Schools of Asceticism: Ideology and Organisation in Medieval Religious Communities.

Schools of Asceticism: Ideology and Organisation in Medieval Religious Communities. LUTZ KAELBER. viii+278 pages. 1998. Pennsylvania (PA): PennsylvaniaState University Pennsylvania State University,main campus at University Park, State College; land-grant and state supported; coeducational; chartered 1855, opened 1859 as Farmers' High School. Press; 0-271-01754-6 hardback $55; 0-271-01755-4paperback $19.95. Profound methodological issues are raised by the approach of thisstudy to questions which are, arguably, theological rather than'ideological'. There must always be broadly two ways ofapproaching the task of explaining a phenomenon which has marked socialfeatures but also a governing set of motivating ideas or principles. Ifwe are looking at the work of an individual writer of the past we aredoing 'intellectual history', and even there there must be anawareness of context, or we shall be in danger of writinganachronistically and reading back into the mind of another agepresumptions of our own. If we are looking at the outward manifestationsof view held by a large group, many of them illiterate, none the authorof a surviving account of his or their thinking, we may be engaged in anexercise closer to the histoire des mentalitds. Then understanding thecontext becomes even more important. And it becomes more crucial stillto avoid imposing upon the evidence a framework of questions andassumptions which belong in a later age. That is the danger this study skirts, not always successfully. The difference between theology and ideology is that embedded inthe Christian system are otherwordly considerations which are notreducible to the terms of reference Terms of reference allude to a mutual agreement under which a command, element, or unit exercises authority or undertakes specific missions or tasks relative to another command, element, or unit. Also called TORs. of a mere theory with a message,which is what I take ideology to amount to. It is also the case that thehistory of Christian thought by the period with which this book wasconcerned had become intricately enmeshed with the history of philosophywhile it had little or nothing to say about social ideas (beyond the'diaconal' instructions to look after the poor and widows andthe higher duty to love one's neighbour). The core theme is asceticism asceticism(əsĕt`ĭsĭzəm), rejection of bodily pleasures through sustained self-denial and self-mortification, with the objective of strengthening spiritual life. . But to understand what mediaeval me��di��ae��val?adj.Variant of medieval.mediaevalAdjectivesame as medievalAdj. 1. ascetical movements understood to be the purpose of self-denial requiresa study at least of Porphyry and Augustine, or the hermetic hermetic/her��met��ic/ (her-met��ik) impervious to air. her��met��icor her��met��i��caladj.Completely sealed, especially against the escape or entry of air. tradition,and all the intellectual baggage on this subject which late antiquephilosophy carried about with it. It also demands a knowledge of theparameters of the tradition of patristic pa��tris��tic? also pa��tris��ti��caladj.Of or relating to the fathers of the early Christian church or their writings.pa��tris and mediaeval exegesis exegesisScholarly interpretation of religious texts, using linguistic, historical, and other methods. In Judaism and Christianity, it has been used extensively in the study of the Bible. Textual criticism tries to establish the accuracy of biblical texts. ofScripture against which the nascent heretical school-traditions of the12th century measured themselves. It is, in short, more necessary to gobackwards than to go forwards, for we are dealing here with the directinfluence such earlier mental attitudes had upon the thinking of an agewhich had a high respect for authority in the form of the texts of auctores. It is tantalizing tan��ta��lize?tr.v. tan��ta��lized, tan��ta��liz��ing, tan��ta��liz��esTo excite (another) by exposing something desirable while keeping it out of reach. that much of what we know about the ideas ofthe Cathars and the Waldensians (who were not really both heretical, butheretical and schismatic schis��mat��ic?adj.Of, relating to, or engaging in schism.n.One who promotes or engages in schism.schis��mat respectively) comes from academic treatiseswritten against them. We need to hear about that, and there is nothingin this study about Alan of Lille, for example. When I read of 'mercatile protocapitalist ideology' or'self-empowerment', I do not find it easy to locate theseconcepts in the world I am reading about. If we do not begin by askingwhat the people we are describing thought they were doing it is not easyto be sure we are talking about them at all, and not about someconstruct of our own. Bernard of Clairvaux appears briefly, but we donot hear from him. Yet he wrote copiously, with passion and clarity,about what he understood to be the purpose and usefulness of thereligious life. There was no more 'rational ascetic', nor onemore lushly sensuous in his imagery, more abandoned in his pursuit ofthe divine, of the 12th century. Why not ask him what he thought? So Iam suspicious of a study which begins with 'Weber, Troeltsch andBeyond' and not with the 'asceticism in lay religiousmovements in the Middle Ages' which we come to in Part II. The kindof lapse this may encourage is the assumption that the Waldensiansthemselves would have drawn the distinction between lay and'professional (professed) religious' quite where the authordoes. The anti-establishment character of their thinking made theminclined to deem the whole people of God the laos, and to be reluctantto see themselves as forming a distinct class. Another reason for being suspicious of this approach is that Weberand Troeltsch wrote in the early years of this century, at a date whenmediaeval studies, particularly of this sort, were at an early stage andthe understandings we now have not always securely in frame. And Weber,in particular, was looking backwards from the preoccupations of theGerman Reformation, for precursors. If they are to occupy so much of thecentre stage of this study it would be sensible to discuss alongsidethem the findings of important recent studies such as Anne Hudson'sThe premature Reformation and Eamon Duffy's The stripping of thealtars. It may be that a reviewer is unjust to bring another set ofpreferences to such a study. There is much in it that is illuminatingand some sensible and clear accounts of the status quaestionis on someof the issues. Perhaps sociology and intellectual history must always beat war in their readings of the driving forces in things. G.R. EVANS Faculty of History, University of Cambridge References DUFFY, E. 1992. The stripping of the altars. London: YaleUniversity Press. HUDSON, A. 1988. The premature Reformation. Oxford: ClarendonPress.

Schools tighten fuel budget belt: skyrocketing costs are forcing districts to rethink standard practices.

Schools tighten fuel budget belt: skyrocketing costs are forcing districts to rethink standard practices. WITH FUEL AND ENERGY PRICES soaring but also fluctuating fluc��tu��ate?v. fluc��tu��at��ed, fluc��tu��at��ing, fluc��tu��atesv.intr.1. To vary irregularly. See Synonyms at swing.2. To rise and fall in or as if in waves; undulate.v. betweenhigh and low, school districts across the country are finding ways tocut corners to keep budgets afloat. The American Association American Association refers to one of the following professional baseball leagues: American Association (19th century), active from 1882 to 1891. American Association (20th century), active from 1902 to 1962 and 1969 to 1997. of SchoolAdministrators' new "Fuel and Energy Snapshot (1) A saved copy of memory including the contents of all memory bytes, hardware registers and status indicators. It is periodically taken in order to restore the system in the event of failure.(2) A saved copy of a file before it is updated. Survey"says that, in an effort to offset fuel and energy costs, nearly one inseven districts is considering moving to a four-day week, one in threeis eliminating teaching jobs, and one in four is considering limits onathletics and extracurricular activities. Reassessing the Budget When negotiating with bus companies, schools are gambling whetherto lock in a rate or keep it floating with what's current. * The Palisades Palisades,cliffs along the west bank of the Hudson River, NE N.J. and SE N.Y., extending from N of Jersey City, N.J., to the vicinity of Piermont, N.Y., with a general altitude of from 350 ft to 550 ft (107–168 m). School District in Kintnersville, Pa., will lock infuel costs for the first time this year at a fixed $4.33 a gallon.Business administrator Jill Ruch says that although it's a"good price for diesel," it's also 58 percent more thanthe $2.74 per gallon budgeted last year. "We were afraid the budgetwould be overextended overextended,adj 1. the situation occurring when a prosthetic appliance is inadvertently constructed in such a way that part of the oral mucosa is injured by the appliance.adj 2. if we didn't lock in at $4.33," shesays. * Bellevue (Neb.) Public Schools is budgeting $600,000 to coverfuel costs for 2008-2009, compared with $250,000 a year ago.Kentucky's Bowling Green Bowling Green.1 City (1990 pop. 40,641), seat of Warren co., S Ky., on the Barren River; inc. 1812. It is a shipping and marketing center for an area producing tobacco, corn, livestock, and dairy items. Independent Schools is budgeting anadditional $45,000 over last year's $130,000, and Durham (N.C.)Public Schools is budgeting $2.75 million for fuel, up from $2 million ayear ago. * Texas lawmakers say they must re-evaluate their state'sschool funding system a system or scheme of finance or revenue by which provision is made for paying the interest or principal of a public debt.See also: Funding , which uses a 20-year-old formula based onoutdated fuel prices to determine state-appropriated transportationfunds. * The Moorpark (Calif.) Unified School District's 2,400 highschool students don't have buses anymore, as officials haveeliminated rides to cope with operating a service that can cost hundredsof thousands to tens of millions of dollars a year. [ILLUSTRATION OMITTED] Shorter Weeks * Two Kentucky districts--Webster County Schools and JenkinsIndependent Schools--are already on four-day-a-week schedules, but withmore than 50 percent of the state's students qualifying for free orreduced-price lunch, those children rely on schools for basic nutritionneeds, and it would be "extremely costly" for most districtsto meet those demands on an extended day schedule, says Kentucky DOEspokeswoman Lisa Gross. * Webster County Webster County is the name of seven counties and a parish in the United States: Webster County, Georgia Webster County, Iowa Webster County, Kentucky Webster County, Mississippi Webster County, Missouri Webster County, Nebraska Schools introduced a four-day school week in the2003-2004 year to cut overall costs, but ended up "gaining muchmore," says the district's director of secondary programs,Carolyn Sholar. Not only did the district save on transportation costs,but state test scores also improved across all subject areas, and theopen Mondays have allowed administrators and and staff to hold committeemeetings and faculty meetings for professional development. Many of thedistrict's high school students now hold part-time jobs on Mondays,and their time at school is spent more effectively. * The 700-student MACCRAY MACCRAY Maynard Clara City, Raymond (Independent School District)school district just west of Minneapolishas cut back to a four-day week for the 2008-2009 year. The change,designed to bring in the extra $65,000 needed to fill buses' tanksfor the year, will mean 23 fewer days of school a year, and the lengthof the day will be extended by a little more than an hour. [ILLUSTRATION OMITTED] Limiting the Fun Stuff * Kentucky districts are cutting back on field trips andextracurricular activities, but the state department of education isalso partnering with school facilities staff to save money in the longterm by achieving energy efficiency through centralized cen��tral��ize?v. cen��tral��ized, cen��tral��iz��ing, cen��tral��iz��esv.tr.1. To draw into or toward a center; consolidate.2. heating andgeothermal ge��o��ther��mal? also ge��o��ther��micadj.Of or relating to the internal heat of the earth.ge systems. * At Webster County Schools, plans to "limittransportation" for athletics and extracurricular activitiesinclude the state board's termination of transportation funds forcompetition-based events. In the past, the board of ed has funded alltransportation costs. "Other districts around us have not had thefinancial support of the board for any athletic and extracurricularactivities for some time now," says Carolyn Sholar, thedistrict's director of secondary programs and instruction, "sowe've been lucky." Each individual school sports team inWebster County is spearheading fundraising efforts to boost theirresources, and Sholar says their plans are all in "pretty goodshape." * At the Palisades School District in Kintnersville, Pa., an addedexpense of $0.50 per mile will be incorporated into the fees for everyschool field trip, and a surcharge An overcharge or additional cost.A surcharge is an added liability imposed on something that is already due, such as a tax on tax. It also refers to the penalty a court can impose on a fiduciary for breaching a duty. of as much as $25 could be filteredinto the overall cost for field trips in other districts in the state,says business administrator Jill Ruch.

