A comparative study on the efficacy of artesunate plus sulphadoxine/pyrimethamine versus artemether-lumefantrine in eastern Sudan

Background

The most important factor for effective zooprophylaxis in reducing malaria transmission is a predominant population of a strongly zoophilic mosquito, Anopheles arabiensis. The feeding preference behaviour of Anopheline mosquitoes was evaluated in odour-baited entry trap (OBET).

Methods

Mosquitoes were captured daily using odour-baited entry traps, light traps and hand catch both indoor and in pit traps. Experimental huts were used for release and recapture experiment. The mosquitoes collected were compared in species abundances.

Results

Anopheles arabiensis was found to account for over 99% of Anopheles species collected in the study area in Lower Moshi, Northern Tanzania. In experimental release/capture trials conducted at the Mabogini verandah huts, An. arabiensis was found to have higher exophilic tendency (80.7%) compared to Anopheles gambiae (59.7%) and Culex spp. (60.8%). OBET experiments conducted at Mabogini collected a total of 506 An. arabiensis in four different trials involving human, cattle, sheep, goat and pig. Odours from the cattle attracted 90.3% (243) compared to odours from human, which attracted 9.7% (26) with a significant difference at P = 0.005. Odours from sheep, goat and pig attracted 9.7%, 7.2% and 7.3%, respectively. Estimation of HBI in An. arabiensis collected from houses in three lower Moshi villages indicated lower ratios for mosquitoes collected from houses with cattle compared to those without cattles. HBI was also lower in mosquitoes collected outdoors (0.1–0.3) compared to indoor (0.4–0.9).

Conclusion

In discussing the results, reference has been made to observation of exophilic, zoophilic and feeding tendencies of An. arabiensis, which are conducive for zooprophylaxis. It is recommended that in areas with a predominant An. arabiensis population, cattle should be placed close to dwelling houses in order to maximize the effects of zooprophylaxis. Protective effects of human from malaria can further be enhanced by keeping cattle in surroundings of residences.     

Combining zooprophylaxis and insecticide spraying: a malaria-control strategy limiting the development of insecticide resistance in vector mosquitoes

Strategies to eradicate the vector-borne infectious diseases (e.g. malaria and Japanese encephalitis) are often directed at controlling vectors with insecticides. Spraying insecticide, however, opens the way for the development of insecticide resistance in vectors, which may lead to the failure of disease control. In this paper, we examine whether the combined use of insecticide spray and zooprophylaxis can limit the development of insecticide resistance in mosquitoes. Zooprophylaxis refers to the control of vector-borne diseases by attracting vectors to domestic animals in which the pathogen cannot amplify (a dead-end host). The human malaria parasite Plasmodium spp. has a closed transmission cycle between humans and mosquitoes, and hence cattle can serve as a dead-end host. Our model reveals that, by a suitable choice of insecticide spraying rate and cattle density and location, malaria can, in some situations, be controlled without mosquitoes developing insecticide resistance.     

Controlling Malaria Using Livestock-Based Interventions: A One Health Approach

Where malaria is transmitted by zoophilic vectors, two types of malaria control strategies have been proposed based on animals: using livestock to divert vector biting from people (zooprophylaxis) or as baits to attract vectors to insecticide sources (insecticide-treated livestock). Opposing findings have been obtained on malaria zooprophylaxis, and despite the success of an insecticide-treated livestock trial in Pakistan, where malaria vectors are highly zoophilic, its effectiveness is yet to be formally tested in Africa where vectors are more anthropophilic. This study aims to clarify the different effects of livestock on malaria and to understand under what circumstances livestock-based interventions could play a role in malaria control programmes. This was explored by developing a mathematical model and combining it with data from Pakistan and Ethiopia. Consistent with previous work, a zooprophylactic effect of untreated livestock is predicted in two situations: if vector population density does not increase with livestock introduction, or if livestock numbers and availability to vectors are sufficiently high such that the increase in vector density is counteracted by the diversion of bites from humans to animals. Although, as expected, insecticide-treatment of livestock is predicted to be more beneficial in settings with highly zoophilic vectors, like South Asia, we find that the intervention could also considerably decrease malaria transmission in regions with more anthropophilic vectors, like Anopheles arabiensis in Africa, under specific circumstances: high treatment coverage of the livestock population, using a product with stronger or longer lasting insecticidal effect than in the Pakistan trial, and with small (ideally null) repellency effect, or if increasing the attractiveness of treated livestock to malaria vectors. The results suggest these are the most appropriate conditions for field testing insecticide-treated livestock in an Africa region with moderately zoophilic vectors, where this intervention could contribute to the integrated control of malaria and livestock diseases.     

