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The extra cost of comorbidity: multiple illnesses and the economic burden of non-communicable diseases
Sébastien Cortaredona ORCID: orcid.org/0000-0003-3523-71581,2 &
Bruno Ventelou2,3
The literature offers competing estimates of disease costs, with each study having its own data and methods. In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment provided guidelines that can be used to set up cost-of-illness (COI) studies, emphasising that most COI analyses have trouble accounting for comorbidity in their cost estimations. When a patient has more than one chronic condition, the conditions may interact such that the patient's healthcare costs are greater than the sum of the costs for the individual diseases. The main objective of this work was to estimate the costs of 10 non-communicable diseases when their co-occurrence is acknowledged and properly assessed.
The French Echantillon Généraliste de Bénéficiaires (EGB) database was used to assign all healthcare expenses for a representative sample of the population covered by the National Health Insurance. COIs were estimated in a bottom-up approach, through regressions on individuals' healthcare expenditure. Two-way interactions between the 10 chronic disease variables were included in the expenditure model to account for possible effect modification in the presence of comorbidity(ies).
The costs of the 10 selected chronic diseases were substantially higher for individuals with comorbidity, demonstrating the pattern of super-additive costs in cases of diseases interaction. For instance, the cost associated with diabetes for people without comorbidity was estimated at 1776 €, whereas this was 2634 € for people with heart disease as a comorbidity. Overall, we detected 41 cases of super-additivity over 45 possible comorbidities. When simulating a preventive action on diabetes, our results showed that significant monetary savings could be achieved not only for diabetes itself, but also for the chronic diseases frequently associated with diabetes.
When comorbidity exists and where super-additivity is involved, a given preventive policy leads to greater monetary savings than the costs associated with the single diagnosis, meaning that the returns from the action are generally underestimated.
The Organisation for Economic Co-operation and Development [1] predicts that healthcare expenditure will continue to rise, putting pressure on public budgets over the next decades. European countries are probably the most exposed to this risk given the factors of population aging and comprehensive public health insurance coverage. However, Europe has no coherent (i.e. using consistent concepts and methods) or comprehensive empirically based framework that can provide measures and forecasts of the burden of healthcare in a disease-oriented approach. As a result, policy-makers are confronted with competing estimates of healthcare costs for particular diseases or risk factors, with each study having its own data and methods [2,3,4,5,6,7].
In 2007, the Dutch Center for Public Health Forecasting of the National Institute for Public Health and the Environment summarised the methodology for general cost-of-illness (COI) studies and provided guidelines that can be used to set up such studies [8]. They emphasised the fact that a common problem in COI analyses is how to deal with patients' comorbidities. Top-down analyses, in which costs for a given disease are calculated by multiplying aggregate health expenditure by the suspected proportion of the 'top' amount spent on that disease, require costs to be attributed to a single diagnosis. Thus, comorbidity is basically not taken into account. On the other hand, a bottom-up approach, in which each unit of healthcare used on a patient is attributed to a disease, still has trouble accounting for comorbidity. A classic example is a consultation for diabetes, which is also a major risk factor for cardiovascular disease. In an ideal bottom-up approach, the costs of this consultation should be applied both to heart disease and to diabetes, with – still ideally – the relative shares reflecting the importance of the consultation in the treatment of each disease, which becomes rapidly unattainable.
We therefore aimed to develop a comprehensive 'bottom-up' approach using person-level data to estimate the costs of chronic diseases using a medico-administrative database. One of the main strengths of our approach is that it takes into account the comorbidity issue, a key factor with the older population. Recent strategies using regression-based frameworks [9,10,11], have also been developed to account for excess spending caused by the presence of comorbidities. Compared to top-down approaches, these types of person-level costing may produce more valid estimates in patients with multiple chronic diseases, as expenditures for comorbidities and complications are better captured [9].
For this study, we focused on 10 chronic disease groups, namely heart disease, stroke, diabetes, cancers (with a focus on breast, liver, lung, colorectal, stomach, oesophageal, kidney and pancreatic cancers), alcohol use disorders, cirrhosis, neurological disorders, major depression, respiratory illness (chronic obstructive pulmonary disease, asthma), and chronic kidney disease (CKD). Our cost-calculation methods address the possible coexistence of these 10 chronic diseases within the same subject, which may interact in the selection of treatments, potentially making costs of diseases 'super-additive'.
A 'simulation exercise' estimates the cost savings by a health system upon elimination of one disease, e.g. diabetes. Where there is super-additivity, there are far greater cost savings than with simply additive costs, meaning that the calculations performed to estimate the benefits (returns) of preventive action generally underestimate them.
We used the Echantillon Généraliste des Bénéficiaires (EGB) database, a permanent, representative and anonymised sample of people affiliated with the three major National Health Insurance funds [12]. These funds cover more than 90% of the French general population, divided into salaried workers, agricultural workers and farmers, and self-employed workers. The EGB was created in 2005 by a national random sampling of 1/97th of the French population, stratified for age and sex; it records information on their healthcare consumption and includes data on reimbursement claims for drugs purchased in the community, classified according to the Anatomical Therapeutic Chemical (ATC) index. The EGB is a dynamic cohort, where every 3 months, registered births and foreign immigrants taking up employment in France and their eligible dependents are added to the sample. Conversely, deaths and people withdrawing from the insurance funds covered by the EGB are extracted from the sample [12].
For this study, we selected people aged 18 or above and listed in the EGB on January 1, 2014, and monitored them until the end of 2014. Those who died or withdrew from the insurance funds covered by the EGB during the monitoring period were excluded from the analysis.
Identification of people with chronic diseases
The list of the 10 chronic diseases selected for this study, with assigned International Classification of Disease (ICD version 10) codes, is provided in Table 1.
Table 1 The 10 chronic diseases and assigned International Classification of Disease version 10 (ICD-10) codes
This study was performed as part of the FRESHER research consortium (FoResight and Modelling for European Health policy and Regulation). We selected non-communicable diseases that contribute to the bulk of deaths worldwide, namely cardiovascular diseases, cancers, diabetes, and chronic lung disease [13]. To these, we added four other health conditions, namely (1) depression, due to its co-morbid status with all of the chronic diseases outlined above, (2) chronic kidney disease, (3) alcohol-related diseases, and (4) chronic neurological disorders, due to their increasing importance in ageing societies. Most of these conditions share commonalities in pathogenesis, aetiology, and risk factors, which are potentially modifiable. With no intervention, their cumulative financial burden is projected to greatly increase in the next decades [14].
Administrative databases, such as drug prescription data, have frequently been used to identify people with chronic diseases in prevalence estimates [15] or epidemiological studies for comorbidity adjustments [16]. In the EGB database, three types of data can be used to identify patients with chronic diseases.
In 2013, Huber et al. [17] developed an updated approach with a special focus on the unambiguous assignment of drug prescriptions to chronic diseases. For chronic diseases, they only included ATC codes, which are exclusively used for the treatment of specific diseases. From 2009 to 2014, we considered that a person had a chronic disease if they had been dispensed at least three drugs in the corresponding ATC category at different times over the calendar year (this threshold of three dispensations was used on various French studies on diabetes [18] and other chronic diseases [19]).
Since 2006, data from the French Medical Information System (Programme de Médicalisation des Systèmes d'information), which covers all French public and private hospitals except military and psychiatric hospitals, have been available for all individuals included in the EGB. In France, each hospital stay is registered in a hospital discharge database from the French Medical Information System and diagnoses are coded using the International Classification of Diseases (ICD-10 [20]) codification either as a primary, related, or significant associated diagnosis. Cchronic diseases were identified using these diagnosis data from 2009 to 2014.
We used long-term illness (LTI) status data from the French social insurance system to identify people with chronic diseases. LTI status is granted to people with long-term and costly diseases, exempting them from co-payments for any associated medical treatment [21]. As with hospital discharge data, chronic diseases were identified from 2009 to 2014 using the ICD-10 classification.
These three sources of data (drug dispensing, hospital discharge and LTI) are available in the EGB database and linked with a unique individual identifier. They were combined to identify prevalent and incident cases for our 10 chronic disease groups.
Healthcare expenditure data
We used reimbursement data to calculate, for each individual in the database, an aggregate healthcare expenditure in 2014, including primary care and consultations with specialists, (reimbursed) medicines, medical procedures, biological tests, medical devices, emergency care, and hospital inpatient care. This pricing of ambulatory care also takes into account possible co-payment from the patient, except for over-the-counter drugs which are not available in the EGB database. Regarding the hospital sector, this cost-evaluation only takes into account the part of the cost which is reimbursed to hospitals through the diagnosis-related group payment system (through which we can clearly assign a diagnosis using the reason of admission). Diagnosis-related group rates were used as proxies of case costs for public and private not‐for‐profit hospital stays. Some specific costs supported by the hospitals are not included in our modelling, e.g.: costs of clinical research; innovative drugs, etc.
Estimating the cost of chronic diseases
In a bottom-up design, healthcare consumption is collected at individual patient level and illness costs are modelled at the same level. Compared to a top-down approach, in which total expenditure for a given area or policy is divided by the number of patients with a given disease, the bottom-up approach provides greater accuracy [22]. However, in the French healthcare system, healthcare expenditure on patients, particularly in the ambulatory care system, cannot be directly linked to one specific diagnosis. To overcome this limitation, we chose to estimate the cost associated with each chronic disease using regression models. The marginal costs associated with one disease were estimated on individual-level data as the mean marginal difference in the predicted outcome (total individual healthcare expenditure in 2014) with the chronic disease independent variables switched on or off. This makes it possible to estimate the 'counterfactual' of what the cost would have been in the absence of chronic disease, while leaving the other model parameters unchanged. This approach is commonly used to estimate incremental costs for diseases and risk factors [23,24,25].
A useful modelling framework in such cases is a two-stage model [26]. Two-stage models are appropriate for analysing zero-inflated cost data with skewness [27], which is typical in medical expenditure data [26]. Our dataset included both many people with zero healthcare spending and some with extremely high spending. In our two-stage model, the first part P (cost > 0) was modelled using a logit model; then, conditional on the healthcare spending being positive, the value of the spending was modelled using gamma regressions with log link [28, 29].
Models were stratified by sex and were age adjusted. The 10 binary chronic disease variables were added as main interest variables. Two-way interactions between these variables were also included in the model to account for possible effect modification in the presence of comorbidities (see latter for a precise assessment of the sign of the modification, namely super-additivity or under-additivity). In order to control for the presence of a chronic condition outside of the list of the 10 selected chronic conditions, we also added 'other LTI' as a systematic covariate in the model (at least one ongoing LTI for another chronic condition in 2014).
In each stratum (combination of age categories and sex), the increase in healthcare expenditure attributable to each disease was calculated by subtracting average predicted expenditure for sick people in each category from average predicted expenditure for the individuals with the other disease variables set to 0 (or 1 in case of comorbidity for a given other disease). For example, in given strata i, the cost associated with chronic disease dj (with no other comorbidity) was estimated as follows:
$$ \widehat{\mathit{\cos}{t}_{i{d}_j}}=\left[{\widehat{c}}_{i\mid {d}_j=1,{d}_{k_{k\ne j}}=0,\kern0.5em {d_{kl}}_{k,l\ne j}=0\ast 0,{d_{jk}}_{k\ne j}=1\ast 0}\right]-\left[{\widehat{c}}_{i\mid {d}_j=0,{d}_{k_{k\ne j}}=0,\kern0.5em {d_{kl}}_{k,l\ne j}=0\ast 0,{d_{jk}}_{k\ne j}=0\ast 0}\right] $$
Where \( \widehat{\mathit{\cos}{t}_{i{d}_j}} \) is cost in 2014 associated with chronic disease j in strata i (no other comorbidity), ĉi is predicted outcome in strata i, di is binary chronic disease variable for disease i, and djk is interaction variable between chronic disease variables dj and dk.
We obtained an average cost per capita attributable to each chronic disease by calculating a weighted mean over all strata, with:
$$ \overline{\widehat{\mathit{\cos}{t}_{d_j}}}=\frac{1}{N}{\sum}_{i=1}^N{w}_i\ast \kern0.5em \widehat{\mathit{\cos}{t}_{i{d}_j}} $$
Where \( \overline{\widehat{\mathit{\cos}{t}_{d_j}}} \) is COI calculation for disease dj, N is total number of strata (=combination of sex and age categories), and wi is weight for stratum i (=number of individuals in the sample of persons with at least one disease).
Estimating super-additivity in costs, aggregated data and the simulation exercise
The econometric models allowed estimation of (1) simple COI calculations (10 diseases with no other comorbidity; \( \overline{\widehat{\mathit{\cos}{t}_{d_j}}} \)), and (2) coupled COI calculations for the 45 two-by-two possible comorbidities ((10 × 9)/2), \( \overline{\widehat{\mathit{\cos}{t}_{\left.{d}_j\right|{d}_k}}} \) for the cost of disease dj in the presence of disease dk (see Additional file 1 for a reformulation of equation (1) in case of comorbidity). The precise assessment of 'super-additivity' was then computed on the basis of the following comparison:
$$ \overline{\widehat{\mathit{\cos}{t}_{\left.{d}_j\right|{d}_k}}}+\overline{\widehat{\mathit{\cos}{t}_{\left.{d}_k\right|{d}_j}}}<>\overline{\widehat{\mathit{\cos}{t}_{d_j}}}+\overline{\widehat{\mathit{\cos}{t}_{d_k}}} $$
