On December 3rd and 4th, the Winter 2012 Opinion Exchange meeting was held in Tokyo. This is a biannual meeting between National AJET, the Council for Local Authorities for International Relations (CLAIR), the Ministry of Internal Affairs and Communications (MIC), the Ministry of Foreign Affairs (MOFA), and the Ministry of Education, Culture, Sports, Science and Technology (MEXT). The discussion topics reported and presented at this meeting were: the Utilisation of Assistant Language Teachers (ALTs) in the Workplace, JET Programme Participants' Relationships with Their Contracting Organisations, and Volunteering on the JET Programme.
This report surveyed the current utilization of ALTs in elementary, junior high, and senior high schools, in order to identify trends in the team-teaching structure at all school levels, common contributions and barriers to various workplace involvement, and other important trends related to the changing role of the ALT in the classroom. You can read the report here and the discussion summary here.
Contracting organisations, as employers, play a defining role in JET participants' personal and professional experiences. As such, this report studied current participants' interactions with their contracting organisations in order to define a more productive working relationship built on successful mutual expectations, support, and communication practices. You can read the report here and the discussion summary here.
Based on current and past JET participants' experiences, this report sought to provide a clearer understanding of the kinds of volunteering activities in which participants engage. The report established that volunteering is widely practiced activity among the JET community, both in Japan and abroad, and its continued support and promotion further develops the internationalisation aim of the Programme. You can read the report here and the discussion summary here.
CLAIR asked National AJET for aspects of the JET Programme and its participants which make it unique and appealing to contracting organisations; National AJET acknowledged the value of international exchange, community involvement, selection processes and criteria, and JET participants' direct involvement in their workplaces and communities which has become a part of the JET Programme and its reputation and recommended that CLAIR emphasize these benefits to contracting organisations.
MEXT and National AJET discussed ways in which National AJET could be more involved in future education projects designed for ALTs as these endeavours would be a great benefit for all ALTs at job trainings and seminars as well as in the workplace.
Regarding future improvements of the JET Programme, CLAIR reiterated their interest in improving and increasing completion rates for the CLAIR TEFL Grant programme, as well as the language courses, and would like to consider ways for addressing these issues in the future. National AJET agreed to provide these responses and assessments on behalf of JETs and extended the invitation to continue this dialogue throughout the year.
Materials at Tokyo Orientation were also discussed, with CLAIR stating an interest in National AJET's suggestion for making these materials, including presentations notes, videos or slides, more available after orientation in a format online or in other media.
With regards to the future AJET report topic on the role of CIRs in the programme, CLAIR requested information on how CIRs are being progressively utilised in different and inventive ways, with the aim of providing information to contracting organisations regarding the benefits, work, and integration of CIRs in local communities and workplaces. National AJET will take these points into consideration for the next Opinion Exchange meeting.
On a final note, CLAIR asked National AJET for assistance in reminding participants of the importance in adhering to national laws and local regulations regarding behaviours and actions both in the workplace and in personal life, particularly with regards to the possession and/or use of illegal or controlled substances. Such actions have serious consequences not only for the individual who fails to observe the law or these regulations, but also have far wider reaching consequences which damage the reputation of the JET Programme and that of the JET participant's home country. It is important that all JET participants do their part and abide by these laws and regulations at all times.


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text:
Q: If $X$ is separable, then $\mathcal{F}(X)$ is also separable, where $\mathcal{F}(X) = \overline{span \{ \delta_x : x \in X \}}$ Suppose $X$ is a Banach space. For any $x \in X$, define the set $\mathcal{F}(X) = \overline{span \{ \delta_x : x \in X \}}$ where $\delta_x(f)=f(x)$ for all $f \in$ Lip$_0(X)$.
The set Lip$_0(X)$ is the set of all real-valued Lipschitz functions which vanish at $0$.
Note that $\delta_x$ is an evaluation functional on Lip$_0(X)$.
I am wondering whether the following statement is true or not.

If $X$ is separable, then $\mathcal{F}(X)$ is also separable.

The statement above is taken from here, so I believe the statement is true. But I have no idea on how to prove it.
UPDATE: The following is my attempt:
Take the set $\{ \delta_x : x \in X \}$ with the norm $\| \delta_x \| = \| x \|$. Note that $\{ \delta_x : x \in X \}$ is isometric to $X$. Hence, $\mathcal{F}(X)$ is separable.
Is it correct?

A: Suppose $X$ is over $\mathbb{R}$.
Let $A$ denote a countable dense subset of $X$. Let $y$ be an element of  ${\cal F}(X)$, and let $\varepsilon>0$. By definition, there exists a finite linear combination $\sum_{k=1}^n a_k \delta_{x_k}$ that belongs to an open ball of radius $\varepsilon/2$ around $y$ in $\mathrm{Lip}_0(X)^*$. For every $f$, and every choice of $z_k\in A$:
$$\left|\left(\sum_{k=1}^n a_k(\delta_{x_k}-\delta_{z_k})\right)(f)\right|=\left|\sum_{k=1}^n a_k(f(x_k)-f(z_k))\right|\leq||f||_{Lip}\sum_{k=1}^n|a_k|\,\|x_k-z_k\|_X$$
Hence,
$$\left\|\sum_{k=1}^n a_k(\delta_{x_k}-\delta_{z_k})\right\|_{\mathrm{Lip}_0(X)^*} \leq \sum_{k=1}^n|a_k| \, \|x_k-z_k\|_X$$
As $A$ is dense in $X$, we can choose $z_k$ so that the r.h.s is less that $\varepsilon/2$. It follows that the distance between $\sum_{k=1}^n a_k\delta_{z_k}$ and $y$ in $\mathrm{Lip}_0(X)^*$ is at most $\varepsilon$. One further approximation argument shows that the set of finite linear combinations $\sum_{k=1}^nr_k\delta_{z_k}$ with rational $r_k$'s, is dense in ${\cal F}(X)$. As this set is countable, it follows that ${\cal F}(X)$ is separable.

redpajama_set_name: RedPajamaStackExchange


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The thermal magnetoresistance, optical magnetoreflectance, and extremal properties of the energy loss spectrum connected with the cyclotron resonance effect are approached on a theoretical basis. The formalism, which applies the idea of two kinds of relaxation times active for the electron magnetotransport in a metal, gives – at least qualitatively – a satisfactory agreement with the observed data in all examined cases.
Key words: Electron Thermo-Magnetoresistance; Optical Reflection in the Magnetic Field; Energy Loss Spectrum in the Cyclotron Resonance Effect; Metals.


text:
<?xml version="1.0" encoding="utf-8"?>
<menu xmlns:android="http://schemas.android.com/apk/res/android"
    xmlns:app="http://schemas.android.com/apk/res-auto">
    <item android:id="@+id/action_search"
        app:actionViewClass="androidx.appcompat.widget.SearchView"
        app:showAsAction="always"
        android:title="@string/search" />

    <item android:id="@+id/filter"
        android:icon="@drawable/ic_filter"
        app:showAsAction="always"
        android:title="Filter" />

    <item android:id="@+id/action_date"
        android:icon="@drawable/ic_event"
        app:showAsAction="always"
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        android:id="@+id/action_supporter"
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        app:showAsAction="ifRoom" />

    <item android:id="@+id/action_refresh"
        android:orderInCategory="2"
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        android:title="@string/refresh" />

    <item
        android:id="@+id/action_settings"
        android:orderInCategory="100"
        android:title="@string/action_settings"
        app:showAsAction="never" />
</menu>

redpajama_set_name: RedPajamaGithub


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text:
Biografia
Nato nel comune montano di Piazza Brembana, rimasto orfano 7 anni della madre Santina Covelli a causa di un'epidemia di colera, esercita la professione di fabbro come il padre Giacomo fino al 1867, anno in cui si iscrive all'Accademia Tadini di Lovere.
Nel 1868 risulta iscritto all'Accademia Carrara di Bergamo, che frequenta fino al 1879 e dove segue i corsi del classicista bergamasco Enrico Scuri e dell'architetto Giovanni Cominetti, al pari di altri giovani artisti locali quali Ponziano Loverini, Giovanni Cavalleri, Rinaldo Agazzi e Abramo Spinelli.

Nel 1876 riceve il premio biennale di pittura del valore di 500 lire, con l'opera Scena di famiglia con bersagliere, mentre nel 1883 sposa Ester Maria Calegari, dalla quale avrà quattro figli, trasferendosi definitivamente a Bergamo.
Nel 1898 è nominato membro della commissione della Società d'Incoraggiamento di Belle Arti di Milano.
Nel 1906 viene colpito da emiparesi destra, che lo costringe a ridurre al minimo il proprio lavoro e a doversi sostentare con la vendita di numerose opere di sua proprietà.
Muore a Bergamo il 10 settembre 1915 per arresto cardiaco.

Valore artistico
La produzione di Calegari è ripartita tra pittura di genere e ritrattistica familiare, che prevale, su commissione pubblica o privata (come le importanti famiglie bergamasche dei Suardi, degli Zanchi e dei Camozzi), talvolta eseguita post-mortem utilizzando il recente strumento della riproduzione fotografica.

Lo stile è caratterizzato da un'aderenza ai temi puramente veristi, dove volti e tratti dei soggetti sono resi con sobrietà e mediante la valorizzazione di luci e colori.

Ampia la produzione di affreschi di scene sacre, realizzate presso le chiese del territorio bergamasco.

Esposizioni
Presso l'Accademia Carrara di Bergamo
1884 con Lavoro campestre, Refezione e Forbice democratica.
1887 con Nozze d'oro.
1891 con Barbiere del nonno e Ritratto di bambini.
1901 con Giovane contadino.

Nel 1892 presso l'esposizione internazionale di Belle Arti di Lugano.

Nel 1896 presso l'esposizione provinciale di Belle arti di Bergamo con Reduce d'Africa.

Nel 1897 presso l'esposizione donizettiana di Bergamo con un ritratto morente del celebre compositore Gaetano Donizetti.

Opere su tela
 Autoritratto (1875);
 Scena di famiglia con bersagliere (1876);
 Lavoro campestre (1884);
 Refezione (1884);
 Forbice democratica (1884);
 Nozze d'oro (1887);
 Ritratto di Giovanni Zanchi (1890-1895), Accademia Carrara, Bergamo;
 Ritratto del cavaliere maggiore Giuseppe Zanchi (1890-1895), Accademia Carrara, Bergamo;
 Ritratto di Francesco Maria Zanchi (1890-1895), Accademia Carrara, Bergamo;
 Ritratto di Luigia Discacciati Zanchi (1890-1895), Accademia Carrara, Bergamo;
 Barbiere del nonno (1891);
 Ritratto di bambini (1891);
 Ritratto di Alessandro Zanchi (1892), Accademia Carrara, Bergamo;
 Sacra famiglia (1893), collezione privata (fino al 2003 esposto presso una cappella in via Roma a Piazza Brembana);
 Reduce d'Africa (1896);
 Ritratto del cavaliere Angelo Bonicelli (1896), Istituti Educativi di Bergamo;
 Donizetti morente (1897);
 Giovane contadino (1901);
 Ritratto di Lorenzo Rota Rossi, cavaliere e avvocato (1901), Ospedale Papa Giovanni XXIII, Bergamo;
 Ritratto del dottor Cherubino Zanchi (1906), Ospedale Papa Giovanni XXIII, Bergamo;
 Ritratto dell'ing. Natale Calvi (1909);
 Ritratto di Rosa Berizzi (1910).

Note

Bibliografia

Voci correlate
 Verismo
 Enrico Scuri
 Rinaldo Agazzi
 Accademia Carrara

Altri progetti

Pittura lombarda dell'Ottocento
Pittori italiani del XIX secolo
Nati a Piazza Brembana
Morti nel 1848
Nati nel 1915

redpajama_set_name: RedPajamaWikipedia


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text:
President Clinton Announces Release of LIHEAP Emergency Funds
President Clinton announces release of LIHEAP Emergency Funds & other steps to ease shortage of home heating oil (9/23/00)
President Clinton today will direct the Department of Health and Human Services (HHS) to release $400 million in Low Income Home Energy Assistance Program (LIHEAP) emergency funds. The President also announced a series of other steps that will reduce the likelihood of high heating oil prices and price spikes this winter. Today's announcement builds on yesterday's announcement that the Department of Energy (DOE) will initiate an exchange of crude oil from the Strategic Petroleum Reserve (SPR) and on the President's July decision to establish a home heating oil reserve in the Northeast. The President will renew his call on Congress to enact key parts of his comprehensive energy strategy, including his energy tax and investment packages; to reauthorize the Energy Policy and Conservation Act, which authorizes operation of the SPR; and, to authorize the establishment and operation of a permanent heating oil reserve in the Northeast.
PRESIDENT CLINTON DIRECTS $400 MILLION RELEASE IN LIHEAP EMERGENCY FUNDS IN RESPONSE TO HIGH HEATING FUEL PRICES: President Clinton today will direct the Department of Health and Human Services (HHS) to release $400 million in Low Income Home Energy Assistance Program (LIHEAP) emergency funds to all States to assist low-income households facing significant increases for heating oil, natural gas, and propane prices this coming winter. This is the largest release of LIHEAP emergency funds ever. By acting early, this action will encourage States to take steps now to help low-income households cope with high fuel prices this coming winter. States can raise benefit levels, adopt the maximum income limits under Federal guidelines or expand outreach to assist more families.
These funds also will enable consumers to take steps to secure their supply of heating fuel for the winter, including filling their heating oil tanks before it gets cold, and entering into fixed price heating oil contracts or contracts that include a price cap where available and appropriate.
By preparing in advance, consumers can reduce the risk that they will be burdened by higher heating fuel costs later this winter.
Today's LIHEAP release will provide funds to all States to cover the increase in fuel prices over last year. Funding allocations factor in states' reliance on heating oil, natural gas and propane.
PRESIDENT CLINTON WILL ALSO DIRECT FEDERAL AGENCIES TO TAKE ADDITIONAL STEPS TO REDUCE THE RISK OF HEATING OIL SHORTAGES THIS WINTER: Distillate inventories, which include both home heating oil and diesel fuel, are at unusually low levels as we head into the Fall. In the New England and Mid-Atlantic, where heating oil is an important residential heating fuel, inventories are currently more than 60 percent and 50 percent below last year's inventory levels, suggesting an increased risk of high heating oil prices and shortages this winter. To reduce the likelihood and severity of heating oil shortages, the President today directed:
Federal agencies to use all available means to fill their storage tanks and contract for the purchase of distillate this winter as early as possible.
Filling storage tanks in advance of the heating season means that additional heating oil supplies will not be required when colder weather first returns later this Fall.
By entering into long-term contracts with heating oil suppliers, uncertainty currently affecting the industry will be reduced, providing for a more stable heating oil market.
DOE to meet with representatives of state and local governments to encourage them to follow the Federal government's lead and fill their storage tanks and contract for the purchase of distillate this winter as early as possible.
DOE to work with state utility commissions to ensure that factories and businesses with interruptible contracts for natural gas that use heating oil as a backup fuel keep adequate heating oil reserves on hand. Natural gas customers with interruptible contracts obtain cheaper natural gas in exchange for service interruptions when the weather is cold and natural gas demand peaks. Many rely on heating oil as a backup fuel when their natural gas is cut off. Encouraging them to maintain backup fuel on hand will keep them from entering the heating oil market all at once when their natural gas service is interrupted. Therefore, it will reduce the risk of demand spikes that affect the prices paid by all heating oil customers.
The Environmental Protection Agency to work with States to review their air quality implementation plans, and to create flexibility to adjust State sulfur content restrictions on home heating oil in a manner that safeguards the environment. This will make it easier to build heating oil inventories this winter. Refineries that produce the lowest sulfur heating oil are currently operating near capacity. By creating flexibility in how States meet their sulfur standards, domestic and foreign refineries would have the ability to produce more heating oil and help build stocks faster;
The Secretary of Energy to meet with representatives of the National Petroleum Council to discuss heating oil production this winter and fall, to encourage the industry to take measure to maximize heating oil production.
PRESIDENT CLINTON WILL CALL ON CONGRESS TO ENACT KEY PARTS OF HIS ENERGY POLICY: President Clinton will renew his call for Congress to authorize permanently a home heating oil reserve with an appropriate trigger. The release of heating oil from the regional reserve that the President established in July using existing administrative authority is governed by current law. The President believes, however, that a permanent home heating oil reserve in the Northeast needs a trigger for its use that is more appropriate to possible regional shortages than current law permits. Congress must also pass the President's energy tax package and budget initiatives, which would help families and businesses buy fuel-saving cars, energy efficient homes, buildings, and appliances, and would accelerate the research and development of cleaner, more efficient energy technology in order to ensure that America has a secure energy future for the 21st century.
What's New at the White House
What's New - December 2000
What's New - November 2000
What's New - October 2000
What's New - September 2000
What's New - July 2000
What's New - May 2000
What's New - April 2000
What's New - March 2000
What's New - February 2000
What's New - January 2000
What's New Archives 1997-1999
What's New Archives: 1994-1996
Presidential Webcast: Meeting the Challenge of Global Warming
President Clinton Joins International Religious and Domestic Aids Policy Leaders to Mark World Aids Day
Urging Congress to Keep its Commitment and Complete this Year's Education Budget
To Implement Title V of the Trade and Development Act of 2000 and to Modify the Generalized System of Preferences
Preserving America's Coral Reefs
Human Rights Day: The Eleanor Roosevelt Award and The Presidential Medal of Freedom
President Clinton Launches New Effort to Increase Immunization Rates Among Children
President Clinton and Vice President Gore: Restoring an American Natural Treasure
Progress in Efforts to Combat International Crime
President Clinton's New Markets Initiative: Revitalizing America's Underserved Communities
President Clinton, Vice President Gore, and Congressional Democrats Win a Landmark Budget
Announcing Welfare Reform Achievements and Budget Wins for America's Families
President Clinton Issues Strong New Consumer Protections to Ensure the Privacy of Medical Records
Enacting a Budget that Invests in Education, Health Care, and America'
President Clinton Appoints Roger Gregory to the United States Court of Appeals for the Fourth Circuit
President Clinton Announces New Steps to Improve Nutrition and Education for Children in Developing Countries
The United States on Track to Pay Off the Debt by End of the Decade
President Clinton: Strengthening the Federal Government-University Research Partnership
Keeping the Heat and Lights On During Unusually Cold Weather

redpajama_set_name: RedPajamaCommonCrawl


Max picked up a stick in the yard and settled down with it. He kept watching me as if he thought I might stop him.
But the stick wasn't very tasty, it seemed.
And after another try, he was finished with it.
Just a couple of shots of Max in the yard for today. He'll walk outside carrying one of his chipmunk toys, pick a spot to settle down in the grass, and just lie there for awhile surveying the yard.
When he sees me pointing the camera toward him, he'll start wagging his tail as he watches me. Then he'll suddenly jump up and run to me. He's about to charge at me in this photo!
It was chilly this morning and never really got hot today. Max was enjoying the temperate weather and wanted to spend a lot of time outside in the yard. He brought one of his many toy chipmunks along with him.
Max and chipmunk relaxing together.
One more of Max and the chipmunk.
Here's my boy Max, out in the yard this afternoon.
I found him at an animal shelter June of last year, so he's been home with us for over a year now. He's very smart, funny, happy, and playful. He gets the newspaper for me most mornings (safely on a long flexi-leash), but sometimes he wants to sniff around the front yard or watch a neighbor leaving for work instead. Then he loses his job for a day or two, and I get the paper myself until he's ready to take it seriously again.
He loves to run around in the yard–though he put on some weight this summer when it was too hot for much outdoor activity. It's cooling down now and we'll start going for walks again soon.
He's still scared of strangers and he barks at anyone passing the house or coming to the door. He barks at other dogs too. But little by little he's coming along. He'll wag his tail when he sees our neighbor across the street now, and he actually likes to go to the vet's office where he's very well behaved for for one particular vet tech. He's a happy little fellow on the whole–though he looks very serious here!
Just a few for today. Here and there we're getting a fall leaf dropping in the backyard–spots of red, orange, yellow, and brown in the grass.
A Long-tailed Skipper, one of the few butterflies still hanging around, visiting the lantana flowers.
A pretty little juvenile female anole–red head and nice markings on her back.
And here's Max, looking like a very serious guard dog on duty.
Looks like fall is on the way.
This leaf will be falling soon.
Lantana flowers with the fence in the background.
And Max, smiling at the camera.


Why am I now in denial?
All because of one triggered thought?
No. But it's dark side is a mess.
Posted in #mentalhealth, #MHAP, #MHBlogFam, #MHCrisisAngels, mental health, therapy.Tagged #KeepTalkingMH, #MHAP, #MHBlogFam, #MHCrisisAngels, #PFYTCAMPAIGN, #SickNotWeak, behavior, bipolar, control, depression, emotions, feelings, frustration, healing, health, help, honesty, issues, mental health, negativity, optimism, positivity, psychiatry, psychology, recovery, sadness, thoughts.


text:
Raheem's family posed no threat when Vandi shot – Inspector
By Onozure Dania
Gbenga, the husband of late Lagos lawyer, Omobolanle Raheem, will testify in court on Thursday (today) in the ongoing trial of an Assistant Superintendent of Police, Drambi Vandi, who allegedly killed her on Christmas Day in the Ajah area of Lagos State.
Our correspondent confirmed the development at the resumed hearing of the proceedings at the Lagos State High Court sitting at the Tafawa Balewa Square on Wednesday.
During the proceedings, a second prosecution witness, Inspector Ebimine Fiyegha, told the court that the deceased and her family were peaceful when they drove past them on the day of the incident.
Fiyegha, while addressing the court, said the vehicle driven by Raheem's husband posed no threat to him or the public.
His testimony before Justice Ibironke Harrison of the Lagos State High Court corroborated the testimony of the first witness, Inspector Matthew Ameh.
The witness, while being led in evidence by the Attorney-General and Commissioner for Justice, Moyosore Onigbanjo (SAN), corroborated Ameh's account of the shooting.
He said, "One woman was in the passenger seat, and a man was driving. I flagged the vehicle down, it didn't stop. They passed me. I wondered why he was not speeding.
"Ameh also flagged him down but he didn't stop. Shortly after, I heard a gunshot from the back. I asked Ameh, 'What is going on?'"
Fiyegha told the court that afterwards, a crowd gathered, swooped on Vandi, brought him out of a commercial minibus where he hid, and put him in the deceased's car.
"I was trying to find out what was going on. I called Vandi on the phone to find out. I said, 'Oga, what happened?' He said, 'Wait'," Fiyegha said.
My wife battled for survival as hospitals refused treatment –Slain lawyer's husband
Slain lawyer buried, cleric consoles family
DPO warned us hours before Vandi shot lawyer – Inspector
He testified that Vandi's response was the same when he called him some minutes later.
While responding to Onigbanjo's questions, the witness said the family posed no threat to him or the public when they drove past.
"As the Venza approached, was there any threat to the general public?" he queried.
The witness said, "No, they were peaceful there."
The witness, who earlier stated that he was armed, denied firing his weapon.
Earlier, Vandi's lawyer, Adetokunbo Odutola, completed his cross-examination of Inspector Ameh, which began on January 16.
Responding to Odutola's questions, Ameh explained that the noise he referenced in his earlier statement could not have been anything else but a gunshot.
"When you hear the sound of a banger, it is different from a gunshot sound. A tyre burst sound is different from a gunshot sound," Ameh stated.
Following Odutola's cross-examination, the court adjourned till Thursday for continuation of trial.


Everglades, Florida (March 23, 2017) Everglades is a well known natural region in Florida that is characterized by the presence of tropical wetlands. It is a National Park that extends for about 1.5 million acres and forms one of the most widely visited tourist spots in USA. The Everglades offer great scope for indulging in different types of adventurous activities, one of which is certainly Everglades airboat rides. There are a number of different companies that offer tourists with the scope to go for Everglades airboat tours around this area. There are numerous touring packages available here for the Everglades airboat rides and one can easily find plenty of options to select a package that satisfies one's budget as well as exploration needs.
While looking for Fort Lauderdale airboat tours, one can easily get in touch with a number of people in the local area who can offer detailed information about the tours. This can help one in choosing a tour package that offers maximum fun and excitement. The travel websites that offer these tours also have customers putting up reviews which can also be of great help. There are also a lot of blog sites that offer detailed information about this area so that the people who are new here can know beforehand what to expect. A ride with the Everglades airboat tours can be a really memorable experience for anyone as he or she gets intimately acquainted with the natural environments of Florida and learns more about the history of this place. Apart from offering great scope for adventure, a trip to the Everglades can also be an excellent learning experience.
Everglades airboat tours offer the most exciting way of exploring the natural beauty of Everglades, a national park which falls under the area of southern Florida.


My Search Console is old. It has been reflecting links and errors dating back to URLs from 2013/2015. In the new website, I have configured everything correctly and made sure there are no internal links pointing out for any old/dead URLs.
The problem is, with the errors, it just says "Validation Passed/Started" but when I inspect the pages, it does not show an error?
PS: I have read the similar questions and understand that if there are soft 404 or not found that keep coming up with old URLs, important ones have to be 301 Redirected. I have did that but still I get these errors. Submitted them in the "removal tools" as well.


Why: When browsing this site, you'll find stylish laptop bags – and you'll find them quickly and easily, because the ingenious Laptop Bag Finder allows you to narrow the selection by price, style, screen size and more.
The Metrochic Paris Laptop Bag (left) would look totally in place next to tailored work clothes and smart black dresses, while the Samsonite Verana Leather Computer Tote is the perfect color for spring and summer.
You can also browse the huge collection of laptop briefcases, laptop backpacks, and adorable luggage – plus many more computer-carrying options. We were drawn to the cheery printed overnight bags, like this dotted one, for just $35 each.
How: Go to kolobags.com, browse around a bit, and pick out what you'd want to buy if you won. Then come back to this post, and leave a comment about your finds, and we'll enter you for a chance to win the $150 credit.
Can't wait to win? Shop now and take advantage of the flat shipping rate – you can stock up on gifts for laptop-toting friends (or for yourself) and pay only $5.95 for shipping.
And stop by MomFinds for a chance to win a $100 holiday card shopping spree at Minted.com.
3. The contest starts now and entries must be date stamped by our server no later than Friday, November 21st, 2008 at 11:59 AM Eastern Time to be eligible.
4. One winner will be selected during a random drawing and will be announced in the November 25th SheFinds newsletter. The winner must reply via email as instructed in the newsletter to claim the prize.


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Mangrove est un film suisse réalisé par  Frédéric Choffat et Julie Gilbert, sorti en 2011.

Synopsis
Une plage isolée sur la côte sud du Pacifique. Au bout de la plage, la mangrove. Une jeune femme européenne revient avec son fils après plusieurs années d'absence. Mais peut-on faire la paix avec les fantômes du passé ?

Fiche technique
 Titre : Mangrove
 Réalisation : Frédéric Choffat et Julie Gilbert
 Scénario : Julie Gilbert et Frédéric Choffat
 Musique : Pierre Audétat
 Production : Frédéric Choffat et Julie Gilbert pour Les Films du Tigre
 Pays d'origine :
 Format : Couleurs (Eastmancolor) - son Dolby - 35 mm - DCP
 Durée : 70 minutes
 Date de sortie :  (Suisse romande)

Distribution
 Vimala Pons : La Femme
 Solal : L'enfant

Festivals
 Festival de Locarno 2011

Réception

Liens externes

 Site officiel

Film suisse sorti en 2011
Film dramatique suisse
Film se déroulant au Mexique


"The 2019 general elections and upcoming March quarter results will remain crucial triggers in the short term," said Hemang Jani, head (advisory), Sharekhan.
"A small negative candle was formed this week in the Nifty as per the weekly timeframe chart. Technical pattern signals a possibility of more range-bound action or minor down correction, before showing a sharp upside breakout of the recent all-time high of 11,761 in the coming weeks," said Nagaraj Shetti, senior technical and derivative analyst, HDFC Securities.


text:
Q: .preventDefault and return false both not working EDIT: I have already searched through the previous questions for solutions, none of which are working. please stop marking as duplicate.
I have a one-page scroller website that uses jQuery animation to scroll down to divs on click, but neither preventDefault or return false are working to prevent the default action from occurring, so instead of scrolling it's just flashing straight to the sections.
$(document).ready(function() {
    $('a[href^="#"]').click(function() {
    var target = this.hash;
    var $target = $(target);

    $('html, body').stop().animate({
      'scrollTop': $target.offset().top
    }, 1500)

    return false;
  });
});

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A:


text:
Battery plan to help Riverland irrigators1 week, 1 day ago
Central Irrigation Trust to form battery partnership and reduce energy costs
Elizabeth Anderson@eliz_andersonsj 13 Jan 2022, 5 a.m.
POWERING AHEAD: Battery energy storage systems will be installed at an initial four CIT pump stations in the Riverland, including the Loveday site.
A new partnership will help irrigators along the River Murray to reduce power bills.
A NEW partnership will help irrigators along the River Murray to reduce their power bills, while also potentially providing power surety for the Riverland region.
The Central Irrigation Trust, a member-based organisation that operates in key Murray irrigation areas, has formed a partnership with Enel X for the installation of battery storage units at CIT sites.
CIT chief executive officer Greg McCarron said the Trust had been seeking ways to reduce its power bills.
"Electricity is a significant cost for us, it's about 30 per cent of our costs," he said.
"For quite a few years, we've been trying to come up with solutions to minimise our electricity costs."
Mr McCarron said they had explored a number of ideas, including renewable options and other onsite generation, but nothing suited their scale.
As part of the partnership, four initial 4.4 megawatt to 7.4MW systems - thought to be Australia's biggest commercial and industrial battery energy storage system - will be installed at the CIT sites at Berri, Loveday, Chaffey and Waikerie, with the potential for a fifth system at Loxton.
The batteries will store power bought from the grid and other sources at times of low cost, with some then resold to the grid at peak times.
Enel X will used its specially-designed distributed energy resources optimisation software to analyse data, including the site energy demand, weather forecasts, electricity grid conditions and more, to negotiate the power market.
Enel X Asia and Oceania head Jeff Renaud said the use of the battery energy storage systems would "intelligently manage" the Trust's energy use.
"Our customised, turnkey solution will help CIT optimise its energy usage and costs, allowing the sites to run more efficiently while increasing resiliency," he said.
"Our proven DER.OS platform will allow the batteries to 'value stack' across our demand response programs, including energy market arbitrage, frequency control ancillary services, and access the upcoming wholesale demand response mechanism."
Climate change impact on agriculture a national security issue: military leaders
Opinion: Floodplain harvesting a risk for Victorian irrigators
Go/Stop/Pause. Granite Belt Irrigation Project hits the mark
While it would not meet the Trust's full power demand, Mr McCarron said there would be a number of advantages in this system at peak times.
"It will help us to manage demand and work as a back up supply for us and the region," he said.
He said the strength of the partnership was there was no upfront costs for the CIT, while the ongoing management was also to be performed by Enel X.
He said this meant the technical and market decisions were being carried out by those with the right knowledge and experience, leaving the Trust and irrigators to focus on their own core responsibilities.
He said the size of the batteries to be located on site were similar to shipping containers and would sit alongside existing infrastructure.
The partnership has an initial 15-year contract, with the first of the systems to be installed within the first half of 2022.
Sign up here to Good Fruit and Vegetables weekly newsletter for all the latest horticulture news each Thursday...
The story Battery plan to help Riverland irrigators first appeared on Stock Journal.


Charge shot game for android description: Take part in a galaxy tournament of bounty hunters.
Apply a powerful blaster jet pack and other unique outfit in arena battles.
Thousands of professional daredevils from all over the galaxy fight for the main prize in this android game.
Join them and try to earn millions of galaxy credits.
Move your character across space arenas.
Apply a jet engine bounce walls and obstacles push the firing trigger of a powerful cannon crush enemies use energy shield for defense.
Join with your friends in the best and latest action rpg multiplayer online battle arena heroes charge! Collect and train your heroes gather your teammates..
It s morphin time! Charge it up with the ultimate digital companion for power rangers dino charge! Download now to morph scan your dino chargers and much m..
Help a kind octopus save cute creatures from falling into water. Move your tentacles to close gaps on tracks. The hero of this game for android shouldered ..
Forget about your usual worlds where you need to save the main hero. Here you need to find a way to die to get further. Solve a lot of puzzles on each leve..
Guide a cute dog through colorful worlds. Collect tasty bones on your way jump onto platforms and avoid different enemies. Help lost puppies find a way hom..
Guide the hero through winding levels with different obstacles and cunning traps. Find a safe way to the finish. Use your logic and wits to guide the hero ..


Jaime Levy is an author, university professor and a pioneer in the creation of innovative digital products and services. Her top-selling O'Reilly Media book is called UX Strategy : How to Devise Innovative Digital Products that People Want. The book presents a solid framework on the practice, which lies at the intersection of UX design and business strategy. She currently runs Jaime Levy Consulting , a strategy firm out of Los Angeles, California. Jaime also teaches graduate-level courses on UX design and UX strategy at the University of Southern California . You can read more about her on Wikipedia.
User experience (UX) strategy lies at the intersection of UX design and business strategy. It is a process that should be started first, before the design or development of a product begins. It relies on empirical, lightweight tactics for pushing cross-functional teams toward a unique digital solution that customers want. Today, a UX differentiation is the digital-product game changer. Differentiated user experiences have completely revolutionized the way we shop, travel, communicate and experience our day-to-day life.
When building a digital product you need to learn as much as you can about the competition. That's why conducting market research and analysis is a crucial component of business strategy. You want to know what's out there, what's worked, and what hasn't. This requires firsthand knowledge of the good and bad user experiences and business models provided by your competitors. If done thoroughly, the research can provide a treasure trove of insight into current trends and outdated manifestations of mental models. Take this workshop to experience a deep dive into the subject matter with both lectures and hands-on exercises. We'll practice with a made-up value proposition of an online product so that you can learn the steps you need to take for informing strategic UX-centric decision-making. It is highly suggested that you bring a laptop to the workshop or be okay with sharing one with another participant.
Why by doing thorough competitive research and analysis on the online marketplace, you can ascertain new opportunities for leveraging killer UX design and innovative business models for your product, platform, or service.
UX strategy is the intersection of UX design and business strategy. It's a series of techniques that help product makers and stakeholders to derisk their product vision before it is released into the marketplace. But what of you aren't working for some hip tech company but instead at a traditional enterprise with legacy systems, outdated processes and a siloed corporate structure? Using a healthcare industry business case, Jaime will walk us through how she applied digital transformation strategy to drive innovative software development and an organizational culture shift to support it.


text:
package beam

import (
	"github.com/apache/beam/sdks/v2/go/pkg/beam/core/graph"
	"github.com/apache/beam/sdks/v2/go/pkg/beam/internal/errors"
)

// Flatten is a PTransform that takes either multiple PCollections of type 'A'
// and returns a single PCollection of type 'A' containing all the elements in
// all the input PCollections. The name "Flatten" suggests taking a list of lists
// and flattening them into a single list.
//
// By default, the Coder of the output PCollection is the same as the Coder
// of the first PCollection.
func Flatten(s Scope, cols ...PCollection) PCollection {
	return Must(TryFlatten(s, cols...))
}

// TryFlatten merges incoming PCollections of type 'A' to a single PCollection
// of type 'A'. Returns an error indicating the set of PCollections that could
// not be flattened.
func TryFlatten(s Scope, cols ...PCollection) (PCollection, error) {
	if !s.IsValid() {
		return PCollection{}, errors.New("invalid scope")
	}
	for i, in := range cols {
		if !in.IsValid() {
			return PCollection{}, errors.Errorf("invalid pcollection to flatten: index %v", i)
		}
	}
	if len(cols) == 0 {
		return PCollection{}, errors.New("no input pcollections")
	}
	if len(cols) == 1 {
		return cols[0], nil // no-op
	}

	var in []*graph.Node
	for _, s := range cols {
		in = append(in, s.n)
	}
	edge, err := graph.NewFlatten(s.real, s.scope, in)
	if err != nil {
		return PCollection{}, err
	}
	ret := PCollection{edge.Output[0].To}
	ret.SetCoder(cols[0].Coder())
	return ret, nil
}


text:
The Mandarin Tree
Art & Concept store
Beehive Art
1034 Gordonton road
RD 1 Gordonton, 3281
art@themandarintree.nz
© 2016 by Claudia Aalderink
The Tea Cup Project
Claudia started exploring environmental artworks and sculptures and the use of recycled material through her BMA study at Wintec. This resulted in "Cornucopia", a well-received installation at the city campus based on consumerism and the 'throw-away society' we live in. Afterwards she was left with all this material and her tutor encouraged her to send a proposal to the Hamilton Gardens for a possible work, hoping it could be placed as a feature. The Hamilton Gardens Arts Festival commissioned Claudia to create this work. Over a period of three months Claudia worked on constructing a large cup, saucer and spoon by weaving corokia hedge clippings around a steel construction. The installation was inspired by Alice in Wonderland's Mad Hatter Tea Party and the feedback has been great. "The large scale of the work makes you feel like a child again" and Claudia says "that is what I love about creating art and especially on a larger scale; the amazement on people's faces is priceless".


The students will be able to practice basic hygiene routines.
The students will be able to identify medicine and know that it is used to stay healthy.
The students will be able to discuss how people stay healthy and fundamental actives for good health.
The students will be able to identify and locate body parts and identify specific practices that support body development and function.
The students will be able to identify and follow basic safety rules, how people keep us safe, and consequences of unsafe behaviors.
The students will be able to name healthy foods and classify foods by their food group.
The students will be able to combine large motor movements with the use of equipment, and demonstrate coordination of body and movement.
The students will be able to demonstrate balance while moving on large motor equipment.
The students will be able to use hands, fingers, and wrists to manipulate objects and practice manual self help skills.
The students will be able to coordinate eye and hand movements to perform a task.
The students will be able to use writing and drawing implements with correct grip to make pictures and use classroom/household tools to accomplish a purpose.


text:
Pennsylvania Travel Teams
PA State Games
Jr. PA State Games
Malvern Prep (HS) • PA
Travel Team: All Star Baseball Academy
@Chris_Newell20
PA 2019
100EXIT
92OF
PBR DRAFT
2019 DRAFT • Cardinals • ROUND 37
2022 DRAFT • Dodgers • ROUND 13
I am Chris Newell and would like to link this profile to my PBR account:
College Crosscheck: Week Two LSU, Virginia, Campbell & more - Mar 2, 2022
2019 Newcomer Breakdowns: Classes 6-10 - Dec 23, 2019
Malvern Prep's Chris Newell Named PBR Pennsylvania Player of the Year - Jun 17, 2019
Prep Baseball Report Announces State Player Of The Year Awards - Jun 17, 2019
Pennsylvania Draft Recap: Rounds 11-30 - Jun 6, 2019
Pennsylvania Draft Preview - May 23, 2019
High School Crosscheck: Week 13 - May 13, 2019
Four Hits For Newell, Two For Siani - May 12, 2019
Dean Working Back; Senior Day For Newell - May 9, 2019
Game of the Day (April 18, 2019) - Apr 19, 2019
2019 Early Draft Preview - Feb 11, 2019
2019 Spring Team Preview: Malvern Prep Friars - Jan 14, 2019
Jupiter: Day 1 Notebook - Oct 19, 2018
2018 Area Code Games: Friday Notebook - Aug 11, 2018
2018 Area Code Games: Tuesday Notebook - Aug 8, 2018
2018 Area Code Games: Monday Notebook - Aug 7, 2018
2018 East Coast Pro Showcase: Day 1 Notebook - Aug 2, 2018
Under Armour All-America Game Notebook - Jul 22, 2018
Scouting Notes: Episcopal Academy at Malvern Prep - Apr 11, 2018
Fall 2017 Rankings Update: Class of 2019 - Nov 8, 2017
Field Set For 2017 NHSI - Jan 5, 2017
2019 Rankings Update: Top 10 in 2019 (#1-5) - Nov 19, 2016
A top-ranked prep, Newell turned down significant professional interest as a high school senior and instead headed to Charlottesville. After an excellent freshman season in 2020 that was shortened to just 18 games due to covid, he earned honors by D1Baseball.com as the ACC's Top Freshman, batting .407 with five doubles, a triple, four home runs and 20 RBI. The lanky, athletic-bodied center fielder showed near average arm strength in pre-game and it typically plays there in the game as well, but during game action on this look his arm played below average as he three-hopped a throw to home plate from short center field after fielding a base hit. As a plus runner Newell covers a lot of ground in the big field and does it in all directions. At the plate his long swing needs some cleanup to realize his hitting potential. His strength and length give him better than average raw power, especially to center and left center. His pull side power is limited due to top spin as the ball does not carry much. The left handed bat has a ton of ability and skill, he simply needs to get to it with greater consistency in games. More speed than instincts he's an occasional base stealer who takes more safe than aggressive leads. Once considered a potential top round pick, Newell is no longer currently viewed by the industry as such, much due to his 33/100 career BB/K ratio, as well as a 31% strikeout rate over his three collegiate seasons.
Newell's tantalizing power/speed combination and standout production during the four-week 2020 season made him a first-team preseason All-American heading into 2021, but that forecast proved premature, as he struggled to make consistent contact for much of the spring, having particular difficulty with breaking stuff. He persevered and found his footing down the stretch, playing very well in the postseason, even leading all CWS hitters in batting after going 6-for-10 with two homers and five RBIs in Omaha. Newell has continued to put up strong numbers in the Cape despite a poor K-BB mark (17-2 in 55 at-bats); he's hitting .291/.328/.582 with four home runs, two doubles, one triple and 11 RBIs. We were on hand for his best game at Hyannis, when he hit both an RBI triple and a two-run double in the first inning alone, then added a single in the sixth. Physical and athletic at 6-foot-3, 205 pounds, Newell has a wide base and a short stride with some length in his lefthanded swing, and he can hit the ball a mile when he connects — as he did on a moonshot to right-center on July 12 at Chatham, crushing a fastball. He still gets fooled by breaking balls at times, but we've seen him make adjustments and handle them better than he did for much of the spring. He has a pull-side approach and can get caught hooking the ball. Newell is at least a solid-average runner up the line, and he can make up for misreads in center field with excellent closing speed. He also has a solid-average or slightly better arm in center. If his plate discipline continues to improve, Newell offers rare five-tool potential for the 2022 draft.
A Virginia recruit, Newell looks like a big leaguer as soon as he takes the field thanks to his strong, athletic frame with broad shoulders at about 6-foot-3, 200 pounds. Newell sets up with a wide base and his weight shifted slightly to his back leg. He gets barrel in his load and takes a short stride before exploding toward the pitch. He has a pull approach. Leading off for the Friars, he dropped down a bunt on the first pitch and beat it out, getting down the line in about 3.7 seconds. He stole second base with relative ease, but was caught trying to swipe third. In his next at-bat, he jumped on the first pitch, yanking a double to right field. He eventually scored on a wild pitch. In his final two at-bats, Newell flew out to left field and grounded out to first base. Was very aggressive Wednesday, putting the ball in play on the first pitch in every at-bat.
OF, has a plus frame at 6-foot-3, 190 pounds. In his first at-bat, he hammered an RBI triple to right-center field off a 90 mph fastball. His exit velocity was 100.
8.6.18 Area Code Games
Left-handed hitter has a plus frame, standing at a projectable 6-foot-3, 190 pounds with lean strength. He was pull oriented in BP and showed a slight arm bar, but has torque in his swing that produced above-average raw power.
6/15/18 Put together impressive offensive numbers during his junior season. Hit .394 with six doubles, seven triples and five home runs while driving in 26 and scoring 43 times. Big power potential from the left side of the plate with above average foot speed.
4/10/18 Newell reached base twice on infield errors on the right side of the infield, beating out play to the base and showcasing some of the impressive speed that makes him an exciting outfield prospect. He served as the DH, so there wasn't a chance to see him showcase his defensive skills. However, he posted home-to-first times at 4.04 and 4.08, and just missed a fastball in his final at bat, flying out to center field (in air for 6.09 seconds). Despite not being at his best, it is still clear why he's such a highly touted prospect.
6/4/17 Long, lanky and loose frame. Ball comes out well on the bump. Quick arm. 3/4 slot. FB has life. 84-90. Really mostly 87. 70 CB. 80 CH.
4/21/17 Left-handed hitting Virginia commit battled a senior UNC-bound RHP (whose fastball touched 94 mph) on his way to two infield singles. Can really, really run, getting down the line with home-to-1B times of 3.94, 4.03, and 4.09. Lean, athletic build with plenty of arm strength from the outfield.
Tweets by pbrpennsylvania


Numerous surgical and nonsurgical approaches to the management of lumbar radiculopathy have been studied and are routinely used within current clinical practice. In addition to standard surgical techniques (e.g., laminectomy, discectomy), minimally invasive surgical techniques that use percutaneous, endoscopic, or laser-assisted approaches are now available. This health technology assessment (HTA) will review the efficacy, safety, and cost-effectiveness of surgical interventions to treat symptomatic lumbar radiculopathy in adults to assist the State of Washington's Health Technology Clinical Committee in determining coverage for selected surgical interventions.


Abstract: The overall current of impact of climate change on public health, its general awareness and mapping of national policy is widely recognized. Nevertheless, some fundamental aspects have also remained underappreciated such as the impact of climatic change on plant biology, impacts of well-being of human in the ecosystem and knowledge-education in exploring the links to pharmacology. Therefore, we aim to address some of these issues linked, particularly feasible links between plant function and human health and present a list of key questions that may help to integrate plant biology into the current paradigm on climate change and human health in the pharmacology. Here, we provide a number of critical examples that range over various health concerns related to plant biology and climate change and focus of their inter-linkage of toxicology, aerobiology, contact dermatitis and pharmacology in exploring the system knowledge in plant biology. As the links among climate change, plant biology and public health that remain underappreciated by both plant scientists and health care providers; therefore, we present the degree of health risk posed by climate change and way forward to minimize adverse impacts.
Abul Quasem Al-Amin, Gazi Mahabubul Alam and Abdul Jalil Othman, 2011. The Impacts of Climate Change on Public Health: Exploring the Link to Pharmacological Knowledge and Education. International Journal of Pharmacology, 7: 765-772.


Still working in acrylics and becoming more and more comfortable with it. I still will probably always consider oils my first love, but acrylics have some great advantages and it's a good thing to become more accustomed to working with them!
This grey kitty looks regal and at the same time, royally ticked off. So, I thought the title fit him. (I assume this kitty is a him!) The blue cast to the greys, with more warm greys throughout the shadows, made for an interesting color exercise.


Avon Tyres have released a new sport touring tyre, called the Spirit ST, which replaces the British firm's Storm 3D range.
The new tyre has been designed to provide high levels of wet grip together with high performance handling on a wide range of sport-touring bikes. The Spirit ST uses the latest high-silica synthetic rubber compounds to increase the mileage of the tyre, which has been designated as a hypersport touring tyre.
The Spirit ST is built around an all-new carcass design that focuses on high performance handling and stability. The rear tyre features multi-compound tread more prolonged life, while the edges use a softer compound for improved grip.
Avon say the new tread pattern means the Spirit ST is able to move more water than ever before while maintaining its operating temperature over a wide range of conditions. You may have noticed the smaller sipes, on the tyres. Avon have given these sipes interlocking 'teeth', which they say eliminates the vague 'squirming' feeling felt on some older tyres and helps the tyres warm up fast.
For more info visit www.avon-tyres.co.uk.


text:
Health Care/ Winter 2014
Healing health care
Do Bob Master and Rushika Fernandopulle have the cure for what ails American medicine?
Michael Jonas	0 Comments Jan 15, 2014
Through the fall, and on into winter, health care was everywhere in the news, with one story after another about problems with various aspects of the rollout of the Affordable Care Act. The one that seemed to capture all the woes with fitting digital-age symbolism was the virtual meltdown of the Obamacare website, the main access point to the new health plans developed under the law.
Stern-faced administration officials from the president on down vowed to pull out all the stops to get the site working. The underlying message seemed to be that, despite some bumps in the road, we are on the way to getting health care right. But as serious as the problem is, fixing a faulty website is hardly the biggest health care challenge facing the country. In many ways, it is American medicine itself that is broken.
The law takes some steps to try to address that. But if you set out to design from scratch a system to deliver compassionate, high-quality health care and do so in as cost-effective manner as possible, you would probably change nearly everything about American health care.
Bob Master and Rushika Fernandopulle are trying to do just that. They do not preside over any massive health care bureaucracy or powerful government office, but that is not where big health care change will come from.
The two Boston physicians are trying to remake health care from the ground up. They have each developed innovative primary care practices that try to deliver good care not by battling through nonsensical reimbursement rules and all the maddening limitations of our current system, but by clearing those obstacles out of the way and making patients and their needs the central focus of the organization and delivery of health care.
Master has been able to cut in half the days elderly patients with multiple health problems spend in the hospital. That might be because he sends nurses on house calls to check on patients, or provides home aides who make sure they are taking medicines on schedule. Or it might even be because he will use health care dollars to get patients a ride to church each week. With social isolation among the elderly a common trigger for depression, which can often start a downward spiral of serious health problems, a $10 transportation charge might be the most powerful — and cost-effective — preventive medicine available.
Fernandopulle's primary care teams, meanwhile, gather in a "huddle" each morning to share information and strategy on patients being seen that day as well as on those who aren't but whose health they are keeping tabs on. They might hop on Skype to chat with a patient, or even to follow-up on a recent visit and see how well a rash is clearing. Avoiding unneeded office visits can free up time for doctor visits or regular sessions with a "health coach," a key part of his plan. Those visits might lead to a breakthrough that gets a patient ready to finally deal with a decades-long weight problem.
'The sicker one is, the less our system meets your needs and the more you're on your own.' In some earlier versions of the model, Fernandopulle was able to decrease overall health care costs by 10 to 15 percent by giving patients more primary care attention.
The two doctors have zeroed in on something that is counterintuitive in the era of MRI imaging, laser-guided surgery, and pharmaceutical answers to every woe: The thing most needed in US health care is not more treatments or more money, but greater connection between patients and health care providers. That can improve our system's success at keeping people from needing all those high-cost treatments, which are regarded as shining successes of modern medicine but just as often represent its failure.
We now spend $2.6 trillion every year on health care, nearly 18 percent of the nation's gross domestic product, a share that is more than 50 percent higher than any other country. Warren Buffett calls rising health care costs the "tapeworm" of the US economy, eating away from the inside at the productivity and competitiveness of US business, while straining public budgets.
"In the beginning there was Bob Master."
What do we get for our orgy of health care spending? Since 1960, the US has dropped from 12th to 46th in infant mortality, and from 16th to 36th in life expectancy. We're literally bursting at the seams with soaring obesity rates, setting Americans up for all the chronic disease complications that follow. When they do, our system falters badly. In the case of high blood pressure, one of the most common serious diagnoses in advanced countries—and one that is almost entirely controllable through good treatment — it is well-managed in only 44 percent of Americans who suffer from the condition.
"We continue to spend considerably more on health care than our counterparts in Europe, and what's shocking and upsetting is that outcomes are often worse," says Melinda Abrams of the Commonwealth Fund, a New York-based health policy foundation.
Spiraling costs and subpart outcomes are, in many ways, the logical results of a system that delivers disorganized and fragmented care, with patients bouncing from specialist to specialist, highly-trained doctors who tend to zero in on the malady or body part that is their expertise while ignoring the fuller picture that forms a patient's complete health profile. Meanwhile, the fuel driving the system is a misaligned health care financing structure that reimburses doctors and hospitals for each visit or procedure. In so doing, it encourages that fragmented system of care as well as over-treatment with unnecessary procedures and tests. Rather than providing incentives to help patients stay healthy, it rewards failures of care that result in return visits to doctors or readmission to the hospital.
For more than a decade, the manifesto detailing what ails the US health care system has been a 2001 report from the Institute of Medicine. "Between the health care we have and the care we could have lies not just a gap, but a chasm," it said.
Fernandopulle: An innovator with a sense of urgency.
That seems like an awfully grim assessment of a health care system that continues to lead the world in the development of cutting-edge treatments and miracle drugs. But there is a fundamental paradox in US medicine, one that lies at the heart of the problem that Bob Master and Rushika Fernandopulle are trying to untangle.
"A lot of people say we have the best health care system in the world, which in some ways we do," says Fernandopulle. "If all of a sudden you were diagnosed with a rare cancer or needed a very high-tech procedure or drug, this would, by all means, be the place you would want to come. Unfortunately, that's not the problem. The problem is the millions and millions of people who've got very common conditions—diabetes, hypertension, heart disease, etcetera —which we don't treat well at all, and not because we don't have the tools to treat them. It's that our systems are not designed to actually fix the problem."
As John McDonough, a Harvard School of Public Health policy expert, puts it: "What to do is not the puzzle. How to get there is the puzzle."
Master and Fernandopulle may be putting together the pieces.
MASTER OF PRIMARY CARE
If our health care system does a poor job at treating common conditions, it does an even poorer job at that for those with multiple serious diagnoses. These, of course, are the patients for whom quality, well-coordinated care could make the biggest difference.
When considering health care costs, policy experts often cite the "80/20" rule, which refers to the fact that roughly 20 percent of any population will account for 80 percent of its total health care spending. Bob Master has spent his career focused on that 20 percent. During his medical training, the observation that our health care system performs worst among those who need its help the most convinced Master that there must be a better way to organize care.
"The sicker one is, the more socially and medically complicated one is, the less our current system of care meets their needs and the more such individuals are on their own," says Master. He says such patients are left feeling like "an anonymous piece of baggage" being shuttled through an impersonal system of medical encounters.
Master has a warm, down-to-earth manner. Favoring sweaters over suits, he seems like the doctor who might have emerged if Mr. Rogers had gone to medical school. People in health care circles talk about Master in reverential, sometimes even biblical, terms when describing efforts to improve primary care in the US medical system.
"In the beginning there was Bob Master," says Robert Restuccia, executive director of Community Catalyst, a national health care advocacy organization based in Boston that works closely with Master.
McDonough, the Harvard health policy professor, calls Master "probably the most important person in primary care in the United States today."
For decades, Master has toiled as a largely unsung hero of American health care, devising better ways to care for the some of the poorest and most needy patients in the country. That is beginning to change, as the health care world wakes up to how potent his low-tech, patient-focused model could be.
Master, the grandson of Russian Jewish immigrants, was born in Roxbury and raised in a working-class household in Lawrence. Early on, Master says he saw how the fragmented way care was delivered, the fee-for-service payment system, and lack of attention to the social factors that can affect a patient's health all "subverted the goals of so many of us who became clinicians or physicians." He says it became clear that what patients needed was an "interdisciplinary care team," which included doctors and nurses as well as non-medical members, who could work together to coordinate care and help guide patients through the often dizzying labyrinth of modern medicine.
"When you have that vision, it's kind of a North Star" for how to proceed, he says. "A lot of the way I was trained had to be unlearned."
Master was involved in several innovative practices that honed this approach, starting with a Jamaica Plain clinic in the late 1970s called Urban Medical Group. One of the most frustrating aspects of the work was trying to care for patients who were covered by both the federal Medicare program and the state-based Medicaid program for the poor. Taking care of these patients, usually poor and elderly, meant navigating through huge government programs, each with its own set of complicated reimbursement rules and sometimes conflicting regulations.
A decade ago, Master helped found the Commonwealth Care Alliance, one of the first programs in the country granted waivers from the federal government and state officials to develop a demonstration project to better coordinate care to those covered under both programs. It has mainly focused on seniors, but has also provided care for a few hundred younger people covered under both programs because of severe disabilities.
Now caring for more than 5,000 patients, the Boston-based organization operates from 25 different primary care sites across the state. In caring for these so-called "dual-eligible" patients, the program does not use the standard fee for service payment system, in which the government gets billed for each visit or procedure. Instead, it gets a single "global payment" to cover all of a patient's health care needs, a figure that is adjusted by the government programs based on the patient's health profile. Meanwhile, the Alliance is given wide latitude to organize patient care and use the payments as it sees fit, without following the extensive rules governing Medicare and Medicaid expenditures.
That means giving patients access by phone to a clinician at all hours, and sending nurse practitioners to make house calls. It might even mean buying an air conditioner for someone with severe respiratory disease, something that would never be covered under standard Medicare and Medicaid rules, but might do far more to improve or maintain their health than any expensive drug or hospital procedure.
Harvard Business School professor Michael Porter calls the work Master is doing 'a national model.' The program will even pay for a patient's transportation to church or other community activities. It's not our usual idea of medicine, but Master and other health care innovators say it should be. We should be treating the whole person, not a discrete diagnosis, they say. For some elderly patients, isolation can be the gateway to declining health.
"You're cut off from the very things that make life worth living, and when life isn't worth living, people check out," says Master.
For Raymond Burcham, the things that make life worth living include Daisy, his frisky Welsh Corgi mix, and an ability to live independently in his modest Chelsea apartment. A cheerful 80-year-old who holds forth from a favorite recliner in his living room, Burcham is good- natured but not in great health. He suffers from diabetes, high blood pressure, and heart failure, and has severe back pain that can be limiting. His daily schedule includes 11 different medications.
For all of that, Burcham is more full of playful one-liners than complaints when Nida Lam, a nurse practitioner with the Commonwealth Care Alliance, comes to see him one afternoon in early December.
"How are you doing with your medications?" she asks.
"My blood sugar is continuing to run a little high," says Burcham, a widower.
He and Lam go over his blood sugar readings. He measures it several times a day on a device that records the levels so that Lam can review two weeks' of readings. Lam sees that at one blood sugar check he was hypoglycemic, with a dangerously low blood-sugar level.
"Were you feeling lightheaded?" Lam asks about the episode, which can result in fainting.
"No, I just called out, 'Charlene, I need something to eat.' That's the advantage of having her in the house," he says.
Charlene is Charlene Roberts, a friend of Burcham's who shares his apartment. Under the flexible approach of the program, she is paid for 21 hours of work as a "personal care assistant," making meals, driving him to appointments and, importantly, helping oversee his pharmacy-sized complement of medicines, including the insulin that must be drawn up into syringes and injected twice a day.
Lam adjusts Burcham's insulin dose, something she carefully goes over with him and Roberts, who jots down notes.
Asked how he would make do without Roberts, Burcham says, "It'd be tough, it'd be very tough. I wouldn't be on schedule. I'd probably forget to take my morning this or my evening that—these zillions of pills I take. I like this situation," he says. "I'm more independent here than I would be any other way."
Care for elderly patients like Burcham does not come cheap. Commonwealth Care Alliance typically receives $1,000 to $5,000 a month from Medicare and Medicaid to care for patients. Three-quarters of them, a group that includes Burcham, are considered "nursing home certified," meaning they are compromised enough that Medicaid would cover full-time nursing home care.
Raymond Burcham and Daisy. The coordinated care he gets has helped him remain in his Chelsea apartment. "I like this situation," he says.
That's why the sort of wrap-around care the program provides potentially could be such a benefit not only to patients and their quality of life, but to the budgets of government programs.
An analysis from 2008 showed that Commonwealth Care Alliance patients were hospitalized for about half the number of days as a comparable population of patients getting typical care in a fee-for-service structure. For the much smaller population with severe disabilities, the average monthly medical costs were $3,061 compared with $5,210 for similar fee-for-service patients in the Medicaid program.
A 2012 policy brief from the Kaiser Family Foundation examined nine studies of programs serving dual-eligible patients, including the Commonwealth Care Alliance. It concluded that there is no clear overall evidence yet of net cost savings from such efforts and cautioned that large savings may be difficult to achieve.
Harvard Business School professor Michael Porter has trained his sights on health care in recent years, and on what he calls "value-based" medical care. It's a way of looking at health care that considers the quality of that care and patient outcomes as well as cost. He calls the work Master is doing among extremely high-cost patients "a national model."
Health care policy is finally taking note of that. The Affordable Care Act established an office specifically assigned to the task of better coordinating care for patients on both Medicare and Medicaid. Under a new demonstration project this office is running in 15 states, tens of thousands of "dual eligible" patients are being enrolled into practices that follow versions of the Commonwealth Care Alliance model of care. The CCA itself is dramatically expanding under the new initiative, enrolling thousands of low-income patients 21 to 64 years old who have pronounced health care needs, including physical disabilities as well as serious mental health diagnoses. The Commonwealth Care Alliance's new "One Care" program for these patients was the first of these new demonstration projects in the country to get underway, and more than 3,000 patients have enrolled since its launch in October. The Alliance could have as many as 20,000 patients enrolled over the next one to two years, which would push its $300 million budget to an astounding $1 billion.
Medicare spending reached $592 billion last year and is projected to hit $1.1 trillion by 2023. There are about 9 million Americans eligible for both Medicare and Medicaid. They account for 21 percent of Medicare enrollees but 31 percent of its costs. They represent 15 percent of Medicaid enrollment but 39 percent of its outlays. Just as outlaw Willie Sutton said he robbed banks because it's where the money was kept, caring for these patients is where the most intensive government health care spending occurs, making it easy to see how even modest savings could multiply into a lot of money.
What happens with the 15-state project "will be very significant," says Restuccia, director of the Community Catalyst advocacy group. "The whole country will be looking at this."
Master's patients are the canaries in the health care coal mine. The shortcomings of the siloed care that US patients get show up first in these high-need patients, who easily fall through the cracks and end up with an avoidable hospital stay, or worse. They are also the patients for whom a dramatically restructured primary care model like the Commonwealth Care Alliance can make a clear difference.
Jerome Foureau getting a blood pressure check at Iora Health's
Carpenters Care clinic in Dorchester.
Rushika Fernandopulle has set out on an even bigger challenge: to remake health care in a way that delivers better care at lower cost not only to the sickest patients, but to everyone.
The 46-year-old Harvard-trained doctor still serves rotations at Massachusetts General Hospital, where he did his residency training in primary care. "You walk around the wards and you say, 'What percentage of these patients in the hospital might not have been here if they actually had better primary care?'" he asks. You can ask the same question in the emergency room, he says. "The answer is probably 40 percent to both those questions," says Fernandopulle.
He says those patients represent the failures of primary care, the results of a health care system that's doing a miserable job at keeping people healthy and staving off avoidable—and much higher cost—types of treatment. That convinced Fernandopulle that fixing health care means fixing primary care, and that anything that just tinkered around the edges wasn't enough.
"What everyone else is doing is making incremental changes to the system," he says. "They're taking the existing model and tweaking it, but we know health care is fundamentally broken. Maybe we should just start over. Maybe what we need is a new entrant who can just break the rules."
Fernandopulle talks about the failures of US health care with a take-no-prisoners urgency, and he shows little restraint in dismissing reform efforts he regards as token moves unlikely to yield meaningful change.
Three years ago, convinced the only way to help drive transformation of the system was by demonstrating it himself, Fernandopulle founded Iora Health, a for-profit company that now operates four primary care practices, including one in Boston that opened last year. Fernandopulle has drawn $20 million in venture capital from investors betting Iora's rule-breaking model of primary care might be the right medicine for what ails US health care.
The premise is straightforward, and has similarities to Bob Master's work. Fernandopulle says just 5 percent of US health care spending goes to primary care, while we spend 95 percent on everything else, including that big chunk he sees regularly at Mass. General that he says represents primary care's failures. Iora asks the sponsoring employer groups or unions it works with to roughly double the outlay for primary care—from about $25 to $30 per month to $50 to $60. In return, lora promises a much more comprehensive model of care—and aims to show that it can more than make up for that added primary care premium through savings of "downstream" costs.
Born in Sri Lanka, Fernandopulle came to the US with his family at age 2½. By his third year at Harvard Medical School, when students began spending a lot of time on hospital wards, "it was pretty clear how screwed up the health care system was," he says. "We design drugs and procedures, but we let how we deliver it all to patients just happen." He studied public policy at Harvard's Kennedy School, which helped him realize that he not only wanted to care for patients, but wanted to help transform the entire system.
He directed something called the Harvard Interfaculty Program for Health System Improvement, meeting with policy big wigs at the university, but also traveling to scout out ideas. He and a partner opened a primary care practice in Arlington that set out to implement many of the same principles his company is now applying. "We got some opposition from the powers that be around here. We were accused of raising expectations and making other practices look bad and upsetting the status quo," he says. "Of course we would plead guilty to all of the above." He says one insurer stopped contracting with them, and it proved difficult to sustain the model under fee-for-service payments, since the practice encouraged patients to do things like email simple questions rather than come in for an appointment, the sort of innovation that makes tremendous sense, but can't be billed for under conventional insurance rules.
Fernandopulle then helped develop primary care models for two big employers and a union group—Boeing in Seattle, a major Atlantic City hospital in New Jersey, and the union for workers in that city's casinos. "Give us this extra money for primary care," he told them, "and then we'll save money on the back end, and they can see the data."
Drug spending went up "because people were actually taking their medicines," he says. But emergency room visits fell—by nearly half in the Atlantic City practices. Hospitalizations there were down 41 percent, and overall net spending decreased about 15 percent.
The Seattle and Atlantic City projects restricted enrollment to workers with preexisting, serious health problems. In that way, they resemble the focus of the Commonwealth Care Alliance on high-need patients.
Iora has enrolled about 5,500 patients in its four practices: one set up with casino workers in Las Vegas, another for employees at Dartmouth College, a third through a Brooklyn organization for freelance workers, and a fourth with the Dorchester-based New England Carpenters Union. The Las Vegas practice is restricted to higher-need workers, but the other three are open to all.
The practices get a fixed global payment to provide primary care. They don't charge any copays—"why do we want to discourage people from getting care?" asks Fernandopulle, one of his many jibes at mainstream US health care. The teams that care for patients include a doctor and nurse, but the backbone of the practices are health coaches—four for every one physician—who are able to devote a lot of time to getting to know patients and helping them craft health plans and then follow them.
'Everyone else is making incremental change, but we know health care is fundamentally broken.' The use of health care coaches, some with backgrounds in health fields but others with none, borrows heavily from an approach used in poor countries, where health care professionals are scarce. Well-known Harvard doctor Paul Farmer has used the model in Haiti, and Fernandopulle spent time in the Dominican Republic during medical school, where he saw its impact first-hand.
"This is all about engaging patients," he says. "You need doctors to make the medical decisions, come up with the right diagnosis and the right treatments. But that isn't the hard part. The hard part is figuring out how that treatment gets played out in the patient's life."
"We can spend that extra time, develop that relationship, which gives the freedom to patients to speak more to what's going on their lives," says Mike Jeudy, a health coach at the Carpenters Union clinic in Dorchester.
That's the sort of relationship Jeudy has formed with Jerome Foureau, a millwright who starting getting his care last summer at Iora's Carpenter Care practice. He was overweight and suffering from high blood pressure that led the team to put him on medication. But he's been working steadily with Jeudy, a former wellness director at a New Hampshire YMCA, and has lost 32 pounds since August. "Mike helped me out a lot—with exercise and what to eat," says Foureau, who says he's cut out red meat, among other changes. His blood pressure is still high enough to keep him on medicine, but it's heading down.
Jeudy knows a lot about diet and exercise, but it's connecting and developing a rapport with patients that's at the heart of the model.
"Before, I didn't go to the doctor much," says the 50-year-old Foureau. "Now, I feel like I'm going to see my friends. I'm not joking."
So far, just 200 union members have joined the start-up practice, the most recent of the Iora offices to open. "Anecdotally, the level of satisfaction is sky high," says Mark Erlich, head of the New England Carpenters Union and a member of the board of MassINC, the publisher of CommonWealth. It's harder to know what will happen with health care costs, the main motivation for the union. "From a common sense point of view," says Erlich, "it's just a much smarter way of delivering quality medical care that, in my view, has a much stronger likelihood of containing costs in a way that the standard medical care delivery system does not."
Health care experts, however, say Fernandopulle faces a tricky challenge.
"It's really hard to save money on people who are healthy," says Dr. Elliott Fisher, director of the Dartmouth Institute for Health Policy and Clinical Practice. "Rushika's problem is there are a lot of people who have bad health behaviors who are not sick but who will be sick. Someone who's smoking and is way overweight and has high blood pressure may not have obvious heart disease now or peripheral vascular disease. But it's coming. It will have a different time horizon and different pay off," he says of what Fernandopulle is doing.
Dr. Arnold Milstein, a Stanford health policy professor, worked with Fernandopulle on the projects in Seattle and Atlantic City. "Iora is a completely different kettle of fish that focuses on a much harder problem," he says of the effort to provide more primary care and reduce spending in a more mainstream population. "The evidence to show that it can be done is much less well established."
Fernandopulle says there may indeed be a longer payoff, though he says preliminary data from the site treating Dartmouth College employees is already encouraging. "It's starting to seem like we may even be saving money after a year," he says, citing a 30 to 40 percent reduction in the costs for medical specialists.
But he says there is also a moral dimension to the effort to transform primary care for everyone, not just the highest-need patients. "To say, 'Sorry, you're not sick enough. Go back to your usual crappy care and when you get really sick we'll take care of you,' is not the answer," he says. "That's the system we're trying to fix."
ENVELOPE PUSHERS
For nearly four decades Bob Master has worked at what often seemed to be the margins of US health care, trying to call attention to the value of a more integrated, patient-focused form of primary care. "For a long time, we all felt like the little match girl outside the party. We were out there in the community and there is a big party of big hospitals and specialists and technology inside," he says. "That was the happening thing, and you're scratching on the window and saying, 'what about us?'"
Master and others who have been doing similar work are suddenly being invited to the dance. There is growing recognition that the party of big hospitals and specialists and technology has not brought us to a health-care promised land. The tools they offer can be lifesaving when appropriately deployed. But putting these features at the center of a system with little coordination, one that is awash in vested interests rewarded by greater utilization of high-cost health care, has not served patients well and has put the country on an unsustainable course.
While headlines about the Affordable Care Act have focused on the faulty website and health plans people had that aren't deemed adequate by the law, the reform also contains a lot of provisions designed to move US health care closer to the sort of model Master and Fernandopulle are putting into practice.
Along with the 15-state demonstration project that the Commonwealth Care Alliance is part of, the law has also created a pilot program to test caring for Medicare patients through "accountable care organizations." These are affiliated groups of doctors and hospitals that agree to care for a set of patients using global payments to try to save money, while being evaluated according to a set of quality criteria designed to ensure they are not doing so by scrimping on needed care. Massachusetts is home to five of the 32 so-called Pioneer ACOs the government approved, and four of the Bay State pilots have shown promising initial cost-savings results. Meanwhile, Blue Cross Blue Shield of Massachusetts has also taken a leadership role nationally in moving away from fee for service coverage through a program similar to ACOs called an "alternative quality contract." A total of 640,000 Blue Cross members in the state are now covered under these contracts. The first two years of results show a slowing of spending growth and improved quality of care.
Overall, the Affordable Care Act is already being credited with driving the biggest slowdown in US health care spending on record.
Master says the sorts of changes being brought by the law and other pressure being put on the system "would have been unthinkable in the past. So you put all this together and you have all the elements for real transformation," he says. "We finally think the winds may be with us rather than in our face."
Fernandopulle, whose passion for "bringing the humanity back to health care" is matched by an impatience with getting there, doesn't think the law goes nearly far enough in bringing needed changes in how care is delivered. "Giving all these people access to a system which is wasteful and achieves poor outcomes is setting the house on fire, because it's not clear where this money is going to come from," he says of the expansion of insurance coverage under the Affordable Care Act. "There's an awful lot of smoke and mirrors and noise going on, and it's not entirely clear that a lot of actual care is changing for actual patients."
"I completely agree with Rushika that stronger medicine was indicated," says Milstein, the Stanford professor. "But I don't think it was politically realistic to think it actually could have been done. There are very powerful lobbying forces that push for the status quo. You have to go for the strongest medicine that current politics will allow."
That means Master and Fernandopulle will, at least for now, continue to serve as the shock troops in the effort to transform US health care, trying to disrupt the status quo and challenge the system by showing what's possible.
Michael Jonas
Executive Editor, CommonWealth
E-mail @bostonjonas
About Michael Jonas
Michael Jonas has worked in journalism in Massachusetts since the early 1980s. Before joining the CommonWealth staff in early 2001, he was a contributing writer for the magazine for two years. His cover story in CommonWealth's Fall 1999 issue on Boston youth outreach workers was selected for a PASS (Prevention for a Safer Society) Award from the National Council on Crime and Delinquency.
Michael got his start in journalism at the Dorchester Community News, a community newspaper serving Boston's largest neighborhood, where he covered a range of urban issues. Since the late 1980s, he has been a regular contributor to the Boston Globe. For 15 years he wrote a weekly column on local politics for the Boston Sunday Globe's City Weekly section.
Michael has also worked in broadcast journalism. In 1989, he was a co-producer for "The AIDS Quarterly," a national PBS series produced by WGBH-TV in Boston, and in the early 1990s, he worked as a producer for "Our Times," a weekly magazine program on WHDH-TV (Ch. 7) in Boston.
Michael lives in Dorchester with his wife and their two daughters.
Porter, the Harvard Business School professor, says change has to come from within health care, from those providing actual care to patients, but he thinks we're on the right track.
"These are the innovators," Porter says of Fernandopulle and Master. "These are the people that have a history of pushing the envelope, and in both cases they're pushing it in the right direction."
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