Schott signs deal with Hal Leonard.

Schott signs deal with Hal Leonard. Hal Leonard Corporation Hal Leonard Corporation is a US sheet music publishing company. It is the largest sheet music publisher in the world. now has exclusive North and South American distribution rights to the classical and educational music catalog of Schott Musik International. Schott, based in Mainz, Germany, is the original publisher of Beethoven and Wagner, as well as renowned contemporary composers such as Paul Hindemith Noun 1. Paul Hindemith - German neoclassical composer and conductor who believed that music should have a social purpose (1895-1963)Hindemith , Gyorgy Ligeti, Carl Orff Noun 1. Carl Orff - German musician who developed a widely used system for teaching music to children (1895-1982)Orff , Krzysztof Penderecki, Sir Michael Tippett Sir Michael Kemp Tippett, OM (2 January 1905 – 8 January 1998) was one of the foremost English composers of the 20th century. BiographyTippett was born in London of English and Cornish stock. , Kurt Weill, Tobias Picker Tobias Picker (b. New York City, 1954) is an American composer. Picker began composing at the age of eight and studied at the Manhattan School of Music, The Juilliard School and Princeton University, where his principal teachers were Charles Wuorinen, Elliott Carter and Milton and Joseph Schwantner. Boasting a catalog of more than 40,000 publications, including everything from performance and teaching materials, urtext editions, contemporary concert and opera literature and study scores, to complete editions, books about music, specialty journals, recordings and multimedia products, the product range of Schott Musik International is extensive enough to meet the needs of all musicians. Milwaukee-based Hal Leonard, the world's largest music print publisher, will be responsible for the sales, distribution and marketing of the Schott catalog in North and South America. This move is expected to introduce these distinguished publications to a much wider American audience. For more information, visit www.halleonard.com.

Schubert's Late Lieder: Beyond the Song-Cycles.

Schubert's Late Lieder: Beyond the Song-Cycles. Susan Youens. Cambridge University Press Cambridge University Press (known colloquially as CUP) is a publisher given a Royal Charter by Henry VIII in 1534, and one of the two privileged presses (the other being Oxford University Press). (40 W. 20th St., New York New York, state, United StatesNew York,Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of ,NY 10011-4211), 2002. 436 pp., $75. Thoughts of the late lieder of Franz Schubert bring to mind thesettings of Wilhelm Muller's Die schone Mullerin and DieWinterreise or the collection of Schwanengesang with the poetry ofRellstab and Heine. But who were the poets Collin, Pyrker, Leitner,Seidl, Reil and Franz Xaver Franz Xaver is a name shared by several different people throughout history. Franz Xaver, Baron Von Zach (1754 - 1832), a German/Hungarian astronomer. Franz Xaver Gabelsberger (1780–1849), a German stenographer. Freiherr yon Schlechta-Wssehrd? In herseventh book on the lieder of Hugo Wolf and Franz Schubert, Susan Youensintroduces us to these six contemporaries of Schubert, whose poetry isderived primarily from their musical settings. Although the work of these otherwise unknown poets can no longerstand on its own, "They have interesting cultural tales to tell,and they made wonderful music." Herein lies the beauty ofYouens's writing on lieder. Following the successful format of theprevious books, she brings together a wealth of knowledge of politicaland social history, literary imagery, art and drama with theauthoritative musical analysis One would expect from a highly respectedmusicologist mu��si��col��o��gy?n.The historical and scientific study of music.musi��co��log . The book offers no direct suggestions for theperformers' interpretation but does provide an abundance ofbackground material on which to base an emotional understanding of theworks. The selection of poetry for his late lieder, written between 1822and his death in 1828, reflects the influence of both Beethoven andSchubert's pending death from syphilis syphilis(sĭf`əlĭs), contagious sexually transmitted disease caused by the spirochete Treponema pallidum (described by Fritz Schaudinn and Erich Hoffmann in 1905). . The lieder often are darkand brooding, echoing his declining health. The songs, however, are byno means unfamiliar to us; Nacht und Traume and Die Allmacht are here aswell as one of my favorites My Favorite is an independent synthpop band from Long Island, New York. They released two CDs: Love at Absolute Zero and Happiest Days of Our Lives. My Favorite broke up on September 14, 2005, when singer Andrea Vaughn left the band. , the powerful ballad, Der Zwerg Der Zwerg (The Dwarf) is an opera in one act by Austrian composer Alexander Zemlinsky. Its libretto was written by George Klaren, based loosely on the story The Birthday of the Infanta by Oscar Wilde. . The book is divided into four large chapters with single chaptersdevoted to Collin, Pyrker and Leitner and a final chapter onSchubert's Viennese contemporaries. Youens's style isscholarly, with footnotes at times wing for page dominance. One has thefeeling she has almost too much to tell. She pours forth so muchunderstanding of her subject matter that we at times lose track ofSchubert's music. Schubert's Late Lieder is a welcome addition to the seriousmusician's library. It provides needed information aboutSchubert's lesser poets and sheds light on the life and literaryinfluences of early nineteenth-century Vienna. Reviewed by BardSuverkrop, Winchester, Virginia.

Schwartz & Wade.

Schwartz & Wade. Schwartz & Wade c/o Random House Children's Books 1745 Broadway, 10-1, New York, NY 10019 www.randomhouse.com/kids Ages 4-8 will appreciate Jonah Winter & Francois Roca'sstory Muhammed Ali: Champion of the World (9780375836220, $ 16.99), ofboxer Muhammed Ali, who was more than a boxer, symbolizing Muslim rightsand his people's efforts to succeed. This biography highlights hislife using large-sized, vivid lettering to capture the drama of his lifeand boxing style. Robert Andrew Parker's PIANO STARTS HERE(9780375839658, $ 16.99) tells of Art Tatum, who was playing keyboardson tiptoe at a very young age: first in church, and later in cafes.PIANO STARTS HERE charts his life, the influence of blindness on hismusical development, and his world travels in a vivid biography.

Science Fiction Authors: A Research Guide.

