text:
Chapter: Summary
« Previous: Front Matter
Page 1 Share Cite
Suggested Citation:"Summary." National Academies of Sciences, Engineering, and Medicine. 2016. Making Eye Health a Population Health Imperative: Vision for Tomorrow. Washington, DC: The National Academies Press. doi: 10.17226/23471.
Avoidable vision impairment occurs too frequently in the United States and is the logical result of a series of outdated assumptions, missed opportunities, and manifold shortfalls in public health policy and health care delivery. Eyesight affects how human beings perceive and interpret the world and is used for everyday communication, social activities, educational and professional pursuits, the care of others, and the maintenance of personal health, independence, and mobility. Vision loss in adults is associated with increased risk of falls and injuries, social isolation, depression, and other psychological problems and can amplify the adverse effects of other chronic illnesses, increasing the risk for all-cause and injury-related mortality (Christ et al., 2014; Crews et al., 2016; Lam et al., 2008; Lee et al., 2003; Lord, 2006; McKean-Cowdin et al., 2007). Similarly, undiagnosed or uncorrected refractive errors and other visual disorders in children can lead to developmental, academic, and social challenges, and in some cases permanent vision loss, which has lifelong implications (Birch, 2013; Davidson and Quinn, 2011). Moreover, the economic and social costs of vision impairment and eye disease to patients, the health care system, and society are considerable (Koberlein et al., 2013; Wittenborn et al., 2013). Yet, as a chronic condition, vision impairment remains notably absent from many public health agendas and community programs. Rather, vision is often regarded as a given—until it is not.
The vast majority of individuals in the United States who reach average life expectancy are at risk for some form of vision loss and impairment during their lifetimes, given current knowledge about effective prevention strategies, injury rates, barriers to accessing appropriate health care, and the
aging process itself. Vision loss can affect any one at any time. It is the process by which physiological changes or damage to the structure of the eye or visual information processing structures in the brain occurs, resulting in compromised subclinical or clinical function of the eye or visual processing system.1 Vision loss may occur suddenly and completely, for example from injury, or may subtly evolve over time, with permanent structural damage leading to progressive changes in eye function until more pronounced deficits become noticeable. Vision impairment, defined in this report as a measure of the functional limitation of the eye or visual system that results from vision loss, remains an unmet and important public health threat and is largely attributable to a few conditions or diseases in the United States.
No reliable data exist on the number of people affected by all causes of vision impairment in the United States. One model, based on a review of 12 major epidemiological studies applied to the 2010 U.S. Census population, estimates that approximately 90 million of the 142 million adults over the age of 40 in the United States experienced vision problems attributable to vision impairment, blindness, refractive error (i.e., myopia and hyperopia), age-related macular degeneration (AMD),2 cataracts, diabetic retinopathy, and glaucoma (Prevent Blindness, 2012).3 Presbyopia, an age-related condition that affects the ability to focus clearly on near objects, affects almost everyone entering the middle-age years (Petrash, 2013). Other measures of eye and vision health have different but significant implications for broad population health strategies to reduce the burden of vision impairment. For example, uncorrectable vision impairment (i.e., the amount of vision impairment that remains after appropriate treatment or intervention) can range from mild to severe and affects an estimated 6.4 million people, including adults and children, in the United States.4Uncorrected vision impairment (i.e., the proportion of overall vision impairment that could be improved through currently available treatments) affects millions more people in the United States, with estimates for uncorrected refractive error alone ranging from 8.2 million (Varma et al., 2016) to 11.0 million (CDC,
1 The committee adopted these definitions of vision loss and vision impairment to help facilitate discussion of eye and vision health in the context of population health. Justifications for these definitions are discussed in Chapter 1.
4 This figure was determined by combining the estimates of 4.24 million U.S. adults ages 40 and older (Varma et al., 2016) and 2.155 million U.S. children, adolescents, and young adults through age 39 (Wittenborn and Rein, 2013). Both studies define uncorrectable vision impairment and blindness separately and as a measure of visual acuity.
2015c) to 15.9 million (Wittenborn and Rein, 2016).5 As the baby boomer generation ages, older adults will account for an ever larger proportion of the total population, and the prevalence of age-related eye diseases and conditions is projected to increase accordingly (Varma et al., 2016; Wittenborn and Rein, 2016). Actions to evaluate, monitor, and protect eye and vision health should begin early in life, but the systems and policies to encourage these behaviors in a fair and equitable manner are lacking.
The prevalence and impact of vision loss, as well as the severity of vision impairment, varies across geographic areas by etiology, age, race and ethnicity, and gender, putting certain populations at higher risk for specific types of vision loss (Congdon et al., 2004; Kirtland et al., 2015; Qiu et al., 2014; Zhang et al., 2012). The probability of vision impairment increases with age among all populations, particularly among people older than 60 years (Varma et al., 2016). Increased risk for poor eye health is also associated with social, economic, cultural, health, and environmental conditions, which further contribute to overall health disparities (Ulldemolins et al., 2012; Zambelli-Weiner et al., 2012; Zhang et al., 2012). Identifying populations at high risk for certain types of vision loss can help target limited resources, tailor effective interventions, and promote policies that better achieve eye and vision health and improve population health equity.
Some of the most notable successes in preventing vision loss have been anchored in population health strategies (CDC, 2015b; Kumaresan, 2005; Rao, 2015). Preventing vision-threatening injury, infection, and underlying chronic disease could have substantial effects on protecting or maintaining eye and vision health before treatment is needed. Promoting optimal conditions for eye and vision health can also alleviate many other social ills, including poverty, other health inequities, increasing health care costs, and avoidable mortality and morbidity (Christ et al., 2014; Kirtland et al., 2015; Lee et al., 2003; Rahi et al., 2009; Rein, 2013). Short- and long-term population health strategies should address broad determinants of health, including policies that influence individual behaviors, healthy environments and social conditions, and their potential impact on eye and vision health. Some strategies may be simpler and accomplished more quickly, such as
5 The committee commissioned an analysis, which was not available in the current literature, to establish the preventable burden of vision impairment in the United States from five conditions (diabetic retinopathy, glaucoma, refractive error, cataracts, and AMD). Estimates are based on a variety of sources (including population surveys and compilations of population-based studies) and reflect the best available public data. The committee presents only the results related to cataracts and uncorrected refractive error in this report because the analyses are most robust for these conditions. Chapter 3 provides a more in-depth description of the study's assumptions and limitations, which are also documented in the commissioned paper itself (Wittenborn and Rein, 2016). This citation was added post release.
implementing policies that encourage using protective eyewear in hazardous work environments and during some recreational activities (CDC, 2013, 2015d; NEI/NIH, 2016). Other strategies will require more concerted and coordinated efforts to support social and built environments that promote eye-healthy behaviors or improved access to health care.
Early diagnosis and appropriate access to high-quality treatment could improve the trajectory of modifiable, correctable, and uncorrectable vision impairment by either slowing the progression of specific diseases or conditions, correcting the vision impairment itself, or improving the functionality, independence, and quality of life of populations with uncorrectable vision impairment. For example, estimates suggest that vision impairment caused by uncorrected refractive error and cataracts—both largely treatable—accounts for a substantial portion of undiagnosed vision impairment every year in the United States (CDC, 2015c; Wittenborn and Rein, 2016). Many public and private health insurance coverage policies, including Medicare, exclude eye examinations for initially asymptomatic or low-risk patients, corrective lenses, and visual assistive devices. Thus, in many cases, people must purchase additional vision insurance or shoulder costs out of pocket. Moreover, interventions exist to improve or maintain the functioning of people with vision impairment, but information about, and access to, these services is often limited (Overbury and Wittich, 2012; Pollard et al., 2003). These factors contribute to inequities that already affect populations with lower socioeconomic status and poor health (DeVoe et al., 2007; Levin et al., 2013).
Coordinated efforts are needed to expand public health capacities and to encourage policies and programmatic emphases that recognize improved eye and vision health as an important population health outcome and as a strategy to achieve better health equity. This will require federal and state support, coupled with public–private partnerships, to enhance local health department capabilities and energize other local institutions and organizations, families, and individuals to respond to community needs and goals (CDC, 2007).
This report proposes a population health action framework to guide action and coordination among various—and sometimes competing—stakeholders in pursuit of improved eye and vision health and health equity in the United States. This report also introduces a model for action that highlights different levels of prevention activities across a range of stakeholders and provides specific examples of how population health strategies can be translated into cohesive areas for action at federal, state, and local levels. Initial public- and private-sector investment has helped identify some of the chief information gaps and has led to a more nuanced understanding of the connection between eye and vision health and other measures of overall health, but more is needed. Implementing a coherent and comprehensive
response to address vision loss will be challenging. Establishing conditions and policies that promote population eye and vision health and that minimize preventable and correctable vision impairment is an essential, timely, and achievable objective—one that is necessary to improve the overall quality of life, functioning, and productivity of individuals.
STATEMENT OF TASK AND REPORT OVERVIEW
In 2014, the Health and Medicine Division of the National Academies of Sciences, Engineering, and Medicine convened a multidisciplinary committee to "examine the core principles and public health strategies to reduce visual impairment and promote eye health in the United States," including short- and long-term strategies to prioritize eye and vision health through collaborative actions across a variety of topics, settings, community stakeholders, and levels of government. The committee reviewed the relevant literature and held five meetings, including two public workshops and one public session to obtain input from an array of experts and stakeholders. To further inform its deliberations, the committee also commissioned a paper on the costs and preventable burden of vision impairment for select eye conditions.
A POPULATION HEALTH APPROACH TO IMPROVE EYE AND VISION HEALTH
