What is Melasma?
Word of the Cybermen spread as far as the Wrarth Galaxy. July 19 Hensel Phelps West. Many were propelled into deep space. The Time of the Doctor. There are a variety of shows and ads that utilize medicine and health as their subjects, and in many cases…. Existing facilities that are operational are under extreme stress as they assume even greater responsibilities to fill the gaps created by the loss of so many facilities. The Mazes of Time.
What causes melasma?
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Working for a World Free of Poverty. BLOG Can chlorine create safe drinking water? Lessons on creating safe water sources. Comments Very interesting strategy to increase clean water access. Nice innovation but what about its sustainability? Await your feed back Regards Mahina Arefin.
Hospital billing offices tabulate lengthy itemized bills and charge a multitude of payers using inefficient, complex and separately negotiated rate schedules. Global budgets would also eliminate hospital billing and relieve clinicians of billing-related documentation, freeing up resources to enhance clinical services. The NHP would accommodate two different modes of payment for physicians and other outpatient practitioners: While conventional wisdom blames the failings of our health care system especially cost 22 on fee-for-service incentives, every mode of payment has pitfalls.
Yet other countries have found fee-for-service — as well as capitation and salaried practice — compatible with quality and cost containment, as long as the fees do not unduly reward procedure-oriented specialists compared with primary care providers. Regardless of the payment mode, the NHP would prohibit the diversion of operating revenues to profits or capital investments, and the payment of bonuses tied either positively or negatively to utilization or to institutional profitability.
For fee-for-service practitioners, the NHP and organizations representing the practitioners would negotiate a simple, binding fee schedule. The NHP could draw on a number of tools that other countries have found effective in countering the inflationary tendency of fee-for-service, including: Practitioners could also choose salaried practice in non-profit globally budgeted providers such as hospitals, clinics, group practices, etc.
Where appropriate, the global budget could include funding for community programming e. Integrated health care systems would also employ salaried practitioners. In such systems, hospitals might be paid through a separate global budget, or through a unified global budget for the entire organization.
Integrated provider networks and accountable care organizations ACOs offer potential benefits, but also the threat that they will exploit oligopoly market power to drive up costs and profits, and pressure physicians to help achieve these goals. Hence, the NHP would allow, even encourage integrated systems, but would mandate that regionally dominant systems be publicly controlled. Local public agencies employing expert panels of social workers, nurses, therapists, and physicians would assess eligibility and coordinate care.
They would contract with individual caregivers, as well as nonprofit and public agencies and facilities. Alternatively, integrated provider organizations could receive an augmented capitation fee or global budget to provide LTC as well as acute care services.
Countries such as Japan and Germany with universal LTC coverage provide more and better care, yet spend no more than the U. The NHP would fund all major capital investments through explicit appropriations. Regional health planning boards would allocate capital funds for new facilities and expensive new equipment based on medical need, project quality and efficiency. Private donations for projects that would entail increases in NHP operating expenses would be proscribed. When capital funding and operating payments are combined in a single revenue stream, as is now the case, profitable health care institutions are able to expand and modernize, regardless of medical need, while those with less favorable bottom lines fall further behind.
Too often, profitability reflects not efficiency or quality, but the avoidance of unprofitable patients and services, a willingness to game payment systems, and the exercise of market clout. As a result, the implicit capital allocation process has created both medical deserts — areas of great need and few resources — and lavish, often redundant medical palaces that compete for lucrative patients and are tempted to provide unneeded care.
Planning should also assure that training programs produce an appropriate mix of health professionals. Residency programs already publicly funded must train generalists and specialists in proportions that reflect societal needs. Instead, we advocate that the NHP fully subsidize the education of physicians, as well as that of nurses, public health professionals and other health care personnel.
The NHP would cover all medically necessary prescription medications, devices and supplies. It would directly negotiate prices with manufacturers, producing substantial savings. An expert panel would establish and update a national formulary, which would specify the use of the lowest cost medications among therapeutically equivalent drugs with exceptions where clinically required. Full drug coverage is an essential component of an NHP.
