Fall 2006

end­­eavors Fall 2006

Research and Creative Activity • The University of North Carolina at Chapel Hill

CANCER AND ADDICTION When will we beat them? Page 9.

These are a few of the people we’ve lost.

Who will our children lose?

We borrowed the photos on the cover from coworkers in our office

Above, Refurbished viruses, shown in green, carry normal genes into cells to replace mutated genes.

Jude Samulski’s lab rebuilds viruses for this purpose and is currently testing them in patients with muscular dystrophy. Some scientists think gene therapy may one day cure various genetic diseases such as cancer and addiction.

Image by Jude Samulski.

and from others we see every day. We talked about the kind of story we were writing, and people brought us the photographs—pulled them out of picture frames and albums, places of honor in their homes.

Not everyone told us a story, but some did. One woman described how cancer grabbed her big, strapping father by the arm and then took the rest. We heard about people who lingered and suffered; we heard about people consumed in a matter of days. We heard about addictions to alcohol, cigarettes. And we thought about how our nation has spent many billions of dollars searching for treatments and cures, but cancer and addiction still invade every family, touch every life. All of us will die of something. Let it be anything other than this.

Let’s have a deadline. Next week would be fine, but that’s dreaming. Let’s look a little farther out, to the year 2050. I won’t be around, but my kids will, and many of your children will be, and they’ll be approaching the stages of life when the odds are no longer in their favor. For their sake, time’s up.

We don’t mean to sound ungrateful. Medical science is a marvelous thing. Over the two decades after I finished high school, my expected life span increased by about three years, and all I had to do was pay my taxes. I may live to play catch with my grandchildren. And, according to the National Science Foundation, improvements in health, as measured by the economic value of added longevity, are at least 50 times what we spend on research, and eliminating cancer would be worth roughly $47 trillion.

But no one who lent us a photograph talked about the economics. They just don’t want their family, or anyone else’s family, to live under threat from a nasty, insidious disease. So we have put some of our top scientists on the spot. We asked them to imagine their science in the year 2050. Tell us, please, that you’ll have this thing solved. The question really wasn’t fair, but they understood. They have families, too.

—The Editor

contents Fall 2006

overview 2

A drug for sleeping sickness, how to feed a creaky knee, liquid coal for cars, a DNA test pushes the envelope, and biofuel for Thailand.

cover story Cancer and Addiction in 2050 5

Families dread the thought of these diseases.

So this kind of research is personal.

by Mark Derewicz

features Tuned In 11

What is your teenager’s “sexual media diet score”?

by Angela Spivey

Will it Ever be Safe to Go Home? 14

Rebuilding Sudan will take more than a peace accord.

by Colie Hoffman

A Deadly Dread of Food 17 Anorexia isn’t a matter of choice.

by Margarite Nathe

Short-circuiting Schizophrenia 21 How can we make patients whole again?

by Mark Derewicz

Water, Water, Everywhere 24

A simple clay filter saves lives in Cambodia.

by Molly Davis

A Culture Shaped by Faith 26 Hoodoo, church, and spirituality in African American fiction.

by Margarite Nathe

end­­eavors Fall 2006 • Volume XXIII, Number 1 Endeavors engages its readers in the intellectual life of the University of North Carolina at Chapel Hill by conveying the excitement of creativity, discovery, and the rigors and risks of the quest for new knowledge.

Endeavors is published three times a year by the Office of the Vice Chancellor for Research and Economic Development at the University of North Carolina at Chapel Hill.

Readers’ comments, requests for permission to reprint material, and requests for extra copies should be sent to: Endeavors Office of Information and Communications CB 4106, 307 Bynum Hall University of North Carolina at Chapel Hill Chapel Hill, NC 27599-4106 phone: (919) 962-6136 e-mail: endeavors@unc.edu James Moeser, Chancellor Bernadette Gray-Little, Provost and Executive Vice Chancellor Tony Waldrop, Vice Chancellor, Research and Economic Development Editor: Neil Caudle, Associate Vice Chancellor, Research and Economic Development Associate Editor: Jason Smith Writers: Molly Davis, Mark Derewicz, Colie Hoffman, Danielle Jacobs, Jan McColm, Margarite Nathe, and Jason Smith Design: Neil Caudle and Jason Smith Production and online design: Jason Smith

http://research.unc.edu/endeavors/

The Passion behind the Business 28 Launching ventures with a conscience.

by Mark Derewicz

in print 30

A first with no end, and Jefferson versus Washington.

©2006 by the University of North Carolina at Chapel Hill in

endview 32 Love through the lens.

by Jason Smith

the United States. All rights reserved. No part of this publication may be reproduced without the consent of the University of North Carolina at Chapel Hill. Use of trade names implies no endorsement by UNC-Chapel Hill.

overview The sleep without rest

Tsetse flies carry a parasite that causes African sleeping sickness. New drugs may help treat the disease.

Copyright Dennis Kunkel Microscopy, Inc.

T

he blood-sucking tsetse fly lives in sub-Saharan Africa and can carry a rather nasty parasite called a trypanosome. If a tsetse fly bites you, millions of these tiny parasites can flow from the fly to you. The parasites multiply and eventually enter your nerves and brain, keeping you up all night and drowsy all day. The diagnosis: African sleeping sickness. The prognosis without treatment: coma and death.

Around sixty million people in sub-Saharan Africa live in areas where African sleeping sickness is endemic. According to the

Centers for Disease Control, around half a million people are infected. Yet the disease remains one of the most under-funded and under-researched. Richard Tidwell, professor of pathology and laboratory medicine, is changing that.

Tidwell has been researching parasitic diseases for twenty years. In 2001, his group received a grant from the Bill and Melinda Gates Foundation to discover new drugs for sleeping sickness and to take those drugs through early clinical trials. The success of this research led to one drug, pafuramidine

maleate, which has many advantages over previous treatments. Current drugs necessitate multiple injections or intravenous infusion, Tidwell says, and because of side effects must be carefully monitored during administration. “Pafuramidine is the first oral drug ever for African sleeping sickness,” he says, and the drug appears to be much less toxic than current drugs.

But pafuramidine does have one drawback—it’s only effective against the first stage of the disease.

The first stage, when parasites are still

Creaky joints? Go nuts.

other joints, but we need to verify these preliminary results.

“The next step will be in the lab to see how selenium affects cartilage. It might act as a protective antioxidant. Later, we’ll see whether selenium supplementation reduces pain or other symptoms.”

People with a varied diet should already have enough selenium in their bodies, Jordan says, but nearly one million North Carolinians and twenty-one million Americans have osteoarthritis. Foods such as seafood, red meat, Brazil nuts, grains, chicken, eggs, and garlic contain selenium, which is also found in some vitamin E supplements and vegetables grown in soil rich in the mineral.

Jordan’s research team became interested

in selenium after learning that people who live in selenium-depleted areas of China are more susceptible to Kashin-Beck disease, which causes joint problems early in life. Scientists also suspect that malnourishment is to blame for the prevalence of osteoarthritis in developing countries.

—Mark Derewicz Joanne Jordan is associate professor of medicine and orthopaedics, adjunct associate professor of epidemiology, and associate director of the Thurston Arthritis Research Center.

T

he older we get, the more our joints creak. Carolina researchers may have found a new reason.

Joanne Jordan says that some people with knee osteoarthritis—a chronic deterioration of joint cartilage that makes walking painful—often have low levels of the mineral selenium.

“We found that when we divided patients into three groups, those with the highest selenium levels faced 40 percent lower odds of knee osteoarthritis than those in the lowest selenium group,” she says. “This suggests that we might be able to prevent or delay osteoarthritis of the knees and possibly 2 endeavors

Suzannah Skelton

in the blood, is usually without symptoms, and can last years as the parasites multiply.

Symptoms, when they do appear, can include headaches, fever, and joint pain, but are easily confused with other diseases common to the area. The second stage, when parasites cross into the nervous system and brain, causes confusion, sensory hallucinations, and poor coordination. The coma, which gives the disease its name, is fatal without treatment.

For pafuramidine to be effective, “patients must have an invasive test to be sure they haven’t progressed to the late-stage disease,” Tidwell says—which is just one of the very tricky issues of conducting clinical trials in Africa. “African sleeping sickness is only in rural settings; it’s not widespread,” he explains. It can be confined to one village and the village two miles down the road may be unaffected. “We have to do a lot of testing and bring in a lot of patients,” Tidwell says. And this approach does have one advantage: it is ramping up the surveillance of the disease.

B

ack in the 1960s, African sleeping sickness had practically disappeared. Mobile teams throughout the region were monitoring it and treating the early stages with drugs. Insecticides helped keep the fly population down. But as increasing numbers of African countries gained independence, money wasn’t available for monitoring and treatment. Tsetse flies became resistant to insecticide, and their parasites became resistant to drugs.

Consequently, Africa is now in the midst of another epidemic.

Tidwell has just received another grant from the Bill and Melinda Gates Foundation to take pafuramidine through more clinical trials in Africa and to complete the regulatory requirements to get the drug registered.

“This is the first real effort being made in this disease,” Tidwell says, and he is optimistic for more than one reason. “Pafuramidine can have a huge impact because it’s an oral drug, easily administered, and it’s a lot less toxic. And if you use pafuramidine correctly you have the potential to control or perhaps even eliminate the disease.” Tidwell and his team are also working on new approaches to treating the late stage, with encouraging preliminary results. “And that would be the real coup,” he says, “to treat both stages with a single medication.”

—Jan McColm

Coal gets a second wind

W

ith global oil supplies stretched to the limit, will the world embrace coal liquefaction? Carolina chemist Maurice Brookhart and Rutgers University chemist Alan Goldman think it’s possible.

The original Fischer-Tropsch coal liquefaction system, developed in 1920s Germany, makes hydrocarbon compounds called alkanes out of coal.

Some of the alkanes have between ten and nineteen carbon atoms per molecule and can be used as cleaner-burning diesel fuel. Other molecules contain one to three carbon atoms (methane, ethane, propane) and can be used as gas fuel. But molecules with four to nine carbon atoms are by-products with little value. Compared to oil refining, the process had been thought to be inefficient, expensive, and environmentally hazardous. But when oil prices soared past fifty dollars a barrel, the Fischer-Tropsch system was put back on the table. And now, Brookhart and Goldman have created a way—a dual catalyst system—to convert those “leftover” alkanes into diesel fuels, making the process more efficient.

“One catalyst compound removes hydrogen, converting alkanes into new Dallas Powell

A better method of liquefying coal may yield cleaner diesel fuel and gasoline.

materials—olefins—that contain carbon-carbon double bonds,” Brookhart says. “And that makes the new material more reactive.” The second catalyst rearranges carbon-carbon bonds. Then, he says, the first catalyst returns hydrogen atoms to the rearranged compounds, which creates two new alkanes with different chain lengths. The longer chains are fuel.

The system still has some big production hurdles. For instance, the process slows and then stops working as one of the catalysts decays, probably because of the reaction’s high heat, Brookhart says. The chemists are trying to improve the system, and, if they succeed, the process could also make fuel from reacting short hydrocarbon chains left over from petroleum refining.

The research has drawn a lot of press attention because coal is abundant in the United States and China. Coal producers in states such as Pennsylvania and Minnesota are already investing in coal liquefaction.

The EPA says that coal diesel burns cleaner than regular diesel or gasoline, but carbon dioxide and other greenhouse gases are still by-products of fuel production and use. Other scientists are developing carbon sequestration methods to help with that.

—Mark Derewicz Brookhart and Goldman receive funding from the National Science Foundation. endeavors 3

A test for cystic fibrosis

E

ddie Vedder wrote the lyrics to “Yellow Ledbetter” on his used cocktail napkin. Emmett “Doc” Brown conceived of the flux capacitor on a scrap of paper after hitting his head on a toilet bowl. Holden Thorp, Kenan professor and chair of the UNC chemistry department, scribbled the foundation of electrochemical DNA diagnostics on the back of an envelope.

The transfer of an electron between an electron donor and an electron acceptor creates electricity. Thirteen years ago, Thorp, along with his first postdoctoral student, Dean Johnston, sought to take advantage of this fact to develop an electrochemical technique to measure the electricity conducted by nucleic acids such as DNA. Johnston soon found that guanine, one of the four repeating molecules that comprise DNA, was a good electron donor by “basically burning the hell out of a piece of DNA and just getting tons of electricity,” as Thorp puts it. Thorp was doubtful at first, but further investigations allayed his skepticism, and he hastily jotted down a scheme for electrochemical DNA detection on the first piece of scrap paper he could find.

Over time, the scribble developed into a tangible target—DNA diagnostics, the testing of DNA for genetic mutations and their related diseases. Thorp realized that it

would be much cheaper to build and operate an electrochemical detector than one for fluorescence, the most prevalent diagnostic method employed today. Fluorescence, which works by measuring the light emission of fluorescently tagged genes, relies on the use of expensive microscopes and optical lasers, and the data have to be further interpreted and resolved to yield any useful information. Thorp’s patented electrochemical technique, on the other hand, is extremely inexpensive and requires the use of less biological sample. The electrical readout is more direct and is easily quantifiable on an instrument called a potentiostat, which, according to Thorp, can be made cheaply in, well, Doc Brown’s basement.

