text:
While on the bus last night the song lyrics were "fill me up Lord, fill me up Lord", my mind kept saying "empty me out Lord, empty me out Lord". I've shared with a few friends that with the shop closing, with needing to look for work, that there is a sense of being lost. I'm not sure what comes next. In one sense I'm fine with this, it's kind of adventuresome. In one sense I'm not. I'd like to know what is around this bend.
Empty me out Lord. As I wrote this a scene from "Touched by an Angel" where Monica is sent to the desert for some reason came to mind. Monica is there to reconnect with God. The desert seems a place of loneliness, it is a place of great love. The desert seems a place of nothing, it is filled with the Presence of God. The desert seems a place of being stripped bare, it is the place where we are dressed in God's glory. Monica is sent there to be reminded, and reconnect with God; to turn towards Him, to experience deeply his love.
My prayer of, "empty me out Lord" surprised me. There is, this morning, a sense of being poured out, a sense of understanding where I can grow, where I can let go of things that I do.
Over the last several months I've had this, what I think is, an unreasonable dream for a quilt shop. I started sharing this dream yesterday with someone and I'll share part of it here with you:
There would be a seating area or three, with comfy chairs, small work tables in varying heights for handwork classes, for quilters to gather and chat, or young moms to sit and care for their little people. A little toy area because kids are welcome.
Staff. This is key to a good shop. Warm, welcoming, kind. But more than that with an understanding that a quilt shop is a happy place. Key to this will be Staff Retreat Days. This would be a day for them to come in, sew, develop ideas, talk about classes, problem solve, rest, and most importantly – play.
Good restrooms.
Coffee and tea bar. I'm not quite sure what this would look like yet. Snacks – baked goods with some gluten free options.
One, or two classrooms. One classroom would have machines, I have specific ones in mind here. The second classroom would be available for charity sewing and guild events, a place for guilds to bring host their own teachers and have classes for the guilds.
Classes for kids.
The rest will happen from fabric and notions, to machines and media, and events.
Dreams are beautiful things. I'll keep dreaming.
I'll keep trusting God that I'm in the right industry, that the right work will come along. That I'll be open to listening to where He's leading. That I'm empty enough to be filled.
God bless!


text:
ERIC Number: ED489618
Record Type: Non-Journal
Publication Date: 2004-Jul
Pages: 8
Abstractor: Author
Interating the History of Mathematics in Educational Praxis
Farmaki, Vassiliki; Klaudatos, Nikos; Paschos, Theodorus
International Group for the Psychology of Mathematics Education, 28th, Bergen, Norway, July 14-18, 2004
The integration of History in the educational practice can lead to the development of a series of activities exploiting genetic "moments" of the history of Mathematics. Utilizing genetic ideas that developed during the 14th century (Merton College, N. Oresme), activities are developed and mathematical models for solving problems related to uniform motions are proposed, using the graph of velocity vs. time. The view of the covered distance as the area of the figure between the time axis and the velocity curve allows for the use of concepts and propositions of the Euclidean geometry. The use of simple geometric transformations leads to equivalent motion problems of a real context. This approach, applied to a wider range of problems, can form the basis for the introduction of basic concepts of calculus (such as integral, derivative, and their interrelation), in the context of a program of instruction in Senior High School. [For complete proceedings, see ED489538.]
Descriptors: Teaching Methods, Mathematics Instruction, Scientific Concepts, Mathematical Models, Geometric Concepts, Geometry, Genetics, Calculus, Educational History, Problem Solving
International Group for the Psychology of Mathematics Education, 35 Aandwind Street, Kirstenhof, Cape Town, 7945, South Africa. Web site: http://igpme.org.
Publication Type: Information Analyses; Speeches/Meeting Papers
Education Level: High Schools
Audience: N/A
Language: English
Sponsor: N/A
Authoring Institution: N/A
Grant or Contract Numbers: N/A

subset: commoncrawl


text:
Vol.08 No.03(2016), Article ID:63358,13 pages
The Role of Health Inequality in the Maternal Health Services Provided by Public Institutions in Mexico
Graciela Freyermuth-Enciso1, Mónica Carrasco-Gómez2, Martín Romero-Martínez3
1Centro de Investigaciones y Estudios Superiores en Antropología Social (CIESAS) sede SURESTE, San Cristóbal de las Casas, México
2Cátedras CONACYT/Centro de Investigaciones y Estudios Superiores en Antropología Social sede SURESTE, San Cristóbal de las Casas, México
3National Public Health Institute's Research Center in Evaluations and Surveys, Cuernavaca, México
Copyright © 2016 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
Received 17 December 2015; accepted 2 February 2016; published 5 February 2016
This work aims to determine the role of inequality in the provision of maternal health services among five regions in Mexico (northwest, northeast, central, the Mexico City-State of Mexico region and the south). We consider the most important service providers corresponding to the main health institutions in Mexico (IMSS, ISSSTE, SESAS, IMSS-Oportunidades). Therefore, a cross-sec- tional prospective study was conducted to analyze eight intervention packages (Prenatal Care, Syphilis, Influenza, Obstetric Urgent Care, HIV in pregnancy, delivery care, neonatal care and accessibility) offered by the Maternal and Perinatal Health (MPH) program. A quantitative analysis demonstrates low to marginal performance of the MPH program in three regions (South, Mexico City-State of Mexico and the Northwest) and marginal in two other regions (Central and Northeast). Furthermore, four of the intervention packages presented the lowest performance in the South (Prenatal Care, Syphilis, Influenza and Obstetric Urgent Care), as did the average of the total of the MPH packages. The performance of HIV in Pregnancy package was marginal in the Southern and Mexico City-State of Mexico regions and Neonatal Care was low in the Northwest. The assessment of the MPH intervention packages allows us to identify their strengths and weaknesses. This information allows us to identify similarities and differences among the geographical regions in order to describe and analyze the strengths, weaknesses, opportunities and threats in the current system and hence to improve the decision making regarding the Maternal and Perinatal Health Programs in Mexico. The results suggest that a homogenization has taken place in terms of the low quality of the services.
Health Inequality, Evaluation of Health Services, Maternal and Perinatal Health, Quality of Care
1. Introduction
The public health system in Mexico has been segmented through institutions that provide social security to different users (i.e., patients) according to their work assignment and also to those who lacked affiliation to a social security institution. Therefore, until the beginning of XXI century the health care services for the Mexicans were differential for population with social security (attended by IMSS and ISSSTE) and without social security who were attended by the Health Secretary and the IMSS-Oportunidades. López Acuña (1986) pointed out the inequalities in the health spending and the resources available for health care in Mexico [1] .
In recent decades, we have witnessed structural changes in the organization of the Mexican health system, which have been influenced by international organizations and multilateral agencies of cooperation. The latter has been reflected in public policies and programs in order to strengthen local systems of health and to reduce the gaps among different geographical regions.
The aim of this article is to assess if public health policy focused on maternal and perinatal health in the 1980- 2010 period has contributed to reducing inequality of care within different geographical regions in Mexico. An overview of the political context and the changes that have been promoted through the decentralization of health services since the eighties is presented in Section 2. Then, the methodology employed in this work is described (Section 3). An assessment on the performance of services in the five geographical regions of the country through the analysis of intervention packages in the four major public institutions is presented in Section 4. Finally, discussion and conclusions are presented in Sections 5 and 6, respectively.
2. Background of the Decentralization of Health Services in Mexico
Public policies have been created in Mexico to strengthen the governance of the health system as well as decrease inequalities among regions and institutions since the 1980s. The purpose of Mexico's health system, its governance, financing, and provision of services has been changing over the past three decades. These changes have been made based on studies that propose more efficient ways to administer resources in order to provide health care coverage to the Mexican population. These include deconcentration (1984), decentralization (1996), universal coverage (1994), universal insurance "Seguro Popular" (2003), and more recently the functional integration of the health system (2011) [2] - [4] .
In 1981, President López Portillo implemented a series of health measures that established the basis for this new reform, which was aimed at providing coverage for the entire population [5] . For instance, the Department of Health Services (Coordinación para los Servicios de Salud) was created in order to develop normative, administrative, financial and technical guidelines which soon thereafter made it possible to integrate public health services under the National Health System. Decrees issued in 1983 and 1984 aimed to establish the basis for the decentralization of the Secretary of Public Education, Secretary of Agrarian Reform and the Secretary of Health and Welfare (SSA, Spanish acronym) [6] [7] . This first decentralization phase was supported not only by the Presidency of the Republic but also by the World Health Organization (WHO) [5] . By 1986, the states were expected to have consolidated their own health systems by establishing their health laws and decentralizing services for the general population without social security.
One problem that arose from the decentralization process was the heterogeneity of the conditions in the health sectors in each state, as well as the need to strengthen services before decentralizing them. Cardozo Brum and González Block et al. (cited by Homedes, 2008) [8] found that the states that decentralized services were wealthier, had a greater capacity to provide services to the uninsured population and had the support of the governor at that time; although they also had little infrastructure from the IMSS-Coplamar [9] [10] . During this stage decentralization was implemented in 14 states from 32.
Nevertheless, the process was interrupted due to lack of experience of decentralized states and/or the economic crisis in the country that took place the second half of the 1980s. The latter was accompanied by cuts in the health budget from 2.5% to 1.3% in the percentage of the gross domestic product allocated to health care and social security between 1980 and 1988 [11] . By the end of the 1980s, a process to modernize health services was initiated during President Salinas' administration (1988-1994), which was said to be a continuation of the plan presented by the previous government. The first agreement with the World Bank was also reached during this government's term, which was aimed at expanding the coverage of services in those states with problems in health care services. This established the foundation to strengthen the infrastructure in states with the greatest deficiencies in health services and infrastructure. Moreover, the institutional capacities of the states were promoted by decentralizing the acquisition of basic supplies and improving capacities to manage information systems.
During 1995-2000 period, the National Development Plan called for a new federalism to emerge out of the recognition of autonomous spaces in political communities and the respect for the various powers ascribed to each level of government. The aim was to harmoniously and effectively bring together the sovereignty of states and municipalities with the constitutional powers of the federal government. This was also intended to promote social participation and to define a new framework for relationships between the State and its citizens and organizations [12] . It was the 1996 National Accord1 that gave a new impetus to the decentralization process [13] and agreements between the federation and the states were signed, the last of which was by Chihuahua in February of 1999 [8] .
Previous studies [14] - [16] pointed out that the majority of Latin American countries were pressured to reform health services, and one of the components of this reform was decentralization. The promoters of these initiatives were the World Bank, the Inter-American Development Bank and certain bilateral and multilateral development agencies. They proposed decentralization as part of a structural adjustment that would make it possible to free up federal resources to pay external debts. Decentralization would also facilitate the privatization of the health system, which is considered by neoliberal theory to be more efficient than public services (Collins 1989; Griffin, 1999; Ugalde and Homedes N. 2002).
It was believed that decentralization would facilitate a more reasonable and equitable distribution of the federal expenditures on health by taking into account mortality and marginalization indicators. It was also considered as a way to help balance per capita expenditures on health, thereby increasing both efficiency and equity. The decentralization process included the state governments' creation of legislative initiatives, or creation decrees, the formation of a government entity and the administration of federal resources through the SSA and the state governments. In turn, the SSA would decentralize the operations of health services from the federal to the state level and stipulate the priorities to be followed by the decentralized agencies. The SSA would also grant programming and budgeting functions to the states according to established federal guidelines [17] .
Decentralization made it possible to allocate funds to the states in a more equitable manner. Thus, income improved for state governments with fewer resources. In terms of programming, the most important policies continued to be generated by the federal government but without the control mechanisms needed for them to be carried out in the states.
In 2003 during Vicente Fox's term (2000-2006) the Social Health Protection System (Sistema de Protección Social en Salud; SPSS, Spanish acronym) and Seguro Popular de Salud (its operational arm) were approved in order to create medical insurance for the population without social security, through the reform of the General Health Law (Ley General de Salud; LGS Spanish acronym). Similar to enrollees in the IMSS and the ISSSTE, the SPSS is a financial instrument aimed at providing a per capita amount to Seguro Popular enrollees. This would standardize the financial structure of these three insurance systems.
The purpose of these reforms were to provide universal coverage for Mexicans through medical insurance with a financial structure similar to that of social security, in order to advance the functional integration of the health system.
The Health Sector Program (Programa Sectorial de Salud; PROSESA) was established in the 1980s to maintain the regulatory role of the Secretary of Health, consolidate the National Health System (SNS, Spanish acronym) and guarantee mechanisms to implement the right to health protection. PROSESA has 13 substantive programs and 3 support programs, including maternal and child health. This program was consolidate in accordance with Mexican Official Norm NOM-007-SSA2-1993 which was established by the federal government and stipulates the criteria for treating and monitoring women's health during pregnancy, delivery and the postnatal period, as well as for newborn care.
This program was created through the implementation of Seguro Popular, which has treated the population without social security since 2004, and at that time provided access to 20 interventions for maternal and child health. Additional initiatives were developed in 2008 and 2009 to decrease economic barriers and thereby improve access: 1) Healthy Pregnancy (Embarazo Saludable) which enabled pregnant women and their families to affiliate and 2) General Agreement on Inter-institutional Collaboration for Obstetric Emergency Care which established treatment for all women experiencing obstetric complications regardless of their affiliation in any of the health institutes (IMSS, ISSSTE or State Health Services [SESA]).
Nevertheless, at both the IMSS and the ISSSTE (institutions coordinated at the federal level, that is, they are not decentralized) maternal health care is based on prenatal health services at the primary level and delivery care at the secondary level, while obstetric emergencies are treated only at the secondary level where the timely treatment of obstetric emergencies and the public health perspective of the The Maternal and Perinatal Health Program (MPH) are not included in their guidelines. However, some of the components of the IMSS-O program are similar to the MPH, such as the organization of social community networks to transport the women and even community promoters to identify risks among pregnant women [18] .
This article is focused on describing the availability of the interventions established by the regulations. It includes the four largest public and social security institutions in the country (IMSS, ISSSTE, SESAS, IMSS- Oportunidades) and encompasses five regions in Mexico (northwest, northeast, central, the Mexico City-State of Mexico region and the south) (See Table 1). This will allow us to identify similarities and differences among the regions in order to describe and analyze the strengths, weaknesses, opportunities and threats in the system and thereby suggest improvements that will ensure that the goods and services established by the regulations are provided in the various regions and health care subsystems.
3. Methodology
A cross-sectional prospective study was conducted using quantitative research methods. The Maternal and Perinatal Health Program was analyzed based on guidelines by the maternal and perinatal program, the Official Mexican Norms (Normas Oficiales Mexicanas; NOM, Spanish acronym), and clinical practice guidelines (CPG). Intervention packages were defined which were composed of a set of the marginal essential interventions needed for the adequate provision of services [19] .
3.1. Instruments
Four instruments were designed to collect the information: 1) checklists, 2) questionnaires, 3) observation guides, and 4) interview guides to obtain information from the various actors. Nineteen areas were also defined to collect information, with specific informants at each establishment and according to level of care. The instruments were adapted and validated based on consensus with those responsible for the programs at each institution.
Eight health care packages covering a total of 134 primary level and 164 hospital level interventions were defined for the maternal and perinatal program2: 1) Accessibility: knowledge of the health care staff and population about the Healthy Pregnancy strategy (Embarazo Saludable) and the General Agreement on Inter-institu- tional Collaboration for Obstetric Emergency Care (Convenio General de Colaboración Interinstitucional para la Atención de Emergencias Obstétricas) as well as no physical, economic and cultural barriers to accessing health facilities; 2) Prenatal care: interventions aimed at identifying the skills and competencies needed to treat urinary infections and to determine risk factors for preeclampsia and hemorrhage. Other packages that represent some of the new challenges in prenatal care were included separately, such as the next three; 3) HIV-STI in Pregnancy: universal access to antiretroviral medication, adequate prevention campaigns and prevention of vertical transmission; 4) Syphilis: resources needed to perform the VDRL blood test for syphilis as well as early treatment; 5) Influenza in Pregnancy: early detection of cases, detection of complications and case referrals, adequate treatment, sufficient and adequate information aimed at the general public; 6) Delivery Care: a) the availability of supplies and instruments, b) the basic knowledge needed to provide medical attention as indicated by norms and
Table 1. Evaluation of the performance of intervention packages, by region.
Significance ***p value ≤0.01, **p ≤ 0.05, *p ≤ 0.10.
to ensure adequate care and the privacy and comfort of the mothers, c) the availability of checkups and monitoring procedures to ensure the early detection of complications); 7) Neonatal Care: interventions that help to identify the neonate's availability to receive checkups (those born with and without complications) and the availability of supplies and strategies for the screening and early detection of hypothyroidism; and 8) Obstetric Emergency Care: the availability of the instruments, supplies and knowledge that enable the physician to make decisions related to the most common obstetric emergencies and the availability of medications to treat those problems.
3.2. Sampling Methods
The sampling framework was dictated by the health sector national directory of health care facilities
(http://clues.salud.gob.mx/). Stratified and clustered sampling methods were used. Five regions were defined (as described in Figure 1) and 10 municipalities were chosen from each region. The facilities were selected with probability proportional to the population of the municipality. In each municipality, one medical establishment was selected for each one of eight strata defined by institution criteria (IMSS, IMSS-Prospera, ISSSTE, SESA) and type of establishment (primary care and hospitalization).
The medical establishments were selected with probability proportional to their size, defined as the inverse square root of the frequency of their typology, as presented by the SSA webpage (http://clues.salud.gob.mx/).
Each unit in the sample was then assigned a weight (w) based on the selection probability. The directory of national medical establishments in the health sector provided by the SSA webpage (http://clues.salud.gob.mx/) was used as the sampling framework.
The sample was composed of 205 medical units, 50 municipalities and 23 states and Mexico City. Responses were obtained from 201 medical units (2% non-response). The sample size was defined based on a study of the performance of maternal services and was nationally representative of institutions providing these services and the types of populations they treat.
The fieldwork was conducted from September to December 2010. The CSPro Census and Survey Processing System (www.census.gov/population/international/software/cspro/) was used for the data entry.
Figure 1. Regional distribution of the states.
3.3. Data Analysis
The scores for each region were estimated for each of the intervention packages (Prenatal Care, Syphilis, Influenza, Obstetric Urgent Care, HIV in pregnancy, delivery care, neonatal care and accessibility). The intervention packages were evaluated using indices that represented a relative score with respect to the total items evaluated, according to the services provided by each unit. This was obtained by calculating the quotient of the sum of points accumulated by a medical unit divided by the number of items evaluated in that unit (minimum value = 0 and maximum value = 1). A detailed description of this analysis can be found in Freyermuth et al. (2011) [18] .
Two levels of analyses were performed. The first consists on a statistical, significance test for a regional comparison of the indices through the obtainment of the T-Student3 test considering the design effect, since the primary units in the sample were the municipalities and not the medical units. All of the T-Student test were run but only tests that were significant for a level of .01 were discussed. The second level of analysis was qualitative, through the traffic light system described above, which explored the deficiencies in the contents of the intervention packages in order to drive public policies. The performance scale proposed by the National Council for the Evaluation of Social Policy (Consejo Nacional de Evaluación de la Política de Desarrollo Social; CONEVAL, Spanish acronym) was used to create a traffic light system based on the indices. A score equal to or more than 0.85 was an indicator of good performance, 0.70 to 0.84 adequate performance, 0.50 to 0.69 marginal performance and low performance is indicated by values under 0.50.
This research was approved by the ISSSTE Research Ethics Committee and written consent to conduct the evaluation was obtained from each institution. The confidentiality of the participants was maintained.
4. Results
4.1. Performance of the MPH Program
The mean index for the program was 0.56 (95%CI; 0.48, 0.64), which can be interpreted as the middle value. This is noteworthy since it is one of the oldest programs provided by public health institutions. According to confidence levels, its performance was low to marginal in three regions (South (with a mean of .50), MexCty-St of Mex and the Northwest) and marginal in two regions (Central and Northeast). Significant differences in the performance of the entire set of packages in the SMP program were found when comparing the South to three other regions (Northeast, Northwest and Central). Also noteworthy is that the MexCty-St of Mex region was not one of the regions with better performance in the provision of this type of service. No differences were found between this region and the South and the performance in both MexCty-St of Mex and the Northwest was significantly lower than in the Northeast. The order of how well this program performed was: Northeast, Central, Northwest, MexCty-St of Mex and South.
Furthermore, four of the eight packages had the lowest performance in the South (Prenatal Care, Syphilis, Influenza and Obstetric Urgent Care), as did the average of the total of the MPH packages. HIV in Pregnancy had marginal performance in the South and the MexCty-St of Mex region and Neonatal Care had low performance in the Northwest. Although no significant differences were found among regions for three packages (delivery care, newborn care and accessibility), we describe them based on the second level of analysis which is aimed at establishing a performance range for the intervention packages and monitoring the components of the program.
4.2. Overall Performance of the Intervention Packages in the MPH Program
In the provision of services related to delivery care, which can be considered to be a traditional maternal-infant care service, adequate performance was found with no significant differences among regions. Furthermore, other traditional intervention packages exist, such as prenatal care which resulted in indices of 0.68, 0.72, 0.70, 0.71 and 0.60 in the Northwest, Northeast, Central, MexCty-St of Mex and Southern regions, respectively, indicating marginal and adequate performance. In the case of neonatal services, the average indices were 0.49, 0.66, 0.77, 0.78 and 0.60 in the above regions, respectively. Thus the extremes were the Northwest with very low performance and the Central and MexCty-St of Mex regions with adequate performance. Nevertheless, it is worth mentioning that the South was notable for having the lowest prenatal care performance index of all the regions.
Obstetric Emergency Care is one of the intervention packages recently implemented in the health sector, which was established in 2006. This package resulted in low performance in the Northwest (0.47), Central (0.49) and especially the South (0.39) and marginal performance in the Northeast and the MexCty-St of Mex regions (0.52).
In terms of prenatal care, the interventions that determined its marginal performance in three of the regions were knowledge about high-risk factors for preeclampsia and about medications indicated for urinary infections during pregnancy. At the hospital level, interventions classified as low performance were also related to a lack of knowledge about detecting risk factors for preeclampsia and treating urinary infections, as well as a failure to indicate to women at their first prenatal checkup (at 24 weeks gestation) the laboratory tests to be performed. Nevertheless, the other interventions presented adequate performance, as mentioned previously, indicating that the prevention of neural tube problems and the availability of supplies for their prevention were adequate for interventions related to the health of the baby.
As mentioned previously, delivery care was the package which presented adequate performance in four of the five regions, with no differences among the regions. This demonstrates the availability of supplies and equipment, having basic knowledge about the medical care indicated in the NOM-007, and the availability of checkups and monitoring procedures to ensure the early detection of complications. Nevertheless, some of the individual interventions resulted in low performance in all of the regions, including insufficient walking space in delivery rooms for women in labor and a lack of partograms (except in MexCty-St of Mex and the Northwest). In the CE4, there was a lack of oxytocin in the Northwest and Central regions and both oxytocin and ergonovine in MexCty-St of Mex, which compromises women's comfort and puts their lives in risk because of hemorrhage.
For neonatal care, adequate performance was found in the Central and MexCty-St of Mex regions, marginal in the South and Northeast and low in the Northwest. This indicates the need to improve the immediate care of neonates by providing interventions that guarantee the treatment of complications, the provision of supplies and strategies for the screening and early detection of hypothyroidism. The interventions with the lowest indices in all the regions were the lack of medical certificates, neonatal resuscitation equipment and Silverman Anderson and Apgar evaluation tables.
Regarding of Obstetric Emergency care, marginal performance was found only in the Northeast and MexCty-St of Mex regions. Performance was low in the other regions and the South had the lowest average index (0.39), where medical staff did not have the competencies needed to make decisions about the most common obstetric emergencies, such as what to do in case of hemorrhaging and toxemia and risk factors for postpartum hemorrhaging. Medications to treat these problems were lacking as well as manuals and algorithms related to obstetric hemorrhage, sepsis and miscarriage. In terms of supplies, plasma expanders, cephalexin and gentamicina were not available or free substitutes were not provided. There was also an inability to perform blood cultures, urine cultures and antibiograms, as well as to identify serum lactate. In addition, ultrasounds were not available 24 hours per day 7 days per week for emergencies.
Intervention packages for prenatal care that have been recently and systematically more implemented include the detection and treatment of HIV-AIDS and syphilis and the prevention of influenza in pregnant women. In the case of HIV detection, interventions related to checkups and early treatment for women who test positive as well as measures to prevent vertical transmission performed adequately in the Northeast and had marginal performance in the other four regions. The main weaknesses in this package were: not offering the rapid HIV test to all pregnant women; deficiency in availability of rapid tests for HIV; lack of informed consent forms for HIV diagnoses; lack of a guide for the use of rapid tests; laboratories without the capacity to perform viral load tests, TCD4 and TCD8 counts and western blot tests; and the unavailability of antiretroviral drugs, including HIV STI/zidovudine (AZT)+lamivudine (3tc)+lopinavir (saquinavir, ritonavir).
A similar situation was found for the influenza packages, which had marginal performance in the Northwest (0.52), Northeast (0.68) and Central (0.55) regions and low performance in MexCty-St of Mex (0.45) and the South (0.40). These differences in performance were primarily associated with the availability of treatment and the timely referral in the event of complications. The main deficiencies were: insufficient information related to recognizing and preventing the transmission of influenza; the absence of oseltamivir, zanamivir and the vaccine; and a lack of clinical guides for treatment and referrals as well as visible algorithms that facilitate diagnosis and treatment.
Even though it has been mandatory for decades, the intervention package to detect and treat syphilis was found to have low performance in the Central (0.39) and South (0.37) and marginal in the Northeast (0.68), Northwest (0.52) and MexCty-St of Mex (0.55) regions. The interventions identified as being most deficient were not performing VDRL syphilis detection tests and not having diagnostic and treatment guides or adequate dosages of medications such as penicillin G benzathine, ceftriaxone (500 mg) and azithromycin (500 mg).
Lastly, the performance of the accessibility package was low in four of the five regions and marginal only in the South, although the difference was not significant. This is important given that difficulties with access have been one of the main problems in the early treatment of obstetric emergencies. In 2010 when the information was collected, two strategies were implemented to improve universal coverage of the service and its functional integration Healthy Pregnancy (Embarazo Saludable) and the Inter-Institutional Agreement for Obstetric Emergency Care (Convenio Interinstitucional para la Atención de la Urgencia Obstétrica). Therefore, in addition to monitoring whether or not physical, economic and cultural barriers to the facilities existed, health care staff and the populations were also evaluated as to whether or not they knew about these strategies (free, support from health staff, ambulance service, telephone, etc.).
The low performance by the accessibility package was primarily due to not visibly displaying hours, lack of staff who spoke the local indigenous language, poor dissemination of information about the Healthy Pregnancy program and insufficient information about the signs and symptoms of obstetric emergencies. It is also worth mentioning that health care staff were not aware of the IMSS-ISSSTE-SESA agreement regarding obstetric emergency care and information was lacking about where to go for delivery care as well as about Seguro Popular and enrollment and complaint procedures.
5. Discussion
The proposed methodology contributes to rapidly identify interventions considered by the health sector to be essential to the performance of services. The methodology can be used to make synthetic comparisons, in this case among regions, as well as institutional comparisons among health care services and among medical units.
While in some ways decentralization tried to homogenize the regions' institutional capacities to produce services, in the case of maternal and perinatal services significant differences were found when comparing the Northwest, Northeast and Central regions with the South and the Northeast and MexCty-St of Mex regions, in which the MPH program performed lowest in the South. What is notable is a homogenization in the performance of regions with marginal to low indices. None of the intervention packages showed good performance and, at best, three of the eight packages studied had adequate performance in the Northeast and the MexCty-St of Mex region.
Although the differences among regions would be expected to range from good and adequate to marginal and low, the quality of maternal-infant services was found to be heterogeneous even within the same region. In addition, all regions had some intervention packages with low performance while most of the services were classified as marginal.
Homedes and Ugalde (2008) concluded that, 25 years after implementing decentralization in Mexico, inequalities in the health system have increased due to an unclear process and ineffective strategies to compensate for inequalities among the decentralized states. We suggest that while these inequalities have continued, the present study shows that the services generally tend to have marginal and low performance in all regions. Thus, not only has there been a failure to homogenize quality and decrease gaps, we consider these results to be more indicative of a homogenization in terms of the low quality of the service than of a deepening of inequalities.
While it is the case that low performance was found in the South for four of the eight intervention packages (Prenatal Care, Syphilis, Influenza, Obstetric Emergencies), the other four were found to have low performance in other regions. The performance of accessibility was low even in the Northeast, which had the highest quality ranking.
The "Evaluation of Women's Health Care Programs" presented results by level of care (primary and secondary) and by the type of population receiving the services (insured and uninsured). This evaluation found significant differences between the secondary level and insured population (IMSS/ISSSTE) as compared to the primary care level and uninsured population, in which the former had better performance. Nevertheless, a worrisome trend was found similar to that presented by the regional findings, in which there was low performance in the capacity to offer Obstetric Emergency Care, especially by institutions aimed at the uninsured population. Furthermore, although the performance of the IMSS/ISSSTE was classified as marginal, this also cannot be considered satisfactory [20] .
Performance in the accessibility to the health system continues to be low, especially in terms of what the National Aboriginal Health Organization refers to as cultural security, which is understood as the capacity of service providers to communicate with patients according to their political, economic, social, spiritual and linguistic perspectives [21] . This has even been associated with resistance towards adhering to portions of the NOM-007, including adopting the position desired by the woman in labor [18] , weaknesses in the infrastructure and placing furniture in such a way that makes it difficult for women to walk during labor. These infrastructure and supply problems have been recognized by the Mexican Collegiate Federation of Obstetrics and Gynecology (Federación Mexicana de Colegios de Obstetricia y Ginecología, A.C.; FEMECOG, Spanish acronym)5.
It is also important to mention that communication within institutions and among their own members was found to be insufficient and it was evident that primary- and secondary-level health care staff in MexCty-St of Mex and the Southern regions lacked knowledge about policy agreements to improve performance and access (such as the Inter-Institutional Agreement for Obstetric Emergency Care). This has also been reported in the states of Guerrero, Oaxaca and Veracruz [22] .
The low performance evident in primary-level obstetric emergency care demonstrated little knowledge on the part of health care staff about protocols used to treat the most common causes of obstetric emergencies and a lack of guides to manage these emergencies and the supplies needed to treat them. In an evaluation of participatory actions related to the MPH program, the measures used to support obstetric emergencies had an influence on the availability of transportation and housing for pregnant women, which helped to obtain international certification of Arranque Parejo en la Vida actions [23] . This information could be compared to our findings, nevertheless while both studies refer to obstetric emergency care they do not evaluate the same actions.
At the hospital level, the low performance by the HIV package indicated deficiencies in the capacity to perform tests and in the availability of antiretroviral drugs, even though a strategy existed and resources were allocated [24] . Deficiencies were also identified in the influenza package, in spite of the severity of the epidemic and its political visibility in 2009 [25] . Therefore, further research, monitoring by citizens and social accountability continue to be necessary not only to see whether the public resources allocated to the programs are being adequately distributed and used but also in order to design and create processes and indicators that evaluate their impacts [26] .
In the South, specifically in the case of Chiapas, Freyermuth identified particular social and political situations as having contributed to a substantial increase in the health budget through the Ramo 33 Health Services Fund (Fondo de Aportaciones para los Servicios de Salud; FASSA, Spanish acronym) [6] such as the Zapatista uprising in 1994 and the decentralization of state services in 1998. While this could have signified an improvement in the performance of the services provided, it is important to note that deficiencies were found in the South, especially at the primary care level of the new programs (syphilis, influenza and obstetric emergency care programs).
In addition, even though the national SPSS budget increased over 600%6 between 2004 and 2010, the IMSS and ISSSTE were the institutions that continued to show better performance.
Therefore, differences in performance among regions could be identified in spite of several attempts to improve the health system. These regional differences persisted even after performing interventions, increasing budgets and implementing programs to attempt to address the lack of coverage by decentralizing the National Health System and implementing Seguro Popular. And even after attempts to improve maternal-infant care by integrating the system through a variety of strategies, such as the Agreement, the 2006 Medical Insurance for a New Generation in 2006 and Healthy Pregnancy in 2009, it can be identified that there are different performances between regions. In this regard, it is important to mention that the region which presented the poorest performance was the South. This can be interpreted as a failure of the concentration of resources to bring about the short-term results expected and the need to ensure a more effective allocation of the budget and to target resources towards the most vulnerable populations.
This inequality has also been identified by recent studies focused on particular programs aimed at combating inequalities in municipalities with a lower human development index, which found that inequality increased [27] . Gwatkin and Ergo (2011) called this phenomenon "regressive universalization," in which programs aimed at universal coverage largely end up benefiting less disadvantaged populations to a greater degree than more vulnerable populations [28] .
6. Conclusions
In this work, an assessment of the interventions in the SMP program allows us to identify their strengths and weaknesses. This analysis provided useful information for policy-makers and health program decision-makers in order to improve the provision of health services of pregnant women and neonates. Surprisingly, regions with the more important health care facilities (i.e., MexCty-St of Mex) presented low to marginal performance in the MPH program with similar scores to the poorest region (South). Four of the eight packages had the lowest performance in the South (Prenatal Care, Syphilis, Influenza and Obstetric Urgent Care), as did the average of the total of the SMP packages.
Despite preeclampsia being the second leading cause of maternal death in Mexico, the evaluation in the prenatal care package showed shortcomings in the knowledge about high-risk factors for preeclampsia and indicated medications for urinary infections during pregnancy. On the other hand, in delivery care, which can be considered to be a traditional maternal-infant care service, adequate performance was found with no significant differences among regions.
We suggest that while these inequalities have continued, the present study shows that the services generally tend to have marginal and low performance in all regions. These results suggest that a homogenization has taken place in terms of the low quality of the service than of a deepening of inequalities.
These monitoring exercises need to be continued at the academic level in order to evaluate the performance of maternal and neonatal programs, so as to identify progress and setbacks and suggest control measures. Lastly, the national health system needs to be strengthened so it can function as a single system operated with public financing.
The authors want to acknowledge to the authorities of the Federal Ministry of Health, IMSS-Oportunidades IMSS, ISSSTE and state health services for the facilities provided in the implementation of this evaluation work. And, for their financial support, to the Women's National Institute (INMUJERES), CIESAS and Catedras program of CONACYT.
Cite this paper
GracielaFreyermuth-Enciso,MónicaCarrasco-Gómez,MartínRomero-Martínez, (2016) The Role of Health Inequality in the Maternal Health Services Provided by Public Institutions in Mexico. Health,08,206-218. doi: 10.4236/health.2016.83024
- 1. Lopez Acuna, D. (1986) La salud desigual en México. Siglo Veintiuno Editores, México.
- 2. Londono, J.L. and Frenk, J. (1997) Structured Pluralism: Towards an Innovative Model for Health System Reform in Latin America. Health Policy, 41,1-36.
- 3. Soberon, G. and Valdéz, C. (2007) Evidencias y salud, Hacia donde va el sistema de salud en México? Salud Pública de México, 49, 5-27.
- 4. Secretary of Health (2011) Hacia la integracion funcional del Sistema Nacional de Salud. Secretaría de Salud, México.
- 5. Soberon-Acevedo, G. and Martínez-Narváez, G. (1996) La descentralizacion de los servicios de salud en México en la década de los ochenta. Salud Pública de México, 38, 371-378.
- 6. Freyermuth Enciso, M.G., Sánchez Pérez, H. and Arguello Avendano, H. (2015) Transparencia y rendicion de cuentas en salud materna: El caso del AFASPE en Chiapas. Revista Pueblos y Fronteras, 9, 79-93.
- 7. Diario Oficial de la Federacion (DOM) (1983) Decreto por el que el Ejecutivo Federal establece bases para el programa de descentralizacion de los Servicios de salud de la SECRETARíA DE SALUBRIDAD Y ASISTENCIA. México.
- 8. Homedes Beguer, N. and Ugalde, A. (2008) 25 anos de descentralizacion del sistema de salud mexicano: Una experiencia para analizar. Revista Gerencia y Políticas de Salud, 7, 26-43.
- 9. Cardozo, M. (1993) Análisis de la política descentralizadora del sector salud: Centro de Investigacion y Docencia Economicas. México, D.F.
- 10. González Block, M.A., Leyva, R., Zapata, O., Loewe, R. and Alagon, J. (1989) Health Services Decentralization in México: Formulation, Implementation and Results of Policy. Health Policy and Planning, 4, 301-315.
- 11. Lopez Arellano, O. and Blanco Gil, J. (1993) La modernizacion neoliberal en salud: México en los ochenta. México Universidad Autonoma Metropolitana, México.
- 12. Diario Oficial de la Federacion (DOM) (1995) Plan Nacional de Desarrollo 1995-2000 (Separata), México.
- 13. Sales Heredia, F.J. (2012) A 30 anos de la descentralizacion de los servicios de salud. Centro de Estudios Sociales y de opinion Pública de la Cámara de Diputados, LX Legislatura. Documento de trabajo núm. 140.
- 14. Collins, C.D. (1989) Decentralization and the Need for Political and Critical Analysis. Health Policy and Planning, 4, 168-171.
- 15. Griffin, C. (1999) Empowering Mayors, Hospital Directors, or Patients? The Decentralization of Health Care. In: Burki, S.J., Perry, G. and Dillinger, W., Eds., Beyond the Center: Decentralizing the State, World Bank, Washington DC.
- 16. Ugalde, A. and Homedes, N. (2002) Descentralizacion del sector salud en América Latina. Gaceta Sanitaria, 16, 18- 29.
- 17. Escalante, E. (2000) El Ramo 33 Aportaciones Federales para Entidades Federativas y Municipios y Avances en el Federalismo. Cronica Legislativa. Cámara de Diputados LVIII Legislatura No. 12, México, 77-81.
- 18. Freyermuth, G., et al. (2011) Monitoreo de la atencion a las mujeres en servicios públicos del sector salud. Cuadernos de Trabajo 29, Instituto Nacional de las Mujeres—Centro de Investigaciones y Estudios Superiores en Antropología Social, México.
- 19. Oohna, C. and Graham, W. (2006) Strategies for Reducing Maternal Mortality: Getting on with What Works. The Lancet, 368, 1284-1299.
- 20. Freyermuth Enciso, G., Meneses Navarro, S. and Romero Martínez, M. (2015) Evaluation of Women's Health Care Programs in the Main Institutions of the Mexican Health System. Cadernos de Saúde Pública, 31, 71-81.
- 21. National Aboriginal Health Organization (2008) Cultural Competency and Safety: A Guide for Health Care Administrators Providers and Educator. National Aboriginal Health Organization, Otawa.
- 22. Rodríguez Soriano, D., Freyermuth Enciso, M.G. and Arguello Avendano, H. (2013) Monitoreos al acuerdo para el fortalecimiento de las acciones de salud pública en los estados y al convenio general de colaboracion interinstitucional para la atencion de la emergencia obstétrica. Un ejercicio de contraloría social. Observatorio de Mortalidad Materna en México.
- 23. Orozco-Nunez, E., González-Block, M.A., Kageyama-Escobar, L.M. and Hernández-Prado, B. (2009) Participacion social en salud: La experiencia del programa de salud materna Arranque Parejo en la Vida. Salud Pública de México, 51, 104-113.
- 24. Secretary of Health (2008) Programa de accion específico Arranque Parejo en la Vida, SSA, México.
- 25. Torres Ramírez, A. (2010) La influenza pandémica A (H1N1) en mujeres embarazadas. Ginecología y Obstetricia de México, 78, 121-127.
- 26. Freyermuth, G. and Sesia, P., Eds. (2013) Monitoreos, diagnosticos y evaluaciones en salud maternal y reproductiva: Nuevas experiencias de contraloría. Centro de Investigaciones y Estudios Superiores en Antropología Social/Comité Promotor por una Maternidad Segura-México, Observatorio de Muerte Materna-México.
- 27. Meneses Navarro, S., González Block, M.A., Quezada Sánchez, A.D. and Freyermuth Enciso, G. (2014) Evolucion de la equidad en el acceso a servicios hospitalarios según composicion indígena municipal en Chiapas, México: 2001 a 2009. In: Page Pliego, J.T., Ed., Enfermedades del rezago y emergentes desde las ciencias sociales y la salud pública, Programa de Investigaciones Interdisciplinarias sobre Mesoamérica y el Sureste, Instituto de Investigaciones Antropologicas, Universidad Nacional Autonoma de México, México, 17-35.
- 28. Gwatkin, D. and Ergo, A. (2011) Universal Health Coverage: Friend or Foe of Health Equity? The Lancet, 377, 2160-2161.
1National Agreement for the decentralization of health services, Journal of the Federation (DOF, Spanish acronym), September 25, 1996.
2These can be consulted in-depth in the technical report.
3The T-student is computed as t = (x − y)/sqrt(Var(x − y)) where x and y are mean scores of different programs and Var() is estimated taking into account the sampling design.
4CE refers to the Rural Medical Units run by the IMSS-Oportunidades program and Health Centers that provide hospitalization for primary care delivery.
5We are referring to the announcement issued on June 10, 2015 about obstetric violence and legislative initiatives in some states, available in: http://www.femecog.org.mx/docs/FEMECOG%20pronunciamiento.pdf
6Comparison in constant pesos from the year 2004 to 2009 of the total budget allocated to the SPSS, with data from the SHCP from the years 2004 to 2008. From the federal treasury department account, 2009, PEF APROBADO (approved federal expense budget). Source: Diaz, D., Pérez, M. A. C., & Navarro, S. M. (2010) p. 39.


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The Truth About Drugs at Coachella | Teen Vogue Take
Released on 04/12/2018
Coachella's coming up, and the Queen B, Cardi B,
her baby bump, and a bunch of our other faves
will be performing.
But we also need to talk about the substance use
that will be happening at the festival,
and more dangerously, the toxic mixing of these substances.
On today's show, we'll talk about drugs at festivals
as this sort of escapism mechanism but more importantly,
how you can stay safe at festivals like Coachella.
You know we have to put a game of your fave's problematic.
So let's get into it today, on Teen Vogue Take.
I'm Tiffany Bender.
I'm Brittney McNamara.
And joining us today is a very special guest,
Dr Joseph Palamar, an epidemiologist from NYU
with nearly two decades of research
and practice under his belt.
So can you tell us a little bit about what you do?
So, the last three or four years I've actually been
overseeing a study in which we survey
people entering parties, primarily nightclubs
and dance festivals in New York City.
We've been asking about 100's of different drugs
and we focus particularly on
the drug ecstasy, also known as molly.
And so what has been some of your findings,
outside of these clubs?
We're finding that pretty consistently,
every year one out of four people, that's 25% of all people
report having used ecstasy or molly within the past year.
That's a lot, because the national prevalence
is only about 2% in this age group.
You made mention in previous conversation and articles
that you actually were finding that
people think that they're taking molly
but it's combination of other drugs,
can you talk a little bit more about that?
Yeah. So I'm my study we've actually been hair testing
a lot of people who take our survey,
and what we've been finding is that
about half of molly users are actually testing positive
for these new drugs called baths salts.
Bath salts are commonly found in molly,
which is supposed to be pure, but it's usually not.
What exactly are bath salts?
Well it's not literally the salt
you put in your bath, some people think that.
It's a street term for synthetic cathinones.
These are new amphetamine-like drugs
that we don't know very much about.
Some of them mimic ecstasy and others mimic
amphetamine or methamphetamine.
That drug flakka that's been all over the news,
that's a bath salt and we're actually detecting that
in people's hair, so we have these young people
who just started using molly
and they're testing positive for flakka.
So they don't even know what they're taking.
They have no idea what they're taking.
Just to bring the conversation back a bit to festivals,
I think that because kids are going to experience
the music live and in action,
they are almost trying to mimic
some of their favorite artists who like,
encourage almost, drug use.
Are you also seeing that in some of
the articles that you guys are editing?
Yeah, so it's kinda this idea of escapism right?
Where you're physically going somewhere,
so you escaping your hometown, this suburban boredom maybe,
and then there's the idea of escapism in music,
people often use it to take them out of their own situation.
So, it seems like it's ...
people are using drugs to enhance this escape
that they're already seeking.
What I'm finding is the people who frequent
these nightclub parties are more experienced
with the drugs, like ecstasy.
But a lot of these people who attend festivals
have never used these drugs before
and they don't know what they're doing.
So, it's almost this, idea that they're seeking something,
maybe that they're seeing from their favorite artists,
you know, in music or through how
the artist are living themselves.
I wanted to also talk specifically
about the dangers of cocktailing.
In an LA Weekly article a veteran festival goer quoted,
It's common for my friends to wake up,
start drinking and taking Adderall.
Then they mix acid and molly together in a water bottle
and take it into the festival.
They drink the mixture throughout the day and night
while continuing to supplement with
booze, weed and Adderall.
Yeah. Dr can you please explain
for people at home why this is so dangerous.
It's not good to mix, really anything, especially alcohol.
If you put alcohol in the mix with anything
that's just bad news to begin with.
The potential for harm, does it increase?
Some drugs could have synergistic effects,
so if you combine two stimulants,
your heart rate might skyrocket
and you might get really anxious for example.
And if you combine two quote unquote downers,
you could pass out, or something really bad could happen.
Okay, so let's say that you're not participating
in substance use, but your friends are.
How do you navigate that space, keep them safe,
without coming across like a judgy friend?
Yeah. So, I've been in this position before
and my method is to just kinda, stick to myself
and do me and if anyone questions it, just be like
Oh it's not for me, you know,
just kinda play it off really cool,
as I am (laughs)
and just not really get into it that much,
if people are offering it to you, if they're
a good friend to you they should understand when you say no
and just want to keep yourself, present
and literally, just do you.
I think it's really important to know if your friends
are on drugs and specifically what drugs they're on.
And if you're a drug user, it's really important
to tell your friends what drugs you've been using
because if something bad happens,
that could really inform what they should do about it.
Youth driven organizations, like DanceSafe,
which I know you are also a fan of their work,
agree that the safest thing you can do,
as a festival goer, is to be honest, like you said, right?
So what are some other tips that we can give to our friends,
that we can give to people who
are going to participate in using drugs?
I would say, stay vigilant.
There was recently a Twitter video
where there was these two girls
and they were just having fun between themselves
and this guy literally dropped something
into one of the girl's drinks.
So you really need to just, be aware, have fun,
have a great time, but be aware of your surroundings
and your friends surroundings, look out for each other.
(Tiffany) Yeah, absolutely.
I recommend that if you insist on using a drug,
such as ecstasy or cocaine that
you do not resort to purchasing it at the festival
from a shady dealer, or an unknown person.
'Cause this is how people get adulterated drugs
and they get harmed from them.
Also I recommend, stay hydrated, with or without partying,
just stay hydrated, especially when it's hot out
at one of these festivals.
And avoid alcohol if you're partying on drugs
like molly and most of all, rest.
Rest of one of the most important factors.
Rest during the festival, once in a while
and rest before going.
You need to rest and eat and feel healthy when you go,
especially if you're going multiple days in a row
because they is how people get exhausted
and wind up in the hospital,
and that's with or without drugs.
Make sure you're planning, make sure you know ...
What you're taking.
.. what you're taking, yeah, and be with people
who can help take care of you and make sure
you plan to take care of yourself.
Yes, and be honest with your friends,
I don't think we can stress that enough.
At Teen Vogue we do have a very non-biased opinion
on drug use, so if you do want to indulge in substances,
please we beg you to be honest with your friends
and those around you, like Dr Palamar said,
so it can better inform if something is to happen to you.
Alright guys, before we go we have to play
a game of Your fave is problematic.
And this week I'm gonna take it, if you don't mind Brit.
Alright, I'll hand it over.
I got something to say. (laughs)
Alright so, Cardi B's album Invasion of privacy
dropped this week and I have not stopped listening to it,
I'm actually going to purchase it
on Dr Palamar's iTunes because he has not heard it yet!
And we're so happy for her
and so proud of her here at Teen Vogue.
She also announced her pregnancy with rapper Offset,
the thing that I think I'm most upset about is like,
our fellow media outlets who have been pitting her
against other females in the industry.
For instance, they compared her debut album to
Nicki Minaj and where Nicki has been,
they compared her pregnancy reveal to Beyonce's
and it's just like, stop.
Like, she's having a good time,
she's really successful right now
and we should just be proud of her for that.
So, that is my problematic fave,
all of our fellow media outlets out there stop, stop.
Alright guys, thank you so much for joining us,
please stay safe if you do plan
on attending any festivals or parties
and as you know, we'll always be reading
your comments and questions,
so use the hashtag Teen Vogue Take
and we'll see you next week.
Don't forget to like, subscribe, follow, all that stuff.
(bouncy music)
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KCPR Radio Alumni Wiki: Adding Pages
Here are some things to know before you add pages:
- This website, kcpralumni.org, has three parts. You can make changes to two of those parts: the wiki and the gallery. There's more info in AboutKcprAlumniWebsite.
- Before making any changes, please log in. The wiki and the gallery are separate software packages, so each has its own login system -- but you can use the same user ID and password on both the wiki and gallery. The best user ID is made of your first and last names, capitalized, with no space between -- like JerryPeek. Any changes made by un-logged-in users may be deleted without notice (because we can't notify someone who's unidentified).
- Before you add a new page, please check whether there's already one like it! Start from the HomePage and browse through the categories. Use the FindPage box (at the top of every wiki page) and, if that doesn't help, try a FullTextSearch from the next page. If you find an existing page that you can edit, please see the editing instructions below under "To edit a page".
If you don't find a similar page to edit, then:
- Choose a new page name made of at least two capitalized words with no space between (like JerryPeek or AboutKcprAlumniWebsite).
- Edit some other page on the wiki and add a sentence or paragraph there that describes your new page. Somewhere within that description, use the new page name. This will become the link to your new page.
- After you save those edits, you'll see a questionmark (?) next to the new page name. Click it to create the new page.
To edit a page:
- Click the "Edit" button and follow some simple editing rules. (Here are more details.)
- If you change your mind, simply click your browser's "back" button to return to the unedited page.
- Once you're happy with your edits, please describe them in the "Summary" box at the bottom (which makes it easy for other people to know what the change is about).
- Remember to click the "Save" button!


text:
Listen to Gates' new album 'Parallel Lives' ahead of its official release tomorrow.
Grab a taste of Pierce The Veil's new album 'Midadventures' with this medley on Spotify.
Listen to Modern Baseball's brand new record 'Holy Ghost' ahead of its release this Friday.
Lacey are streaming their brand new EP in full, listen to it here!
Listen to Weatherstate's brand new EP 'Dumbstruck' in full!


text:
Amortization Of Prepayments With printable amortization schedule and option for Wikipedia defines a balloon loan or mortgage as a loan "which does Bank Of america: accelerating rmbs Premium Amortization Is The Biggest Risk – As underlying mortgages in the pool prepay (lower rates accelerate prepayments), the average life of the bond declines and the premium amortization.
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After suffering its deepest recession of the past century, respect for government has taken a battering: at the same time, a multibillion-dollar corruption. more than 10 percentage points ahead of.
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The Rounding Calculator an online tool which shows Rounding for the given input. Byju's Rounding Calculator is a tool which makes calculations very simple and interesting. If an input is given then it can easily show the result for the given number.


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Saturday Jul 04, 2020
Episode 38: On Social Media
Saturday Jul 04, 2020
Saturday Jul 04, 2020
We're back! After a year-long hiatus, we came back together to discuss social media. We dig in to cognitive bias, disunity in the church, and other spiritual dangers that Facebook, Twitter, and similar platforms present. We also offer some simple suggestions for Christians struggling in this area.
This episode's "book you should read" is an article by Mark Dever: 12 Questions to Ask Yourself Before Posting Something Online
Version: 20221013


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Client: Achieve Accreditation
Discipline: Web Design, Branding, Video, Presentations
This Chicago niche business specializes in hands-on guidance and comprehensive accreditation readiness resources to guide skilled nursing and assisted living organizations.. We needed to create an engaging customer online experience to scale nationally for this rapidly growing business. The Fuze Group designed & branded a mobile optimized website complete with explainer videos, talk through presentations, infographics and a slick blog. The Visual Impact Program also Included: a refreshed brand identity, pro images and messaging that were utilized in email marketing campaigns and social media platforms.
visit website: AchieveAccreditation.com
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More than two decades ago, the board-certified gastroenterologists at Specialists in Gastroenterology were among the first in their field to identify the relationship between small intestinal bacterial overgrowth (SIBO) and irritable bowel syndrome (IBS). Today, SIBO is a common problem that's now known to affect up to 80% of people with IBS. At their St. Louis, Missouri office, the area's leading GI experts diagnose SIBO using an advanced lactulose breath test and then manage the condition with a unique combination of highly effective therapies. Book your appointment by phone or schedule your SIBO evaluation online today.
Small intestinal bacterial overgrowth refers to excessive bacteria inside your small intestine, which typically occurs at the same time as troublesome gastrointestinal symptoms. It affects up to 80% of irritable bowel syndrome (IBS) sufferers.
SIBO affects many gastrointestinal diseases, including Crohn's disease, celiac disease, chronic pancreatitis, and immune syndromes. The most common cause of SIBO is poor neuromuscular function within your small intestine.
Small intestinal bacterial overgrowth symptoms commonly include:
In quite severe cases, you might also experience unintended weight loss or nutritional disorders. Toxic bacteria in your GI tract can lead to many different symptoms, including:
If you suspect SIBO or another GI problem, the SIBO center at Specialists in Gastroenterology can help.
To diagnose SIBO, Specialists in Gastroenterology uses a simple painless test, the lactulose breath test home test kit. After eating sugar — something the harmful bacteria thrives upon — you collect breath samples.
Specialists in Gastroenterology processes the samples on-site using a state-of-the-art gas chromatography machine.
Specialists in Gastroenterology was among the first providers in the area to recognize the role that bacterial imbalance plays in irritable bowel syndrome more than 20 years ago. They use their decades of knowledge, experience, and extensive SIBO research to design an ideal treatment plan for you.
This typically includes traditional antibiotics, alternative medicine, and specific dietary changes. With this balanced approach, you can overcome the uncomfortable IBS symptoms that hold you back from living your best life.
The experts at Specialists in Gastroenterology are widely known as pioneers in SIBO research, diagnosis, and treatment. They presented their first SIBO research in 2006 and continue to lecture, publish in medical journals, and contribute to SIBO books, as well as contributing to newspaper and TV interviews on the subject.
To learn more about how small intestinal bacterial overgrowth testing and treatment can help with your chronic GI symptoms, call Specialists in Gastroenterology or use online booking to make an appointment today.


text: Clackamas Community College's Board of Education voted to raise in-state tuition by $5 for the 2020-2021 school year at its March 11 meeting. Where tuition was previously $103 per credit hour, it will be $108 per credit starting in summer term. The cost of a typical four-credit class will be $432, compared to the previous…Read More


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My superfluous and corrugated vocabulary.
My ability to influence people with weak minds to do my bidding. But please, continue reading…
My belly makes a great island for when I play boats in the bathtub. My naval is a volcanic lake, in case you were wondering.
I always know the right thing to have theoretically said.
I don't split infinitives… I crush them into a fine paste…
Even when things get really bad, it does not change my determination because I'm usually not very determined from the start.
I'm proud of my poetry in that it hasn't directly killed anyone yet.
I like that I was always able to predict when my pregnant wife was going to act crazy. Hint: It was all the time.
I like that my work ethic doesn't interfere with my sloth ethic or my thief ethic.
I can determine if a woman is a natural blonde or a dyed blonde. Sometimes just by looking; but, other times, through a surreptitiously taken DNA sample.
My kind nature, which people have described as "corrugated" and "superfluous".
In jeans, my butt doesn't look as much like a weather balloon stuffed into a backpack as it used to.
I am very polite. I open doors for ladies. If they refuse to go through that door, then, she and I are gonna have a problem…
I can write on any topic; moreover, I can ignore all the criticism from people who read that writing.
I can name all of Elizabeth Taylor's husbands but sadly, they've already got names.


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It started with a voice mail on Jaime Bardacke's cell phone that sounded work-related. It came on Father's Day, and the licensed clinical social worker was driving back to her San Francisco apartment after visiting family, eager to eat dinner and watch the NBA playoffs.
That message kicked off a harrowing 6½-hour odyssey during which she was fleeced of thousands of dollars as she drove around San Francisco and the Peninsula on the phone with a swindler — who was in her head both literally through her earbuds and metaphorically through manipulation tactics.
It was like being kidnapped.
"He held me hostage with no gun but with his words," Bardacke said. "I never expected a call on a Sunday night to be from a sociopath."
Phone scams are incredibly common.
A stunning 59.4 million Americans lost $29.8 billion to them in the 12 months that ended in March, according to a report from Truecaller, based on a survey by the Harris Poll. That was a huge jump from pre-pandemic numbers. In 2019, 43 million Americans lost $10.5 billion to phone scams, according to the same poll for that year. Experts theorize that the lockdown isolation and virus anxiety made people more vulnerable to smooth-talking strangers. And despite the perception that seniors are more likely to be victimized, it was actually people ages 18 to 44 who fell prey most often.
While some are robocalls that scream fake — purportedly from the IRS or about an expired car warranty — others are perpetrated by criminals who use sophisticated mind-control tactics, experts say.
"Grifters are amateur psychologists," said Alan Castel, a UCLA psychology professor who studied scams for his book "Better With Age: The Psychology of Successful Aging."
"They understand that people respond to social influences, especially to authority," Castel said. "They know people don't use all their cognitive resources when they're stressed. They know that if you can rush people, scare people, they'll become hyper-focused on trying to solve a problem. Fraudsters create a powerful situation that induces compliance."
The man's message that Sunday said he was calling from the San Mateo County Sheriff's Office about a legal matter. That wasn't surprising. Bardacke, 45, deals with legal issues involving her clients.
When Bardacke returned home and called back, the man identified himself as Lt. Timothy Reid and asked Bardacke why she had failed to testify at a trial after having signed a subpoena saying she would appear. Now there was an order to arrest her for contempt of court, he told her.
"I was immediately concerned because I have been subpoenaed as an expert witness as part of my work," she said. "I knew this could affect the status of my license. My whole livelihood depends on that."
Bardacke told the man she'd never received a subpoena. He said she needed to come to the sheriff's office in Redwood City to sign her name to prove that her signature had been forged. Once she'd done so, she could be on her way, he said.
Bardacke Googled the caller's name and the Redwood City address he gave her. There was an officer with that name, and the address was for the Sheriff's Office.
The caller told Bardacke it was a federal case and a judge had issued a gag order so he couldn't say more about it. He had authority to bring her in and clear up the matter, but she would need to post a bail with the federal government that would be reimbursed once they proved her signature was forged.
As they talked, she could hear noises in the background that sounded as if he were at a police station — people talking, phones ringing.
"I was taken aback, but I was like, 'OK,'" she said. "He said it was $6,000 bail, and I said I didn't have that amount here. He said, 'That's OK, I can tell you how to get it and you'll be reimbursed as soon as you come into the station and verify.'"
Some internal alarm bells went off. Bardacke said she wanted to call a friend who's a lawyer.
The caller was firm.
"I'm sorry but once you're on the phone with me, you're not allowed to get off because you're considered a flight risk," she recalls him saying. "This phone call is being monitored and you're not allowed to send a text message or make any calls about this case because it's in violation of the gag order."
She shouldn't think of contacting the police either, he said.
"He said if I had any interaction with a police officer, I would be taken into custody and held at least 72 hours before the warrant could be lifted," she said. "I couldn't go to the police, call the police, set foot on police property until I posted this bond; otherwise I would be taken into custody."
Bardacke was scared, worrying how she would get the money, wondering about a request that seemed outrageous — but also remembering all the clients she'd known who were forced to spend time behind bars because they couldn't post bail.
"If you want to spend 72 hours in jail, that's your choice," the man kept saying. "I can stop helping you."
Bardacke's ordeal was not unique. Scores of therapists in California and throughout the country have fallen prey to similar phone calls, according to messages on professional list servers, news articles and warnings from industry associations.
The script varies, but there are some constants. The victims are women, many of whom list their work cell phone numbers on a website for people seeking therapists. (Some were actually notified by the site that someone had requested their contact information the same day the calls came.) The perpetrator is a man with a confident tone of authority. He tells them they are in legal trouble, but he can help them avoid jail time if they pay a fine or bail. He coaches them to buy gift cards.
The Chronicle interviewed four other Bay Area therapists who recounted very similar calls to the one that targeted Bardacke.
"I have been date-raped in my life, and this felt just as violating as that did," said one of the women who was granted anonymity in accordance with The Chronicle's policy on anonymous sources. "It was emotionally and psychologically violating and traumatic."
Bardacke told the caller she wasn't dressed to go out and needed to change clothes. "That's OK; you can put me on video," he said. She recoiled at the crude joke, and he apologized.
She dressed and got in her car, still on the phone. As instructed, she took two forms of ID and a manila envelope.
She hadn't had time to eat dinner. "I left my house hungry and scared, feeling kind of frantic," she said.
The caller instructed her to go a nearby ATM. Her daily withdrawal limit was $800. He told her to increase the limit via the bank's app, but she couldn't do it — "I was getting more and more flustered; it was hard to figure out" — so he told her to call the bank while he stayed on the line, listening in. She upped the limit to $1,500 and withdrew that amount.
The caller told Bardacke to go to a nearby Safeway to buy prepaid Visa cards with the money.
He said she then needed to send the cards via designated mailboxes that had arrangements with the Department of Treasury to serve as direct drop boxes. She wouldn't need to put postage on the envelope; just his name and badge number would suffice, he said.
He directed her where to find one of the mailboxes. She got more and more confused as she drove, seemingly in circles. Finally she found it. It was just a regular blue U.S. Postal Service mailbox, but he insisted it was special.
Right before she put a card in the mailbox, he had her read him the card number, scratch off the covering on the PINs and read those aloud too.
The entire time, he kept talking. He would scare her with the prospect of jail time, then be friendly by updating her on the score of the playoff game, then make her feel guilty for doubting him, then be nice, then scare her again.
"He had a whole rhythm of working me up into a state where I couldn't think straight," she said.
Seesawing between negative and positive emotions such as fear and friendliness is a classic gaslighting technique, said Stacey Wood, a professor of psychology at Scripps College, who researches scams. Swindlers invoke authority to give themselves credibility, she said.
Fear or the promise of a huge reward "place you into a less deliberative mind-set because your emotions are invoked," Wood said.
Another tactic: "Saying here's a problem and here's a solution," she said. "We all want a quick fix when we're in a bind."
Fraudsters use grooming behavior, starting their victims on small things and then escalating. In this case, getting a victim into her car was step one. Then came getting money from the ATM, buying gift cards and reading aloud the numbers.
Bardacke now can look back and analyze what happened, realizing that the situation triggered her to "fight, freeze and fawn" — well-known responses to trauma (along with flight, which she felt powerless to do).
Initially she tried to be friendly and engaging with the caller. As he frightened her, she fought back with her words, saying things like, "I can't do this. This isn't right. It's disgusting that this justice system works this way. This is a terrible thing you're asking me to do. Why should I believe you? This is cruel."
At other times she would freeze, breaking down and feeling unable to continue. He would coach her to take deep breaths and say they'd get through this together.
"I went through all those cycles, and then he would scare me again as soon as I started to think a little more clearly," Bardacke said. "Fear interrupts your executive functioning."
Almost two hours after she received the voice mail, the man was telling Bardacke to go to other stores for more prepaid cards. Once she had used up her cash, she should use her credit cards to buy the prepaid Visa cards, he said. She visited a 7-Eleven, a Target, a CVS, another Safeway. At each, the routine was the same: Buy the cards, drive around seeking the special mailboxes, then read him the numbers.
By then she was crying and distraught.
At Rite-Aid, the clerk looked her in the eyes and slipped her a preprinted flyer saying, "Are you the victim of a scam?" It listed common scams, including one where someone says you have to post a bail bond.
"That was the closest I came to ending it," she said. "Instead I walked away from the counter and told the guy on the phone."
He said he could prove he was legitimate by calling her back from his desk phone. He told her to Google the Sheriff's Office number. Sure enough, her phone rang a minute later, seemingly from that number. Bardacke didn't know that con artists can use a technique called spoofing to falsify caller ID information.
He said, "Jaime, how could I call you from this number if it were a scam?" she recalled. "He made me feel guilty for doubting him."
Prepaid cards are popular with scammers because they are easy to buy and have few consumer protections, according to the Federal Trade Commission.
Out of 556,792 fraud reports to the FTC for "imposter scams" — a criminal who pretends to be someone else — made from January to June, the top payment method was gift cards or reloading cards. The top contact method was a phone call.
About 14% of those half-million people reported losing money, totaling some $974.6 million in all, with a median loss of $1,000.
Imposter scams are surging, the agency says. In the second quarter of this year, almost a quarter of a million were reported, more than double the 91,000 at the same time last year.
It was now after 11 p.m. Bardacke was exhausted. She'd bought $6,000 worth of prepaid cards, read the numbers and put them in the mail. Now she just had to go to the Sheriff's Office in Redwood City, and it would all be over.
But the man wasn't done with her.
"He said, 'Before you get here, I want to warn you, you'll be subject to a strip search and cavity search when you arrive,'" Bardacke said. "'And we don't have a female officer here so I'll be doing it.'"
He described it to her in graphic detail.
"I panicked," she said. "I said, 'No, no, no, this can't be true.'"
The man again said he would help her. Instead of an in-person search, she could disrobe in a bathroom at a nearby drugstore and video herself doing the search. He gave her a .gov email address where she could send it.
She drove to a CVS. Sobbing, she begged the manager to let her in the closed bathroom, saying it was an emergency.
She had to hang up the phone to take a video. Her hands were shaking. She couldn't work her phone. She realized she couldn't do this to herself. She decided she'd just let him search her.
She drove to the address he'd given her in Redwood City.
The windows were dark. It was clearly a daytime office.
She called him and there was no answer.
"And that's when I knew," she said.
For Bridget Early, 45, the call came through the main office of the San Francisco middle school where she is a social worker. Her principal called her to say she had an urgent call from a sergeant, and transferred the call to her in the library. "He said my date of birth and my Social Security number," Early said. "He sounded really legitimate."
He told her there was a warrant for her arrest for not going through the proper channels for jury duty. "I totally believed it, and was really freaked out," Early said. "He kept saying, 'Yes, ma'am, I know this is really scary; don't worry, we're going to figure it out.'"
He told her that she could handle it with a $500 fine to be paid at 850 Bryant, the San Francisco Hall of Justice. He said she could pay the money via a gift card from Walgreens.
She hung up and told her principal and some co-workers, who said it sounded like a scam. But she was so rattled and fearful of being arrested that she felt she had to comply.
Early got in her car and the man called on her cell phone to see if she was getting the money. She started driving.
But then she listened to her own protective instincts. She called a friend who works nights at a jail. "He said, 'Stop your car, turn around — this is totally a scam,'" she said.
The "sergeant" called her over and over, probably seven times. He left messages saying, "Are you on your way? We're waiting; you don't want to be arrested."
Her friend called co-workers at 850 Bryant. One of them went out front to pretend to be Early, calling out that she was Bridget and had the money. No one responded.
Barnacke's first thought was relief — both that her ordeal was over, and that her inner voice, which all along had told her this was not OK, was trustworthy. "I just overrode that," she said.
She called 911, went to the San Francisco police station and reported it. The officer filed two reports, for a financial crime and a sexual crime. The calls were from a burner phone, he told her. She would have no recourse with the banks or credit card companies because she herself had taken out the money.
She reached out to local colleagues in the next days, and about 15 said they had been victimized by a similar scam.
"It's clearly targeting our profession," she said.
It seems ironic that therapists, who understand psychology, would be particularly vulnerable, but there are some reasons.
One is that a threat to a therapist's license is a powerful motivator because their livelihood depends on that.
Another is that many therapists are committed to trying to understand other people and see their humanity.
"There's an empathy therapists have that I think can get easily exploited," Bardacke said.
San Francisco police received 632 reports of fraudulent game or trick for obtaining money or property in 2020, and 322 this year as of Aug. 23.
Apprehending criminals who use prepaid phones and receive prepaid cards is rare.
"Tracking down and identifying suspects for crimes like this is the most difficult aspect of the investigation," said SFPD spokesperson Officer Robert Rueca. While the department's goal is to catch perpetrators, its other mission is to prevent people from becoming victims by educating the public.
"Any person can be susceptible to one of these scams," said Castel, the UCLA professor. "It's not just lonely older people. It's often very intelligent, rational people who are looking to solve a problem. Victims aren't necessarily gullible, ignorant or uneducated; often it is the exact opposite."
Castel said he thinks support groups that offer victims a safe space to share their stories would be a great way to help them recover. People who are willing to speak up publicly are doing a service by helping spread awareness, he said.
That was Bardacke's motivation in going public about her ordeal.
"If even a few people can be saved from this, it's worth it," she said. "The only way these people get away with this is because it's not talked about because of the shame involved. It's a crime where information is the only thing that will save you."
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Book/Printed Material [ Martha Graham, Little Theatre, October 16, 1927]
About this Item
- [ Martha Graham, Little Theatre, October 16, 1927]
- Graham, Martha (performer)
- Horst, Louis (instrumentalist)
- Sabin, Evelyn (performer)
- MacDonald, Betty (performer)
- Savelli, Rosina (performer)
Created / Published
- Little Theatre, New York, October 16, 1927.
- - Adagio
- - Danse
- - Esquisse Antique
- - Five Poems
- - Ronde
- - Tanzstück
- - Two Poems from the East
- - Dance Piece
- - Fragilité
- - Poeme ailé
- - Lugubre
- - Désir
- - Madonna
- - Revolt
- - Reproduced with permission of Martha Graham Resources, a division of The Martha Graham Center of Contemporary Dance, www.marthagraham.org. (Copyright Notice)
- concert program
- 4 p., 5 x 8 in.
- Music Division
LC Classification
- Martha Graham Collection Box 308, #14
Online Format
- image
Additional Metadata Formats
Part of
Rights & Access
The Library of Congress is providing access to these materials for educational and research purposes and makes no warranty with regard to their use for other purposes. The written permission of the copyright owners and/or other rights holders (such as holders of publicity and/or privacy rights) is required for distribution, reproduction, or other use of protected items beyond that allowed by fair use or other statutory exemptions. There may be content that is protected as "works for hire" (copyright may be held by the party that commissioned the original work) and/or under the copyright or neighboring-rights laws of other nations.
Responsibility for making an independent legal assessment of an item and securing any necessary permission ultimately rests with persons desiring to use the item. Users should consult the bibliographic information that accompanies each item for specific information. This catalog data provides the details known to the Library of Congress regarding the corresponding items and may assist users in making independent assessments of the legal status of these items as related to their desired uses.
Items included here with the permission of the rights holders are indicated as such in the bibliographic record for each item.
In some cases, the Library was unable to identify a possible rights holder and has elected to place some of those items online as an exercise of fair use for strictly non-commercial educational uses. The Library of Congress would like to learn more about these materials and would like to hear from individuals or institutions that have any additional information or know of their history. Please contact: Performing Arts Reading Room.
Suggested credit line: Library of Congress, Music Division.
Cite This Item
Citations are generated automatically from bibliographic data as a convenience, and may not be complete or accurate.
Chicago citation style:
Graham, Martha, Louis Horst, Evelyn Sabin, Betty Macdonald, and Rosina Savelli. Martha Graham, Little Theatre. Little Theatre, New York, 1927. Pdf. https://www.loc.gov/item/ihas.200153301/.
APA citation style:
Graham, M., Horst, L., Sabin, E., Macdonald, B. & Savelli, R. (1927) Martha Graham, Little Theatre. Little Theatre, New York. [Pdf] Retrieved from the Library of Congress, https://www.loc.gov/item/ihas.200153301/.
MLA citation style:
Graham, Martha, et al. Martha Graham, Little Theatre. Little Theatre, New York, 1927. Pdf. Retrieved from the Library of Congress, <www.loc.gov/item/ihas.200153301/>.


text: Tyler's art was recently featured at an art show here in San José. We went downtown to the Costa Rican American Cultural Center where those who were up for awards were invited. It was a big deal. There were probably 25 private schools represented. Tyler didn't win, but still, just getting invited to the show was pretty cool. We are really excited for him.


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I've said it before and I'll say it again: Medical treatment is something we take for granted and we really shouldn't. Even a simple cut in the P.A.W. can be life-threatening if you don't treat it. For something more serious like a gunshot wound it is imperative that you know how to stop the bleeding and treat the wound in order to survive, whether you're the one shot or not. The OutdoorLife Survival blog has an article on how to survive being shot.
While most of you will likely never be in the position that Reeson found himself, the question is worth asking: If, god forbid, you are ever shot, what should you do to survive?
The short answer is that you survive getting shot with a little bit of luck, some skill, ample trauma first aid supplies, a degree of stubbornness and maybe a little divine providence.
How To Survive A Gunshot Wound via [OutdoorLife Survival Blog]