Southeast Wisconsin Research Articles

Examining the Association between Quality of Life and Functional Status in African American Adults with CKD in Southeast Wisconsin: A Cross-Sectional Study

Examining the Association between Quality of Life and Functional Status in African American Adults with CKD in Southeast Wisconsin: A Cross-Sectional Study

Counter-Mapping Community: Using Inquiry-Based Curriculum to Interrogate the Politics of Place with Fifth-Grade Students

This paper reports on a qualitative participatory curriculum study where 5th graders from southeast Wisconsin investigate the concept of community through a process of counter-mapping. Framed by place-based education and spatial justice, this counter-mapping curriculum centers student collaboration and analysis, which provides a way for students to share and complicate their relations to place and implicit spatial knowledge of community. Through this curriculum students demonstrated the ability to collaboratively analyze normative assumptions embedded in the idea of community. In the process, they interrogated economic, racialized, and colonial politics of place, and started to interrogate dominant white spatial epistemologies. Counter-mapping as a curricular method not only facilitates new understanding through a shared critical spatial analysis but can also cultivate new ways of relating to and being with one another that are essential for more-just spatial imaginations.

Association between body-mass index, patient characteristics, and obesity-related comorbidities among COVID-19 patients: A prospective cohort study

ObjectiveObesity is a major risk factor for adverse outcomes after COVID-19 infection. However, it is unknown if the worse outcomes are due to the confounding effect of demographic and obesity-related comorbidities. The study objective is to analyze associations between body mass index, patient characteristics, obesity-related comorbidity, and clinical outcomes in COVID-19 patients. MethodsIn this prospective cohort study, we chose patient records between March 1st, 2020, and December 1st, 2022, in a large tertiary care center in southeast Wisconsin in the United States. Patients over the age of 18 who tested positive were included in the study. Clinical outcomes included hospitalization, intensive care unit (ICU) admission, mechanical ventilation, and mortality rates. We examined the characteristics of patients who had positive clinical outcomes. We created unadjusted logistic regression models, sequentially adjusting for demographic and comorbidity variables, to assess the independent associations between BMI, patient characteristics, obesity-related comorbidities, and clinical outcomes. ResultsFrom a record of 1.67 million inpatients and outpatients at Froedtert Health Center, 55,299 (BMI: 30.5 ± 7.4 kg/m2, 62.5 % female) tested COVID-19 positive during the study period. 17,580 (31.8 %) patients were admitted to hospitals, and of hospitalized patients required ICU admission. 1038 (36.3 %) required mechanical ventilation, and 462 (44.5 %) died after a positive test for COVID-19. We found female patients show a higher hospitalization rate, while male patients have a higher rate of ICU admission, mechanical ventilation, and mortality. Obesity-related comorbidities are associated with worse outcomes compared to simple obesity without comorbidities. In logistic regression models, we found four similar V-shaped associations between BMI and four clinical outcomes. Patients with a BMI of 25 kg/m2 are at the lowest risk for clinical outcomes. Patients with a BMI lower than 18 kg/m2 or higher than 30 kg/m2 are associated with a higher risk of hospitalization, ICU, mechanical ventilation, and death. After adjusting the model for demographic factors and hypertension and diabetes as two common comorbidities, we found that demographic factors do not significantly increase the risk. Obesity alone does not significantly increase the risk of severe clinical outcomes. Obesity-related comorbidities, on the other hand, resulted in a significantly higher risk of outcomes. ConclusionObesity alone does not increase the risk of worse clinical outcomes after COVID-19 infection. It may suggest that the worse clinical outcomes of patients with obesity are mediated via hypertension and type 2 diabetes. Patients with obesity and comorbidities have a higher risk of poor outcomes. Obesity-related comorbidities, including hypertension and diabetes, are independently associated with poorer clinical outcomes among COVID-19 patients. At a BMI of more than 30 kg/m2 or less than 18 kg/m2, we found an increase in the risk of severe COVID-19 outcomes leading to hospitalization, ICU, mechanical ventilation, and death. The increased risk of severe outcomes is not attributed to patient characteristics but can be attributed to hypertension and diabetes.

Gobbling across landscapes: Eastern wild turkey distribution and occupancy-habitat associations.

