EAT LOCALLY? THINK GLOBALLY

Findings: Christopher Columbusand the locavore’s dilemma.

JOHN TIERNEY PAGE 2

8.7 MILLION, GIVE OR TAKE

Scientists’ latest species estimatehas lots of room for disagreement.

CARL ZIMMER PAGE 3

OnlineA video report on an assisted livingcenter for people who live in theirrecreational vehicles.

nytimes.com/health

WellChocolate milk gets a makeover,and the (minimal) risks of vaccines.

nytimes.com/well

Science

VIKTOR KOEN

D1N

TUESDAY, AUGUST 30, 2011

‘GOOD DEATH’ IS HARD TO FIND

A couple sought to die by fasting.No, said the assisted living home.

PAULA SPAN PAGE 5

TWO PIECES OF ADVICE

Books: Life after prostate cancer,and how to talk to your doctor.

ABIGAIL ZUGER, M.D. PAGE 6

Health

By ALIYAH BARUCHIN

FREETOWN, Sierra Leone — On asweltering morning on a red-earth lanea few blocks from the largest mosque inthis West African capital, Jeneba Kabbastands up.

A tall, striking woman with a seriousmanner, Mrs. Kabba has been sittingunder an awning in the outdoor class-room of a vocational training programfor people with epilepsy. Every week-

day, some 20 Sierra Leoneans, fromteenagers to adults in middle age, gath-er here to learn skills like tailoring,weaving, tie-dyeing and soap-making,as well as reading — skills that, in thissociety, will give them a chance to earna living. Mrs. Kabba, 30, a graduate ofthe program, is now a tutor.

Her composure belies what she hassurvived. As a teenager she was takento a traditional healer, who boiled herbsand made her inhale the fumes from asteam tent for hours. The treatmentwas supposed to drive out the demonsthought to cause epilepsy; she nearlyfainted and could have been burned.

But worse was yet to come: She wasforced to drink a two-liter bottle of kero-sene. “Mi ches don cook,” she says inthe Krio language, her voice falteringeven now: “My chest started to boil.”Only a panicked trip to the hospitalsaved her life.

Mrs. Kabba not only survived, buthas been seizure-free for 10 years withthe help of phenobarbital, one of the old-est anti-epileptic drugs and virtually theonly one available here. And in a coun-try where people with epilepsy are oftenconsidered uneducable, unemployableand unmarriageable, Mrs. Kabba teach-es, is happily married and has a child.

Now, recalling the personal and pro-fessional distance that she has traveled,she rises to her feet. “People used tothink I was crazy,” Mrs. Kabba says, hervoice shaking. “Now they’re seekingme out; I’m the one that they want.Now, when I teach here, unless I tell you

that I have epilepsy, you wouldn’t know.I’m proud of myself.”

Among Sierra Leoneans with epilep-sy, Mrs. Kabba and her students are thelucky few, their successes due to the ef-forts of two tiny groups of advocates.

The Epilepsy Association of SierraLeone opened this vocational trainingprogram 11 years ago, near the end of adevastating decade-long civil war. Nowit has been joined by Dr. Radcliffe Duro-dami Lisk, a Sierra Leonean neurologisttrained in Britain, who returned to Free-town last year to open the EpilepsyProject, offering clinics in the city and

Stigma Is Toughest Foe in an Epilepsy Fight

TOM BRADLEY PHOTOGRAPHY/MEDICAL ASSISTANCE SIERRA LEONE

SEEKING REAL ANSWERS A child in Sierra Leone is given an EEG scan.

In Sierra Leone, manymistaken notions andonly one neurologist.

Continued on Page 6

By HENRY FOUNTAIN

The past week was a busy one forFrank Marks, the director of the Na-tional Oceanic and Atmospheric Ad-ministration’s hurricane research di-vision in Miami. There were scientiststo supervise, V.I.P.’s to greet — and onFriday and Saturday mornings he hadto fly into the heart of Irene.