Copayments reduce adherence to medications and worsen clinical outcomes. The NHP would, like other large purchasers, use its market clout and formularies to negotiate lower drug prices with manufacturers.
A single-payer system would trim administration, reduce incentives to over-treat, lower drug prices, minimize wasteful investments in redundant facilities, and eliminate almost all marketing and investor profits. These measures would yield the substantial savings needed to fund universal care and new investments in currently under-funded services and public health activities — without any net increase in national health spending.
As a result, U. Total expenditures under the NHP would be limited to approximately the same proportion of GDP as the year prior to its establishment. While the needed funds could be garnered in a variety of ways, we favor the use of progressive taxes in order to reduce income inequality — itself an important social determinant of poor health. During a transition period, all public funds currently spent on health care — including Medicare, Medicaid, and state and local health care programs — would be redirected to the unified NHP budget.
During the transition period, these additional public funds could be raised through a variety of measures, e. In the longer term, however, direct funding through progressive taxes would be fairer. By unburdening employers, the NHP would facilitate entrepreneurship while increasing the global competitiveness of American business.
The ACA embodies the hopes of many for a more just health care system. Nor will it eliminate underinsurance. Disturbingly, the ACA has facilitated the imposition of new out-of-pocket costs on Medicaid recipients, and the skimpy coverage provided by many of the plans sold through the exchanges codifies the trend towards higher cost sharing for the privately insured.
Moreover, care obtained outside of the narrow provider networks provided by many exchange plans is neither covered nor applied to the out-of-pocket cap. ACOs are now widely promoted as a solution to our health care problems. Under ACO arrangements, insurers offer bonuses to hospitals and medical groups if they reduce health care costs, and under some arrangements penalize them when costs exceed targets.
Like the HMOs of a previous era, ACOs invert fee-for-service incentives to provide excess care, instead offering rewards for reducing care. To counter the obvious risk that these inverted incentives may lead to the denial of needed care, ACO payment schemes invariably mandate extensive reporting of quality indicators, and withhold some payments unless quality targets are met.
Unfortunately, experience warns that quality monitoring may not protect patients in a profit-driven medical environment. Such monitoring figured prominently in the seminal HMO proposal 31 that preceded the well-documented abuses of the s. Many argue that rewarding providers on the basis of the value they create for patients, rather than the volume of care they deliver, will improve outcomes, contain costs, and foster innovation. Unfortunately, empiric support for this approach is lacking, and it rests on dubious assumptions about measurement and motivation.
Despite decades of effort to develop inpatient risk adjustment, four widely used algorithms yield strikingly divergent rankings of hospital mortality performance. Similarly, even excellent doctors who care for disadvantaged patients often score poorly on quality metrics. NAPA Report , He was the Governor of Vermont from Prior to his service to the President, Secretary Ridge was the governor of Pennsylvania.
WW Norton and Company , The development of the NRP included extensive vetting and coordination with Federal, State, local, and tribal agencies, nongovernmental organizations, private-sector entities, and the first-responder and emergency management communities. For a list of the signatories of the NRP, see U. In addition, many requests by Governors for Federal assistance are made that do not result in a disaster declaration but are nevertheless significant.
Although the National Response Plan by virtue of the Catastrophic Incident Annex did anticipate the need for a more robust Federal response to a catastrophic incident, that is all it did. Without the Catastrophic Incident Supplement , that acknowledgement was not made operational and thus had no practical effect. NRP actions that had not yet been taken at this time included standup of the Interagency Incident Management Group and establishment of a fully functional Joint Field Office.
I arrived in Baton Rouge late in the afternoon. The State was heavily involved in the ongoing evacuation efforts but did begin working with us on such issues as search and rescue, commodity distribution, and medical needs. We worked late into the night and began again early on Sunday morning.