Extensive restoration and translocation efforts beginning in the mid‐20th century helped to reestablish eastern wild turkeys (Meleagris gallopavo silvestris) throughout their ancestral range. The adaptability of wild turkeys resulted in further population expansion in regions that were considered unfavorable during initial reintroductions across the northern United States. Identification and understanding of species distributions and contemporary habitat associations are important for guiding effective conservation and management strategies across different ecological landscapes. To investigate differences in wild turkey distribution across two contrasting regions, heavily forested northern Wisconsin, USA, and predominately agricultural southeast Wisconsin, we conducted 3050 gobbling call‐count surveys from March to May of 2014–2018 and used multiseason correlated‐replicate occupancy models to evaluate occupancy–habitat associations and distributions of wild turkeys in each study region. Detection probabilities varied widely and were influenced by sampling period, time of day, and wind speed. Spatial autocorrelation between successive stations was prevalent along survey routes but was stronger in our northern study area. In heavily forested northern Wisconsin, turkeys were more likely to occupy areas characterized by moderate availability of open land cover. Conversely, large agricultural fields decreased the likelihood of turkey occupancy in southeast Wisconsin, but occupancy probability increased as upland hardwood forest cover became more aggregated on the landscape. Turkeys in northern Wisconsin were more likely to occupy landscapes with less snow cover and a higher percentage of row crops planted in corn. However, we were unable to find supporting evidence in either study area that the abandonment of turkeys from survey routes was associated with snow depth or with the percentage of agricultural cover. Spatially, model‐predicted estimates of patch‐specific occupancy indicated turkey distribution was nonuniform across northern and southeast Wisconsin. Our findings demonstrated that the environmental constraints of turkey occupancy varied across the latitudinal gradient of the state with open cover, snow, and row crops being influential in the north, and agricultural areas and hardwood forest cover important in the southeast. These forces contribute to nonstationarity in wild turkey–environment relationships. Key habitat–occupancy associations identified in our results can be used to prioritize and strategically target management efforts and resources in areas that are more likely to harbor sustainable turkey populations.

Projected lake sturgeon recovery in the Milwaukee River, Wisconsin, USA

Using a forward projecting population model, the timing and scale of Lake Sturgeon Acipenser fulvescens (LS) recovery and natural reproduction was estimated for the Milwaukee River in Wisconsin, USA for the years 2004–2048. LS, a widely distributed potamodromous Acipenseridae species in North America, have, like other sturgeon species, suffered population declines due to overharvest and other factors since the 1800s. LS recovery efforts were initiated in the early 1980s following the successful development of LS propagation techniques and stocking has become a widely utilized tool in LS recovery programs. Sturgeon recovery programs are long-term endeavors, with annual stocking usually planned for 25 plus years, along with population assessments and habitat improvements conducted over decades before project success can be verified. LS recovery activities on the Milwaukee River, a Lake Michigan tributary in southeast Wisconsin, began with barrier mitigation in 1997 and stocking in 2003. The modest size of the Milwaukee River, along with habitat improvements, and 17 years of stocking, provided an opportunity to model and predict LS population recovery trends. A forward projecting population model with an imbedded stochastic Ricker stock-recruitment relationship, adjusted for the estimated LS productive capacity of the Milwaukee River, estimated the timing and scale of LS recovery during 2004–2048 predicting a 18.3% annual average population rate of increase during the stocking period, and a 5.7% post-stocking rate. Accelerated LS growth and maturity due to goby consumption built into the model resulted in projections of gravid adult males present in 2012 and spawning adult females and natural recruitment in 2019. During the 2020 spawning period a group of adult-sized LS were observed in the Milwaukee River below an intermittent barrier on the river. The model predicted adult LS densities to grow from 22 in 2012 to 8088 in 2048, and annual natural recruitment to grow steadily from 76 yearlings in 2019 to an average of 4000 yearlings/year during 2039-2049. The estimated number of yearling recruits per spawning (gravid) female dropped steadily from 21 in 2019 to 8 recruits per gravid female in 2048 as a function of the Ricker stock-recruitment relationship built into the model. The model results indicate that significant LS recovery can possibly begin in a shorter time frame on Great Lakes tributaries than originally expected through systematic resolution of habitat issues and LS stocking. Results can also be used to help anticipate recovery trends, fine tune stocking and habitat strategies, and plan LS recovery assessments.

Relationship between mental health diagnoses and COVID-19 test positivity, hospitalization, and mortality in Southeast Wisconsin.

