GANADO, ARIZ—As Sage Memorial Hospital begins its second century of service to people here in the heart of the Navajo Nation, this unique facility located on a compound of 110 acres of high desert in northeastern Arizona faces problems unimagined by the Presbyterian missionaries who founded it in 1901. At the same time, a cadre of dedicated health care professionals, augmented by a frequently changing cast of visiting colleagues, offers the 18000 Navajo people in its service area—1500 sq miles of the 25000-sq mile reservation, the largest in the United States—stateof-the-art attention to their well-being. A short stay in Ganado guided by Louis A. Kazal, Jr, MD, a family physician who spent 10 years here, part of it as the hospital’s medical director, and is now a Robert Wood Johnson Health Policy Fellow in Washington, DC, afforded a glimpse of how a combination of high tech/“high touch” medicine is practiced in a challenging setting. The setting, in Kazal’s words, “is not just rural, it is remote.” Twentyeight miles from Window Rock, Ariz, capital of the Navajo Nation, 176 from Flagstaff, Ariz, and 52 from Gallup, NM, this is country that readers of Tony Hillerman’s mystery novels know well. For others, it is a revelation. Vast stretches of sagebrushcovered earth are dotted with small dwellings, single-story houses or traditional six-sided, east-facing hogans, a daunting distance apart. Outhouses are not unheard of. Sheep and cattle roam on the few paved roads at will, almost as if aware that their economic value to the tribe enhances their safety. Herds of horses graze. Bear and elk live in the nearby Chuska Mountains. An hour’s drive away is Canyon de Chelly, a natural wonder of spectacular beauty and—along with the clean air, the quiet, and the chance to live simply and know one’s neighbors well—one of the big attractions for professional staff, many of whom enjoy hiking and camping. But the bucolic surroundings are no barrier to natural ills. The staff at Sage Memorial, which is a full-time hospital, and its three part-time clinics in the communities of Greasewood (28 miles away), Wide Ruins (20 miles), and Sanders (38 miles), deal with the same medical problems encountered by their city colleagues, as well as those spawned or exacerbated by the situations found on reservations. Few people have much money; many still earn their living by weaving rugs or raising sheep. With a 50% unemployment rate, job opportunities for young people are limited, leading to idle time to indulge in alcohol or other drug use, and frequent domestic abuse. A particular problem is the number of people with diabetes mellitus, nearly all of it type 2. Estimates of its prevalence range widely, but Kazal said he believes nearly one fourth of Navajos are affected.

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Context.-There is significant controversy about how best to control cholera epidemics in refugee settings. Specifically, there is marked disagreement about whether to use oral cholera vaccines in these settings, despite the improved safety and effectiveness profiles of these vaccines. Objective.-To determine the cost-effectiveness of alternative intervention strategies, including vaccination, to control cholera outbreaks in sub-Saharan refugee camps. Design.-A cost-effectiveness analysis based on probabilities of cholera outcomes derived from epidemiologic data compiled for refugee settings in Malawi from 1987 through 1993; data for costs were obtained from a large relief agency that provides medical care in such settings. Setting and Participants.-A hypothetical refugee camp with 50 000 persons in sub-Saharan Africa evaluated for a 2-year period. Interventions.-We compared the costs and outcomes of alternative strategies in which appropriate rehydration therapy for cholera is introduced preemptively (at the establishment of a camp) or reactively (once an epidemic is recognized) and in which mass immunization with oral B subunit killed whole-cell (BS-WC) cholera vaccine is added to a rehydration program either preemptively or reactively. Main Outcome Measures.-Cost per cholera case prevented and cost per cholera death averted. Results.-In a situation with no available rehydration therapy suitable for the management of severe cholera, a strategy of preemptive therapy ($320 per death averted) costs less and is more effective than a strategy of reactive therapy ($586 per death averted). Adding vaccination to preemptive therapy is expensive: $1745 per additional death averted for preemptive vaccination and $3833 per additional death averted for reactive vaccination. However, if the cost of vaccine falls below $0.22 per dose, strategies combining vaccination and preemptive therapy become more cost-effective than therapy alone. Conclusions.-Provision for managing cholera outbreaks at the inception of a refugee camp (preemptive therapy) is the most cost-effective strategy for controlling cholera outbreaks in sub-Saharan refugee settings. Should the price of BS-WC cholera vaccine fall below $0.22 per dose, however, supplementation of preemptive therapy with mass vaccination will become a cost-effective option.

STENTING IS A wide-open field. Implanting minute metallic mesh expandable cages to keep coronary arteries patent "is one of the hottest things in cardiology right now," agreed numerous speakers at the 69th Scientific Sessions of the American Heart Association (AHA), held in New Orleans, La. And even as many cardiologists are documenting the ways in which stents provide what one called "a smoother ride" for patients with plaque-prone arteries, others are experimenting with newer models, improved placement methods, and adjunct therapies. In the 2 years since the Food and Drug Administration (FDA) gave the go-ahead to the Palmaz-Schatz stent (made by Johnson & Johnson, New Brunswick, NJ) —the first and so far only stent approved for use in the United States—the percentage of postangioplasty patients in whom the device is used has risen from approximately 9% to 39%, said Daniel B. Mark, MD, MPH, director of the Outcomes Research

AS REGULARLY as turning leaves and returning students, autumn brings an announcement of the winners of 2 prestigious medical prizes. Both the Albert Lasker Medical Research Awards, presented in the United States, and the Gairdner Foundation International Awards, presented in Canada, are considered strong predictors of future Nobel Prize winners. Fifty-six Lasker awardees and 47 Gairdner winners have gone on to become Nobel Laureates. The 1997 winners and citations for their accomplishments are as follows. Albert Lasker Medical Research Awards Established 52 years ago by New York, NY-based philanthropists Albert and Mary Woodard Lasker, these awards, according to the Albert and Mary Lasker Foundation, celebrate scientists, physicians, and public servants whose accomplishments have made major advances in the understanding, diagnosis, treatment, prevention, and even cure of many of the great cripplers and killers of our century. At ceremonies in New York City, each winner receives an honorarium, a citation in

WHEN BROTHER Cadfael prescribed herbs and simples to heal his patients in Ellis Peters' popular medieval mystery series, it's safe to say he didn't worry about obtaining consent and setting up a control group of fasting monks or fainting maidens. If the remedies worked then they worked, and praise the Lord. The gratitude of patients (and rarely a fat purse) was Cadfael's reward. The conduct of 20th-century research on pharmaceuticals and therapies for still extant ancient ailments, as well as newer disorders, would surprise the good friar. The potential profitability of finding the most efficacious treatment for a disease would astound and perhaps trouble him. But his deep understanding of human nature would no doubt carry the day. It might even shed some light on how to approach maladies experts can't agree on how to fight and point the way to making clinical trials—the subject of this Contempo issue's MEDICAL