We worked on identifying distribution sites; sending food and water to the Superdome; coordinating with health officials in New Orleans and the State; and planning with State and Federal agencies on potential search and rescue efforts. National Response Plan , Appendix 5. National Response Plan , The delineation of roles and responsibilities between the statutorily empowered FCO and the policy constructed PFO are unclear.
Section of the Stafford Act expressly requires the President, immediately upon his declaration of a major disaster or emergency, to appoint a FCO to conduct response and recovery operations in the affected area. The President has also formally delegated his response and recovery powers granted him in the Stafford Act to the Secretary of Homeland Security. The Stafford Act of gave this authority to direct other departments to the President; Executive Order delegated this authority in to the FEMA Director; and Executive Order subsequently transferred the authority in to the Secretary of Homeland Security.
See Executive Order no. See also note Many have years of experience, while others may have little to no prior disaster or emergency response experience.
These employees are only used to assist in the aftermath of specific disasters and emergencies. The reservists are trained to fulfill specific disaster response staffing needs, including key program, technical, and administrative functions. Region VI has employees and over reservists, and Region VI has employees and over reservists. FEMA employs more than 2, full-time staff, about 1, of them in its ten regional offices, and nearly 4, disaster reservists.
FEMA disaster reservists, officially known as Disaster Assistance Employees, serve as a surge force for rapidly increasing the pool of Federal response personnel during a major disaster. The agency has access to this collective pool of human resources, but does not have its own critical response assets, such as buses, trucks, and ambulances.
Furthermore, our experience in Hurricane Katrina suggests it must now be reconsidered to make it more robust in ensuring that Federal assistance arrives as soo as possible. In , the hurricane season had been particularly devastating.
Twenty seven disasters were declared in fifteen States and two U. The season was especially difficult for Florida, which took a direct hit from four hurricanes and one tropical storm in six weeks. Brown, and Eric S. Blake, Tropical Cyclone Report: Lawrence and Hugh D. Cobb, Tropical Cyclone Report: FEMA conducted coordination calls between Federal, State and local officials, positioned liaison officers at State Emergency Operations Centers, pre-staged emergency supplies and response teams at various locations, and requested the activation of the First U.
C, August 2, Excerpt from this text: This trough, located over the western Atlantic and the Bahamas, produced strong westerly shear across Tropical Depression Ten, causing it to degenerate on 14 August approximately n.
The low-level circulation gradually weakened while continuing westward, and it eventually dissipated on 21 August in the vicinity of Cuba. Meanwhile, a middle tropospheric circulation originating from Tropical Depression Ten lagged behind and passed north of the Leeward Islands on August. A tropical wave moved through the Leeward Islands and merged with the middle tropospheric remnants of Tropical Depression Ten on 19 August, forming a large area of showers and thunderstorms north of Puerto Rico.
This activity continued to move slowly northwestward, passing north of Hispaniola and then consolidating just east of the Turks and Caicos during the afternoon of 22 August. The upper tropospheric trough weakened as it moved westward toward Florida, and the shear relaxed enough to allow the system to develop into a tropical depression by utc 23 August over the southeastern Bahamas about n.
National Hurricane Center Katrina Advisories were released every several hours beginning at 5: Advisories were typically issued at 5: The advisories are numbered sequentially from 1 to Advisory 2 was released at Northern Command, written statement for a hearing on Hurricane Katrina: The HLT had begun monitoring the storm the previous evening.
The Emergency Operations Center is the physical location at which the coordination of information and resources to support domestic incident management activities normally takes place. An EOC may be a temporary facility or may be located in a more central or permanently established facility. Throughout this Report, note that events were occurring in different time zones. Times referenced as Central Daylight Time cdt reflect the local time events took place in Louisiana.
Throughout the report, times are referenced in accordance with the source material supporting the text. These advisories are available at the U. Katrina made landfall at 6: See generally, Robert R. Random House, , Note that statistics for disasters can vary significantly depending on the source consulted, due to both variances in how terms are defined and the difficulty of confirming specific data in the aftermath of a devastating event.