They were among more than half adozen flights by NOAA aircraft intothe hurricane, organized to collectdata to help forecasters and research-ers better understand the storm.These days, Dr. Marks, who has beenmaking observation flights into hurri-canes for 32 years, usually leaves themissions to others. “I fill in,” he said.

But regardless of whether he’s onboard, the flights — especially thoseby the agency’s two P-3 turboprops,which are outfitted with Doppler ra-dar systems that can map a storm’sstructure in three dimensions — arecrucial to Dr. Marks’s goal of improv-ing hurricane forecasts.

For scientists who specialize in hur-ricanes, Irene, which roared up theEastern Seaboard over the weekend,has shone an uncomfortable light ontheir profession. They acknowledgethat while they have become adept atgauging the track a hurricane willtake, their predictions of a storm’s in-tensity leave much to be desired.

Officials with NOAA’s National Hur-ricane Center had accurately forecastthat Irene would hit North Carolina,and then churn up the mid-Atlanticcoast into New York. But they thoughtthe storm would be more powerful, its

winds increasing in intensity after itpassed through the Bahamas onThursday.

Instead, the storm lost strength. Bythe time it made landfall in North Car-olina two days later, its winds wereabout 10 percent lighter than pre-dicted.

It’s not a new problem. “With inten-sity, we just haven’t moved off squarezero,” Dr. Marks said. Forecasting astorm’s strength requires knowingthe fine details of its structure — the

internal organization and movementthat can affect whether it gains ener-gy or loses it — and then pluggingthose details into an accurate comput-er model.

Scientists have struggled to do that.They often overestimate strength,which can lead to griping about over-preparedness, as it has with Irene.But they have sometimes underesti-mated a storm’s power, too, as with

Intensity of Hurricanes Still Bedevils Scientists

LYNNE SLADKY/ASSOCIATED PRESS

BAHAMAS Hurricane Irene passednear Nassau on Thursday.

Continued on Page 3

By GINA KOLATA

It was Tuesday evening, June 7. Afrightening outbreak of food-borne bac-teria was killing dozens of people inGermany and sickening hundreds. Andthe five doctors having dinner at DaMarco Cucina e Vino, a restaurant inHouston, could not stop talking about it.

What would they do if something likethat happened in Houston? Suppose apatient came in, dying of a rapidly pro-gressing infection of unknown origin?How could they figure out the cause andprevent an epidemic? They talked forhours, finally agreeing on a strategy.

That night one of the doctors, JamesM. Musser, chairman of pathology andgenomic medicine at the Methodist

Hospital System, heard from a worriedresident. A patient had just died fromwhat looked like inhalation anthrax.What should she do?

“I said, ‘I know precisely what to do,’”Dr. Musser said. “‘We just spent threehours talking about it.’”

The questions were: Was it anthrax?If so, was it a genetically engineeredbioterrorism strain, or a strain that nor-mally lives in the soil? How dangerouswas it?

And the answers, Dr. Musser real-ized, could come very quickly from new-ly available technology that would allowinvestigators to determine the entiregenome sequence of the suspect micro-organism.

It is the start of a new age in micro-biology, Dr. Musser and others say. Andthe sort of molecular epidemiology heand his colleagues wanted to do is onlya small part of it. New methods of quick-ly sequencing entire microbial genomesare revolutionizing the field.

The first bacterial genome was se-quenced in 1995 — a triumph at thetime, requiring 13 months of work. To-day researchers can sequence the DNAthat constitutes a micro-organism’s ge-nome in a few days or even, with the lat-est equipment, a day. (Analyzing ittakes a bit longer, though.) They can si-multaneously get sequences of all themicrobes on a tooth or in saliva or in asample of sewage. And the cost hasdropped to about $1,000 per genome,

The New Generation of Microbe Hunters

o o o yyyyyyyyy

ddddd

PPP

LLLLLLLLLLLLLL ddd

PACIFIC BIOSCIENCES; IMAGES FROM TERRAMETRICS AND GOOGLE, VIA GOOGLE EARTH

HOT SPOTS Researchers hope to use rapid DNA sequencing of microbes to make “disease weather maps” of large areas, like a hypothetical disease outbreak in the Bay Area, above.

