I actually think that Dr. Martin and I might have a lot in common. We are both passionate about healthcare. We both believe that Canada's public health care system could do a lot better when it comes to serving the needs of Canadians who rely on it. We both believe that timely access to medical care should not be reliant on a person's wealth. We both believe that social determinants of health (things like income, education and housing) drive health outcomes and the use of the healthcare system – and that by addressing those issues significant improvements in the health and well-being of Canadians could be realized. We are both young women with well-informed opinions (hers developed in the context of being a physician and my own developed as a result of being a health economist and first hand experiences as a patient) and a willingness to debate those opinions publicly.
Dr. Martin believes that a single-payer system that has a monopoly on medically necessary care is critical. Further, she believes the system could be salvaged if just 3 big ideas were implemented – National Public Drug Coverage, Less is More, and a Guaranteed Income Supplement.
In contrast – I have come to the conclusion that the single-payer system and how it is structured is a very big part of the problems that seem endemic to our system and that no idea is "Big Enough" to salvage it, and absent structural change that the most promising "Big Ideas" are simply not feasible. I believe there's a reason why every other first-world country in the world with a universal public health system that out performs Canada's also has a parallel private system that also provides medically necessary care. Single-payer is simply one of those ideas (like communism) that is nice in theory, but in practice and in the context of a complex reality fails to deliver the best outcomes and leaves many suffering the very real consequences of the system's inadequacies.
Dr. Danielle's first "Big Idea" is National Public Drug Coverage for the top 20 drugs used to treat chronic conditions in Canada. It is nothing short of shameful that Canada does not include pharmaceuticals as part of its public health system – particularly given that pharmaceutical therapy has become the cornerstone of effective medical care for many conditions. It is also shameful that the approach to pharmaceutical policy in Canada is a provincial/federal/territorial patchwork quilt. It is true that bulk buying the most common drugs would save the system money, and that providing access to those drugs would likely improve adherence among those for whom cost is the primary reason for lack of treatment adherence. National coverage of the top 20 pharmaceuticals would be a good start.
However, that is all this particular "Big Idea" is; a start. It is nowhere near big enough to actually remedy the larger problems and the larger reality that Canada's health system is a patchwork quilt of practice and policy that is far from comprehensive. The fact that Canada runs more than a dozen different health systems (each province and territory effectively administering its own system, plus the systems run to address the needs of first nations, prisoners, members of the military, etc.) – is a massive waste of resources in and of itself. Further, while the lack of pharmaceutical coverage is lamentable, other big voids include the absence of coverage for dentistry and the services of many para-health professionals (psychologists, chiropractors, massage therapists, physiotherapists, etc.) and the absence of comprehensive coverage for long-term care. If we want a public health care system that is truly functional and comprehensive – the multitude of public systems would be collapsed into a single federal entity, and the system would be expanded to be truly comprehensive in nature to include pharmaceuticals, the services of para-professionals, and long-term care.
Dr. Danielle Martin's second "Big Idea" is less is more. This idea is aimed at limiting the number of tests and procedures that are of questionable value or duplicative in nature. In retrospect there are a lot of things that happen in the health system that prove to be of little value, in retrospect there are things that are done that perhaps should not be done. In a perfect world – and even in this imperfect world, it is hard not to say that doing some things less would save the system money and not result in worse outcomes, in some cases, doing less might even result in better outcomes (for example the prescription of unnecessary antibiotics that lead to resistant strains of bacteria). This idea is alluring in its simplicity and echoes the environmental movement to reduce, reuse, and recycle in order to stretch what is available to the limit of its potential.
However, the idea of "Less is More" is deserving of scrutiny, particularly in healthcare. Born out of "Less is More", are care protocols that exhaust conservative options first, denial or delay of access to diagnostic testing and denial or delay of access to treatment. The first thing to understand, is that healthcare decisions are not made retrospectively. There is no "way-back" machine to turn back time and make a different choice if the choice made proves to have been the wrong one – and for some the "less is more" will exact a terrible human toll. Further, patients are a diverse group of individuals with a diverse range of preferences and a diverse tolerance of risk. Not all patients want to wander through the conservative options first. Not all patients are going to be satisfied with denial and delay of access diagnostics or treatment. "Less is More" as a philosophy has the potential to deprive patients of informed choice and decision making with respect to their own bodies and has the potential of moving the system further away from being patient centred. Too many patients in Canada have already borne the brunt of "Less is More", of having doctors put the needs of the system ahead of the needs of the patient – and absent any alternative route for patients to access, seems like an unjust infringement of rights that should be contested.
Dr. Danielle's third big idea is a guaranteed income supplement. Poverty is highly correlated with levels of poor health. If you do not have an adequate income, you may not eat an adequate diet, you may not have access to adequate housing, you may not be able to make investments in your own skills to improve your chances in the labour market. Dr. Danielle's answer is a straight-up hand out to the poor. She proposes that the tax system be used to directly transfer wealth, and that doing so will address the ills that poverty causes. Doing so will make the problems of inadequate housing, inadequate education and inadequate nutrition simply disappear.
However, this is another idea that is deserving of scrutiny and more than cursory thought. Simply giving money to the poor is attractive in its simplicity. It is what is done every time you walk down the street and give the panhandlers change. However, it neglects the reality that poverty is a symptom of underlying problems, many of which are not solved by a hand-out and for some, money may make those problems worse (in the case of addictions). It is also a bit of a "cop-out", instead of trying to understand and address the causes of poverty and impacts on those impoverished, society buys itself out of the responsibility to be compassionate, the responsibility to give the impoverished a hand-up rather than a mere-hand out. Further, doing so would negatively distort individual decisions with respect to the development of skills, participation in the labour force, and other life choices. If the cost of making poor decisions is lowered, inevitably more poor decisions may be made. Further, it may generate even greater levels of disdain for those who are impoverished – particularly as significant tax increases on those who have made "good decisions" would be used to subsidize a share of the poor who are poor as a direct result of "bad decisions". Merely giving money does not translate into better housing, better nutrition, better education and social integration. Canada needs to do the hard work in this area and truly get a handle on understanding poverty and its underlying causes as the solution is unlikely to be a mere hand-out. After all, it'd be a shame to spend all that money, and still have to contend with the results of inadequate nutrition, inadequate housing, inadequate education, and inadequate social integration – when that money could have been used to provide better nutrition, better housing, better education, and better social support. Good medicine is treating the underlying causes of disease and disorder, rather than ameliorating only the symptoms.
Big ideas are most definitely needed if we are going to get to a place where a truly comprehensive, universal public health system that meets the needs of Canadians is to be achieved, the biggest of which is the acceptance of the idea that it does not need to be a single-payer monopoly on medically necessary care.
Freedom of Information and Protection of Privacy (FOIPPA) legislation was not intended to hamstring data scientists and policy workers. It was not intended to cause a culture of fear that inhibits the pursuit of knowledge in the public's interest. It was not intended to cause the sharing of data and information to grind to a near halt. It was not intended to squander resources to ensure adherence to the letter of the law. It was not intended to result in the gutting of capacity to do valuable research on the efficacy and safety of drugs.
Yet, those are the very real unintended consequences – consequences that are difficult to cope with and understand unless you have attempted to grapple with them first hand.
When it comes to data and government's use of data – many in British Columbia and Canada are in the dark about how it works and why it critically matters. Many are incredibly fearful of the use of their personal information, and the words "Data Privacy Breech" often elicit a tremendous fear of identity theft. Further, personal medical information is sensitive information that needs to be kept confidential as it has the potential to negatively impact an individual's personal life. Protection of privacy and the mitigation of risks associated with sensitive personal information needs to be a priority. Those trusted with access to that information have a responsibility and a duty not to violate the privacy of individuals by accessing information to satisfy "personal curiosities" as was recently the case in Vancouver Island Health Authority (http://www.timescolonist.com/news/local/curiosity-of-island-health-employees-led-to-privacy-breach-probe-reveals-1.1622518#) or to sell that information for personal gain as was the case in Ontario a little while ago when a Rouge Valley Centenary Hospital clerk sold the information of birthing mothers to financial companies (http://www.thestar.com/news/crime/2014/11/24/hospital_clerk_charged_with_misusing_records_after_confidential_patient_files_were_sold.html).
The collection of data (either directly or indirectly), use and disclosure of that information are all governed by FOIPPA legislation – collection, use or disclosure that does not meet the needs of the legislation are subject to significant sanctions including termination of employment, substantial fines or even jail time.
It means that every time Ministry A wishes to link individual record level data with Ministry B or to share information with the health authorities, there has to be a Privacy Impact Assessment (PIA) and an Information Sharing Agreement in place. As a result significant resources are used to undertake Privacy Impact Assessments and to draft Information Sharing Agreements. As a result, far less information sharing between different organizations that are publicly funded occurs than what might be optimal, simply because sharing data is an onerous activity. As an example, consider a program that is being tailored to improve upon the health status of "at-risk" families. It is suspected that families who receive welfare, families who are newly arrived, families who have a history of domestic violence, families who have low income are "at-risk" of poor health outcomes. However, much of the needed information is not collected by the Ministry of Health – but is collected through a variety of other ministries and organizations including Revenue Canada, the Ministry of Justice, the Department of Corrections, the Ministry of Social Development, the Ministry of Children and Families, etc.. Much of that information was not collected with the purpose of evaluating or developing health policies or programs. As such, even though "the Government" collects the information, it might be severely limited in the sharing of that information and its use and at a minimum would need to undertake a Privacy Impact Assessment and enter into one or more Information Sharing Agreements. If it is an outside researcher needing the information there would significant costs (thousands of dollars) and delays in the production of information. This would need to happen not just once, but for every project that requires information to be shared between ministries or outside researchers – and every project would have to specify the use and disclosure of the information collected.
Further, it means that once those charged with analysing the information have the data in hand – they are limited in the kinds of analysis and explorations that they may undertake. They are able to undertake the analysis for which they have been granted permission under the Privacy Impact Assessment and the Information Sharing Agreement (or via other legislation) only. Unfortunately, this often means that there is a tremendous opportunity cost that is incurred.
As an analogy, imagine for a moment, that a chef has been given the ingredients for a meal, but rather than enabling and empowering the chef to make the "best meal possible" with the ingredients that they have been given, the chef has also been given a precise recipe to follow and have been told that if they deviate from that recipe that they will be fired. If the chef wants to do something different with the ingredients that they have been given (and retain their job), the chef must first submit a revised recipe to their superior and only after that recipe has been approved by a joint board will the chef be allowed to make the revised dish – however, when the chef has suggested revisions to the recipe before, the suggestions are often dismissed out of hand either because of lack of time, or fear that the chef will produce something that is not palatable.
Imagine what that does for innovation?
Imagine what that does for job satisfaction?
Imagine how hard it would be to keep the best and brightest interested in public data?
Imagine the difference between what is done and what could be done?
Those who work with health data need to be empowered and enabled to make the most of the information resources that are available. They need to be free to explore the data and to make potentially profound discoveries about how the public can be served better. There needs to be a better way to protect the privacy and interests of individuals without sacrificing the potential to develop, implement and evaluate the policies and programs that are publicly funded.
Working with data is not just a science, it is also an art – and unless we are willing to enable and empower those who work with data to make the most out of the information resources available – the gap between what is and what could be will remain.
