Birdlife, a tourist attraction for the southern portion of Bacalar Lagoon, Quintana Roo, Mexico.

The Bacalar Lagoon (BL) in Quintana Roo, Mexico; is an area of high interest due to its tourist potential. However, the changes in landuse patterns, urbanization, extensive cattle ranching and rapidly expanding agriculture, have generated negative impacts on areas of adjacent plan communities and wildlife habitats. The objective of this study has to evaluate the level of vegetation conservation in the southern portion of the BL through the avifauna present in sites with contrasting degrees of conservation. Additionally, change "and their habitat preference(s) in the different communities" to and their habitat use preferences in the different communities. To evaluate the level of conservation of the BL, field visits and botanical collections were carried out to identify species. For the counting and identification of birds, monthly surveys were made through coastal tours along the cenote Xul-ha in 2.5 km transects. Four transects were established: two for sites characterized as semi-conserved and two with disturbed sites. A total richness of 40 taxa was observed, which corresponds to 8.1% of the Quintana Roo avifauna and 32% to wetland birds (125 species). The species accumulation curves indicated that semi-conserved and disturbed sites tend to reach asymptotes and with a coverage percentage greater than 90%. In terms of diversity and community structure, no significant differences were observed. However, the semi-conserved and disturbed sites each have 11 unique species and share 18 species. The LB has an intermediate diversity of bird species compared to studies at the Mexican level, the habitat is important for the conservation of birdlife; as it functions as a reservoir of diversity. Strategies has been suggested that promote sustainable tourism, support the restoration of natural vegetation; and facilitate the economic development of the region.

Cost-effectiveness of lenalidomide plus dexamethasone vs. bortezomib plus melphalan and prednisone in transplant-ineligible U.S. patients with newly-diagnosed multiple myeloma.

OBJECTIVE: To conduct a cost-effectiveness assessment of lenalidomide plus dexamethasone (Rd) vs bortezomib plus melphalan and prednisone (VMP) as initial treatment for transplant-ineligible patients with newly-diagnosed multiple myeloma (MM), from a U.S. payer perspective. METHODS: A partitioned survival model was developed to estimate expected life-years (LYs), quality-adjusted LYs (QALYs), direct costs and incremental costs per QALY and LY gained associated with use of Rd vs VMP over a patient's lifetime. Information on the efficacy and safety of Rd and VMP was based on data from multinational phase III clinical trials and a network meta-analysis. Pre-progression direct costs included the costs of Rd and VMP, treatment of adverse events (including prophylaxis) and routine care and monitoring associated with MM. Post-progression direct costs included costs of subsequent treatment(s) and routine care and monitoring for progressive disease, all obtained from published literature and estimated from a U.S. payer perspective. Utilities were obtained from the aforementioned trials. Costs and outcomes were discounted at 3% annually. RESULTS: Relative to VMP, use of Rd was expected to result in an additional 2.22 LYs and 1.47 QALYs (discounted). Patients initiated with Rd were expected to incur an additional $78,977 in mean lifetime direct costs (discounted) vs those initiated with VMP. The incremental costs per QALY and per LY gained with Rd vs VMP were $53,826 and $35,552, respectively. In sensitivity analyses, results were found to be most sensitive to differences in survival associated with Rd vs VMP, the cost of lenalidomide and the discount rate applied to effectiveness outcomes. CONCLUSIONS: Rd was expected to result in greater LYs and QALYs compared with VMP, with similar overall costs per LY for each regimen. Results of this analysis indicated that Rd may be a cost-effective alternative to VMP as initial treatment for transplant-ineligible patients with MM, with an incremental cost-effectiveness ratio well within the levels for recent advancements in oncology.

Loop mediated isothermal amplification assay using hydroxy naphthol blue, conventional polymerase chain reaction and real-time PCR in the diagnosis of intraocular tuberculosis.

This study is a comparative evaluation (Chi-square test) of a closed tube loop mediated isothermal amplification assay using hydroxy naphthol blue dye (HNB-LAMP), real-time polymerase chain reaction (PCR) and conventional PCR in the diagnosis of intraocular tuberculosis. Considering clinical presentation as the gold standard in 33 patients, the sensitivity of HNB-LAMP assay (75.8%) was higher (not significant, P value 0.2) than conventional PCR (57.6%) and lower than real-time PCR (90.9%). Specificity was 100% by all three methods. No amplification was observed in negative controls (n = 20) by all three methods. The cost of the HNB-LAMP assay was Rs. 500.00 and it does not require thermocycler, therefore, it can be used as an alternative to conventional PCR in resource-poor settings.

La ventaja epidemiológica de la orientación preferencial del control de la tuberculosis hacia los pobres

La tuberculosis (TB) continúa concentrada de manera desproporcionada entre los pobres, pero los determinantes conocidos de reactivación de la TB pueden no explicar las desigualdades observadas en las tasas de enfermedad según la riqueza. En el presente estudio, mediante la revisión de datos sobre desigualdades en TB en la India y la distribución de factores de riesgo de TB conocidos según riqueza, se describe cómo los patrones de mezcla social pueden estar contribuyendo a las desigualdades en TB. La mezcla social por afinidad selectiva según la riqueza, por la cual es más probable que las personas entren en contacto con otras personas de orígenes socioeconómicos similares, amplifica las pequeñas diferencias en el riesgo de TB y genera grandes desigualdades a nivel poblacional. A medida que las desigualdades y la asortatividad (o afinidad selectiva) aumentan, se hace más difícil controlar la TB; este efecto queda enmascarado cuando se examinan solamente promedios poblacionales de parámetros epidemiológicos, tales como las tasas de detección de casos. El estudio ilustra cómo los esfuerzos de control de TB pueden beneficiarse a partir de una orientación preferencial hacia los pobres. En la India, una intervención a escala equivalente podría tener un impacto sustancialmente mayor si se orientara a quienes viven por debajo de la línea de pobreza que el de una estrategia a toda la población. Además de las eficiencias potenciales de focalizar en poblaciones en más alto riesgo, los esfuerzos de control de la TB podrían llevar a una mayor reducción en el número de casos secundarios de TB por cada caso primario diagnosticado si es que tales esfuerzos fuesen preferencialmente orientados hacia los pobres. El estudio destaca la necesidad de recolectar datos programáticos sobre las desigualdades en TB e incorporar de manera explícita consideraciones de equidad en los planes de control de la TB.

The epidemiological advantage of preferential targeting of tuberculosis control at the poor.

Tuberculosis (TB) remains disproportionately concentrated among the poor, yet known determinants of TB reactivation may fail to explain observed disparities in disease rates according to wealth. Reviewing data on TB disparities in India and the wealth distribution of known TB risk factors, we describe how social mixing patterns could be contributing to TB disparities. Wealth-assortative mixing, whereby individuals are more likely to be in contact with others from similar socio-economic backgrounds, amplifies smaller differences in risk of TB, resulting in large population-level disparities. As disparities and assortativeness increase, TB becomes more difficult to control, an effect that is obscured by looking at population averages of epidemiological parameters, such as case detection rates. We illustrate how TB control efforts may benefit from preferential targeting toward the poor. In India, an equivalent-scale intervention could have a substantially greater impact if targeted at those living below the poverty line than with a population-wide strategy. In addition to potential efficiencies in targeting higher-risk populations, TB control efforts would lead to a greater reduction in secondary TB cases per primary case diagnosed if they were preferentially targeted at the poor. We highlight the need to collect programmatic data on TB disparities and explicitly incorporate equity considerations into TB control plans.

Pre-placement screening for tuberculosis in healthcare workers.

BACKGROUND: Healthcare workers (HCWs) are at occupational risk of contracting and transmitting tuberculosis (TB). Despite national guidance, the optimal process for the pre-placement screening of new entrant HCWs for TB in the UK is not certain, nor the appropriateness of using a one-step interferon gamma release assay (IGRA) screening programme. AIMS: To assess the potential for an IGRA-only TB screening programme for new entrant HCWs, and identify cost savings achieved through this process. METHODS: We conducted a retrospective analysis of IGRA and tuberculin skin tests (TST) within our occupational health service over a 3-year period. HCWs with markedly discordant test results (IGRA negative, TST positive) were followed up to determine whether they developed active TB. We also estimated the yearly cost savings if the existing two-step process was replaced with an IGRA-only programme. RESULTS: Totally, 96/1258 (8%) HCWs had positive IGRA results; 788 TSTs were performed for newly screened IGRA-negative HCWs without Bacille Calmette-Guérin scars, among which 597 (76%) tested negative (TST <6 mm). None of the 10 individuals with grossly discordant test results (TST >15 mm) developed active TB during the study period. We calculated savings of £20,453 if the two-step process was replaced with an IGRA-only programme. CONCLUSIONS: The absence of disease progression in individuals with markedly discordant results in this study suggest that an IGRA-only screening programme for new HCWs in the UK is feasible, and may be safe although our follow-up period was insufficient. Our results also suggest that substantial cost savings can be made by using this programme.