LOCAL TESTING On a smaller scale, colors show increasing amounts of flu virus measured at different locations and surfaces inside the Pacific Biosciences building during flu season.

PacificBiosciences

San Francisco Bay

San Francisco

Oakland

Dublin

San Leandro

San Mateo

Fremont

Menlo Park

Continued on Page 4

As diseases emerge,genome sequencingproves a powerful tool.

C M Y K Nxxx,2011-08-30,D,001,Bs-4C,E1

The number of im-plantable cardiacdevices in use hasdoubled since 1993,

and the number of infections asso-ciated with them has more thantripled, a new study has found.

Use of implanted defibrillators,which prevent irregular heart-beats, increased by more than 500percent from 1993 to 2008, whileuse of implanted pacemakers,which speed up a slowly beatingheart, increased by 45 percent,the report said. More than 4.2 mil-lion of these devices were im-planted during the 16-year period.

The study, in the Aug. 30 issueof The Journal of the AmericanCollege of Cardiology, used a rep-resentative sample of hospital dis-charge records to estimate thenumber of infections caused bythe devices. The incidence of in-

fection in 2008 increased to 2.4percent from less than 1.5 percentin 2004. Treating one infectioncosts, on average, $146,000.

The reasons for the increaseare not clear, but the recipients’age and poorer health may be fac-tors. And defibrillators requirefrequent replacement, with eachprocedure providing another op-portunity for infection.

“I don’t want people to thinkthat doctors are using these de-vices needlessly,” said Dr. ArnoldJ. Greenspon, the lead author anda professor of medicine at Thom-as Jefferson University Hospital.“They save lives and improve thequality of life. But the populationis getting older, with more co-morbid conditions.”

Several authors of the studyhave received payments frommedical device manufacturers.

RISKS

Infections Follow Rise in Cardiac Implants

An analysis of stud-ies including morethan 100,000 sub-jects has found that

high levels of chocolate consump-tion are associated with a signifi-cant reduction in the risk of cer-tain cardiovascular disorders.

The seven studies looked at theconsumption of a variety of choco-late — candies and candy bars,chocolate drinks, cookies, des-serts and nutritional supple-ments. By many measures, con-sumption of chocolate was linkedto lower rates of stroke, coronaryheart disease, blood pressure andother cardiovascular conditions.

But there was no beneficial ef-fect on the risk for heart failure ordiabetes.

Over all, the report, published

Monday in the British medicaljournal BMJ, showed that those inthe group that consumed the mostchocolate had decreases of 37 per-cent in the risk of any cardiovas-cular disorder and 29 percent inthe risk for stroke.

Still, the lead author, Dr. OscarH. Franco, a lecturer in publichealth at the University of Cam-bridge, warned that this findingwas not a license to indulge andnoted that none of the studies re-viewed involved randomized con-trolled trials.

“Chocolate may be beneficial,but it should be eaten in a moder-ate way, not in large quantitiesand not in binges,” he said. “If it isconsumed in large quantities, anybeneficial effect is going to disap-pear.”

PREVENTION

Evidence of Heart Benefits From Chocolate

Prolonged breast-feeding is widelybelieved to protectinfants against de-

veloping eczema and other aller-gic diseases. But a new study hasfound no evidence for the belief.

Researchers in Britain gath-ered data on more than 50,000children ages 8 to 12 in 21 coun-tries, assessing the prevalenceand severity of eczema with skinexaminations of the children, fam-ily medical histories and question-naires about past symptoms. Thechildren also received skin-pricktests for common allergens.