The sustainability of the health care system is a legitimate concern - worthy of attention and actions to ensure that it remains capable of meeting the health needs of the population in the decades to come.
Unfortunately, the conversation around sustainability as it relates to the healthcare system is often limited to the cost of providing healthcare. The focus is on saving the system money - almost by any means feasible. The focus is on demand management. The focus is on doing the things that will cost the least amount of money to do, or alternatively, choosing to save money by doing less, doing nothing or denying or delaying access.
There is no end of angst when people (some highly educated and informed) look at the historical patterns of health care use and growth in health care costs and apply current forecasts of population and forecasts of costs. The conclusion that things will go from bad to worse, is an easy conclusion to reach. If a person applies a pessimistic view to the trajectory of general levels of health and well-being (the consequences of less than optimal lifestyles) - a grey picture becomes darker still. However, it is folly to look at the future in this way - can you imagine if people viewed other industries similarly, with a view that how things are done will be the way that things will continue to be done and that demand would simply outstrip supply (note: such an approach does sound somewhat familiar with respect to worries about the food supply).
Almost paradoxically, by focussing on the money (on "taxpayer value"), on the cost of care - the sustainability of the system itself is being jeopardized, opportunities to advance the health and well-being of the population are being foregone, and things very likely will go from bad to worse.
By focussing on the money - policy makers put blinders on and are subject to thinking in the short-term, managing this year's budget and next year's budget - and perhaps if the government is newly elected maybe the budget 3 or 4 years down the road is taken into consideration. The ability to truly consider impacts for a generation or more is limited. The long-term view is abused to inspire "chicken-little" thinking. As such an investment in health that might take a decade (or more) to "pay-off" is likely to be foregone in favor of investments that have pay-offs in the short term. As such, short-term cuts to access become appealing because they improve the budget that is on the immediate horizon - the budget that becomes so central at the time of the next election. Cuts that impact a small group of people are chosen in order to please the majority of taxpayers with promises to keep expenditures "in-check". All the while, undertaking the business of healthcare, becomes ever more frustrating (and unsustainable) to both patients and providers, as innovation becomes an unintended casuality and provider burnout becomes an unintended side-effect of short-sighted cost-cutting.
However, consider for a moment, what might happen if the focus were to shift away from "taxpayer value" and towards a system intent on pleasing those who use it (patients), by doing what can reasonably be done to improve the health and well-being of patients. A system that truly values patients, and those who provide services to those patients. A system that is compassionate enough to understand that health needs often have soci-economic causes. Think about the kinds of wide-angle thinking that might be fostered - the kinds of innovation that might come to fruition.
If we desire a "sustainable health-system", the first step is fostering a shift in thinking and shift in focus, and to believe that "taxpayer value" will follow as a side-effect. I conceed, it is a radical leap to be made - but a critical one if true sustainability is the goal.
Perhaps, as some measure of evidence of the potential for this kind of shift, consider the results businesses have been able to achieve by making similar shifts. Consider the businesses that have shifted their thinking away from "shareholder value" towards delighting their customers - notable examples include WestJet, Telus, and Apple and in contrast, organizations who have refused to make similar shifts. Is there any real evidence that thinking a parallel shift in thought applied to public systems is foolish?
I will be blunt, in the year and a bit since I returned from maternity leave I have spent most of that year wanting to leave behind the place I have gone to work to for the past decade. I have spent most of that year frustrated and floundering. Most of that year stressed. Most of that year disengaged at best. Often quietly angry by the lack of what once was.
I have gone through 3 supervisors as a result of re-orgs in the past year.
The overall vacancy rate on our floor hovers around 30 percent (nearly 40 percent of all cubicles are empty and 10 percent of offices).
The vast majority of halls have remained as they have been for the past 10 years – barren expanses of cream.
The effects of the 2012 scandal continue to reverberate through the organization.
The scores of the Workplace Environment Survey had sunk to new lows and our branch, had gone from a group with some of the highest scores in the ministry to the group with the lowest scores in the ministry.
On a personal level, a good chunk of the time since my daughter was born has been a struggle (as illustrated by countless posts on this blog). As a result, it has required a great deal of effort simply to tread water, and to get back to a place where I feel that I can once again make headway on the things that I care about. For most of the past four years it was not possible to think about where I wanted to go, when as a consequence of what happened I was stuck on where I had been.
Then there was a dawn of sorts.
In the past 4 years I had not just "tread water", I had not just kept my head above the level (although often times it had felt that, that was all I was intent on doing), I had made a difference. People had read my blog and for some what I had wrote resonated, for others I was allowed to help them achieve their goals or to better navigate the system, my perspective on the health system had shifted, my perspective on my work had change; I had built new bridges. I was once again at a place where I felt that I was able to not just "tread water" but to move forward in meaningful ways. I am at a place where I feel that I have learned a great deal of very important lessons, and that working to apply those lessons has a great deal of potential, even where I currently am at.
I could "abandon ship" – and indeed, if the right opportunity materialized, a position where the purpose of the position and my purpose and passions aligned, I would. However, in the interim, I could make where I am at, a better place. I could do what is feasible to align my work, my purpose and my passions. I could do things to improve upon the empty walls in the halls, I could do things to shift thinking, I could help others navigate towards being happier here (or elsewhere), I could make where I was at a place where at the very least, the little voice that says "This is not a place I want to be," shifts, and says, "This could be a place where I'd want to be, if…" and then set about doing those things that will transform this place a little bit each day.
So 14 months after coming back from Maternity Leave, I'm finally, settling in, my boxes are unpacked and the cardboard has been taken to recycling and I'm making where I am at a place where I can do good work, that matters – a place where the difference between what is and what could be, gets a little smaller each day.
Ready. Set. Go. This is the starting line.
Money. It is a distraction from focusing on what matters. What happens when a business makes making a profit, it's only reason for being? What happens when a government makes exceptionally low tax rates it's only reason for being? In both cases, the organizations quickly forget why they exist in the first place and begin to make decisions that jeopardize and limit the potential of their organizations to do good (even great) work, that matters.
I'll be blunt, saving the taxpayer an extra $100 or even $1,000 a year, is not going to motivate the kinds of public servants the province needs to innovate, to effectively run its programs and to deliver exceptional taxpayer value (services bought for the money spent). Similarly, making money for the shareholders of a business, likely will not be able to inspire employees to bring their "A" game to the office, day in and day out. A nameless, faceless shareholder or taxpayer simply fails to inspire and meet a deeper need for meaningful work. Even if those working are objectively paid well for the work that is done.
Meeting a deeper need for meaningful work is what enables people to go above and beyond, is what makes a difference between a job done well, and a job done exceptionally well. Finding passion and purpose in the work that is done, unleashes the potential to do not only good things, but, amazing things. People who have passion and purpose in the work they do, do not work 9 to 5, they work 24/7/365 because their work fills an intrinsic need beyond just paying the bills. A need to know that what a person has done matters, that it makes a meaningful difference to lives of others.
That's not to say that the work that is done should be done without thinking about the financial impact of undertaking the work (resources are not unlimited), or that employees should be wasteful in their use of resources. Rather, it is to say, that in the long run focusing on what really matters is likely to yield much better outcomes.
Applying this thinking to the health system, think about the kind of system that results from focusing on the cost of care (taxpayer centered) versus the kind of system that results on focusing on the quality of care (patient centered).
If the costs of care become the focus, then what is in the best financial interest of the system becomes the priority when making a decision. In a system focused on cost, there is rationing of care. In a system focused on cost, there is a need to control information and decision-making, there is a need for "gatekeepers" and collateral damage becomes an acceptable cost of doing business. In a system where cost of care is what matters, even the needs of providers might be neglected. In a system focused on cost, it is not about what is possible, it is about what is affordable. A system focused on costs sacrifices the needs of both patients and those who provide services in order to appease the taxpayer – it sacrifices the great in favor of the mediocre.
If the costs of care are taken as a given (as much resources are used as are needed to meet needs), then the focus shifts to what is in the best interests of the patients and what is in the best interests of those delivering the services to patients. Information is no longer feared and hoarded. Innovation is embraced. There is no need for care rationing and there is a great incentive for shared decision-making. Further, the work becomes intrinsically meaningful as it becomes about making life better for others, and in particular about making life better for patients. The pursuit of better care and better outcomes becomes the goal. The possible is unleashed.
To highlight the difference between these two approaches, consider the work of Elizabeth Holmes and her company Theranos. In a system focused on costs of care, her work could be seen as a threat, as it opens the door to demands for health services that would otherwise be deferred or go unneeded. In a system focused on quality of care, her work becomes a tremendous opportunity to avoid bad outcomes from ever materializing in the first place. A system that might cost more, but might also deliver far more for the dollars spent.
On occasion, I have blogged about my workplace – about the frustration and angst of being where I am at. In short, I have "poked the bear", I don't know if "the bear" reads my blog – the bear might, parts of the bear probably do. I have also "poked the bear" more directly, via a book review in the divisional newsletter and the intranet and to that end, the bear has responded somewhat in mixed ways. Granted, the direct pokes are perhaps a little more diplomatic than some of what can be found on this blog. To date the bear hasn't taken a swipe at me, although I have at times thought that it might.
However, my experience has sold me on the power of writing, and more broadly on the power of blogging and other social media (twitter, facebook) to affect change (both personal and social). It was not until I started pouring my thoughts and ideas out in a way that others might read and respond to that the challenges I was facing started to become surmountable in real and tangible ways. It is a way of speaking the name that should not be spoken; a way of peeling back the façade of a challenge to identify and explore what is beneath the surface and from there to think about how that challenge might then be overcome. The beautiful thing about blogging, about allowing those who read my blog to respond either via comments or through email – is that the door is then open for collaboration.
I recognize that my current situation is not sustainable in the long-run; that it results in a longing for something more. The writing is clearly on the wall. The culture as it has evolved, and who I am are not compatible and a consequence of that has been profound disengagement. Writing is my coping mechanism – and beyond that it is a tool to affect change, it builds a path from where I have been, to where I am at, to where I will be.
The capacity for compassion, the ability to see each other through, rather than to see through each other is perhaps the one thing that sets Canada apart from many other nations in the world. It is a culture of being there for one another – of lending a hand-up when times are rough, and of sharing in success when times are good. It is a culture of true leadership. For decades, compassion has shaped Canada's public policy at all levels of government, municipal, provincial and federal. For decades, Canada has been a leader in health and social policy – Canada has demonstrated the power of compassion to overcome the most significant of challenges.
As such, as a Canadian – the move away from compassion as a core value, as a way of being, should be seen as being deeply disturbing. It should be seen as a move away from a culture that has enabled many great successes, towards a strategy of every man, woman and child for themselves, a strategy that will ultimately lead to a Canada that is far less than what it is capable of doing and being. The loss of compassion among Canadians, and particularly among those who are our leaders is nothing short of heartbreaking.
The underfunding of public systems of health and education, and an unwavering focus on the second dumbest idea ever – "Taxpayer Value", is at its core a demonstration of a lack of compassion for others and in particular a lack of compassion for those who work in the public service and those who rely on the services it provides. High-quality, high-performing public health and public education systems need to be a priority and they need to be based on a compassionate view of those they employ and those they serve – they need to embody the hand-up that they are capable of being.
Is it compassionate to have wait times that effectively deny access to care in order to manage budgets and at the same time prohibit people from their own resources to expedite their care to mitigate the costs of their illness and or disability?
Is it compassionate to deny access to adequate compensation to those harmed by medical error?