Assessment of accuracy of Cockcroft-Gault and MDRD formulae in critically ill Indian patients.

BACKGROUND: Cockroft-Gault (CG) and Modification of Diet in Renal Disease (MDRD) formulae have not been validated in critically ill Indian patients. We sought to quantify the discrepancy, if any, in Glomerular Filteration Rate (GFR) estimated by CG and MDRD formulae with 24 hrs urine Creatinine Clearance (Cr Cl). MATERIALS AND METHODS: Prospective cohort study in 50 adult patients in a mixed medical-surgical intensive care unit. INCLUSION CRITERIA: Intensive Therapy Unit (ITU) stay >48 hrs and indwelling urinary catheter. EXCLUSION CRITERIA: Age <18 years, pregnancy, dialysis, urine output <400 ml/day and patients receiving ranitidine, cefoxitin, trimethoprim or diuretics. We estimated Creatinine Clearance by CG and MDRD formula and measured GFR by 24 hrs urine creatinine clearance. Bland Altman plot was used to find the difference between the paired observations. The association between the methods was measured by the product moment correlation coefficient. RESULT: The mean GFR as calculated by Creatinine Clearance was 79.76 ml/min/1.73 m(2) [95% Confidence Interval (CI) 65.79 to 93.72], that by CG formula was 90.05 ml/min/1.73 m(2) [95% CI: 74.50 to 105.60], by MDRD was 85.92 ml/min/1.73 m(2) [95% CI: 71.25 to 100.59]. The Bias and Precision between CG and Cr Cl were -4.5 and 140.24 respectively, between MDRD and Cr Cl was -6.1 and 122.52. The Correlation coefficient of CG formula as a measure of GFR was 0.65 (P < 0.0001), that of MDRD was 0.70 (P < 0.0001). CONCLUSION: We conclude that CG and MDRD formulae have a strong correlation with measured GFR but are not a reliable measure and overestimate GFR in critically ill Indian patients.

Cost-effectiveness analysis of MMR immunization in health care workers.

BACKGROUND: Assessment of measles, mumps and rubella (MMR) status is an essential part of occupational health clearance for new health care workers (HCWs). At the time of this study the policy at Sheffield Occupational Health Service (SOHS) was to perform serological testing of HCWs without evidence of previous immunization prior to MMR vaccination. AIMS: To identify the cost implications of changing policy to offer vaccination without prior serological testing to HCWs without evidence of previous immunization. METHODS: A retrospective cohort analysis of all MMR serological results from individuals attending SOHS for pre-placement assessment between 1 April 2010 and 31 March 2012. RESULTS: Seven thousand five hundred and sixty-nine individuals attended SOHS for pre-placement screening. Of these, 52% (3921) had no evidence of prior vaccination to at least one MMR disease and underwent serological testing. Thirty-three per cent (1204) of these HCWs were sero-negative to at least one condition requiring vaccination. With the suggested change in policy, our data indicate a cost-saving of over £105 000 per year may currently be achieved at SOHS. CONCLUSIONS: Our findings highlight significant savings through offering vaccination without prior serology for HCWs with no evidence of prior immunization to MMR. An awareness of costs associated with serology, vaccination and staff clinics, as well as the wider impact of population vaccination campaigns, are important factors determining the most cost-effective strategy in this area.

Blood and body fluid exposures: consent for source patient testing.

BACKGROUND: Exposure to blood and body fluids (BBF) remains a major occupational hazard in health care. Routine testing of source patients for blood borne viruses where exposure has occurred is recommended in the UK. Whilst in practice source patient identification may be challenging the reasons why identified individuals are not tested, including issues relating to consent and procedure compliance, are not fully understood. AIMS: To identify the frequency of serological testing in identified source patients and the reasons for not testing, including refusal and absence of consent. METHODS: A review of all BBF exposure incidents reported to the Sheffield Occupational Health Service between 1 January 2009 and 31 December 2009. RESULTS: Of 490 reported BBF exposure incidents source patients were identified in 87% of cases and tested in 56% of the incidents. Rates of source patient testing were higher following incidents affecting medical (76%) and nursing staff (69%) than those involving non-clinical (36%) and dental staff (17%). Reasons for not testing source serology among identifiable patients (151) were not recorded in 66% of incidents, in 20% there was incapacity to give consent and in 5% testing was refused. CONCLUSIONS: This study found that despite guidance, routine source testing is not universal. Incapacity to consent is a contributory factor for some source serology not being tested and clarification of the ethical and legal position would be helpful. Larger studies should explore other reasons why identified source patients are not tested in practice and explore the policy implications of those findings.

Towards a public health curriculum in undergraduate medicine.

BACKGROUND: The need to adequately train medical professionals in public health has been recognised internationally. Despite this, public health curricula, particularly in undergraduate medicine, are poorly defined. This study explored the public health disciplines that newly qualified doctors in the United Kingdom (UK) should know. METHODS: We developed a 31-item questionnaire covering public health subject areas and expected competencies that medical graduates should know. The questionnaire was then administered to a stratified sample of medically trained individuals across a number of postgraduate schools of public health in the UK. Following administration, a ranking list was developed by subject area and by competency. RESULTS: There was an 85% response rate (69/81). Subject areas ranked highest included epidemiology, health promotion and health protection. Sociology and the history of public health ranked lowest. Competencies perceived as important by the respondents included understanding health inequalities, empowering people about health issues and assessing the effectiveness of healthcare programmes. DISCUSSION: Our study identifies the expected public health subject areas and competencies that newly graduating medical students should know. They provide a context through which to begin addressing concerns over the disparity between these expectations and what is actually taught in medical school, highlighting the continuing need to reframe undergraduate public health education in the UK.

Exploring the role of FDG-PET in the assessment of bone marrow involvement in lymphoma patients as interpreted by qualitative and semiquantitative disease metabolic activity parameter.

Bone marrow biopsy (BMB) is currently the standard method to evaluate marrow involvement in malignant lymphomas. However, there exist a number of pitfalls in this technique that can have important implications for initial staging, prognostification, and treatment of the disease. The present study was undertaken to investigate the utility of FDG-PET imaging in the detection of bone marrow involvement in untreated lymphoma patients. Forty untreated patients (36 males and 12 females) with either Hodgkin's disease (HD) (n = 17) or non-Hodgkin's lymphoma (NHL) (n = 31) underwent whole body FDG-PET study for disease evaluation. Bone marrow uptake of FDG was graded as absence or presence of disease activity at marrow sites by qualitative assessment. Semiquantitative analysis involved deriving disease metabolic index (DMI) using the following formula: DMI = SUV max of suitable circular ROI over PSIS or trochanteric region/ SUVmax of similar ROI over adjoining background. Findings of BMB and FDG-PET were compared for final analysis. Eleven out of 17 HD patients (12 males and 5 females) demonstrated concordance between FDG PET findings and BMB reports. Remaining 6 cases showed discordance of FDG-PET demonstrating presence of marrow involvement at marrow sites and uninvolved marrow on BMB. Twenty six of the 31 NHL cases (24 males and 7 females) demonstrated concordance between FDG PET findings and BMB reports. Remaining 5 cases showed discordance of FDG-PET demonstrating presence of marrow involvement at marrow sites and uninvolved marrow on BMB. All the BMB positive patients (2 of HD and 5 of NHL) demonstrated disease activity in bone marrow on FDG-PET study. All patients with absence of disease activity at marrow sites on FDG-PET scan (9 of HD and 21 of NHL) had histology proven uninvolved marrow. The quantitative assessment by DMI showed a mean of > 2.5 in HD and NHL patients at the PSIS region and the trochanteric region bilaterally in cases of bone marrow involvement by the disease. FDG-PET is a useful adjuvant to BMB for the evaluation of bone marrow involvement in lymphoma patients. The disease metabolic index of > 2.5 at the marrow sites can serve as a semiquantitative parameter for such diagnosis on FDG-PET in untreated patients of lymphoma.

PET imaging in the management of tumors of testis and ovary: current thinking and future directions.