Even among children who hadbeen breast-fed for six months orlonger, there was no evidence thatbreast-feeding prevented eczemaor limited its severity. The resultswere the same for children whosemothers had a history of allergy

and for those who had a positivereaction to the allergens used inthe skin-prick test.

In more affluent countries,breast-feeding actually was asso-ciated with a slight increase in therisk for eczema. The researcherssuspect that this is because moth-ers who see an allergic reaction inan infant may try to breast-feedlonger, not because breast-feed-ing causes the allergy.

“We’re not questioning thebenefits of breast-feeding,” saidCarsten Flohr, the lead authorand a senior lecturer in pediatricsat Kings College London. “Butwhen it comes to prevention of ec-zema, neither breast-feeding itselfnor prolonged breast-feedingseems to be protective.”

The study appears online inThe British Journal of Dermatolo-gy.

Vital Signs Nicholas Bakalar

NUTRITION

Breast-Feeding Does Not Prevent Eczema

Cholera outbreaks seem to be onthe increase, but a new study hasfound they cannot be explainedby global warming.

A bigger factor may be the cy-cle of droughts and floods alongbig rivers, according to Tufts Uni-versity scientists who published astudy in The American Journal ofTropical Medicine and Hygienethis month.

Cholera is caused by a bacteri-um, Vibrio cholerae, whose toxinstriggers severe diarrhea when itgets into drinking water.

Vibrio must be introduced to anenvironment — sewage from acamp of United Nations peace-keepers from Nepal, for instance,presumably introduced a Vibriostrain to Haiti last year. (Above, ayoung patient there.)

Vibrio lives in water near river

mouths, waxing and waning in cy-cles based on blooms of plantplankton. The plankton are eatenby tiny crustaceans to whoseshells Vibrio attaches. Warmerocean surface waters suppressplankton growth, so scientists hadassumed cholera outbreaks woulddecrease with global warming.

But satellite photographs of themouths of the Ganges, Amazon,Congo and Orinoco Rivers sug-gest that heavy rainfall and gla-cier melt have the bigger effect bywashing soil nutrients down riv-ers to feed the plankton blooms.

“Cholera seems to be gaining afoothold in more places than itused to,” said Dr. Peter J. Hotez,president of the American Societyof Tropical Medicine and Hygiene.“We obviously need to be taking adifferent approach.”

Global Update Donald G. McNeil Jr.

CHOLERA

Climate Change Isn’t a CulpritIn Increasing Outbreaks, Study Finds

RAMON ESPINOSA/ASSOCIATED PRESS

Standard outpatient medical care affrontsall logical time management. You wait for anappointment, you wait to be seen, and thencomes the hectic series of milliseconds thatconstitutes the medical encounter itself. Be-fore you remember half your agenda, you are

firmly ushered on your way, down the exitchute to start the process all over again.

Suppose it were different, and you could ac-tually rent the doctor’s attention for as longas you needed it? Suppose, for that matter,you could rent the actual doctor, proppingthat distinguished figure up by your bed tosoothe your midnight terrors, and then re-suming the dialogue in the morning?

There is no shortage of books aiming toprovide exactly this experience: paper doc-tors to calm you through the night and boreyou over breakfast. Many are written in suchself-help generalities you might as well saveyour cash. But some are timely or originalenough to warrant a careful look.

In the timely department is a new book byDr. Arnold Melman, chief of urology at AlbertEinstein College of Medicine in the Bronx,about coping with a diagnosis of prostate can-cer. There is probably no more confusing partof the body these days than the prostate, atleast in the sense that prostate cancer is con-fusing more doctors and patients than anyother disease. Regulatory bodies cannotagree on the best screening strategies for thiscommon illness. Meanwhile, the blood testused for screening has difficulty discriminat-ing between aggressive and nonaggressivecancers, which means that standard cancertreatments are sometimes vastly worse thanthe disease itself.