Is it compassionate to have students who are the most in need of resources the least able to access the resources needed – is it compassionate to fund every student in every school district similarly, when the availability and effectiveness of PACs varies substantially?
Is it compassionate to treat the children of Canadian mothers and foreign fathers differently from the children of Canadian fathers and foreign mothers with respect to their access to healthcare?
A Canada without compassion, is a cold and heartless country – a country that turns its back on tremendous potential and as a result pays a huge opportunity cost. A Canada without compassion, will struggle – as those in their time of need are abandoned, and in turn, those previously abandoned turn their backs on the needs of others. A Canada without compassion will be unable to overcome the challenges it confronts – it will condemn some of its citizens to poverty, others to pain and disability. It will fail to enable and empower its citizens to contribute what they are capable of, in favour of ensuring that those who are lucky enough to avoid adversity will keep a little more money in their pockets.
Sadly, I feel that stories, like that of this Ottawa family – are about to be more common place, and sadder yet, the comments that follow it seem to reflect a loss of compassion among Canadians that is nothing short of heartbreaking.
Alternate level of care (ALC) patients are often the scapegoats to what ails the healthcare system. They are accused of being overly expensive bed blockers who use up more resources than they need and prevent somebody who needs a higher level care from accessing those services.
I would argue that the system does not adequately understand the issue of alternate level of care patients, that alternate level of care patients might not use as many resources as they are accused of using, and that if the system addressed the problem of ALC it does not follow that access to healthcare, and in particular a reduction in wait times to care would follow.
First, the system does not adequately understand the issue of alternate level of care patients. It should be noted that all patients who are not "acute care" patients are "alternate level of care" patients. This would include patients who are admitted and waiting for a procedure (pre-procedure ALC), as well as patients who are "well enough" to be discharged but cannot be discharged because of inadequate post-discharge care environments. The problem of pre-procedure ALC is not the same as the problem of post-procedure ALC but rarely are the two kinds of ALC looked at separately. Typically, when people think of "bed blockers", they are thinking of patients who are adequately recovered from their illness or surgery to be discharged but cannot be discharged because they still require some level of care, or their home environment is inappropriate. Some of these patients will not need a permanent placement in a long-term care home, but rather need a place where they can recover further before returning home or are waiting for home care or informal care providers to be available to provide for their needs. At any rate, the needs and reasons that those patients are ALC needs to be better understood before leaping to the conclusion that building more long-term care facilities is the solution to the problem.
Second, on the issue of cost it is erroneous to assume that the "average cost" of a hospital day is the appropriate cost to attribute to an ALC patient. The average cost of a hospital day is an aggregate number that reflects the costs of "high needs" patients and "low needs" patients - it is all of the costs of hospitals divided by all of the hospital days. The mere existence of a patient in a hospital does not attract spending on that patient. It is absolutely ridiculous to think that an ALC patient is as resource intense as a patient who is within the first 48 hours post-surgery, or who is acutely ill, yet - declaring that an ALC patient costs the same as these other patients is often what happens in the hand-wringing over ALC. If it takes 5 nurses to care for 20 acutely ill patients, those same 5 nurses might be able to care for 50 "alternate level of care" patients, or perhaps nurse aides are adequate to address their needs. Further, it may be desirable to have some "less resource" intensive patients in the mix as it provides for a bit of a break. Do we really want a system where nurses are working at the limits of their capacity, all the time? What might that mean for rates of medical error? What might that mean for rates of nurse burnout? What might that mean for rates of occupational injuries among nurses? It is even imaginable that having these patients in hospital might be the most efficient way to address their needs under some circumstances. In short - do not expect resolving the ALC problem to save as much money as is often estimated. If the ALC problem were adequately addressed we would see the average cost per patient day increase, not decrease.
Lastly, because governments set health budgets, even if the beds were available in hospital - it is a heroic assumption to think that the number of procedures performed would increase by any substantial amount. To the extent that money is actually saved and could be reallocated to provide access to care, some additional surgeries might be performed. However, the increase in access is likely to be far less than what is often imagined - just because a bed or an OR is available in the public system does not mean that it will be used. Unless governments are willing to spend more on healthcare, they will simply reduce the number of beds "staffed and in operation" or will close OR's to manage budgets.
A Year From now my daughter will be heading to her first days of kindergarten - she will start her academic journey. As a parent, I know she already has some tremendous advantages, and that if she needs any help along the way that we will do what we can and what needs to be done to ensure that she is able to reach her potential. Our plan was to send our children to public school, at least for their elementary years. We have every confidence in the curriculum. We have every confidence in the ability of public school teachers to inspire learning - we know that there are many dedicated individuals who work tirelessly every school day and every other day to not only do their job, but to do it well. We appreciate the diversity in public school classrooms and feel that it is a benefit to our children.
However, the dispute between the BCTF and the Government, now has me asking some questions about the school system, about how it works, and about how it might be in a state of dysfunction going forward. It has me questioning whether or not the public school system is "healthy" - if it is a place where teachers feel they can innovate and practice to the fullest of their abilities? A place where all students have their needs met? It has me questioning the statistics that the "outcomes are the best in the world" and wondering if those statistics are subject to a kind of statistical slight of hand. Not that the statistics are wrong, just that they fail to tell the full story or have been subjected to cherry-picking. I am wondering about the culture of the public school system - about the relationship between those who teach and those who manage the system.
And I am left with a sense of trepidation and dread.
I fully support a universally accessible, public education system that performs well and meets the needs of the students it serves - but, I have a hard time coming to the conclusion that the system in British Columbia is where it needs to be in order to be a system that performs well, and meets the needs of the students it serves. A system where there is little gap between what the people who work in the system are capable of and what they actually achieve. I am very worried, that given the rhetoric and propaganda, the posturing, and the statistics - that what should be, is and will be, very different from what my daughter and son will actually experience if they go to public school.
First, I have serious concerns about the adequacy of funding in the school system. I know on a per-capita basis student funding has increased at a rate that is slightly ahead of inflation. However, that statistic hides a lot of details and in isolation actually says very little about whether or not that level of funding is "adequate". It fails to take into consideration changes in the composition of the population being served. Are there more high-needs students being served? Are there more students who are facing food insecurity or home instability? How has technology changed, is the system expected to deliver the same things it did 10 years ago, using the same tools? A proxy for adequacy is to look at the funding in other jurisdictions (again a lot of nuances, but in a pinch it will do) - and in British Columbia public school funding as 2010/11 was about $750 less per student per year than the Canadian average. Further, there is some argument to be made that funding all public schools equally at a per student level leaves a lot to be desired in the way of equity as schools in "better-off" neighbourhoods may have a much easier time suplementing their budgets than schools in economically disadvantaged areas. As a result, public funding might be adequate in some areas and inadequate in other areas. However, unlike in health, there is little measurement of the supplemental spending, the private spending, in education.
Second, in terms of outcomes and what is measured, again there are a lot of nuances and considerations to be made. The catchment school that my children would attend, has good outcomes. It also is in a very middle to upper middle class neighbourhood. Consequently, the students who attend might not be grappling with some of the challenges to learning that other students face. There might not be as many who are learning english as a second language. There might not be as many who face food insecurity. There might not be as many in adequate housing. There might be more students with parents who hold post-secondary credentials. There might be less unemployment. There might not be as many with absentee parents. There might not be as many who struggle with the tab for school supplies or field trips. There might be more parents willing to engage tutors to imporve academic performance. The students might be more likely to have a regular family doctor and to have thier health needs met. There might be more parents willing to chip in to fill the gaps in the budget for class room supplies. There might be fewer students waiting for psych-ed assessments simply because their parents have expedited access by paying out of pocket. As a result, the funding that follows students as having special learning needs might be more likely to be available, simply because a greater share of those students will have been identified. (I do not believe the government publically reports how many students are on the wait list for psych-ed assessments and what their average wait time is). In short, the outcomes observed are not entirely a result of what was done within the context of the school system.
Lastly, and perhaps my biggest area of concern - is the state of the relationship between those who manage the school system (government and administrators) and those who are on the front lines - the teachers. I have come to the conclusion that high-performing organizations are able to return exceptional results with the resources they have because they focus on two things: (1) empowering their staff to work to the fullest extent of their capabilities; and, (2) meeting the needs of their customers. There does not seem to be a whole lot of collaboration. There does not seem to be a whole lot of respect. There does not seem to be a lot of trust. There does not seem to be a focus on students and what they need from the education system (which might not be the same thing in all areas). There does not seem to be genuine leadership. There seems to be a lot of ideology, and a lot of frustration. That is not a recipe for innovation - that is not a recipe for "being the best" by any length of the imagination.
When I think of what the public school system should be capable of doing, particularly in a developed country with adequate resource to fund it, there is not a doubt in my mind that it would be more than adequate to meet the needs of my daughter or any other child in British Columbia. However, now less than a year from the time that my daughter will enter the "school system" - I sit very apprehensive. I suppose I could consider myself fortunate that if push came to shove, private school would be an option for us, but there again it disturbs me that the government would benefit from that decision with a substantial savings from not having to meet its full funding obligation with absolutely no requirement to redirect the money saved into the public system. Again, it seems wrong that there is an incentive for the government to encourage parents to opt out of the public system.
Something awful happens when a business focuses its resources on achieving shareholder value. Things are done that improve the bottom line, but risk the long-run viability of the business. Before long, it's a lean mean business machine that is unable to deliver because of high staff turn-over and abysmal customer satisfaction. Without the right staff, and without a demand for product, the writing is on the wall. It's not that shareholder value is not important, it is – but rather that, the road to shareholder value is paved with having the right people to do the right things, and having a product or service that customers want, that meets their needs. Shareholder value is a happy side-effect to being successful in business, and paradoxically, when companies focus on shareholder value instead of the things that lead to business success, companies fail.
Despite clear indications that focusing on shareholder value leads to corporate dysfunction and failure – the parallel concept in government, "taxpayer value" has grown to be the dominant focus. The focus is on achieving the lowest possible tax rates – both corporate and individual. Unfortunately, a focus on "taxpayer value" will lead to the same dysfunction that it yields in the corporate world. There is reason to believe that the road to "taxpayer value" is paved by having the right people do the right things, and providing high-quality services that meet the needs of the public.
The relentless focus on "taxpayer value" has resulted in a situation where there is a lot of frustration – and seems to be leading to a situation where the government struggles to attract and retain the best and brightest and seems to be struggling to provide high-quality services that meet the needs of the public (particularly in the healthcare and education sectors). The government seems content with a command and control philosophy – even though, it seems that the world has shifted towards collaborate and innovate. I do not believe, absent a shift in thinking and a change in course, that this will end well.
If companies can shift their thinking and recognize that the road to shareholder value is paved by focussing on their human resources and their customers – why can't government be capable of a parallel shift in thinking and recognize that the road to taxpayer value is paved with employee engagement and services that meet the needs of those who use them? There is nothing in particular about government that makes collaborate and innovate impossible - rather, all that is needed is the courage to do so, and the commitment to the public service and those it serves.