When the left-hand side of the inequality was superior to the right-hand side, the assessment was 'super-additivity' – the two estimated costs coupled in comorbidity were superior to the addition of the two separate COI calculations with no other comorbidity. Aggregate estimates were determined by multiplying the per capita estimates by the number of people in the corresponding strata. Since the EGB was created by a national random sampling of 1/97th of the French population, we multiplied all figures by 97 in order to get an estimate of the national expenditure associated with each chronic disease.
We also performed a simulation exercise in which we 'eliminated' diabetes from the two-stage models, by switching the dummy variable to 'off' in all cases (the computer-program was able to estimate the virtual elimination of the nine other diseases; estimates are available on request). The population remained the same; we only simulated a 'virtual' situation of people suddenly healed of the disease. The objective of this simulation was to estimate how the savings resulting from preventive action on one disease would also affect the treatment costs of the nine remaining chronic diseases through its super-additivity effect. Confidence intervals (CIs) were computed via Monte Carlo simulations (10,000 replications). Statistical analyses were performed with SAS statistical software, version 9.4 (SAS Institute Inc., Cary, NC, USA).
Of the 476,252 people included in the cohort, 48.9% were men and 22.7% were aged over 65, which is relatively close to the census estimates for the French general population in 2014 (23.1% [30]; Table 2).
Table 2 Sociodemographic characteristics of the study population (n = 476,252)
Prevalence of chronic diseases
Using LTI, drug dispensing and hospital discharge data, we found that the chronic disease with the highest number of cases was respiratory illness (7.8%), followed by diabetes (7.1%) and heart disease (3.7%) (Table 3). Prevalence rates tended to be higher among men. Prevalence estimates according to the identification method are available in Table 3.
Table 3 Prevalence estimates according to the identification method (n = 476,252)
Prevalence of comorbidities
Of our cohort, 78.7% had none of the 10 selected chronic diseases in 2014, 15.8% had only one chronic disease, 4.0% had two chronic diseases, and 1.5% had at least three chronic diseases. Among persons with two chronic diseases or less, the most frequent type of comorbidity was diabetes associated with respiratory illness (Table 4).
Table 4 Prevalence of comorbidities among the 10 selected chronic diseases (%, n = 469,255)a
Per capita healthcare expenditure
For our cohort, the average healthcare expenditure per capita in 2014 was estimated at 2684 € (±7646 €). For those under 50 years old, costs were significantly higher among women (1841 vs. 1186 €; P < 0.001). However, for those aged 50 years and above, costs were not significantly different between men and women (4011 vs. 4029 €; P = 0.657).
Cost associated with each chronic disease for people without comorbidity
Two-stage model estimations are provided in Table 5, as defined in the methods section by the quantity \( \overline{\widehat{\mathit{\cos}{t}_{d_j}}} \), with the mean of each substrata-estimated marginal difference in the predicted outcome with the chronic disease variables dj switched on or off. Column 1 of Table 5 indicates the figures and CIs among people with no comorbidity (involving the selected chronic diseases). The average estimated cost per capita associated with one chronic disease was the highest for CKD (8323 €, 95% CI 7090–9555 €) and the lowest for respiratory illnesses (1285 €, 95% CI 1103–1466 €). Please note that these figures relate to the weighted average estimates of the costs in 2014 for prevalent cases (detected before July 2013) and incident cases (diagnosed between July 2013 and June 2014). The method also allowed the generation of COI calculations in 2014, stratified by dates of diagnosis (results available on request).
Table 5 Average costs per capita in 2014 and 95% CI associated with the 10 selected chronic diseases according to type of comorbidity – two-stage model estimates (n = 476,252)
Extra cost associated with each chronic disease in the presence of comorbidity
Disease by disease, extra costs due to the presence of a comorbidity estimate varied greatly depending on the nature of the chronic disease and the comorbidity (Table 5, columns 2–11, see also Additional file 1 for the calculation method). The extra costs associated with diabetes were estimated at 1776 € without comorbidity, 2446 € (+670 €) when associated with respiratory illness, and 2634 € (+858 €) when associated with heart disease. The costs associated with heart disease were estimated at approximately 1828 € for individuals with no comorbidity, 2687 € (+859 €) for individuals with diabetes as comorbidity, 2566 € (+738 €) for individuals with stroke as comorbidity, and 2876 € (+1048 €) for individuals with respiratory illness as comorbidity.
The resulting events of super-additivity were assessed by the comparison described in inequality (3). A synthetic view is given in Table 6 for the 45 two-by-two possible comorbidities. There were only four cases where the costs were not super-additive.
Table 6 Assessment of 'super-additivity' for the 45 two-by-two possible comorbidity combinations (n = 476,252)
Aggregate costs
When these per capita costs were aggregated at national level, the chronic diseases with the highest estimated costs were cancer (6.8 billion €) followed by CKD and diabetes (6.4 billion €; Table 7).
Table 7 Aggregate costs in 2014 associated with the 10 selected chronic diseases (n = 476,252)
Simulation exercise without diabetes
When diabetes was 'virtually' cancelled from society (all sick people are cured of diabetes), we first saved 6.4 billion € as a direct effect (Table 7). However, diabetes may also interact super-additively with other treatment costs and, therefore, its cancelation would also have indirect effects; for example, the aggregate costs of CKD were significantly lower (−481 million €; Table 6) when diabetes was removed from the model. Termination of diabetes had also an impact on the aggregate cost of heart disease (−170 million €; Table 7), which is frequently associated with diabetes. A lesser impact was observed on the aggregate costs of respiratory illness (−164 million €) or stroke (−97 million €).
The costs of the 10 selected chronic diseases were substantially higher for individuals with comorbidity (compared to similar agents without comorbidity), demonstrating the pattern of super-additive costs in cases of diseases interaction. Super-additivity was demonstrated for 41 cases out of the 45 couples studied. We also simulated preventive action on diabetes (prevalence set at 0%). Our results show that the system can save a significant amount of money not only on diabetes itself, but also on the chronic diseases that are frequently associated with diabetes. We estimate that the direct effect of diabetes disappearing is a saving of 6 billion €, but that the indirect effect is a saving of more than 1 billion €, cutting costs by an extra 18%. This points to severe underestimation of the economic benefits (returns) of preventive action, and confirms that comorbidity(ies) should be taken into account in COI analyses.
A major strength of the study is the estimation of disease-related healthcare costs both in the absence and presence of comorbidity. As recommended elsewhere [31], we used a regression-based bottom-up approach to estimate disease costs. Moreover, our COI analysis was performed on a very large sample of claim data. Compared to a top-down (attributable fraction) approach, estimates based on a bottom-up approach are more accurate because they can account for the occurrence of higher treatment intensity among those with the disease and, subsequently, the extra-expenditures for comorbidities are better captured [9, 31]; therefore, we were able to obtain more reliable estimates [26, 32]. By adding two-way interactions between the chronic disease variables in the two-stage cost model, we estimated the costs of multiple combinations of disease, and thus the extra cost of comorbidity. This enabled us to achieve accurate cost estimations and to precisely compute the super-additive monetary impact of comorbidity. To our knowledge, this kind of approach has not been used previously in a COI study.
Nevertheless, the study has several limitations. Firstly, drug-based diagnoses are only proxies for medical diagnoses. Using drug prescription data to identify individuals with chronic diseases could result in errors in prevalence/incidence estimates. However, in our view, the other methods used to detect illnesses (hospital discharge data and LTI) compensate for this.
Secondly, we limited our study to a selection of 10 chronic diseases. Since we examined a relatively low number of diseases, there are likely important comorbidities that have been missed. Including too few comorbidities in a cost regression model may lead to an overestimation of the effects of the comorbidities that are included if they are correlated with omitted comorbidities [33]. In order to limit this effect, we added the 'other LTI' variable in the two-step regression model, controlling for the presence of a chronic disease outside of the list of the 10 selected chronic diseases, and reducing unobserved heterogeneity.
Thirdly, this study was performed on a medico-administrative database from France, whose healthcare system comprises a fully integrated network of public hospitals, private hospitals, doctors and other medical service providers. The individual receiving care is generally reimbursed for all medical treatment on the basis of a price established by the Social Security administration, unlike practices in other countries. Access to care in France is very easy, with a large decisional autonomy allowed to both the physician and the patient, who are free to adapt treatments as they wish [34]. Therefore, a major limitation of our results regarding super-additivity concerns the generalisability of the results to other countries with different healthcare systems, relying, for instance, on tighter treatment protocols.
Fourthly, in the simulation exercise (where we eliminated diabetes), our estimate of savings only took into account the nine other comorbidities and their resulting super-additive costs. Further analyses should be performed to estimate how much more could be saved if a wider range of chronic and non-chronic diseases were considered, particularly comorbidities that are clinically related to the disease of interest [33].
Finally, the number of variables was very limited in our study (age, sex and estimated date of diagnosis) since we had no information on income level, educational level, employment status, supplementary mutual health insurance or the presence of risk factors (like tobacco/alcohol consumption, body mass index).
Comparison with other COI studies
The literature offers competing estimates of disease costs, with each study having its own data and methods [2,3,4,5,6,7]. First, we found per capita healthcare expenditures similar to those estimated in 2010 by the French Directorate for Research, Studies, Assessment and Statistics [35] (2698 € vs. 2684 € in our study). In a French study published in 2003 [36], the total amount spent by the general health scheme on care for diabetic patients was estimated at 6 billion € in 2000, with 2.4 billion € attributed to the treatment of diabetes alone. In another study on the French ENTRED survey [37], including 6710 diabetic patients covered by the National Health Insurance, the total reimbursement cost for patients was estimated at 12.5 billion € in 2007, but the amount attributable to diabetes alone was not estimated. In a report published in 2007 by the French National Cancer Institute [38], cancer-related healthcare costs in 2004 were estimated at 11 billion €. However, in a study published in 2013 [39], cancer-related healthcare costs for France were estimated at 7 billion € in 2008.
The main lessons from this paper are, firstly, that there are indeed considerable comorbidities in the French population – of the 21.3% of the population who suffer from the 10 selected illnesses, 25.7% are in fact suffering from more than one. Secondly, the treatment costs of the illnesses are clearly super-additive when they co-exist within the same patient, creating an extra cost that is ignored when disease treatments are considered separately. Our simulation exercise, although unrealistic, highlights this last point – if a disease like diabetes were to be avoided, the healthcare system could save not only the direct costs of diabetes, but also the extra costs that diabetes may generate through its interaction with other diseases. This represents more than 15% of the cost-of-diabetes valuation (and billions of euros), and suggests that the potential benefits of any preventive action against this kind of chronic disease are generally underestimated.
ATC:
CKD:
cost of illness
ICD:
International Classification of Disease
LTI:
long-term illnesses
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Nay O, Béjean S, Benamouzig D, Bergeron H, Castel P, Ventelou B. Achieving universal health coverage in France: policy reforms and the challenge of inequalities. Lancet. 2016;387:2236–49.
Directorate for Research, Studies, Evaluation and Statistics (DREES). National Health Accounts 2010. 2012. http://solidarites-sante.gouv.fr/IMG/pdf/Comptes_nationaux_sante_2010.pdf. Accessed 1 Dec 2016.
Ricordeau P, Weill A, Vallier N, Bourrel R, Schwartz D, Guilhot J, et al. The prevalence and cost of diabetes in metropolitan France: what trends between 1998 and 2000?*. Diabetes Metab. 2003;29:497–504.
Ricci P, Michèle C, Bruno D, Nathalie P, Odile K-J, Véronique R. Coûts des soins remboursés par l'Assurance maladie aux personnes traitées pour diabèt. Études Entred 2001 et 2007. Bull Epidemiol Hebd. 2009. http://opac.invs.sante.fr/doc_num.php?explnum_id=607. Accessed 1 July 2016.
French National Institute of Cancer (INCA). Cost of Cancer in France. 2007. http://www.bdsp.ehesp.fr/Base/358204/. Accessed 1 Jan 2017.
Luengo-Fernandez R, Leal J, Gray A, Sullivan R. Economic burden of cancer across the European Union: a population-based cost analysis. Lancet Oncol. 2013;14:1165–74.
We thank Marion Devaux, Alienor Lerouge, Alain Paraponaris, Franco Sassi and Alain Trannoy for suggestions, reactions or comments.
The project is funded by the European Commission through the Horizon 2020 Framework under the grant agreement number: 643576.
The data that support the findings of this study are available from the French National Health Insurance Fund for Employees (CNAMTS), but restrictions apply to the availability of these data, which were used under license for the current study, and are therefore not publicly available. However, data are available from the authors upon reasonable request and with permission of CNAMTS.
Aix-Marseille University, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, 19-21 boulevard Jean Moulin, 13005, Marseille, France
Sébastien Cortaredona
ORS PACA, Observatoire régional de la santé Provence-Alpes-Côte d'Azur, Marseille, France
& Bruno Ventelou
Aix-Marseille Univ., CNRS, EHESS, Centrale Marseille, Aix-Marseille School of Economics, Marseille, France
Bruno Ventelou
Search for Sébastien Cortaredona in:
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SC and BV conceived and designed the study, performed the literature search, and revised the article. SC performed data collection, statistical analysis and drafting. Both authors read and approved the final version submitted.
Correspondence to Sébastien Cortaredona.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This study was also approved by the French Commission on Individual Data Protection and Public Liberties (Commission Nationale Informatique et Libertés). Patient information was anonymised and de-identified prior to analysis.
Estimating the cost of chronic diseases in the presence of a comorbidity. (PDF 354 kb)
Cortaredona, S., Ventelou, B. The extra cost of comorbidity: multiple illnesses and the economic burden of non-communicable diseases. BMC Med 15, 216 (2017) doi:10.1186/s12916-017-0978-2
Accepted: 14 November 2017
Prevention policies


eh030 - Energy Conservation Sticky Notepad 4"x3"
I just wanted to thank you for your help with my energy conservation stickie note pad order.
Your company promotes good and wise messages, something to be proud of!
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Further to my earlier post on "Better Landscape Photography", I thought I'd share one of my new landscape photos from the recent trip through Botswana and Namibia. This is Spitzkoppe's Arch "The Bridge" in Erongo, Namibia.
I had been on tented safari through Botswana with Dean Fitzpatrick of Wildlight Safaris, hosting our annual Wildlife Photo Tour (click here for 2014 trip info and dates). Following the workshop – which was a huge success and such an enjoyable trip for everyone involved – Dean and I set off on our own little road trip to photograph additional wildlife in Botswana, after which we would make our way into Namibia to capture the amazing desert landscapes and unique Himba culture of this stunning country. The purpose of this trip was to shoot new promotional material for Nikon New Zealand and HP. Well known NZ videographer Ollie Dale joined us to shoot some behind the scenes video – watch for this content to be released over the next few months.
For this arch image we slept out overnight on the rock face to be in position early for the sunrise. Despite the mosquitoes who kept us company it was a wonderful night spent beneath the stars (the temperature was typical African summer, ranging from "hot" to "bloody hot" meaning we were more than comfy in our sleeping bags and bed rolls).
As you can imagine the sunrise was magical and the hardest task was picking what to photograph and when. Waking up surrounded by the wild Namibian landscape was surreal – if you haven't had the opportunity to sleep out under the stars, I recommend you add it to your bucket list.
To create this image I chose to use my Nikkor 14-24mm f2.8 lens (at 14mm) on my Nikon D800E. By selecting a small aperture of f16 I was able to create a nice sunstar in the image.
As the arch was fully backlit I also fired a single remote SB910 speedlite along the face of the arch nearest to the camera using Nikon's CLS system to add some detail to the otherwise dark side of the arch. I used the pop-up flash of the D800E in commander mode to trigger the off camera SB910 speedlite.
I love the shape created by the arch and the foreground rock, almost like a wave sweeping from the top right of the image down and around towards the sunstar (or up and back, depending on your point of view)! It was a magical moment and a magical image.
Nikon D800E. Nikkor 14-24 2.8 lens.
ISO 200. f16 at 1/40 second.
Lexar Pro 1000x CF. Lowepro ProTrekker 400.
Edited on the new HP Z book with Dreamcolor technology.
Top Image and text copyright Chris McLennan.


Leather logo patch at back waist.
Slim fit through straight leg.
Impeccably detailed, this is Giorgio Armani's diffusion line of fine-tailored clothing, stylish sportswear, eveningwear, outerwear and accessories for professionals. It embodies Giorgio Armani's signature elements: clean lines and subtle coloration, exclusive fabrics, exceptional attention to detail, fit and finish. Armani Collezioni reflects the latest, most broadly appealing new additions to the vocabulary of Armani style.
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text:
Q: Error in installing libssl-dev and libssl1.0-dev in Ubuntu I am trying to install libssl-dev and libssl1.0-dev in Ubuntu 18.04 via the following command:
sudo apt-get -y install build-essential openssl libssl-dev libssl1.0 libgl1-mesa-dev libqt5x11extras5

I am getting the following output:
Reading package lists... Done
Building dependency tree
Reading state information... Done
Note, selecting 'libssl1.0-dev' for regex 'libssl1.0'
Note, selecting 'libssl1.0.0' for regex 'libssl1.0'
Note, selecting 'libssl1.0.2' for regex 'libssl1.0'
build-essential is already the newest version (12.4ubuntu1).
libqt5x11extras5 is already the newest version (5.9.5-0ubuntu1).
libqt5x11extras5 set to manually installed.
libgl1-mesa-dev is already the newest version (20.0.8-0ubuntu1~18.04.1).
libgl1-mesa-dev set to manually installed.
libssl-dev is already the newest version (1.1.1-1ubuntu2.1~18.04.20).
libssl1.0.0 is already the newest version (1.0.2n-1ubuntu5.10).
openssl is already the newest version (1.1.1-1ubuntu2.1~18.04.20).
Some packages could not be installed. This may mean that you have
requested an impossible situation or if you are using the unstable
distribution that some required packages have not yet been created
or been moved out of Incoming.
The following information may help to resolve the situation:

**The following packages have unmet dependencies:
 libssl-dev : Conflicts: libssl1.0-dev but 1.0.2n-1ubuntu5.10 is to be installed
 libssl1.0-dev : Conflicts: libssl-dev but 1.1.1-1ubuntu2.1~18.04.20 is to be installed
E: Unable to correct problems, you have held broken packages.**

How do I solve these errors?

A: There are three ways to install libssl1.0-dev on Ubuntu. We can use apt-get, apt and aptitude. In the following sections we will describe each method. You can choose one of them.
Install libssl1.0-dev Using apt-get
sudo apt-get update
sudo apt-get -y install libssl1.0-dev

Install libssl1.0-dev Using apt
sudo apt update
sudo apt -y install libssl1.0-dev

Install libssl1.0-dev Using aptitude
sudo aptitude update
sudo aptitude -y install libssl1.0-dev

A: The following sequence of commands should work to resolve dependencies.
# Fix broken dependencies on your system.
sudo apt-get install -f
# Reconfigure all unpacked packages.
sudo dpkg -–configure -a
# Fix broken dependencies in your system.
sudo apt-get install -f
# Install package on the system.
sudo apt-get install <package_name>

redpajama_set_name: RedPajamaStackExchange


The Subaru Forester is a big SUV with standard all-wheel drive (AWD). It's car like driving experience sets it apart from other SUVs as the design is based on sedans and wagons. Therefore, you might think this 4x4 car is small but it is larger then the Toyota RAV4 and excellent for driving out on the Icelandic highways.
Best rental company in Iceland! We rent the Subaru Forester, this car perfect for winter. We got e-mail notification for snow storm or bad driving condition during our rental period. It's really helpful for our schedule arrangement.
I rented a Subaru Forester from here for a whole week and was very happy with the car and the service. The car was clean, very reliable, and a had a full tank of gas when I picked it up. The staff helped me understand the rules and situations I would face when driving in Iceland and gave me an information packet with the same information just in case I needed it again. Returning the car was a breeze and the airport offers a shuttle between the business and the terminals.
I rented Subaru Forester for a week from 13-21 April 2018. The car was in great condition. It was very smooth and easy when pick up and drop off the car. I rented with Platinum insurance coverage so it went easy when I return.
Would recommend anyone to rent with Reykavik rent a car!


text:
Best Field Support Apps of 2021 (Android)
1 Field Support
2 ORBCOMM Field Support Tool
3 Field Service
4 Milacron Field Support
5 Field Service Mobile
6 Intuit Field Service
7 Oracle Field Service Cloud Mobile
8 IsoPlexis Field Support
9 Field service report
10 Field Nation
11 Field Agent
12 Jobber – CRM for Field Service: Estimate & Invoice
13 ArcGIS Field Maps
14 GPS Fields Area Tracker – Area Measure App
15 MYReport Field Service
This article outlines LeapDroids top picks for the best field support apps. We have tried to select a variety of apps catering to different needs in the field support app space.
These apps are all pretty awesome and well worth a download. We selected these field support apps for exceptional performance in one of these categories:
Developer: Tennant
Field Support is an app made by Tennant. It has an average rating of 0 and has received 0 ratings. The last update was on 2020-07-08T19:43:33.000Z.
ORBCOMM Field Support Tool
Developer: ORBCOMM INC
ORBCOMM Field Support Tool is an app made by ORBCOMM INC. It has an average rating of 0 and has received 0 ratings. The last update was on 2020-09-23T20:59:22.000Z.
Developer: Salesforce.com, inc.
Field Service is an app made by Salesforce.com, inc.. It has an average rating of 2.6 and has received 808 ratings. The last update was on 2021-03-17T21:58:58.000Z.
Milacron Field Support
Developer: Milacron India Pvt. Ltd.
Milacron Field Support is an app made by Milacron India Pvt. Ltd.. It has an average rating of 4.5 and has received 13 ratings. The last update was on 2020-06-14T06:51:58.000Z.
Field Service Mobile
Developer: Microsoft Corporation
Field Service Mobile is an app made by Microsoft Corporation. It has an average rating of 2.8 and has received 211 ratings. The last update was on 2021-04-28T02:55:09.000Z.
Intuit Field Service
Developer: Corrigo Incorporated
Intuit Field Service is an app made by Corrigo Incorporated. It has an average rating of 3 and has received 119 ratings. The last update was on 2019-07-03T05:47:21.000Z.
Oracle Field Service Cloud Mobile
Developer: Oracle America, Inc.
Oracle Field Service Cloud Mobile is an app made by Oracle America, Inc.. It has an average rating of 2 and has received 54 ratings. The last update was on 2021-05-05T17:49:50.000Z.
IsoPlexis Field Support
Developer: SightCall
IsoPlexis Field Support is an app made by SightCall. It has an average rating of 0 and has received 0 ratings. The last update was on 2021-01-07T16:33:12.000Z.
Field service report
Developer: ABIzzyApp
Field service report is an app made by ABIzzyApp. It has an average rating of 4.6 and has received 884 ratings. The last update was on 2020-08-06T19:06:50.000Z.
Field Nation
Developer: Field Nation
Field Nation is an app made by Field Nation. It has an average rating of 3.9 and has received 3188 ratings. The last update was on 2021-04-30T19:35:07.000Z.
Field Agent
Developer: Field Agent Inc.
Field Agent is an app made by Field Agent Inc.. It has an average rating of 3.8 and has received 7163 ratings. The last update was on 2021-05-05T04:47:38.000Z.
Jobber – CRM for Field Service: Estimate & Invoice
Developer: Jobber Software
Jobber – CRM for Field Service: Estimate & Invoice is an app made by Jobber Software. It has an average rating of 3.8 and has received 606 ratings. The last update was on 2021-05-06T16:55:07.000Z.
ArcGIS Field Maps
Developer: Esri
ArcGIS Field Maps is an app made by Esri. It has an average rating of 3.7 and has received 65 ratings. The last update was on 2021-04-07T20:20:46.000Z.
GPS Fields Area Tracker – Area Measure App
Developer: TenWhite Studio
GPS Fields Area Tracker – Area Measure App is an app made by TenWhite Studio. It has an average rating of 4.1 and has received 89 ratings. The last update was on 2020-12-01T09:19:15.000Z.
MYReport Field Service
Developer: Ossola
MYReport Field Service is an app made by Ossola. It has an average rating of 4.6 and has received 1974 ratings. The last update was on 2017-05-08T19:56:27.000Z.
Best Fertility Apps of 2021 (Android)
Best Field-Programmable Gate Array (FPGA) Apps of 2021 (Android)

redpajama_set_name: RedPajamaCommonCrawl


text:
KCU News: May 2021
KCU Breaks Ground on College of Dental Medicine on Anniversary of Joplin Tornado
Kansas City University (KCU), with a 105-year history of improving the well-being of the communities it serves, held a ceremonial groundbreaking for a new College of Dental Medicine on its campus in Joplin, Missouri.
KCU PsyD Receives APA Accreditation
Kansas City University has taken an important step in reaching the goal of attaining full accreditation in its doctorate of clinical psychology program.
KCU-Joplin College of Osteopathic Medicine Celebrates Inaugural Commencement
Three-Star General Joins for Keynote Address
(Kansas City, Mo. – May 8, 2021) Kansas City University (KCU), the 8th largest medical school in the nation hosted a history-making Lt. General and...


text:
Constitution of the Greater Columbia Association of Veterinarians
Article I. Title
The association shall be known as the Greater Columbia Association of Veterinarians (G.C.A.V.).
Article II. Organization
Section 1 The association shall be operated as a not-for-profit organization.
Section 2 The term of the organization shall be perpetual. However, in the event of dissolution, property owned by the organization shall be dedicated to the South Carolina Association of Veterinarians.
Section 3 The association shall not be operated for profit and no part of the net earnings shall inure to the benefit of any member or private individual.
Section 4 The objectives of the G.C.A.V. shall be to advance veterinary medicine, to promote animal welfare and public health, and to encourage fellowship amongst local veterinarians.
Article III. Objectives
Section 1 The objectives of the association shall be to:
Advance the science and art of veterinary medicine, including its relationship to public health and agriculture.
Actively encourage and assist in continuing veterinary medical education.
Article IV. Membership
Section 1 Members in the association shall be graduates of colleges and schools of veterinary medicine who meet the qualifications specified in the by-laws.
Section 2 Other Members: The by-laws may provide for and specify the qualifications for other members of the association.
Article V. Officers
Section1 The officers of the association shall be the President, Vice President, Secretary, Treasurer, and Information Technology Officer. The officers shall perform such duties as prescribed in the by-laws.
Section 2 Each officer shall be elected at the regular October meeting and serve for a term of one year, beginning January 1.
Article VI. Executive Committee
Section 1 The executive Committee shall include the officers and the Immediate Past-President of the association and shall have charge of the property and financial affairs of the association and shall perform duties prescribed by the by-laws.
Article VII. Amendments
Section 1 The constitution may be amended at a regularly scheduled meeting by two-thirds majority of the votes cast, providing:
The proposed amendment(s) shall have been mailed/e-mailed to the membership at least sixty (60) days prior to the meeting at which action is requested.
The proposed amendment(s) shall have been read to the membership at a regularly scheduled meeting at least thirty (30) days prior to the meeting at which action is requested.
By-Laws of the Greater Columbia Association of Veterinarians
Article I. Membership
Section 1 Members shall have privileges of the Association, including participation in educational meetings, voting and holding office.
Section 2 Qualified persons (Article IV-Constitution) may become a member of the Association by:
A request for membership directed to the secretary of the association with payment of annual dues and
By submission of at least one letter of recommendation from an association member.
In response to payment of due and receipt of the letter of recommendation, new members shall receive a membership packet including but not limited to the Constitution and By-laws of the organization.
Section 3 Other members
The executive committee, after consideration to length of service and contribution to the veterinary profession, may elect life members from the membership to have all the privileges of membership without payment of due or the payment of assessed educational fees.
The association, by vote of the majority of the membership may elect an honorary membership to a non-veterinarian who shall have made outstanding contributions to the objectives of the association, with all rights of the association, except voting, without payment of due or educational fees.
Section 4 Dues
Dues for members shall be payable on January 1 of each year and shall be $150.00 per annum.
Dues not paid by the end of the third meeting of the year will be considered late. A $25.00 late fee will be assessed in these cases.
Retired members of the G.C.A.V. will pay a discounted fee of $75.00 for dues.
Late fees will be assessed as for the general membership dues.
Section 5 Assessed Educational Fees
The executive committee may, in case of financial need, assess each member an educational fee to defray costs of continuing veterinary medical education programs.
Section 6 Delinquent Members
A member shall be delinquent when dues are not paid by April 1 of the calendar year for which they are payable or
A member shall be delinquent when assessed educational fees are not paid within three (3) months of the assessment.
Delinquent members are not entitled to the privileges of the association.
Members delinquent for nine (9) months shall be dropped from the membership roster.
Delinquent members shall not be eligible to receive any continuing education credit from the beginning of the calendar year following the last fully paid dues and educational fees, if applicable.
Section 7 Re-Instatement
A membership that has lapsed for failure to pay dues may be automatically reinstated upon receipt of all delinquent dues.
Article II. Officers
Section 1 Election of Officers
The executive committee shall act as nominating committee with the immediate past president as chairman.
The committee shall present, one month prior to the election meeting, a slate of at least one nominee from the voting membership for the offices of Vice President, Secretary, Treasurer, and Information Technology Officer. Consent of the nominees shall be obtained prior to the submission of the slate to the membership.
Additionally, nominees are present and consent to serve.
Election of officers shall be held at the October meeting of the association.
The term of office for each officer shall be twelve (12) months, beginning January 1.
Each officer may serve a maximum of two (2) successive terms in any one office.
Vacancies in an office may be filled by special election as determined by the executive committee.
Section 2 The President shall:
Preside over all meetings of the association.
Administer the affairs of the association in accordance with the terms of the Constitution and by-laws.
Appoint members to committees and serve as ex-officio member of each committee.
Convene special meetings of the association as needed.
Preside over the executive committee except when it is in session as a nominating committee.
Transfer duties and knowledge pertaining to the position to his/her successor
Serve as a member of the executive committee
Be exempt from payment of annual membership dues while in office.
Section 3 The Vice-President shall:
Succeed the President
Be chairman of the Membership Committee
Be an ex-officio member of the presidentially appointed committees
Be program chairman
Perform the duties of the president in the absence of the president
Be exempt from payment of annual membership dues while in office
Section 4 The Immediate Past-President
Serve as chairman of the executive committee when it is meeting as a nominating committee
Serve as the association parliamentarian.
Section 5 The Secretary shall:
Maintain the general record of the association
Attend all business meetings of the association and executive committee and report the business transactions
Maintain a roster of all members of the association
Supervise the tabulation of votes cast in elections
Notify, by March 1, each member whose dues are not paid
Notify, after three (3) months, each member who has not paid assessed educational fees
Notify delinquent members after nine (9) months that they are being dropped from the membership roster
Serve as a member of the executive board
Conduct the correspondence of the association
Notify all members of the date, time, and location of each meeting no later than seven (7) days prior to the meeting
Keep an attendance log and provide an end of the year summary for each member in accordance with the CE licensing requirements
Maintain continuing education credit approval with the State of South Carolina Board of Veterinary Medical Examiners
Section 6 The Treasurer shall:
Maintain all financial records of the association
Maintain records of payment of dues and assessments
Act as custodian of the association assets and be responsible to deposit association monies in federally insured banks
Pay all debts incurred by the association as directed by the executive committee
Prepare an annual audit of the association financial transactions and properties
Prepare an annual report, for the record, as a not-for-profit association
Transfer all fund, properties, and records to his/her successor
Inform the executive committee when a member is delinquent, as indicated in Article I, Section 5 of the by-laws
Section 7 The Information Technology Officer shall:
Maintain and update the G.C.A.V. website including, but not limited to:
Post monthly meeting information on the website as it is scheduled by the vice president
Current members and photographs if available
Links, calendar and documents (e.g. G.C.A.V. Constitution)
Maintain and update G.C.A.V. social media (e.g. Facebook, Twitter, etc.) as agreed upon by the executive committee.
Keep the executive committee up to date with expenses associated with the G.C.A.V. website and
Provide billing associated with the G.C.A.V. website or other expenses to the treasurer in a timely manner for on time payment
Article III. Executive Committee
Section 1 The executive committee shall:
Consist of the officers of the association and the immediate past-president
Serve as the administrative body of the association with the duty and responsibility to administer the association in accordance with the wishes of the membership
Serve as nominating committee in preparing a slate of officers for the association
Act on questions of qualification for membership
Section2 Four members of the executive committee shall constitute a quorum for the transaction of business.
Section 3 The executive committee shall meet at least quarterly or as needed to conduct all business transactions and develop plans and agendas for association meetings and programs.
Article IV. Meetings
Section1 G.C.A.V. Meetings shall be held monthly on the 4th Tuesday evening of each month at a location designated by the vice president.
Section2 Business may be conducted at each meeting, as needed, with election of officers to be held in October of each year.
Section 3 The number of voting members present shall constitute a quorum.
Section 4 Business meetings shall be conducted in accordance with Robert's Rules of Order
Section 5 Special meetings of the G.C.A.V. may be called by the president when, in his or her opinion, the necessity exits. No business other than that specified for the special meeting shall be conducted.
Section 6 Continuing Education
The G.C.A.V. shall provide a minimum of 9 hours of continuing education to occur during the monthly meetings, except June, August and December.
The fee for monthly CE shall be $25.00/hour for non-members
Additional continuing education programs (beyond 9 hours) may be provided by the G.C.A.V. as desired by the membership with additional fees applicable if deemed necessary to defray costs.
Article V. Committees
Section 1 The association shall establish committees as deemed necessary by the president.
Section 2 Committee Membership
Any active member may serve on a standing committee. The president shall appoint all committee members.
At least one (1) member of the executive committee shall serve on each committee.
Section 3 Committee Chairman
When the chairmanship of a standing committee is not specified in the by-laws, the president shall make the appointment.
Section 4 Community Liaison Committee
The purpose of the committee is to address animal welfare and animal control issues, as well as, address concerns of the G.C.A.V. and its interaction with animal support and protection groups.
This committee was established in July of 2001 and was "in the early stages of development"
Article VI. Amendments
Section 1 The by-laws may be amended as prescribed in Article VII of the constitution.


The Fastenal Company would like to invite ambitious, hard-working individuals to apply for the position of full-time Sales Support. Applicants should be able to bring new ideas and improvements to business practices; remain fair, respectful and moral in all situations; and work well both independently and as part of a team.
See the job posting document for more information.


Hotspot iphone guida in USA and United Kingdom!
if you're with one of these guys we recommend using hotspot iphone guida ExpressVPN or one of the others covered above. Here are the services not currently working based on our testing.
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My computer is winking at me knowingly when I sit down at my desk. I touch the keyboard, and a photo of Paul appears on my screen. It's the one I took of him in Rome on our honeymoon, eyes full of love across a table in the Campo dei Fiori. I try to smile back at him but as I lean in, I catch a glimpse of my reflection in the screen and stop. I hate seeing myself without warning. Don't recognize myself sometimes. You think you know what you look like and there is this stranger looking at you. It can frighten me.
But today I study the stranger's face. The brown hair half pulled up on top of the head in a frantic work bun, naked skin, shadows and lines creeping towards the eyes like cracks in pavement.
My yoga teacher is doing a guided relaxation, her voice purring over the tinkling of finger cymbals, lulling us into a coma. I love this bit of the class normally, but today I'm lying on my mat trying not to think about the ghosts of Howard Street. About the baby. About Professor Will (p. 63).
Synopsis: As an old house is demolished in a gentrifying section of London, a workman discovers a tiny skeleton, buried for years. For journalist Kate Waters, it's a story that deserves attention. She cobbles together a piece for her newspaper, but at a loss for answers, she can only pose a question: Who is the Building Site Baby?
This one is a definite for my list as it has been recommended to me by so many of my blogging friends. Yours are the first extracts I have read however and that only confirms my decision, especially those teaser lines … Just who is this Professor Will ?
Thanks for visiting, Yvonne, and I have been ogling this book for ages…and reading good reactions from readers. I am excited about it! Enjoy your reading.
Thanks, Sarah, I think it will be. I'm starting it later this week.
Love the writing. I've been bumping into this book everywhere. I'm sure I'll be giving it a try.
Thanks, Laura, I loved the author's previous book, The Widow, so I'm eager to dive in.
First I've heard of this but I'm not sure I could read it. I'm palpitating already just from the excerpt. I hope you enjoy it, though.
I'm sure it's not for everybody, Ms. M; I hope to enjoy it! Thanks for stopping by.
I have this on my list of books to buy – it sounds good!
Thanks, Emma, I've been waiting for it for a long time! I'm eager to start reading it.
Great teaser! I've heard mixed things about The Child but I still have it on my wishlist… I hope you are enjoying it so far. Happy reading! Here's my teaser of Little Monsters by Kara Thomas.
Thanks for stopping by, Yvo, and I hope to love this book.
Thanks, Stephanie, I have good feelings about it. Enjoy your week!
This looks like a really good book – but probably one that's pretty intense too! Thanks for visiting my Teaser this week!
Thanks for visiting, Kym, and yes, it is definitely intense!
What a fabulous story! The intro caught my attention, but what a synopsis. Now I want to know the secrets…and these three women.
Thanks for visiting, Charlie, I loved the book!
! Thanks for visiting my Teaser this week!
You're welcome, Todd, and thanks for the return visit.
Thanks, Arsenios…glad you could return the visit! And thanks for following.
Thanks, Timothy, I did love it!


The executive board, whose members and officers are elected by the general membership, is the principal governing body of the society. The board oversees the fulfillment of the purposes of the society in accord with its constitution and bylaws.
The society, a 501(c)(3) organization, operates under a charter of incorporation issued by the State of New York.


Local Elections End Friday at 5:00 p.m.
Local elections end Friday, April 5, 2019 at 5:00 p.m. NEA-Salina members should have received an email with voting instructions to their @usd305.com accounts.
Please email Jonathan Eshnaur if you have any questions.
7 Days Until "Got Spring Fever?"
NEA-Salina Members in the Recognized for Excellence!


text:
Q: I don't understand why this is giving me a error I am trying to create a part of a program that will eventually simulate blackjack.
def getShuffleDeck():
    newDeck = ['A','2','3','4','5','6','7','8','9','T','J','Q','K'] * 4
    shuffleDeck = []
    print(newDeck)
    deckPreshuffle = list(newDeck)
    shuffleDeck = random.shuffle(newDeck)
    return shuffleDeck

def dealCard(playingDeck):
    playDeck = []
    player1CardDealt = playDeck[0]
    print("Dealer gave you: " + playDeck[0])
    player2CardDealt = playDeck[1]
    print("Dealer is dealt a card.")

    playingDeck.remove(playerCardDealt)
    playingDeck.remove(dealerCardDealt)
    return (playerCardDealt, dealerCardDealt, playDeck)

# def cardValues(cardDealt):
dealCards = []
dealCards = (getShuffleDeck())
print(dealCards)

# print(dealtCard)

player1Card = dealCards
player2Card = dealCards[1]
currentDeck = dealCards[2]
print(player1Card)
print(player2Card)

the program is giving me a nonetype error. can someone please explain to me what i'm doing wrong?

A: playDeck = []
player1CardDealt = playDeck[0]

will always give you an error since you are trying to access the first element of an empty list ...
additionally
def getShuffleDeck():
    newDeck = ['A','2','3','4','5','6','7','8','9','T','J','Q','K'] * 4
    shuffleDeck = []
    print(newDeck)
    deckPreshuffle = list(newDeck)
    shuffleDeck = random.shuffle(newDeck)
    return shuffleDeck

will always return None ... since random.shuffle shuffles the deck in place and does not return a value (Im pretty sure at least)


If you are looking to sculpt other parts of your body, CoolSculpting has various applicators in different sizes to treat stubbornt fat from different parts of our body. This includes the chin, chest, bra fat, arms, flank, lower back, buttocks, outer and inner thighs, and above the knee. Finally, be sure to consult a doctor on what is the best way to achieve your body goal. A six-pack may seem like the holy grail of fitness but it isn't. A strong, healthy body comes in all shapes and sizes so don't let the media (or social media) make that definition for you.


text:
Why macropha…althy tissues
Why macrophages are less active in healthy tissues
Added November 23rd 2018, 2:56 PM
Macrophages are a type of white blood cell. The term comes from the Greek for "big eater", which describes one of the roles these cells play in our bodies: they detect and engulf pathogenic bacteria, triggering an inflammatory response that fights the infection. Macrophages are regulated by cytokines and other biochemical substances. These molecules stimulate macrophages to increase their activity when needed and to calm down once their job is done.
Researchers have now discovered another regulatory mechanism for pro-inflammatory macrophages: spatial information. When macrophages sit in the tissue between other cells and are constricted by them, their activity is lowered - even if upregulating stimuli are present.
"Not only do macrophages circulate in the blood, they can also be found in all the body's tissues. They wait quietly, like guards, until they are needed," the senior author explains. It's very important for the body that tissue residing macrophages stay inactive, as they could otherwise trigger unnecessary inflammatory responses: However, the mechanisms that dampen pro-inflammatory macrophage activity in healthy tissues have so far not been fully understood.
By conducting cell culture experiments in the lab, the scientists have been able to determine that macrophages are regulated both biochemically and mechanically. By placing macrophages into pore-like indentations, they could restrict the spreading of individual cells.
These experiments also allowed the researchers to unlock underpinning molecular mechanisms. The function of a macrophage is tied to its size: if it is activated, it grows by expanding its cytoskeleton. This releases factors that influence the activity of the genes. The macrophage, however, cannot grow if it is caged in by external barriers.
The discovery that spatial factors steer the activation of macrophages has major implications for the understanding of various diseases. "Many age related diseases are associated with the latent production of pro-inflammatory cytokines as produced by insufficiently controlled macrophages," the author says. This includes rheumatic diseases, atherosclerosis, obesity, cancer and several auto-immune diseases.
In addition, the discovery will spark new ideas how to structure the surfaces of implants so as to reduce inflammation. "We show that the structure of a material surface affects the macrophage response," the author says. The next step could be to see if, for example, patients who receive implants with porous surfaces form less scar tissue around it, as suggested already by some previous observations.
https://www.ethz.ch/en/news-and-events/eth-news/news/2018/11/why-macrophages-rest-in-healthy-tissue.html
Edited November 23rd 2018


A seminar organised by the Birkbeck Sport Business Society, a student society of Birkbeck, University of London.
Birkbeck Sport Business Society, Birkbeck, University of London, is pleased to welcome to Birkbeck two of the world's leading academic authorities in the sport economics and sport governance fields. In this presentation, Professor Stefan Szymanski and Professor Stephen Ross will discuss alternative perspectives on football's "transfer system," a product of private arrangement by European clubs adhering to FIFA regulations for when a player seeks to change teams despite having signed a multi-year contract.
An employee's ability to switch employers is generally governed by the contract law of EU member states. These laws vary widely; the remedies available to employers and range from minimal (worker pays a few weeks' salary) to money damages where the employing club can clearly demonstrate economic harm. In contrast, FIFA rules provide an unclear set of damages and penalties that sharply limit player mobility.
Professor Stefan Szymanski is a noted critic of the transfer system. His remarks will focus on the extraordinary exploitation of thousands of players as a result of FIFA rules. He will also articulate policy objections to treating football players differently than other European employees. Professor Stephen Ross will focus on the extraordinary players whose damage to their team from moving on cannot be precisely measured in Euros or Sterling.
Ross' current research focuses on this significant sporting controversy as a means of examining, more generally, whether EU laws that effectively prevent workers with special talent from binding themselves to multi-year employment contracts serves the EU interest in free movement of labour.
Szymanski was retained by the global football players's union FIFPro to argue the case that the current transfer system violates European competition law as part of the challenge they have made to the system in the European Court of Justice, and his paper on the subject can be downloaded here.
Lucy Tallentire (School of Business, Economics and Informatics) and students Vasiliki Panou (MSc Sport Management & Marketing) and George Totomis (MSc Sport Management and the Business of Football) review the presentations on the Birkbeck Events Blog.
Professor Stefan Szymanski is the Stephen J. Galetti Professor of Sport Management at the University of Michigan. He started researching the economics of professional football in 1989, and has since come to spend his entire time researching the economics and business of sport. He has published 55 scholarly articles, 14 book chapters, six books and four edited volumes on sports related subjects. He has also acted as consultant to sport governing bodies and national governments, and has appeared in court as an expert witness on the economics of sport. He has become a regular pundit in the media on business related sports issues.
Professor Stephen Ross is a Professor of Law, the Pennsylvania State University (Penn State), and Director, Penn State Institute for Sports Law, Policy, and Research. He teaches and writes in the disparate areas of Sports Law and Comparative Constitutional Law. He has provided expert testimony and advice on sports antitrust issues to governmental entities in both the United States and Canada. He has also consulted on sports league design for professional sports organizations in ice hockey, cricket, and motorcycle racing. Professor Ross has also served as a senior fellow of the American Antitrust Institute and as pro bono counsel to the AAI and consumer groups including the Consumer Federation of America on antitrust and sports litigation. He has co-authored casebooks in Sports Law and Comparative Constitutional Law. In 2016, Ross was named the founding executive director of the University-wide Center for the Study of Sports in Society.
FIFPro.com (15 October 2015). New Study: Abusive Transfer System Is Failing. FIFPro.com.


text:
Power Business Solutions > Blog > Games > What Are Peer To Peer Games?
What Are Peer To Peer Games?
posted on Aug. 19, 2021 at 9:50 am August 30, 2021
The term 'peer to peer' in multi-player games refers to both the way the game is implemented and how players connect to each other. In peer to peer games players connect with each other directly in order to play the game. This is contrasted with dedicated server approaches in which all players connect with a server that hosts the game.
There are two ways that peer to peer approaches can be implemented: the first is where one player acts as the server (and all players must connect with that player in the same way as a dedicated server), the second is where all players must connect with each other in a so-called 'mesh'. This means that all players run the game software and information is sent between all players when an action occurs in the game. There are other requirements to support players called 'game services' which refer to servers that provide non-gameplay support. This can include matchmaking between computers or sharing IP addresses between players so that they can connect or chat.
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Comment: Thanks so much for the nice letter. I love the pretty stickers and pamplet about St. Patrick's day. That was interesting.
Comment: I loved the drawing on the outside of the envelope! And thanks for the good choices of cartoons.
Comment: Got your letter yesterday :) I'll write back soon!


text:
Hindumanes is een geslacht van spinnen uit de familie springspinnen (Salticidae).

Soort
De volgende soort is bij het geslacht ingedeeld:
 Hindumanes karnatakaensis (Tikader & Biswas, 1978)

Springspinnen

redpajama_set_name: RedPajamaWikipedia


MAINTENANCE SUPPORT. Staffed by Avaya® and WMA-trained specialists, we service only Avaya®-manufactured PBXs. We provide maintenance support with two plans: a formal prepaid Maintenance Agreement, and informally "as-required".
MAINTENANCE AGREEMENTS. We have a complete stock of spares for each equipment type that we service. PBX status may be remotely monitored and immediate fault-corrective action will be taken. Additionally, we have functioning PBX switches to provide rapid disaster recovery (fire, flood, etc.). WMA Maintenance Agreements (24hr, 7days/week) are typically priced 20% lower than Avaya® (8hr, 5days/week).
SOFTWARE: Your translations can be downloaded for safekeeping at our facility.
HARDWARE: We maintain fully functional PBX switches on hand.
"AS-REQUIRED" MAINTENANCE. Optionally, PBX status is remotely monitored, and immediate alarm notification performed.
HARDWARE: We maintain functional PBX switches on hand.
WMA has a fully developed training center located in Vancouver, Washington. We offer a one-week System Administration training seminar covering everything from starting with a system that has no information in it to a fully functional and practical system within that week. All aspects of the system are fully covered, and it is all hands-on training on real, not simulated, AVAYA® Communication Manager and Definity® switches. You will get the actual touch and feel of the system hardware, along with the software.
The training is suitable for both client administrators and field technicians. The training covers system setup, stations, trunks, groups, lists, ARS, Audix®, etc., and includes training manuals, exercises and most importantly, one-year of ongoing "refresher" calls to our facility to help digest the information over that time, not just cramming it all in during the one week.
We have small groups targeted at a maximum of 12 trainees per class. This allows more time for individual questions and concerns, and additional exchange of information during the time allotted. We also try to assign each trainee to the same type of system they will be managing on the job. At each table there is a Definity® version 9.5 PBX, an AVAYA® Communication Manager VoIP switch, and an Intuity Audix® voicemail.
Classes are currently scheduled for each month and are filling rapidly for this term, so it would be wise to get an early start by contacting us at training@medak.com as early as possible.


Extracted from text ... E D ITO R IAL Since 1990, two issues have almost become synonymous on the political and security landscape in Africa. As conflicts have broken out in various parts of the continent, so too has the debate about the forms and methods that should be used to keep the peace in these trouble spots. Thus, the conceptualisation of peacekeeping in Africa has shifted considerably since the newly independent states joined the United Nations (UN) to keep the peace in the newly independent Congo Republic (now Democratic Republic of Congo, or DRC) in the 1960s. Subsequent efforts at responding to ..
In the wake of heightened media and political pressure about the Darfur humanitarian catastrophe, the African Union (AU) hurriedly deployed its monitors in Darfur, to be augmented later by a protection force to safeguard the monitors, albeit without adequate pre-deployment and logistic assessment. Without doubt, the Darfur crisis has become the AU's major preoccupation for the past year. The deployment of the African Mission in Sudan (AMIS) since June 2004 has presented many challenges to the AU and its partners. A restrictive mandate, inadequate troops to cover Darfur, serious operational, logistical and capacity shortfalls have combined in an inextricable way to present the AU's mission to some observers as spineless and ineffective. The UN and partners have acknowledged the lead role of the AU in Darfur, and have been very supportive with assistance in these critical deficient areas. How the AU will take advantage of this favourable environment and optimise the benefits from its partners will be crucial to its success in Darfur. The article emphasises the need for the AU to strengthen its capacity and expertise at all levels of command through technical cooperation and appropriate assistance from the UN and partners. The entire world is waiting to see how Africa delivers on this critical assignment.
The authors consider the recent referral by the UN Security Council of the situation in the western region of Sudan (Darfur) for investigation and prosecution to the International Criminal Court. The paper focuses on the context of this referral, especially since the referral signals a capitulation by the United States of America (which had the power to veto the referral) in the face of worldwide pressure for the United Nations to take action against perpetrators of atrocities in Sudan. In considering the referral, the authors point out that the International Criminal Court has been handed a hot potato. Because it is one of the first cases that the court will hear, the spotlight will be on the court's effectiveness as an instrument of international criminal justice. Sudan is not party to the court's statute, however, and accordingly owes the court no obligation to cooperate in the investigation and prosecution of Sudanese offenders.
Peace and security have become priority issues for the African continent, and for the international community. The dynamics that Africa has developed on its own, as well as the dynamics currently involved in outside support for Africa, are concerned not exclusively, but in large measure, with military capabilities. In fact, in the past many examples indicate that mechanisms put in place by African nations themselves or by the international community have been unwilling or unable to intervene militarily in emergency situations to protect civilian populations.
Against this background, the paper seeks to determine how and in what form external actors are supporting African efforts, and what shape future challenges may take. The paper will also discuss whether the ongoing debate on the military dimension is an indication of a 'backlog' of issues that demand more attention, or whether the discussion must be seen as an indication of an overly narrow focus on the military. Finally, the implications for development policy will be discussed.
The paper concludes that ongoing African efforts and measures aimed at implementing a new peace and security architecture must be seen as positive. However, a number of structural deficits must still be overcome to implement a truly effective peace and security architecture.
Extracted from text ... AFRICA WATCH C?TE D'IVOIRE A region at stake Between 3 and 6 April this year, a peace summit was held in Pretoria under the chairmanship of President Thabo Mbeki, in what many observers saw as a final chance to avert a return to open conflict in C?te d'Ivoire's slow civil war. What was remarkable about the event was that Mbeki not only secured the attendance of the principal players in the crisis, but let them know that they would not be leaving the venue until he had secured their agreement to a way forward in the stalled peace process. After ..
Extracted from text ... AFRICA WATCH IN TRANSIT? The socio-economic transformation of Burundi As Burundi prepares for its first democratic elections since the beginning of war in 1993, civil society expectations of the new government are set to rise. Violence that racked the tiny, landlocked country for so long has ceased to motivate the majority who voted in favour of the interim constitution in the recent referendum. The constitution, like the Arusha Peace and Reconciliation Accords signed between 19 political parties in 2000, is based on the principle of "power sharing" between the dominant Hutu and minority Tutsi and Twa constituencies, signalling a dramatic ..
Extracted from text ... AFRICA WATCH DEMOBILISATION, DISARMAMENT AND REINTEGRATION (DD&R) A key to peace in C?te d'Ivoire During the peace talks that finished in Pretoria on 6 April 2005, the parties to the Ivorian conflict agreed that the Chiefs of Staff of the National Armed Forces of the C?te d' Ivoire (FANCI) and the Armed Forces of the New Forces (FAFN) would meet immediately to ensure the implementation of the National Disarmament Demobilisation and Reintegration Plan (PNDDR). DDR has been a priority since the signature of the Marcoussis peace accord in January 2003, and the Accra III agreement in July 2004. In the ..
Extracted from text ... AFRICA WATCH ZIMBABWE More of the same? On 31 March this year Zimbabweans went to the polls to elect a new parliament. The ruling Zimbabwe African National Union-Patriotic Front (ZANU-PF) had laid the groundwork for yet another victory, having in the last few years hobbled the opposition press, hounded its principal rival, the Movement for Democratic Change (MDC) by means fair and foul, and either co-opted or cowed the population at large with a welter of blandishments and threats. Under the circumstances, there were few external observers who expected the MDC to achieve anything like its brave showing in the ..
Extracted from text ... AFRICA WATCH ZIMBABWE 2000 PARLIAMENTARY ELECTION RESULTS Province Constituency ZANU-PF votes MDC votes Independents votes ZANU Ndonga votes Spoilt votes Total votes Masvingo Bikita East 7, 047 5, 015 187 212 523 12, 984 Bikita West 7, 441 7, 726 0 0 15, 167 Chiredzi North 10, 154 8, 674 100 530 0 19, 458 Chiredzi South 11, 611 6, 414 794 0 18, 819 Chivi North 10, 947 3, 938 116 3, 762 483 19, 246 Chivi South 12, 056 4, 312 123 1, 683 374 18, 548 Gutu North 14, 867 8, 179 130 678 432 24, 286 ..
Extracted from text ... ESSAY UN REFORM AND FUNDING PEACEKEEPING IN AFRICA Introduction Two recent reports, the Report of the Secretary- General's High Level Panel on Threats, Challenges and Change1 and the Report of the Secretary-General, In Larger Freedom: towards development, security and human rights for all2 are extremely welcome and appropriate documents for those concerned with improvements in global peace and security, particularly in Africa. The two reports include a set of findings and recommendations that aim to address many of the gaps that have developed in modern peacekeeping. On the one hand, both reports argue that the role of regional organisations in ..
In the post-Cold World era, West Africa, like most other regions of the world, experienced significant shifts in its approach to, and understanding of security. The outbreak of brutal domestic conflicts in the sub-region and ECOWAS's subsequent deployment of its peacekeeping force, ECOMOG, marked a turning point in the sub-region's attempt to develop a security architecture that began in the 1970s. This paper argues that in the post-Cold War era, West Africa is in the process of evolving from a security complex to a security community. The inter-linked nature of the conflicts in the Mano River basin reinforced the security interdependence of member states of the Economic Community of West African States (ECOWAS). These factors, coupled with the close cultural and historical ties, geographical proximity qualifies West Africa as a security complex. The adoption of the ECOWAS Protocol on Conflict Prevention, Management, Resolution and Peacekeeping, the supplementary Protocol on Democracy and Good Governance and the ECOWAS Moratorium on Small Arms and Light Weapons are clearly aimed at the institutionalisation of conflict resolution mechanisms - a move away from the ad hoc approach of the 1990s. If the democratic peace theory holds true (that democracies do not fight each other), one could make the argument that democracies do not harbour dissidents from neighbouring states. Hence, the development and consolidation of a democratic ethos in the sub-region would lead to the eventual development of a security community.
I am afraid there is clear evidence that acts of gross misconduct have taken place. This is a shameful thing for the United Nations to have to say, and I am absolutely outraged by it. - Kofi Annan, United Nations Secretary-General
Despite promulgating a comprehensive set of guidelines to deter UN personnel from committing acts of sexual misconduct, allegations of sexual exploitation and abuse have become widespread within United Nations peacekeeping missions. The policy of zero-tolerance for peacekeeper misconduct has not been matched by strong disciplinary measures, and crimes are often ignored and rarely punished: absentee fathers, rapists and murderers simply disappear back in their home countries. In countries where women and children rarely have the same economic resources, political rights and authority or control over their environment - or their bodies - they easily become prey for those in perceived positions of power and authority. By failing to hold those responsible to account, the UN may in fact be fuelling even greater discrimination and violence against women and children. In order to ensure those who are mandated to protect to do not become perpetrators of abuse, the UN must take a stronger stand against those who commit acts of sexual misconduct, and must ensure that victims see that their abuser is brought to justice and that reparation is offered. A recent report submitted by the Secretary-General's Special Envoy on Sexual Exploitation and Sexual Abuse makes a comprehensive set of recommendations to prevent, detect, and respond to these allegations. The aim of this essay is to highlight some of the main points of the Special Envoy's report, and to examine the practical challenges the UN and troop/police contributing countries will face when attempting to implement these recommendations.
This study was designed to examine the influence of gender and age on attitudes toward professional ethics among a sample of the Nigeria police officers. Using a cross-sectional survey, data was collected from a total of 163 participants. Results revealed that gender and age were significant predictors of unethical beliefs; female and older police participants were also more ethical than their male and younger counterparts. These findings were discussed in the context of socialization theory, Gilligan's moral development theory and other organisational practices, while its practical implications for the recruitment, selection and placement in the Nigeria police were also emphasized.
Extracted from text ... COMMENTARY HUMAN-CENTRED ENVIRONMENTAL SECURITY IN AFRICA The people of Africa entered the 21st century facing a security and development crisis of immense proportions. It is the continent hardest hit by growing poverty and inequity: average life expectancy has declined from 50 years to 46 since 1990, and in most of sub-Saharan Africa one in 10 children dies before it reaches age five. Africans are threatened by their lack of access to resources and the growing pressure on the natural resource base. The loss of arable land, water scarcity, over-fishing, deforestation and loss of biodiversity presents enormous challenges for sustainable development. ..
Extracted from text ... COMMENTARY THE 3rd PAN-AFRICAN PARLIAMENT SESSION Utility or futility? Amid the ceremony and fanfare that characterised the launch of the Pan-African Parliament (PAP) in March 2003, there were critical voices that cautioned Africans not to expect miracles. The questions relate to the difference the continental assembly would make in promoting democracy and human rights, given its self-proclaimed role in this regard. To what extent might the parliament manage to twist the arms of heads of state to deal with a range of challenges facing the continent? Of what practical value would the parliament be to ordinary Africans tired of wars ..
Extracted from text ... COMMENTARY PEACE SUPPORT OPERATIONS AND PERPETUAL HUMAN FAILINGS 'Are we all human, or are some more human than others?'1 Introduction In 1994, in the tiny African country of Rwanda, eight hundred thousand Rwandans were brutally murdered in a period of a hundred days. In the words of Lt. General Romeo Dallaire, the force commander of the United Nations (UN) Assistance Mission for Rwanda from July 1993 to September 1994 (UNAMIR), it was a case of 'betrayal, failure, na?vet?, indifference, hatred, genocide, war, inhumanity and evil'2. The UN stood by and the world's great powers chose to do nothing. On the ..
Extracted from text ... BOOK REVIEWS FAMINE THAT KILLS Darfur, Sudan ALEX DE WAAL Oxford University Press, Revised edition 2005. victims. He notes the frequent lack of coherence between macro-economic theory and micro-level research on livelihoods and coping strategies. He revisits his original questioning of the very concept of "famine", and what it means to those who experience it. He emphasises the importance of avoiding the simplicities inherent in confusing famine with the idea of "food insecurity", and of ignoring the broader issues of livelihoods, health and social cohesion. On this view, famine kills not merely by having people starve to death but in ..
Extracted from text ... 120 African Security Review 14(2) ? 2005 Al Venter is well known in military circles. He has written twenty books since 1969 ranging from accounts of insurgency wars in Guinea Bissau, Angola, the former Rhodesia and in Africa generally. For the last 25 years, Venter has served as correspondent for a number of the Jane's publications, including International Defence Review, Defence Weekly, Terrorism and Security Monitor. He knows what he is writing about and clearly has sympathy with soldiering, with mercenaries and anything to do with guns - hence almost a chapter (one of twenty four) devoted to extolling the ..
Extracted from text ... LETTING THEM DIE Why HIV prevention programmes often fail CATHERINE CAMPBELL The International African Institute, in association with James Currey publishers, Oxford; Indiana Uniersity Press, Bloomington and Indianapolis; and Double Storey, Cape Town. With the HIV / AIDS epidemic increasingly recognised as one of the greatest humanitarian, development and, many argue, security challenges of our time, vast resources are being pumped into preventing the spread of the virus. Encouraging responsible, healthy sexuality has become a veritable industry, fuelled by a multitude of 'gold standard' models, research studies and practice guidelines. Yet for all the time, money and energy devoted to ..