Some doctors let their patients decidewhether to be screened, and some men electto skip the whole thing. Dr. Melman has seentoo many men die from prostate cancer to beparticularly sympathetic to this strategy. In-stead, he operates from the position that menshould want to know if they have cancer, andthen should want to become cancer-free inshort order.

A variety of treatment options will achievethis end; Dr. Melman and his co-author,Rosemary Newnham, a medical writer, de-liver a detailed, straightforward and methodi-cal description of them all. Illustrations helpwith the anatomy, and ample attention is paidto the severe side effects all these treatmentscan have.

The most common side effects are urinaryincontinence and erectile dysfunction, bothcaused by surgical or radiation damage to thenetwork of nerves traversing the prostate.Despite the newest amazingly capable surgi-cal robots and finely tuned beams of radia-tion, either or both of these conditions may ul-

timately replace cancer as a man’s most sig-nificant medical problem.

“After Prostate Cancer” details everythingthat can be done to help, from Viagra and uri-nary catheters to a variety of additional sur-geries. A final section is directed toward menwhose cancer has spread; although they willprobably die of the cancer, treatments cankeep them well for a while.

There is nothing revolutionary in any ofthis; Dr. Melman is merely outlining what ca-pable urologists know and do. What is un-usual is the patient, unhurried, slightly pe-dantic but altogether reassuring tone. Theman has all the time in the world for you, andfor that reason alone this book may well sup-ply the cancer patient with what he has diffi-culty finding elsewhere.

Dr. Steven Z. Kussin, by contrast, address-es not a particular group of patients but theworld at large. A bad car accident 10 yearsago prompted him to reflect at length on the“process and philosophy” of medical care,and his book is an encyclopedic treatise onthe sad state of medicine today and the bestways for an Internet-savvy consumer to cope.

Dr. Kussin, trained as a gastroenterologist,is a talker. One suspects that even in the of-fice he was never one to hurry folks along.With the luxury of print he waxes supremelychatty.

Some of his ruminations are sphinxlike(“Trusting your fate to strangers with fingerscrossed is the beginning of a star-crossedcourse”). Some are on the far edge of contro-versial, like diatribes against clinical trialsand hospitalists (doctors who take over yourcare if you are admitted): he says both arelikely to endanger the average patient’s wel-fare.

He also offers the occasional nugget of un-usual advice. Should you really send yourdoctor a birthday card and gift to get bettercare, as he suggests? As bad as things are outthere, one does like to think this particularprecaution has not yet become necessary.

The sardonic commentary loops on — KurtVonnegut meeting Miss Manners — as Dr.Kussin settles himself down at the edge ofyour bed for a nice long lecture. “Don’t be anannoying evening telemarketer,” he cautions.(In other words, call a covering doctor onlywhen absolutely necessary.) “Don’t ventureinto what is surely one of Dante’s Nine Cir-cles of Hell with only a boo-boo.” (Steer clearof emergency rooms except in a true emer-gency.) “Going to a top hospital means noth-ing if you are about to be cared for by thatname-brand hospital’s village idiot.” (Amento that.)

Dr. Kussin does offer comprehensive ad-vice on using medical Web sites to advantage,but the casual reader may still find his com-pany a little too much monologue and too lit-tle dialogue. Still, for future sociologists, thisbook will serve as an invaluable guide to theechoing chambers of the 2011 doctor’s mind.

BOOKS Abigail Zuger, M.D.

Doctors With Plenty of Time for Patients

AFTER PROSTATE CANCERA What-Comes-Next Guide to a Safe and In-formed Recovery. By Arnold Melman, M.D., andRosemary E. Newnham. Oxford UniversityPress. 256 pages. $19.95.

DOCTOR, YOUR PATIENT WILL SEE YOU NOWGaining the Upper Hand in Your Medical Care.By Steven Z. Kussin, M.D. Rowman & Littlefield.314 pages. $34.95.