There is a paucity of literature on the relationship between pre-existing mental health conditions and coronavirus disease-2019 (COVID-19) outcomes. The aim was to examine the association between pre-existing mental health diagnosis and COVID-19 outcomes (positive screen, hospitalization, mortality). Electronic medical record data for 30 976 adults tested for COVID-19 between March 2020 and 10th July 2020 was analyzed. COVID-19 outcomes included positive screen, hospitalization among screened positive, and mortality among screened positive and hospitalized. Primary independent variable, mental health disorders, was based on ICD-10 codes categorized as bipolar, internalizing, externalizing, and psychoses. Descriptive statistics were calculated, unadjusted and adjusted logistic regression and Cox proportional hazard models were used to investigate the relationship between each mental health disorder and COVID-19 outcomes. Adults with externalizing (odds ratio (OR) 0.67, 95%CI 0.57-0.79) and internalizing disorders (OR 0.78, 95% CI 0.70-0.88) had lower odds of having a positive COVID-19 test in fully adjusted models. Adults with bipolar disorder had significantly higher odds of hospitalization in fully adjusted models (OR 4.27, 95% CI 2.06-8.86), and odds of hospitalization were significantly higher among those with externalizing disorders after adjusting for demographics (OR 1.71, 95% CI 1.23-2.38). Mortality was significantly higher in the fully adjusted model for patients with bipolar disorder (hazard ratio 2.67, 95% CI 1.07-6.67). Adults with mental health disorders, while less likely to test positive for COVID-19, were more likely to be hospitalized and to die in the hospital. Study results suggest the importance of developing interventions that incorporate elements designed to address smoking cessation, nutrition and physical activity counseling and other needs specific to this population to improve COVID-19 outcomes.

Correlating Bedrock Folds to Higher Rates of Arsenic Detection in Groundwater, Southeast Wisconsin, USA.

Arsenic in private drinking water wells is a significant problem across much of eastern Wisconsin, USA. The release mechanism and stratigraphic distribution of sulfide and iron (hydr)oxide sources of arsenic in bedrock aquifers are well understood for northeastern Wisconsin. However, recent geologic mapping has identified numerous small bedrock folds to the south, and the impact of these geologic structures on local groundwater flow and well contamination has been little studied. This paper examines the hydrologic and structural effects of the Beaver Dam anticline, southeast Wisconsin, on arsenic in groundwater in the region. Multivariate logistic regression shows wells near the Beaver Dam anticline are statistically more likely to detect arsenic in groundwater compared to wells farther away. Structural and hydrologic changes related to folding are interpreted to be the cause. Core drilled near the fold axis is heavily fractured, and many fractures are filled with sulfides. Elevated hydraulic conductivity estimates are also recorded near the fold axis, which may reflect a higher concentration of vertical fractures. These structural and hydrologic changes may have led to systematic changes in the distribution and concentration of arsenic-bearing mineral hosts, resulting in the observed detection pattern. For areas with similar underlying geology, this approach may improve prediction of arsenic risk down to the local level.

17101 A retrospective review of delay in diagnosis and dermatology visits characterized by insurance type in patients with hidradenitis suppurativa in a Midwestern population

Hidradenitis suppurativa (HS) is an inflammatory skin condition that is believed to disproportionately affect populations with low socioeconomic status. We searched the Medical College of Wisconsin and Froedtert Health i2b2 electronic data warehouse, including more than 1.3 million patients in Southeast Wisconsin, for patients with an HS diagnosis and ≥3 encounters for HS using ICD9 705.83 and ICD10 L73.2 codes. We randomly characterized 373 of 1190 identified patients by retrospective chart review, excluding patients without an encounter for HS treatment. Of 243 patients with documentation of insurer at the time of HS diagnosis, 25.5% (62) had private insurance, 20.6% (50) had Medicaid, 12.8% (31) had Medicare, and 41.2% (100) were uninsured. 223 of these patients also had documentation of year of symptom onset and year of HS diagnosis. The mean delay in diagnosis was 2.84 years (n = 89) for uninsured patients, 3.86 years (n = 56) for patients with private insurance, 4.6 years (n = 30) with Medicare, and 6.77 years (n = 48) with Medicaid. Of 243 patients with documentation of insurer at the time of HS diagnosis, 64.5% (40) of patients with private insurance, 60.0% (30) with Medicaid, 46.0% (46) of uninsured patients, and 32.3% (10) with Medicare have seen a dermatologist for treatment of HS. Our findings suggest that insurance class, a determinant of access to care, may impact effective management of HS and should be further explored.

16604 A retrospective review of delay in diagnosis, severity of disease, and dermatology visits characterized by race in patients with hidradenitis suppurativa in a Midwestern population

Hidradenitis suppurativa (HS) is an inflammatory skin condition that disproportionately affects African Americans. We searched the Medical College of Wisconsin and Froedtert Health i2b2 electronic data warehouse, including more than 1.3 million patients in Southeast Wisconsin, for patients with an HS diagnosis and ≥3 encounters for HS using ICD9 705.83 and ICD10 L73.2 codes. We randomly characterized 373 of 1190 identified patients by retrospective chart review, excluding patients without an encounter for HS treatment.

Racial/Ethnic Differences In COVID-19 Screening, Hospitalization, And Mortality In Southeast Wisconsin.

This study aimed to understand racial/ethnic differences in coronavirus disease 2019 (COVID-19) screening, symptom presentation, hospitalization, and mortality, using data from 31,549 adults tested for COVID-19 between March 1 and July 10, 2020, in Milwaukee and Southeast Wisconsin. Racial/ethnic differences existed in adults who screened positive for COVID-19 (4.5percent of non-Hispanic Whites, 14.9percent of non-Hispanic Blacks, and 14.8percent of Hispanics). After adjustment for demographics and comorbidities, Blacks and Hispanics were more than three times more likely to screen positive and two times more likely to be hospitalized relative to Whites, and Hispanics were two times more likely to die than Whites. Given the long-standing history of structural racism, residential segregation, and social risk in the US and their role as contributors to poor health, we propose and discuss the part these issues play as explanatory factors for our findings.

Using a process improvement approach to identifying barriers to research in a CTSA hub environment.

For the past 4 years, as part of the National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) grant award number UL1TR001436, the Clinical Translational Science Institute of Southeast Wisconsin (CTSI) has used process engineering approaches to identify and understand barriers that local researchers and other stakeholders face when engaging in clinical and translational science. We describe these approaches and present preliminary results. We identified barriers from published and unpublished work at other CTSA hubs, supplemented by surveys and semi-structured interviews of CTSI faculty. We then used a multifaceted approach to organize, visualize, and analyze the barriers. We have identified 27 barriers to date. We ranked their priority for CTSI to address based on the barrier's impact, the feasibility of intervention, and whether addressing the barrier aligned with CTSI's institutional role. This approach provides a systematic framework to scope and address the "barriers to research problem" at CTSI institutions.

Workers wanted: Changing employee accessibility with industrial development ─ Evidence from Foxconn

In response to the trends of manufacturing revitalization and workforce shortage in the U.S., this study investigates how Foxconn changes accessibility to industrial employees by automobile and by transit in Southeast Wisconsin. Results suggest that there is a mismatch between the Foxconn site and the areas with high accessibility to industrial employees. With a great demand for labor, Foxconn reduces employee accessibility by automobile throughout the region, while its impact on employee accessibility by transit is more localized. The results inform industrial firm locations, workforce housing development, and transportation service provisions. The analysis framework shifts the angle of accessibility research to focusing on the perspective of employers, and it can be applied to investigate future large-scale economic development projects.

Analysis on residential density dynamics in USA-a case study in southeast Wisconsin

Residential development was a dynamic and complex process along with urbanization. Suitable residential density has become the core content of urban densification, which promote local prosperity and the sustainability of the urban landscape. Much recent research has examined residential expansion, but less attention has been paid to dynamics among different residential densities, which was a significant indicator of urban densification and greatly related to the city’s livability. This paper focused on the residential density dynamics and its driving forces in southeastern Wisconsin. Our results revealed that low density was the main residential pattern, and that increasing suburban density was a very common characteristic among all counties from 1990 to 2010. The significant drivers of residential densities included the perfection degree of urban function, water supply service, access to existing urban and residential areas, and the elevation. The significant drivers varied from the distance to historical center and among counties. The results highlighted the importance of perfection degree of urban function as an essential factor to explain the residential density dynamics. Accordingly, the regulation of urban function and carrying capacity also become a powerful tool for controlling suitable residential density, which was essential for the urban planning and real estate industry.

Stormwater management actions under regulatory pressure: a case study of southeast Wisconsin

In the United States, new legislation has given regulatory authorities greater oversight of municipal stormwater management programs. However, estimating the impact of greater oversight on municipal actions is difficult due to the uncertainty in current compliance efforts and their associated costs. This paper seeks to fill this gap through a case study of NPDES stormwater runoff permit reports from municipalities in Southeast Wisconsin. Specifically, this study evaluates the reported actions and expenditures against socioeconomic variables to identify the relationships between cost, socioeconomics, and the best management practices (BMPs) used for compliance. Results indicate that there are distinct differences between municipalities with and without financial and personnel resources, clear high- and low-cost BMPs, and large variation in the practices municipalities implement to meet regulatory requirements. Furthermore, results suggest that regulators should take a flexible and pragmatic approach that considers individual municipal constraints and limitations when exercising greater regulatory authority.

Naturally Occurring versus Anthropogenic Sources of Elevated Molybdenum in Groundwater: Evidence for Geogenic Contamination from Southeast Wisconsin, United States

Molybdenum (Mo) is an essential trace nutrient but has negative health effects at high concentrations. Groundwater typically has low Mo (<2 μg/L), and elevated levels are associated with anthropogenic contamination, although geogenic sources have also been reported. Coal combustion residues (CCRs) are enriched in Mo, and thus present a potential anthropogenic contamination source. Here, we use diagnostic geochemical tracers combined with groundwater residence time indicators to investigate the sources of Mo in drinking-water wells from shallow aquifers in a region of widespread CCR disposal in southeastern Wisconsin. Samples from drinking-water wells were collected in areas near and away from known CCR disposal sites, and analyzed for Mo and inorganic geochemistry indicators, including boron and strontium isotope ratios, along with groundwater tritium-helium and radiogenic 4He in-growth age-dating techniques. Mo concentrations ranged from <1 to 149 μg/L. Concentrations exceeding the U.S. Environmental Protection Agency health advisory of 40 μg/L were found in deeper, older groundwater (mean residence time >300 y). The B (δ11B = 22.9 ± 3.5‰) and Sr (87Sr/86Sr = 0.70923 ± 0.00024) isotope ratios were not consistent with the expected isotope fingerprints of CCRs, but rather mimic the compositions of local lithologies. The isotope signatures combined with mean groundwater residence times of more than 300 years for groundwater with high Mo concentrations support a geogenic source of Mo to the groundwater, rather than CCR-induced contamination. This study demonstrates the utility of a multi-isotope approach to distinguish between fossil fuel-related and natural sources of groundwater contamination.

Modeling lane-change-related crashes with lane-specific real-time traffic and weather data

ABSTRACTThis study investigates the relationship between lane-change-related crashes and lane-specific, real-time traffic factors. It is anticipated that the real-time traffic data for the two lanes—the vehicle's lane (subject lane) and the lane to which that a vehicle intends to change (target lane)—are more closely related to lane-change-related crashes, as opposed to congregated traffic data for all lanes. Lane-change-related crash data were obtained from a 62-mile long freeway in Southeast Wisconsin in 2012 and 2013. One-minute traffic data from the 5- to 10-minute interval prior to the crashes were extracted from an immediately upstream detector station and two immediately downstream stations from the crash location. Weather information was collected from a major historical weather database. A matched case-control logistic regression was used for analysis. Results show that the following factors significantly affect the probability of a lane-change-related crash: average flow into the target lane at the first downstream station, the flow ratio at the second downstream station, and snow conditions. Additionally, the average speed in the target lane at the first downstream station contributes to the occurrence of lane-change crashes during snowy conditions. According to the model, the probability of a lane-change-related crash under real-time traffic conditions can aid in flagging potential crash-prone conditions. The identified contributing factors can help traffic operators select traffic control and management countermeasures to proactively mitigate lane-change-related crashes.

Science Cafés: Transforming citizens to scientific citizens-What influences participants' perceived change in health and scientific literacy?

Science Cafés facilitated by the Clinical and Translational Science Institute of Southeast Wisconsin seek to increase health and scientific literacy through informal conversation between researchers and community members. The goal was to understand what factors have the greatest influence on attendees' perceived changes in health and science literacy levels (PCHSL) to increase impact. Previous research established the evaluation used in the Science Cafés to measure PCHSL. In this study, comparisons were made between (1) 2 different approaches to Science Cafés (Genomics Science Cafés or Health Science Cafés) and (2) regression models to show which factors best predicted PCHSL. The approach of the Genomics Science Cafés series to Science Cafés showed a larger impact on PCHSL. Regression models suggest SES and education significantly contributes to PCHSL. Insights for program development to have greater impact on PCHSL were identified. Continuing to optimize dissemination of research findings to the public is essential for improving community health and well-being.

Reactions of Low-Income African American Women to Breastfeeding Peer Counselors

ObjectiveTo examine the influence of breastfeeding peer counseling on the breastfeeding experiences of African American mothers who participated in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DesignQualitative study using focus groups. SettingTwo WIC clinics in Southeast Wisconsin were used for recruitment and data collection. ParticipantsA convenience sample of nine African American mothers participated in one of two focus groups. MethodsThe women responded to a series of open-ended questions about their breastfeeding experiences and the effect of breastfeeding peer counselors (BPCs). Content and thematic analyses were used to analyze patterns related to the influence of BPCs on breastfeeding. ResultsFour themes were categorized: Educating With Truth, Validating for Confidence, Countering Others' Negativity, and Supporting With Solutions. Mothers in this study expressed positive reactions to educational, emotional, and social support from BPCs. The mothers noted that the contact they had with BPCs had a direct positive influence on their breastfeeding experiences. However, the contact from BPCs varied between the two WIC clinics. ConclusionThe findings demonstrate the positive effects of BPCs on breastfeeding experiences among African American WIC participants. Findings from this study can guide future explorations using BPCs. Interventions are needed to develop standardized guidelines to bring about homogeneity of, better access to, and greater use of BPCs.

Science Cafés: Engaging Scientists and Community through Health and Science Dialogue

Engagement of the community through informal dialogue with researchers and physicians around health and science topics is an important avenue to build understanding and affect health and science literacy. Science Cafés are one model for this casual interchange; however the impact of this approach remains under researched. The Community Engagement Key Function of the Clinical and Translational Science Institute of Southeast Wisconsin hosted a series of Science Cafés in which topics were collaboratively decided upon by input from the community. Topics ranged from Personalized Medicine to Alzheimer's and Dementia to BioMedical Innovation. A systematic evaluation of the impact of Science Cafés on attendees' self-confidence related to five health and scientific literacy concepts showed statistically significant increases across all items (Mean differences between mean retrospective pre-scores and post-scores, one tailed, paired samples t-test, n=141, p<.0001 for all items). The internal consistency of the five health and scientific literacy items was excellent (n=126, α=0.87). Thematic analysis of attendees' comments provides more nuance about positive experience and suggestions for possible improvements. The evaluation provides important evidence supporting the effectiveness of brief, casual dialogue as a way to increase the public's self-rated confidence in health and science topics.

Deep Pharma: Psychiatry, Anthropology, and Pharmaceutical Detox

Psychiatric medication, or psychotropics, are increasingly prescribed for people of all ages by both psychiatry and primary care doctors for a multitude of mental health and/or behavioral disorders, creating a sharp rise in polypharmacy (i.e., multiple medications). This paper explores the clinical reality of modern psychotropy at the level of the prescribing doctor and clinical exchanges with patients. Part I, Geographies of High Prescribing, documents the types of factors (pharmaceutical-promotional, historical, cultural, etc.) that can shape specific psychotropic landscapes. Ethnographic attention is focused on high prescribing in Japan in the 1990s and more recently in the Upper Peninsula of Michigan, in the US. These examples help to identify factors that have converged over time to produce specific kinds of branded psychotropic profiles in specific locales. Part II, Pharmaceutical Detox, explores a new kind of clinical work being carried out by pharmaceutically conscious doctors, which reduces the number of medications being prescribed to patients while re-diagnosing their mental illnesses. A high-prescribing psychiatrist in southeast Wisconsin is highlighted to illustrate a kind of med-checking taking place at the level of individual patients. These various examples and cases call for a renewed emphasis by anthropology to critically examine the "total efficacies" of modern pharmaceuticals and to continue to disaggregate mental illness categories in the Boasian tradition. This type of detox will require a holistic approach, incorporating emergent fields such as neuroanthropology and other kinds of creative collaborations.