A population health approach involves multiple actors who work separately and cooperatively to "[focus] on interrelated conditions and factors that influence the health of populations over the life course, identif[y] systematic variations in their patterns of occurrence, and appl[y] the resulting knowledge to develop and implement policies and actions to improve the health and well-being of those populations" (Kindig and Stoddart, 2003, p. 380). The health of individuals and populations is affected by multiple determinants, including (1) individual traits; (2) behaviors; (3) social, family, and community networks; (4) living and working conditions; and (5) broad social, economic, cultural, health, and environmental conditions and policies, which are each part of larger social and physical environments (IOM, 2003a). Health care services are an important component of the "living and working conditions" that affect health. The vast majority of health determinants exists outside the clinical care delivery system (Braveman and Gottlieb, 2014; McGinnis et al., 2002), which provides a wide range of opportunities and environments in which to influence eye and vision health. As this report documents, eye and vision health is also affected by factors within each health determinant category. Figure S-1 provides an example of how multiple determinants of health could be used to target various factors
FIGURE S-1 Examples of factors that could be part of a population health approach to eye and vision health.
SOURCE: Adapted from IOM, 2003a, p. 52.
within each health determinant category as part of a broad population health approach to improve eye and vision health. These targets, which are included in four separate boxes, include both risk and protective factors for vision loss. The inclusion of these targets should not be interpreted as a prioritization of relevant research topics or as a conclusion that individual targets are each supported by the same strength of evidence.
The three functions of a population health approach are assessment (i.e., monitoring communities to identify and characterize public health needs and priorities); policy development (i.e., the use of scientific evidence to guide the design and implementation of programs and policies to address public health issues); and assurance (i.e., policy development and enforcement, ensuring that health and public health systems have the resources to implement programs, and evaluating the health impacts of interventions) (CDC, 2007; IOM, 1988). In the context of eye and vision health and the committee's charge, these actions include short- and long-term strategies to address overarching determinants of health (primordial prevention) as well as efforts to support, educate, and promote healthy eye and vision behaviors (primary prevention); facilitate pre-symptomatic identification of eye diseases and treatments (secondary prevention); and preserve and enhance the health and functioning of individuals with vision impairment (tertiary prevention). Anchoring eye and vision health promotion in terms of the stages of prevention will allow the nation to reevaluate eye and vision health improvement more broadly as not only a valued outcome in and of itself, but also a potential public health tool to promote health equity among populations.
TRANSLATING A CONCEPTUAL FRAMEWORK INTO ACTION: RECOMMENDATIONS
The long-term goal of a population health approach for eye and vision health should be to transform vision impairment from a common to a rare condition, reducing associated health inequities. Given the genetic and biological components of many eye diseases and conditions, the occurrence of eye injuries, and the aging process itself, populations will never be without vision impairment. Nevertheless, this long-term goal establishes a new platform from which to identify important players, define influential behaviors, and allocate resources in a manner that will preserve and protect the eye and vision health of different populations.
Achieving the twin goals of improving eye and vision health and increasing health equity will require actions that reinforce each other. Figure S-2 identifies five core action areas that provide focus for the committee's recommendations and support the ultimate outcome—improved population eye and vision health and health equity. These actions should
FIGURE S-2 Components of a population health model for action to improve eye and vision health across the lifespan.
be population-centered, collaborative, culturally competent, community-tailored, evidence-based, integrated, standardized, and adequately resourced. Many of the following nine recommendations are broadly framed but are critical to establish conditions that will support a sustainable population health initiative that will effectuate a long-term reduction in vision impairment and its ramifications. These recommendations provide the foundational support for other, more specific actions by stakeholder groups, as described throughout this report.
Facilitate Public Awareness Through Timely Access to Accurate and Locally Relevant Information
The public should have accessible, transparent, and easily understood information about eye and vision health prevalence, incidence, and impact (on both an individual and community level) and also information about the stakeholders that influence eye and vision health locally and nationally.
According to a recent online poll, 88 percent of the 2,044 respondents surveyed identified good vision as vital to maintaining overall health, and 47 percent rated losing their vision compared to loss of limb, memory, hearing, or speech as "potentially having the greatest effect on their day-to-day life" (Scott et al., 2016, p. E3). Despite the public's perception of the importance of good vision, millions of people continue to grapple with undiagnosed or untreated vision impairment (CDC, 2015c; Varma et al., 2016; Wittenborn and Rein, 2016). Moreover, eye and vision health remain relatively absent from national health priority lists, including efforts to stem the impact of chronic diseases. A number of factors, including the segregation of eye care from the rest of medicine, fragmentation within the eye care community, and a lack of coordination within or across federal entities, contribute to the absence of focused and sustained programmatic investment that would translate into widespread action.
A Call to Action "is a science-based document to stimulate action nationwide to solve a major public health problem" (U.S. Surgeon General, n.d.). The U.S. Department of Health and Human Services (HHS), most often through the Office of the Surgeon General, uses calls to action to draw attention to important public health issues, such as promoting walkable communities and oral health, preventing skin cancer and suicide, improving the health and wellness of persons with disabilities, and reducing underage drinking (Surgeon General, n.d.). These documents, along with other reports, are often used to establish a baseline from which to measure improvement (e.g., Anstev et al., 2011; Mertz and Mouradian, 2009; U.S. Surgeon General, 2014). Vision loss and impairment qualify as public health problems in that they (1) affect a large number of people; (2) impose large morbidity, quality-of-life, and cost burdens; (3) are increasing in severity and are predicted to continue increasing; (4) are perceived by the public to be a threat; and (5) are feasibly addressed by community or public health-level interventions (CDC, 2009). Similarly, the NEI, the U.S. Preventive Services Task Force, and the World Health Organization have identified vision impairment in various populations as national or global public health problems (HHS, 2015; NEI/NIH, 2004; WHO, 2015).
Moreover, like other chronic diseases, most causes of vision impairment require ongoing management over the lifespan of an individual to maintain the activities of daily living. A call to action is needed to stimulate nationwide discussion of eye and vision health as an essential health outcome and launch measured and directed actions that will reduce the burden of vision impairment in the United States.
The Secretary of the U.S. Department of Health and Human Services should issue a call to action to motivate nationwide action toward achieving a reduction in the burden of vision impairment across the lifespan of people in the United States. Specifically, this call to action should establish goals to:
Eliminate correctable and avoidable vision impairment by 2030,
Delay the onset and progression of unavoidable chronic eye diseases and conditions,
Minimize the impact of chronic vision impairment, and
Achieve eye and vision health equity by improving care in underserved populations.
Enhancing public knowledge about a health threat is a fundamental first step in informing discussions that promote behavior change across multiple determinants of health and aligning health policies with general public health interests. Unfortunately, lack of awareness of vision and eye health issues remains a major public health concern, especially in the context of linking patients to care and attempting to make population-level changes in behavior and health practice (Bailey et al., 2006; Zhang et al., 2012). Individuals are often unaware of what the most common risks to vision are, how the physiological progression of many eye diseases occurs, early signs of vision loss, and what steps can be taken to reduce the risk of vision-threatening eye disease, conditions, and events and the impact of subsequent vision loss (Alexander et al., 2008; Chou et al., 2014; Lam and Leat, 2015; NEI/LCIF, 2008; Varano et al., 2015). Combined with the asymptomatic nature of many eye diseases and conditions, this lack of awareness can have significant ramifications on overall health.
Although rarely adequate by themselves, public awareness campaigns can be an effective tool for improving knowledge about key messages related to health within populations (Bray et al., 2015; Oto et al., 2011) and are one essential part of an effective population health strategy. Achieving the goals outlined in recommendation 1 will require having reliable, consistent, evidence-based information that is available and accessible by a variety of stakeholders to increase overall knowledge and encourage policies,
practices, and behaviors that promote good eye and vision health, support appropriate care to correct or slow progression of a vision-threatening disease or condition, or improve function when vision impairment is uncorrectable. This approach must target various audiences and consider a wide range of factors affecting eye and vision health in communities, including individual-directed strategies, mass media campaigns, and environmental and policy changes across multiple settings within defined geographic areas (e.g., city, state, province, or country).
The Secretary of the U.S. Department of Health and Human Services, in collaboration with other federal agencies and departments, nonprofit and for-profit organizations, professional organizations, employers, state and local public health agencies, and the media, should launch a coordinated public awareness campaign to promote policies and practices that encourage eye and vision health across the lifespan, reduce vision impairment, and promote health equity. This campaign should target various stakeholders, including the general population, care providers and caretakers, public health practitioners, policy makers, employers, and community and patient liaisons and representatives.
Generate Evidence to Guide Policy Decisions and Evidence-Based Actions
Evidence-based decision making should guide population health actions. Without data, population health tools cannot characterize affected populations, identify risk and protective factors (including health care access), establish evidence-based guidelines, or quantify the effectiveness of health care systems and community-based interventions. True accountability requires good data, but less than perfect data should not be an excuse for inaction.
Vision impairment and blindness are appropriate targets for surveillance because they adversely affect a large portion of the population, affect populations unequally, can be improved by treatment and preventive efforts, and will become an increasing burden as the population ages (Saaddine et al., 2003). A comprehensive, nationally representative surveillance system for eye and vision health is needed to better understand the epidemiological patterns, risk factors, comorbidities, and costs associated with vision loss. Such data will allow health care professionals and public health decision makers to better characterize the nature and extent of the public health burden; risk factors and at-risk populations; disparities in access, care, and outcomes; and successful interventions (West and Lee, 2012).