Lots of wisdom andadvice, and no rush todispense them.

“upline,” in the remote eastern and southernprovinces. In this nation of six million people,Dr. Lisk is the only neurologist.

The vocational program replaces the op-portunities that its students have lost, one af-ter another: Their schools have asked themto leave; their employers have fired them forhaving had a seizure in the workplace; theirspouses and families often shun them for fearthat they are contagious, or possessed.

And they live here, in one of Africa’s poor-est countries, where scarce health care re-sources and the stigma surrounding epilepsyadd up to a “treatment gap” of more than 90percent — meaning that fewer than 10 per-cent of the estimated 60,000 to 100,000 SierraLeoneans with epilepsy are getting the treat-ment they need.

Looking at the array of public-health prob-lems facing many African societies, it is easyto wonder how a disease like epilepsy evenmakes its way onto the radar. “There is grow-ing appreciation for the importance of non-communicable chronic diseases in these re-gions,” said Dr. Gretchen Birbeck, a globalepilepsy expert who directs a clinic outsideLusaka, the capital of Zambia. “But the focuswhere it counts — policy and money — is stillon H.I.V./AIDS, tuberculosis and malaria.”

Yet epilepsy affects 50 million peopleworldwide, and according to the WorldHealth Organization, nearly 90 percent ofpeople with epilepsy live in developing coun-tries. In Sierra Leone, Dr. Lisk said, “certainsituations increase our prevalence: infectiousdiseases, childhood asphyxias, injuries fromthe rebel war, head trauma.”

Epilepsy treatment gaps are driven largelyby low income and rural location, makingsub-Saharan Africa a treatment-gap hot spot.Treatment in Sierra Leone is not expensive;Dr. Lisk’s patients pay about $2 a month forphenobarbital, which gives more than 60 per-cent of users significant seizure control. Thecosts of untreated epilepsy, on the other hand,are enormous, especially in lost productivity.

“People with epilepsy here become dis-proportionately disadvantaged in the jobmarket,” said Max Bangura, founder of theEpilepsy Association of Sierra Leone and itsvocational program. “With this training, peo-ple now know our students as excellent tai-lors; they are useful in their communities.”

While Dr. Lisk and Mr. Bangura fight ashortage of resources, they say their most in-tractable problem is still the intense stigmasurrounding epilepsy, which often acts as abar to treatment. “The first hurdle is whetheror not the family believes that this is an ill-ness that can be treated,” Dr. Lisk said.

Stigma here is based on two myths: thatepilepsy is contagious and that it is caused bydemonic possession. Dr. Lisk is quick to pointout that beliefs about possession traverse so-cietal boundaries. “You think it relates to lev-el of education, of literacy, but somehow itdoesn’t,” he said. “Sometimes it’s the mosteducated people who will tell you that it’s de-monic. They say it’s in the Bible.” (Some bibli-cal references to possession have long beenthought to describe people with epilepsy.)

As a result, discrimination against peoplewith epilepsy here is blatant and unabashed,and it begins in elementary school. “Theschool authorities often ask the students withepilepsy to leave,” Mr. Bangura said. “Thereis the notion that epilepsy is contagious; sowhen somebody has an attack during school,the perception is that if somebody happens tostep on the spittle of an affected student, thatwould be one way of contracting the disease.”

Nearly half of Sierra Leonean children withepilepsy drop out of school once their condi-tion is discovered. Teachers are often unwill-ing to help a child having a seizure in class.

“Wherever the kid fell, they circle it and tellpeople to stay away from it, because that spotis a bad spot,” said Lima Kanu, a graduate of

Mrs. Kabba was; some male healers sexuallyabuse teenage girls with epilepsy, claimingthat sex is a way to drive out demons.

But Dr. Lisk’s clinics are starting to make adifference. “A lot of the doctors — and it’s notonly in this country, but generally — theyreally don’t know how to deal with epilepsy,”he said. “They’re happy that there’s some-where patients can be referred now.”