Hey guys, today I am reviewing a new product called Outsourcers Bible.
If you been trying to make money online for any length of time, chances are you've outsourced something, whether it's an ebook or a banner graphic on Fiverr, or even a bigger project like a software script or plugin rebranding.
If you have you will know that finding a reliable outsourcer is not easy. If you post a job on an outsourcing site you will often get many bids some of whom have not even read your briefing properly. To test this I usually ask them to quote a secret phrase when applying. Sadly, most don't. So if they can't follow the most basic of instructions, how will they cope with a more demanding job?
So I'm always incredibly grateful when somebody does all the hard work for me. And that's exactly what Craig Crawford has done.
Craig has compiled a directory of reliable sources in 12 different areas you're likely to need outside help. Any time you need some work done you can simply go to that section, go to the relevant subsection and then just choose from one of the outsourcers there.
The front-end consists of a membership site with 12 different sections, each with varying numbers of subsections. Each of the outsourcers in the subsection has their profile the past job history and ratings. There is also a link to go straight to the relevant page to hire them. If you use a certain outsourcer you will also have the ability to rate them yourself, so that this becomes a valuable resource as time progresses, with each employer being able to rate the employees.
Simply open the site, click on the area you want to outsource, and pick an employee.
Each subsection can be downloaded as a pdf so you have all the information without having to be online.
An 11-video course teaching you the ins and outs of outsourcing, so you're not left in the dark with a load of outsourcers but no idea how to use them.
The bonus report includes the best places to find reliable outsourcers. It's an ideal companion to the Outsourcers Bible.
The price on the Frontend is $7 raising to $12.95 on a dime sale.
OTO 1 is a monthly membership where the guys will continue to find the best outsourcers every month.
This will essentially allow you to sell Outsourcers Bible and get 100% commissions across the funnel. This is not the same as PLR or even reseller rights as you can't change the price. It also means you would need to connect an autoresponder to your jvzoo account in order to keep the customers you refer, but this is a small price to pay for having an in-demand product ready to go.
As well as all the bonuses listed below (which all the affiliates get), I also managed to get you access to Flipp.me, Art Flair's best selling course. It sells HERE for $9.97, but I got you it just for buying through my link. Just send your receipt to my support desk and my unusually handsome assistant David will send you access. He's the best.
I love hearing from you guys, so please leave me a comment and let me know what you think.