The role of fluoro-D-deoxyglucose positron-emission tomography (FDG-PET) in testicular malignancies has been examined in various studies primarily in three specific settings: 1) differentiation of active disease from fibrosis/mature teratoma in patients with residual mass following chemotherapy and evaluation of the response to treatment; 2) initial staging and disease assessment after orchidectomy identification of suspected recurrences in the context of elevated circulating serum markers; and 3) predicting response to treatment. Of these, the area where FDG-PET imaging has been examined the most in testicular tumors is the evaluation of postchemotherapy residual mass in both seminoma and nonseminomatous germ cell tumors (NSGCT) of the testis, a critical step in determining the subsequent management approach of these tumors that vary amongst various centers. From the available data, this should be the test of choice for the assessment of a computed tomography (CT)-visualized residual mass following chemotherapy. In patients with residual masses or raised marker levels following therapy, positron-emission tomography (PET) appears sensitive and specific for detecting recurrent disease, at suspected and unsuspected sites. Fewer studies are available investigating its usefulness for staging at diagnosis and this requires further investigation to determine its eventual place as an imaging modality in this setting. Its precise role in disease prognostification is yet to be clearly defined in this malignancy but the initial results are promising. With regard to its role in ovarian carcinoma, it appears to be particularly useful for the diagnosis of recurrence when CA125 levels are rising and conventional imaging is inconclusive or negative. The role of fluoro-D-deoxyglucose (FDG)-PET/CT for the detection of recurrent ovarian cancer appears very promising and has the potential to replace the current surveillance techniques in detecting recurrent disease.

Antibiotic misuse in children by the primary care physicians--an Indian experience.

OBJECTIVE: To determine the misuse of antibiotics in the Pediatric outpatients department' (OPD) of a busy teaching hospital and to ascertain the probable reasons behind it. METHODS: Over a 6 months period, new cases primarily treated with antibiotics by Medical Officers (first contact physicians in Peadiatric Medicine and Surgery OPD) were recruited in the study after obtaining written consent from the parents. Various errors of antibiotic usage were noted. All Medical Officers were asked to fill up a preformed questionnaire and the parents/guardians were interviewed on their ideas about antibiotics. Data were analyzed by the statistical software SPSS 10. RESULTS: Antibiotics were prescribed in 2427 (84.9%) new patients. Misuse of antibiotics was documented in 36.8% patients (no indication in 35.3%, improper selection in 17.9% and incorrect dosage in 7.7%). All medical officers were aware that they overuse antibiotics. The various reasons sited were demand of the parents, reluctance to counsel due to patient overload, free supply of medicines from OPD and sympathetic grounds as follow up visits were uncertain. Majority of the parents/attendants belonged to poor socioeconomic status and did not have any idea regarding antibiotics. All parents wanted quick relief without hospitalization and only 2.3% were willing to revisit the OPD for the same illness. Both medical officers and parents felt that base line investigations were unnecessary. CONCLUSION: Antibiotic misuse is quite common in this part of the world. Irrational use was mostly seen in over-prescribing and improper selection of antibiotic. Poor socio-economic status and overcrowding of patients in OPD were the main responsible factors.

Cost-effective laparoscopic TEP inguinal hernia repair: the Portsmouth technique.

NICE (UK) has not recommended unilateral primary laparoscopic inguinal hernia repair because of its expense. A two-port technique without balloon inflator or routine tacking was developed, which helped reduce costs to just Pounds 35 more than day-case open hernia repair. Over a 6-month period, 40 patients underwent 60 TEP repairs with a 6-month follow up. Zero degree laparoscope (10 mm) and blunt graspers (5 mm) created the pre-peritoneal space, identified landmarks and completed the dissection. Trimmed 15 x 15 cm mesh was placed over each defect. Operating times for unilateral and bilateral hernias for consultants and supervised trainees were 30*, 42.5* and 40*, 55* min (*: Median) respectively. Verbal rating pain scores at 24 and 72 h were 1* (0-3) and 0* (0-2) respectively. Patients returned to activity, driving and work in 5*, 7* and 14* days respectively. Cost of laparoscopic hernia repair was calculated at Pounds 105. A two-port laparoscopic hernia repair can be performed effectively and safely, in reasonable time and at a low cost. These data support the use of this technique in primary unilateral inguinal hernia.

Correlation between symptoms and radiological findings in patients with chronic rhinosinusitis: an evaluation study using the Sinonasal Assessment Questionnaire and Lund-Mackay grading system.