Blood-feeding behaviour of the malarial mosquito Anopheles arabiensis: implications for vector control

Feeding behaviour of the malaria vector Anopheles arabiensis Patton (Diptera: Culicidae) was monitored for 12 months (March 2003-February 2004) in the Konso District of southern Ethiopia (5 degrees 15'N, 37 degrees 28'E). More than 45 000 An. arabiensis females were collected by host-baited sampling methods (light-traps, human landing catches, cattle-baited traps) and from resting sites (huts and pit shelters). In the village of Fuchucha, where the ratio of cattle : humans was 0.6 : 1, 51% of outdoor-resting mosquitoes and 66% of those collected indoors had fed on humans, human baits outdoors caught > 2.5 times more mosquitoes than those indoors and the mean catch of mosquitoes from pit shelters was about five times that from huts. Overall, the vast majority of feeding and resting occurred outdoors. In the cattle camps of Konso, where humans slept outdoors close to their cattle, approximately 46% of resting mosquitoes collected outdoors had fed on humans despite the high cattle : human ratio (17 : 1). In both places, relatively high proportions of bloodmeals were mixed cow + human: 22-25% at Fuchucha and 37% in the cattle camps. Anthropophily was also gauged experimentally by comparing the numbers of mosquitoes caught in odour-baited entry traps baited with either human or cattle odour. The human-baited trap caught about five times as many mosquitoes as the cattle-baited one. Notwithstanding the potential pitfalls of using standard sampling devices to analyse mosquito behaviour, the results suggest that the An. arabiensis population is inherently anthropophagic, but this is counterbalanced by exophagic and postprandial exophilic tendencies. Consequently, the population feeds sufficiently on humans to transmit malaria (sporozoite rates: 0.3% for Plasmodium falciparum and 0.5% for P. vivax, by detection of circumsporozoite antigen) but also takes a high proportion of meals from non-human hosts, with 59-91% of resting mosquitoes containing blood from cattle. Hence, classical zooprophylaxis is unlikely to have a significant impact on the malaria vectorial capacity of An. arabiensis in Konso, whereas treating cattle with insecticide might do.     

An entomological investigation of the likely impact of cattle ownership on malaria in an Afghan refugee camp in the North West Frontier Province of Pakistan

Abstract. Field trials were undertaken to determine the effect of close proximity of humans to livestock on the human biting rates exhibited by various anophelines. The results indicate that proximity to cattle and to goats increases the subject's chances of being bitten by anophelines. Man-biting by Anopheles stephensi rose by 38% (8–68% CI) in the presence of a cow, and by 50% (16–84% CI) in the presence of two goats. Other species exhibited similar trends. These findings explain the results of an earlier trial which revealed that malaria prevalence was higher amongst families that kept cattle than those that did not.
The findings are discussed in relation to existing information regarding the host preferences of local anophelines and classic theories regarding zooprophylaxis. Our findings suggest that animals are only likely to have a worthwhile prophylactic affect when the vector is zoophilic, and then only when the animals are deployed to form a barrier between that vector and man. In situations where deployment of livestock to form a zoobarrier is impractical, the livestock should be located as far from man as possible.     

The dilution effect of the domestic animal population on the transmission of P. vivax malaria

The diversion of disease carrying insect from humans to animals may reduce transmission of diseases such as malaria. The use of animals to mitigate mosquito bites on human is called ‘zooprophylaxis’. We introduce a mathematical model for Plasmodium vivax malaria transmission with two bloodmeal hosts (humans and domestic animals) to study the effect of zooprophylaxis. After computing the basic reproduction number from the proposed model, we explore how perturbations in the parameters, sensitive to the effects of control measures, affect its value. Zooprophylaxis is shown to determine whether a basic reproduction becomes bigger than an outbreak threshold value or not. Sensitivity analysis shows that increasing the relative animal population size works better in P. vivax malaria control than decreasing the mosquito population when the relative animal population size is larger than a threshold value.     