text:
BACK TO INTERNATIONALIZATION
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Peru is undoubtedly one of the most attractive countries in Latin America. Its ecological and cultural diversity, the impressive variety of its landscapes, the cheerful character of its people and its historically rich cities and beautiful archaeological monuments make of Peru a unique country in the world. Located on the central west coast of South America, Peru offers a huge variety of landscapes and climates due to its unique geographical location. Historically, the current Peruvian territory has also been the home to some of the richest pre-Columbian civilizations, complex societies that achieved extremely high levels of development in terms of architecture, textiles, ceramics, gold and silver work, among others.
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Peru, a country with over 5000 years of history, one of the most diverse nations on the planet and a destination that holds infinite vacation destinations. There is a Peru for everyone and we invite you to find out.
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redpajama_set_name: RedPajamaCommonCrawl


Bee Forever Apiary offers a consultation service. If you encounter a problem with your hives and you would like to receive advise or assistance don't hesitate to contact us. We are also ready to help accomplish specials tasks like moving hives or extracting honey for you.
The costs are determined by the driving distance and the effective time worked on site.
The rate for the on-site working time is $35.00 per hour.
The driving distance for a roundtrip can be found with mapquest or google map. Starting address is 16306 Bald Hill Rd SE, Yelm,WA 98597 (the Bald Hill Fire Station).The costs is $0.75 per mile.