Osmetech, a California-based health-care firm, is the first company to take advantage of Thorp’s electrochemical technique, which currently forms the basis of their genetic testing for carriers of recessive cystic fibrosis (CF) genes. It works by simply hybridizing— or attaching—an amplified DNA sample to a cheap metal electrode, and comparing the electricity released to that of known CF gene mutations.

Various mutations of the CF gene are responsible for causing the disease. Fluorescence technology can only sense one mutation at a time. Thorp’s electrochemical technique allows for an array of DNA, which

Paul Latham

Biofuel for Thailand Andy Shapiro, a senior environmental health science major, researched how to transform water heaters into biodiesel reactors—contraptions that can make car fuel out of vegetable oil. Shapiro traveled to Thailand this summer as one of four UNC Entrepreneurial Public Service Fellows and helped build a biodiesel reactor for farmers near the town of Krabi.

In 2005, Shapiro researched the native jatropha plant’s potential as a good source of inedible oil. Tens of thousands of jatropha saplings were given to local farmers, and this year Shapiro helped them make fuel from the seeds.

4 endeavors

Seeds of Jatropha curcas yield biofuel.

Researchers can attach a patient’s DNA to the electrodes on this chip to test for genetic mutations implicated in diseases.

scientists can test for several mutations simultaneously.

But Thorp believes that electrochemical DNA detection will be most promising in the realm of personalized medicine. For instance, the genetic makeup of cytochrome P450 (CP450), the enzyme responsible for the metabolism of many medications, differs from one individual to another. Since drug efficacy, potency, and toxicity are inherently dependent on this genetic profile, electrochemical CP450 prescreening could make it safer and cheaper to qualify good drug candidates. Thorp uses his own positive reaction to the asthma drug Singulair to explain: “If you had a genetic test to find the people like me who could take Singulair and have it work for them, then when you did your trial you’d only try it out on those folks. You would not only be using less drug when you got it to market, but you’d have the chance of getting drugs that only work on specific subsets of people to market much more easily. You’d have more successful drugs, and safer ways to give them to people.”

You might also one day test your DNA at home. The promise of anonymity and privacy, without the knowledge or involvement of a health insurance company or hospital, makes home diagnostics attractive for testing for genetic diseases. “This is the first step that will make it cheaper to get genetic information,” Thorp says. The next step is to overcome the “minor problem of getting DNA out of the cell and amplifying them.” It’s hard to figure out how you would do that at home, he says. “You never know.

It’s possible.”

— Danielle Jacobs Danielle Jacobs is a doctoral student studying organic chemistry at Carolina.

Cures from gene therapy?

Jude Samulski’s lab engineers viruses that carry therapeutic genes to cells with damaged or mutated genes. As they enter a cell, these viruses (shown here in green) hijack proteins (red) to help them deliver their therapeutic cargo to the nucleus (blue). Image by Jude Samulski.

CANCER AND ADDICTION IN THE YEAR 2050

W

hen I was eleven I watched a cancer patient die. Doctors thought that they could remove a tumor from his throat, but surgery revealed that the tumor had metastasized. After a few rounds of radiation and chemotherapy—just three months after I saw this man sipping a beer in his favorite chair—he was utterly defeated and hardly recognizable lying on his deathbed.

Soon after, one of this man’s sons—a heavy drinker like his father—was cited for drunken driving for the second time. His brother, fed up, pinned him against a wall and said, “You’re acting like a bum, and your boozing is gonna ruin your life!” It wasn’t pretty, and could’ve made things worse, but it worked. The drinking stopped. And it never started again.

Many families share similar or worse stories. And each family hopes for a cure, even though cancer and addiction have been entrenched in our society for centuries. Is this hope realistic? In 2050, when I might be sitting in my favorite chair, will we be rid of these scourges?

RID OF THEM AT LAST?

BY MARK DEREWICZ

State of the union In 2000, cancer killed more Americans than anything except heart disease, leaping past six other leading causes of death in less than one hundred years. And in 2005 it passed heart disease for the first time as the leading killer of Americans under eighty-five. Back in 1900 cancer accounted for less than 4 percent of all deaths. Today, it’s nearly 25 percent.

The percentage jumped in part because more cancers are accurately diagnosed today than in 1900. Our Western diet and new carcinogens in the environment account for some of the rise. Perhaps most importantly, treatments and prevention methods for other diseases improved, allowing people to live longer but succumb to cancer later. According to the American Cancer Society, mortality rates for other major killers plummeted between 1970 and 2002—stroke by 63 percent; heart disease by 52 percent; and accidents by 41 percent. During the same span, cancer mortality rates decreased by less than 3 percent. endeavors 5

Still, Shelton Earp, director of Carolina’s Lineberger Comprehensive Cancer Center, says two-thirds of the 1.5 million Americans annually diagnosed with cancer are cured, usually because the disease is caught early.

But some cancers evolve quietly, without detection. They metastasize—break free of their capsules, as Earp says, and spread.

“Those are the tumors we can’t treat very well.”

But things are changing, he says, because of better use of early detection and personalized medicines that supplement radiation, surgery, and existing chemotherapy drugs.

Earp points to Herceptin, a drug now used to treat the 20 percent of breast cancer patients who over-express a molecule called HER2.

“This is one of the first examples where understanding the biology of a particular cancer subtype resulted in a targeted drug that has become the standard of care,” Earp says. Herceptin works best in concert with chemotherapy, and such combinations, he

says, will become more common during the next two decades.

“The 2050 dream is dropping the chemo part and just treating tumors with targeted agents—maybe multiple ones—which would either cure the cancer or, more likely in some instances, suppress it,” Earp says. “It’s possible that we will turn some forms of cancer into chronic diseases, so that you might have cancer but it would be like having diabetes.”

One reason for such hope is genetic analysis. Geneticist Chuck Perou pinpointed five biologically distinct breast tumors that come from at least two cell types—basal-like and luminal epithelial cells. This knowledge— gained by using DNA microarrays that allow scientists to view thousands of genes simultaneously—could unveil more targets for drugs. It has already helped explain one reason why breast cancer kills more African American women than white women (see “Race as a Factor in Breast Cancer,” below).

Looking ahead, Perou says, “I think we’ll get ten standard treatments for a disease like breast cancer in the next ten years, whereas five or ten years ago we only had one or two.”

Making it personal Earp says that by 2050 genetic analysis will help family doctors, not just geneticists, predict which people will inherit genetic mutations or predispositions to cancer.

Someone with a predisposition might never get cancer unless a carcinogen triggers the disease. Genetic research, he says, might also show how individual patients will react to chemotherapy or medication so that doses can be better regulated.

This is one reason why Earp, Perou, and geneticist Jim Evans are excited about the Thousand Dollar Genome project, an NIHfunded effort to create technology so that sequencing a patient’s entire genome costs a thousand dollars instead of a million.

RACE AS A FACTOR IN BREAST CANCER

I

f you are a young African American woman who develops breast cancer,” says medical oncologist Lisa Carey, “you are more than twice as likely to develop one of the more aggressive subtypes—the basal-like subtype. And you’re less likely to develop the least aggressive subtype.”

In June, Carey and her colleagues found that premenopausal black women who develop breast cancer are more likely to have this basal-like subtype, which is estrogen receptor and human epidermal growth factor receptor-2 (HER2) negative. Because the only targeted treatments for breast cancer target the estrogen and HER2 pathways, chemotherapy is the only option for these patients.

Scientists don’t yet know why younger black women are more likely to develop deadlier breast cancers, Carey says.

Carey is now involved in a clinical trial that “looks at a targeted 6 endeavors

therapy for the basal-like subtype,” she says. At the end of the trial, which will close in the next year or two, the researchers may be a step closer to developing more targeted breast cancer treatments.

“My grandmother was diagnosed with breast cancer in the 1960s,” Carey says. “At that time, sixty percent of the women who developed breast cancer died from it. Now it’s about twenty percent.

There’s not one thing that we’ve done to help women with breast cancer that didn’t come out of a clinical trial.”

—Margarite Nathe Lisa Carey, lead author of the study, is medical director of the UNC Breast Center and a Lineberger clinical faculty member. Study co-authors from Carolina are Charles Perou, Robert Millikan, Chad Livasy, Lynn Dressler, David Cowan, H. Shelton Earp, Kathleen Conway, and Melissa Troester.

As a clinical geneticist, Evans helps determine if current cancer patients are at risk of recurrence due to inheritance, having an unusual cancer, or being diagnosed at a young age. He also consults with patients on prevention options, some of which—mastectomy and preventive drug therapy—will probably seem draconian in fifty years. But right now they are real options for people at high genetic risk. People with some other diseases, such as Alzheimer’s disease, have no preventive options.

Evans hopes that by 2050 treatments and prevention methods for Alzheimer’s and other diseases catch up with genetic testing.

We might even develop different ways to cure genetic disorders.

Between hope and reality Gene therapy could be one such way. In simplest terms, gene therapy is replacing bad genes with good ones to cure a disease.

In the 1990s, scientists were excited, the

Chuck Perou

A UNC study found that basal-like tumors, the deadliest breast tumor subtype, occur more often in African American women. Researchers say that this helps explain why African American women under fifty are 77 percent more likely to die from the disease than white women of the same age.

media grasped the basic idea immediately, and people expected quick results. But some early clinical trials didn’t work. In 1999, a patient with liver disease died after receiving gene therapy. That triggered a backlash and stigmatized the procedure.

Even some successful trials drew criticism, says Jude Samulski, director of the UNC Gene Therapy Center. Gene therapy cured nine of eleven patients with severe combined immunodeficiency disease—or bubble boy disease—but two patients got leukemia because the therapy somehow turned on the cancer-causing gene LMO2. Chemotherapy helped those two patients, who are now in remission. (In another study, twenty-four immunodeficiency disease patients were cured, so far without side effects.)

Conversely, other drug trials have far worse results but are often deemed successful. Gene therapy has a stigma, Samulski says, in part because people think scientists are messing with our basic building blocks.

We expected too much too soon, he says.

“When the human genome was sequenced, everybody thought it would be like a recipe book. But like most things, there’s more mystery to it.”

Gene therapy, he says, requires sophisticated understanding of several things, including molecular biology, gene regulation, and virology—Samulski’s specialty. He takes a virus, strips out the infectious parts, and builds the virus back up so it can act like a shuttle delivering cargo—normal genes.

In one trial, he injected a shuttle virus into a mouse with muscular dystrophy, and now the mouse can run on a treadmill. After many steps, scientists are currently making sure that the treatment is safe for humans.

If that checks out, then the therapy will be tested as a cure.

So will gene therapy cure some forms of cancer by 2050?

“Absolutely,” Samulski says. “No doubt about it. We’re not even in the infancy of this, we’re in the womb, but that’s an exciting and important place to be.”

It’s exciting, but complex and time-consuming, and few scientists understand this better than pathologist Oliver Smithies.

For fifty years, he’s been unveiling genetic mysteries in lab animals. His technique, gene targeting, allows scientists to replace normal genes with mutated ones in the embryonic stem cells of female mice. The mutated stem cells are returned to female mice, whose offspring then develop a particular disease. The technique led to the creation of thousands of varieties of genetically engineered mouse models, each with a particular disease biology that scientists can study and use to test potential cures. This method is quickening research at UNC and around the world.

Smithies says that by 2050 some diseases that originate from a single inherited defect will likely be cured. “But these single-defect diseases are uncommon,” he says. “The common inherited problems, like high blood pressure, are very complex and we don’t know all the factors. There are many little things in different combinations that make it difficult to sort out.”

It will take years—a lifetime in some cases—to get a handle on such genetic problems. Huge breakthroughs are possible, Smithies says, but most of the time progress comes incrementally.

Carolina researchers are getting close to creating cancer mouse-models that mimic human tumors, Earp says, and these will dramatically speed the testing of new targeted therapies and novel means of early detection.

“This will be very important, for example, in lung cancer, where we don’t have curative therapy, and we desperately need better means of early detection,” he says. endeavors 7

Nanotechnology, Earp points out, also offers hope for new treatments and detection methods. Carolina researchers are exploring several options. For instance, chemist Joseph DeSimone is using techniques from the electronics industry to develop nanoparticles that carry conventional cancer-killing agents. The surfaces of these particles are laced with peptides or nucleic acid aptamers designed to seek out only tumor blood vessels and tumor cell receptors. This way, normal cells won’t be harmed as they are with chemotherapy.

Also, chemist Wenbin Lin is developing magnetized nanoparticles that enhance brain MRIs so doctors can see a patient’s brain tumor more definitively, and also determine more quickly whether therapy is working.

And since the nanoparticles are magnetic, it might be possible to use a magnetic field outside the body to direct anti-cancer nanoparticles into tumors. For this, Lin is working with physicist Richard Superfine, who created the magnetic field technology, and is using one of Terry Van Dyke’s engineered mice that develop brain cancer.

The unknowns New and better treatments will come, scientists say, but Earp points out that “there’s always the law of unintended consequences.”

Sometimes anti-cancer drugs cause other serious problems.

Evans says that there are intricate interactions among environment, genes, behavior, medicine, and chance that we don’t understand at all.

“Genetics is very important,” he says, “but it’s not the whole ball game.”