Effectiveness of zooprophylaxis in malaria control: a theoretical inquiry, with a model for mosquito populations with two bloodmeal hosts

A model for a vector mosquito population with two bloodmeal hosts (man and a domestic animal) was developed to study the influences of domestic animals on the frequency of mosquito bites on man and the endemicity of human malaria. The vector population model, including blood-feeding success in the adult stage (depending on host density and biting efficiency) and density-dependent regulation in the larval stage, was combined with the Ross-Macdonald malaria transmission model. Model analyses suggested that introduction of domestic animals easily fed upon by mosquitoes increases mosquito density and, in some situations, frequency of mosquito bites on man and the infection rate of malaria through increased success of blood-feeding. Extinction of malaria was predicted only when an extremely large number of easily accessible (as compared to man) domestic animals are introduced. Limitations in the concept of zooprophylaxis and problems of livestock management in malaria control are discussed.     

Zooprophylaxis or zoopotentiation: the outcome of introducing animals on vector transmission is highly dependent on the mosquito mortality while searching

Background

Zooprophylaxis, the diversion of disease carrying insects from humans to animals, may reduce transmission of diseases such as malaria. However, as the number of animals increases, improved availability of blood meals may increase mosquito survival, thereby countering the impact of diverting feeds.

Methods

Computer simulation was used to examine the effects of animals on the transmission of human diseases by mosquitoes. Three scenarios were modelled: (1) endemic transmission, where the animals cannot be infected, eg. malaria; (2) epidemic transmission, where the animals cannot be infected but humans remain susceptible, e.g. malaria; (3) epidemic disease, where both humans and animals can be infected, but develop sterile immunity, eg. Japanese encephalitis B. For each, the passive impact of animals as well as the use of animals as bait to attract mosquitoes to insecticide was examined. The computer programmes are available from the author. A teaching model accompanies this article.

Results

For endemic and epidemic malaria with significant searching-associated vector mortality, changing animal numbers and accessibility had little impact. Changing the accessibility of the humans had a much greater effect. For diseases with an animal amplification cycle, the most critical factor was the proximity of the animals to the mosquito breeding sites.

Conclusion

Estimates of searching-associated vector mortality are essential before the effects of changing animal husbandry practices can be predicted. With realistic values of searching-associated vector mortality rates, zooprophylaxis may be ineffective. However, use of animals as bait to attract mosquitoes to insecticide is predicted to be a promising strategy.     

Malaria prophylaxis: taking aim at constantly moving targets.

The prevention of malaria infections is one of the most important functions that any clinician can perform for those traveling to tropical geographic regions where malaria risks are present. The prophylaxis question has become complicated by continued emergence of chloroquine-resistant strains of Plasmodium falciparum, the recent appearance of Plasmodium vivax resistance, and the availability of a wide choice of antimalarial pharmaceuticals. Chemoprophylaxis may produce different toxicities among various patient populations. With increasing numbers of women who travel during their professional lives, there are potential implications for using chemoprophylaxis during pregnancy. Children are unable to tolerate certain antimalarials because of toxicities unique for them. In some instances, the safest and most palatable formulations for children are not even available in the United States and must be purchased in Canada or elsewhere. Reliance upon chemoprophylaxis alone has proven to be increasingly futile. With the introduction of new repellent formulations and nontoxic insecticides for use on clothing or bed netting, there are non-pharmacologic adjunctive measures which can now be considered first-line for the prevention of malaria infections.     

Revisiting the basic reproductive number for malaria and its implications for malaria control

The prospects for the success of malaria control depend, in part, on the basic reproductive number for malaria, R0. Here, we estimate R0 in a novel way for 121 African populations, and thereby increase the number of R0 estimates for malaria by an order of magnitude. The estimates range from around one to more than 3,000. We also consider malaria transmission and control in finite human populations, of size H. We show that classic formulas approximate the expected number of mosquitoes that could trace infection back to one mosquito after one parasite generation, Z0(H), but they overestimate the expected number of infected humans per infected human, R0(H). Heterogeneous biting increases R0 and, as we show, Z0(H), but we also show that it sometimes reduces R0(H); those who are bitten most both infect many vectors and absorb infectious bites. The large range of R0 estimates strongly supports the long-held notion that malaria control presents variable challenges across its transmission spectrum. In populations where R0 is highest, malaria control will require multiple, integrated methods that target those who are bitten most. Therefore, strategic planning for malaria control should consider R0, the spatial scale of transmission, human population density, and heterogeneous biting.     

Selective Introgression of Paracentric Inversions between Two Sibling Species of the Anopheles Gambiae Complex

The Anopheles gambiae complex includes the major vectors of malaria in sub-Saharan Africa where >80% of all world-wide cases occur. These mosquitoes are characterized by chromosomal inversions associated to the speciation process and to intraspecific ecological and behavioral flexibility. It has been postulated that introgressive hybridization has selectively transferred inversions on the second chromosome between A. gambiae and A. arabiensis, the two most important vectors of malaria. Here we directly test this hypothesis with laboratory experiments in which hybrid populations were established and the fate of chromosomal inversions were followed. Consistent with the hypothesis, ``foreign' X chromosomes were eliminated within two generations, while some ``foreign' second chromosomes persisted for the duration of the experiments and, judging from the excess of heterozygotes, established stable heterotic polymorphisms. Only those second chromosome inversions found naturally in the species could be introgressed.     

Farm animal proteomics--a review

In agricultural sciences as in all other areas of life science, the implementation of proteomics and other post-genomic tools is an important step towards more detailed understanding of the complex biological systems that control physiology and pathology of living beings. Farm animals are raised in large-scale operations, with the aim to obtain animal products for human consumption. Hence, understanding the biological traits that impact yield and quality of these products is the specific aim of much biological experimentation. However, most of the data gathered from experiments on e.g. swine and cattle are relevant not only for farm animal sciences, but also for adding to our understanding of complex biological mechanisms of health and disease in humans. The aim of this review is to present an overview of the specific topics of interest within farm animal proteomics, and to highlight some of the areas where synergy between classic model organism proteomics and farm animal proteomics is rapidly emerging. Focus will be on introducing the special biological traits that play an important role in food production, and on how proteomics may help optimize farm animal production.     

Could insecticide‐treated cattle reduce Afrotropical malaria transmission? Effects of deltamethrin‐treated Zebu on Anopheles arabiensis behaviour and survival in Ethiopia

Anopheles arabiensis Patton (Diptera: Culicidae) is the most widespread vector of malaria in the Afrotropical Region. Because An. arabiensis feeds readily on cattle as well as humans, the insecticide-treatment of cattle--as employed to control tsetse (Diptera: Glossinidae) and ticks (Acari: Ixodidae)--might simultaneously affect the malaria vectorial capacity of this mosquito. Therefore, we conducted field experiments in southern Ethiopia to establish whether Zebu cattle (Bos indicus L.) treated with a pour-on pyrethroid formulation of 1% deltamethrin, widely used to control ticks and tsetse, would be effective against An. arabiensis or cause the female mosquitoes to feed more frequently on humans, due to behavioural avoidance of insecticide-treated cattle. Contact bioassays (3 min exposure) showed that the insecticide remained effective for about 1 month (kill rate > 50%) against mosquitoes feeding on the flanks of treated cattle. A novel behavioural assay demonstrated that An. arabiensis readily fed on insecticide-treated cattle and were not deflected to human hosts in the presence of treated cattle. DNA-fingerprinting of bloodmeals revealed that An. arabiensis naturally feeds most frequently on older animals, consistent with the established practice of applying insecticide only to older cattle, while allowing younger untreated animals to gain immunity against infections transmitted by ticks. These encouraging results were tempered by finding that > 90% of An. arabiensis, An. pharoensis and An. tenebrosus females feed on the legs of cattle, farthest from the site of pour-on application along the animal's back and where the treatment may be least residual due to weathering. Observations of mosquitoes feeding naturally on insecticide-treated cattle showed that the majority of wild female anophelines alighted on the host animal for less than 1 min to feed, with significantly shorter mean duration of feeding bouts on insecticide-treated animals, and the effective life of the insecticide was only 1 week. Thus the monthly application of deltamethrin to cattle, typically used to control tsetse and ticks, is unlikely to be effective against An. arabiensis populations or their vectorial capacity. Even so, it seems likely that far greater impact on anopheline mosquitoes could be achieved by applying insecticide selectively to the legs of cattle.     

A historical perspective on malaria control in Brazil

Malaria has always been an important public health problem in Brazil. The early history of Brazilian malaria and its control was powered by colonisation by Europeans and the forced relocation of Africans as slaves. Internal migration brought malaria to many regions in Brazil where, given suitableAnopheles mosquito vectors, it thrived. Almost from the start, officials recognised the problem malaria presented to economic development, but early control efforts were hampered by still developing public health control and ignorance of the underlying biology and ecology of malaria. Multiple regional and national malaria control efforts have been attempted with varying success. At present, the Amazon Basin accounts for 99% of Brazil’s reported malaria cases with regional increases in incidence often associated with large scale public works or migration. Here, we provide an exhaustive summary of primary literature in English, Spanish and Portuguese regarding Brazilian malaria control. Our goal was not to interpret the history of Brazilian malaria control from a particular political or theoretical perspective, but rather to provide a straightforward, chronological narrative of the events that have transpired in Brazil over the past 200 years and identify common themes.     

