK government in the Europe Against Cancer Programme; being passionate about smoking prevention campaigns. He served on the editorial boards of numerous cancer-related journals. He was nonetheless, a rather modest man, who did not pursue the limelight, but the worth of his work was recognised and he received many honours and awards. He was most proud of his 1990 honorary doctorate from the University of Bologna, the oldest university in the world, and his CBE for services to medicine, received in 1994, at the height of his career and influence.Norman and Tirza were very hospitable; family, friends, colleagues and visitors, many from overseas, enjoyed their lovingly tended garden and beautiful house in quiet leafy Cambridge. An asparagus bed, particularly suited to the local soil, was Norman's special enthusiasm. Their nephews and niece have had a second home with them throughout their lives, two are continuing the medical tradition.Norman retired in 1995, and while he remained a Fellow of St John's College and continued to serve on a variety of committees, he was able to indulge his enthusiasm for opera and his garden and to travel more extensively with Tirza, especially to her family in Australia. While there he fell ill with lung cancer, a cruel fate for a man who had spent so much of his professional career treating the disease, who had never smoked and had worked hard to deter people from smoking. Ever an academic clinician, Norman gained new insights into the disease and was gratified to find them taken up in clinical trials.