For instance, American women—who are more susceptible to breast cancer than women from any other nation—are ten times more likely to develop breast cancer 8 endeavors

than Japanese women. But as soon as Japanese women come to the United States, their risk increases substantially, and the next generation of Japanese American women face almost the same risk as American women. Is it diet, pesticides, food additives, pollution?

All of the above? Earp says, “I think it’s the food. There’s a change in human physiology that results from our Western lifestyle and diet. It’s unlikely to be growth hormone in milk or pesticides. Every time we’ve looked at that, the link to cancer just hasn’t been found.”

It’s tough to keep track of the many epidemiological studies about one food causing this or helping that, especially when various foods affect people differently. (See Endeavors, Spring 2005, “Ten Simple Rules.”)

Some health behavior specialists suggest that researchers should come up with better ways to study diet. In a perfect world, researchers could make sure that participants in epidemiological studies maintain their eating habits for much longer periods of time so that the effects of food, vitamins, or minerals can be better understood. Also, nutrition might play a critical role during certain times of life. What if our diets and environment—years before we have kids—are the underlying sources of problems that affect our children way down the line?

The addiction dilemma There’s still much that we don’t know about cancer, even though it’s been classified as a disease for millennia. On the other hand, there is still disagreement in the general public about whether the age-old problem of drug addiction is a disease or a personal weakness. And although addiction is a huge public health problem, few treatments have broken the cycle of drug use, abstinence, and repeated relapse. People battling drug

dependency still face a stigma, says psychologist Linda Dykstra, even though research has clearly revealed that addiction is a disease of the brain, involving specific brain regions and neurotransmitter systems.

Thanks to these findings, researchers are developing new treatments for drug dependence, especially for opiate dependence— the most recent one being buprenorphine.

Dykstra’s lab was one of the first to reveal that buprenorphine has many of the same pharmacological properties as drugs such as heroin, and therefore can suppress heroin withdrawal in a similar way to methadone.

Buprenorphine, though, doesn’t produce as many unwanted effects as methadone. And a doctor can prescribe it, so patients can avoid the stigma of visiting a methadone clinic. Scientists are now trying to develop a sustained-release form of buprenorphine that would require only a single injection once a month; this is a good example of an important incremental improvement for addiction treatment. A catch-all cure for addiction is unlikely, Dykstra says, even as genetic research unfolds swiftly.

“It’s not clear how new knowledge about genetics or individual susceptibility to drug addiction will advance the treatment of drug dependence,” Dykstra says. “But I don’t think addiction will go away. Simply popping a pill to cure addiction flies in the face of all we know about this disease right now. In time, we’ll certainly have better treatments, and it’s likely that many of these will lead to better compliance. Medications will have fewer side effects; they will be delivered in more convenient forms, perhaps even automatically released into the body in response to implanted devices that monitor brain circuits. Treatments will be less likely to disrupt work patterns and treatment regimens will be easier to follow.”

Dykstra says that behavioral support systems will likely always be a necessary component of treatment. “Addiction research is a relatively young field. It’s likely that recent advances in biomedical and behavioral sciences will provide knowledge needed to curtail the devastating cycle of relapse that so many drug-dependent people face. It’s also likely that we will more readily view drug dependence as a treatable disease.

“Current treatments for diabetes or even heart disease focus on managing the problem, not necessarily curing the disease,” she says. “Perhaps the same criteria should be applied to drug dependence.”

Society has already altered the way it views some forms of addiction. When Dykstra

taught a course on drugs and human behavior, students watched scenes from old movies in which most characters had a drink in one hand and a cigarette in the other.

“The students were struck by that,” she says. “We’ve changed the way we view smoking in our culture.”

Alcohol’s grip on the brain Fulton Crews, director of Carolina’s Bowles Center for Alcohol Studies, says that a similar change could happen with alcohol, to which 7 to 15 percent of Americans will be addicted sometime in their lives. “There’s a huge industry dedicated to teaching people that they are more attractive and interesting when holding an alcoholic beverage.”

That’s how the cigarette industry operated until health organizations attacked tobacco companies for basically selling nicotine addiction and hiding evidence that proved it. Most drinkers, though, are not alcoholics.

So there’s not a direct parallel.

But Crews says that kids in their early teens who start drinking regularly have a 50 percent chance of becoming alcoholics, compared to 7 percent if they start at twentyone. The developing adolescent brain of a regular drinker is learning to depend on alcohol, he says.

The alcohol industry won’t block efforts to curb underage drinking, Crews says, and parents will have to stop thinking of drinking as a right of passage. His center developed

MEDICAL MARVELS

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edical technologies that we take for granted today, such as CAT scans and laser surgery, weren’t dreamed of in 1950. Can we deduce what the year 2050 might hold? Dan Reed, director of the Renaissance Computing Institute, offers a look at how technology could revolutionize health care during the next fifty years.

• Sensors—some embedded and some worn like jewelry or a watch—will monitor everything from heart rate to blood-sugar level to respiration. They will allow doctors to diagnose and treat patients remotely. Other embedded devices will respond to the sensors with continuous therapies, such as incremental insulin for a diabetic.

• Artificial arms, legs, and joints will be tailored to an individual’s needs with the aid of computer models that will analyze a person’s gait to create an artificial limb with a more natural feel. Sensors will help create “smart” legs able to mimic the natural limb and respond to changing terrain.

• High-resolution, non-invasive brain imaging will continue to improve, and should give scientists new insights into how memories are stored and recalled, which in turn could advance the development of true artificial intelligence (AI). Although computers will soon surpass the human brain in terms of raw computing power, AI has yet to match the reasoning and recall power of the brain.

• Many medical records are already electronic. In the future, each person’s genetic profile, medical history, lifestyle, and environmental history could be placed on a chip and embedded just under the skin.

Emergency medical teams could instantly access immunization records and information about allergies and chronic conditions to avoid fatal mistakes. Of course, the same technology means that insurance companies might know about a person’s susceptibility to certain types of cancer—information most of us would prefer to keep private. Privacy and security, Reed says, will be the key issues as new medical technologies emerge.

• A better understanding of the genetic causes of disease will lead to better treatments and cures. Will it also allow people to choose their baby’s eye color, math or musical aptitude, or athletic prowess?

What are the social implications of genetic manipulation? What if only the rich can afford it?

The hope, Reed says, is for truly personalized medicine—the ability to give treatments that fit an individual’s genetic makeup and personal preferences—without treading too heavily on privacy or fundamental ethics. And for this, he says, an informed debate should also be in our future.

—Mark Derewicz endeavors 9

an educational kit to help science teachers show students the effects of alcohol on the brain.

Beyond prevention—and treatment programs such as Alcoholics Anonymous and cognitive behavior therapy—Crews says that there will be more drug therapies for addiction by 2050.

“There’s a hypothesis that those who respond well to one alcoholism medication called naltrexone actually have a genetic factor that makes them responsive,” Crews says. “If that’s true, then we’ll be able to genotype people and determine who should get it, and we’ll then have a robustly respon-

sive group.” More people will use the drug, and pharmaceutical companies will produce more and better drugs, which is what happened with anti-depressants.

“If we can block that early progression of alcoholism in teens and improve therapy, we’ll have a huge impact by 2050.”

Maybe there won’t be catch-all cures for cancer and addiction by 2050, but what seems most likely is that fewer eleven-yearolds will watch seventy-year-olds succumb to cancer in three months, and there will be more ways to treat both diseases.

The man who quit drinking back in 1982 is thankful for the progress that science has

already made. He took care of his widowed mother for twenty-two years until the very day she died. Then he got prostate cancer.

Doctors found it early, and today he’s fine.

He enjoys life, especially when he gets to bicker with his brother on just about every topic, except drinking. e Linda Dykstra, Jim Evans, and Oliver Smithies will speak at Carolina’s “What’s The Big Idea?” lecture series entitled The Human Being in 2050. The series features a lecture every Thursday evening in October. For more information, go to http://fridaycenter.unc. edu/pdep/bigidea/.

THE HEARTBURN SCARE IT MAY BE OUR SIZE, NOT OUR ACIDS THAT ARE INCREASING THE RISK

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f you get heartburn regularly, is cancer of the esophagus next?

Some drug advertisements imply as much. Many heartburn sufferers believe so. Even insurance companies have taken notice.

But epidemiologist Nicholas Shaheen says the correlation is not so simple.

Heartburn is the most common symptom of acid reflux disease—a weakening of the lower esophageal valve, which lets stomach acid flow into the esophagus. Eating spicy, acidic, and fatty foods can aggravate the condition, as can too much caffeine, tobacco, overeating, and lying down after a meal. About eightyseven million Americans experience reflux weekly. In 2005, about eight thousand people were diagnosed with esophageal adenocarcinoma—one of two rare but deadly esophageal cancers.

These numbers suggest that only .009 percent of weekly reflux sufferers will get adenocarcinoma.

Yet Shaheen says that many doctors and patients overuse endoscopy—insertion of a camera down the throat—because they think it will protect people from cancer. Endoscopies are safe, Shaheen says, but they are expensive, and there’s a small risk of complications. There’s also no strong evidence that they save lives, he says.

“We can’t scope everyone with reflux,” he says. “That’s nearly half the adult population.”

Although the risk of getting cancer is low, one reason acid reflux has gained attention among gastroenterologists is that the number of adenocarcinoma cases has increased 300 to 500 percent over the past thirty to forty years.

So Shaheen’s goal is to educate patients while researching the upward trend, which may be linked to the increase in obesity.

In a large research study, he and his team found that people who carry weight in the abdomen get precancerous changes of the esophagus more often than people who carry weight in their hips 10 endeavors

and buttocks. Men tend to carry weight in their abdominal area, and men are eight times more likely to get esophageal cancer than women. Weight-related pressure on the diaphragm may push acid through the lower esophageal valve. But people who carry weight in the abdomen also produce more insulin and insulin-like growth factor, which have been associated with other types of cancer in overweight people. Shaheen also found other demographic predictors: overweight white men over sixty, for example, face the greatest risk.

But even if pat ients develop Barrett’s esophag us—a precancerous condition where typical esophagus cells change into intestinal-type cells—the chances of getting cancer are still slim.

Shaheen found that only one-half of 1 percent of Barrett’s patients develop cancer each year. When surveyed, his own patients—whom Shaheen tries to keep well-informed—thought that 8 percent of Barrett’s patients get cancer. Patients at another hospital thought the risk was 24 percent.

Barrett’s esophagus, Shaheen says, has not been demonstrated to reduce life expectancy. But when he found the cellular change in an otherwise healthy forty-three-year-old man, the patient’s insurance rate more than doubled. Shaheen wrote letters to twenty insurance companies as part of a study. Only one agreed to change its policy.

“A lot of people have become very alarmist in the way they emphasize the esophageal cancer risk,” Shaheen says. “In reality, it’s important to know some of the risk factors, and we need to follow these worrisome trends, but it’s just not all that common.

So the main reason to get treated for your heartburn is not because you are going to die of cancer; it’s because heartburn really affects quality of life and we can make it better.”

—Mark Derewicz Nicholas Shaheen is associate professor of medicine and epidemiology, and the director of the Center for Esophageal Diseases & Swallowing.

Steve Exum

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tuned in The TV is on. What are your kids learning about sex? By Angela Spivey

id your parents actually sit you down and have “the talk?” Did your school teach sex ed?

Or was it your best friend? Your older brother? Some paperback that got passed around in seventh grade?

These are the kinds of questions that Jane Brown isn’t afraid to ask kids. And she wants parents to get more comfortable asking them too.

Schools certainly aren’t talking about it, especially in North Carolina, where only a handful of counties offer anything but abstinence-only sex education.

Brown, professor of journalism and mass communication, led a team of researchers who visited the homes of 1,017 teenagers in three North Carolina counties to ask them about their sexual attitudes and behaviors.

The team asked parents for permission first, and let them read the sexual health questionnaire that their child would complete confidentially, using a laptop computer.

“We found that parents were actually glad for us to visit,” Brown says. “Very few refused.

“And some parents even said, ‘Thank goodness somebody’s talking with our teen about sex!’” Then Brown’s big laugh erupts. It does that often. Wearing jeans on a Wednesday in May, when Carolina is in a post-graduation lull, Brown, who has a fifteen-year-old daughter of her own, seems like someone a kid wouldn’t mind talking to about this stuff.

Brown worries that if both parents and schools stay silent, kids will turn to whatever source of information they can find. With TVs in kids’ bedrooms and iPods in their pockets, the media become an always-on friend. Or, as Brown calls it, a kind of “sexual super peer.”

What’s the problem with that? Results of Brown and colleagues’ five-year study suggest that the media don’t make very good sex educators.

The researchers surveyed kids twelve to fourteen years old about what they watch, listen to, and read. The team conducted the sexual-health and attitudes survey with a endeavors 11

subset of those kids, and then interviewed them again two years later.

The adolescents who chose media with a lot of sexual content when they were ages twelve to fourteen were two times more likely than the other kids to have had sex by age sixteen.

While the researchers can’t go so far as to say that the sexy media caused the adolescents to have sex earlier, their study is one of the first to establish a relationship between sexual content in the media and adolescents’ behavior. “It’s a very strong association,” Brown says.

What in the world were those kids watching?

In the early stages of the study, the researchers really made an effort to answer that question.

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irst they did focus groups in North Carolina schools, asking adolescents which TV shows, movies, and magazines they watched or read most often.