Improving ability to identify malaria and correctly use chloroquine in children at household level in Nakonde District, Northern Province of Zambia

BACKGROUND: This study investigated causes of malaria and how cases were managed at household level, in order to improve the ability to identify malaria and ensure correct use of chloroquine. It was conducted in Nakonde District, Northern Province of Zambia, between 2000 and 2001. Nakonde district is in a hyperendemic malaria province, where Plasmodium falciparum is predominant. The district has a total population of 153, 548 people, the majority of whom are peasant farmers. The main aim of the post intervention survey was to establish the proportion of caretakers of children five years and below, who were able to identify simple and severe malaria and treat it correctly using chloroquine in the home. METHODS: A baseline survey was conducted in five wards divided into intervention and control.Intervention and control wards were compared. Village health motivators and vendors were identified and trained in three intervention wards, as a channel through which information on correct chloroquine dose could be transmitted. A total of 575 carers, who were 15 years old and above and had a child who had suffered from malaria 14 days before the survey commenced, were interviewed. The two control wards received no intervention. 345 caretakers were from the intervention wards, while 230 came from the control wards. Identification of malaria and correct use of anti-malarial drugs was assessed in terms of household diagnosis of malaria in children under five years, type and dose of anti-malarial drugs used, self medication and the source of these anti-malarials. RESULTS: The majority of respondents in the study were females (81%). Chloroquine was the most frequently used anti-malarial (48.5%) in both the intervention and control wards. There was no difference between the intervention and control wards at pre-intervention (P = 0.266 and P = 0.956), in the way mothers and other caretakers identified simple and severe malaria. At baseline, knowledge on correct chloroquine dosage in the under five children was comparable between intervention and control wards. Post-intervention revealed that mothers and other caretakers were 32% and 51%, respectively, more likely to identify simple and severe malaria. There was a 60% increase on correct chloroquine dosage in all age groups among carers living in post-intervention wards. CONCLUSION: Compliance with standard therapeutic doses and correct identification of malaria was poorest in control wards, where no motivators and vendors were trained.     

West African Cattle Farmers’ Perception of Tick-Borne Diseases

Worldwide, cattle production is struggling to face the negative impacts caused by ticks and Rhipicephalus (Boophilus) microplus is one of the most harmful ticks for livestock. Most of the people in West Africa depend on cattle farming and subsistence agriculture. The presence of ticks on cattle is a major problem faced by smallholder farmers who fight for their livelihood. National and regional tick control programs could assist these rural communities in protecting their livelihoods against ticks and tick-borne diseases, but only if they take into account the targeted herders and their perception on cattle management and tick control. This paper aims to provide a better insight in the socio-economic characteristics of Beninese cattle farmers, and their perception on tick burden, as well as to document common tick control strategies. Different tick species and their seasonality are well understood by cattle herders. For tick control, many still use manual tick removal, especially in the north of the country. The high cost of acaricides, the lack of financial means of African farmers, and of the local stockbreeders in particular, limits the use of acaricides in livestock breeding in Benin. While aiming to increase the meat or milk production of their animals, stockbreeders who can afford it sometimes turn to an abusive use of acaricides, which might in time lead to an increase in tick resistance. This study remains one of the rare studies to report extensively on the perceptions of West African cattle herders.     

The strain concept in phytoplankton ecology

Laboratory cultures are important tools for investigating the biology of microalgae, allowing experimentation under controlled conditions. This control is critical for comparative studies, such as those often used to investigate intra-specific variation in properties of interest. By holding the environment constant, the experimentalist can gain insight into the genetic basis of phytoplankton phenotypes and by extension, into the adaptive history of those genotypes. In most cases the adaptations of interest are those that the algae have evolved in response to their natural environment. However, here it is argued that such experiments may instead reveal evolutionary adaptations to, and/or non-adaptive changes induced by, the culture conditions under which the alga is maintained. We present a review of the processes of evolution as they pertain to microalgal culture, and illustrate this discussion with examples of in-culture evolution from both within and outside the field of phycology. With these considerations in mind, recommendations are made for experimental practice focusing on comparative physiology, for which the effects of in-culture evolution are particularly confounding. Finally we argue that, although problematic in some contexts, the evolutionary propensities of phytoplankton cultures actually present an important opportunity for experimental evolutionary research with direct environmental significance.     