Computerised tomography (CT) scans are routinely performed prior to endoscopic sinus surgery (ESS) in order to confirm the diagnosis, assess the response to medical treatment and provide important landmarks for surgery. However, the correlation between the findings of CT scans and the patient's symptoms remains ambiguous. The objective was to assess the correlation between preoperative symptom scores using the validated Sino-Nasal Assessment Questionnaire and CT scores in patients undergoing ESS. Twenty-two patients who attended otolaryngology clinics with chronic rhinosinusitis (CRS) were prospectively enrolled in the study. All of these patients completed Sinonasal Questionnaires (SNAQ) before they had ESS. Their CT scans were scored blindly by the surgeon and a radiologist following Lund-Mackay grading. Patients with high preoperative SNAQ scores had high or low CT scores. The same applied for patients with low preoperative SNAQ scores. There was no statistically significant correlation between SNAQ and Lund-Mackay scores (P = 0.5). However, there was a very strong correlation (P < 0.001) between the scoring of scans by the surgeon and the radiologist, while there was a moderate degree of discrepancy in the grading of anterior ethmoid sinuses and osteo-meatal complexes. Morbidity of patients with CRS cannot be predicted from the magnitude of changes in their CT scans. Significant inter-rater variability exists in the grading of pathological changes in anterior ethmoid sinus and osteo-meatal complex as recorded in CT scans.

Bayesian inference for kappa from single and multiple studies.

Cohen's kappa coefficient is a widely popular measure for chance-corrected nominal scale agreement between two raters. This article describes Bayesian analysis for kappa that can be routinely implemented using Markov chain Monte Carlo (MCMC) methodology. We consider the case of m > or = 2 independent samples of measured agreement, where in each sample a given subject is rated by two rating protocols on a binary scale. A major focus here is on testing the homogeneity of the kappa coefficient across the different samples. The existing frequentist tests for this case assume exchangeability of rating protocols, whereas our proposed Bayesian test does not make any such assumption. Extensive simulation is carried out to compare the performances of the Bayesian and the frequentist tests. The developed methodology is illustrated using data from a clinical trial in ophthalmology.

Function and medical comorbidity in south Texas nursing home residents: variations by ethnic group.

OBJECTIVE: To evaluate differences in functional status and burdens of medical conditions in Mexican American and non-Hispanic white nursing home residents. DESIGN AND SETTING: Cross-sectional survey of 17 nursing homes in south Texas. PARTICIPANTS: A total of 617 older nursing home residents, of whom 366 were Mexican American and 251 were non-Hispanic white. MEASURES: Activities of Daily Living (ADL) status abstracted from standard nurses notes and Burden of Disease abstracted from medical records. RESULTS: Mexican American residents had greater numbers of ADL dependencies and poorer overall ADL scores than non-Hispanic white residents. This poor functioning was not explained by age, gender, or marital or educational status. The average number of medical conditions was greater, and specific conditions, such as cerebrovascular disease, recent acute infections, diabetes, hypertension, and anemia, were more common in Mexican American residents compared with non-Hispanic white residents. In models relating function with medical conditions and ethnic group, ADL scores and dependencies were significantly related to bowel and bladder incontinence, cerebrovascular disease, dementia, recent infections, and skin decubiti, but not to ethnic group. CONCLUSION: Mexican American nursing home residents are more functionally dependent than non-Hispanic white residents. The difference in function is explained by a greater burden of medical conditions in the Mexican American residents.

Health and culture among the underprivileged groups.

PIP: This article discusses the issues involved in raising the health status of India's underprivileged groups. India's underprivileged population includes the following groups: scheduled tribes, scheduled castes, hill people, mothers and children, urban slum dwellers, handicapped population, and other backward communities. A sizable portion of India's population, these groups are economically and socially disadvantaged, and often live in geographically remote areas. They are also frequent victims of political, social, or religious turmoil. These people suffer from dismal health conditions, the result of poverty, illiteracy, malnutrition, lack of personal hygiene, and lack of sanitation. National health services have often bypassed these people. In addition to the social and economic factors contributing to the low health status of underprivileged groups, cultural factors might also play a role. Even when health services are provided, groups such as the scheduled tribes and scheduled castes underutilize the services. In 1982, with the establishment of the National Health Policy, the Indian government declared the need to improve the health status and quality of life of the underprivileged groups. The policy stressed the need to involve nongovernmental organizations in efforts to reach these groups. As the article points out, the delivery of health care to underprivileged groups needs to take into account the culture and specific situations of the populations. Furthermore, programs to improve the health status and quality of life of underprivileged groups cannot succeed unless they form part of a larger effort to bring about and overall transformation of society.^ieng