That turned up a list of titles to use in the media survey. About half of those titles

never appeared on commercial ratings systems such as Billboard or Nielsen. Some TV shows, for example, weren’t popular enough overall to show up on Nielsen, but 80 percent of the African American girls in the study watched them regularly.

Then the researchers painstakingly analyzed the sexual content of all these media.

We’re talking a summer and fall of twelve graduate and undergraduate students poring over and assigning a value to every scene in seventy-one TV shows. Every non-breaking camera shot in ninety-four movies. Every photo, paragraph, and headline in thirty-two magazines. Every line of every song in sixtyseven music albums. That detailed analysis enabled the researchers to assign each child an individual “sexual media diet score.”

Kelly Ladin L’Engle oversaw the content analysis while earning her doctoral degree from Carolina’s School of Public Health.

Overall, says L’Engle, now project director of the study, the favorite media of these twelve- to fourteen-year-olds contained 12 percent sexual content.

“So that doesn’t sound so bad,” L’Engle

video games and the brain

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an the things we watch really change our behavior? A Carolina researcher has shown that heavy playing of violent video games results in an actual physical change in the brain.

Marc Sestir, a doctoral candidate in social psychology, worked with then-Carolina faculty member Bruce Bartholow (now of the University of Missouri-Columbia) to study reactions to various images among undergraduates who said they regularly played violent video games and those who said they did not. Some of the images were neutral. Others were negative but nonviolent, such as a child with an eye tumor. Others depicted violence, such as a knife being held to a woman’s throat.

The researchers measured the participants’ P300 brain waves, which occur about three-tenths of a second after someone sees an image or object. “The bigger the spike in P300 waves, the more attention your brain

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says. “But once you look at what that content actually is, you see that there are no healthy messages for kids about sexuality.”

The sexual content included innuendo, flirting, double entendre. But very little of what Brown and L’Engle call “the three Cs”—contraception, commitment, and consequences.

“Less than one half of one percent of all this content we looked at had what we might construe as sexually healthy information in it,” Brown says. “And we defined that very broadly to even include masturbation as a potentially healthy sexual behavior.

“So here we are with twelve- to fourteen-year-olds who are totally into how their bodies are changing and puberty, and there’s no information about puberty, there’s no information about contraception or STDs or protecting yourself against those,” Brown says. “There’s rarely any abstinence portrayed, or any waiting, and there’s very little love or real kind of substantial relationships shown.”

L’Engle adds, “There is a lot of talking about dating and sexual relationships in the

is paying to the image,” Sestir says. “You show a bigger spike when you perceive something as unusual or disturbing.”

The participants who played a lot of violent video games showed a smaller spike in P300 waves when they viewed the violent images. “They viewed a picture of a guy with a gun in his mouth pretty similarly to the way they viewed a lamp or a chair,” Sestir says. “They’re more numb to it. They don’t see it as being as disturbing as people who don’t play violent games do.

“Playing these video games does produce some sort of basic physiological change, but we don’t know what effects that has for the average player,” Sestir says. “The idea is not that violent video games will cause anyone to be a violent killer. But violent video game playing may enable violence to a greater degree. Which may mean nothing for most people. But we’re worried that, for a minority of people, playing these games may incline them more toward serious acts of violence.”

—Angela Spivey This study was published July 2006 in the Journal of Experimental Social Psychology.

media that could be teachable moments.

There’s an important role for the media to play that they’re not stepping into.”

The study did find some good news—parents can make a difference. Kids who said that they knew their parents disapproved of teen sex were less likely to have had sex by age sixteen.

Brown’s advice: talk to your kids early, even before adolescence. And be an “askable parent.” Let your kids know you are open to talking with them about anything.

Now the team is exploring how to tailor different messages for different kids. “You would communicate to a teen who still finds sex ‘gross and disgusting’ very differently than to a teen who is a ‘player,’ who is very into it, and having multiple sex partners,” Brown says. (See “Virgin Valedictorian or Sexual Sophisticate,” right.)

“A fundamental idea of the project is that adolescents are active in choosing what they’re seeing and using in the media,” Brown says. So teens who are choosing shows, songs, or movies with a lot of sexual content may be doing so for a reason. “Parents should be aware of what their children are looking for,” she says.

“We know very little about how you actually get parents to become more involved and do a better job of monitoring their children and teens’ media use,” L’Engle says. “So that’s a next step for this type of work.”

In Brown’s study, 68 percent of the kids had TVs in their bedrooms. “When I talk to parent groups, I say, ‘Just don’t ever put the TV in the kid’s room,’” Brown says. “‘Because then, you won’t have to try to get it out.’

“The media can also be helpful and stimulate a discussion that kids and their parents might not otherwise have,” she says.

“But you have to be watching or listening with your teenager to be able to have those conversations.” e Brown’s study was published in April 2006 in the journal Pediatrics. Other authors were professor of sociology Guang Guo and sociology doctoral student Kristin Kenneavy, both of Carolina; Carol Pardun, Director of Middle Tennessee State University’s School of Journalism; and Christine Jackson of the Pacific Institute for Research and Evaluation.

Funded by the National Institute of Child Health and Human Development.

Learn more at the Teen Media web site: http:// www.unc.edu/depts/jomc/teenmedia/.

Steve Exum

virgin valedictorian or sexual sophisticate?

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he teens who took the sexual-attitudes survey conducted by Jane Brown and Kelly Ladin L’Engle were all fourteen to sixteen years old, but their knowledge about and interest in sex varied widely. The researchers identified four “sexual self-concept” clusters that cut across racial and gender lines and that may suggest ways to tailor sexual-health messages.

Virgin valedictorians. “They pretty much couldn’t care less about sex,” L’Engle says. “They’re really into getting good grades and having good relationships with their families, and they’re pretty religious too.”

Curious conservatives. These teens also report good relationships with their parents and frequent attendance at church, but they are curious about sex. “They look for information about sex in all kinds of places. They talk with their parents, with clergy members, with their peers. And they look to media for sexual information,” L’Engle says.

Silent susceptibles. “These are kids who really want to have sex. They’re really interested, but they’re not getting information about sexuality and romantic relationships from anywhere,” L’Engle says. Like the curious conservatives, few of these kids had had sex, but because they’re not getting any information, they may be at risk of jumping into it without considering the consequences.

Sexual sophisticates. “They essentially are the players,” L’Engle says. Sixty-two percent of the teens in this group had had sexual intercourse. In the other three groups, only 8 to 27 percent of kids had had intercourse.

These analyses are under review for publication. Other authors are LaHoma Smith Romocki of North Carolina Central University and Kristin Kenneavy, a doctoral student in sociology at Carolina.

endeavors 13

This Sudanese schoolboy is a soldier on his holidays.

Will it ever be safe to go home?

For many Sudanese, the risks still outweigh the rewards. story by Colie Hoffman photos by Kavita Singh 14 endeavors

Decades of civil war—and now genocide in Darfur—have driven thousands of Sudanese people from their homes. Refugees, unsure of their safety and fearful about what the future has in store, have made do in other, less war-torn parts of Sudan and in neighboring Kenya, Uganda, and Chad. Now that a peace agreement is on the table, will the people come home?

Strong ties With so many Sudanese displaced or dead, there may not be much reason for refugees to make the treacherous journey back to their villages. “The flight

from home is extremely traumatic,” says Kavita Singh, a research assistant professor in UNC’s Maternal and Child Health Department and research associate for the MEASURE (Monitoring and Evaluation to Assess and Use Results) Evaluation project.

“People are moving with basically nothing.

They’re walking hundreds of miles. South Sudan has such a harsh climate. In the hot season, it’s incredibly hot and dry, and there’s very little water. And in the rainy season, it’s hard to move—the rain floods everything.

There’s very high mortality during the actual migration, because people are moving without food or water.”

And the trip can be especially harrowing for children and the elderly, who are more vulnerable to malnutrition and infectious diseases.

The return home can be traumatic, but the longing for home is powerful. And if the move is organized and humanitarian organizations are involved, it generally goes more smoothly than the initial journey.

Singh is confident that people eventually will go back, even if their houses are no longer standing.

“I think it will take time,” she says. “Some of the better-off families who migrated to Uganda or Kenya may have their children in some very good schools, and would be more hesitant to go back. But slowly, people will go.”

Given the trip’s difficulty, people will first want to hear from their relatives and friends that the basics are covered: that schools and health facilities are available, and that they can live in their villages without fear of bombing. “Because of the war, the infrastructure of the country hasn’t developed or it’s been destroyed,” says Singh, who worked in south Sudan training community health workers and did her graduate study with populations displaced by forced migration.

The schools and hospitals that exist in south Sudan, for example, have often been targeted and bombed.

When refugees do come back, they may have to rebuild more than their homes. Over time, many Sudanese towns and villages have become bereft of young men, who have left to become soldiers, been killed, or been kidnapped, Singh says. But now that the war has officially ended, the survivors among these men will start to return, and communities will eventually normalize.

Now that an official peace agreement

has been enacted, refugees in neighboring countries may also face pressure from those governments to return to Sudan.

Darfur The Darfur region, a land of harsh, sandy winds and fierce desert sun, lies in the west along Sudan’s border with Chad. Since 2003, Darfur has been the site of government-sponsored genocide of black Africans

by Arab militias (called Janjaweed). The violence began when black tribes in the west, their interests long neglected by the mostly Arab government in Khartoum, took arms to voice their grievances at being left out of negotiations for the Comprehensive Peace Agreement (CPA).

Unwilling to relinquish any share of government power, the Janjaweed destroyed villages throughout Darfur, raping and killing along the way. Though Khartoum officially claims that the government opposes the militias, the Janjaweed’s arms and money are federally supplied.

Despite the fact that the massacre in Rwanda was only a decade ago, no one has come to Sudan’s rescue. And it’s too late now to do much, says Andrew Reynolds, political science professor at UNC and advisor

to the Southern Sudanese during last year’s peace talks. “The conflict has effectively burned itself out,” he says. “Khartoum has won. There are few people left to rape or murder and no villages left to raze—everyone is either displaced elsewhere in Sudan, in Chad, or dead.”

Another try at peace In January 2005, Sudan signed the CPA. The pact arranged for power to be shared between the country’s main factions: the north’s National Congress Party and the south’s Sudan People’s Liberation Movement, along with a small handful of other political groups.

Civil conflict is nothing new for Sudan, and neither is the signing of a peace agreement. The country has struggled with war for decades, Reynolds says. Historically, the greatest conflict has been between northern and southern Sudan, a perpetual violence over differences in religion, ethnicity, and access to natural resources.

Northern Sudan, mostly Muslim and Arab, lacks the natural resources of the primarily Christian, black African south, including oil, fertile agricultural land, minerals, and water. But thanks to a fifty-year legacy of

Kavita Singh, surrounded by school children: When refugees do return, they will have to rebuild more than their homes.

endeavors 15

and allow them to respond on the radio program,” Stigant says. “Lack of information is a serious problem here, and we hope that by providing this information, we’re preparing people to begin participating in political processes. It’s a step-by-step process, and will take time.”

A people’s future

Communities will rebuild as former soldiers like these, many of them children, return.

powerful Islamic military regimes, the north has dominated the country’s government and wealth.

So while the enactment of the CPA is a positive and important step, it alone will not be effective, Reynolds says. Because of the intensity of the power struggle between north and south, and the length of time the two forces have been at war, both groups are reluctant to cede even a fraction of power to any other group—including tribes fighting for a voice in Darfur.

But Susan Stigant, of the UNC-Duke Rotary Peace Studies Program, remains hopeful. She’s currently working in southern Sudan with the National Democratic Institute (NDI) for International Affairs. Her goal is to allow ordinary citizens to communicate with political leaders. In effect, she’s working for peace from the ground up.

One of the crucial steps on the bumpy road to democracy—particularly in a warravaged place such as Sudan, with a scattered and unstable population—is getting the message out to the people about what’s going on with the government, Reynolds says.

And that’s where Stigant comes in. Every six months, she recruits and trains teams of Sudanese moderators and goes with them to local communities to gauge public opinion and awareness about the country’s political developments.

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Turning ears toward democracy Stigant’s group is also working with Sudan Radio Service to produce a civic education program that will be aired a few times a week. Citizens will be able to tune in to discussions about the new constitution and bill of rights, gender equity, the fighting of corruption, and the census, and learn how democracy works in general.

Many Sudanese have radios, but for those who don’t, Stigant and the NDI are stepping in. To ensure that people can access the program, Stigant’s group is distributing approximately forty thousand hand-crank and solar-powered radios.

Radios can reach the highest number of people, but face-to-face interaction is still essential for effective civic education, Stigant says. To this end, the NDI will hold listening groups in six main locations to bring people together to hear and discuss the radio program. The plan is to record segments of these discussions and integrate them into future radio programs. This will give people a chance to hear diverse voices from throughout the country—Arabs will hear blacks’ views, southerners will hear northerners’ views. In a country as vast and divided as Sudan, crossing these boundaries is a big deal.

“Ultimately, we also hope to take some of people’s questions to government officials

Will the peace agreement hold? That’s the million-dollar question. “The systems of governance are there on paper, but they are proving difficult in the implementation,” Stigant says. “My sense is that Sudan is going to be an elastic band of democracy. There are going to be a lot of forces trying to stretch it to its capacity to get the most possible for their own personal gain.”