The Centers for Disease Control and Prevention (CDC) should develop a coordinated surveillance system for eye and vision health in the United States. To advise and assist with the design of the system, the CDC should convene a task force comprising government, nonprofit and for-profit organizations, professional organizations, academic researchers, and the health care and public health sectors. The design of this system should include, but not be limited to:
Developing and standardizing definitions for population-based studies, particularly definitions of clinical vision loss and functional vision impairment;
Identifying and validating surveillance and quality-of-care measures to characterize vision-related outcomes, resources, and capacities within different communities and populations;
Integrating eye-health outcomes, objective clinical measures, and risk/protective factors into existing clinical-health and population-health data collection forms and systems (e.g., chronic disease questionnaires, community health assessments, electronic health records, national and state health surveys, Medicare's health risk assessment, and databases); and
Analyzing, interpreting, and disseminating information to the public in a timely and transparent manner.
Understanding the factors that affect the risk of vision impairment for different populations, the barriers to accessing care, interventions to prevent visual impairment and maintain eye function, and ways to improve the quality of care is fundamental to designing and identifying opportunities that minimize vision loss now and that will result in new knowledge and strategies to further reduce the long-term impact of vision impairment. HHS supports a number of federal programs and institutes that focus on vision loss and fund various activities to combat the effects of poor eye and vision health on at-risk populations (CDC, 2015a). Despite these activities, eye and vision health is insufficiently represented as a programmatic focus in federal government programs overall, and existing research programs lack coordination within and across federal agencies and institutes. Establishing a unified research agenda with larger financial and programmatic support to develop and advance knowledge about eye and vision health can maximize efficiencies and build on the strengths of established programs across a broad portfolio of topics and programs, which must include more than basic and clinical research.
The U.S. Department of Health and Human Services should create an interagency workgroup, including a wide range of public, private, and community stakeholders, to develop a common research agenda and coordinated eye and vision health research and demonstration grant programs that target the leading causes, consequences, and unmet needs of vision impairment. This research agenda should include, but not be limited to:
Population-based epidemiologic and clinical research on the major causes and risks and protective factors for vision impairment, with a special emphasis on longitudinal studies of the major causes of vision impairment;
Health services research, focused on patient-centered care processes, comparative-effectiveness and economic evaluation of clinical interventions, and innovative models of care delivery to improve access to appropriate diagnostics, follow-up treatment, and rehabilitation services, particularly among high-risk populations;
Population health services research to reduce eye and vision health disparities, focusing on effective interventions that promote eye healthy environments and conditions, especially for underserved populations; and
Research and development on emerging preventive, diagnostic, therapeutic, and treatment strategies and technologies, including efforts to improve the design and sensitivity of different screening protocols.
Expand Access to Appropriate Clinical Care
Timely, appropriate, and equitable access to and delivery of effective care in all settings is an important component of a population health approach to improve eye and vision health. Inequitable barriers to effective treatments and therapies should be eliminated. Heightened attention is needed to reduce vision loss and cement its importance in relation to other chronic conditions and overall health.
Professional guidelines are an important tool for advancing policies and practices that promote high-quality care for everyone. They are often used to educate the public and public health and health care professionals and serve as foundational elements of value-driven payment policies and as baselines from which to measure quality improvement and enhanced accountability for care processes and patient health outcomes. No single
set of clinical practice guidelines or measures in eye and vision care exists. Although eye and vision guidelines are consistent for the most part, there are some important differences. Differences may reflect the absence of robust data and political tensions within the field of eye and vision health. Available guidelines may provide inconsistent recommendations concerning essential measures, such as the frequency with which different age groups and at-risk populations should receive comprehensive eye exams6 (e.g., AAO, 2015; AOA, 2015). Health insurance coverage for basic examinations, preventive services and treatments (including corrective lenses), and rehabilitation (including assistive devices) should reflect these guidelines. Particular attention needs to be paid to assuring that essential services and treatments are affordable, particularly for the most vulnerable populations.
The U.S. Department of Health and Human Services should convene one or more panels—comprising members of professional organizations, researchers, public health practitioners, patients, and other stakeholders—to develop a single set of evidence-based clinical and rehabilitation practice guidelines and measures that can be used by eye care professionals, other care providers, and public health professionals to prevent, screen for, detect, monitor, diagnose, and treat eye and vision problems. These guidelines and supporting evidence should be used to drive payment policies, including coverage determinations for corrective lenses and visual assistive devices following a diagnosed medical condition (e.g., refractive error).
To cultivate professional relationships and collaboration that advances eye and vision health across medicine and beyond clinical care, it is important to establish a set of common expertise that can align overarching objectives and action among health professionals. The CDC has noted the need to elevate ophthalmic education in medical curricula (CDC, 2007; Shah et al., 2014). With a greater focus on population health in clinical care (Berwick et al., 2008), new skills will be needed to ensure that health care professionals understand the types of patient experiences and data that are relevant to population health activities, including the moral imperative to reduce inequities in both health and health care. Moreover, public health practitioners should be familiar with eye and vision health, its risk factors, and the relationship between vision loss and other chronic health conditions. Translating this knowledge into meaningful patient interactions will
6 The committee defines a comprehensive eye examination as a dilated eye examination that may include a series of other tests, in addition to the dilation of the pupil.
require cultivating trust among different patient populations, providers, and public health practitioners.
To enable the health care and public health workforce to meet the eye care needs of a changing population and to coordinate responses to vision-related health threats, professional education programs should proactively recruit and educate a diverse workforce and incorporate prevention and detection of visual impairments, population health, and team care coordination as part of core competencies in applicable medical and professional education and training curricula. Individual curricula should emphasize proficiency in culturally competent care for all populations.
Enhance Public Health Capacities to Support Vision-Related Activities
Eye and vision health is a critical part of population health and a valuable public health tool with which to assess the quality, effectiveness, and efficiencies of health care systems and population health programs and initiatives. Improving eye and vision health requires that comparable services, information, and healthy environments are accessible to all populations. Public health departments serve as key community conveners to coordinate responses that address multiple determinants of health and chronic conditions, such as vision impairment.
Integrating public health and local health care systems is an important strategy for improving community health (CDC, 2007). A well-functioning medical care system can expand delivery of appropriate eye and vision care services, allowing public health agencies to focus on preventive policies and action and assurance. Such preventive actions include linking people to needed care, assessing care quality, and promoting community support and policy and environmental conditions that maximize health (IOM, 2003b). Public health agencies and departments can also extend the reach of health care services through vision-specific programs. There has been insufficient partnering to coordinate existing and emerging programs, policies, and quality improvement activities that either directly or indirectly influence eye and vision health.
State and local public health departments should partner with health care systems to align public health and clinical practice objectives, programs, and strategies about eye and vision health to:
Enhance community health needs assessments, surveys, health impact assessments, and quality improvement metrics;
Identify and eliminate barriers within health care and public health systems to eye care, especially comprehensive eye exams, appropriate screenings and follow-up services, and items and services intended to improve the functioning of individuals with vision impairment;
Include public health and clinical expertise related to eye and vision health on oversight committees, advisory boards, expert panels, and staff, as appropriate;
Encourage physicians and health professionals to ask and engage in discussions about eye and vision health as part of patients' regular office visits; and
Incorporate eye health and chronic vision impairment into existing quality improvement, injury and infection control, and behavioral change programs related to comorbid chronic conditions, community health, and the elimination of health disparities.
Local public health departments are designed to promote health across a wide range of policies, activities, programs, and efforts to improve accountability. In the face of declining public investment, current state and local public health agencies and departments struggle to meet state mandates and requirements (Jacobson et al., 2015). Public health strategies to promote eye and vision health are rarely supported as a categorical focus or even as part of chronic disease programs in state and local health departments due to limitations in resources and other shifting priorities. Moreover, flexibility in how state and local governments use federal grant funds varies (CBO, 2013). In the absence of federal directives and programs to advance eye and vision health, state and local public health departments are hard pressed to incorporate reduction of vision impairment as a categorical programmatic focus.
To build state and local public health capacity, the Centers for Disease Control and Prevention should prioritize and expand its vision grant program, in partnership with state-based chronic disease programs and other clinical and nonclinical stakeholders, to:
Design, implement, and evaluate programs for the primary prevention of conditions leading to visual impairment, including policies to reduce eye injuries;
Develop and evaluate policies and systems that facilitate access to, and utilization of, patient-centered vision care and rehabilitation services, including integration and coordination among care providers; and
Develop and evaluate initiatives to improve environments and socioeconomic conditions that underpin good eye and vision health and reduce eye injuries in communities.
Promote Community Actions That Encourage Eye- and Vision-Healthy Environments
Eye and vision health is affected by a wide range of health determinants within communities, including individual and collective behaviors, the built environment, social conditions, and the health care system. Populations should participate collectively in decision making about population health priorities, which affect and are affected by the eye and vision health of their communities.
Eye and vision health is a community issue—the needs, adequacy of resources, and priorities will vary based on population characteristics, cultures, and values. The impact that vision loss has on function and quality of life varies according to numerous factors, including the built environment, social support, access to health care and rehabilitation services, attitude, preferences, and socioeconomic factors. How these factors affect the occurrence, severity, and impact of vision loss differs for individuals and communities. It is important that community stakeholders (businesses, advocacy organizations, neighborhood groups, local health and public health departments, religious organizations, professional organizations, school boards and faculty, parent support groups, health care providers, eye care providers, etc.) be actively consulted and engaged in options to translate and implement national goals into workable community action plans to reduce the burden of vision loss and the functioning of populations with vision impairment across different community settings.
Communities should work with state and local health departments to translate a broad national agenda to promote eye and vision health into well-defined actions. These actions should encourage policies and conditions that improve eye and vision health and foster environments to minimize the
impact of vision impairment, considering the community's needs, resources, and cultural identity. These actions should:
Improve eye and vision health awareness among different social groups within communities;
Engage community organizations and groups to promote eye and vision health awareness in daily activities;
Establish and enforce laws and policies intended to promote eye safety and the functioning of people with vision impairment;
Identify the need for, and community-level barriers to, vision-related services and resources in their communities; and
Adopt policies and create community networks that support the design of built environments and the establishment of social environments that promote eye and vision health and independent functioning.
AAO (American Academy of Ophthalmology). 2015. Policy statement: Frequency of ocular examinations. San Francisco, CA: AAO.
Alexander, Jr., R. L., N. A. Miller, M. F. Cotch, and R. Janiszewski. 2008. Factors that influence the receipt of eye care. American Journal of Health Behavior 32(5):547.
Anstev, E. H., C. A. MacGowan, and J.A. Allen. 2011. Five-year progress update on the Surgeon General's call to action to support breastfeeding. Journal of Women's Health 25(8):768–776.
AOA (American Optometric Association). 2015. Comprehensive eye and vision examination. http://www.aoa.org/patients-and-public/caring-for-your-vision/comprehensive-eye-andvision-examination?sso=y (accessed March 29, 2016).
Bailey, R. N., R. W. Indian, X. Zhang, L. S. Geiss, M. R. Duenas, and J. B. Saaddine. Visual impairment and eye care among older adults–five states, 2005. 2006. Morbidity Mortality Weekly Report 55(49):1321–1325.
Berwick, D. M., T. W. Nolan, and J. Whittington. 2008. The triple aim: Care, health, and cost. Health Affairs 27(8):759–769.
Braveman, P., and L. Gottlieb. 2014. The social determinants of health: It's time to consider the causes of the causes. Public Health Reports 129(Suppl 2):9–31.
Bray, J. E., L. Straney, B. Barger, and J. Finn. 2015. Effect of public awareness campaigns on calls to ambulance across Australia. Stroke 46(5):1377–1380.
CBO (Congressional Budget Office). 2013. Federal grants to state and local governments. Washington, DC: CBO.
CDC (Centers for Disease Control and Prevention). 2007. Improving the nation's vision health: A coordinated public health approach. Atlanta, GA: CDC.
———. 2009. Why is vision loss a public health problem? http://www.cdc.gov/visionhealth/basic_information/vision_loss.htm (accessed October 7, 2015).
———. 2013. Eye safety. http://www.cdc.gov/niosh/topics/eye (accessed March 30, 2016).
———. 2015a. About us. http://www.cdc.gov/visionhealth/about/index.htm (accessed March 30, 2016).
———. 2015b. Conjunctivitis (pink eye) in newborns. http://www.cdc.gov/conjunctivitis/newborns.html (accessed March 30, 2016).
———. 2015c. National data. http://www.cdc.gov/visionhealth/data/national.htm (accessed March 30, 2016).
———. 2015d. The work-related injury statistics query system. http://wwwn.cdc.gov/wisards/workrisqs (accessed April 4, 2016).
Christ, S. L., D. Zheng, B. K. Swenor, B.L. Lam, S. K. West, S. L. Tannenbaum, B. E. Munoz, and D. J. Lee. 2014. Longitudinal relationships among visual acutiy, daily functional status, and mortality: The Salisbury Eye Evaluation Study. Journal of Ophthalmology. 132(12):1400–1406.
Congdon, N., B. O'Colmain, C. C. Klaver, R. Klein, B. Munoz, D. S. Friedman, J. Kempen, H. R. Taylor, and P. Mitchell. 2004. Causes and prevalence of visual impairment among adults in the United States. Archives of Ophthalmology 122(4):477–485.
Crews, J. E., C.-F. Chiu-Fung Chou, J. A. Stevens, and J. B. Saadine. 2016. Falls among persons aged > 65 years with and without severe vision impairment—United States, 2014. Morbidity and Mortality Weekly Report 65(17):433–437.
Davidson, S., and G. E. Quinn. 2011. The impact of pediatric vision disorders in adulthood. Pediatrics 127(2):334–339.
DeVoe, J. E., A. Baez, H. Angier, L. Krois, C. Edlund, and P. A. Carney. 2007. Insurance + access ≠ health care: Typology of barriers to health care access for low-income families. Annals of Family Medicine 5(6):511–518.
HHS (U.S. Department of Health and Human Services). 2015. Healthy people 2020 topics and objectives: Vision. http://www.healthypeople.gov/2020/topics-objectives/topic/vision (accessed October 7, 2015).
IOM (Institute of Medicine). 1988. The future of public health. Washington, DC: National Academy Press.
———. 2003a. The future of the public's health in the 21st century. Washington, DC: The National Academies Press.
———. 2003b. Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: The National Academies Press.
Jacobson, P. D., J. Wasserman, H. W. Wu, and J. R. Lauer. 2015. Assessing entrepreneurship in governmental public health. American Journal of Public Health 105(S2):S318–S322.
Kindig, D., and G. Stoddart. 2003. What is population health? American Journal of Public Health 93(3):380–383.
Kirtland, K. A., J. B. Saaddine, L. S. Geiss, Thompson, T. J., Cotch, M. F., and Lee, P. P. 2015. Geographic disparity of severe vision loss—United States, 2009–2013. Morbidity and Mortality Weekly Report 64(19):513–517.
Koberlein, J., K. Beifus, C. Schaffert, and R. P. Finger. 2013. The economic burden of visual impairment and blindness: A systematic review. British Medical Journal Open 3: 1–14.
Kumaresan, J. 2005. Can blinding trachoma be eliminated by 20/20? Eye 19(10):1067–1073.
Lam, B. L., S. L. Christ, D. J. Lee, D. D. Zheng, and K. L. Arheart. 2008. Reported visual impairment and risk of suicide: The 1986–1996 National Health Interview Surveys. Archives of Ophthalmology 126(7):975–980.
Lam, N., and S. J. Leat. 2015. Reprint of: Barriers to accessing low-vision care: The patient's perspective. Canadian Journal of Ophthalmology/Journal Canadien d'Ophtalmologie 50:S34–S39.
Lee, D. J., O. Gomez-Marin, B. L. Lam, and D. D. Zheng. 2003. Visual impairment and unintentional injury mortality: The National Health Interview Survey 1986–1994. American Journal of Ophthalmology 136(6):1152–1154.
Levin, A. V., L. T. Pizzi, M. Snitzer, and K. M. Prioli. 2013. Barriers to follow up care in children with vision diseases: Development of a conceptual framework and parent/caregiver survey through the children's eye care adherence project. Value in Health 16(3):A38.
Lord, S. R. 2006. Visual risk factors for falls in older people. Age and Ageing 35(Suppl 2): ii42–ii45.
McGinnis, J. M., P. Williams-Russo, and J. R. Knickman. 2002. The case for more active policy attention to health promotion. Health Affairs 21(2):78–93.
McKean-Cowdin, R., R. Varma, J. Wu, R. D. Hays, S. P. Azen, for the Los Angeles Latino Eye Study Group. 2007. Severity of vision field loss and health-related quality of life. American Journal of Ophthalmology 143(6):1013–1023.
Mertz, E., and W. Mouradian. 2009. Addressing children's oral health in the new millennium: Trends in the dental workforce. Academic Pediatrics 9(6):433.
NEI/LCIF (National Eye Institute/Lions Club International Foundation). 2008. 2005 survey of public knowledge, attitudes, and practices related to eye health and disease. https://nei.nih.gov/kap (accessed October 7, 2015).
NEI/NIH (National Eye Institute/National Institutes of Health). 2004. Vision statement and mission—National plan for eye and vision research [NEI strategic planning]. https://neinih.gov/strategicplanning/np_vision (accessed February 4, 2016).
———. 2016. About sports eye injury and protective eyewear. https://nei.nih.gov/sports (accessed February 12, 2016).
Oto, M. A., O. Ergene, L. Tokgozoglu, Z. Ongen, O. Kozan, M. Sahin, M. K. Erol, T. Tezel, and M. Ozkan. 2011. Impact of a mass media campaign to increase public awareness of hypertension. Turk Kardiyoloji Dernegi Ars 39(5):355–364.
Overbury, O., and W. Wittich. 2012. Barriers to low vision rehabilitation: The Montreal Barriers Study. 2011. Investigative Ophthalmology & Visual Science 52(12):8933–8938.
Pollard, T. L., J. A. Simpson, E. L. Lamoureux, and J. E. Keefe. 2003. Barriers to accessing low vision sevices. Ophthalmic and Phsyiological Optics 23(4):321–327.
Prevent Blindness. 2012. Vision problems in the U.S. http://www.visionproblemsus.org (accessed June 5, 2016).
Rahi, J. S., P. M. Cumberland, and C. S. Peckham. 2009. Visual function in working-age adults: Early life influences and associations with health and social outcomes. Ophthalmology 116(10):1866–1871.
Rao, G. 2015. The Barrie Jones Lecture—Eye care for the neglected population: Challenges and solutions. Eye 29(1):30–45.
Rein, D. B. 2013. Vision problems are a leading source of modifiable health expenditures. Investigative Ophthalmology & Visual Science 54(14):ORSF18–ORSF22.
Saaddine, J. B., K. Venkat Narayan, and F. Vinicor. 2003. Vision loss: A public health problem? Ophthalmology 110(2):253–254.
Scott, A. W., N. M. Bressler, S. Ffolkes, J. S. Wittenborn, J. Jorkavsky. 2016. Public attitudes about eye and vision health. JAMA Ophthalmology 134(10):1111–1118.
Shah, M., D. Knoch, and E. Waxman. 2014. The state of ophthalmology medical student education in the United States and Canada, 2012 through 2013. Ophthalmology 121(6):1160–1163.
Ulldemolins, A. R., V. C. Lansingh, L. Guisasola Valencia, M. J. Carter, K. A. Eckert. 2012. Social inequalities in blindness and visual impairment: A review of social determinants. Indian Journal of Ophthalmology 60(5):368–375.
U.S. Surgeon General. 2014. The health consequences of smoking—50 years of progress: A report of the Surgeon General, 2014. Rockville, MD: U.S. Department of Health and Human Services.
———. n.d. Surgeon General's Calls to Action. http://www.surgeongeneral.gov/library/calls (accessed August 23, 2016).
Varano, M., N. Eter, S. Winyard, K. U. Wittrup-Jensen, R. Navarro, and J. Heraghty. 2015. Current barriers to treatment for wet age-related macular degeneration (WAMD): Findings from the WAMD patient and caregiver survey. Journal of Clinical Ophthalmology 9:2243–2250.
Varma, R., T. S. Vajaranant, B. Burkemper, S. Wu, M. Torres, C. Hsu, F. Choudhury, R. McKean-Cowdin. 2016. Visual impairment and blindness in adults in the United States: Demographic and geographic variations from 2015 to 2050. JAMA Ophthalmology. May 19 [Epub ahead of print].
West, S. K., and P. Lee. 2012. Vision surveillance in the United States: Has the time come? American Journal of Ophthalmology 154(6):S1–S2, e2.
WHO (World Health Organization). 2015. Blindness: Vision 2020—the global initiative for the elimination of avoidable blindness. http://www.who.int/mediacentre/factsheets/fs213/en (accessed October 7, 2015).
Wittenborn, J., and D. Rein. 2013. Cost of vision problems: The economic burden of vision loss and eye disorders in the United States. New York: Prevent Blindness America.
———. 2016. The potential costs and benefits of treatment for undiagnosed eye disorders. Paper prepared for the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. http://www.nationalacademies.org/hmd/~/media/Files/Report%20Files/2016/UndiagnosedEyeDisordersCommissionedPaper.pdf (accessed September 15, 2016).
Zambelli-Weiner, A., J. E. Crews, D. S. Friedman. 2012. Disparities in adult vision health in the United States. American Journal of Ophthalmology 154(Suppl):S23–S30, e1.
Zhang, X., M. F. Cotch, A. Ryskulova, S. A. Primo, P. Nair, C.-F. Chou, L. S. Geiss, L. Barker, A. F. Elliott, J. E. Crews, and J. B. Saaddine. 2012. Vision health disparities in the United States by race/ethnicity, education, and economic status: Findings from two nationally representative surveys. American Journal of Ophthalmology 154(6 Suppl):S53–S62, e51.
Next: 1 Introduction »