Science Fiction Authors: A Research Guide. Science Fiction Authors Note that this partial list contains some authors whose works of fantastic fiction would today be called science fiction, even if they predate, or did not work in that genre. There is also a considerable overlap with the List of fantasy authors, since many authors are equally comfortable : A Research Guide BY MAURA HEAPHY Author Research Series. Westport, CT: Libraries Unlimited, 2009.318 pp. 22.95 [pounds sterling] soft cover ISBN ISBNabbr.International Standard Book NumberISBNInternational Standard Book NumberISBNn abbr (= International Standard Book Number) → ISBN m9781591585152 (availablefrom Inbooks) Maura Heaphy's Science Fiction Authors. A Research Guide isaimed at libraries, particularly those in the USA, and readers wanting abasic starting point Noun 1. starting point - earliest limiting pointterminus a quocommencement, get-go, offset, outset, showtime, starting time, beginning, start, kickoff, first - the time at which something is supposed to begin; "they got an early start"; "she knew from the to the science fiction (SF) genre. Heaphy, a seniorlecturer at Ohio State University Ohio State University,main campus at Columbus; land-grant and state supported; coeducational; chartered 1870, opened 1873 as Ohio Agricultural and Mechanical College, renamed 1878. There are also campuses at Lima, Mansfield, Marion, and Newark. , states that her guide aims to fill agap in SF reference books, being 'intended for those who alreadyknow the given writer and want to learn more'. Heaphy works, however, within the guidelines of the LibrariesUnlimited Author Research Series, which attempts to cater for 'theneeds of fans, students, teachers, librarians and bookclubleaders'. Heaphy understandably has difficulties meeting the needsof all of these diverse groups. Each author entry begins with a short quotation 'to give ataste of the writer's style', but two to three lines arepatently insufficient to summarise writers as diverse as Robert Heinleinand Mary Shelley. Heaphy provides short biographies, lists of majorworks, selective resource and critical sources and websites to 100authors from Douglas Adams to Roger Zelazny. Heaphy acknowledges that her choices ultimately reflect herpersonal opinion as to 'the best and brightest of ScienceFiction'. She has naturally a decidedly American bias, althoughsome major British authors, such as M. John Harrison Michael John Harrison (born July 26, 1945), who writes as M. John Harrison, is a British author of science fiction, fantasy and literary fiction.Harrison was born in Warwickshire. , Charles Stross andBrian Aldiss, are included, along with Karel Capek and Stanislaw Lem torepresent Europe. There are few non-Northern Hemisphere authors listed.It is unfortunate that Australia's leading SF author, Greg Egan, isnot included, given hisstanding in the field and in other 'best of' lists. Theauthor and publisher clearly reflect where they think their book saleswill be. Appendices include the major awards of the genre and a generalbibliography covering encyclopaedias, guides to biography and some'frequently cited' sources. While these are not comprehensive,and again are American in focus, they are sound initial referencepoints. The usefulness of the List of Authors by Type, under suchheaders as Far Future and Gothic SF'is, however, debatable. ScienceFiction Authors will be useful for libraries and students wanting abasic guide to predominantly American authors. Colin Steele Australian National University

Science Play.

Science Play. Science Play Jill Frankel Hauser Williamson Books c/o Ideals Publications Suite 250, 535 Metroplex A metroplex is large metropolitan area containing several cities and their suburbs.[1] It is also sometimes used as an alternative to metropolis or megalopolis, which is a chain of continuous metropolitan areas. Drive, Nashville, Tennessee “Nashville” redirects here. For other uses, see Nashville (disambiguation).Nashville is the capital and the second most populous city of the U.S. state of Tennessee, after Memphis. 37211 1885593201 $12.95 www.idealpublications.com Kindergarten teacher Jill Frankel Hauser presents Science Play, acompendium com��pen��di��um?n. pl. com��pen��di��ums or com��pen��di��a1. A short, complete summary; an abstract.2. A list or collection of various items. of over 65 safe, age-appropriate activities designed tofoster creativity and a sense of discovery in children ages 2 to 6.Step-by-step instructions and simple black-and-white illustrations walkreaders through activities such as observing earthworms at work, makingpuddle prints with food coloring, water, and a simple medicine dropper drop��pern.A device that produces drops, especially a small tube with a suction bulb at one end for drawing in a liquid and releasing it in drops. Also called instillator.dropper1. ,or gathering and sorting rocks. Young children will most likely need anadult's help with reading the instructions, but the activitiesthemselves are easy to do and highly inexpensive. Enthusiasticallyrecommended for parents, teachers, and caregivers of young childreneverywhere.

Science cafes: real science, plus cake.

Science cafes: real science, plus cake. A MOVEMENT TO SPREAD SCIENTIFIC learning in a casual environmentthat started in Britain in the late 1990s has gotten a foothold in theUnited States United States,officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area. . At science cafes, adults gather at a restaurant, bar orother nonacademic spot to listen to a presentation on a scientific topicwhile enjoying their favorite beverage. Kathy Savage, science teacher at Oviedo High School Oviedo High School is a grade 9-12 public secondary school set on a 52-acre campus in Oviedo, Florida, a growing community situated in southeastern Seminole County operated by Seminole County Public Schools. in Oviedo,Fla., thought a similar program could work in her school. With thesponsorship of the Florida Academy of Sciences and assistance from otherscience teachers and the student members of the school's chapter ofthe National Science Honor Society honor societyn.An organization to which students are admitted in recognition of academic achievement. , the first science cafe was held inSeptember 2008. The program took off immediately. Now, says Savage,"I am absolutely amazed at how well these cafes are both receivedand attended." Cafes are held monthly, about half an hour after the end of theschool day. The format is simple: Over cake and punch, students listento a speaker and then ask questions. In the first year, topics rangedfrom Neanderthals to invasive species See also: Introduced speciesInvasive species is a phrase with many definitions. The first definition expresses the phrase in terms of non-indigenous species (e.g. . Savage identifies five main reasons why these science cafes areimportant: * They put "real faces" to science (which she contrastswith "the typically geeky males in many of the videos or theiraging and irrelevant teachers"). * They show students that science is something "realpeople" do. * They show real-life applications for science. * They give students opportunities to meet scientists and personswho use science in their professions--and who may be important contactsfor them later. * They serve as a "cheerleading The examples and perspective in this article or section may not represent a worldwide view of the subject.Please [ improve this article] or discuss the issue on the talk page. platform" for motivatingstudents to consider majoring in a science-related field in college. Most of the program's speakers have been professors orgraduate students from the nearby University of Central Florida “UCF” redirects here. For other uses, see UCF (disambiguation).UCF is a member institution of the State University System of Florida. UCF was founded in 1963 as Florida Technological University with the goal of providing highly trained personnel to support the Kennedy . Savagesays that the school was "super lucky," however, to have hadtwo big-name speakers in the program's first year: Jan Garavaglia Dr. Jan Garavaglia is the medical examiner who performs autopsies at the medical examiner's office in Orlando, Florida. She stars in on the Discovery Health Channel. External linksDr. G: Medical Examiner official site ,Orange County's medical examiner A public official charged with investigating all sudden, suspicious, unexplained, or unnatural deaths within the area of his or her appointed jurisdiction. A medical examiner differs from a Coroner in that a medical examiner is a physician. and star of Discovery HealthChannel's reality show Dr. G.: Medical Examiner, and Eugenie Scott,executive director of the National Center for Science Education. [ILLUSTRATION OMITTED] A highlight for Savage came during a cafe given by a local man whoruns a multimillion-dollar laser technology business. In describing howa laser works he wrote "c = [lambda] x v" (speed of light =wavelength x frequency) on the whiteboard and then referred to thatequation several times. "We had recently finished an extensivelesson using that very equation," says Savage of one of herclasses. "One student raised his hand and asked, 'Do youactually use that equation?' to which the speaker replied,'Every day.'" Savage reports that the students were"flabbergasted flab��ber��gast?tr.v. flab��ber��gast��ed, flab��ber��gast��ing, flab��ber��gastsTo cause to be overcome with astonishment; astound. See Synonyms at surprise.[Origin unknown. " by this reply but also "a littleimpressed with themselves that they actually knew some 'realscience.'" Science cards for kids have appeared in other places as well,including several high schools in Portland, Ore.

Science of uncertainty: making cases for drug incorporation in Brazil.