Singh is more optimistic. “There might be breaches, but I think the peace agreement will hold overall—at least until 2011, when they’ll have a referendum on whether the south wants to remain part of Sudan or whether it wants its own sovereignty,” she predicts.

Despite the lack of access to education and resources, most Sudanese are eager to learn and work toward a brighter future, Singh says, and this will work in their favor as the country begins rebuilding itself. “People would come to our training centers asking, ‘What’s next?’ You often find young people saying they want to get an education so they can help their people, which is really inspiring. They have a commitment to making things better in their country,” she says.

“My Sudanese counterparts are a dedicated group with incredible vision and unwavering commitment to implement that vision,” Stigant says. “The struggle for democracy and stability in Sudan has only begun. I have to believe in the possibility of change, or I wouldn’t be here and I wouldn’t get out of bed every day.” e For more information on MEASURE Evaluation, visit http://www.cpc.unc.edu/measure.

For more on Sudan, visit http://www.cia. gov/cia/publications/factbook/geos/su.html.

To find out what you can do for the victims of Darfur, visit http://savedarfur.org or http:// www.unc.edu/sudan/home.htm.

Scala/Art Resource, NY

A deadly dread of food

by Margarite Nathe

St. Catherine of Siena died of anorexia in 1380, after she refused food and water for nearly a month. This painting, “Scenes from the life of Saint Catherine of Siena: the swooning of the saint,” by Giovanni Antonio Bazzi Sodoma (1477-1549), depicts the effects of one of her fasts. “Anorexia nervosa has been functionally the same for hundreds of years, at its core,” Cynthia Bulik says. “That pathology found a home back then in religiosity, fasting, and purity.”

Inside Lauren Brown’s head, a voice was scolding her. “You aren’t good enough for that food,” it said.

“Why should you have it when there are children starving in this world?”

Her parents were worried. She started losing weight at the end of her sophomore year of high school, when she was on the basketball team. “Oh, I’m just eating healthy,” she’d said. “You know, fresh fruits and vegetables, low fat.” She trained harder and harder, and shed pounds rapidly. By spring of her junior year, Lauren hadn’t had a period in four months.

——— “There’s a choice when it comes to going on your first diet,” says Cynthia Bulik. “Just like there’s a choice when someone takes their first cigarette or when they have their first drink. After a certain point, though, it’s no longer a choice.” endeavors 17

People genetically predisposed to anorexia nervosa are biologically different, Bulik says.

While most of us get grumpy or distracted when we haven’t eaten, food deprivation has a calming effect on some people. They generally like that feeling, and while environmental factors may cause someone to go on their first diet, their biological response will keep them at it.

In March, Bulik and her colleagues from UNC and around the world found that about 56 percent of the liability for developing anorexia rests in the genes, while environmental factors account for 44 percent.

Bulik’s team collaborated with the Karolinska Institute in Sweden to collect data from 31,406 individuals in the Swedish Twin Registry, the largest twin registry in the world. After linking registry data to death, birth, and hospital records, the team found that both members of the identical twin pairs (who are genetic duplicates) had anorexia nervosa more frequently than did both members of the fraternal twin pairs (who are genetically distinct).

What’s more, Bulik and another research team have identified a hotspot for anorexia nervosa on the genome, which means they’re closer to determining which genes affect one’s likelihood of developing anorexia.

The human genome has about thirty thousand genes; this study led the team to focus their search on a specific area on Chromosome 1.

“We don’t know a lot about the biology of anorexia,” Bulik says. “But if we can go backwards from identifying genes to having the genes tell us something about the neurobiology, we might be able to develop a medication that works for this disorder.

Right now, we have no medications that are effective in treating anorexia nervosa.”

——— As a child, Lauren was gentle, caring, a devout Christian, and had a shy but razorsharp sense of humor. “And she described herself as definitely not a girly-girl,” says Diane, Lauren’s mother.

The summer after her junior year of high school, Lauren went to Houston to do volunteer work with inner-city Hispanic kids.

When she got home, her parents saw that even though she’d gained five pounds, she hadn’t had a period in six months and still looked disturbingly underweight. They took her to a pediatric endocrinologist.

“Lauren is fine,” the doctor told Diane 18 endeavors

Jason Smith

“No one would ever wish this on their very worst enemy,” says Diane Brown. She holds a photo of her daughter, taken before Lauren developed anorexia.

as Lauren listened. “She has no problem.

You are her problem. If she wanted to, she could even lose those pounds she gained in Houston.”

“We were ignorant at the time,” Diane says. “We trusted the doctor. But he empowered the eating disorder. I know now that he shouldn’t even have made a diagnosis like that. He did not have the training. We

lost two valuable years of treatment because of it.”

A month later, Lauren turned eighteen, and her parents no longer had access to any of her medical or treatment records, nor were her doctors allowed to speak with them about her condition. Embarrassed and terrified that the stigma of an eating disorder might ruin her medical career aspirations,

she swore her family to secrecy about the problem. “For over ten years, we all suffered in silence,” Diane says. “She adamantly demanded that we not tell a living soul.”

——— “Anorexia often has a very secretive component,” Bulik says. It can be devastating for parents who don’t get support from professionals and from other parents going through the same struggle.

A childhood tendency that Bulik calls neuroticism may be an indicator for parents, doctors, and teachers to screen for children who are genetically predisposed to anorexia before they become sick.

“These kids are emotional Velcro,” Bulik says. Troubles that roll off other children’s backs really stick to them, and sometimes so subtly that their parents can’t tell. They tend to be well behaved and smart, but anxious and depressed, often about things over which they have no control—a dead animal in the road, for instance.

——— Throughout college, Lauren sought treatment sporadically, only when it didn’t interfere with her studies. She sparkled academically and graduated a semester early from Georgia Tech. Then it was off to med school at Carolina. Before her classes started, she went for treatment regularly and made some progress. Her therapist told Lauren’s parents that they could maintain that progress by keeping in touch through e-mail and phone calls. “That was our plan,” Diane says. “Well, by the spring it was pretty obvious that plan wasn’t working. Lauren’s therapist called my husband one night about something, an insurance issue maybe.”

“How do you think she’s doing?” asked Lauren’s father desperately.

“How do you think she’s doing?” the therapist responded.

“Not well at all,” he said.

“I agree.”

“Lauren would never have gone to treatment at Carolina because she knew people there,” Diane says. So the summer after her first year of medical school, Lauren’s parents decided to take her to Remuda Ranch for residential care. Lauren was angry and hurt, and she fought them at first. The night before they were to leave, Lauren’s parents thought she might refuse to go. “It came to the point where I had to accept the fact that if I forced her, my only child might never speak to me again,” Diane says. In the end, though,

Lauren stayed at the treatment center in the Arizona desert for seven weeks. “Her body weight was so low that they wouldn’t even let her walk between buildings,” Diane says.

“She rode in golf carts.”

Lauren resisted treatment, and itched to get back to school. “That summer was the most difficult time of our lives,” Diane says.

“But I think Remuda Ranch extended her life a couple of years.”

——— Back when Bulik entered the field of eating disorders research in 1982, anorexia nervosa was still considered to be a frivolous disease of choice. Girls want to be skinny, society said, and they go overboard when their parents are too strict. “It’s the same misperception we’ve seen with schizophrenia,” Bulik says. “People thought it was unhealthy parenting that caused it. We went through it with autism, where mothers were blamed for being cold and not bonding with their children. Now, decades later, it’s clear that these are biological disorders. We are now seeing the exact same transformation with anorexia nervosa.

“These parents are some of the most loving and caring parents you’ll ever meet.

They want to help. I’ve got three children, and there is nothing in the parental playbook that tells you what to do when your child stops eating.”

——— Back in medical school, Lauren learned how to keep herself alive. She became expert at keeping her electrolytes up while still refusing food.

One month before she was to finish her third year at Carolina, Lauren came down with a virus. “She was so sick by then that she finally agreed to take a medical leave,” Diane says. It was the beginning of June, and the family took a trip to the beach. “She was so emaciated by then that people pointed and nudged others to look,” Diane says.

Lauren’s father refused to take photographs on that trip.

——— “If your child comes to you and they’re a normal weight and they say they’re going on a diet,” Bulik says, “you should take that as seriously as if your child was to say, ‘Mom, I’m going to have my first cigarette today,’ or ‘I’m going to have a beer with dinner tonight.’ The red flags need to go up.”

Screening your children for budding symptoms, she says, may save your family years of

heartache. “I say this to families all the time.

If you have a mom or a grandmother who has diabetes, even if you’re clean, you’re always on the lookout for signs of diabetes in your children. Because you’ve got a family history, and you’re vigilant about it. Why should it be any different with eating disorders?”

For people with certain wiring, Bulik says, “biology takes on a life of its own. The train just starts running.”

——— Diane nods her head firmly and says, her voice shaking, “Lauren died in her sleep on a Thursday.” It was August 2003. Lauren was 25 years old.

“To this day, we don’t know how much Lauren weighed when she died,” Diane says.

“But I can guarantee you I wouldn’t want to know. We saw how she looked.

“Lauren was suffering so much. As much as I miss her and wish she were here, I know she she’s not suffering now. Lauren was a strong Christian, and we know she’s safe and well in Heaven. We know we’ll see her again one day. And that’s a wonderful thing to be sure of.”

——— Two months after Lauren’s death, when Diane was speaking about her daughter at an eating disorders forum, she met and made friends with Cynthia Bulik. And years later, when Bulik called Diane with the results of her study, the two celebrated. They were ecstatic, Diane says, because the general public just doesn’t know about the biological component of the disorder.

Anorexia nervosa, Bulik says, does not just happen to adolescent white girls. It occurs in men, African Americans, older women, children. The stereotypes have only set patients back, she says. What doctors have called a teenagers’ disease could be anyone’s—because, Diane says, “it is a disease; it’s not a choice.” e Cynthia Bulik is William R. and Jeanne H. Jordan Distinguished Professor of Eating Disorders. She and her colleagues are now collaborating with the Norwegian Institute of Public Health to build a biorepository of DNA samples from one hundred thousand babies and their parents to pull psychological and genetic information together to better understand the genetic and environmental risk factors for eating disorders.

Diane Brown chairs the outreach and education committee of the Board of Visitors of UNC’s Eating Disorders Program. endeavors 19

Back to life A survivor talks about her bout with anorexia, and offers a word of advice.

I

spoke with Michele Crisafulli on a sunny Friday morning on the patio of a coffee shop. She’s a research assistant in Cynthia Bulik’s office, and she’s one of the industrious undergraduates the scientists call Very Helpful People.

When do you think you first began developing an eating disorder?

My thirteenth birthday was the first time I remember explicitly thinking, “I’m not going to eat something because of the calories in it.” I was at my birthday party and decided not to drink soda.

I was hospitalized with anorexia for five days in the eighth grade. I wasn’t really aware that it was a problem. I can remember right before going to the hospital, writing in my journal, “My parents are taking me to the doctor. They think I’m not eating enough. And I just can’t wait to go to the doctor and have him tell them that they’re being stupid and everything’s fine.”

When did your parents first get concerned about your behavior?

My mom told a family friend who’s a nurse that she was concerned about me. Her friend said, “She’s probably fine, but see if her fingernail beds are turning purplish or bluish, because that means there are circulation problems.” Mom looked right away, and they were pretty blue. She flipped out.

What happened when you were hospitalized?

I was constantly looking for ways to cheat the system. At that point, I was still in denial that this had anything to do with emotional issues. It was just about food, just about weight, just about calories. I would say that I worked against my nutritionist and entire treatment team, not only for the five days that I was in the hospital, but also for the whole first year or so that I was in treatment.

What made you finally decide to work with your doctors and nutritionists to get better?

After I was hospitalized, I got up to my former weight, relapsed

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a little over the next year, and then started bingeing at the very end of my freshman year of high school. So I’ve been at both ends of the eating disorders spectrum.

I gained thirty pounds over three months, which isn’t a healthy way to gain the weight I needed. At one point I had my parents install a lock on our refrigerator, and everything—crackers, cereal, everything—went into the refrigerator. I know they were really uncomfortable with it and didn’t want to do it, but I was so desperate. It wasn’t effective because I’d find things that were totally unappealing, and even binge on them. Like dry pasta. I felt like such a bottomless pit.

But ironically, I think gaining so much weight brought me back to life. Cognitively, you’re not functioning the way you should be when you’re underweight. I started realizing how much more energy I had. How people didn’t look at me and get scared anymore. I decided I needed to learn how to accept my new body.

Cynthia Bulik says that neuroticism can be a risk indicator in children. As a child, did you fit any of Bulik’s descriptions?

I was definitely a very neurotic child. I’d always been a perfectionist—straight As, tried to be the angel child for my parents, never cause any trouble, that kind of thing. A couple of years before the development of my eating disorder, what I fixated on was thunderstorms, to the point where any time they were even calling for thunderstorms, I’d be shaking.

Eating disorders can be deadly. Did you ever think your life might be in danger?

I never felt like I was so thin that I’d die. But a lot of the mortality from anorexia comes from suicide. I was never miserable enough that I didn’t want to live at all; I just didn’t want to live the way I was living.

Is this something you still struggle with daily?

I would say that I’m completely recovered. One thing that upsets me about the way that eating disorders are portrayed in our society is this idea that it’s a problem that no one ever gets over. I disagree with that. Obviously not everyone does, but it’s possible.