Another problem is getting patients to stayon their medication. “People expect instantresponse,” Dr. Lisk said. “If you give the med-ication and two or three weeks later theyhave a seizure, they think, ‘No, it’s not work-ing.’ And then it’s the ‘I told you so’ from therelatives — and they stop.”

As with everything in Sierra Leone, cost isa deciding factor. Dr. Lisk’s program makesphenobarbital available for about $2 a monthregardless of how many times a day a patienttakes it. Even so, Mr. Bangura said, many pa-tients say they cannot afford it.

In the developed world, epilepsy care in-volves brain imaging. Sierra Leone has oneelectroencephalogram machine (thanks inpart to Medical Assistance Sierra Leone, aBritish charity), one CT scanner and noM.R.I. machines. More complex epilepsytreatments like neurosurgery are unheard of.

Yet Dr. Birbeck, in Zambia, said such hightechnology was “not needed to have a publichealth impact on epilepsy” and added, “Youhave to have a different approach.”

That, she says, includes the priorities thatshe and Dr. Lisk have set in their own pro-grams: raising awareness that epilepsy is amedical condition that can be treated; havinga functioning health care system with facili-ties patients can reach; training health work-ers in epilepsy care; and offering anticon-vulsive medicine at low or no cost.

Mr. Bangura and Dr. Lisk aim to expandtheir efforts. The Epilepsy Association wantsto open 10 more vocational training pro-grams; Dr. Lisk is trying to integrate epilepsycare into Sierra Leone’s health care system.

“We hold almost all of our clinics withinMinistry of Health facilities, and we also trainthe staff,” he said. “Because we have one eyeon the future: These are the people who haveto be able to take over.”

But he added: “We need to have enoughtrained personnel — more than one neurolo-gist, epilepsy nurses, trained communityhealth officers. We need to do what we are do-ing 10 times over.”

And ultimately, all efforts come back to dis-pelling the stigma that still clings to epilepsyhere.

“Epilepsy is just a sickness,” said Mrs. Kab-ba, the vocational tutor. “If your child got asickness, you wouldn’t just let them down.Look after them. Take great care of them.”

the vocational training program who is nowin charge of tailoring instruction.

A young woman in the program tells of be-ing thrown out of school after having a sei-zure in class. Accepted into a new school, shestayed for three years but ultimately left. “Itwas my decision,” she says. “I was ashamed.”

And in some cases, parents keep their chil-dren out of school. “They know the shameepilepsy might mean to their family, so theyprefer that their children not go,” Mr. Bangu-ra said.

The situation is no better in the workplace,even for professionals. One woman in the vo-cational training program lost her civil serv-

ice job in the country’s Ministry of Works thefirst time she had a seizure at the office.

Against this backdrop, anticonvulsive med-ications become a shield against discrimina-tion, since they can prevent a person’s epi-lepsy from becoming known.

“People who would never have touchedthese students now come and say, ‘Please,can you do this handiwork for me?’” saidAssanatu Blessing Turay, an administrator atthe vocational training program. “Now theyinteract.”

Finding medication is often a battle. “Whenyou have epilepsy and you go to the hospitalhere, they say, ‘We don’t have medicine forthat,’ so people are forced to go to traditionalhealers,” Mr. Bangura said. These patientsare often at risk of burns or other injuries, as

Stigma Is Toughest Foe in an Epilepsy FightFrom First Science Page

PHOTOGRAPHS BY TOM BRADLEY PHOTOGRAPHY/MEDICAL ASSISTANCE SIERRA LEONE

VIGIL At an epilepsy clinic, a mother attends her son, who has had a severe seizure.

SCARS Seizures that hit as she cooked ata fire caused Aminata Bangura’s burns.

D6 N THE NEW YORK TIMES, TUESDAY, AUGUST 30, 2011

Nxxx,2011-08-30,D,006,Bs-BW,E1