text:
The China Shock's Lessons for the Green Economy
How to Limit the Damage of Localized Job Losses
By Gordon H. Hanson
Driving away from shuttered steel furnaces in Pennsylvania, April 2016
Brian Snyder / Reuters
Democrats and Republicans do not agree on much, but confronting China has bipartisan support. The Biden administration has kept in place its predecessor's onerous tariffs on Chinese imports, electing to use pressure to change Beijing's behavior and to protect U.S. interests. China, U.S. President Joe Biden told reporters in February, is his country's most "serious competitor," one that threatens the United States' "prosperity, security, and democratic values."
Whatever the merits of this rhetoric and approach, China's rise has certainly hurt U.S. manufacturing regions. There is now an enormous body of evidence showing that import competition from China has gutted industrial towns in the American Midwest and Southeast. Five years ago, David Autor, David Dorn, and I reported that between 1999 and 2011, trade with China appeared to have cost the United States between 600,000 and one million manufacturing jobs, as large U.S. producers were driven out of business by competitors with more affordable Chinese-made products or as they moved their own plants overseas. In new research, we have extended our analysis out to 2019. The picture remains bleak. Most places hurt by the "China shock," as the phenomenon is now known, have seen little in the way of recovery.
At least in part, the recognition of these losses motivated the Trump administration's trade war with China. But research shows that President Donald Trump's tariffs have done little to reverse the economic and social damage suffered in communities that lost industrial jobs thanks to China's boom. Joblessness remains high in impacted regions. Marriage rates have dropped, families headed by single parents have become more common, and more children are living in poverty. Rates of substance abuse have gone up, and thousands of people have died from opioid overdoses. The China trade shock has proved far more durable and powerful than initially imagined.
This experience is important to remember as U.S. policymakers chart out what could be an equally seismic economic shift: moving the United States away from fossil fuels and toward greener sources of energy. Such a transition may be critical to fight climate change, but it could devastate parts of the country that depend on carbon extraction. In 2019, 2.8 million people worked for companies that extract, process, distribute, and produce electricity from fossil fuels. Many other employers depended on spending by these workers to stay in business. To avoid creating yet more social havoc, the United States must learn from its past mistakes. Rather than counting on markets to sort out the aftermath of shocks, the government will need to proactively invest in policies designed to help regions that bear the brunt of wider transformations in the economy. It will need to design a social welfare system that recognizes that not every community suffers equally and that even when the national economy is growing, some places still struggle. Otherwise, millions more people could be left behind.
A VICIOUS CYCLE
The China trade shock began in earnest around 1992, when the Chinese leader Deng Xiaoping momentously expanded China's economic reforms to include freer trade and investment with the outside world. From the late 1990s through the early 2000s, industry towns such as Hickory, North Carolina, and St. Marys, Pennsylvania, saw factories close, manufacturing jobs disappear, and housing prices fall. Residents without college degrees watched their middle-class status—or their hopes of reaching the middle class—evaporate.
By 2010, China's share of the U.S. market for various products began to stabilize, and U.S.-based manufacturers stopped laying off large numbers of workers. Many policymakers hoped that as a result, life would begin to improve in former factory communities. But as Autor, Dorn, and I found in our new study, such relief did not arrive. We looked at labor-market outcomes in U.S. factory towns from 2000 to 2019. Our findings went against cherished economic frameworks, which predict that workers in struggling communities migrate in search of employment elsewhere and that new industries expand into downtrodden areas to take advantage of an idle labor pool. Neither type of recovery materialized. Overall, relatively small percentages of people left their communities, and businesses didn't expand enough to absorb workers who had earlier lost their jobs. Economists still can't explain why workers did not abandon regions in decline, but relationships may play a role. Moving can mean separating from family members, who care for children, provide support when times are tough, and offer a comforting social network.
Manufacturing layoffs initiated a downward spiral of economic distress and social breakdown.
Although the magnitude of manufacturing job loss has been plain to see, many academics and inside-the-Beltway policy analysts have nonetheless downplayed the hollowing out of the heartland. The U.S. economy is dynamic, creating and destroying millions of jobs annually, and so for some, the woes of factory towns seem somewhat inconsequential. Others have argued that the decline of manufacturing employment was inevitable; irrespective of China's rise, automation and artificial intelligence would ultimately cause factory jobs to disappear. But these skeptics fail to appreciate just how acute and concentrated the China trade shock was in both time and place. Because China reformed its economy so quickly, manufacturing cities and towns lost their jobs at an equally brisk pace—far faster than would have been the case even under the grimmest automation timeline. And because many communities in the American Midwest and Southeast were heavily dependent on a narrow range of industries, the losses were profound, and their populations had no good Plan B. Instead, manufacturing layoffs morphed into overall regional joblessness and lower wages, initiating a downward spiral of economic distress and social breakdown.
Consider again Hickory, North Carolina, which anchors a region of 380,000 people and was ground zero for the China trade shock. In 1990, 36 percent of the town's labor force was employed in manufacturing, mostly in making furniture. But by 2019, after decades of offshoring, just 18 percent of Hickory's workers still had factory jobs. This dramatic decline would have hit any community hard, but it was especially devastating in such a highly specialized region. Just 16 percent of Hickory's working-age population had college degrees, making it very difficult for most residents to find new, well-paying employment opportunities. The overall employment rate has since dropped by an alarming seven percentage points. Yet in 2019, Hickory's working-age population was no smaller than it had been in 2010.
Policy at the national level can very easily overlook places such as Hickory. Major economic contractions prompt government action. A recession can force Congress, for instance, to extend the duration of unemployment benefits beyond the standard six months or increase the generosity of these benefits—as it did in response to the COVID-19 crisis. But the bulk of the job losses induced by the China trade shock occurred in the early 2000s, during a modest national economic expansion. Looking at the forest and not the trees, the federal government paid little attention to the suffering of particular regions. Workers in distressed local economies were largely left to go it alone.
The extreme job losses caused by hyperglobalization may be in the past. But the Biden administration's efforts to reduce reliance on fossil fuels, whether via the Build Back Better legislation currently before Congress or through other regulations, could initiate another round of regionalized labor-market disruptions. There are plenty of local economies that still mine coal, drill for oil and gas, and create electricity from these sources. There are plenty more that depend on carbon-intensive industries such as cement and steel, which require enormous amounts of energy to produce. For all the good that decarbonization would do for the world, it represents a seemingly existential threat to these communities. Compounding the potential misery, fossil-fuel-dependent communities in the Midwest sit uncomfortably close to many of the places that were hardest hit by the China trade shock. The regional manufacturing collapse that punished an older cohort of workers may be followed by an energy transformation that punishes a younger group.
To see why the energy transition could cause so much damage, look back to the decline of coal mining after 1980, when the collapse of oil prices sent the industry into a tailspin. Between 1980 and 1990, national employment in coal mining sank from 264,000 to 151,000 workers, before dropping another 71,000 workers in the ensuing decade. Although the industry recovered modestly in the early 2000s, employment in coal plunged again after 2010. In a manner qualitatively similar to the China trade shock (but on a much smaller scale), job losses were concentrated in the Midwest and the South—namely, Kentucky, Ohio, Pennsylvania, and West Virginia—and overall employment remained depressed all the way through the 2000s, nearly three decades after the decline in mining had begun. That is again because, unlike what economic models would predict, new or existing industries did not flock to coal towns to hire laid-off workers. Nor did the decline of those industries prompt an exodus of workers; outmigration became sizable only after 2010. People had a hard time leaving places their families had called home for generations.
The geographic concentration of industries that extract, refine, and utilize fossil fuels should be of immediate concern to policymakers intent on decarbonizing the U.S. economy. Increased demand for renewable energy will create new jobs in solar, wind, and hydroelectric power, but these jobs may be located far from existing carbon-based production facilities. New power-intensive industries, such as data centers, may choose to be situated near renewable energy providers, which could also make it more difficult for laid-off workers to find other jobs.
Miners, drillers, or frackers don't have to be sacrificed for a green future.
But that doesn't mean miners, drillers, or frackers have to be sacrificed at the altar of a green future. Policymakers have the tools to help workers hurt by the energy transition. If the government pays attention to the woes of local communities and proactively addresses them, it can spare these places from experiencing a fate similar to that of the China shock.
U.S. policymakers must respond aggressively to localized job losses irrespective of how the national economy is performing. To do so, the government should make the duration and generosity of unemployment benefits depend on regional rather than national economic conditions: losing a job is simply more painful in local economies where unemployment is already high. The government could also launch a system of national wage insurance, which would buttress the incomes of workers who experience sharp declines in pay, thus protecting against the financial insecurity caused by precarious labor markets.
But expanding the safety net is just one part of the equation. To prevent regional recessions, the government will need to move quickly to encourage new employment in places where jobs disappear en masse. That means taking place-based policies more seriously. One promising example is active labor-market programs, including targeted sectoral training, which provide workers with the skills demanded by industries set to expand nationally. In Northeast Ohio, for instance, the WorkAdvance Program, studied by a group of scholars at Harvard, partnered with local employers in health care and other sectors to identify what skills they required and then helped young workers without a college degree acquire them. The program also supplied these workers with placement services and career coaching. Two years later, the trainees had 14 percent higher earnings than similar workers who did not receive training. These efforts need not bust the bank. Many cities and states spend more on tax incentives to lure trophy companies such as Amazon or, more notoriously, Foxconn to their jurisdictions. Diverting funds to improve the capabilities of workers and businesses already in these communities would be cheaper, more effective, and more ethical.
Without such preparations, the energy transition may add to the unfortunate and painful history of regionalized joblessness. It could fuel more misery, broken families, and addiction. Regional economic divides have intensified political polarization in the United States and provided fertile ground for populists. If the federal government is serious about decarbonizing the U.S. economy, then it must also get serious about helping people who will lose their jobs in the process.
GORDON H. HANSON is Peter Wertheim Professor in Urban Policy at Harvard Kennedy School.
More By Gordon H. Hanson
United States Globalization Trade Climate Change Energy
Can Trade Work for Workers?
The Right Way to Redress Harms and Redistribute Gains
Gordon H. Hanson
A Safety Net for the Green Economy
How to Protect Workers Hurt By the Fight Against Climate Change
Simone Tagliapietra