HSBC admitted today that details of 24,000 customers with Swiss bank accounts have been stolen. The theft potentially exposes large numbers of international clients to prosecution by the tax authorities including HMRC in the UK.
A former IT employee of HSBC Private Bank (Suisse) SA, Herve Falciani, apparently stole the information about accounts opened before October 2006, sometime between late 2006 and early 2007. HSBC says it has contacted the relevant customers and doesn't believe the stolen data has or will allow any unauthorized access the accounts themselves. However, the theft could leave account holders exposed to criminal prosecution by the tax authorities, including HMRC.
This is the latest in a series of tax haven bank data thefts. In previous cases in Switzerland and Liechtenstein, the information was bought by foreign governments who are using it to track down suspected tax evaders.
If you have an offshore bank account are worried about your tax affairs Lynam Tax can help you. Lynam Tax Enquiry Experts have substantial experience of the key issues and are helping many clients and their agents with both the current tax amnesties: the New Disclosure Opportunity and the Liechtenstein Disclosure Facility.
Next post: The NDO: what was it?


text:
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#define nsHtml5Speculation_h__

#include "nsHtml5UTF16Buffer.h"
#include "nsAHtml5TreeBuilderState.h"
#include "nsHtml5TreeOperation.h"
#include "nsAHtml5TreeOpSink.h"
#include "nsTArray.h"
#include "nsAutoPtr.h"

class nsHtml5Speculation : public nsAHtml5TreeOpSink
{
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    PRInt32 GetStart() {
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    nsAHtml5TreeBuilderState* GetSnapshot() {
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    void FlushToSink(nsAHtml5TreeOpSink* aSink);

  private:
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    nsTArray<nsHtml5TreeOperation>      mOpQueue;
};

#endif // nsHtml5Speculation_h__

redpajama_set_name: RedPajamaGithub


text:
The Eloquent Peasant (, "a peasant good of speech") is an Ancient Egyptian story that was composed around 1850 BCE during the time of the Middle Kingdom in Egypt. It is one of the longest Egyptian tales that has survived completed. The tale is about a peasant, Khun-Anup, who stumbles upon the property of the high steward, the noble Rensi son of Meru, guarded by its harsh overseer, Nemtynakht. It is set in the Ninth or Tenth Dynasty around Herakleopolis. This tale is described as an elaborate reflection on the connection – or disconnection – of ethical order and refined speech, as transliterated into refined writing.