What would you like to say to people who are now struggling with anorexia?

Listen to your doctors. Try to do the re-feeding process the right way, because if you don’t, eventually your body will rebel and you will binge, and it’s not pretty.

I spent so much of my life not feeling good about myself, constantly striving to be better and not being okay with who I already was. I see that so much, especially at a university like UNC where there are so many high-achieving people who are constantly striving to be thinner, smarter, do more extracurricular activities. It’s okay to be okay with yourself. That doesn’t make you lazy; it doesn’t make you fat. It just makes you calm and at peace, and generally a positive influence on other people.

—Margarite Nathe Michele Crisafulli is a senior at Carolina, and co-president and cofounder of Students Helping to Achieve Positive Esteem (SHAPE).

A soft-spoken 24-year-old named Court says that this watercolor painting symbolizes seeing various things with many different eyes. He painted it after he was attacked outside a Chapel Hill café—an incident that doctors say triggered a psychotic breakdown. Court is now a patient of Sylvia Saade, the program director of OASIS, which helps people with early onset of psychosis.

Short-circuiting schizophrenia

by Mark Derewicz

F

ew medical conditions are steeped in as many stereotypes as schizophrenia—it’s rare (but eighty-five thousand North Carolinians have it); schizophrenic people are violent (the condition does not always lead to violent behavior); it’s not a real disease (scientific research has shown that it’s a debilitating, often degenerative brain illness that affects nearly three million Americans).

Scientists, though, also know that many people with schizophrenia will develop violent tendencies, including criminal and selfdestructive behaviors. Carolina psychiatrist Diana Perkins has seen this up close. She’s

seen people with schizophrenia in police handcuffs after violent outbursts. She’s seen a patient’s broken body lying in a hospital bed after voices in his head told him to leap off a wall. But she has also seen patients live healthy and active lives if the disease is caught and treated early. That’s why Perkins created Outreach and Support Intervention Services (OASIS).

“Patients recovering from a first episode have a good chance for a complete recovery,” she says, “unlike patients who are in the chronic stage of illness.”

OASIS treats patients who have had an

episode of schizophrenic behavior—usually delusions or hallucinations—and have sought help in the early stages of schizophrenia. But seeking help, Perkins says, is just the beginning. Patients have to be dedicated to a medication regimen that can have many side effects. That’s not new. Medication for the disease has been around for decades.

“What’s new is helping people around the education of the illness, and what they can do to control the illness instead of letting it control them,” she says.

What’s also new is the knowledge that patients who do not respond to one mediendeavors 21

cation or who experience severe side effects will often find relief in another similar drug, according to a study led by Carolina researcher Scott Stroup. His study also provides information about which drugs doctors should prescribe depending on how patients respond to medication they’ve already tried.

Such research adds a needed layer to schizophrenia treatment, Perkins says, because for decades patients have been stopping their medication regimens to see if symptoms will return, usually with grim results.

“We know that if a person stops medication, the risk of relapse is very high and the illness starts to take its natural, often degenerative course,” Perkins says. “They have to stay on meds long term. We work with patients about why that’s the case.”

Perkins says that people with early-stage schizophrenia often know that their minds are playing tricks on them. “Early on, people can have a lot of insight,” she says.

“Patients buy into it. They think, ‘It’s a brain disease. My brain is short-circuiting, and these meds help restore normal function.’”

If patients can be helped to reach these conclusions rather than accepting their own explanations, then they are more likely to stay on medication and get better, Perkins says.

The trouble with drugs There are many kinds of schizophrenia medication, but all of them work by blocking dopamine receptors in the brain.

Dopamine is a pleasure neurotransmitter, so blocking it can result in dulled emotions. “People really hate that,” Perkins says. “Newer meds are much less likely to have that side effect.” The new drugs partially block dopamine receptors, but they have other side effects, such as the need to sleep a lot, daytime drowsiness, and feelings of restlessness. “Weight gain is the worst side effect because of the diabetes risk,” Perkins says. “About a third of the patients treated with some of the newer antipsychotics will gain a lot of weight, sometimes fifty pounds or more.”

Although these side effects can be serious, patients often stop taking medication for other reasons. It’s expensive, and if 22 endeavors

symptoms completely disappear for a year or two, patients often choose to go without, Perkins says, despite the good chance of symptoms returning. “Maybe not in the first week or first month, but within a year or two, a relapse will likely occur. And unlike the first episode, the patient may not completely recover from a relapse. We still want to be involved even if they choose to stop taking medications, because if a relapse happens, we want to catch it early, maybe prevent hospitalization or minimize consequences.”

Perkins says that there is no evidence that medication cures schizophrenia, even though patients who don’t relapse while on medication often believe that they’ve been cured.

OASIS uses medical evidence to show patients why medication is so important. For a small percentage of people with schizophrenia, Perkins says, the condition will run its course with or without drugs. Sometimes that course leads to chronic schizophrenia, which is when hallucinations, delusions,

Court says that some of his drawings symbolize evil—sometimes inside of him, sometimes outside. Keeping an art journal, he says, is therapeutic and helps him relax.

or other symptoms such as problems with organization set in. Here, medication might not help. Other times, people develop a mild form of the disease that lacks the degenerative element. “But early treatment makes a big difference for probably a third to twothirds of people with schizophrenia,” Perkins says. “Most people will dramatically recover from a first episode. And for 80 to 90 percent of patients for whom medication works, the symptoms go away completely.”

Despite mounting research that supports drug therapy, Perkins says that true stories are often more effective. Of the many patients she’s been working with for a long time, only one has stayed on meds long term. And that patient is the only one never to relapse.

“One of the most heartbreaking stories for me is about a patient who had a first episode, and recovered completely on medication. He was working full-time at a prestigious job.

He had a good income. He got engaged.

And then he didn’t want to have schizophrenia anymore, so he stopped taking medication, and he had a relapse about six months later. He had symptoms for a year before he was hospitalized, and he has not fully recovered from that second episode.”

His girlfriend and job are gone. His life is completely different. “He hears voices all the time—every hour,” Perkins says, “even while on medication.”

Brain circuitry Why patients stop drug therapy is linked to schizophrenia’s mysterious pathology, which is different from person to person. Carolina psychologist Aysenil Belger is uncovering the science behind the disease.

She uses neuroimaging technology to measure blood flow and blood oxygenation changes linked with particular brain functions in autistic and schizophrenic patients. When you make a decision, speak, or listen, blood flow and oxygen consumption increase in the specific brain regions engaged during these functions.

Belger has found that during attention and decision-making tasks, blood flow and oxygenation to certain parts of the brain are typically a lot less in people with schizophrenia. And tests typically

indicate that patients with “The longer people are schizophrenia have trouble psychotic, the more develwith certain decision-making opmental ground they lose,” tasks. Her preliminary tests Perkins says. “They drop show that the same can be out of life, and it’s very hard said for at-risk adolescents— to regain that lost ground, those with immediate relabecause from adolescence to tives diagnosed with schizoadulthood, you are learning phrenia but who have yet to how to behave emotionally, show signs of the full-blown intellectually, and socially. disorder.

Some of our patients are “The disease has already treated for a first episode occurred long before the at age twenty, but developonset of symptoms or before mentally, they are fifteen a person sees a psychiatrist,” because symptoms began at she says. that age.”

Ten to 15 percent of indiWhen patients come to viduals who have a firstOASIS, social worker Brent degree relative with psychoMoos and program direcsis will develop schizophretor Sylvia Saade help them nia. “But we don’t know what figure out what is happening triggers the onset of psychoto them. Moos and Saade sis in these people,” Belger offer psychotherapy, group says, “and that’s what we’re therapy, ongoing education, interested in studying—the home visits, and support for physiological, cognitive, family members who often Court says that this drawing is symbolic of something unnatural psychological, and clinical struggle with the idea of a growing inside his mind. The tiny daffodil represents death— changes that are present mentally ill loved one. not hope or something delicate—because it is commonly found before the onset of the illness “All the studies show that at grave sites. in at-risk individuals.” first-episode patients see If Belger can find the really great recovery symppathological mechanisms tomatically, but some never underlying abnormal brain development warning signs of psychosis. Moreover, early recover function,” Perkins says. “OASIS or function, then there’s a better chance to symptoms mimic common occurrences. spends a lot of time figuring out the individdevelop localized treatments or even ways of “Most people’s brains make mistakes in ual’s roadblock to functional recovery.” preventing or delaying the onset of schizo- perception,” she says. “You’re in the shower A second reason to intercept it early is to phrenia. Right now, medication is a blanket and you think you hear the telephone. avoid the trauma and stigma that stem from solution, but it’s the only solution.

Did you hear the phone? This happens to full-blown chronic schizophrenia. In these everyone. But with people in early stages of cases, patients struggle to rejoin society in Subtle beginnings schizophrenia, it happens a lot, and in more a meaningful way. Untreated illness is also At most, 10 percent of the people who profound ways.” associated with increased risk of a person develop schizophrenia feel fine one day A person who is developing schizophrenia hurting themselves or someone else. and hear voices the next. The vast majority, might first experience frequent mispercepUltimately, that’s what Perkins wants to Perkins says, experience subtle symptoms tions, like thinking they hear someone call- avoid. e first, and these will usually develop during ing their name. Next they might hear brief There are twelve early detection and treatment late adolescence or early adulthood. High hallucinations, for example a voice saying clinics in the United States, and more than fifty school or college students in the early stages “Don’t do that!” Eventually a conversation others around the world. OASIS in Chapel Hill of schizophrenia will get distracted easily between two people might break out in a receives support from the Duke Endowment, and become disorganized. Grades will slip sufferer’s mind. the Kate B. Reynolds Charitable Trust, and markedly, and students will often become A hallucination will seem utterly clear and Carolina’s psychiatry department. Diana Perkins paranoid or disinterested in friends. Antiso- real. Perkins says that, on average, a person is professor of psychiatry, and Scott Stroup is cial behavior is a hallmark of the disease. will experience full-blown psychosis for a associate professor of psychiatry. Aysenil Belger, Perkins says that parents often struggle year before a proper diagnosis is made and associate professor of psychiatry and psychology, to differentiate between typical adolescent treatment initiated. OASIS aims to shorten recently won a Hettleman Prize for Artistic and behavioral changes, drug use, and early that time frame.

Scholarly Achievement for brain research. endeavors 23

In Pursat province, Cambodia, La Thyda collects her family’s drinking water from a fetid pond where water buffaloes bathe. She uses a ceramic filter to treat the water. Photo by Van Sokheng.

Water, Water, Everywhere

by Molly Davis

W

e see them every day, those commercials for charities in the developing world, where a child kneels by a muddy stream to drink. Most of us have never had to depend on untreated sources of water, to be surrounded by water that’s too dirty to drink, to have to drink it anyway. And most of us have no idea what it means to watch a child grow dehydrated and weak from diarrhea and not know what’s causing it.

But in Cambodia, waterborne illnesses are a major public health problem, particularly for the rural poor. Joe Brown describes a world of waving mango trees and flat, swampy expanses. Water abounds in rivers, 24 endeavors

rain collection systems, lakes, wells, and the stagnant pools left by floods. But the untreated water teems with pathogens—bacteria, parasites, and viruses—deposited by human and animal waste. Cambodia has only two piped water supply systems—one in each of the two largest cities—and neither is properly treated. That, Brown says, is not likely to change any time soon. Building treated, piped water systems requires money, infrastructure, and expertise that don’t exist in Cambodia, where diarrheal illnesses are a major killer. Most of the victims are less than five years old. Researchers estimate that anywhere from 15 to 80 percent of

Cambodia’s diarrheal disease comes from drinking water.

“Something we think of as annoying is one of the major health problems in Cambodia,” Brown says. “They have very few choices when it comes to water.”

But sometimes the answer is right under your shoes.

Brown is trying to help Cambodian people clean their water with the same dirt that they’ve been walking on all of their lives.

He’s working with not-for-profit groups to develop a ceramic water filter, locally made from clay, for home use.

Brown has come up with a recipe for a

filter that kills over 99 percent of the viruses that cause life-threatening diarrhea and other illnesses. The filter’s key ingredient is goethite, an iron oxyhydroxide commonly found in the tropical soils of many of the world’s poorest countries. Brown developed the idea with his advisor Mark Sobsey, then collaborated on the design with Potters for Peace, a not-for-profit group based in Nicaragua.

Brown’s idea builds on existing but less effective water filters already in use around the world. A ceramic filter element resembling a flower pot sits inside a receiving container. When water is poured into the top of the container, it trickles through the porous ceramic filter into the bottom of the container, where it is released through a tap.

But existing clay filters don’t remove viruses, which are much too small to get trapped in the pores of the clay. So Brown added goethite.

W

hen we think of Johann Wolfgang von Goethe, we usually think of Faust. But Goethe was also interested in mineralogy and mining. Goethe’s mineralogical namesake, goethite, has been used as a yellow pigment for centuries. It’s in house

Joe Brown is trying to help Cambodian people clean their water with the same dirt that they’ve been walking on all of their lives.

paint, and it’s in the ancient handprints and animal images on the walls of the Caves of Lascaux. And it happens to be one of the most common elements in tropical soils.

Brown knew that various kinds of metal oxyhydroxides could create a fatal attraction for viruses on a water filter’s surface. Most treatable water has a neutral pH, and viruses in neutral pH water tend to have a slightly negative charge. Goethite, on the other hand, effectively creates a positive charge when it is mixed into ordinary ceramic

clay in the right proportions. This positive charge on the filter’s surface inactivates the viruses. The clay’s pores catch larger organisms such as bacteria and protozoan parasites, and the water comes out of the tap much cleaner and safer to drink.

Adding goethite to the filters already manufactured in Cambodia adds only 25 cents to the price, Brown says. The simpler clay filter, with no virus-killing properties, costs $7. But the average yearly wage in Cambodia is only about $350.

“It really represents a substantial investment,” Brown says. “It’s basically a week’s income.” This drives him to make sure that the filter is as effective as possible.

He’s working as a consultant for UNICEF, conducting field trials with eight colleagues in Cambodia to test the filter’s ability to inactivate viruses and to maintain that ability through repeated use. And he drinks the filtered water himself.

“I use the ceramic filters we promote, partly because I believe in the technology and partly because I’m a scientist,” he says. “What better research subject than yourself?” e Joe Brown is a doctoral student in the Department of Environmental Sciences and Engineering at Carolina.

Left, An infant in Kandal province eyes a filter. At any given time, one in five children in Cambodia have life-threatening diarrheal disease, partially due to contaminated drinking water. Center, A woman in Kampong Lourng, Pursat province, shows her ceramic filter after its weekly cleaning. She says she is proud to be using the filter to improve her family’s health. Right, Chounn Bunnara (left), a Cambodian community health educator, is teaching this fisherman how to use a filter to treat drinking water for his family of eight, who live on the Tonle Sap river in Kampong Chhnang province. Photos by Van Sokheng.

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A Culture Shaped by Faith James Coleman says there’s still a place for the spiritual among scholars. By Margarite Nathe

H

is grandfather used to tell him hoodoo horror stories about the neighbors. “I saw it!” he’d say.

“This woman put something on him and he fell down and died and black bugs ran out of his mouth.”

“It terrified me,” James Coleman says.

“My grandfather could tell some scary stories.”

Even now, he’s found, there’s no way to avoid it. Coleman had barely gotten his feet wet in his research for Faithful Vision: Treatments of the Sacred, Spiritual, and Supernatural in Twentieth-Century African American Fiction when he realized that hoodoo mythology and its influence were in almost every book he read. Christianity was formative for those writers, he says, but hoodoo—the African American manifestation of voodoo—is tightly enmeshed in their spiritual themes.

Coleman was raised in the Baptist faith in a small community in Virginia. “Everybody in my family was devoutly Christian,” he says. “But there was this other aspect of supernatural experience that was very real for them. My grandfather would separate that from his Christianity.” Hoodoo, which has a way of melding with local religions, became part of the community’s spirituality.

“I was afraid of hoodoo just like everyone else. The main fear that people of my grandfather’s generation talked about—and I never really witnessed this—was of someone burying something under your doorstep to conjure you. That was one way that you’d be hoodooed. It was all so shadowy and obscure, and at the same time so real. You know, all of that sounds so fantastic and unbelievable, but people swear by it.”

Facing page, James Coleman’s latest work on contemporary African American fiction grew from his own spiritual development, he says. Photo by Coke Whitworth.

It was a different story when Coleman left home for a life in academia. Literary critics don’t put a lot of stock in what some call superstition, or even in mainstream religion, he says, and he eventually found himself alienated from the community in which he was raised. “I think that academia tends not to take religion seriously,” he says. “I grew up in a community where not only the black people, but the white people too, were really serious about religion. Even the drunks and reprobates. And people still are. As I moved further into academia, I went further and further away from that whole spiritual and religious focus.”

Now, he wonders, where does all of this fit in his research to come?

Christianity and the Bible are weighty influences for contemporary African American writers, Coleman says, and it shows in their work. Faithful Vision explores how some authors such as James Baldwin and Toni Morrison are extremely critical of the religious experience. But, Coleman says, “there’s a difference between critiquing something while still taking it seriously, and not being serious about it at all.”

Literary kin The estranged black intellectual is not a new phenomenon, Coleman says. Novelist John Edgar Wideman, one of Coleman’s literary heroes, found himself isolated from the values of his community as he drifted further into academia after becoming one of the first black Rhodes Scholars. Wideman’s novels, Coleman says, reveal African American spirituality as a mainstay of black people.

“Wideman’s life is fraught with tragedy,” Coleman says. “That’s part of the attraction and fascination of his work.” Wideman’s literary career and turbulent family history—his brother and son are both in prison for murder—led to his disenchantment and uncertainty about his relationship to the

black community, which is a theme in some of his novels. It was Wideman’s tumultuous family relationships that drew his interest and appreciation, Coleman says, “because I’ve always felt uncertain about my place in my own family.

“I grew up in a shroud of secrecy about who I was,” Coleman says. Raised an only child with a loving but secretly surrogate mother, he began to piece together his family history from things he heard friends and neighbors say. No one in his family explicitly told him about his biological mother and five siblings until only fifteen years ago. It was his own spirituality, he says, that helped him deal with that exposed secret.

Religion and spirituality have not only shaped the African American novels we read today, Coleman says, but are also sculpting the novels we’ll read in fifty years.

“In talking to my students, who have all kinds of contemporary influences, including hip-hop, I find that particularly African American students are if anything more religious right now than they’ve ever been.” And Coleman’s research is moving him toward an opportunity to explore his own religious roots, he says, possibly in the form of some autobiographical writing.

“Faith is what brought African Americans through slavery,” he says. “It doesn’t seem to me that the world is becoming any less challenging for anybody. The challenges are just different. Religion is just the fundamental way that many African Americans address that challenge.” e James Coleman is professor of African American literature at Carolina. His most recent book, Faithful Vision: Treatments of the Sacred, Spiritual, and Supernatural in TwentiethCentury African American Fiction, was published in 2006 by Louisiana State University Press. He’s currently writing a biography of James Edgar Wideman for Praeger Press. endeavors 27

The Passion behind the Business

by Mark Derewicz Conjure a new idea, start a business, and make that business fly—easier dreamt than done. So Carolina business school professors Randy Myer and Ted Zoller created a course called “Launching the Venture” to help students, staff, and faculty navigate our dog-eat-dog economy.

About one hundred entrepreneurs apply for the course each year, and one-third of them are accepted into the half-semester class where participants conduct market research to vet their own ventures. Then they defend their findings before judges— usually industry people Myer and Zoller

Sindura Citineni founded Nourish International to raise money for aid organizations around the world. Photo by Jason Smith.

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bring in. Last year, thirteen ventures passed the test and were invited to take another half-semester class on cranking up a successful company. Five were focused on science and technology, four were service- and retail-oriented, and four were focused on publishing and social activism.

The Office of Technology Development co-sponsors the Launching the Venture course. Its main goal is to help inventors license discoveries, secure financial support from corporate sponsors, provide patent assistance, and negotiate agreements with interested companies.

The business of activism The caption of an online world map read: each time a country changes color, another person dies from hunger. Sindura Citenini watched one country change color. Then another.

Then India, her homeland, faded to black.

“When I saw this map and pictured all these people, it was almost like I could feel the pain,” she says. First she wept. Then she started Hunger Lunch, a UNC-based nonprofit that sells rice-and-beans meals on campus several times a year—a model that was inspired by former UNC medical student Kelly Fogleman. Citineni raised seventy-five hundred dollars for the largest slum in her hometown of Hyderabad, where she then sought advice at India’s National Institute of Nutrition, modified a special nutritional beverage, and worked with community leaders, cooks, and aid organizations to feed one hundred and fifty malnourished children for four years.

She was successful, but working with so many disparate groups nearly overwhelmed the nineteen-year-old undergrad. She came back to Carolina and created Nourish International (NI), a nonprofit group of Carolina students that organizes campus Hunger Lunches, poker tournaments, and

dance events to raise money for sustainable projects around the world.

Citineni wanted to take it to the next level. “But we had no marketing analysis, no financial analysis,” she says. “We were a just a bunch of students sitting around talking.”

Citineni, along with NI members Joel Thomas and Brian Zandt, took “Launching the Venture” to help them develop a detailed business plan and set clear ground rules: NI must work with a grassroots aid organization with long-standing ties to an impoverished community; projects must be sustainable; NI members must consult with indigenous community members; there must be tangible results; and aid groups must allow Carolina students to work on location each summer.

This summer, NI helped develop sustainable gardens in Argentina and a fruit orchard on the outskirts of Bombay. Duke, N.C. State, and the University of Nebraska at Omaha started NI chapters as mini-ventures with help from UNC-Chapel Hill’s chapter.

Citineni, now attending Carolina’s dental school, wants more than three hundred college chapters open in five years. Ambitious—but according to the business plan, that estimate might be conservative.

James Loehr founded iCardiogram to allow heart specialists to download echocardiogram images, interpret them, and advise a patient’s doctor immediately.

Photo by Jason Smith.

Downloading the heart What if you need an ultrasound of your heart, but there’s no specialist in town able to interpret the echocardiogram? Your doctor might make a video, and then mail it to a cardiologist. These days, your doctor could schedule a video conference call with a specialist.

“Or they just won’t do the ultrasound, and instead send you to UNC Hospital unnecessarily,” says pediatric cardiologist James Loehr. His company iCardiogram developed technology to change all that. It’s called an EchoEncoder, essentially a laptop and special software Loehr and company cofounder David Reaugh devised to let doctors upload analog and digital echocardiograms to a server in Raleigh so that heart specialists anywhere in the world can download and interpret the data and immediately advise other doctors.

“This is the general advantage of videoconferencing,” Loehr says. “But with video

conferencing, if I knew a video was coming in, I’d have to drive to the hospital at a scheduled time. With iCardiogram, I can read the echo at home or on any computer that has QuickTime software.”

Loehr also says that iCardiogram’s image quality is superior to video conferencing and that it’s less expensive.

But the key difference is the quickness.

Even in Baghdad, doctors have used iCardiogram to diagnose children who needed immediate surgery. Loehr says that aid organizations in the Dominican Republic also use the technology. iCardiogram started four years ago with one client in Nevada. Today, Loehr says, between seven hundred and one thousand echocardiograms are transferred through the company’s server each month. Pretty good for a couple of guys with no business background. “Launching the Venture,” Loehr says, helped him refine his financials and make contacts in the business world.

An educational identity Remember the story of the ugly duckling?

Andre Wesson saw the metaphor play out while teaching at an elementary school— some kids might be seen as ugly ducklings but they should all become swans. Wesson saw that too many minority kids didn’t understand their own history and culture.

They thought they were just different.

“And I think this lack of identity leads to a lack of motivation to pursue positive things into the future,” he says.

This ideal and a little research into the $35 billion publishing industry led Wesson to form Seventh Swan Publishing, which will produce educational and historical books, CDs, and DVDs for African American and Hispanic children ages three to ten.

“When I started thinking about this, I wondered how many times as a kid I saw a face similar to mine in a book,” Wesson says.

Wesson, now an academic advisor at Carolina, wrote two series of children’s books based on his teaching experience in a multicultural classroom. The books cover

material—the alphabet, numbers, etc.—that the state says young children must learn.

He searched for a publisher and found that less than 2 percent of publishing houses produce any kind of educational material for minority youth. Yet he found that 71 percent of minority parents polled wanted more literature geared toward their children. And when he told friends, coworkers, and family what he was up to, a network of customers appeared. He took twenty-five hundred preorders for his books in just three months.

“That led me to believe that this project was much more than a book,” he says.

Wesson created Seventh Swan, and then heard about “Launching the Venture.” He submitted a business plan based on his research and a vision for empowering kids to think creatively and passionately about their lives. By course’s end, he’d earned the coach’s award for most improved venture.

Seventh Swan’s initial focus is on North Carolina, but Wesson will soon reach out to leaders in academia, government, business, the community, and religious organizations in neighboring states. e

Andre Wesson developed Seventh Swan to publish children’s books, DVDs, and audio material for minority kids. Photo by Jason Smith.

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in print A FIRST WITH NO END The Curse of Caste. By Julia C. Collins.

Edited by William Andrews and Mitch Kachun. Oxford University Press, 224 pages, $22.00. black woman marries a white man.

Then death during childbirth, a heartbroken father, and an orphaned baby girl who grows up knowing nothing of her black ancestry or the circumstances of her mother’s end. Fast forward through the years, and under the employment of her oblivious and racist grandfather, she attracts the affections of a white European aristocrat intended for another woman. Would the dashing count propose? Would she accept? Would her family tolerate an interracial marriage? She— And that was where the story ended on September 23, 1865.

Julia C. Collins, a black woman whose readers were mainly African Americans, died of tuberculosis just as her novel reached its climax. Readers had devoured over thirty installments of The Curse of Caste before the column disappeared.

Bill Andrews believes that Collins’s serialized story is the first novel ever written by an African American woman.

For decades, English professors have taught that Our Nig (1859) was the first, but, Andrews says, research has proven that Harriet Wilson’s book was almost entirely autobiographical.

Harriet Jacobs also wrote Incidents in the Life of a Slave Girl (1861) more from her life than from her imagination, he says. Although these books are staples in English classes today, not many of Wilson or Jacobs’s contemporaries ever saw their work.

A

Right, a portion of the cover. Collins left her work unfinished—and her readers pleading for more.

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An accidental discovery At Cornell University, historian Mitch Kachun was wading through old issues of The Christian Recorder on microfilm when he happened on Collins’s story. After several years of investigating Collins’s life, Kachun brought his findings to Andrews, a literary scholar, who immediately realized they had something special. “It’s hard to know how many people may have come across Collins’s story at one time or another while doing historical research on The Christian Recorder,” Andrews says. Dozens of historians may have skimmed over The Curse of Caste

because they were searching for historical facts, not fiction. “If someone had come across Frances Ellen Watkins Harper, reading through the Recorder,” Andrews says, “they would have said ‘Oh, I know who she is,’ and then they might have paid more attention to her work.” No one knows the name Julia Collins, he says, so she’s been invisible for decades.

The Curse of Caste may never have seen the light of day if Collins had approached a publisher to distribute it for her, and she may have foreseen that. She may have also known that self-publishing, as Harriet Wilson struggled through when she wrote Our Nig, would be expensive and difficult.

When she decided to serialize her novel in The Christian Recorder, the official newspaper of the African Methodist Episcopal Church, Collins most likely knew that black readers across the country would find her words, and that the story would get farther than she could ever push it by herself.

Who was this woman? Where did she come from? And what gave her the audacity to think that she could write a successful novel in 1865?

Kachun dug through property records, probate records, tax records, birth and death records, and countless newspapers. “I found a couple of scattered references that don’t tell us much,” he says. We do know that Collins was from Williamsport, Pennsylvania, and that she was one of about five hundred African Americans in a rapidly growing city of ten thousand people. We know that Collins was her married name, and that she was literate. And we know that she had a strong social conscience and cared passionately about the education of women.

In 1865, most white readers approached literature with certain assumptions, Andrews says. Their perception of women of color was that they weren’t really interested in or devoted to marriage the way white women were. But unlike white authors of that time, whose work was most of what people read, Collins presented her female characters as being utterly committed to their marriages—a breath of fresh air to her readers.

Julia Collins, Andrews believes, was extremely ambitious. “She was trying

Stefan Klein

Spirited revolutionaries Revolution in America: Considerations and Comparisons. By Don Higginbotham. University of Virginia Press, 230 pages, $19.50.

T

homas Jefferson had a way with words—and insults.

“We hold these truths to be self evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty, and the pursuit of happiness.”

Eight years later, Jefferson wrote choice words about fellow revolutionary Patrick Henry in a letter: “While Mr. Henry lives, another bad constitution would be formed, and saddled forever on us. What we have to do I think is devoutly pray for his death.”

So much for Henry’s right to life.

Jefferson wanted a different constitution for Virginia, and he blamed Henry for blocking his legislation. And as historian Don Higginbotham writes in his book of essays, Revolution in America, Henry and Jefferson constantly wrangled over state issues, as well as a federal one—the separation of church and state, in which Jefferson strongly believed and Henry did not. Jefferson won that battle, and the victory probably felt like political retribution, Higginbotham says, because Jefferson had previously blamed Henry for trying to get the Virginia legislature to investigate Jefferson’s conduct as governor in 1781.

“Jefferson lived twenty-six years longer, and to his death he bad-mouthed Henry to friends and travelers to Monticello,” Higginbotham says.

to present the character of African American women in a way that would put them at the front of the stage instead of at the back. She did that in a way that doesn’t just make them objects of pity, doesn’t just present them as victims. Collins was determined to honor the love of African American women by showing them committed to the institution of marriage, regardless of caste barriers designed to limit their choices.”

And now, almost 150 years later, we can decide how the story should have ended. The Curse of Caste will appear in book form for

Henry never aspired to national office, but Jefferson did battle with other political heavyweights, including John Adams and George Washington.

Jefferson and Washington respected each other during the Revolution and Jefferson served as Washington’s secretary of state for five years after the war. But the two entrenched themselves on opposite sides of several political issues including the biggie—strong central government versus more states’ rights. Their relationship soured forever when a letter that Jefferson wrote to friend Phillip Mazzei was leaked to the press in 1796. In it, Jefferson wrote of “an Anglican, monarchical, and aristicratical party” that was in favor of mimicking the British form of government. Jefferson was referring to the federalists, whom he called “apostates.” The letter included a disparaging reference to Washington as a British puppet. The two never corresponded after that, and Washington died in 1799.

Their relationship deteriorated so badly that when President Jefferson visited Martha Washington in 1801, the two shared an awkward visit that she later described as the second most painful occurrence of her life—the first being the death of her husband.

Martha once called Jefferson “the most detestable of mankind; the greatest misfortune our country had ever experienced.”

Still, Higginbotham says, Jefferson’s attitude toward Washington softened over time.

“Jefferson refers to Washington in his 1801 inaugural address, and in a letter of 1814, Jefferson analyzes Washington’s contributions in a fair and positive light,” Higginbotham says. “There’s a theory that Jefferson was crafting his own image, because no one wanted to go down in history as Washington’s enemy. But I also think Jefferson wanted Americans to know how he felt about the father of the country.”

Jefferson and Washington never made amends, but Adams and Jefferson did. Those two political rivals corresponded more than one hundred times between 1813 and July 4, 1826—the day both of them died.

But Higginbotham reminds readers that these political differences were resolved at the ballot box. The Founding Fathers hung together when it counted most, as Benjamin Franklin advised, instead of hanging separately.

—Mark Derewicz Don Higginbotham is Dowd Professor of History at Carolina.

the first time this October. Because Collins never finished her novel, Andrews outlined two alternate endings: one happy, one tragic. This edition, which will include the proposed endings, should promote discussion and debate in many African American literature classes, he says.

Readers wrote to The Christian Recorder after The Curse of Caste disappeared from the front page, pleading for a conclusion and the whereabouts of the writer. Collins’s readers, Andrews says, had no doubt that hers was the first story of its kind. “They must have

thought, ‘Here is a black woman’s voice like none we’ve ever heard before.’” ­—Margarite Nathe William Andrews is E. Maynard Adams Professor of English at Carolina. Mitch Kachun is Associate Professor of History at Western Michigan University. Kachun discovered Collins’s work while researching his book, Festivals of Freedom: Memory and Meaning in African American Emancipation Celebrations, 1808-1915. The Curse of Caste by Julia Collins will be available from Oxford University Press in October. endeavors 31

Love through the lens

P

atrick Davison’s mother used to carry him around like a suitcase. When he was four, Patrick broke his leg so badly that he had to wear a body cast from his armpits to his toes. So his mother Viola, who had five other kids to manage, put a handle on Patrick’s cast.

Years later, when Viola developed Alzheimer’s, Pat Davison relocated to be closer to her. “Mom had seen me through a lot of hard times thirty years before,” Davison says, “and now she needed someone. So I found a job in Denver, packed up, and left my wife and kids to sell our house in Dallas.”

Then Davison did what he always does: he took pictures. He’s not a physician. He couldn’t make his mother’s brain well again.

He’s a photojournalist. And though he didn’t set out to document Viola’s decline, he realized that his pictures might somehow help other families deal with the disease. So after Viola passed away, Davison told her story with pictures and his words. He called it Undying Love, a son’s meditation on his mother’s death. You can watch it and listen to it online. And it will break your heart.

Davison is soft-spoken and unassuming, 32 endeavors

by Jason Smith • photos by Pat Davison

but earnest. “Everything that you cover as a journalist doesn’t have to change the world,” he says. “Everything doesn’t have to be an earth-shaking issue.” Introduce your readers to their community, he tells his students. Sure, report on the issues, but try to show people things they wouldn’t otherwise know or see. Try to make people’s lives a little richer.

Go up, for example, in a Blue Angels F-18.

Or go show how commercial development might be washing away the boardwalk culture of blue-collar Carolina Beach. Tell the story of Vukani, a squatter camp in South Africa, where people are being wiped out by poverty and AIDS. Work with groups of students on summer-long multimedia projects about Galicia, Chile, or South Africa.

Davison did all these. He also covered the Columbine High School shootings as part of a Rocky Mountain News team that won a Pulitzer Prize.

But Davison says photojournalists don’t have to jet all over the world or be dropped into war zones. Instead, they can look at what’s happening in the United States and in the world, and bring it home. “For example,

with the immigration issues that are going on right now, photojournalists should be figuring out visual ways to tell that story locally—and not just the protests, because that’s the obvious thing. They should be trying to find people in the community who are experiencing it, and getting their stories,” he says.

“That’s one great thing about photojournalism: you can evoke emotion from people through photographs. People really relate.

We’re such a visual society that people are a lot more visually sophisticated than they think they are.”

After the fall of Life and other big photojournalism magazines, people started wondering if photojournalism was dead. “But I think it’s pretty commonly accepted now that photojournalism is definitely not dying,” Davison says. “It’s just not as sexy right now as some of the other forms of media.” That’s partly because small and affordable digital cameras and digital video cameras, blogs, and citizen journalism are putting the reporting power into the hands of the average Joe. As our bits and bytes run rampant, we can all become stringers of sorts.

endview That’s a good thing, Davison says, but it means that photojournalists can’t just shoot pictures anymore. They need to learn how to tell stories using audio, too, and maybe even video. Newspapers like slideshows because they have a relatively long shelf-life. And papers can use them to cover local events in greater depth.

“The great thing about multimedia is that the level of content that you can deliver is so much richer—it has so many different levels compared to broadcast television or print journalism,” Davison says. “You can have audio, you can have 3-D animated infographics, you can have multiple photos, you can have video. And you put the control into the users’ hands, so that they can digest the stuff the way they want to.”

As more people look to the web for their news—Davison requires his students to read the newspaper, but they all want to read it online—publishers are realizing that they have to offer more than a newspaper. They have to become a news source. Give people a compelling reason to visit your site, and they will.

Don’t count print out just yet, though. The Rocky Mountain News printed Undying Love as a twenty-page special section. “The day it was published, the phones started ringing

off the hook, and the e-mails started pouring in,” Davison says. The paper ran two full pages of letters to the editor. Davison still gets e-mails and letters about it. (One person wrote to say that Davison had been a vulture. To his own mother.)

B

ut Davison always felt like Undying Love was something he had to create. “Alzheimer’s is so prevalent that almost everyone knows someone who’s been touched by it,” he says. “I wanted to be able to communicate what it’s like to somebody who’s at the beginning stages of going through it with a parent. Yes, it is terrible, but there’s a lot of value in spending that time, and a lot of value left in that person’s life.

“She was a great mother and a great woman, but she didn’t have a huge role in this world during this life. So her dying could be just another leaf blowing in the wind, if you allow me to wax poetic. It could just be meaningful to the family, and have no reach beyond that. And I’ve spent my whole career communicating with people, and trying to reach people. So I felt like her life could actually have some sort of a reach beyond our family. And it has, and it still does.

“Honestly, I knew my mom well enough to know that if she had been in her right

mind, she would have said, ‘If I am going to pass away from this disease, if I can do anything to help raise awareness, to make people donate for research or to make people write their congressman trying to get money allocated for research, then, heck yeah. Do it.’

She would have been all for it.” Davison gave Undying Love to the Alzheimer’s Foundation of America, which used it to raise $135,000.

There’s a scene at the beginning of Undying Love that comes from an old home movie of Viola next to a swimming pool. She’s wearing a thick white rubber swim cap and a white bathing suit with a floral print. She half-crouches in a diver’s pose. She holds it, longer than she might need to. The dive is ordinary, a little self-conscious. Viola swims a few strokes, then stops. She says something we can’t hear, gives a little wave, and splashes a smile, and it hits you: she could be your mother. She could be anyone’s mother. e Davison is assistant professor of journalism and a winner of the 2006 Phillip and Ruth Hettleman Prize for Artistic and Scholarly Achievement. See and hear more online: Undying Love is at www.undyinglove.org. In-depth summer multimedia projects are at www. theancientway.org, www.chiloestories.org, and www.tenyearson.org. More of Davison’s work is at www.patdavisonphotography.com.

Top left, Viola and her daughter, Cindy.

When Pat Davison and his sisters had to move Viola from her home to an assisted living facility, Davison wrote in his journal, “Does she hear the door locking behind us? Is this betrayal?” But even with Alzheimer’s, Davison says, Viola “could sense that we were upset, and she would soothe us.”

Top right, Viola with her granddaughters, Mariko (left) and Hanna.

Bottom left, Viola eventually had to move to a nursing home. Davison wrote in his journal, “She seems like an airship, scuttling baggage at each stop, straining against the pull of this world, straining to soar heavenward.”

Bottom right, “She and I were a team when I was back in that body cast,” Davison says. “And I felt like we were a team again, and that we could tell her story.”

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Page 11: iPods and music videos, magazines

Page 32: Photojournalist Pat Davison didn’t

Page 26: James Coleman leans on everything

and books, TV shows and movies—for many kids, they’re an always-on friend. But what are they teaching your teenager about sex? Photo

by Steve Exum.

set out to document his mother’s battle with Alzheimer’s. But he realized there was at least one way he could strike back at the disease.

Photo by Pat Davison.

from Christianity to hoodoo—the African American manifestation of voodoo—to explain how faith shapes the work of African American authors. Photo by Coke Whitworth.

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