Robert Koch and the invention of the carrier state: tropical medicine, veterinary infections and epidemiology around 1900

This paper reassesses Robert Koch's work on tropical infections of humans and cattle as being inspired by an underlying interest in epidemiology. Such an interest was developed from the early 1890s when it became clear that an exclusive focus on pathogens was insufficient as an approach to explain the genesis and dynamics of epidemics. Koch, who had failed to do so before, now highlighted differences between infection and disease and described the role of various sub-clinical states of disease in the propagation and--consequently--in the control of epidemics. Studying pathologies of men and cattle in tropical countries eventually facilitated the application of such measures in Europe through the screening of healthy carriers of typhoid, which was carried out in 1902. The concept of the carrier state can be understood as a spin-off from tropical medicine into the study and control of infectious disease in Europe. With it travelled assumptions that were typical for colonial and veterinary medicine where the health of indigenous individuals or cattle would be a secondary objective compared to the control of diseases in populations.     

Prospects for malaria control

Malaria control strategies have to be established locally according to epidemiological situations, including socio-economic factors and to resources available for their implementation. It has been stressed that all antimalaria activities be integrated in PHC.Stratification of malaria is the introduction to malaria control and serves as a basis for the planning which should be established by a body of experts on malaria at the central level (epidemiologist, entomologist, specialists in social sciences, sanitary engineer) who later will guide, supervise and evaluate the activities.Case treatments, sometimes presumptive, are the most basic activities of control. They are cheap and they can be carried out by PHC which insures the coverage of the entire population at risk. Drug resistance of Plasmodium falciparum is a growing and threatening problem. In a number of areas cheap and harmless chloroquine has to be replaced by drugs or combinations of drugs which can only be delivered by experienced personnel. Chemoprophylaxis is recommended for pregnant women but questioned for infants and young children because the risk of side-effects and resistance selection and the difficulties of maintaining a good coverage for a long time.Vector control by house-spraying remains the best means of reducing transmission and is still the basis of malaria control in countries in Asia and America where the disease has been seriously reduced. In some areas resistance to DDT lead to the use of more expensive organophosphates and/or carbamates. Resistance to these compounds has also been reported in several countries. House-spraying is probably one of the malaria activities which is the most difficult to integrate in PHC. Some attempts have been successful.Integrated vector control with community participation is not a simple task nor a panacea. To be efficient it needs to be established on a strong scientific basis. Tools and technics have to be selected for each area according to the vector ecology and socio-cultural habits of the population. Maintaining community interest in a long lasting activity is a problem which has never been really explored. Self-protection against vectors (mainly by using impregnated mosquito nets) has shown promise and is currently being evaluated at an operational scale with community involvement. There is great hope for a vaccine but more advances are necessary before its place in malaria control can be established.Intersectorial approach is the best way to counteract undesirable effects of development schemes like irrigation. There is a need for training in the scope of interdisciplinary actions for high level personnel. PHC agents need special training whatever they are, specialized or multipurpose. Special attention must be paid to malaria in health education for communities at risk. Some researches dealing with the most immediate problems are suggested.     

Are Statistical Contributions to Medicine Undervalued?

Econometricians Daniel McFadden and James Heckman won the 2000 Nobel Prize in economics for their work on discrete choice models and selection bias. Statisticians and epidemiologists have made similar contributions to medicine with their work on case-control studies, analysis of incomplete data, and causal inference. In spite of repeated nominations of such eminent figures as Bradford Hill and Richard Doll, however, the Nobel Prize in physiology and medicine has never been awarded for work in biostatistics or epidemiology. (The "exception who proves the rule" is Ronald Ross, who, in 1902, won the second medical Nobel for his discovery that the mosquito was the vector for malaria. Ross then went on to develop the mathematics of epidemic theory--which he considered his most important scientific contribution-and applied his insights to malaria control programs.) The low esteem accorded epidemiology and biostatistics in some medical circles, and increasingly among the public, correlates highly with the contradictory results from observational studies that are displayed so prominently in the lay press. In spite of its demonstrated efficacy in saving lives, the "black box" approach of risk factor epidemiology is not well respected. To correct these unfortunate perceptions, statisticians would do well to follow more closely their own teachings: conduct larger, fewer studies designed to test specific hypotheses, follow strict protocols for study design and analysis, better integrate statistical findings with those from the laboratory, and exercise greater caution in promoting apparently positive results.