Story summary
The story begins with a poor peasant, Khun-Anup, traveling to market with his donkeys heavily laden with goods to exchange for supplies for his family. While Khun-Anup was en route, Nemtynakht, a vassal of the high steward Rensi, notices the peasant approaching his lands and devises a scheme to steal Khun-Anup's donkeys and supplies. Nemtynakht tricks the peasant by placing a cloth on the narrow public path, where one side was bordered by the river and the other side were the private fields of Nemtynakht. His placing of the cloth on the path forces the peasant to either trample the cloth, step into the water, or take his donkeys over Nemtynakht's fields in order to continue his journey. As Khun-Anup is appealing to Nemtynakht's sense of reason in blocking his path with the cloth, one of Khun-Anup's donkeys eats a bite of barley, and Nemtynakht uses this as a justification to take Khun-Anup's donkeys and goods. When Khun-Anup complains this punishment is unfair, Nemtynakht beats him. Khun-Anup cries out for justice, and Nemtynakht threatens the peasant with death if he dares to complain. Khun-Anup does not accept this injustice and continues to appeal to Nemtynakht for ten days.

Failing to receive justice from Nemtynakht, Khun-Anup seeks out the high steward, the noble Rensi son of Meru, and presents his case. Rensi brings the peasant's case to the magistrates, who dismiss the case as merely being a matter of a peasant at odds with a landowner, but Rensi does not relay this information to the peasant. Rensi brings the story of the wronged peasant before the pharaoh, Nebkaure (who is believed to be Nebkaure Khety), telling him how elegantly the peasant speaks. Intrigued by the report of a peasant who speaks so elegantly, the pharaoh instructs Rensi to not respond to the peasant's pleas, so that the peasant would continue to make his elegant speeches and they could be written down for the pharaoh. The pharaoh orders Rensi to feed the peasant and his family while the peasant continues to plead his case, further instructing Rensi not to let the peasant know he was providing the food.

For nine days Khun-Anup complimented the high steward Rensi and begged for justice. After nine days of speeches, Khun-Anup threatened suicide. After sensing that he was being ignored, Khun-Anup insulted Rensi and was punished with a beating. After one last speech, the discouraged peasant left, but Rensi sent for him and ordered him to return. But rather than being punished for his insolence, the peasant was given justice. Rensi, after reading Khun-Anup's last speech, was impressed and ordered the donkeys and the goods to be returned to Khun-Anup and the peasant to be compensated with all the property of Nemtynakht, making Nemtynakht as poor as Khun-Anup had been.

Characters

Khun-anup
The poor peasant, Khun-Anup, lives with his wife, Marye, and their children in an oasis around the Nile Delta in Egypt.

Rensi son of Meru
The noble Rensi son of Meru is the high steward of Pharaoh Nebkaure. The peasant Khun-Anup appeals to Rensi when he does not receive justice from Nemtynakht.

Nemtynakht
A greedy vassal to the high steward Rensi, Nemtynakht notices the peasant Khun-Anup's supply-laden donkeys and devises a trap that will provide him with a reason for taking Khun-Anup's donkeys and goods.

Nebkaure
He is his Majesty of the Dual King Nebkaure, the justified. "The justified" is a standard epithet of the deceased. Nebkaure is a Pharaoh of the tenth dynasty of Heracleopolis, ca. 2050 BCE, during the First Intermediate Period.

Themes

Ma'at
Ma'at is the ancient Egyptian law based on the idea of harmony and balance and allows for the social hierarchy to be prevalent in citizen's everyday lives. This theme is present throughout the work, especially in Khun-Anup's speeches about what justice means to his situation.

Ma'at is also exemplified in the courts of the story because justice and social hierarchy is fully dependent on the judge and how he interprets ma'at in relation to the trials.

Textual history

Origin
While we do have a somewhat cohesive narrative for The Eloquent Peasant, to our current knowledge, a narrative for the entirety of the poem does not exist. The tale is a compilation of four incomplete manuscripts that have some conflict in overlapping sections. The names of people and places seem to differ amongst the four different pieces. Despite this, there is an understanding that they are all versions of the same story. Like most stories, it is implied that different people told the story in different ways - leading to some discrepancies in written versions.

Author
Information concerning the author (or authors) of the text is minimal. It is assumed that the author(s) were more than likely male(s), but even that information may not be correct. The themes and intellectual points in the story make it evident that the author - if it was one person - was a part of the educated class. He or she was literate enough to put the story in hieroglyphics. The story was likely not originally told in the form of poetry, but was later translated.

Time period
While the story of The Eloquent Peasant was set in the ninth and tenth dynasties, it is generally accepted that the poem itself was written during the Middle Kingdom, around the same time as "The Tale of Sinuhe, during Egypt's Classical Age. This time period was said to have produced some of the greatest works of literature and art. The wealthy and well educated Egyptians focused greatly on these aspects, as well as entertainment. The Eloquent Peasant would have been considered a generous amount of both. The poem was also one of the first recorded texts that focused on the lives of people other than the kings or the gods. The story reflected ideals of Egypt at the time among the common people. It was extremely popular.

The Eloquent Peasant was one of the few texts that highlighted some of the concepts of Egyptian law during the Middle Kingdom dynasties.

Influence on arts and literature
The Eloquent Peasant shows the modern reader a glimpse of how justice in crime might have been attained in ancient Egyptian culture. While it is natural to assume that guilt may be determined by the hierarchy of the time, The Eloquent Peasant shows us that you could speak your mind and possibly change the verdict cast upon you. The theme of justice featured so prominently in The Eloquent Peasant might have been a precursor to themes of justice in later works.