Science of uncertainty: making cases for drug incorporation in Brazil. "This health technology assessment is a new wave,"Anderson Pereira, an official at the Brazilian Ministry of Health, toldme in one of a row of uniform public buildings in the planned city ofBrasilia in August of 2008. At the time, Pereira, a doctor, wasresponsible for making recommendations to the Minister on healthtechnology incorporation decisions, that is, which drugs and medicaldevices would be used within Brazil's public healthcare system. In2006, the Ministry of Health had overhauled the institutions responsiblefor the incorporation of new health technologies. In the newincorporation system, the Ministry opened itself to proposals for newtechnologies. These proposals consisted primarily of economic analyses,and, as in earlier policy (re)formulations, the "rational use"of drugs was heavily implicated in the reform rationale (see Guimaraes2004). Pereira was in charge of the newly-formed commission that analyzedproposals and made recommendations to the Minister. A Ministry paperoutlining the reform stated, "The unsystematic incorporation anduse of inadequate technologies create risks for users and compromise thehealth system's overall effectiveness" (Decit 2006). Pereiramade it clear he had no elusions about the incorporation system'slimitations. He confirmed that most proposals were for new high-costdrugs for genetic disorders affecting small numbers of patients andthat, though the commission was open to proposals from any source,nearly all of them came from the drug industry. The Ministry lackedprofessionals to adequately assess proposals and had yet to make theincorporation scheme transparent, Pereira said. In contrast to theMinistry's neatly stated goals of systemization, Pereira saw acomplex system encompassing both public and private fields of practicewherein various actors were struggling to identify their interests andhow best to pursue them. "Brazilian society builds things and thenthinks about how to fix them," he said, "it changes the wheelof the car while the car is driving." Global Pharmaceuticals and Evidence Production Public health efforts around the globe are increasingly dominatedby concerns over the development, access, and distribution ofpharmaceutical products (Petryna et al. 2006; Biehl 2006, 2007a, 2007b;Farmer 2001; Ecks 2008; Whitmarsh 2008; Geest et al. 1996).Anthropologists Adriana Petryna and Arthur Kleinman propose the notionof a "pharmaceutical nexus" to capture and examine the"broad set of political and social transitions that fall under andto some extent happen through the globalization of pharmaceuticals"(Petryna and Kleinman 2006:21). The pharmaceutical nexus is usefulprecisely for its ability to bring into view the varied fields ofpractice and theory that are altered through the creation anddistribution of pharmaceutical remedies. Petryna's work in theglobalizing of pharmaceutical clinical trials demonstrates how fields ofevidence use and production are also at stake in these "politicaland social transitions." Globalized commercial interests, variableethical notions, and national public health priorities can be elaboratedthrough evidence-producing practices (Petryna 2006, 2009). Evidence concerning public health efforts and interventions isgaining in importance as governments are struggling with how to bestguarantee sustained access to healthcare for their populations. Withincreased pressure to justify decisions and maximize resources in publichealth, the practice of basing decisions on evidence, rather thanrelying directly on other bases for policy, such as societal input orcommercial interests, has been gaining popularity (Niessen 2000:859).Economic evidence, in particular, has been increasingly used, especiallyin the United Kingdom, Canada, and Australia and especially for healthtechnology incorporation decisions (Drummond 2001). In Brazil, anthropologist Joao Biehl, who coined the expressionpharmaceuticalization of public health (2007a), writes on how thecreation of the AIDS program depended, in part, on the government'sability to generate economic forms of evidence that justified theprogram's costs to its transnational sponsor, the World Bank, andits ability to contest pharmaceutical knowledge-monopolies in drug pricenegotiations (Serra 2004, Biehl 2007b). Even so, health officialsdisregarded Biehl's own attempt to generate evidence concerning theprogram's systematic exclusion of certain social groups (Biehl2007b:218-223). As Biehl's work shows, through the contestation andimplementation of particular notions of evidence, health efforts arelegitimized or compromised, populations are deemed worthy of treatmentor systematically disregarded, and markets either expand or are leftunexplored. With the pharmaceutical nexus and the recent history of theBrazilian AIDS program in mind, we cannot responsibly understand thedevelopment and use of economic evidence for technology incorporation inBrazil as a self-evident application of scientific principles or arational evolution of decision-making practices, as implied in theMinistry's reform rationale. Rather, as Pereira's commentsuggests, we must be suspicious of tidy constructions and sensitive toareas of uncertainty. We must consider the use of economic evidence inincorporation decisions as responsive to localized public and privatedemands and implicated in global pharmaceutical politics. Health Net: Making Models, Making Markets At about the same time as the Ministry of Health was introducingthe new system for health technology incorporation, two long-timefriends in Rio de Janeiro, a professor of medicine in a publicuniversity and an owner of a group of private clinics, decided to starta health technology assessment (HTA) company that I will call HealthNet. HTA has developed as a way to assess the effectiveness, safety, andcost of technologies in order to inform health and policy decisions. HTAhas many definitions (Goodman 2004), but as a set of practices itincludes various forms of evidence creation, analysis, and review. Health Net's first project was to conduct an economic analysisof an anti-cancer drug with the purpose of requesting its incorporationinto the Sistema Unico de Saude (SUS), Brazil's public healthcaresystem. Monica Barros was the first engineer Health Net hired. "Iwas frantic," Barros said jokingly, "People took everything Isaid as an absolute truth." Health Net now specializes in preparingthe economic analyses the Ministry requires for the incorporation of newtechnologies, and Barros is the company's most experiencedengineer. Health Net typically executes these analyses on behalf of thecompanies that own the technologies, mostly drugs. By late 2008, HealthNet was the only company of its kind in Brazil and had grown from thetwo founders and Barros to a full-time staff of three doctors, a nurse,four engineers, a secretary, and a chief financial officer. Its clientsincluded local subsidiaries of seven of the ten largest drug companiesin the world ranked by revenue at the time (MedAdNews 2007). From mid-June to August of 2008, I conductedparticipant-observation and semi-structured interviews in Health Net.The company provided a place from which to View reforming governmentpolicies, emerging market strategies, and evolving scientific practices.The creation of health technology assessments at Health Net typicallyinvolved negotiating evidentiary, methodological, and ethical ambiguityin the presence of clearly-defined commercial interests and nebulousnotions of the public good. Even as Health Net employees struggled toidentify the Ministry's expectations, to satisfy drugcompany's demands, to meet transnational methodological standards,and to negotiate a set of self-imposed ethics, the company thrived.Uncertainty was not a recurrent obstacle in their work; it was the norm.This article explores the sources and types of uncertainty that emergewithin a "rational, evidence-based" system for healthtechnology incorporation and how company employees responded to it. To understand the sources and types of uncertainty involved inHealth Net's work, one must understand some of its particulars. Theparticular type of HTA Health Net conducts can be categorized astechnology-oriented assessments, "intended to determine thecharacteristics or impacts of particular technologies," especiallythe economic and public health impacts of mass technology use orimplementation (Goodman 2008:16). In conducting such technology-orientedassessments, this company employed almost exclusively integrativemethods, used to synthesize and analyze existing evidence taken frompublished studies and reports, rather than primary data methods, used tocollect original data. Central to Health Net's practice was theproduction of mathematical models. Modeling is "used to answer'What if?' questions." In other words, it is "usedto represent (or simulate) health care processes or decisions and theirimpacts under condition of uncertainty, such as in the absence of actualdata or when it is not possible to collect data on all potentialconditions, decisions, and outcomes" (Goodman 2006:45). Theconstruction of a model allowed employees to then perform an economicanalysis of the results, typically either a cost-effectiveness analysisor a cost-benefit analysis. (1) Such analyses were always used tocompare two or more treatments in order to demonstrate one'ssuperiority. The daily work of Health Net employees revolved around the creationof these mathematical models and economic analyses, from the collectionof evidence for the models, to negotiation with the model's sponsoron its particular goals and parameters, to presentation of results.These models and analyses were meant to simulate how a particulartechnology would behave within SUS, the public healthcare system: whatit would cost, what benefits it would have, what forms of treatment itwould ease or replace, and so on. For a model to be reliable, its inputparameters, such as the drug's effectiveness and how many patientswould receive it, must be well-measured or accurately estimated, and therelationships between parameters must be well-understood and representedwithin the model. No model is perfect, and models may be subjected touncertainty analyses to attempt to determine their reliability. Indeed,all evidence-production involves uncertainty, and I do not intend todiscredit HTA by revealing it to be no different from other fields inthis respect. Rather, my aim is to identify sources of uncertainty andoffer a critical understanding of responses to it. In order toillustrate some of the challenges involved in producing analyses, I willbegin by describing the case of a particular drug. The remainder of thearticle will discuss how these challenges stem from areas of incompleteor uncertain knowledge and practice, implicated in global pharmaceuticalpolitics, and how Health Net's employees managed theseuncertainties. The Case of Rivex When I arrived in mid-June of 2008, Health Net was finalizing aneconomic analysis for a drug company of the impact of including a newdrug in SUS, Brazil's public healthcare system. The pharmaceuticalcompany wished to incorporate the drug into the country's list of"essential medicines," which would necessitate its widespreadavailability. (2) The drug, which I will call Rivex, was intended totreat a significant cause of child and infant mortality in Brazil. I satin on the presentation Health Net's analysts made to the drugcompany representatives. Health Net's analysts found through a systematic review ofliterature that Rivex could reduce hospitalization time for childrenwith severe cases of the disease from 5 to 3 days on average, but therewas no evidence in published literature that it reduced mortality. Inother words, the drug would not affect the disease's contributionto child and infant mortality in the country. Even so, as long as thecost of Rivex was less than the cost of a 3 day hospitalization, onemight suppose that the drug could still reduce costs for SUS. Thiscost-saving potential could in itself be a rationale for incorporation.Indeed, the drug was relatively cheap, but, according to the analysts,this argument did not hold because of the way the drug would befinanced. SUS creates resource packages for patients being hospitalizedaccording to different conditions or diagnoses. According to adiagnosis, the hospital releases a certain amount of money from SUS fortreatment) As long as the child survives, SUS is not concerned with howthe hospital uses the resource package, the analysts said. So if a newdrug has no effect on mortality, SUS has little incentive to changeexisting directives in order to incorporate it. (4,5) There was another problem, the analysts pointed out, as the diseasein question presents with rather generic symptoms, and doctors in thiscontext are not in the habit of testing for a particular diagnosisbefore beginning what could be beneficial treatments. Rather, patientsin SUS might receive a generic diagnosis, such as "fever" or"diarrhea" and be given the drug just in case. As a result,more children than have the disease would likely receive the drug as aprecaution, though how many more would depend on the prescriptive habitsof doctors, making an accurate economic analysis of the drug's usedifficult. Unconvinced that the drug was suited for the list ofessential medicines, the analysts proposed that the pharmaceuticalcompany market it privately outside of SUS. If it decided to carry through with its incorporation proposal, thepharmaceutical company that owned Rivex would be asking the governmentto pay 25 million dollars over 5 years for the drug. This figure wasbased on the prevalence of disease in 2005. However, one of thepharmaceutical company's employees noted that in 2006 a vaccine forthe disease began being implemented in some populations. Since then, noassessment of the incidence or prevalence of this disease had takenplace. As a result, the analysts had to revise the model according toestimates of prevalence and incidence based on the scope of vaccinationand the effectiveness of the vaccine. Since less of the drug would benecessary, this revision would likely reduce the total cost. Thepharmaceutical company employees, who had frequently interrupted thepresentation with questions and criticisms, were relieved by this. Theybelieved a lower amount would increase the chances of the drug beingincorporated. Over lunch, the Health Net analysts complained about thepressure drug companies put on them to produce favorable analyses. Theynoted that failure to have a drug incorporated could cause the drugcompany staff to lose their jobs. As I explained above, a mathematical model is constructed fromseveral known or, rather, measured parameters. In the case of Rivex,these parameters included the drug's effect, the population'sepidemiological profile, physicians' prescriptive habits, and thehealth system's financing mechanisms. Knowledge of parameters isinevitably incomplete. The incidence and prevalence of disease areestimates, prescriptive habits are unknown, and the health system'sfinancing mechanisms are not always properly understood. Even the effectof the drug can be highly uncertain. Frequently, drug companies demandedmodels and analyses be reconfigured if they did not present favorableresults. Health Net employees struggled with the nature of the evidencethey used for models, the rigor of their methods, and the ethicaldimensions of their work. Uncertain Evidence: Quality and Context In discussing the challenges of their work, company employeesconsistently cited the dearth of available information or evidence forthe construction of models. In particular, they were frustrated by thelack of public health data specific to Brazilian populations andtreatment contexts. Simple public health data concerning diseaseprevalence were frequently incomplete or out-dated, as in the case ofRivex. A discussion of the limitations of data reporting, aggregation,and analysis by the Ministry of Health is beyond the scope of thisstudy. However, many Health Net employees, having worked in SUS, weresensitive to the unreliability of reported data at the source. SandraMarchi, a nurse, was responsible for conducting systematic literaturereviews and assisting with constructing mathematical models. Sometimesthe needed data existed in health posts, she said, but it was"written by hand, mixed with other papers, in some notebook, insidean old cupboard, and no one knows where it is." When aggregateddata was available, it was through difficult-to-navigate onlinedatabases. Employees said data concerning the effect of interventions onBrazilian populations was also lacking. The employees presumed thetypical Brazilian patient would likely respond differently to a medicalintervention than, say, a European or North American patient because ofdifferences in diet, environments, genes, etc. They attributed thedearth of Brazilian studies to the absence of a "researchculture" among Brazilian health professionals, though certainly theavailability of funds to properly study every relevant intervention andthe nature of global clinical research were also contributing factors(Petryna 2006, 2009). In the absence of national public healthinformation, company employees frequently used foreign sources of data.During my time at Health Net, employees were working on a model for adevice I will call Endomaz to treat menorrhagia, heavy menstrualbleeding. Marchi, who was assigned to the project, was using data on theefficacy of Endomaz and the patient satisfaction associated with its usefrom a randomized clinical trial conducted in the United Kingdom."I have to assume the data is similar [for Brazil], but it'sobvious that it isn't," she said. When it comes to HTA, notions and standards of rigor are typicallyconcerned with the "quality" of evidence used to conductintegrative studies such as economic analyses, and not with the contextin which the evidence is produced. Quality is typically judged bystudies' design, which demonstrates a concern for studies'internal validity (Rychetnik 2002:121). Evidence hierarchies explicitlyrank the quality of evidence according to the design of the study thatproduced the evidence (Rychetnik 2002:121). Randomized controlled trials(RCTs) are considered uniquely able to avoid biases associated withother study formats and, as a result, are considered the gold-standardin primary data collection studies. RCTs are nonetheless also subject tobiases, and must be carefully planned and carried out in order toeffectively avoid them. Many RCTs are funded by drug companies, andthere has been much concern over the reliability of these (Damdron 1986,Easterbrook 1991, Smith 2005, Heres et al. 2006). According to reigningnotions of evidence quality, Marchi was entirely justified in utilizingthe British RCT data. The Ministry of Health's health technologyincorporation submission form even has an evidence hierarchy tableprinted on it. She knew, nevertheless, that the "quality"category alone was insufficient to fully assess the reliability andunderstand the implications of evidence utilized for public healthdecision-making. Dobrow et al. (2004) argue that it is insufficient to consider onlythe "quality" of the evidence as determined by study design inpublic health decision-making. The contexts in which evidence isproduced must be considered. Contextual factors can be taken intoaccount through evaluative categories such as "relevance,appropriateness, applicability, acceptability, and utility" (Dobrowet al. 2004:214). The authors remind us that technologies necessitatetheir own context-specific considerations and practices, requiringknowledge from care-givers and accommodations from patients inimplementation. Implicated in the authors' arguments is a concernfor the relevance of evidence collected in one epidemiological,institutional, and clinical setting to other dissimilar settings. Such"context-specific" forms of knowledge and assessment challengethe seeming universal applicability of "high-quality" evidencebut are, nevertheless, excluded from evidence hierarchies. Indeed, RCTs are purposefully intended not to producecontext-specific data. Rather, RCTs are intended to produce measures ofefficacy, the capacity of a treatment to produce an effect. These aredifferent from measures of effectiveness, the actual effects of atechnology once it is implemented in real-life care environments wheremistakes take place, resource constraints may disrupt therapy, andpatients with multiple disorders may not respond as well totreatment--that is, the very nature of efficacy trials requires them tobe conducted in highly controlled circumstances with selectivepopulations. As a result, RCTs may not even be representative of theregional contexts in which they are conducted. "Controlledconditions" used for efficacy trials should not be taken forgranted, and, as anthropologist Andrew Lakoff discusses in the case ofanti-depressants, demonstrating favorable results can depend uponselecting the "right patients" for the trial (2002). In such highly-controlled trials, real-life uncertainties, such asthose discussed in the case of Rivex, are not present. These trials areboth highly context-specific, because they occur in highly controlledconditions, and wholly non-specific, because they supposedly produce ameasure of a drug's theoretical ability to work. According toPetryna (2009), pharmaceutical companies make the non-specificity ofevidence produced through trials into an advantage. Clinical trials ofproducts intended for developed-country markets are increasinglyconducted in developing countries. Because results are notregion-specific, they can be extended to virtually any locality. Thenon-specificity of clinical trial results follows from a biomedicalunderstanding of treatment that favors measures of efficacy overeffectiveness. Lakoff (2002) writes that in the biomedical understandingof treatment "the drug is understood to operate directly on aphysical problem through its biochemical effects on the body of thepatient" (73). This understanding leaves no room for the influenceof contextual factors on treatment success. Because a drug'seffectiveness is virtually assured to be less than its efficacy, theapplication of evidence on efficacy to HTA models results in optimisticresults for the drug's marketers. Recently, there have been callsfor more "pragmatic" randomized clinical trials that enrollvaried patient populations and may be carried out within existinghealthcare infrastructures (see Tunis et al. 2003, Treweek andZwarenstein 2009). To sum up, in the absence of Brazilian data concerning publichealth measures and clinical outcomes, employees relied on data fromforeign sources bolstered by general notions of evidence admissibilitybased on study design. Such notions of evidence admissibility stem froma narrowly-conceived biomedical understanding of treatment and areimplicated in the global commerce of evidence production. AsMarchi's comment makes clear, however, these accepted notionsoffend the obvious. Where guidelines or consensuses on evidenceadmissibility are tenuous or inexistent, standards of evidence can bemolded to meet local interests and needs, while preserving the semblanceof rigor. In such cases, what is methodologically permissible maydisagree with what is sensibly sound. Marchi, who had worked in public health posts and private clinics,suspected many of her patients would prefer Endomaz over a hysterectomy,the standard treatment in SUS, but no such data was available. Rather,she had evidence concerning patient satisfaction with treatment fromother countries. As Marchi's comment demonstrated, in the absenceof categories and practices to assess sensible concerns, configurationsthat favor commercial interests are free to take hold. The tools(language) to critique such approaches or include other-dimensionalconcerns in analyses either do not exist or, as Dobrow et al. note, arenot considered as part of evidence hierarchies. When employees did tryto include "on-the-ground" perspectives from the publichealthcare system, it was typically through panels of doctors. Sincesuch panels rank very low on evidence hierarchies, employees avoidedthis option whenever possible. The suggestion here is not that company employees altered theirevidence standards according to immediate commercial interests nor thatthey were insensitive to the importance of local contexts. Companyemployees simply relied on generally accepted norms concerning evidence"quality" from existing scientific literature, having noreason or incentive to do otherwise. Where areas of knowledgeuncertainty or analytical absence are bolstered by commercial interests,rigorousness loses traction, and logical considerations, such asfeasibility and patient preferences, are easily elided. Uncertain Methods: Harmonization and Pragmatism Despite the uncertainties they detected in the evidence theyutilized, Health Net employees needed to find ways to rigorously assessthe technology in question and present it in a favorable light. Whilethe previous discussion has focused on uncertainties associated withevidence, employees also had to deal with complex and subjectivecomparison criteria and results from models. Such challenges bring tolight methodological uncertainties in the employees' practice. Whenit came to the Endomaz project, the studies for various alternativetreatments did not utilize the same efficacy measures or follow-upperiods, making comparison within a model difficult. The use ofdissimilar measures between trials can be a strategy used by clinicalresearchers to manipulate the outcome of studies and constituted anotherchallenge in Health Net employees' work. In a review ofhead-to-head trials (6) of second-generation anti-psychotics, forinstance, Heres et al found that trials testing the same drugsfrequently came to opposite conclusions (Heres et al. 2006). In 90.0% ofstudies, the outcome was in favor of the trial's sponsor. Theauthors identified dosing, entry criteria, and reporting of results asonly some sources of bias (Heres et al. 2006). "[Endomaz] is better than the other ones in parameters thathave no appeal," Marchi said. In other parameters, Endomaz was attimes better but not within statistical significance. Endomaz was lessefficacious than a hysterectomy, the standard treatment in SUS formenorrhagia, and had lower satisfaction ratings in the literature. Onthe other hand, it was also less expensive and produced fewercomplications than a hysterectomy. Employees needed to reduce thesecomplex trade-offs to an un-ambiguous argument in favor of oneintervention. They considered inventing their own measure ofeffectiveness, "cost per satisfied patient," in order todemonstrate/construct Endomaz's superiority. Just as uncertaintiespervaded the use and selection of evidence, they were present in theconstruction of models and economic analyses. "When we look back, there is always something that could havebeen done better," Barros, Health Net's most experiencedengineer, said. Like the other engineers, Barros had not had anyexperience performing economic analyses of health technologies beforeworking for Health Net. "No one studies this in college, notproduction engineers, not economists, not statisticians, not doctors,not nurses, no one," Marchi said. While employees had found acorrespondence program on the economic evaluation of health technologiesfrom a British university, they knew of no comparable programs in theBrazilian educational system. Even so, nearly every employee was engagedin a graduate program or some other form of continuing education whileworking at Health Net. Through conferences and congresses, conversationsand partnerships with other researchers, reading articles, and,ultimately, this long-distance program at a British university, Barrosgained a working-knowledge of HTA practices that coalesced into a formof expertise. According to Marchi, the pharmaceutical industry employees sheworked with frequently did not understand the methods used to conducteconomic analyses. "Most people who do pharma-economics in theindustry don't understand the step-by-step processes involved inthese analyses. They understand the general concepts," she said."They sometimes ask questions that someone who doesn't knowanything about the field would ask." In this atmosphere ofuncertainty, the creation of economic analyses involved frequentconsultation with pharmaceutical companies and reconfiguration ofparameters until a model could be reached that produced some sort offavorable result for the technology in question. "In reality, theclient frequently doesn't know what he wants," Barros saidreferring to the different types of models and analyses that can beperformed and to the drug company employees who commission them. Butthey know they want to request incorporation, I asked. "Yes, thatthey know." She continued, "They know, for example, that theywant to solicit the drug's incorporation into the list ofexceptional drugs ... but they don't know how they will do it or ifit can be done. How