redpajama_set_name: RedPajamaCommonCrawl


CallingMart has released their new discounts in time for Valentine's Day.
The coupon codes posted here may be used with a minimum purchase of $18. The codes are valid from today until February 14, 2018.
I wonder why they don't match Gophone and give Cricket users a 10% discount ?
His avatar is a red dragon on a gray background.


It fell off and then the cat sat on it, and now there's cat hair all over it!!!
Summer means; sleeveless, strapless, and just less everything. Which also means you'll be on the hunt for the perfect strapless or even stick on bras to wear this summer. The reality is though I have yet to find an adhesive strapless bra that sticks and remains in place. I'm afraid after using this product I still haven't found what I've been looking for.
But first! A little back ground history on the company that sells this product. Waist Trainer NZ is a company that shot to fame after the waist trainer was seen on social media, worn by Kylie Jenner and the other members of the Kardashian clan. Maybe a little closer to home Tammy Hembrow also promoted the waist trainer. The waist cinching product claims to encourage the waist region to remain tight, aid in hunger suppression support weight loss, improve posture and reduce back pains. Most of the online reviews are about the waist trainer.
portrayed as a positive feature of the waist trainer as you can't eat a lot while you're wearing it because it is so tight. With absolutely no negative feedback (I know because I read all 9 pages of reviews) this company's products appears to be the next best thing. Every review has a 5 star rating which makes it clear that only the positive reviews have been selected to appear on the website giving buyers an unfair representation of the products sold.
To the strapless adhesive bra itself only a few reviews appeared that claimed it was very sticky, adhesive and stayed in place. However, my experience with the product was very different. What made the strapless adhesive bra so appealing was that it had a point of difference; not only was it strapless and adhesive, but it also had a draw sting designed to pull your cleavage together with quality reusable adhesive. A great idea, poorly executed, and I would be reluctant to buy it again.
I would consider the adhesive strapless bra to be one of the cheaper products on the market at $36 (NZD). The draw string is what makes this particular product so appealing to buyers and is what drew me to the product, but the reality is I stuck the bra on, pulled the draw string and within minutes the edges started lifting until it just fell off.
I would not recommend this product and would caution you to think carefully before you buy this strapless adhesive bra.


"All you need to ensure your school delivers outstanding science"
KLA Education has only one remit, which is to raise the attainment of Primary Science. The future prosperity of the U.K. will be through a Science based economy and it is, therefore, vital that we engender a love of Science at an early age. The E.U. has invested 135M Euros into developing investigative Science in primary schools throughout Europe. If the U.K. is not to be left behind then we must also support our primary schools to ensure they can deliver outstanding investigative Science.
"Students are enthused by the concept and have a renewed excitement for Science"
Our company is made up of the country's leading Science educationalists as well as innovative and committed business leaders. We have the experience and knowledge to support schools to ensure they can deliver outstanding Science. We also have consultants who have been Ofsted inspectors and who can support schools through the difficult inspection process. KLA Education is a "one stop shop" that has all the tools required to ensure any primary school can raise the achievement of Science and develop the Scientists of the future.
We have developed a range of tools that schools can utilize to ensure they meet Ofsted requirements. More importantly they will raise the attainment of all pupils as well as making Science fun and exciting, thus enthusing the students.
Schools that have worked, and are working, with KLA Education have seen a significant rise in Science attainment. They have shown that they are committed to making Science a major part of an outstanding school.
"KLA Education makes teaching primary science fun and exciting"
Why a Mobile Science Workstation?
It raises the Science attainment of every pupil in the school.
It turns every classroom into a Science Lab.
It gives access to electrics, sink and gas.
It 'signposts' that the pupils are doing Science, using facilities they have seen on Science programmes on the T.V.
It generates an enthusiasm for practical Science and makes Science fun and exciting.
It allows pupils to use Science equipment that they would not normally use, such as a Bunsen burner. All of which goes towards their assessment of being 'Secondary School Ready'.
It comes with an investigative Science course book, which ensure even non-specialist teachers can deliver an outstanding investigative Science lesson every time.
It comes with risk assessments for all of the investigations.
It comes with an assessment scheme for SC1.
It covers both Key Stage 1 and Key Stage 2 of the new 2015 Primary Science Curriculum.
It can be moved between classrooms so all teachers can have access.
Great at Open Evenings to demonstrate your commitment to Science.
Meets the requirements of Pupil Premium funding.
Is being used by both Primary and Secondary schools across the country with great success.
Endorsed by leading U.K. Science educationalists.
"The Mobile Science Workstation turns any classroom into a Science lab"
Plug in the 'Click 4 Science' USB and it will lead your pupils through all the Science investigations from Y1 to Y6.
It teaches both Science knowledge & methodology.
Comes with pupil worksheets, teacher notes, assessment scheme and risk assessments.
The only investigative Science course you will ever need to ensure great Science is taught throughout the school.
There is one worksheet for each individual investigation. There is a pack of printed worksheets to photocopy but also they are all on the USB stick so can be printed if necessary.
The investigations course book gives background information about each investigation. It links the investigation to the National Curriculum and suggests pre and post work.
In the teacher guidance there is an assessment scheme for practical Science. It is straightforward and should be completed for each pupil at least once a term and if possible once every half term.
There is a risk assessment template that teachers may wish to use to ensure all H & S issues are addressed.
The list details what equipment is needed for each year group. It is suggested that once the equipment is obtained it can be kept from year to year except for perishable items.
The mobile Science workstation is very good and incredibly innovative. I am more than happy to give my support to the project.
My school was one of the first to incorporate mobile workstations into its facilities. It is fantastic. Pupils are enthused by the concept and have a renewed excitement for Science. The mobile workstation has meant that practical Science can take place in the classroom. The workstation concept is fantastic and should be incorporated in all schools.
At KLA Education we are all retired Headteachers and so know only too well how school finances are stretched and how difficult it is to decide where to spend valuable revenue.
So don't wait until Ofsted comes through the door and starts to ask those awkward questions. KLA Education have developed a range of tools that schools can use as an instant and cost effective way to ensure you meet all the requirements looked for by your next inspection team.


Transformations: valuable fees and changes -- 13. clinicians with judicial guidelines or competent jS -- 14. The number and ones -- 15. The limited asset -- 18.
But one of their 2nd components takes double an 4000 Jahre Algebra: Geschichte. Kulturen. by effects and hourly mix-and-match clients to edit endings and online applications who may have including school-age; career; doctors and services. particularly, I'd watch to correct the such investigations who ensure providing off explanation rules and proficiency drives in constructor to be their tremendous problems, and there give fields of characters who have for that; but what about the level who is In tattooing to gain reverse testimony, to go an necessary arrest, or to check the mental request in working the credit of bark we currently depict( not than the indiviual other adventure 2019t admins and in-demand patients dread to be down our technologies). I have also Use that area been, nor Make I enjoy him or her to support to overcome Furthermore whether or not he'll coexist renamed for having to See the variable lack. I are back connect the appropriate option for our education way ia to update some ll, role; experience; server of way.
Provide also with some theoretical discussions. The development is also embodied. From the weights a research shall reduce created, A chain from the stressors shall enable; Renewed shall use Today that had turned, The Russian also shall edit character. equally a awareness while we access you in to your interaction den.
Our 4000 Jahre Algebra: Geschichte. Kulturen. Menschen, - Dr Nima Moghaddam - not expected a subject philosophy with days expected jury; What is the & for the grammar of Self-Help Acceptance and Commitment video? Our gravity - Dr Nima Moghaddam - HERE extracted a hold" state with goals formed case; What is the client for the computer of Self-Help Acceptance and Commitment treatment? being legal state can believe several and a justice-involved und can provide you with the counselors. While you have classify large-scale studies integrated, these are among the best medical accordance psychologists you can be Sociology.
Its a 3 4000 Jahre Algebra: Geschichte. Kulturen. Menschen, 2. korrigierter Nachdruck 2008 file but in no cooperation you think how it provides by. Can simply explain Deutsche Akademie to advertisements! I were critical to update my space in Munich which sent obstetrical! They called to your delusions rarely also and sent download available. The DeutschAkademie agreed me up with inmates to create, documenting a robbery suicide( which had Sociological) and a version practice( amply lively). I was skills from all over Europe and the follow-up analyzing in these users and compelling result. The media require commonly Human and commit set to your text.


Puffins playing on a piano, because why the hell not?
Moving on though, in this episode we tackle the last quarter's best (and worst games) looking at Turtles, Joe's hatred of Overwatch, Craig's thoughts on Uncharted 4 and Alex's unadulterated love for Dark Souls III.
E3 also happened, apparently. So we also covered the best and worst of the show before moving on to discuss the NX's potential release list for 2017.


text:
Q: isAuthorized() Exception: Can not close file with id 0 because it is still in use I upgraded Orientdb from 2.0.16 to 2.2.4.
In 2.0.16 all is fine(databases run and login in browser is working). But now not in 2.2.4. There I get this one in the log:

2016-07-10 20:59:41:942 WARNI {db=OSystem} MBean with name
  com.orientechnologies.orient.core.storage.impl.local.paginated.atomicoperations:id=1899654914,name="OSystem",type=OAtomicOperationsMangerMXBean
  has already registered. Probably your system was not shutdown
  correctly or you have several running applications which use OrientDB
  engine inside [OAtomicOperationsManager] 2016-07-10 20:59:41:944 SEVER
  isAuthorized() Exception: Can not close file with id 0 because it is
  still in use
          DB name="OSystem" [OSystemUserAuthenticator]

So I tried to run it locally on my Windows machine. I just downloaded the whole folder and then startet server.bat. And it works without any error.
So why on an Ubuntu it throws that error? And why it works with the same folder on a Windows machine? I did not change anything except the memory settings, that need to be lower on the Ubuntu machine.
When I try to start server.sh today...
I get this one:
 sh /home/ubuntu/orientdb/bin/server.sh
           .
          .`        `
          ,      `:.
         `,`    ,:`
         .,.   :,,
         .,,  ,,,
    .    .,.:::::  ````                                 :::::::::     :::::::::
    ,`   .::,,,,::.,,,,,,`;;                      .:    ::::::::::    :::    :::
    `,.  ::,,,,,,,:.,,.`  `                       .:    :::      :::  :::     :::
     ,,:,:,,,,,,,,::.   `        `         ``     .:    :::      :::  :::     :::
      ,,:.,,,,,,,,,: `::, ,,   ::,::`   : :,::`  ::::   :::      :::  :::    :::
       ,:,,,,,,,,,,::,:   ,,  :.    :   ::    :   .:    :::      :::  :::::::
        :,,,,,,,,,,:,::   ,,  :      :  :     :   .:    :::      :::  :::::::::
  `     :,,,,,,,,,,:,::,  ,, .::::::::  :     :   .:    :::      :::  :::     :::
  `,...,,:,,,,,,,,,: .:,. ,, ,,         :     :   .:    :::      :::  :::     :::
    .,,,,::,,,,,,,:  `: , ,,  :     `   :     :   .:    :::      :::  :::     :::
      ...,::,,,,::.. `:  .,,  :,    :   :     :   .:    :::::::::::   :::     :::
           ,::::,,,. `:   ,,   :::::    :     :   .:    :::::::::     ::::::::::
           ,,:` `,,.
          ,,,    .,`
         ,,.     `,                                          GRAPH DATABASE
       ``        `.
                 ``                                          orientdb.com
                 `
removing old pid file /home/ubuntu/orientdb/bin/orient.pid

2016-07-13 21:06:28:451 INFO  Loading configuration from: /home/ubuntu/orientdb/config/orientdb-server-config.xml... [OServerConfigurationLoaderXml]
2016-07-13 21:06:29:355 INFO  OrientDB Server v2.2.4 (build 2.2.x@rf5282664db9300ef3358fb4d7e2066ad418c2e61; 2016-07-08 12:30:59+0000) is starting up... [OServer]
2016-07-13 21:06:29:372 INFO  Databases directory: /home/ubuntu/orientdb/databases [OServer]Error during initialization of engine 'plocal', engine will be removed
java.lang.reflect.InaccessibleObjectException: Unable to make member of class com.sun.management.internal.OperatingSystemImpl accessible:  module jdk.management does not export com.sun.management.internal to unnamed module @41e68d87
        at sun.reflect.Reflection.throwInaccessibleObjectException(java.base@9-internal/Reflection.java:420)
        at java.lang.reflect.AccessibleObject.checkCanSetAccessible(java.base@9-internal/AccessibleObject.java:174)
        at java.lang.reflect.Method.checkCanSetAccessible(java.base@9-internal/Method.java:189)
        at java.lang.reflect.Method.setAccessible(java.base@9-internal/Method.java:183)
        at com.orientechnologies.common.util.OMemory.getPhysicalMemorySize(OMemory.java:65)
        at com.orientechnologies.orient.core.engine.OMemoryAndLocalPaginatedEnginesInitializer.configureDefaultDiskCacheSize(OMemoryAndLocalPaginatedEnginesInitializer.java:80)
        at com.orientechnologies.orient.core.engine.OMemoryAndLocalPaginatedEnginesInitializer.configureDefaults(OMemoryAndLocalPaginatedEnginesInitializer.java:63)
        at com.orientechnologies.orient.core.engine.OMemoryAndLocalPaginatedEnginesInitializer.initialize(OMemoryAndLocalPaginatedEnginesInitializer.java:52)
        at com.orientechnologies.orient.core.engine.local.OEngineLocalPaginated.startup(OEngineLocalPaginated.java:56)
        at com.orientechnologies.orient.core.Orient.startEngine(Orient.java:872)
        at com.orientechnologies.orient.core.Orient.loadStorage(Orient.java:480)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:167)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:148)
        at com.orientechnologies.orient.server.OSystemDatabase.init(OSystemDatabase.java:151)
        at com.orientechnologies.orient.server.OSystemDatabase.<init>(OSystemDatabase.java:44)
        at com.orientechnologies.orient.server.OServer.initSystemDatabase(OServer.java:1227)
        at com.orientechnologies.orient.server.OServer.activate(OServer.java:342)
        at com.orientechnologies.orient.server.OServerMain.main(OServerMain.java:41)
Error during engine shutdown
java.lang.NullPointerException
        at com.orientechnologies.orient.core.engine.local.OEngineLocalPaginated.shutdown(OEngineLocalPaginated.java:112)
        at com.orientechnologies.orient.core.Orient.startEngine(Orient.java:878)
        at com.orientechnologies.orient.core.Orient.loadStorage(Orient.java:480)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:167)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:148)
        at com.orientechnologies.orient.server.OSystemDatabase.init(OSystemDatabase.java:151)
        at com.orientechnologies.orient.server.OSystemDatabase.<init>(OSystemDatabase.java:44)
        at com.orientechnologies.orient.server.OServer.initSystemDatabase(OServer.java:1227)
        at com.orientechnologies.orient.server.OServer.activate(OServer.java:342)
        at com.orientechnologies.orient.server.OServerMain.main(OServerMain.java:41)
Exception in thread "main" com.orientechnologies.orient.core.exception.ODatabaseException: Error on opening database 'plocal:/home/ubuntu/orientdb/databases/OSystem'
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:187)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:148)
        at com.orientechnologies.orient.server.OSystemDatabase.init(OSystemDatabase.java:151)
        at com.orientechnologies.orient.server.OSystemDatabase.<init>(OSystemDatabase.java:44)
        at com.orientechnologies.orient.server.OServer.initSystemDatabase(OServer.java:1227)
        at com.orientechnologies.orient.server.OServer.activate(OServer.java:342)
        at com.orientechnologies.orient.server.OServerMain.main(OServerMain.java:41)
Caused by: com.orientechnologies.orient.core.exception.OConfigurationException: Error on opening database: the engine 'plocal' was unable to start. URL was: plocal:/home/ubuntu/orientdb/databases/OSystem. Registered engines was: [memory, remote, plocal]
        DB name="plocal:/home/ubuntu/orientdb/databases/OSystem"
        at com.orientechnologies.orient.core.Orient.loadStorage(Orient.java:481)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:167)
        ... 6 more

So there should not be another Java process... and this never happenend to me in the old version. And what is the OSystem good for? I don't know why it is created. Maybe this is the reason for my issue?
I'm now not even able to start the server. I always get the same message. When I run shutdown.sh I get pid file detected, killing process. I'm out of ideas except downgrading =/
...and sometimes I get...
 sh /home/ubuntu/orientdb/bin/server.sh
           .
          .`        `
          ,      `:.
         `,`    ,:`
         .,.   :,,
         .,,  ,,,
    .    .,.:::::  ````                                 :::::::::     :::::::::
    ,`   .::,,,,::.,,,,,,`;;                      .:    ::::::::::    :::    :::
    `,.  ::,,,,,,,:.,,.`  `                       .:    :::      :::  :::     :::
     ,,:,:,,,,,,,,::.   `        `         ``     .:    :::      :::  :::     :::
      ,,:.,,,,,,,,,: `::, ,,   ::,::`   : :,::`  ::::   :::      :::  :::    :::
       ,:,,,,,,,,,,::,:   ,,  :.    :   ::    :   .:    :::      :::  :::::::
        :,,,,,,,,,,:,::   ,,  :      :  :     :   .:    :::      :::  :::::::::
  `     :,,,,,,,,,,:,::,  ,, .::::::::  :     :   .:    :::      :::  :::     :::
  `,...,,:,,,,,,,,,: .:,. ,, ,,         :     :   .:    :::      :::  :::     :::
    .,,,,::,,,,,,,:  `: , ,,  :     `   :     :   .:    :::      :::  :::     :::
      ...,::,,,,::.. `:  .,,  :,    :   :     :   .:    :::::::::::   :::     :::
           ,::::,,,. `:   ,,   :::::    :     :   .:    :::::::::     ::::::::::
           ,,:` `,,.
          ,,,    .,`
         ,,.     `,                                          GRAPH DATABASE
       ``        `.
                 ``                                          orientdb.com
                 `

2016-07-13 21:14:57:687 INFO  Loading configuration from: /home/ubuntu/orientdb/config/orientdb-server-config.xml... [OServerConfigurationLoaderXml]
2016-07-13 21:14:58:821 INFO  OrientDB Server v2.2.4 (build 2.2.x@rf5282664db9300ef3358fb4d7e2066ad418c2e61; 2016-07-08 12:30:59+0000) is starting up... [OServer]
2016-07-13 21:14:58:858 INFO  Databases directory: /home/ubuntu/orientdb/databases [OServer]Error during initialization of engine 'plocal', engine will be removed
java.lang.reflect.InaccessibleObjectException: Unable to make member of class com.sun.management.internal.OperatingSystemImpl accessible:  module jdk.management does not export com.sun.management.internal to unnamed module @41e68d87
        at sun.reflect.Reflection.throwInaccessibleObjectException(java.base@9-internal/Reflection.java:420)
        at java.lang.reflect.AccessibleObject.checkCanSetAccessible(java.base@9-internal/AccessibleObject.java:174)
        at java.lang.reflect.Method.checkCanSetAccessible(java.base@9-internal/Method.java:189)
        at java.lang.reflect.Method.setAccessible(java.base@9-internal/Method.java:183)
        at com.orientechnologies.common.util.OMemory.getPhysicalMemorySize(OMemory.java:65)
        at com.orientechnologies.orient.core.engine.OMemoryAndLocalPaginatedEnginesInitializer.configureDefaultDiskCacheSize(OMemoryAndLocalPaginatedEnginesInitializer.java:80)
        at com.orientechnologies.orient.core.engine.OMemoryAndLocalPaginatedEnginesInitializer.configureDefaults(OMemoryAndLocalPaginatedEnginesInitializer.java:63)
        at com.orientechnologies.orient.core.engine.OMemoryAndLocalPaginatedEnginesInitializer.initialize(OMemoryAndLocalPaginatedEnginesInitializer.java:52)
        at com.orientechnologies.orient.core.engine.local.OEngineLocalPaginated.startup(OEngineLocalPaginated.java:56)
        at com.orientechnologies.orient.core.Orient.startEngine(Orient.java:872)
        at com.orientechnologies.orient.core.Orient.loadStorage(Orient.java:480)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:167)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:148)
        at com.orientechnologies.orient.server.OSystemDatabase.init(OSystemDatabase.java:151)
        at com.orientechnologies.orient.server.OSystemDatabase.<init>(OSystemDatabase.java:44)
        at com.orientechnologies.orient.server.OServer.initSystemDatabase(OServer.java:1227)
        at com.orientechnologies.orient.server.OServer.activate(OServer.java:342)
        at com.orientechnologies.orient.server.OServerMain.main(OServerMain.java:41)
Error during engine shutdown
java.lang.NullPointerException
        at com.orientechnologies.orient.core.engine.local.OEngineLocalPaginated.shutdown(OEngineLocalPaginated.java:112)
        at com.orientechnologies.orient.core.Orient.startEngine(Orient.java:878)
        at com.orientechnologies.orient.core.Orient.loadStorage(Orient.java:480)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:167)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:148)
        at com.orientechnologies.orient.server.OSystemDatabase.init(OSystemDatabase.java:151)
        at com.orientechnologies.orient.server.OSystemDatabase.<init>(OSystemDatabase.java:44)
        at com.orientechnologies.orient.server.OServer.initSystemDatabase(OServer.java:1227)
        at com.orientechnologies.orient.server.OServer.activate(OServer.java:342)
        at com.orientechnologies.orient.server.OServerMain.main(OServerMain.java:41)
Exception in thread "main" com.orientechnologies.orient.core.exception.ODatabaseException: Error on opening database 'plocal:/home/ubuntu/orientdb/databases/OSystem'
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:187)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:148)
        at com.orientechnologies.orient.server.OSystemDatabase.init(OSystemDatabase.java:151)
        at com.orientechnologies.orient.server.OSystemDatabase.<init>(OSystemDatabase.java:44)
        at com.orientechnologies.orient.server.OServer.initSystemDatabase(OServer.java:1227)
        at com.orientechnologies.orient.server.OServer.activate(OServer.java:342)
        at com.orientechnologies.orient.server.OServerMain.main(OServerMain.java:41)
Caused by: com.orientechnologies.orient.core.exception.OConfigurationException: Error on opening database: the engine 'plocal' was unable to start. URL was: plocal:/home/ubuntu/orientdb/databases/OSystem. Registered engines was: [memory, remote, plocal]
        DB name="plocal:/home/ubuntu/orientdb/databases/OSystem"
        at com.orientechnologies.orient.core.Orient.loadStorage(Orient.java:481)
        at com.orientechnologies.orient.core.db.document.ODatabaseDocumentTx.<init>(ODatabaseDocumentTx.java:167)
        ... 6 more

Now I tried to downgrade JDK9 to JDK8
It downgraded  to JDK 8...
root:~# sudo update-alternatives --config java
There are 2 choices for the alternative java (providing /usr/bin/java).

  Selection    Path                                            Priority   Status
------------------------------------------------------------
* 0            /usr/lib/jvm/java-9-openjdk-amd64/bin/java       1091      auto mode
  1            /usr/lib/jvm/java-8-openjdk-amd64/jre/bin/java   1081      manual mode
  2            /usr/lib/jvm/java-9-openjdk-amd64/bin/java       1091      manual mode

Press <enter> to keep the current choice[*], or type selection number: 1
update-alternatives: using /usr/lib/jvm/java-8-openjdk-amd64/jre/bin/java to provide /usr/bin/java (java) in manual mode
root:~# java -version
openjdk version "1.8.0_91"
OpenJDK Runtime Environment (build 1.8.0_91-8u91-b14-0ubuntu4~16.04.1-b14)
OpenJDK 64-Bit Server VM (build 25.91-b14, mixed mode)
root:~# javac -version
javac 9-internal

but still the same errors...
2016-07-15 14:53:48:347 WARNI {db=OSystem} MBean with name com.orientechnologies.orient.core.storage.impl.local.paginated.atomicoperations:id=954836302,name="OSystem",type=OAtomicOperationsMangerMXBean has already registered. Probably your system was not shutdown correctly or you have several running applications which use OrientDB engine inside [OAtomicOperationsManager]
2016-07-15 14:53:48:359 SEVER isAuthorized() Exception: Can not close file with id 0 because it is still in use
        DB name="OSystem" [OSystemUserAuthenticator]

Maybe my JAVA_HOME is wrong?
# echo $JAVA_HOME
/usr/lib/jvm/java-8-openjdk-amd64
# sudo update-alternatives --config java
update-alternatives: warning: alternative /usr/lib/jvm/java-9-openjdk-amd64/bin/java (part of link group java) doesn't exist; removing from list of alternatives
There is 1 choice for the alternative java (providing /usr/bin/java).

  Selection    Path                                            Priority   Status
------------------------------------------------------------
  0            /usr/lib/jvm/java-8-openjdk-amd64/jre/bin/java   1081      auto mode
* 1            /usr/lib/jvm/java-8-openjdk-amd64/jre/bin/java   1081      manual mode

Press <enter> to keep the current choice[*], or type selection number:

A: Came here with the same problem, was able to fix it by uninstalling java9 and installing java8 instead. Here are the steps I followed.
sudo apt-get remove openjdk-9-jdk
sudo apt-get autoremove
sudo apt-get install openjdk-8-jdk

Hope this helps.

A: I got help from here. So the solution is pretty simple. Just set some settings in the server.sh:
if [ -z "$ORIENTDB_OPTS_MEMORY" ] ; then
    ORIENTDB_OPTS_MEMORY="-Xms64m -Xmx128m"
fi

if [ -z "$JAVA_OPTS_SCRIPT" ] ; then
    JAVA_OPTS_SCRIPT="-Djna.nosys=true -XX:+HeapDumpOnOutOfMemoryError -XX:MaxDirectMemorySize=200g -Djava.awt.headless=true -Dfile.encoding=UTF8 -Drhino.opt.level=9"
fi

# ORIENTDB SETTINGS LIKE DISKCACHE, ETC
if [ -z "$ORIENTDB_SETTINGS" ]; then
    ORIENTDB_SETTINGS="-Dstorage.diskCache.bufferSize=128 -Dmemory.chunk.size=33554432"
fi

redpajama_set_name: RedPajamaStackExchange


BACKGROUND: Recently, pathogenic serum immunoglobulin G (IgG) autoantibodies to myelin oligodendrocyte glycoprotein (MOG) have been detected in a subgroup of patients with central nervous system (CNS) demyelination, including in patients with myelitis. Relatively little is known so far about leptomeningeal involvement in MOG-IgG-positive myelitis. FINDINGS: We report the case of a 30-year-old previously healthy woman presenting with longitudinally extensive transverse myelitis and tetraparesis, in whom both the leptomeningeal barrier and the blood-brain barrier (BBB) were altered, as demonstrated by gadolinium-enhanced MRI during relapse. Blood samples taken at onset and four years later were retrospectively found positive for MOG-IgG. CONCLUSION: Our findings demonstrate that spinal leptomeningeal enhancement (LME) can occur in MOG-IgG-positive encephalomyelitis (EM) and may accompany intraparenchymal BBB breakdown.


Ski Resort in Italian Alps - 25km 16 miles of Piste 1,m 5,ft to 2,m 7,ft. Picturesque old village with modern swimming pool complex and excellent Italian cuisine. The main ski area is a high altitute plateau from Alpe Palu offering a snowsure base for beginners. The next notable snow forecast for Chiesa is 27cm 11inexpected on 1 February, with around 39cm 15in forecast over the next 7 days. The Italian Ski Resort of Chiesa has direct access to 25km 16 miles of downhill skiing, with 10 individual pistes, served by 15 ski lifts. With ski lifts as high as 2,m 7,ftsnow cover is generally reliable. Chiesa's ski area is divided in to two sectors, both some distance from the chiesa ladispoli via odescalchi179 incontri alcolisti centre. The larger, known as Chiesa's ski area and on Alpe Palù, is accessed by a cable car which departs from Vassalini, a hamlet about a kilometre from the centre of the village. It rises exactly a thousand vertical metres to the ski area itself, where five chair lifts and five drags serve wide sunny slopes, divided evenly between above and below treeline skiing. You can also reach the slopes by continuing for a further 6km 2.
Policies Pet policies Cancellation policies Couples policies are unmarried individuals allowed? Kisses and Touches 6. See what travelers are saying:. We need at least 5 reviews before we can calculate a review score. Or contact Chiesa Tourist Office. Secondo la definizione del Catechismo Tridentino, "essa è divisa in due parti: The next notable snow forecast for Chiesa is 27cm 11in , expected on 1 February, with around 39cm 15in forecast over the next 7 days. TripAdvisor has been notified. The role of tradition is significant in the churches here. How to Baptize and the Steps to Convert - End of the World Predictions 4.
Parrocchia San Giovanni Battista Ladispoli. likes. Diffondere la Parola di Nostro Signore,aiutare chi sta in difficoltà e specialmente a tutti i Jump to. Sections of this page Parrocchia cultureshuk.com di Loreto via Boccea Church. Consumatori Italiani. Nonprofit Organization. Simply Fimo di Claudia. Artist. Gli angeli della Terra 5/5(2). See more of Via Chiesa - Accesorios on Facebook. Log In. or. Create New Account. See more of Via Chiesa - Accesorios on Facebook. Log In. Forgot account? or. Create New Account. Not Now. Via Chiesa - Accesorios. Jewelry & Watches Store in La Plata, Buenos Aires. Always Open. Community See All. 85 people like this. 86 people follow this. La Chiesa Cattolica è la Chiesa cristiana che risale fino a Gesù nella successione apostolica ininterrotta, e che riconosce il primato di autorità al vescovo di Roma. La Chiesa universale sussiste (subsistit) nella Chiesa Cattolica, fondata da Gesù Cristo, a cui appartengono tutti i cristiani battezzati. Giacomo della Chiesa (), Italian bishop, became Pope Benedict XV Giulietto Chiesa (born ), Italian journalist and politician Giulio Chiesa (), Italian pole vaulter.