The Eloquent Peasant was adapted into an award winning short film with the same name, directed by Egyptian director Shadi Abdel Salam in 1969.

References

External links
 In hieroglyphs (includes literal translations by various contributors)
 Older translation
 Papyrus with the tale at Google Arts & Culture
 Excerpts from The Tale of the Eloquent Peasant (.pdf)

Eloquent Peasant, The

redpajama_set_name: RedPajamaWikipedia


text:
General Cup 2013 − nierankingowy turniej snookerowy rozegrany w General Snooker Club w Hongkongu (Chiny) w dniach 9–13 września 2013 roku.

W finale rozegranym 13 września reprezentant Anglii Mark Davis pokonał Australijczyka Neila Robertsona 7–2.

Nagrody
 Zwycięzca: $120 000
 II miejsce: $60 000
 Półfinalista: $40 000
 Break 100+: $2 000
 Najwyższy break turnieju: $20 000
 Break maksymalny: $367 000

Faza główna turnieju

Faza grupowa

Grupa A

 Barry Hawkins 2–3 Joe Perry
 Neil Robertson 3–1 Andrew Higginson
 Joe Perry 3–1 Andrew Higginson
 Neil Robertson 1–3 Barry Hawkins
 Barry Hawkins 3–1 Andrew Higginson
 Neil Robertson 3–0 Joe Perry

Grupa B

 Shaun Murphy 2–3 Ricky Walden
 Ricky Walden 1–3 Mark Davis
 Shaun Murphy 2–3 Mark Davis
 Ricky Walden 1–3 Marco Fu
 Shaun Murphy 2–3 Marco Fu
 Marco Fu 3–2 Mark Davis

Runda finałowa

Finał

Przypisy

Nierankingowe turnieje snookerowe
2013 w sporcie
2013 w Azji
Sport w Hongkongu


Our life - sprinkled with light.
I AM A MOTHER FIRST. I HAVE THREE GIRLS WHO ARE TRULY THE BEST THINGS I'VE EVER CREATED AND NURTURED. THEY'RE BEAUTIFUL LITTLE HUMANS AND I'M THANKFUL FOR EACH DAY I'M GIVEN TO BE THEIR MOTHER. I AIM TO TEACH THEM TO BE STRONG WOMEN WHO GO AFTER THEIR DREAMS. I WORK HARD - EVERY DAY - TO SHOW THEM EXACTLY HOW THAT'S DONE.
EVER SINCE I PICKED UP A CAMERA AS A TEENAGER IN HIGH SCHOOL - I'VE AIMED TO DO NOTHING ELSE BUT PHOTOGRAPH LIFE - HOW I SEE IT. I BELIEVE IN MY VISION. WHATEVER IT IS THEY CHOOSE TO DO IN LIFE - I HOPE THEY TOO BELIEVE IN THEMSELVES - FEARLESSLY - AUTHENTICALLY - RELENTLESSLY.
WE ENJOY LOOKING UP AT THE SKY WHETHER IT BE AT SUNRISE, SUNSET OR LONG AFTER THE SUN HAS GONE DOWN. OUR FAMILY FACILITATES THE LINK BETWEEN SCIENCE AND THE ARTS WHICH OFTENTIMES FEULS OUR CONVERSATIONS AT THE DINNER TABLE… WELL THAT AND WHOLE LOT MORE.
I AM A SPECIAL NEEDS MAMA AND WHILE MY GIRLS ARE HIGH FUNCTIONING - I FEEL PULLED TO CONNECT WITH OTHER FAMILIES WHO HAVE BEEN FACED WITH SIMILAR STRUGGLES AND TRIUMPHS - ESPECIALLY MAMAS. I LEAD THE EFFORTS OVER AT SPECTRUM INSPIRED, A 501C3 NON PROFIT THAT AIMS TO DOCUMENT THE LIVES OF FAMILIES TOUCHED BY AUTISM TO FEUL A MUCH NEEDED LEVEL OF AWARENESS.
SOME THINGS I ESPECIALLY ENJOY BEYOND MY WORK INCLUDE: COOKING, MAKEUP TUTORIALS, MY SIDE HUSTLE: MONAT, WANDERING AROUND KROGER, THE AMAZON PRIME LIFE, GOOD BEER AND GREAT MUSIC.


text:
Walter Katzenstein ist der Name folgender Personen:

 Walter Katzenstein (1878–1929), deutscher Ruderer, siehe Walther Katzenstein
* Walter Katzenstein (1902–nach 1942), deutscher Rechtsanwalt, siehe Liste der Stolpersteine im Kölner Stadtteil Neustadt-Süd #Walter Katzenstein


This may be a case of choanal atresia. It could also be infection. YOU need to have this bird seen by an avian veterinarian immediately.
Has this bird been examined by an Avian Vet? If not, now is the time since it's suffered all this time with what may very well be an infection. Birth defects normally don't affect something like the nostrils, though I suppose they could. It will be interesting to find out anyway from an Avian Vet.
Get an appointment to have your bird thoroughly examined by Avian Vet as soon as is possible. It may be that he's had a low grade infection all this time, and the only way you'll know is to take him in for exam for infections both bacterial and viral plus some basic bloodwork to see how kidneys, liver and thyroid are doing.
Birds should be taken into Avian Vet at least once a year for a well-bird check. Since this one has never been well, it's time to have him looked at by a trained professional. Where did your sister get her information about a birth defect? If it came from anyone except an Avian Vet, it is an incorrect diagnosis.


text:
Home > Acura Integra
Acura Integra is a Japanese compact car from the manufacturer Honda Motor Co., Ltd. Produced from 1985 to 2006 in four generations. Integra has body modifications coupe, sedan and hatchback with front- and all-wheel drive layout. The car was sold under its real name on the US market, in Japan it was called Honda Integra. The peak of car sales was in the late 80s – mid 90s. Integra has taken part in the Pirelli World Challenge car races on several occasions.
The 1.6-liter Honda D16A engine was assembled at the concern's enterprises from 1986 to 1995 and was installed on a number of such popular company models as the Civic, Integra or Concerto. The D16A motor existed in many versions, but they are divided into two groups: with SOHC and DOHC cylinder heads. Continue reading Engine Honda D16A
Engine Honda B18C
Unlike the B18B, on which the manufacturer experimented without using VTEC, Honda decided to add VTEC to the 1.8-liter engine for the B18C. The release of the B18C engine marked the emergence of a new generation of engines with "motorcycle" characteristics, when more than 100 hp were obtained from one liter of volume, and which could spin over 9000 rpm. Continue reading Engine Honda B18C