can one ask for the incorporation of a drug thatdoesn't demonstrate benefits? Impossible." Even so, Barrosrecognized that the demonstration of benefits can be subjective as inthe case of Rivex described above. Indeed, the demonstration of benefits may be highly dependent onwhich two treatments are being compared. A treatment may look favorablein comparison to one alternative but not another. Fernanda Amaral, apsychiatrist who performed systematic literature reviews at Health Net,confirmed that pharmaceutical representatives frequently do not knowwhat kind of analysis they need, and analysts can go through severalconfigurations before reaching a satisfactory result. "They want tocompare [the drug] to something that will show a good result," shesaid. "You can decide on something and at the end, when they seethe result, they may decide they don't like it and want to changeeverything." Arnaral said employees tried to make the case topharmaceutical companies that it was the "drug which isn'tgood, not the analysis." As in Lakoff's (2002) work withclinical trials, the drug is the stable reference point and all othervariables are alterable. The Ministry of Health does formally require that technologiesbeing proposed for incorporation be compared in economic analyses tobest existing treatment. Presumably, the Ministry issues this guidelinein order to maintain equal standards across technologies and to minimizesubjectivity in analyses--a technology is either better than the currentbest or it is not. Nonetheless, this sort of analysis does not alwaystake place. "Many of our treatments lines are so technologicallydefunct that the comparisons are not against the gold-standard but thetreatment used in SUS," said Pereira, the Ministry of Healthofficial responsible for making recommendations to the Minister. High-income countries with experience utilizing HTA to informpolicy decisions, such as the United Kingdom and Australia, have lengthyand detailed guidelines on the use and application of economic analysesin technology appraisal (NICE 2007, PBS 2008). In Brazil, where few haveexperience or knowledge of HTA, the Ministry's guidelines offerlittle more than general suggestions on what kinds of studies shouldaccompany proposals, saying nothing about how these studies should beconducted, according to what standards or best set of practices(Ministerio de Saude 2006). According to the manager of an internationalmember-based organization of agencies and individuals involved inhealth-technology assessment, HTA is an "emerging discipline"even in North America. Efforts to fully "harmonize" HTApractices have only begun in last 2 years, he said, and have primarilytaken place in Europe (see Hutton et al. 2008). He confirmed that theharmonization of HTA practices is particularly difficult in developingcountries that have typically had little experience with the field. Harmonization efforts may offer a way to address current issues inHTA such as how to treat the context-specificity of evidence. In arecent article on the history and future possibilities of harmonizationof evidence admissibility in HTA, Hutton et al. write, "... Whereassome aspects of economic evaluation remain highly context-specific,there is scope for further exploration of harmonization of others"(Hutton et al. 2008:513). They suggest standards for evidenceadmissibility given divergent contexts may be different acrossindications, but they stop short of offering any suggestions on whatstandards should be or how to determine them, indicating harmonizationmay be a far-off goal. Even if some form of harmonization were achievedit would not necessarily result in common standards for evidenceadmissibility. As Petryna (2006) discusses in the field of clinicaltrials, "the ethical standard for the world was claimed to bevariability" in part through the International Conference onHarmonization (44). In other words, harmonization can be used toinstitutionalize uncertainty and promote local variability in settingswhere commercial interests dominate research practices and prerogatives. Even as Health Net employees sought to learn about and emulateEuropean and North American HTA practices, they responded to localizedneeds and priorities. One study employees were particularly excitedabout sought to make a case for the incorporation of an expensivemedication to treat a rare genetic disorder. Andre Silva, a professor ofmedicine and one of Health Net's founders, explained that it isdifficult to make a case for treatments for rare conditions where thereis no existing alternative treatment for comparison. He decided HealthNet would compare the cost-benefit relationship for Brazil's AIDSprogram with a program to be created for this rare disease. The impliedquestion was, "if the government will spend a certain amount on anAIDS patient, why not on another type of patient?" "Brazil's AIDS program is its vitrine to the world,"Silva told me. The Portuguese word vitrine can be translated to mean"display-case," though its most frequent meaning is"shop-window." The commercial connotation is apt, consideringBrazil's growth as a drug market, the AIDS program'sincreasing budget for antitroviral drugs, approximately 227 milliondollars in 2005 (Grangeiro et al. 2006), and the program's originin an administration that championed neo-liberal reforms (Biehl 2007b).In this project, Health Net employees utilized trans-national methodsand appealed to local sensibilities to produce an argument ofeffectiveness as well as equality. Standardization and innovationoccurred together, producing a study that was a sort of patchwork oftrans-national authorizing practices and a locally-appealing rationale. The significance of harmonization for HTA, a relatively youngfield, extends beyond ethical or methodological flexibilities, however.The shop-window metaphor is not merely one of cold, calculating,commercial opportunity. As neo-liberal reform rationales employarguments concerning "opening-up to the world," Silva'sshop-window metaphor communicates a longing, for approval, purchase,acceptance. Science historians Steven Shapin and Simon Schaffer (1985)recount how Robert Boyle developed various strategies or"technologies" to extend the "empirical experience"in 17th century England. "The role of Boyle's literarytechnology was to create an experimental community, to bound itsdiscourse internally and externally, and to provide the forms andconventions of social relations within it" (Shapin and Schaffer1985:77). The significance of harmonization for the scientific integrityof HTA may be fully appreciated in light of this statement.Harmonization is best understood not as a standardization ofmethodologies but as the bounding of a self-legitimizing transnationalcommunity. It is not only important for the methodology to be public,but for it to conform to a bounded set of methodological allowances.Company employees relied on various sources of methods because of theirown inexperience, as a kind of self-regulation, but also because theysearched for the creation of such a community and for inclusion in it.In such communities, members can agree on what forms of uncertainty arelegitimate and what forms are not. Uncertainty is not so much eliminatedas some forms are slated for elaboration and others excluded. Employeescould at times crave standardization even as they took advantage ofopportunities resulting from its absence. Marchi considered not carrying on with the analysis for Endomazgiven the apparent methodological impossibility, but later she said she"found a path." Such paths were paved with various forms ofevidence, and their shapes and directions were defined by methodologicalallowances, commercial interests, existing evidence, and notions of whatserves the public good, partially conceived through the Ministry ofHealth's supposed expectations. Methodological allowances werestable but sufficiently flexible to allow for several possibleconfigurations of analyses. Commercial interests largely determined theultimate form these analyses took. As in the case of Rivex, analystsalso attempted to preempt what the Ministry of Health would findfavorable in a drug. Where within the health system a technology wasproposed for incorporation depended on which properties of thetechnology were demonstrated, which depended both on which could bedemonstrated and which Health Net had an interest in demonstrating. Asthe Rivex case shows, which properties could be demonstrated depended onexisting evidence, funding mechanisms within the public system, clinicalforms of common sense, and how the technology's benefits interactwith the existing healthcare system. Ultimately, in making models and conducting economic analyses,Health Net's members sought to locate/construct from known/measuredparameters, a need/demand for the drug within the public system, thuscreating a market. Psychiatrist David Healy (2006)writes, "Theportfolio of marketing maneuvers has grown ... Clinical trials andghostwritten scientific articles have increasingly become part of themarketing of disorders and their treatments ... The result is a growthof disorders tailor-made to fit ever more visible drugs" (62).According to Healy, pharmaceutical companies' (re)construction ofdisorders to fit existing pharmaceutical arsenals involvesaltering/manipulating the nature of disorders. In Health Net'swork, the context of drug delivery, the health system itself as well asthe alternative treatments available, is (re)constructed in mathematicalmodels and within methodological allowances until it favorably fits thecharacteristics of proposed drugs. Bruno Latour contends that the laboratory's ability to makeknowledge claims that are of interest to members of society arises fromits potential to translate the field in the laboratory and thelaboratory in the field. "... The laboratory positions itselfprecisely so as to reproduce inside its walls an event that seems to behappening only outside--the first move--and then to extend outside toall farms what seem to be happening only inside laboratories"(Latour 1983:266). A model is not the healthcare system, but thetranslation of the healthcare system. The power of Health Net analystslies in their ability to convincingly recreate the healthcare system. However, one cannot extend laboratory before extending "theconditions of verification that existed in the laboratory" (Latour1983:272). Indeed, efforts seem to be underway on the part of theMinistry to improve data production and management throughout SUS. A May2009 Ministry decree stated, "Information is fundamental for thedemocratization of Health and the improvement of its management. Thecomputerization of the activities of the Sistema Unico de Saude (SUS),within the appropriate protocols, is essential in order to decentralizehealth activities and make viable Social Control over the utilization ofavailable resources" (Ministerio de Saude 2009). As I statedearlier, Health Net employees were sensitive to the unreliability ofreported data at the source. Amaral stated that doctors in herpsychiatric hospital would misreport what treatments patients receivedin order to provide them with newer drugs while receiving reimbursementfrom SUS. (7) Computerization of health activities will likely notaddress the principal reasons and ways in which health professionalsmisreport information. Even as the rules of the laboratory are extendedinto new fields, we must be sensitive to how these rules representopportunities rather than simply restrictions. According to Latour, certainty is created in the laboratory throughthe ability to make mistakes. "Certainty does not increase in alaboratory because people in it are more honest, more rigorous, or more'falsificationist.' It is simply that they can make as manymistakes as they wish...Each mistake is in turn achieved, saved,recorded, and made easily readable again, whatever the specific field ortopic may be " (271). In light of Latour's statement, HealthNet's practice of reconfiguring models until a rationale forincorporation emerged becomes less sinister and more mundane. Latourdoes not pretend these certainties are not guided or selected accordingto interests. Indeed, he credits Pasteur's success in part to hisability to "capture" the interests of farmers (259-260).However, to say interests are necessarily involved in experimentation isnot to say that which interests in particular dominate is irrelevant. Pereira, the Ministry of Health official mentioned earlier, notedthat at some point commercial interests meet public needs. "Afterall, [pharmaceutical companies] are not producing astronauticalartifacts, they are producing health products." As economistMichael Kremer discusses, however, pharmaceutical drug development isoverwhelmingly directed towards developed world diseases, rather thandeveloping world health priorities (Kremer 2002). The confluence oftechnology incorporation and public health priorities becomes inpractice a chance occurrence. In his work on the effect of pharmaceutical representatives onprescriptive patterns in Argentina, Lakoff (2006) writes, "...Themutual imbrication of science, regulation, and business in thecirculation of pharmaceuticals is best seen not as a contamination ofpure science but rather as part of a distinctive and emergent regime forauthorizing knowledge claims and expert action" (112). Similarly,the production of models involved not a distortion of methods byinterests, but the construction of an "authorized knowledgeclaim." Authorized methods, such as the use of evidencehierarchies, learned from various authorized sources, such as theBritish university, were used to construct such claims. Ultimately,Health Net's methods were successful for their ability to satisfycommercial interests while making use of scientific knowledge-makingtechnologies. Uncertain Ethics: Rigor and Interests To say the final forms of the economic analyses Health Netperformed were largely defined by commercial interests is not to say theemployees were somehow sold to the pharmaceutical industry. In fact, theemployees frequently viewed the industry with suspicion and distaste."I wouldn't want to work in the industry," Marchi said.She and other employees had turned down job offers to work forpharmaceutical companies at increased pay. In justifying thesedecisions, employees cited the openness and flexibility of their currentpositions. These preferences overlapped with ethical concerns as well."If I work for the industry, I have to swear to the ends of theEarth that [the product] is marvelous," Marchi said, regardless ofwhat she thought or what the evidence may suggest. Health Net employeesmentioned that failure to have a technology incorporated could lead topharmaceutical industry employees' termination. Health Net employees openly discussed their opinions of thetechnologies they assessed. When it came to Rivex, the engineerresponsible for the project plainly told me, "[Rivex] is bad."Despite their efforts to construct favorable analyses, employees said itwas clear when drugs were "good" or "bad" andtrusted that Ministry officials would be able to make decisionsaccordingly. Employees gathered to laugh and sneer at a presentationRivex's sponsor planned to show the Ministry of Health. Thepresentation contained cartoon slides telling the story of a young girlfalling ill after being contaminated during play with her friends andtaking Rivex to get better (see Martin 2007 for imbuing drugs withpersonalities). Employees greatly valued working for drugs they thought were good."When you have projects where you believe in the drug, it'svery good," said Amaral, who had worked in a public psychiatrichospital before coming to Health Net. In the hospital, studies comparingtreatment were of little worth, she said, since most drugs were inshortage and many patients ended up receiving haloperidol, an olderanti-psychotic with serious adverse effects, in the place of newertreatments. "Your distance to the patient is very great but so isyour responsibility to him," Amaral said of her HTA work. In theabsence of formal ethical guidelines, employees relied heavily on theirown sensibilities. Working in favor of pharmaceutical interests they did not alwaystrust, and marketing products they frequently did not approve of,employees were highly conscious of questions of ethics andresponsibility. "You're not selling a bed-sheet where theworst that can happen is that it is a lousy bed-sheet and no one dies asa result," Marchi said. "The ethics are in the methods. It isclear for all to see," Silva told me, encapsulating the view heldby many in Health Net. As a professor in a public university, Silvaperformed economic analyses directly for the Ministry of Health with thehelp of one or two of Health Net employees who were also his graduatestudents. (8) At the time, he was performing in his academic role ananalysis Health Net had performed for a pharmaceutical industry client.Silva said that ideally he should not be permitted to perform theanalysis. However, he added, "Conflicts of interest are onlyproblematic when people are unethical." He noted it was in HealthNet's long-term financial interest to maintain a rigorousmethodological ethic. The manager of the member-based HTA organization proposed a similarviewpoint, "If you go deep enough in any relationship you'llfind a conflict of interest. The issue is how do you deal with it? Doyou recognize it and manage it, in which case everyone benefits...or doyou pretend it doesn't exist in which case it comes back to biteyou later." As long as Health Net did not compromise itselfmethodologically, Amaral argued, it was always serving the public good,either by demonstrating a technology was good or demonstrating it wasnot. In these configurations, ethics are dislodged to either methods orinterests, and do not seem to exist as a separate field to be consideredon its own terms. Despite these conceptions, ethical ambiguities still arose inHealth Net's business practices. Employees struggled with how toset up a contract with clients, given that mid-way through a projectthey may come to the conclusion that a favorable economic analysis wassimply not methodologically possible. They resisted the suggestion thata favorable analysis could be produced for every product. Nevertheless,employees said they had only produced one analysis that showed adecidedly negative result for a client. Even so, completed analyses weredelivered to pharmaceutical companies, which held the right to alterthem, before going to the Ministry of Health. The Ministry of Health hasnot made health technology incorporation decisions, much less theeconomic analyses that supposedly inform them, public. As a result,neither is it possible to independently assess the quality of suchanalyses nor to determine to what extent the Minister relies on suchanalyses to inform incorporation decisions. Final Considerations: Cultivating Uncertainty While a discussion of the origins of the importance of rationalityand economic evidence in public health is beyond the scope of thisstudy, some important trends and milestones can be identified. Since themid-1990s Canada, Australia, and European countries, particularly theUnited Kingdom, have been giving greater importance to economic evidencein public health decision-making, particularly in health technologyincorporation (Drummond 2001). At about that same time, the WorldBank's World Development Report 1993: Investing in Health proposedcultivating economic development as a means of improving health,recommended redirecting government spending to "more cost-effectiveprograms," and utilized disability-adjusted life years (DALYs) toquantify disease burden (World Bank 1993). In addition, as Biehl's work shows, the World Bank'ssupport of Brazil's universal antiretroviral policy depended on theprogram's ability to generate economic forms of evidence thatjustified its costs (2007b). Biehl also explores how the AIDS programarose in the midst neo-liberal state reforms (2007b). At first glance,then, the rationale for the Ministry of Health's new system ofhealth technology incorporation seems rooted in novel forms of economicgovernance arising in certain developed democracies, elaborated througha then-growing transnational force in global health, and consistent withneo-liberal forms of thinking that served to justify the universalantiretroviral policy, regarded internationally as an enormous publichealth success. When I spoke to Pereira, the Ministry of Health official, in Augustof 2008, he indicated the Ministry would be making its incorporationdecisions public beginning in November. Since then, anotherinstitutional restructuring has taken place, he is no longer involvedwith technology incorporation, and the incorporation decisions are stillnot made public. The Ministry's failing is not that it did notsucceed in constructing a rational system of incorporation or that itdoes not account for commercial influence, but that it has not allowedfor a public discussion of the merits and limitations of its approach.Shapin and Schaffer (1985) write, "We regard our scientificknowledge as open and accessible in principle, but the public does notunderstand it...A form of knowledge that is the most open in principlehas become the most closed in practice. To entertain these doubts aboutour science is to question the constitution of our society. It is nowonder that scientific knowledge is so difficult to hold up toscrutiny" (343). Rationality was a given in the Ministry'sjustification for reform. As shown, in practice, evidence production andinterpretation are highly subjective and necessitate managing severalforms of uncertainty. HTA is positioned as a way of allowing governments to make"rational decisions" or, put differently, to ensure resourcesare used "rationally." Its ability to appear neutral isderived both from the use of scientific "trappings" andknowledge-making technologies, but also its success in satisfying all ofthe immediate commercial demands and public expectations placed upon it.As in other "audit cultures," the efficiency and costs ofintermediary processes are well-managed, while ultimate measures ofeffectiveness are overlooked (McDonald 2000:64 and see Strathern 2000).Health Net employees worked to produce high-quality analyses and Pereiraclaimed to scrutinize these as rigorously as possible. In the meantime,little consideration was given to attracting technologies that respondedto public health priorities or to monitoring the ultimate effect oftechnologies once implemented. In all, strategies to manage uncertainty involved elidingproblematic forms of knowledge, relying on commercial interests toevaluate analyses' configurations, and relocating ethics to morefamiliar fields of practice. These strategies reveal an extremediscomfort with uncertainty, and accounting for uncertainty ofteninvolved attempting to minimize it in ways that veiled, disqualified, ordislodged it. Actors were frequently unable or unwilling to communicatetheir concerns. Marchi, the nurse, knew of the limitation of her use ofBritish evidence but had no immediate way, reason, or incentive toaddress it. Silva wondered about the ethics of his work but lacked acritical framework or accountability mechanisms with which to scrutinizeit. And Pereira recognized crippling limitations of the healthtechnology incorporation system, but saw no timely ways of addressingthem. Petryna notes how the practical uncertainties involved in globalclinical trials are obfuscated in their final presentations (2009). Theminimizing of uncertainty, the rift between what we think we know andwhat we suspect may be, while understandable, does not make our pursuitsof knowledge more certain. Rather, it makes the limitations of ourapproaches insidious and more difficult to resolve. Globalized and globalizing fields of knowledge-production presentparticular epistemological and practical concerns. Uncertainty hascharacterized many of the recent global health phenomena such asemerging epidemics like SARS and the H1N1 flu, attempts to quantifyglobal pandemics such as HIV/AIDS or hepatitis C, or the potentialimpact of chemical or pharmaceutical products like DTT or Vioxx.Uncertainty results, it seems, from the sheer scale and mutability ofhealth challenges, which thwart expectations for immediate redress.Institutions, practices, and ways-of-thinking that promise some form ofknowing and order are understandably appealing (see McDonald 2000). While the costs of mistakes in public health decisions are dire,the expectation that a singular paradigm will succeed in fullyaddressing health challenges is unhelpful. If we are to openly discussthe vulnerabilities of our approaches to public health decision-making,we must first renegotiate our relationship with uncertainty. Perhapsthere is room for rethinking uncertainty as common rather thanexceptional, and as productive rather than menacing. Where inefficiencyor ill-will are frequently blamed for the failure of projects, perhapsthere is room to consider the forgivable state of not-knowing withoutforfeiting a commitment to health rights or a sharp analyticalperspective that is sensitive to market forces. Shapin and Schafferwrite, "To identify the role of human agency in the making of anitem of knowledge is to identify the possibility of its beingotherwise" (1985:23). By cultivating uncertainty, we open avenuesto more faithful and sensible sciences. ACKNOWLEDGEMENT This research is funded by Princeton University's GrandChallenges Program in Global Health and Infectious Disease. I amgrateful to all my informants for giving their time and sharing theirexperiences. I would also like to thank Anthropological Quarterly'seditorial staff for their consideration and assistance. Suggestions fromRena Lederman and Joao Biehl improved the piece immeasurably, and Ithank them for their time. I also thank the anonymous reviewers fortheir careful reading and helpful comments. I am indebted to thefollowing people for deeply meaningful and intellectually fruitfulrelationships over the years: Sonya Bishop, Dion Bubar-Hall, JoshFranklin, Leo Gertner, PJ Henley, Matthew Hooper, Laura Kergosien,Miguel Sansalone, Pamela Usukumah, and all members of the 2-DickinsonCooperative. In addition, I must thank my parents for their hardwork andencouragement. Finally, there is no way to fully acknowledge thegenerous, invaluable, and multi-faceted support of Joao Biehl andAdriana Petryna in this and other endeavors. REFERENCES Biehl, Joao. 2006. "Pharmaceutical Governance." InAdriana Petryna, Andrew Lakoff and Arthur Kleinman, eds. GlobalPharmaceuticals: Ethics, Markets, Practices, 206-239. Durham: DukeUniversity Press. --. 2007a. 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Treweek, Sflaun and Merrick Zwarenstein. 2009. "Making TrialsMatter: Pragmatic and Explanatory Trials and the Problem ofApplicability." Trials 10(37). Whitmarsh, lan. 2008. "Biomedical Ambivalence: AsthmaDiagnosis, the Pharmaceutical, and Other Contradictions inBarbados." American Ethnologist 35(1):49-63. World Bank. 1993. World Development Report 1993: Investing inHealth. New York: Oxford University Press. Alex Gertner Princeton University ENDNOTES (1) Cost-effectiveness analyses compare the costs of two or moreinterventions in monetary units and their effectiveness in non-monetaryunits. Cost-benefit analyses, in contrast, compare interventions usingonly monetary units and are typically used to compare interventions fordifferent clinical indications. (2) Medicines provided through SUS are divided into variouscategories or lists that indicate their cost, availability, andcomplexity. Essential medicines are the most widely available type inthe system. (3) According to Health Net employees, several of whom hadpreviously worked in SUS, such resource packages are frequentlyinsufficient to cover a patient's treatment, and public hospitalsare perennially in debt as a result. (4) The employees who explained this spoke primarily fromexperience working in SUS. At the time, a company intern was working ona project to gather published or other wise written information on howprecisely different forms of treatment were financed in differentsections of SUS. I assisted with this project, which turned up fewofficial or informative sources. (5) The Ministry of Health required that economic analyses beperformed using SUS's perspective, rather than from a societalperspective. A societal perspective may consider outcomes such as apatient's lost productivity as a result of illness. (6) Head-to-head trials are designed to test different drugs underthe same conditions in order to unequivocally demonstrate one'ssuperiority. (7) This sort of exchange is possible because hospitals frequentlyoperate within SUS as well as for private insurers and patients willingto pay for procedures. As a result, a hospital may have newer drugsavailable for private patients but not for public patients. (8) While company employees could conduct analyses directly for theMinistry of Health from academic positions, and did, they could not as aprivate company.

Americas.

Americas. CHR CHRcanine hypoxic rhabdomyolysis. 1STOPHER N. MATTHEWS. The archaeology of American capitalism:the American experience in archaeological perspective, xiv+256 pages, 34illustrations, 1 table. 2010. Gainesville (FL): University Press ofFlorida: 978-0-813-03524-6 hardback $69.95. PAUL. A. SHACKEL. New Philadelphia: an archaeology of face in theHeartland. xxiv+208 pages, 45 illustrations, 5 tables. 2011. Berkeley,Los Angeles (CA) & London: University of California Press "UC Press" redirects here, but this is also an abbreviation for University of Chicago PressUniversity of California Press, also known as UC Press, is a publishing house associated with the University of California that engages in academic publishing. ;978-0-520-26629-2 hardback; 978-0-520-26630-8 paperback 19.95 [euro]. BENJAMIN M. AUERBACH. Human variation in the Americas: theintegration of archaeology and biological anthropology (Center forArchaeological Investigations Occasional Paper 38). xiv+376 pages, 43illustrations, 42 tables. 2010. Carbondale (IL): Southern IllinoisUniversity; 978-0-88104-095-1 $35. DIANA DIPAOLO LOREN. The archaeology of clothing and bodilyadornment in colonial America. xviii+121 pages, 28 illustrations. 2010.Gainesville (FL): University Press of Florida; 978-0-8130-3501-7hardback $69.95. SCOTT M. FITZPATRICK & ANN H. ROSS (ed.). Island shores,distant pasts: archaeological and biological approaches to thepre-Columbian settlement of the Caribbean. xvi+246 pages, 49illustrations, 19 tables. 2010. Gainesville (FL): University Press ofFlorida; 978-0-813-03522-2 hardback $75. JULIA GUERNSEY, JOHN E. CLARK & BARBARA ARROYO (ed.). The placeof stone monuments: context, use, and meaning in Mesoamerica'sPreclassic transition, xx+358 pages, 291 illustrations, 5 tables. 2010.Washington D.C.: Dumbarton Oaks Research Library and Collection, HarvardUniversity; 978-0-88402-364-7 hardback 44.95 [pounds sterling], 54[euro] & $59.95. LISA J. LECOUNT & JASON Jason, in Greek mythologyJason,in Greek mythology, son of Aeson. When Pelias usurped the throne of Iolcus and killed (or imprisoned) Aeson and most of his descendants, Jason was smuggled off to the centaur Chiron, who reared him secretly on Mt. Pelion. YAEGER (ed.). Classic Maya provincialpolitics: Xunantunich and its hinterlands. xii+451 pages, 53illustrations, 27 tables. 2010. Tucson (AZ): University of Arizona (body, education) University of Arizona - The University was founded in 1885 as a Land Grant institution with a three-fold mission of teaching, research and public service. Press; 978-08165-2884-4 hardback $72.50.