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March 28, 2017
An invitation from this distinguished society to deliver the Annual Discourse is a signal honor —one that I deeply appreciate and of whose significance I am keenly aware. It may or may not be of some moment that I am the first commissioner of public health to be honored in this way, but, in any case, my emphasis here on matters of public health will not be a "first" in the history of this occasion. A large number of the discourses have been on subjects that are clearly within the area of public health or closely related to it. They have ranged in content from such obviously germane topics as the effects of mass programs of immunization to important problems of medical economics. It should be noted, too, that although I am the first commissioner among those who have addressed the Society in this long succession of speakers, there was one, Henry P. Walcott, who occupied a similar role as far back as 1889. He was chairman of the State Board of Health, a position that he held for twenty-eight years, and his topic on that occasion was "State and Preventive Medicine in Massachusetts."
While I am in this historical frame of mind, it may be well to look back for a moment and review a few of the events that, with the perspective lent by hindsight, now stand out as important milestones in the evolution of this pact, this partnership in public responsibility that has been shared by government and the Massachusetts Medical Society through the years.
The charter of the Massachusetts Medical Society was granted by the General Court in 1781. It was the first such document to be issued by the new state government, and it reads, in part, as follows:
Health is essentially necessary to the happiness of Society; and its preservation or recovery is closely connected with the knowledge of the animal economy and of the properties and effects of medicines; the benefit of medical institutions formed on liberal principles and encouraged by the patronage of the law is universally acknowledged.
Many years later, in 1924, Stone outlined in his Annual Discourse the purposes for which the Society was founded. They were stated thus:
The advancement of public health.
The advancement of medical knowledge.
The sound training of physicians.
The information of the public upon medical matters.
As though in anticipation of these basic objectives, the Massachusetts Medical Society petitioned the Legislature in 1861 urging the establishment of a state board of health. But this event had been preceded by years of study and effort by responsible persons who were deeply concerned about health conditions in the Commonwealth. One of the leaders in the advancement of public-health measures under law was Dr. Henry Ingersoll Bowditch. Long familiar with the work of Chadwick in England, he was dismayed at the poor sanitary conditions of this country and deeply troubled over the lack of action to remedy them and to control rampant communicable diseases.
It must have been a frustrating and bitter period in the life of Dr. Bowditch. Eleven years before the Society's petition, the report of a legislative commission had laid a solid scientific foundation that clearly supported the need for organized public-health activity. A member of the Legislature, a Boston book-seller named Lemuel Shattuck, had written the memorable document that has become one of the classics of medical literature, but nineteen years elapsed before its recommendations were translated into action.
Shattuck's now famous Sanitary Survey of 1850 may have languished on some official shelf, but it had eloquent spokesmen in the community. The medical profession was, of course, in the forefront of those demanding that the State Government take an active role in minimizing conditions that needed attention at mid-century. As time wore on, epidemics — many of them aggravated by the chaotic conditions that grew out of the Civil War — spoke eloquently, too. Diphtheria reached a fearsome peak; the death rate from tuberculosis stood at about 400 per 100,000 of population and accounted for 20 to 25 per cent of all deaths. These pressures from medical men and medical crises accumulated without apparent effect until 1869, when, ironically, the wife of a legislative leader pressed for action. She was prompted by a typhoid epidemic that occurred in a girls' school in which she was personally interested; this final straw broke the back of legislative resistance and brought about the first agency of its kind in this country — the Massachusetts Board of Health.
Dr. Bowditch became the chairman of the Board and was a logical choice for such an important position. His leadership within the medical profession itself, his intense activity in promoting the idea of a state board of health and his keen sense of organization made him especially well fitted to guide the Board in its early years of development.
It was noted above that the birth of the new Board, attended by a proud medical profession, was not accomplished without considerable travail. Let us now see how the relation between these two entities developed. In order to do so, we may briefly consider two important and well known programs as concrete examples: tuberculosis control and the cancer program.
In a survey of the field of tuberculosis, we come again upon a familiar name, this time that of Dr. Vincent Bowditch, the son of the Board's first chairman. For some years he had sensed the need for an institution in the vicinity of Boston for the benefit of the many persons who, for pecuniary or other reasons, were unable to go to distant health resorts for treatment. As a result of his efforts, Sharon Sanatorium was opened in 1891. It was soon demonstrated that tuberculosis could be cured near home and that bed rest was a more important element in its treatment than the vaunted salubrious climates of distant health resorts. As a direct outgrowth of this work at Sharon, the State appointed a board to select a site and to build thereon a hospital for consumptive patients. Thus, in 1898, the first state-operated sanatorium in this country was opened at Rutland, Massachusetts.
With the acceptance of the idea that tuberculosis could be cured and with the establishment of a means of doing it, medicine could now turn its attention to the tasks of prevention and improved control. In 1907 the Legislature caused fifteen health districts to be created, administered by physicians working on a part-time basis and known officially as state inspectors of health. Each was charged with the responsibility of informing himself on the prevalence of tuberculosis and other health hazards in his district.
In 1914 the Metropolitan Life Insurance Company showed the practicability of community effort to control tuberculosis — the Framingham demonstration. In a seven-year period this program reduced the tuberculosis death rate of that community from 121 to 38 per 100,000 population. This was followed in 1916 by the enactment of a law making it mandatory for the counties to erect and maintain hospitals with sufficient beds to care for the tuberculous patients of each county. And in 1924 the ten-year program of Chadwick Clinics was started as an intensive effort to discover, treat and eradicate tuberculosis in children. Thus was the pressure against this disease maintained over the years.
But although the tuberculosis programs that have been developed over the last seventy-five years owe their success to a high degree of co-operation between government and the medical profession, the present-day harmony was not achieved without the intrusion of painful periods of dispute and contention. There was reluctance to support the spending of tax funds for the long-term care of consumptive patients; considerable suspicion and misgivings were aroused when physicians were appointed as district health officers, since it was feared by some that they might interfere with the clinician's treatment of his patient. Even the provision of laboratory services for the identification of tubercle bacilli was not viewed as an unmixed blessing. Undoubtedly, the most controversial aspect of the new plan was the compulsory reporting of tuberculous persons by name to the Board of Health. It was strenuously resisted by the medical profession as an unwarranted invasion of the patient-physician relationship.
At this juncture, it is well to point out that opposition to these measures was not universal in the medical profession. Some of its members opposed, but progress came about through the vision and leadership of others, and because of their vision we have been able to move ahead to the present situation. Today, we have many more sanatorium beds than there are patients to fill them, and the virtual eradication of this once great killer is close at hand. The fact that this progress has created a problem in the teaching of medical students is disquieting, but we would obviously rather contend with this problem than with the disease itself.
So much for tuberculosis. There are those who, in discussing the role of health departments, contend that tuberculosis control is a logical area for governmental activity because the disease is communicable and requires community surveillance. But what of cancer? Here is a noncommunicable disease that, unlike tuberculosis, has been on the increase for the past fifty years.
The need for government to concern itself with the problem of cancer control was noted by the Board before the turn of this century. It is instructive to study the interaction between organized medicine and government in the development of this type of program, in which the factor of contagiousness does not operate but where, nevertheless, the task is that of coping with a problem whose magnitude is increasing.
In 1900, in the thirty-second annual report of the State Board of Health, W. F. Whitney presented a painstaking review of the statistics on cancer mortality. A year later, he delivered the Shattuck Lecture before the Massachusetts Medical Society and on this occasion again showed a keen awareness of the growing importance of cancer as a health problem.
In 1916 the Massachusetts Medical Society appointed a cancer committee with Edward Reynolds as its chairman. In its very first report this committee recommended state-wide opportunities for free laboratory diagnosis of pathologic tissues, and it also urged a widespread campaign of public education. The committee was responsible for other advances, such as arranging with the various district societies to devote one meeting a year to the subject of cancer control, and the initiating of Cancer Week in 1921.
Others were active, too. In 1917 the Harvard Cancer Commission volunteered to diagnose specimens of tissue suspected of being malignant. The connection between the recommendation by the Society's Cancer Committee of this as a needed service and the offer made by the Harvard Cancer Commission is readily apparent. The next logical step followed promptly: in 1919, Dr. Eugene Kelley, Commissioner of Public Health, requested funds to assist in the support of the Tumor Diagnostic Service and to conduct an educational campaign. The diagnostic service has continued to be a joint effort of the Cancer Commission and the State up to the present time.
In 1914, after his attendance at the International Cancer Conference in Brussels, Dr. Francis D. Donoghue introduced a resolve in the House of Representatives to study the general problem, but the Legislature did not authorize such a study until 1925, when the departments of Health and of Welfare were directed to study the problem jointly and submit a report. The outcome of this work was that in 1926 the present cancer clinic program was authorized, as was the transfer of Pondville Hospital from the Department of Mental Health to the Department of Public Health and its designation as a facility for the treatment of cancer.
Although the Massachusetts Medical Society provided much of the impetus for the development of the cancer program, it furnished strong opposition — at the time — to the operation of a cancer hospital by the State; nor should it pass unmentioned that the Health Department itself was far from enthusiastic about the idea! Curiously enough, support for this move came from the laity. Prominent among the leaders were Monsignor Ambrose F. Roche, of Watertown, Mr. Wilbur Trussell, one of the founders of the Massachusetts Society for the Control of Cancer, and State Senator (now Congressman) John W. McCormack.
Pondville Hospital was opened as a cancer hospital in 1926 and has served its purpose admirably, not only in the realm of treatment but in the functions of research and the specialized training of physicians as well. A section of the statute that established the cancer program calls attention to the Legislature's determination to defy the attitude of organized medicine. It reads:
The department, with or without the cooperation of local Boards of Health, hospitals, dispensaries or other agencies shall establish and maintain cancer clinics and may otherwise provide services and treatment for cancer.
Whereas a detailed evaluation of the cancer program is not within the scope or intent of this discourse, it may at least be noted that results have measured up to our hopes and expectations. The tumor diagnostic work has provided an excellent resource for practicing physicians and has encouraged them to have suspected tissues examined. The cancer clinics are available throughout the State and are providing excellent services for diagnosis and follow-up study. The hospitals give expert care and cooperate fully with the medical profession and with other hospitals in the use of expensive equipment, as well as in the performance of highly technical surgical procedures. A large number of physicians in the Commonwealth have received training in the management of this disease at the hospitals operated by the Department. And, lastly, important contributions have been made to our knowledge of this problem by the various aspects of the research effort.
Here, then, is a venture in public service that has endured as an activity of the Department of Public Health for more than forty years and has earned favorable acceptance and support from the medical profession. Apart from the curious fact that there are still some physicians who regard the cancer program as an autonomous entity operating outside the orbit of the State's public-health work, it is nevertheless gratifying to have periodic assurance from the profession at large that this undertaking is an appropriate activity for state government and that it is being adequately managed. The old question of the extent to which the cancer program has interfered with private practice is rarely raised these days. Moreover, so far as the Legislature is an index of public attitudes, there is consistently strong support for the Department's cancer-control activities; the program is clearly accepted as one of the modern responsibilities of government.
Laying all speculation aside, one may postulate that this high degree of approval results from the fact that the cancer program evolved from a pressing need whose true dimensions were accurately assessed by those concerned, and that it was developed in close collaboration with the medical profession. In this connection, full recognition must be given to the contributions made by Drs. Eugene R. Kelley, George H. Bigelow and Herbert L. Lombard. Their zeal in laying a sound foundation and their tireless efforts to obtain the understanding and support of organized medicine were crucial ingredients in building the program to its present stature.
And now, a new problem looms before the people of the nation and has found its way into the debates of the public forum — one that is not concerned specifically with disease as such, either communicable or noncommunicable. This is the challenging problem of medical care for the aged. For reasons well understood by this assemblage, we are witnessing an era in which our increasing population is living longer and contains a greater proportion of old people than ever before. We know that this is not a transient situation and that the weight of its implications will increase before the statistical picture becomes relatively stable. Whatever economic and political debates may rage, this is a responsibility that civilized society must assume. That both medicine and government should participate is scarcely debatable; the question is merely one of how rather than whether.
The Great Depression of the 1930's taught us that voluntary welfare organizations were not adequate to bear the burdens imposed by national crises. The massive and rapid growth of our economy has brought about changes that have far-reaching consequences, and, irrespective of differing political philosophies, there is nearly universal agreement on the propriety of government extending its functions and resources to embrace areas of community life in a way never imagined by our forefathers when this nation was born.
Properly or not, the State has been in the business of health up to the hilt and could not extricate itself even if it were sensible to do so. Government has no desire to assume undue proprietorships, but it will take the best minds and talents we can mobilize if we are to match the vision and discrimination of those who have preceded us in making a viable blueprint for the future — a plan that will confine governmental activity within limits that will best serve the public interest and, at the same time, enhance the rights and basic incentives of the medical profession. This is not to say that walls should be built around separate domains; it is to say that the health department and organized medicine should supplement one another, sometimes through co-ordinated efforts in disparate fields, sometimes combining for the sake of maximum accomplishment in the same field. But none of these things can be fully realized without the clarifications and easy communication that are the by-products of joint planning; no enduring philosophy can emerge to guide us through the difficult years that surely lie ahead without complete co-operation.
Whatever the future is to bring in terms of planning requires an inventory of the Department's present activity and a statement of what it sees as some of its problems. The trend toward a broadened responsibility in the realm of chronic disease is clear. The Department did not start operating hospitals until 1920, when 4 state institutions were brought into the structure as part of the Division of Sanatoria and Tuberculosis Control. At the present time, the Department has 390 beds for tuberculosis, 160 for cancer, 360 for crippling conditions and 2284 in the general category of chronic disease. The operation of these institutions accounts for 75 per cent of the Department's budget.
Another function that grows naturally out of our responsibility for actually providing care is the licensing of hospitals, nursing homes and rest homes. This program was developed with the active co-operation of the medical profession and those concerned with the operation of hospitals and nursing homes; it has been designated as a necessary function of government and has placed an important task in the hands of the Department, that of establishing minimum standards for physical facilities and the qualifications of personnel. Still another adjunct of the Department's activity is our responsibility for the allocation of funds that are available for hospital construction under the provisions of the federal Hill—Burton Act. Although functions of this sort are not medical in the literal sense, they are not without influence in shaping the character of the medical-care program of the Commonwealth.
However, our program must not be allowed to become arrested at its present level of development. There are many problems that urgently require solution. A case in point is seen in the difficulties associated with the provision of continuing care of good quality in the management of chronic disease. Our hospitals are like islands of efficiency surrounded by areas that do not contain the rich variety of facilities necessary for the support of the physician's treatment goals. Far too often, the patient who could be at home must remain in the hospital or be returned to a community setting that is poorly organized in terms of its medical care. Thus, a reasonable and attainable aim for the concerted efforts of government and organized medicine is that of developing services in the community to a degree of reliability that will approximate the excellence of service to be found inside our hospitals.
It may be that the term "medical care" is too general for the direct communication of what I intend as a specific suggestion. If we refract the phrase, so to speak, into a five-part spectrum, it is possible to see its components — namely, health maintenance, office treatment, care in the home, hospital care and custodial care. In the same manner in which these categories range from the well patient to the chronically ill or disabled, there is a progression from the least to the most expensive forms of medical care. Herein lies the key to planning and action on a broad scale. It involves the co-ordinated use of voluntary and other agencies as resources for the practicing physician to avoid duplication of effort on the one hand and to improve health services for our citizenry on the other. It would attempt to shift the emphasis from the hospital-type services that are often most expensive to services that are preventive and much less costly both in financial terms and to the welfare of the patient.
Major obstacles stand in the way of a more effective public-health service, and they affect a field of action even broader in scope than that of chronic disease alone. These obstacles are derivatives of and, in large part, attributable to weaknesses in the structural aspect of the state's local health services. For example, of the 351 communities in the Commonwealth, there are 144 where boards of selectmen discharge the responsibilities of a board of health in addition to their normal duties. This means that in 43 per cent of the state's communities there is no single organization primarily concerned with the health problems of its citizens. This fact would be less disturbing if one could feel that, in general, physicians participated actively in the formulation of the health policies of their local communities, but, contrary to popular belief, they do not. There are 189 additional communities where boards of health do exist, but in all 333 of these two groups of communities combined there are fewer than 40 per cent that have the benefit of medically trained personnel to participate in their deliberations and activities.
The fact that the Department of Public Health is not equipped to be of optimal assistance to the areas most lacking in resources only adds to the frustration of all concerned. At present, the entire state is divided into 5 geographic areas served by only 4 district health officers, who, in each case, act in advisory and "trouble-shooting" capacities to a large number of localities. The two western districts, covered by 1 medical officer, comprise 100 communities, 670,000 persons and 2800 square miles; the Northeastern District embraces an area of 838 square miles and 65 communities with an aggregate population of well over 1,500,000. The remaining 2 districts are no better off with regard to adequate coverage. Contacts between a given local health agency and the district health officer are, perforce, infrequent and of minimal impact except in cases of emergency. A mere courtesy visit once a year to each community would consume about half the working time of any district officer.
To sum up, the inescapable fact is that, although a few communities possess well organized health departments, the ability of boards of health and of selectmen to deal with the health problems of their people falls seriously short of attainable standards. This statement is made in sympathy, not in criticism. Most of those involved are hard pressed, conscientious officers who are well aware of the disparity between the size of their tasks and the tools available for accomplishing them. I have met with representatives of these boards personally and believe that I am giving voice to their points of view. They want help and guidance; the Department wants to join them in finding practical answers to their most elusive questions.
To find solutions to these pressing problems, it is necessary to develop a set of guiding principles that can be applied to the wide range of situations in which we continually find ourselves. If it is true that we have too frequently insisted that functions must adjust themselves to a predetermined structure, it follows that our search must be for an operational framework that is capable of bending itself to the tasks that must be performed. Not long ago, I was told a story about a college that was established in this country. In planning the sidewalks from one building to another, the architects decided to wait and see where people actually walked before laying out the pathways and pouring concrete. When the school was opened and students began to move about the grounds, natural paths were formed, sometimes cutting diagonally across grassy areas, sometimes describing arcs and angles — depending on the kind of needs and habits that developed. Permanent walks were then made to follow these paths and, so the story goes, the newly planted grass was allowed to grow without warning signs or roped-off areas — which often do not work anyway.
Our problem is more important than the nurture and development of thick carpets of grass, but I believe that a principle in this story is applicable to the over-all problem of devising local health services that will be performed in a well co-ordinated and effective manner. The solution, of course, lies in understanding the ways and habits of our people, both lay and professional, and the logistics involved in serving their needs with the resources at hand. From this point of view, geographic boundaries serve no constructive purposes unless they facilitate the development of sound functional relations.
What, then, are the alternatives? What pathways can be followed that will lead us to increased communication without endangering valuable, indigenous social structures? How shall we establish two-way traffic between medicine, government and the people without treading on somebody's cherished grass?
My most recent reflections have led me to take a hard look at the organizational structure of the Massachusetts Medical Society and its 20 component districts. As one examines the geographic distribution of these districts, it becomes obvious that they correspond quite closely to what may be called "trade areas," or medical-service areas. In so doing, they fulfill a prime requisite for the efficient reorganization of public-health services by and for groups who have both manifest and implied commitments to each other within contexts of social interaction that tend to foster communication rather than to impede it. In the face of our acknowledged need for closer collaboration, it may be most logical to revamp the Department's mechanisms for local health administration along lines that will correspond with the Society's district pattern. Besides satisfying an important principle of organization, such an arrangement would provide opportunities for local health boards to work closely with organized medicine in a way that is only fortuitously possible under present circumstances.
Public-health activities have a desperate need for the insights and leadership of the medical profession throughout our network of local communities. It is not enough that, traditionally, there has been a high degree of co-operation between the Society and the Department at the state level, where relatively few persons from each group are involved; the active participation of practicing physicians in the communities is needed. It is vital for them to exercise leadership wherever they are, because unless they become the heart and soul of the broad public-health function, this service cannot become a mature enterprise with the wisdoms necessary for meeting the challenges that are to come — to say nothing of those that are already upon us.
We in the Department of Public Health are convinced that there is a way of working with the medical profession at the district-society level so as to bring about desired results and with the full co-operation of local boards of health. To this end, we intend to approach one or more district societies soon to elicit their help in working out a plan of study that will enable us to demonstrate whether our considered opinions have validity in the field of practice. We need to know whether public-health organization at the local level is amenable to changes that may be indicated by whatever pertinent facts are brought to light, but most of all we want to preserve what is best in the principle of local mobilization for the solution of local problems. It is our hope that the rank-and-file members of the Society will reassert the leadership in local health affairs that is rightfully theirs. Their voices are needed. If these roles are not filled by medical men, they will be taken over increasingly by others less well qualified. Actually, a large intrusion into community health programs has already occurred: school boards were the first to organize school health services in a number of localities, and there are medical-care services operating with large budgets in the State departments of Education and Welfare. The Department of Education developed the physical rehabilitation program, and the Department of Welfare has expanded its medical-care section to a point where it is now the largest single program operated by this state agency. This fact has serious implications. Health programs are scattered through many parts of state government and often have little or no dynamic contact with the medical profession. It is not that there is a failure to employ physicians to do medical chores; the point of my complaint is that these men are much too remote from the planning and development aspects of these programs. Doctors contribute their technical skills once it has been determined what the activities shall be, but they play a negligible part in designing them. These are structures built without architects. If they are sometimes unlovely in shape, the reasons are clear.
Reluctance on the part of the individual physician to assume leadership in community-health affairs is puzzling. It is a phenomenon that is too complex to be explained by a simple statement of causation. There is a myth that physicians are not good administrators, but this is a libel that falls of its own weight. Similarly, it is not possible to give serious thought to the assertion that they are indifferent to community problems. Doctors give freely to the needy; undoubtedly, medicine is still the most generous of the professions, and service to others is so ingrained in their experience that they seldom think of it except as a normal way of life. Nevertheless, the image of the physician as a community leader, especially in the field of public health, is fading. One suspects that the public is being re-educated — through what it does not perceive — to associate leadership in local health programs with those who are more vocal and more readily drawn into the vacuums created by the withdrawal of medical skills from the public-health scene. There are no villains in this piece, and no maligning of motives. One simply reports what has happened and registers uneasiness lest it continue. The nonmedical administrator of public health did not spring full grown out of nowhere; he came into being as a result of needs that could not be asked to wait.
Still another charge is leveled at private practitioners to explain their apparent aloofness from public-health activities: it is said that they have a serious mistrust of public-health operations as well as of public-health physicians. These criticisms originate from within our own profession and are perhaps epitomized by a statement made by Dr. Ben Freedman in the Journal of the Louisiana State Medical Society, from which I quote:
Organized medicine has developed an almost obsessed suspicion of community organized health programs, particularly when administered by the government. Because public health agencies are the traditional operators of community organization health programs, public health physicians, who are agents of the government, have received the brunt of the private practitioner's suspicions and have been tolerated with reluctance in organized medicine's circles.
Closer to home, in discussing the merits of a home care program, a recent president of this society said to me, "You have to realize that you are tarred with the brush of public health."
In spite of the fact that organized medicine gave life to the public-health movement and in spite of the evidence that there has been no demonstrable interference with private practice, a wide gulf continues to separate these two great entities from one another except for the slender bridges that communicate with limited areas on either side. The division is the more baffling because there is no fundamental barrier to their active partnership. Certainly, nobody would seek the discontinuance of public-health activity at this late date. It is all too clear that such programs as tuberculosis control, cancer, child-health services, crippled children's clinics, alcoholism and the investigation of epidemics and of venereal-disease contacts are supportive and indispensable to the private practice of medicine. Nobody would deny that this activity has contributed importantly to the high level of health enjoyed by our citizens.
Finally, it is less constructive to view with alarm than to join forces to solve the problems that exist. Public health and organized medicine have a common heritage and are motivated by the same ethics. These are invaluable assets with which to make a beginning. Realignments of similar nature have been accomplished elsewhere in the face of much initial pessimism. In recent years the Pennsylvania Medical Society has achieved a remarkable resurgence of medical leadership in the public-health field. Through its Commission on Public Health and Preventive Medicine it has revitalized the public-health service of that commonwealth. The physicians of the State have combined to foster a broad program of public health for each community. The Society is developing a program to encourage gifted young physicians to go into public health as a dignified and rewarding career. At the same time the Society has interested itself in the immediate problem of placing highly competent career personnel in the top administrative posts of the state health department. An active educational campaign, aimed at the establishment of full-time, medically directed local health departments, was carried on with remarkable success. At present, the Pennsylvania Medical Society is addressing itself to the problem of fragmentation of health services and their distribution among many state agencies. The goal in this campaign is to combine all these services under the direction of a single agency — one that will be in tune with the aspirations of the communities served and structured according to the ideals of the medical profession. All this is reminiscent of the Massachusetts Medical Society of an earlier day when the activities of the new state board of health were being acclaimed by the groups of physicians who had brought it into being. I submit that it can be so again — that history can repeat itself on the grand scale and in keeping with the multiple requirements of the modern era.
We in Massachusetts have a past that is replete with pioneering efforts in behalf of the public's state of health; the aggressive curiosity, the spirit of adventure that lay behind those heroic achievements has, in some way, become diluted — for reasons that have as much to do with technologic advances as with shifting emphases in the responsibilities allocated to and assumed by government. Furthermore, whereas governmental expansion in the field of medical care is viewed by some as undue encroachment on professional preserves, it has been a long time since the interested parties have convened for the purpose of assessing needs and meeting them with programs that are efficient and technically sound.
I should like to close with an assertion and a plea. All of us recognize the inseparability of private medicine and the enterprise known as the field of public health. This relationship will not change in the foreseeable future. In addition, in the task of fashioning a totality of health care, no individual need bear a heavy burden. It is vital for all to give a little so that a few do not have to give too much. We in public health need your help; the people of the Commonwealth need both of us functioning at our best.
Frechette, Alfred L. "The Massachusetts Medical Society and the Organization of Public-Health Services — Retrospect and Prospect." New England Journal of Medicine 265, no. 4 (1961): 153-59.
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text: Peaks urge more home support for older Australians Aug 17, 2018, 15:12 PM by Maiy Azize Anglicare Australia has joined a coalition of leading not-for-profit aged care peak bodies said that in spite of a recent increase in home care funding today's data shows a worrying and unsustainable trend in the demand and provision of home care packages for older Australians. "These figures show a trend towards more people waiting for home care, more people being assigned packages that don't meet their needs and more people joining the queue for services," said ACSA CEO Pat Sparrow. Figures for the quarter ended 31 March 2018, show the queue of those waiting to receive a package, or an appropriate package for their needs, rose to 108, 456 people compared to 104, 602 for the December quarter. Around half (54, 821 people) of those in the queue were assigned a lower level package than their needs required, and the remaining half were yet to receive a package (53,635 people). "Nationally, there are now 54,821 people in the queue still without any package assigned, or settling for a lower package than they require - a more than 14 per cent jump since the last data report." "This is beyond frustrating for those older Australians waiting for care, not to mention their families, and without further investment recognising the problem as one of sustainability in funding going forward the problem will only get worse," said Ms. Sparrow. Paul Sadler, spokesperson for Presbyterian Care Australia, said limited home care choice and provision will eventually add pressure on other aged care services: "It is important for people to get the care they need at home for their quality of life and also to avoid or defer a move to costlier permanent residential aged care. An inability to access a HCP when it is needed may severely limit the support choices of an older person," he said. "Projecting into a future with growing numbers of older Australians, home care provision will get even worse unless the government takes action to fix the problem now," said Marcia Balzer, Executive Director of Baptist Care Australia. "This is about how we value older Australians. People must be able to get the care they need at home - or we are severely limiting the choices of older people," said Kasy Chambers, Executive Director of Anglicare Australia. "More must be done to deliver timely care to those that need it," said Ms. Sparrow. "It's unacceptable that so many older Australians should be left without the care they need or endure a long and unnecessary wait." ACSA and the other peaks are calling on the Government to provide: An immediate release of more packages particularly more level 3 and 4. Additional support for assessment processes and services to ensure the prioritisation process is as effective and efficient as it can be.

subset: commoncrawl


text:
Status: In Progress
Genre: Erotica
The hot water washed the sweat off Dave's magnificent body. He had just finished another tough workout with Diane. Life was good, he thought. How many men had a hot wealthy blonde doing their backs in a shower? Not many, he decided but this hot wealthy blonde was doing his back. Dave had just heard Diane say, "I'm done, muscleman" when he saw an arm go across his upper torso and felt a hand grab his crotch. "Resistance is futile, muscleman," she declared as she squeezed it. Diane nuzzled and kissed his neck and sank her teeth in his ear lobe. Her hand fondled his penis as she purred in his ear, "I'm going to make you big and hard." As his penis grew rigid, she purred, "That's it. You're big and hard. Just the way I like it. And you like being big and hard, don't you, darling?"
He smiled. "You know I do, honey."
Her hand stopped fondling his penis and gripped it tightly. It moved back and forth rapidly. In a moment, Dave ejaculated.
He shut off the water and faced Diane. "That was a pleasant surprise."
"It was a spur of the moment thing. There I was doing your beautiful back and I thought I'd give you a little treat. Keeps things interesting, you know."
"It certainly does. And now, my beautiful golden-haired goddess, I need to thank you properly."
They shared a long kiss. After the kiss, Dave said, "Let's finish our shower."
As Dave stood under the spray, he thought, Yes, indeed. Life was good.
© Copyright 2020 HaroldF. All rights reserved.
That was a nice morning treat. Dave and Diane sure are the perfect couple. I liked this short to the point story. Great job.
Short Story / Erotica
Short Story / Erotica
Short Story / Erotica


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True enough…we've posted this next bit before…but it wasn't embedded and it was eight years ago. And not even for Halloween. So I would say it's fair game again. I'm talking about the Edward Haber and Citizen Kafka bit entitled "Abbott and Costello Meet the Antichrist." Which fills me with joy, so it should for you as well.
[fusion_builder_container hundred_percent="yes" overflow="visible"][fusion_builder_row][fusion_builder_column type="1_1″ background_position="left top" background_color="" border_size="" border_color="" border_style="solid" spacing="yes" background_image="" background_repeat="no-repeat" padding="" margin_top="0px" margin_bottom="0px" class="" id="" animation_type="" animation_speed="0.3″ animation_direction="left" hide_on_mobile="no" center_content="no" min_height="none"][ad#shortpost]
For our main event, however, that kicks off Day 15 of this year's marathon mayhem, we go to the Haunted Mansion, something we can't stay away from because it's…well, awesome. In 1969, when the attraction finally opened in Disneyland, there was a commemorative album released as well: narrated by Thurl Ravenscroft (he sang "You're a Mean One, Mr. Grinch"), it stars Ron Howard as one of the teenagers who has the adventure within the Mansion that plays out in true old school storyteller album format. The whole shebang was finally re-released on CD back in 2009.
And one of these damn days I'm going to make it to Disneyland for the Haunted Mansion/Nightmare Before Christmas mashup.[/fusion_builder_column][/fusion_builder_row][/fusion_builder_container]


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When HVAC is something you want to learn about, you're going to need some solid advice on the subject. It's not hard to learn about if you're able to get the right kind of information. That's what this article will provide you with, so when you're ready you should read along.
If you must hire someone to help you out with your HVAC system, be sure to learn about all of the requirements your state has legislated regarding licencing and insurance. You need to be able to ask anyone you plan to hire if they meet these requirements before you hire them.
Let your friends and family know about the discounts that are possible via ENERGY STAR. There's a lot of savings that can be had here, so why hold this good news all to yourself! You can save those closest to you hundreds of dollars over the course of a year.
One of the most important things to consider when purchasing a new heating and cooling system is the manufacturer's warranty. Units come with a variety of warranties. Choose one with a long warranty for maximum long term savings. Generally, it is advised that homeowners should purchase the extended warranty if one is offered.
If you want to know where you should put an outdoor compressor, you should place it somewhere where there is a lot of shade. The cooler air entering the unit will require less work to get to the proper temperature.
Make sure that your contractor provides a home assessment. Not every HVAC solution is for everyone. Your home could have special needs for heating and cooling. Your contractor should do a walk around of your space to judge what is best. If they aren't be sure to request one.
If you want to cool your home in the summer without using your air conditioning on full, consider installing fans in your home. An attic fan can blow hot air out while sucking in cool air into your basement, and ceiling fans help distribute the air in your rooms evenly.
If you want to turn off your air conditioning at night to save money, consider putting a standing fan next to your bed. You can set it to oscillate from your toes to your head, blowing cool air over your body and letting you sleep comfortably all night long.
It is possible for air conditioners to ice over. Freezes also occur in your drain line. These freezes are easily confused as leaks to the untrained eye. If this happens, turn the thermostat so it is on fan only mode, which will disable the compressor. If the issue persists, call in help.
It's easy to see that HVAC isn't hard to get into if you just take your time with it. In the end, you won't have too much trouble if you put what you've learned here to good use. Don't take our word for it and give it a try yourself before you do anything else!


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- Cousins Who Geek
New Disney Movie Trailers
Disney graced us with not one but TWO new teaser trailers this week for two of their upcoming fall/winter releases, Mary Poppins Returns and Christopher Robbin.
MARY POPPINS RETURNS (December 25)
This of course is the sequel of sorts to the beloved 1964 Mary Poppins with Julie Andrews. This new version sees Emily Blunt re-cast in the role of the famous nanny with Lin-Manuel Miranda of Hamilton fame cast as Lamplighter Jack.
We don't get much in the trailer but we do see a return to Cherry Tree Lane a well as grown-up versions of Michael and Jane Banks, the children from the original film.
Now I am excited for this one, Mary Poppins is one of my favorite films and I love Emily Blunt who I think was a perfect casting choice here. Plus we will get new music from Lin-Manuel.
CHRISTOPHER ROBBIN (August 3)
Now first, let us not get this confused with Goodbye, Christopher Robbin which is a totally different film that cam out in 2017. Disney's Christopher Robbin will follow a grown-up Christopher (Ewan McGregor) who seems to have lost his way a bit and will see the return of his silly, willy, nilly old bear Winnie the Pooh along with the rest of the residents of the Hundred Acre Woods.
Now I'm not gonna lie, this trailer made me tear up a bit. I LOVE Pooh Bear, he was the first Disney character was I introduced to as a baby and that has stuck with me.
What do you think of the two new trailers Disney gave us this week? Are you excited for either of these two films, yes or no let us know if the comments below.
#ewanmcgregor #linmanuelmiranda #winniethepooh #emilyblunt #disney #disneymovies #disneyblogger #marypoppins


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Wholeschool Portal
21 September 2020
Transfer 2016
Academic Policy
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Art and Design
Economics, Accounting, and Business Studies
Modern Languages
Moving Image Arts
Performing Arts
R.E. & Life and Work
Internal Exams Timetable
Yr 12 Summer Tasks
Extra Curricular
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Duke of Edinburgh
European Day of Languages
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Scripture Union
E8 Conference
Ski Trip 2015
Cross Country and Athletics
Careers Overview
Careers Resources
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Post-16 Options
Careers Events
Final Destinations
Careers Curriculum
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Enniskillen Royal Grammar School
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Email us!
Ms N. Heap
Ms H. Gibson
Mr. J. Mulholland
Mrs S. Rees
Key Stage 3
In the English department, we value the skills of independent reading, thinking and problem solving, developing communication skills and working with others. During the course of the Key Stage 3 curriculum, we aim to provide opportunities for pupils to pursue these skills through a range of texts, themes and tasks. Our aim is to give all students the opportunity to explore both fiction and non-fiction texts, as well as to learn the functional skills needed to communicate in the world through reading, writing, talking and listening and ICT.
Year 8
, pupils study their own language development, a range of spelling strategies, different forms of poetry, Shakespeare's Macbeth and creative writing, as well as entering into the Accelerated Reader programme which allows pupils to track their reading, set targets and earn points.
Year 9
, pupils study the genre of fantasy fiction, Irish poetry, film, Shakespeare's Romeo and Juliet, media texts, persuasive writing, as well as continuing to read independently to earn points in the Accelerated Reader programme in the library. In Year 9, we also teach drama within English, exploring character through role play and other interactive strategies in the drama studio.
At the end of
Year 10
, pupils are accessed on their Communication skills, and so we provide a range of opportunities for reading, writing and talking and listening within class time. Activities in these units include a formal debate, writing newspaper articles and analysing leaflets. As well as those functional skills, pupils also study a play by Willy Russell, Our Day Out, an anthology of poetry and a collection of short stories in preparation for their GCSE English and English Literature courses in Years 11 and 12.
In the English department, we are also keen to provide opportunities outside of the classroom, so in addition to regular theatre visits and cinema trips, we enter the Mock Trial competition (at both junior and senior level) and the Times Spelling Bee on an annual basis. Pupils who take part thrive on the experiences gained from practicing their English skills outside the classroom and we encourage all pupils to get involved.
Key Stage 4
At Key Stage 4 we build on the skills such as independent reading, thinking and problem solving, developing communication skills and working with others that have been developed at Key Stage 3. We continue to provide a balance between fiction and non-fiction as well as providing some literature focus for those pupils who do not pursue English Literature GCSE as an optional subject.
Key Stage 4: GCSE
English Language
This subject is compulsory for all pupils. It consists of assessment three controlled assessment tasks, three controlled assessment speaking and listening tasks and two external examinations.
The examination board is CEA.
Internal, controlled assessment tasks (60%)
Speaking and listening assessment (20%) based on three best assessments
Written assessment: Studying Spoken and Written Language and Writing Creatively: (40%)
Task 1: The Study of Spoken Language (10%)
Task 2: The Study of Written Language (15%)
Task 3: Writing Creatively (15%)
External examination Assessment (40%)
Unit 1
Section A - Personal Writing: fluent, organised, engaging, accurate writing
Section B – Reading Multi-modal texts: analyse and explain how texts engage readers
Unit 2
Section A – Functional Writing:
Inform, Explain, Describe
Section B – Reading non-fiction:
Response to Non-fiction and Media
English Literature
This subject is optional at GCSE and consists of assessment through two terminal examinations and one controlled assessment task.
The examination board used will be AQA
Examination Assessment (75%)
(Choice of texts subject to change)
Unit 1: Exploring modern texts
The study of two prose texts (such as Lord of the Flies and Of Mice and Men)
Unit 2: Poetry across time (poetry cluster from anthology and unseen poem)
Internally assessed tasks (25%)
(Choice of texts subject to change)
Unit 3: The significance of Shakespeare and the English Literary Heritage (such as Macbeth and Animal Farm)
One comparative task
Key Stage 5/sixth form
At Key Stage 5 we seek to balance the development of skills such as independent study and critical analysis within the support of collaborative class study.
Pupils are given extra curricular opportunities to develop their skills and creativity through theatre visits, the annual Joyce Beckett writing competition run with Clongowes Wood College, participating in the senior mock trial, public speaking competitions and the annual Royal Schools debating competitions.
Key Stage 5: AS and A2 level
English Literature
The examination board used will be AQA
Unit 1: Aspects of narrative
Comparative study of Poetry and Prose pre and post 1900 (such as McEwan: Enduring Love, Fitzgerald: The Great Gatsby, Browning anthology and Tennyson anthology)
(60% 0f AS, 30% of A2 level)
Study of two novels and two poetry texts answering two questions from two sections
2 hours open book
AS 2: Dramatic Genres
Coursework on two dramatists, one to be Shakespeare
(40% 0f AS, 20% of A2 level)
Study of two texts within dramatic genre of comedy (theme is subject to change): William Shakespeare's As You Like It and Oscar Wilde's The Importance of Being Earnest.
2 pieces of coursework
A2 3: Texts and genres
Comparative study of texts across genre pre and post 1800 (30% of A level)
Study of three texts within theme of gothic (theme is subject to change): William Shakespeare's Macbeth, Mary Shelley's Frankenstein and Christopher Marlowe's Dr Faustus.
2 hours closed book
A2 4: Further and Independent Reading
Study of prose (such as Joyce: Dubliners, Friel: Translations and Shakespeare: The Tempest)
(20% of A level)
2 pieces of coursework, one to be comparative and one to show critical awareness
School News :


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Magnum P.I. (season 1, 2, 3, 4) full Episodes 720p
Here you can TV show Magnum P.I. (season 1, 2, 3, 4) full episodes. Just select the season below and enjoy high speed safe downloading without torrents and ads. Supported formats: .mp4 .mkv and .avi. Supported devices: laptop, Mac, PC, tables, mobile – iphone and Android. Quality formats: 480p, 720p, 1080p Full HD.
The plot of the series sends viewers to Hawaii, where it is sunny, warm, but not as safe as we would like. Crimes occur even in such a paradise, so there is a place for an outstanding detective Thomas Magnum, who conducts investigations of varying complexity. Not long ago, Thomas returned from a long trip to Afghanistan. He got a detective job. Together with colleagues Theodore Kelvin and Orville Wright, Magnum will have to work on solving crimes on a sunny American island. However, in addition to the work, the main character has to resolve issues with people from the past.


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Wow, this was a fun problem. An Acer all-in-one computer, everything was great except for this annoying bug, everytime you copied a file (drag and drop, copy and paste, whatever) Windows explorer puts up the "Windows Explorer has stopped working" message. Tried all the standard stuuff, SFC /scannow, virus and malware removal, chkdsk all to no avail. Looked at the drivers, all looked good, but when I tried to update the drivers for the NVVIDIA GT 204M card it failed. Started the machine up on Ubuntu 14.04, and the graphics card just did not do its job. In Ubuntu 9.10 it was fine. It looked a bit like the video card was not 100%. On the web there are stories of incorrect video drivers causing this issue, so it sounded related.
I investigated the cost of a new card, and including shipping, fitting and GST the customer was up for about NZ$450.
As a last resort, I did a Repair Upgrade of Windows 7 Home Premium. This worked fine, and lo and behold, the drag and drop was working fine again! So I fixed the windows 7 update issue, and started rolling forward all the windows 7 updates, about 220 of them! At the end of it all, the problem was back!
OK, use the restore function to go back to the last check point, and everything works again. Only one thing for it, find out which update is causing the issue. I decided the problem was probably with the 80 or so "Updates for Windows 7 …" rather than the security updates or the .NET updates, so I did a binary chop installing half of what was left each time. Of course the issue was in the last 4, then the last 2, until I finally determined it was update KB3184143, not KB3182203 (an update to allow for a summer time change in Novosibirsk in Russia).
KB3184143 turns out to be the update to remove all the Windows 10 upgrade stuff, all that nagging reminders agro and nasty software that attempted to install Windows 10 even when you didn't want it! As this was a clean install (well a refresh anyway) none of this software was present, so it sulked for a bit and stopped Windows Explorer working. After uninstalling, I hid the update, and carried on with the rest of the updates. It was probably related to the video card issue, as Windows 10 can struggle with video cards, but it is much too hard for me.


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We're pleased to have welcomed two new members of the Aquarius team since moving to our new office in Tileyard in 2018.
Georgie Weston joined the team in October as an Associate, having recently completed her Master of Public Health at the London School of Hygiene and Tropical Medicine, awarded with Distinction. Georgie has experience working with a range of organisations, including the WHO, health charities, and large pharmaceutical companies where she worked within communications and marketing strategy.
Since joining, Georgie has worked on several health economic models, including Excel budget impact tools, decision tree models in TreeAge, and our cloud-based tools, all of which are designed to provide evidence and persuade decision makers in healthcare.
Georgie has also led training workshops and written journal articles.
We asked her to tell us a little more about herself.
What have you most enjoyed about working at Aquarius so far?
"It's really interesting to work on projects right from inception, using different types of qualitative and quantitative methods to uncover insights into the problem. This spans from pinpointing the client's unmet need and then designing a bespoke solution, such as creating health economics models and digital tools to predict and communicate the impact of innovation within healthcare systems."
What do you like most about the new office?
"It's great to have Teddy (our Well-being Officer) in the office with us every day – I've bonded with him already! He's always up for a trip across the road to our onsite café Vinyl with me."
If you were to work on any healthcare condition – what would it be?
"I've done a bit on modelling of antimicrobial resistance since I started, and it's a fascinating topic. There is so much research still to be done, plus it's really challenging topic so it would be exciting to be part of the solution."
More recently in April, we welcomed Dr Florence Mowlem to the team as an Associate. Flo recently completed her MSc and PhD at the Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London. You can find the papers from her PhD published in peer-reviewed journals. She also has experience working with the Academy of Medical Sciences and was a member of an HRA Research Ethics Committee. After her PhD she spent some time working at King's on the statistical analysis of a clinical trial investigating a treatment for autism.
Here's a bit more about her:
What are you most looking forward to about working at Aquarius?
"I'm looking forward to getting stuck in with a variety of the interesting projects that Aquarius works on, and the opportunity to contribute to providing the robust evidence that clients need to demonstrate value. It's so important to understand unmet need and the most effective ways to deliver healthcare for maximizing patient benefit, which is central to Aquarius' work."
I think you've already bonded with Teddy. Is that right?
"I have already been impressed by his full repertoire of tricks, and he brings great light relief to the office!"
What challenging healthcare question would you like to work on at Aquarius?
"Given my background in psychology and mental health research, I think it would be interesting to work on a project that aims to understand the economic impact of a mental health intervention for a given condition. Often physical health diseases seem more tangible and, given there is not a biomarker or blood test for most mental health disorders, challenges exist around the reliability and validity of psychiatric diagnoses. Poor mental health is affecting more and more of the population and costing the healthcare system, society, and the individual a lot, and so it's really important to be developing effective interventions and having a clear understanding of their value through economic evaluation.
For example, phone app interventions have been developed to reduce relapse in schizophrenia patients by encouraging medication adherence, and it's important to understand how much this could save the healthcare system."
We know that Georgie and Flo's wealth of experience will benefit the team along with the projects they are involved in.
We are also looking to fill a number of new openings in the team, so if you think you'd be the right fit for Aquarius, then please get in touch!
You can find us on twitter (@AquariusPH) and Linkedin, where you can keep up to date with our work and recent developments.


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106 Faithway Street, Santa Fe, New Mexico 87501
Absolute Nirvana is a luxurious spa in Santa Fe, New Mexico. Located in the gardens of the Madeleine Inn, a beautiful 1886 Victorian Queen Anne buildi... Read More
855 Cerrillos Rd Suite C, Santa Fe, New Mexico 87505
Getting beautiful hair should be a great experience. B beautiful Salon clients leave the salon happy, relaxed and satisfied. We have created a welcomi... Read More
1424 Second Street, Santa Fe, New Mexico 87505
505.982. 3899
Beautiful Skin is a local medical spa in Santa Fe, New Mexico owned by mother and daughter, Barbara Salas CNP and Charlene Stehling. The two have a un... Read More
333 West Cordova Road, Santa Fe, New Mexico 87505
Founded by Lorin Parrish in 2004, BODY is a yoga and dance studio, café, spa, fitness center and boutique as well as a childcare center and yoga teac... Read More
1544 Cerrillos Road, Santa Fe, New Mexico 87505
Brazilian Waxing Boutique is an Award Winning Wax & Skincare Spa that Specializes in both the Male & Female Brazilian Bikini Wax.... Read More
540 W Cordova Rd # 1 , Santa Fe, New Mexico 87505
At Chrysalis Salon and Beauty Store we are committed to bringing our clients a welcoming salon where quality is the priority. Our team is made up of... Read More
104 Old Las Vegas Hwy , Santa Fe, New Mexico 87505
El Gancho Fitness, Swim & Racquet Club is a full-service private health club.... Read More
1501 Paseo de Peralta, Santa Fe, New Mexico 87501
Upon entering the Spa, you will be immersed in a sense of Nature's elements; water falling, open sky, and Mother Earth's nurturing. Our highly tra... Read More
330 East Palace Avenue, Santa Fe, New Mexico 87501
Welcome to New Mexico's premier resort, where the rich history of the Southwest meets modern amenities and upscale comforts. Set on six beautifully la... Read More
845 Agua Fria, Santa Fe, New Mexico 87501
Jacqueline opened Lotus Beauty 3 years ago with the vision that she could create a salon with a healthy, spa-like atmosphere. A salon where you can re... Read More
309 W San Francisco Street, Santa Fe, New Mexico 87501
Authentic, Time Honored Traditions Make Nidah One of the Best Santa Fe Spas In America's most unique city, discover a mystical Santa Fe Day Spa that ... Read More
3545 Zafarano Drive, Suite B, Santa Fe, New Mexico 87507
Our mission at Aveda is to care for the world we live in, from the products we make to the ways in which we give back to society. At Aveda, we strive ... Read More
530 W. Cordova Rd. Suite E, Santa Fe, New Mexico 87505
If the eyes are the windows to the soul, the eyebrows are the windows treatments. The eyebrows are the most important feature on your face. The perfec... Read More
229 Johnson St., Suite C, Santa Fe, New Mexico 87501
Sanctuary Santa Fe was founded in 1996 by European Esthetician Kerstyn Porsch.... Read More
2205 Miguel Chavez Road, Suite E, Santa Fe, New Mexico 87505
As the first medi-spa in the Santa Fe area, Santa Ana Skin Care Clinic offers leading-edge treatments in skin care and anti-aging to rejuvenate your c... Read More
1297 Bishops Lodge Road, Santa Fe, New Mexico 87506
Experience SháNah Spa & Wellness Center — honored by Condé Nast Johansens as "Most Outstanding Spa" for North America and Caribbean. Far more ... Read More
(505) 660-4299
Keller Williams Realty
130 Lincoln Avenue - Ste K
Santa Fe, NM 87501
Keller Williams Realty, Inc. is a real estate franchise company. Each Keller Williams office is independently owned and operated. Keller Williams Realty, Inc. is an Equal Opportunity Employer and supports the Fair Housing Act.


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Our short morning was taken up with a leisurely breakfast in our room and some phone calls to friends.
Leaving the hotel around 1.00pm we headed for a local government registry. The Princess has had enough of sharing identities on various documents so she is putting all official documents in her married name. Anyone who has done this will remember the effort (and paperwork) required. It is now underway so when I return to Calgary in late July I will be returning to a "new" wife – at least that's what her passport will say!
Nellies on 4th was our choice for lunch. This natty little restaurant is located (as the name suggests) on 4th Avenue near downtown Calgary. The menu is simple so it matches the decor and service. However, the food was tasty and light and we enjoyed the window seat in the sun.
A drive around the local area along the Elbow River after lunch, a quick stop for the afternoon "brew" in Altadore (where our condo is located) then onto find a business that took passport photo's.
The south of Calgary was our choice for passport photo's. Why – because we were having supper with friends that lived nearby. We stopped in the Shawnessy Town Centre – a sprawling outer suburban development that has been built to service the increasing population in the south of Calgary.
The Princess powdered her nose and face (literally because she was too shiny according to the photographer) and smiled for the camera. We parted with $16.00CAD for the pleasure (I don't seem to remember passport photo's costing that much in Hong Kong!) and left the store in search of a liquor store that sold nice red wine. Actually there was one next door so we didn't have to walk far!
Our friends, Victor and Charlotte, had invited us to share supper with them at their wonderful home in Shawnessy at 6.30pm. The short drive to their house meant that we arrived on time.
Dinner conversation was fun and fascinating – catching up on 18 months of each other's news. The hosts are a fascinating couple that are wonderful conversationalists. At 12.30pm we had to "wrap things up" for fear of us continuing on until breakfast!
Needless to say we did not get to bed early. Indeed, it was close to 2.00am before we finally turned out the lights in the hotel room. We were not really tired but our bodies and minds appreciated our heads finally sinking into the pillows.
In summary – a fun day outside in Calgary's warming weather and some wonderful time with friends.
We hope this finds you all living your lives just as you planned – we plan to live it in THE NOW.
Roey and The Princess
Tags: calgary, Canada, coffee, dining, Elbow River, mountains, Nellies On 4th, North America, Photography, Princess, Roey, travel, we go two, WeGoTwo, wegotwo travel, wine


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Marketing Certificate
Linfield University Online and Continuing Education's online marketing certificate program builds the skills necessary to excel in marketing. This certificate program develops the business acumen needed to compete in today's global marketplace while exposing you to a balanced curriculum designed to develop critical thinking, effective communication, and proficiency in marketing technologies and processes. With the ability to identify and target emerging markets, Linfield University marketing certificate program graduates have a competitive advantage when searching for promising careers.
Employment Opportunities
- Marketing Specialist
- Advertising Manager
- Promotion Manager
- Marketing Manager
- Marketing Research Analyst
- Sales Manager
Who Should Enroll
Linfield University's marketing certificate program is the perfect match for you, if you are interested in public relations, advertising, or research. The curriculum also complements bachelor's degrees, as it offers further insights into marketing, sales, and promotions management within the modern global economy. With marketing professionals in demand in just about every industry, Linfield credentials help make prospective employees stand out and achieve their professional potential.
Courses You Will Take
As a nationally accredited institution with the highest standards, Linfield's online marketing certificate program requires not only marketing courses, but also classes meant to teach critical thinking and communication skills. All courses are taught by faculty members with real-world experience. The program requires the completion of two core courses and three elective courses.
BNSS 250 - Contemporary Business / 4 credits
BNMK 321 - Marketing / 4 credits *
Plus 3 of the following:
BNMK 420 - Sales and Sales Management / 4 credits **
BNMK 421 - Promotions Management / 4 credits **
BNMK 426 - International Marketing / 4 credits **
BNMK 427 - Topics in Marketing / 4 credits
For a list of courses offered this academic year view the Year Long Plan.
Why Linfield University?
At Linfield University, the marketing certificate program is offered 100 percent online, which makes it an invaluable opportunity for students with busy lifestyles, families, and full-time employment. With accreditation by the Northwest Commission on Colleges and Universities, Linfield University credentials open up new employment paths with higher earning potentials. The faculty members are dedicated to the academic success of each student, and students receive continual support through the academic advising program. Linfield also offers access to technical support, research resources, and online tutoring. Linfield University increases access to higher education through affordable tuition rates and financial aid. With a higher completion rate than the national average, Linfield University students are on the track to succeed.
I'd like to find out more. What are my next steps?
- Fill out the Request Information form to learn more.
- Schedule a conversation with the admission counselor for this program.
- Call 503-883-2213 or email firstname.lastname@example.com with any questions.
- Just apply now if you're ready to invest in your future.
Of the students who completed this program within normal time, the typical graduate leaves with $ n/a* of debt. *Fewer than 10 students completed this program in the normal time. This number has been withheld to preserve the confidentiality of the students.
The following States do not have licensure requirements for this profession: Oregon
For more information about graduation rates, loan repayment rates, and post-enrollment earnings about this institution and other postsecondary institutions please click here: https://collegescorecard.ed.gov/


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Although I thrive under pressure, this photo shoot took the cake! I had less than an hour to wrangle three kids and a dog for pictures fit for a Christmas card. And just between you and me, I had just started learning to shoot in anything but auto mode. Oy.
Did I mention that it was freezing out? I made these poor children sit on an ice-cold rock for this shot.The kids were troopers though and even let me do some individual shots before running back inside to warm up!
Give me two hours next year and some sweaters and I promise it'll be golden. 😉


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- North America
- United States
- Michigan
- Red Mill
- Search
Traveling Luck for Red Mill Michigan, United States
The timezone in Red Mill is America/Iqaluit
Morning Sunrise at 07:40 and Evening Sunset at 19:28. It's Dark
Rough GPS position Latitude. 42.0558°, Longitude. -86.1292°
Morning Sunrise at 07:40 and Evening Sunset at 19:28. It's Dark
Rough GPS position Latitude. 42.0558°, Longitude. -86.1292°
Weather near Red Mill Last report from Benton Harbor, Southwest Michigan Regional Airport, MI 30.5km awayTemperature: 14°C / 57°F
Wind: 6.9km/h Northwest
Cloud: Scattered at 2700ft Broken at 3200ft Solid Overcast at 6000ft
Satellite map of Red Mill and it's surroudings...
Geographic features & Photographs around Red Mill in Michigan, United States
lake a large inland body of standing water.
- Priest Lake (2.1km)
- Round Lake (3.5km)
- Geer Lake (3.7km)
- Magician Lake (3.7km)
- Pitcher Lake (4.1km)
- Dewey Lake (5.7km)
- Keeler Lake (6.6km)
- Cook Lake (6.6km)
- Cable Lake (6.8km)
- Crooked Lake (7.6km)
- Pine Lake (8km)
- Pine Lake (8.1km)
- Brown Lake (8.4km)
- Osborn Lake (8.5km)
- Twin Lakes (8.5km)
- Grabemeyer Lake (8.6km)
- Round Lake (8.7km)
- Knickerbocker Lake (9.5km)
- School Lake (10.5km)
- Johnson Lake (10.6km)
school building(s) where instruction in one or more branches of knowledge takes place.
- Daly School (3.2km)
- Hill School (3.5km)
- North Wayne School (3.7km)
- Bell School (5.1km)
- Gregory School (5.2km)
- Hinchman School (6.3km)
- Field School (7km)
- Gage School (7.4km)
- Baker School (8.2km)
- Cushing Corners School (8.8km)
- California School (8.8km)
- Indian Lake School (9.3km)
- Hayden School (9.6km)
- Celery Center School (10km)
- Sykes School (10.1km)
- First School (10.2km)
populated place a city, town, village, or other agglomeration of buildings where people live and work.
- Maple Island (4.8km)
- Sandy Beach (5.9km)
- Woodland Beach (7.1km)
- Sister Lakes (7.3km)
- Keeler (8.4km)
- Glenwood (9.5km)
- Dowagiac (9.7km)
- Indian Lake (10.4km)
administrative division an administrative division of a country, undifferentiated as to administrative level.
- Silver Creek, Township of (5.9km)
- Keeler, Township of (8.5km)
- Wayne, Township of (8.7km)
- Dowagiac, City of (9.7km)
- Hamilton, Township of (10.6km)
Accommodation around Red Mill
Baymont Inn and Suites Dowagiac/Niles, MI 29291 Amerihost Dr, Dowagiac
Fairfield Inn & Suites Watervliet Berrien County 8258 Arnt Blvd, Watervliet
Village Inn Motel Berrien Springs 9008 Us Highway 31, Berrien Springs
stream a body of running water moving to a lower level in a channel on land.
- Silver Creek (5km)
- Lake of the Woods Drain (9.5km)
- Dowagiac Creek (10.6km)
airport a place where aircraft regularly land and take off, with runways, navigational aids, and major facilities for the commercial handling of passengers and cargo.
- Dowagiac Municipal Airport (8.3km)
- Lee Memorial Hospital Heliport (9.6km)
Local Feature A Nearby feature worthy of being marked on a map..
- Red Mill (0km)
- Moores Corners (7.7km)
swamp a wetland dominated by tree vegetation.
- Dowagiac Swamp (5.6km)
post office a public building in which mail is received, sorted and distributed.
tower a high conspicuous structure, typically much higher than its diameter.
- WDOW-AM (Dowagiac) (9.3km)
cemetery a burial place or ground.
- Riverside Cemetery (10.6km)
canal an artificial watercourse.
- Osborn Drain (4.2km)
Wikipedia entries close to Red Mill
- Berrien Center, Michigan city o
- Benton Charter Township, Michigan city o
- Dowagiac River river
- Southwest Michigan Regional Airport airport airport
- Paw Paw River river
- Calvin crater impact crate landmark
- Palisades Nuclear Generating Station building landmark
- Granger, Indiana city o city
- South Haven Charter Township, Michigan city o
- Simonton Lake, Indiana city o city
- Georgetown, St. Joseph County, Indiana city o city
- Donald C. Cook Nuclear Generating Station building landmark
- Dayton, Berrien County, Michigan city o
- Roseland, Indiana city o city
- Indian Village, Indiana city o city
- Weesaw Township, Michigan city o
Airports close to Red MillGerald r ford international(GRR), Grand rapids, Usa (123.8km)
Chicago midway international(MDW), Chicago, Usa (164.3km)
Chicago ohare international(ORD), Chicago, Usa (175.3km)
Waukegan rgnl(UGN), Chicago, Usa (177.3km)
Capital city(LAN), Lansing, Usa (178.2km)


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CORPUS CHRISTI, Texas – Faculty and staff at Texas A&M University-Corpus Christi participated in #GivingTuesday, a global initiative inviting people from all corners of the world to give back to their communities. #GivingTuesday takes place on the first Tuesday after Thanksgiving. This year, it fell on Tuesday, Nov. 29. This is the third year Island University faculty and staff have participated in #GivingTuesday.
"Participating in something that is going on worldwide is pretty exciting," said Ann DeGaish, Associate Vice President for Student Engagement and Success and Dean of Students at Texas A&M-Corpus Christi. "The Corpus Christi community provides so much support for the university that it's important for us to give back in person to the community."
To support the university's Momentum 20/20 plan, the division of Student Engagement and Success began looking for a way to a be more involved in the local community. Three years ago, they discovered this program and decided to make it available to faculty and staff campus-wide. This year, 125 Islander faculty and staff volunteers contributed 269 hours of service and were able to make a difference at ten off-campus locations. The number of participants has increased dramatically from 44 participants in 2014.
"Giving Tuesday is an important event for our campus to be involved in because we are able to give back to the community," said Claudia Ayala, Assistant Director at the University Counseling Center. "I am amazed at how many new people are interested in participating each year."
Volunteers participated many service-based activities including sorting goods for the Food Bank of Corpus Christi and donating blood at the Coastal Bend Blood Center. Other volunteer sites included the Glenoak Therapeutic Riding Center, Mission 911, The Gulf Coast Humane Society and Gloria Hicks Elementary School. A group of volunteers also handed out warm meals to the homeless at Corpus Christi Metro Ministries.
"I was overwhelmed by the response of our faculty and staff to the program," said DeGaish. "I'm looking forward to Giving Tuesday growing each year. I am very grateful that Dr. Killebrew has supported this program and has allowed us this opportunity."
#GivingTuesday was founded in 2012 by New York's 92nd Street Y in partnership with the United Nations Foundation. Together, with a team of influencers and founding partners, a global movement was launched that has engaged more than 10,000 organizations worldwide.
"For me, higher education was a way out of poverty and doing things like participating in Giving Tuesday reminds how fortunate I am," said Dr. Amy Aldridge Sanford, Associate Vice President for Academic Affairs. "If not for my higher education, I could be in similar situations. It is humbling for me to work in these non-profit spaces where I am able to hear people's stories, humanize them and provide hope."
To see the full #GivingTuesday photo album, click HERE.


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What we feel and what we say
Are so different, the way
To know which way I am leaning
Is to heed carefully my poem's meaning
Because poetry, written on the page
Is helpless to show my tears and rage.
My feelings have nothing to do with speech—
Which has a mental agility feelings cannot reach.
So you and I must agree
To not look for feelings in my poetry.
Just listen to me very carefully:
I love you. I'm trapped. In this poem. Help me.


text:
Technavio has been monitoring the global water and gas valves market since 2016, and the market is poised to grow by USD 6.71 billion during 2019-2023, progressing at a CAGR of over 5% during the forecast period. Request Free Sample Pages
This press release features multimedia. View the full release here: https://www.businesswire.com/news/home/20191015005950/en/
Technavio has announced its latest market research report titled global water and gas valves market 2019-2023. (Graphic: Business Wire)
Read the 158-page research report with TOC on "Water and Gas Valves Market Analysis Report by Geography (APAC, Europe, MEA, North America, and South America), by Type (quarter-turn valves, multi-turn valves, and control valves), by End-users (oil and gas industry and water and wastewater treatment industry), and Segment Forecasts, 2019 2023".
The market is driven by the expansion of oil terminals. In addition, the gradual recovery in upstream activities is anticipated to further boost the growth of the water and gas valves market.
The global oil and gas industry is witnessing growth due to the expansion of oil terminals across mid-stream and downstream activities to support the oil and gas supply chain. This is driving the need for strong pipeline infrastructure which in turn, will boost the demand for valves and fluid handling systems in the oil and gas industry. Companies are venturing into hydrocarbon exploration projects. This is further increasing the need for pipelines to transport oil and gas that can be ramped up or shut down at any time. Thus, the expansion of oil terminals is also driving the need for pipeline infrastructure and water and gas valves. Such developments are expected to drive market growth during the forecast period.
Buy 1 Technavio report and get the second for 50% off. Buy 2 Technavio reports and get the third for free.
View market snapshot before purchasing
Major Five Water and Gas Valves Market Companies:
Alfa Laval AB
Alfa Laval AB is headquartered in Sweden and owns and operates businesses under various segments such as energy, food water, marine, greenhouse, and operations others. The company offers ball valves, butterfly valves, control/check valves, regulating valves, safety valves, and sampling valves.
CRANE Co.
CRANE Co. is headquartered in the US and manufactures and offers products through global product segments: fluid handling, payment merchandising technologies, aerospace electronics, and engineered materials. The company offers check valves, sleeved plug valves, lined valves, process ball valves, and multi/quarter-turn valves.
Curtiss-Wright Corp.
Curtiss-Wright Corp. is headquartered in the US and has business operations under various segments, commercial/industrial, defense, and power. The company offers a wide range of valves under the Farris, Daume Regelarmaturen, PHÖNIX, and Target Rock brands.
Emerson Electric Co.
Emerson Electric Co. is headquartered in the US and offers products through business segments such as automation solutions and commercial and residential solutions. The company provides various types of valves such as fisher vee-ball V150 flanged control valves, fisher D4 control valves, and virgo WL series welded body trunnion ball valves.
Flowserve Corp.
Flowserve Corp. is headquartered in the US and offers products through business segments including engineered product division, industrial product division, and flow control division. The company provides analog valves such as duball DL floating ball valves; argus EK71, AKH2 lined ball valves; valbart RSBV rising stem ball valves; and valtek linear globe valve.
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Water and Gas Valves Type Outlook (Revenue, USD Million, 2019 2023)
- Quarter-turn valves
- Multi-turn valves
- Control valves
Water and Gas Valves Regional Outlook (Revenue, USD Million, 2019 2023)
- Europe
- North America
- South America
Technavio's sample reports are free of charge and contain multiple sections of the report, such as the market size and forecast, drivers, challenges, trends, and more. Request a free sample report
Related Reports on Industrials are:
Aerosol Valves Market Global Aerosol Valves Market by geography (APAC, Europe, MEA, North America, and South America) and application (cosmetics, household products, and others).
Industrial Valve Actuators Market- Global Industrial Valve Actuators Market by geography (APAC, Europe, MEA, North America, and South America), product (electric-valve actuators, pneumatic-valve actuators, hydraulic-valve actuators, and mechanical-valve actuators) and end-users (oil and gas, chemical and petrochemical, power, water and wastewater, metals and mining, and other end-users).
About Technavio
Technavio is a leading global technology research and advisory company. Their research and analysis focus on emerging market trends and provides actionable insights to help businesses identify market opportunities and develop effective strategies to optimize their market positions.
With over 500 specialized analysts, Technavio's report library consists of more than 10,000 reports and counting, covering 800 technologies, spanning across 50 countries. Their client base consists of enterprises of all sizes, including more than 100 Fortune 500 companies. This growing client base relies on Technavio's comprehensive coverage, extensive research, and actionable market insights to identify opportunities in existing and potential markets and assess their competitive positions within changing market scenarios.
View source version on businesswire.com: https://www.businesswire.com/news/home/20191015005950/en/
Technavio Research
Jesse Maida
Media Marketing Executive
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Website: https://www.technavio.com


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Shrek the Musical
June 19-28, 2020
It's hard to believe nearly twenty years have passed since Shrek, Donkey and
Fiona stole our hearts on the silver screen. All the beloved characters have been brought to life onstage as Little Theatre takes to the swamp with Shrek.
Based on the DreamWorks Animation Motion Picture and the book by William Steig
Book and Lyrics by David Lindsay-Abaire
Music by Jeanine Tesori
Origianlly produced on Broadway by DreamWorks Theatricals and Neal Street Productions
Shrek the Musical is presented through special arrangement with Music Theatre International (MTI).
Little Theatre of Wilkes-Barre | 537 North Main Street | Wilkes-Barre, PA 18705 | 570-823-1875
© 2017 - Little Theatre of Wilkes-Barre - Website by Dawe Consulting, LLC


text:
UND Bismarck-Hettinger Rural Track Program Overview
The UND SMHS Rural Track Hettinger program was approved by the Accreditation Council for Graduate Medical Education (ACGME) and began July 2014.
The Hettinger rural track program has many unique qualities that are not found in your typical residency program. The uniqueness stems from the patient interaction and care along with a group of Attendings who are dedicated to passing their experience and knowledge to the next generation of physicians. At WRHS, there are currently two residents. We also have medical students who rotate throughout the year. This provides a great one-on-one environment to help teach and guide medical students. Along with this, the Attendings outnumber the residents 4:1. Each attending has their own different strengths that they share and the teaching is outstanding. The Attendings understand that through an educational environment, residents are able to incorporate their advice and skills into their own practice.
The first year of residency is done in Bismarck, ND, which provides a great intern year program to get the resident ready to practice and treat patients when the arrive to Hettinger. The program in Hettinger is set up in a manner similar to others in the fact that each month you do ACGME required rotations. Along with this, one night a week you are on call for the ER. This provides a great opportunity to initially see the patients and follow through with their care: whether this be discharging and following up in clinic or admitting to the hospital. It truly does embody the role of a family medicine physician.


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Most sellers want to be paid all of their money up front, and most buyers want to avoid paying anything up front. Deals usually get done somewhere in the middle, where the seller agrees to accept some cash and to be paid some of their proceeds over time.
Eric Weiner, for example, started All Occasion Transportation in college and by the time he turned 35, his company was grossing more than $3MM a year. That's when Weiner decided he wanted out.
Weiner found a buyer and agreed to accept half of his money in a five-year consulting contract, which sounded great in theory but ended up becoming hard to enforce. In this cautionary episode, you'll learn: