title: Social exclusion modifies climate and deforestation impacts on a vector-borne disease.
abstract: BACKGROUND
  The emergence of American Cutaneous Leishmaniasis (ACL) has been associated with changes in the relationship between people and forests, leading to the view that forest ecosystems increase infection risk and subsequent proposal that deforestation could reduce re-emergence of this disease.
  
  
  RESULTS
  We analyzed county-level incidence rates of ACL in Costa Rica (1996-2000) as a function of social and environmental variables relevant to transmission ecology with statistical models that incorporate breakpoints. Once social marginality was taken into account, the effect of living close to a forest on infection risk was small, and diminished exponentially above a breakpoint. Forest cover was associated with the modulation of temporal effects of El Niño Southern Oscillation (ENSO) at small spatial scales, revealing an additional complex interplay of environmental forces and disease patterns.
  
  
  CONCLUSIONS
  Social factors, which previously have not been evaluated rigorously together with environmental and climatic factors, appear to play a critical role that may ultimately determine disease risk.
authors.affiliation: Department of Ecology and Evolutionary Biology, University of Michigan, Ann Arbor, Michigan, United States of America. lfchaves@umich.edu
authors.forename: Luis Fernando
authors.initials: LF
authors.lastname: Chaves
authors.forename: Justin M
authors.initials: JM
authors.lastname: Cohen
authors.forename: Mercedes
authors.initials: M
authors.lastname: Pascual
authors.forename: Mark L
authors.initials: ML
authors.lastname: Wilson
mesh_terms: D000818:Animals; D002980:Climate; D003141:Communicable Diseases / Q000453:epidemiology*; D003247:Conservation of Natural Resources; D003364:Costa Rica / Q000453:epidemiology; D004199:Disease Vectors; D006801:Humans; D016773:Leishmaniasis, Cutaneous / Q000453:epidemiology*; D012931:Social Environment