The classification of Hurricane Betsy as a Category 3 storm was made retroactively based on wind speed readings. For general information on Hurricane Betsy, see U. For deaths, see Eric S. For extent of flooding by parish see, Joseph A. For deaths, see Ernest Zebrowski and Judith A. For other information, see U. It is important to note that the levees protecting New Orleans were designed in advance of the Saffir-Simpson model.
The central pressure for an SPH is in the Category 4 range, the highest wind speed is that of a high strength Category 2, and the surge is similar to that of a Category 3.
Army Corps of Engineers to provide continuous hurricane protection from Morgan City to the Mississippi border. Army Corps of Engineers was released in June However, this is not always the case. A weak, slow moving tropical storm can cause more damage due to flooding than a more powerful fast moving hurricane. FEMA granted the State funding in , but was forced to withdraw those funds a year later, due to budgetary constraints.
Despite this setback, the need for catastrophic hurricane planning in Louisiana continued to be recognized at both the Federal and State level. Tammany, Tangipahoa, and Terrebonne. State Representative Cedric Richmond called Governor Blanco on Saturday afternoon after visiting a ballpark where hundreds were in attendance. He worries that many may have thought that the hurricane was still targeting the Florida panhandle.
Furthermore, during the Precautionary stage the Plan directs that nursing homes and other custodial care organizations in the risk areas should be contacted to ensure that they are prepared to evacuate their residents.
On Saturday August 27, , representatives of the Louisiana Nursing Home Association LNHA , sitting at the Louisiana State EOC, started calling and emailing all the at-risk nursing homes in Louisiana, checking on their preparedness for the storm and determining if they were planning to evacuate or shelter-in-place. They were able to reach most of the nursing homes. They learned that the State EOP was also calling nursing homes, as were the local parish sheriffs.
By Sunday morning, some nursing homes that intended to shelter-in-place had decided to evacuate. They had previously been told that buses were available but, by the time they decided to evacuate, drivers were not available. At that point the LNHA made formal requests for bus drivers, but none materialized prior to landfall. In all, prior to the storm, twenty-one nursing homes evacuated and sixty-eight sheltered-in-place.
See generally, Joseph A. As a result of these problems, Governor Barbour asked Mississippi Public Safety Commissioner George Phillips to develop a plan that would provide additional law enforcement officers to support evacuations, especially in the Hattiesburg area.
Sheltering New Orleans, n. Pratts] responded no, that they do not require anything at this time, and they would be in touch if and when they needed assistance. The Louisiana evacuation plan called for New Orleans to begin evacuations thirty hours prior to projected landfall. So public confidence was a little low at the time. I think regardless of what we do in this town, some people will stay. The Superdome was first used in this capacity in when people sought refuge from Hurricane Georges.
Unlike a shelter, there may be little or no water or food and possibly no utilities. A Last Resort Refuge is intended to provide best available survival protection for the duration of the hurricane only. Dialysis will not be available. Persons who are acutely ill will be evaluated and referred to local hospitals for definitive care. On a daily basis, every person with a chronic medical problem should have a viable plan that has been discussed with their primary physician so that when a disaster occurs, they will have an action plan established which can be put into effect.
Governor Riley said the state already has , bags of ice, more than , gallons of water, , MREs meals ready to eat , and , tarps measuring 20 feet by 25 feet. The figures for liters of water, pounds of ice, and number of MREs and tarps were converted using FEMA conversion factors of 18, liters of water, 40, pounds of ice, 2, tarps, and 21, MREs per truckload. Department of Transportation, Federal Highway Administration, http: Presidential states of emergency were declared for both States on August See also, Robert T.
Hurricane Floyd did not make landfall until 6: He did the same for the Carolinas the following day. For more information, see: That same day President Bush declared a state of emergency in Louisiana.
I called the former Governor of Louisiana in And this was Saturday night around 8: But the whole purpose of that was just to be absolutely sure that they understood the severity of the situation and I do remember telling all three of them that I want to leave the National Hurricane Center that night and be able to go home and sleep knowing that I had done everything that I could do. Department of Commerce, U. The system aims to reach the broadest possible audience by disseminating emergency updates on existing radio and television stations, including via digital and satellite networks.
EAS was officially launched on January 1, for radio stations and December 31, for television. While EAS fulfills the same function as EBS, it differs in that it takes advantage of digital technology to permit automation of transmission. The Emergency Broadcast System and its EAS successor were originally designed for the President to speak to the Nation during an emergency, particularly following catastrophic nuclear attacks. But the system was made available to State and local officials in , and since then has been used primarily for weather emergencies.
Coast Guard at its Best Washington, D. Louisiana law provides the parish presidents with the authority to issue mandatory evacuation orders. Although a State responsibility, it is unclear how the State or Parish law enforcement authorities intended to enforce this order. The Mayor ordered a mandatory evacuation for the entire Parish of Orleans, with the exceptions of essential personnel of the Federal government, State of Louisiana and City of New Orleans, as well as essential personnel of regulated utilities and mass transportation services, hospitals and their patients, essential media, Orleans Parish Criminal Sheriff's office and its inmates, and the essential personnel of operating hotels and their patrons.
The Mayor ordered every person not exempt to immediately evacuate the City of New Orleans, or if no other alternative was available, to immediately move to one of the facilities within the City that would be designated a refuge of last resort. Have we reached out to them, and have we I guess made any kind of arrangement in case we need some additional help from them?
They are fully engaged, and we are having those discussions with them now. It was Lokey in Louisiana and Carwile in Mississippi. But Brown went down as their supervisor with direct authority over them to be on the ground in charge of the entire Gulf Coast response. In other words, he went down on Sunday. He was in charge of this thing on the ground from his arrival on Sunday through the end.
The designation as a PFO, I guess, was a kind of formal recognition of that. I am proud that we rapidly moved over 1. We opened the Superdome as our refuge of last resort, and we staged buses throughout the city to transport people to the Superdome, and set a curfew for dusk.
The city also evacuated special needs residents to the state shelter and then opened the Superdome at 8 a. There were thousands of residents that did not leave, including those with means who would choose to ride out the storm like their parents had done during Hurricane Betsy.
When reality set in for many of them on Sunday, they made their way to the refuge of last resort, the Superdome. Louisiana National Guard personnel on-scene reported no evacuees at the Superdome until after noon. A shelter of last resort is intended to serve only as a location to ride out the winds of a storm. On November 29, , a Federal grand jury had indicted Michael L. This grant program funds mitigation projects to prevent flood loses or flood claims made upon the National Flood Insurance Program.
Alabama also requested the transport and delivery of two man Joint Field Office kits to Montgomery. Mississippi requested the pre-positioning of 30 trucks of water with tractors at Meridian NAS and two helicopters to transport response personnel.
We do not establish shelters in facilities that do not meet our criteria for safety during landfall. However, the Red Cross was not against the use of the Superdome as a shelter of last resort.
With the hurricane bearing down, the city government decided to open a shelter of last resort in the Superdome downtown. We applaud this decision and believe it saved a significant number of lives. The State declined assistance. John the Baptist parishes. Officials declared mandatory evacuations for limited geographical or flood-prone areas of the following parishes: James, Livingston, Tangipahoa, St. Parish officials recommended evacuations in Ascension, Assumption and Washington parishes.
MERS detachments are designed to provide communications capabilities and operational and logistical support to first responders. Each MERS detachment has a suite of vehicle assets to provide support.
MERS detachments also have rapid response teams to provide initial support immediately following a disaster. Since there are still 2, people from the Gulf Coast area missing, it is likely that the death toll numbers will increase. Summary Asheville, NC, January , http: