Looking back on Tedeschi Trucks Band‘s recent Wheels of Soul tour, it was without-a-doubt one of the best string of shows this summer–packing a stellar lineup with an ever-changing setlist that honored all music, past and present. The summer 2017 iteration of Tedeschi Trucks Band’s multi-band tour proved to be the biggest and most successful “Wheels of Soul” voyage to date. With support from The Wood Brothers and Hot Tuna, husband-and-wife bandleaders Derek Trucks and Susan Tedeschi and their well-oiled 12-piece outfit consistently shattered personal records throughout the tour.The collaborations came to a peak at the band’s sold-out two-night run at the iconic Red Rocks Amphitheatre in Colorado. In addition to The Wood Brothers and Hot Tuna, Tedeschi Trucks band was joined over the course of the weekend by renowned jam scene elder statesmen like John Medeski of Medeski Martin & Wood and John Bell of Widespread Panic. TTB has shared pro-shot footage of their “Dark End Of The Street” rehearsal ahead of the big night, which you can enjoy below:Dark End of the Street w/ John BellEarlier this month, they shared pro-shot videos of the same night:Tedeschi Trucks Band’s backstage rehearsal of Bob Dylan’s “Down Along The Cove” with Widespread Panic’s John Bell at Red Rocks:Pro-shot footage of Tedeschi Trucks Band covering The Rolling Stones’ “Sweet Virginia” at Red Rocks with help from The Wood Brothers:Tedeschi Trucks Band is currently on a brief hiatus from the road before heading back out for their 2017 Fall Tour beginning on September 15th in Birmingham, AL. The tour encompasses the band’s annual residency at the Beacon Theatre, which will include their milestone 25th performance at the storied Manhattan venue on Wednesday, October 11th. The rest of the band’s remaining schedule for the year includes performances in L.A., San Diego, Phoenix, and Portland, as well as a 2-night run in Seattle and a 3-night stand in Susan’s native Boston to cap a busy 2017. The band is also currently in the studio working on material for their next studio album, the follow-up to their acclaimed 2016 studio release, Let Me Get By, which Live For Live Music ranked among the best albums of 2016 in a year-end poll.You can see a list of upcoming Tedeschi Trucks Band tour dates below. For more information, or to purchase tickets, head to the band’s website.Upcoming 2017 Tedeschi Trucks Band Tour Dates:9/15 Birmingham, AL Alabama Theatre +9/16 New Orleans, LA Saenger Theatre9/17 Little Rock, AR Robinson Center Music Hall +9/21 Houston, TX Hobby Center #9/22 Dallas, TX Music Hall at Fair Park #9/23 Austin, TX ACL Moody Theater # sold out10/6 New York, NY Beacon Theatre +10/7 New York, NY Beacon Theatre10/10 New York, NY Beacon Theatre %10/11 New York, NY Beacon Theatre @10/13 New York, NY Beacon Theatre10/14 New York, NY Beacon Theatre11/3 Portland, OR Keller Auditorium #11/4 Seattle, WA Paramount Theatre #11/5 Seattle, WA Paramount Theater11/7 Santa Barbara, CA Arlington Theatre &11/9 San Diego, CA San Diego Civic Theatre #11/10 Los Angeles, CA Orpheum Theatre #11/11 Los Angeles, CA Orpheum Theatre &11/14 Phoenix, AZ Orpheum Theatre +11/15 Phoenix, AZ Orpheum Theatre +11/17 Oakland, CA Fox Theater #11/18 Oakland, CA Fox Theater11/30 Boston, MA Orpheum Theatre @12/1 Boston, MA Orpheum Theatre12/2 Boston, MA Orpheum Theatre+ with Greyhounds# with Hard Working Americans% with The Wood [email protected] with North Mississippi Allstars& with David Luning[Cover photo via Bill McAlaine]
The Harvard School of Public Health’s (HSPH) Nutrition Round Table recently presented Sen. Tom Harkin from Iowa with the third annual Healthy Cup Award on May 18 for “his leadership in developing policies that support and promote good nutrition, healthier lifestyles, and disease prevention” and for playing a key role in the national health care reform bill signed in March.The Nutrition Round Table is a group that helps to bridge the gap between scientific advances and sustainable changes in food policy, practices, and products, with a focus on obesity, healthy lifestyles, global nutrition, and chronic diseases.Harkin, who succeeded the late Sen. Edward Kennedy as chair of the Health, Education, Labor and Pension Oversight Committee in September 2009, was presented the award as part of a lecture and reception at the School, and was cited for his efforts to address obesity issues in children, cardiovascular disease, and women’s health issues, as well as other efforts to lead the way toward a healthier country.“We couldn’t have asked for a better person to follow in this important role,” said Walter Willett, chair of the HSPH Department of Nutrition, who presented the award. Harkin has shown “tremendous leadership over the years, putting wellness and health on the American agenda.” To read the full story, visit the Harvard School of Public Health Web site.
Reimagined, redesigned, and replete with new restaurants and study spaces, the Richard A. and Susan F. Smith Campus Center officially opened Thursday with a dedication ceremony attended by Harvard President Larry Bacow, President Emerita Drew Faust, and members of the Harvard and Cambridge communities.The center is an anchor for Harvard’s campus, and now a crossroads for the entire community. The first and second floors include the Moise Y. Safra Welcome Pavilion and Plaza along Massachusetts Avenue, where people can mingle, join tours of Harvard, and take in views of the square and the city beyond. Outside, new plazas open to Mass. Ave. and Mount Auburn Street; while indoors people lounge in large interior spaces with soaring ceilings, and a new roof deck along Dunster Street.With its open-air vitrine garden, glass facades, and green walls irrigated with UV-filtered rainwater harvested from the center’s rooftop, the renovations increase access to daylight and nature.Hungry passersby can grab a bite at Pavement Coffeehouse, Swissbäkers, Bon Me, Blackbird Doughnuts, and Oggi Gourmet, which will be joined in the coming weeks by Whole Heart Provisions and James Beard winner Jody Adams’ Saloniki. The center also offers spaces for meeting and performances, or a game of chess at any of 14 new tables.The Campus Center first opened in 1966, designed by renowned architect Josep Lluís Sert, dean of the Harvard Graduate School of Design from 1953 to 1969. The renovations were designed by Hopkins Architects of London, with the Cambridge-based firms Bruner/Cott as executive architect and Michael Van Valkenburgh Associates as landscape architect.,Learn more about the Smith Campus Center, as well as Harvard’s Common Spaces program, which oversees events, activities, and reservations in the new spaces by visiting commonspaces.harvard.edu.
ATHENS, GA. – If dry conditions persist, Georgia is in for a very hot summer. If the drought intensifies, temperatures across the mountains could reach into the middle to upper 90s while the piedmont bakes in the low 100s. Across the coastal plains temperatures in the 104 to 106 range may not be out of the question.Georgia is entering the climatological summer. Climatologists define summer as June, July and August. This year’s astronomical summer, the summer solstice, begins June 21.Drought conditions have already spread into south-central and southwest Georgia. Much of southeast and coastal Georgia is now abnormally dry for early June.After improvements in drought conditions across north Georgia during the cool season, conditions are expected to worsen over the next several months. Summer routinely brings temperatures in the 90s. Georgians can expect hot, dry weather to cause very rapid soil moisture loss over the next week. This loss in soil moisture will also drop stream flows and groundwater levels. Several indicators are used in drought classification: 30 day rainfall, 90 day rainfall, 6 month rainfall, 12 month rainfall, 24 month rainfall, rainfall since the previous October 1 (the “water year”), soil moisture, stream flows, groundwater levels and reservoir levels. Across much of south Georgia, 30- and 90-day rainfall has been well below normal. Thirty day rainfall over much of south-central and southwest Georgia has been less than half of normal. Some locations reported less than one-quarter of normal rainfall over the past month.Ninety day rainfall across the southern half of the state has been generally less than 70 percent of normal with pockets in south-central and southwest receiving less than 50 percent of normal rain.Stream flows across most of the state are currently just above the previous record-low flows for early June. Many of the current stream-flow records across the state were set in 1988 and 2007. By David Emory StooksburyUniversity of Georgia A few locations are setting daily records for low flow including the Chattooga River near Clayton, the Oconee River at Milledgeville, the Flint River near Oakfield and at Newton and the Withlacoochee River near Quitman.Soil moisture levels are extremely low along and west of I-75 and along and north of I-20. With little rainfall and temperatures in the 90s, soil moisture levels which had been in relatively good shape for the remainder of the state have been dropping very quickly over the past couple of weeks.Farm ponds, especially ponds not fed by springs, are starting to show the lack of rain. Many ponds didn’t receive adequate recharge during the winter and entered the summer already low. Extreme drought conditions exist in Banks, Elbert, Franklin, Hart and Stephens counties of northeast Georgia. This means that multiple drought indicators are at levels that we expect about once in 50 years. The counties north of a Carroll – Fulton – Clayton – DeKalb – Rockdale – Walton – Oconee – Oglethorpe – Wilkes – Lincoln counties line are classified as being in severe drought. This means that multiple drought indicators are at levels that we expect about once in 20 years. Moderate drought is now found in the counties north and west of a Lowndes – Cook – Tift – Turner – Crisp – Dooly – Houston – Bibb – Jones – Baldwin – Hancock – Glascock – Warren – McDuffie – Richmond line. Moderate drought classification occurs when multiple drought indicators are at levels we expect about once in 10 years. Mild drought conditions have developed in Ben Hill, Berrien, Bleckley, Bryan, Burke, Chatham, Echols, Effingham, Irwin, Jefferson, Lanier, Liberty, Pulaski, Twiggs, Washington, Wilcox and Wilkinson counties. Mild drought means that several drought indicators are at levels we expect about once in seven years. The following seven southeast Georgia counties are currently classified as not being in drought: Appling, Bacon, Brantley, Glynn, Pierce, northern Ware and Wayne. However, soil moisture is decreasing rapidly in these counties. Drought conditions could develop over the next several weeks in these counties.The remaining south Georgia counties are classified as abnormally dry for early June. Localized drought conditions are starting to develop in these counties. Widespread drought conditions are expected in these counties within the next couple of weeks. Abnormally dry means that several drought indicators are at levels that we expect about once in five years. For the next several months, Georgia’s best chance for widespread drought relief will be tropical disturbances. However, the tropics usually don’t become active until late summer. June and July are critical. Without major rain events the soils will continue to become drier leading to lower stream flows, groundwater levels and reservoir and pond levels. For current Georgia drought information, go to the Web site www.georgiadrought.org. Weather information is available at the University of Georgia automated weather station network Web site www.georgiaweather.net.
I think it’s fascinating to wonder what the insides of the Blue Ridge Mountains look like. Layers of bedrock stripped down over time can reveal stories no different than the pages of a book. Having seen the impressive granite spires of the Sierra Nevada Mountains and the jagged peaks of the Northern Cascades, it is safe to say I found inspiration on a different scale. With that said though, the Blue Ridge Mountains still capture my attention just the same.Ancient geology amongst the Appalachian Mountain range captivates those that visit them and for good reason. In an effort to continually explore these mountains we call home, Jess and I visited Old Rag Mountain in the Shenandoah National Park near Sperryville, Va. Course granite features made of white feldspar and the unique blue quartz, shaped one billion years ago, standing at 3,284 feet make this hike one of the most unique places to visit in the Blue Ridge. Because of its unique characteristics and compelling hike to the summit, Old Rag has become one of the most popular hikes in the region.We set off on a Wednesday, early in the morning with the intent to beat the crowds. To our surprise though, we pulled into a parking lot at the base of the mountain filled with people. Slightly jaded by what we saw, but still excited, we set out on the 9.5-mile circuit hike to the summit and back.You start by climbing for nearly three miles, meandering through beautiful stands of old forest on a well-graded trail. We passed people occasionally, but it wasn’t until the bottleneck at mile three where the serenity of the walk really took a hit. People began to move slowly as the infamous rock scramble of Old Rag took its toll. Now, almost in single file, I started feeling quite uncomfortable. There were two miles left to climb and people were everywhere. Loud hip-hop music blasted from a speaker close behind me. How could this be? The obnoxious music and voices filled the crevasses in the rock. It’s out of respect for the place you are and the people around you to remain quiet, peaceful even, when present in such a beautiful place.As Jess and I climbed and crawled through the ancient rock we began to separate ourselves from the circus down below. I was thankful to hear nothing but the wind and the occasional caw of a crow, which I’m still convinced was yelling at the people down below. As we reached the summit, we quickly located a place of solitude to hunker down for a while. Old Rag Mountain’s summit is a powerful place to say the least. The large igneous rock displays, towering over the valley floor are an amazing exhibit of power and time. I was grateful for the quiet time we received at the top. The rest of the hike descends from the summit. Feeling the sunburn on our winter-white skin, we made our way back to our van. With mixed feelings about the day I gazed up on the rocky summit where we just were. Inspired by the magnitude of natural beauty, but wearied by the people, I decided instead to be grateful for the day spent outside in hopes that future visitors to Old Rag, and any outdoor destination, will consider a compromise. The compromise is this —let us all seek unity with the natural world while still respecting the people, the experience, and most importantly, the place.Adam Ritter
Central American defense ministers acknowledged that the region needs an immediate budget of US$ 150 million dollars to renew armaments and equipment, as well as other security needs, in order to effectively battle organized crime. This was confirmed by Salvadoran Defense Minister Gen. David Munguía Payés in the context of a meeting with the majority of his regional counterparts in San Salvador on 27 July, as part of the Conference of Central American Armed Forces (CFAC), a body the Higher Council of which Munguía also chairs. The Dominican Republic also participates in the Central American Armed Forces body as a guest, as in the majority of the isthmus’s integration institutions. U.S. Under Secretary of the Army Joseph W. Westphal, who is on a tour of the region, also participated as a special guest in the high-level meeting of military leaders from the Central American region and the Dominican Republic. With regard to the deficiencies in the equipment of the region’s armies, Munguía Payés again drew attention to El Salvador’s lack of air defense, since the A-37 fighters of the Salvadoran Air Force (FAS) are presumed to be grounded due to the planes’ age and their high cost of operation. In May, Munguía announced that the Salvadoran Army would need a budgetary supplement of more than US$ 30 million for the remainder of the year, but President Mauricio Funes announced in July that many ministries would have to tighten their fiscal belts for the rest of the year, since the state would not have enough money. The lack of these planes is noticeable, above all, because they were the “interceptors” of planes suspected of carrying drugs that invade Salvadoran airspace and are then escorted out of it in order to prevent them from unloading their cargo on the country’s territory, General Munguía acknowledged. “As you know, the United States has a monitoring center at El Salvador International Airport, but at the moment, we lack the aircraft that can intercept planes that enter our airspace illegally,” Munguía said. Guatemala urgently needs at least two or three primary radars to cover its airspace and combat “small drug planes” or other kinds of planes carrying illicit cargos. In the case of Honduras, it is also believed to need equipment of that kind for its waters and airspace in the Caribbean, where on 13 July it detained a crew who were in possession of drugs and had scuttled a submersible allegedly carrying more narcotics. Honduras is also weighing the purchase of a fleet of Embraer Super Tucanos. General Munguía also recalled the concept of the shared responsibility of the United States, especially in the area of drug trafficking, and that seed money of US$ 200 million has already been offered, following President Barack Obama’s visit to El Salvador in mid-February. “In fact, in the particular case of El Salvador, we work very closely with the U.S. Southern Command; we liaise with the monitoring facilities they have in Florida to track drug trafficking,” the Salvadoran military leader specified. By Dialogo August 01, 2011 The USA has 150 Million for defense against organized crimeâ€¦Why not use it instead on education and legalize the business of those that are occupied with the organized crime? I suppose that trafficking of drugs is the most lucrative, it seems like a good startâ€¦..
ShareShareSharePrintMailGooglePinterestDiggRedditStumbleuponDeliciousBufferTumblr Tom Kane continue reading » Last year, the Illinois Credit Union System (ICUS) set out to determine where its 120 employees experience the most financial anxiety in an attempt to alleviate their stress levels and improve their overall health.An employee survey revealed the main culprits: student loan debt, the need to save for college, and overall debt levels.The effort was partly due to National Credit Union Foundation research showing how financial stressors can affect physical health and work performance, says Tom Kane, ICUS president/CEO.“If people are stressed about their financial situations, they obviously don’t leave that at home,” Kane says. “They bring it to work with them.”
Sign up for our COVID-19 newsletter to stay up-to-date on the latest coronavirus news throughout New York The US Congress—the only branch of government that can declare war—will finally have a debate about President Obama’s six-month-old battle with ISIS. How Long Island’s Congressional delegation will vote is still up in the air.The Obama administration’s military offensive against the brutal terrorist organization, which has laid siege to large swaths of Iraq and Syria, and is responsible for the slaying of four Americans and countless religious minorities and so-called “infidels,” has persisted for half a year without any legitimate discussion in Congress about how long the US will be entangled in the war, if ground troops will ever step foot in Iraq or Syria, or whether the current conflict is even legal.At the outset of the war, the Obama administration said the 2001 Authorization to Use Military Force (AUMF) provided the president legal authority to battle ISIS.“We do not believe the President needs that new authorization in order to take sustained action against ISIL,” a senior administration official said in a background call with reporters in September. “We believe that he can rely on the 2001 AUMF as statutory authority for the military airstrike operations he is directing against ISIL, for instance.”That version has been criticized as overbroad and outdated because it authorized President George W. Bush to use force against those responsible for the Sept. 11, 2001 attacks, meaning al Qaeda. ISIS did not exist at the time, and although it was eventually born out of al Qaeda, the group disavowed ISIS last year.Obama prefers a bipartisan authorization to use military force (AUMF), ostensibly to portray a unified front against America’s latest enemy.On Wednesday, the president sent a draft letter to Congress outlining a new AUMF, one that would authorize a three-year offensive against ISIS, also known as ISIL or the Islamic State. Obama’s version also includes any “associated forces” fighting alongside ISIS or any “closely-related successor entity.” It would also sunset the 2002 AUMF, which enabled Bush to “defend the national security of the United States against the continuing threat posed by Iraq.”Essentially, Obama wants authorization for a war he’s already fighting, using a 14-year-old authorization for military force enacted exactly one week after 9/11 that gives the administration sweeping powers to ether detain or kill militants in undeclared warzones. It’s also been used to justify the drone attack that killed US citizen Anwar Al-Awlaki in Yemen and Samir Khan, editor of the al Qaeda magazine Inspire, who spent his teenage years in Westbury. The government has said Khan was not targeted in the strike.The authorization, if approved by Congress, sets no geographical boundaries, meaning the US can essentially fight ISIS anywhere. It also prohibits ground troops in “enduring offensive” combat operations, but gives the president enough wiggle room to call in Special Forces if the opportunity exists to take out high-level ISIS militants. That ambiguity has some liberals in Congress worried the US could get be mixed up in another open-ended war, with no reasonable end date.Obama’s proposal was also greeted with skepticism from Republicans. Some on the right criticized Obama’s AUMF for allowing it to sunset in three years, which they argued, is as good as giving the enemy America’s playbook. Rep. Peter King (R-Seaford) is one of them.“I’m from the school who believes that the president has the inherent power to do this without Congressional authorization,” King told the Press. “Having said that, it’s always better to get it. But if you are going to get it, don’t be putting limits on yourself. Again, he did this with Afghanistan, where he said he was going to, back in ’09, there’s going to be a troop surge but they’re going to be pulled out within 18 months. Well, they’re just giving the enemy the opportunity to plan their defenses against what we do.“We should never tell them how long we’re going to be there, what we’re going to do,” he continued. “You’re not limited at all as far as the enemy is concerned…Again, let them think the very worse, and be uncertain at all times.”LI’s freshmen Representatives were non-committal.Rep. Lee Zeldin (R-Shirley), unlike King, appears to want more specifics laid out in Obama’s proposal, blasting it as “barren on strategy.”Rep. Kathleen Rice (D-Garden City) said she looks forward to a bipartisan conversation.“Valid concerns have been raised about the President’s proposal and the language and details certainly need to be clarified,” Rice said in a statement.There’s no question how longtime Rep. Steve Israel (D-Huntington) will vote:“ISIS is barbaric and must be stopped,” he said in a statement. “I believe this President and future Presidents should have tools necessary to do so. This Authorization for Use of Military Force resolution provides those tools without putting combat troops on the ground in Syria and Iraq.”Obama’s desire for a new AUMF isn’t new.He pressed upon Congress to act in his post-midterm election speech last year, and did so again in last month’s State of the Union.“Enacting an AUMF that is specific to the threat posed by ISIL could serve as a model for how we can work together to tailor the authorities granted by the 2001 AUMF,” Obama said in a statement this week.“I can think of no better way for the Congress to join me in supporting our Nation’s security than by enacting this legislation,” he added, “which would show the world we are united in our resolve to counter the threat posed by ISIL.”The president also expressed a long-held desire to “refine, and ultimately repeal” the 2001 AUMF, despite how much it’s influenced his drone wars and conflict with ISIS.This was what Obama had to say on the matter in May 2013, before ISIS was beheading US journalists and burning people alive:“Groups like AQAP [al Qaeda in the Arabian Peninsula] must be dealt with, but in the years to come, not every collection of thugs that labels themselves al Qaeda will pose a credible threat to the United States,” he said. “I look forward to engaging Congress and the American people in efforts to refine, and ultimately repeal, the AUMF’s mandate.”On Wednesday, Obama said he “remains committed to working with the Congress and the American people to refine, and ultimately repeal, the 2001 AUMF.”Time will tell if Obama ever gets the repeal he’s looking for or if Congress approves his authorization measure. But what we do know, is that the president believes he already has the legal justification for his war on ISIS, and that battle is likely to rage on well into the future.Just ask King.“These are going to be long, hard struggles. They’re not easy,” King told the Press. “The fact is, if he hadn’t pulled all the troops out of Iraq, I think we wouldn’t be in this situation now with ISIS. But al Qaeda has had so many mutations, so many groups. We have to condition the American people: This is going to go on for a long time. It’s terrible to say but that’s the reality. They’re not going to go away easy.”
Apr 30, 2007 (CIDRAP News) – A hypothetical but not unlikely scenario: Amid an influenza pandemic, a small hospital has three patients who need mechanical ventilation. One has terminal cancer, another has severe chronic lung disease, and a third has a severe case of flu. With only one ventilator available, which patient will get it?When the next flu pandemic comes, it’s a good bet that ventilators will run short and clinicians will face wrenching decisions like these. Expecting that such choices will be excruciating for already stressed healthcare workers, a group of experts assembled by the New York State Department of Health (NYSDOH) is offering guidelines for rationing scarce ventilators.Last month the group released a 52-page draft plan that provides detailed guidance for determining who will receive ventilator treatment in the face of a pandemic-related shortage. The plan calls for allocating ventilators in acute care hospitals solely on the basis of patients’ medical need and chance of survival, without regard for age, occupation, ability to pay, or other factors.”This isn’t perfect,” Tia Powell, MD, co-chair of the task force that wrote the guidelines, said in an interview. “People will certainly feel this proposal can be made better, but it’s important to have some plan in place, and not simply defer to the overworked frontline provider in a crisis, to make a decision that you didn’t grapple with when you had a good night’s sleep and a meal.”The task force, called the New York State Workgroup on Ventilator Allocation in an Influenza Pandemic, has invited public comments on the proposed guidelines and plans to revise them in coming months.Once the guidelines are finished, the expectation is that New York hospitals could use them as an acceptable standard of care if ventilators ran short in a pandemic, said Guthrie S. Birkhead, MD, the other co-chair of the task force and director of the NYSDOH Center for Community Health. Given that status, the guidelines might offer hospitals some protection against legal liability for ventilator allocation, he said.Severe shortages possibleHospitals in New York State have about 6,100 ventilators, 85% of which are in use at any given time, according to the draft guidelines. In a moderate pandemic, the authors estimate, more than 7,000 flu patients will need ventilators, more than 2,171 of them at the same time. Given the 85% usage rate, the state shortfall would be 1,256 ventilators.In a severe pandemic (with the same 35% attack rate as a moderate pandemic but involving more severe disease), 58,000 patients may need ventilation, including 17,844 during the peak weeks, the document says. The state would need an estimated 16,929 more ventilators.The state is stockpiling ventilators and other medical supplies for a pandemic. “But even so, in looking at the pandemic scenarios, the need would exceed any conceivable stockpile that we could maintain,” Birkhead said. And even if there were enough ventilators, there wouldn’t be enough trained staff to operate them, the report says.The concern about ventilators goes back at least to 2005, when hospital officials at a pandemic planning conference in New York City talked about possible shortages of ventilators and other resources, according to Birkhead. “The question came back to us, ‘Are you going to do some thinking about what the altered standards of care [in a pandemic] would be?'” he said.The issue was handed over to the New York State Task Force on Life and the Law, a bioethics commission appointed by the governor, said Powell. The 29-member work group that was set up to write the guidelines consists partly of task force member and partly of nonmembers, including some experts from outside New York.The plan is based on a set of ethical principles, including (1) healthcare workers’ fundamental duty to care for patients, (2) the duty to steward scarce resources wisely, (3) the duty to plan in advance how to allocate ventilators, (4) statewide application of the allocation guidelines, so that the same rules apply in different hospitals and communities, and (5) transparency in proposing and refining the guidelines.The proposal depicts rationing as a last resort. Hospitals would need to limit the need for ventilators by canceling or postponing elective medical procedures and would be expected to acquire as many ventilators as possible from their own suppliers or networks and the state and federal stockpiles.”We’d reach this point [of rationing ventilators] only after many steps, and hospitals wouldn’t do it on their own or in isolation, but as part of a whole statewide response,” said Birkhead.When rationing becomes necessary, the rules will apply to all patients in acute care hospitals, not just flu patients, without regard for age, occupation, or role in the community. The measuring stick will be patients’ survival chances.Relying on clinical criteria”When a ventilator becomes available and many potential patients are waiting, clinicians may choose the patient with pulmonary failure who has the best chance of survival with ventilatory support, based on objective clinical criteria,” the proposal states.The clinical criteria are adapted from a protocol developed for the Ontario Health Plan for an Influenza Pandemic (OHPIP) and released in April 2006. The protocol relies on a critical care triage tool called the Sequential Organ Failure Assessment score, based on measurements of blood platelets, bilirubin, hypotension, creatinine, and other variables.The proposal includes a set of “exclusion criteria”—conditions that signal a high risk of mortality and thus exclude the patient from getting a ventilator. Among them are cardiac arrest, matastatic cancer with a poor prognosis, severe burns over more than 40% of the body, and end-stage failure of major organs.Unlike some other proposals for allocating ventilators, the New York group decided not to list either specific diseases, such as AIDS, or age as exclusion criteria. “We tried to focus more on functionality—we just want to know how sick you are and what your probability of survival is,” said Powell.Patients who do get a ventilator will be reassessed after 48 hours and again after 120 hours to see if they still need and can benefit from the treatment, the proposal says. Patients who don’t receive ventilation or are taken off a ventilator would receive palliative care.In an effort to protect primary treating physicians from the heavy burden of deciding whether their own patients will get or keep a ventilator, the guidelines assign the rationing decisions to the supervising clinician in charge of intensive care patients. This approach follows recommendations on emergency mass critical care published by a group of experts in 2005.The aim is to put decisions in the hands of physicians who have the most experience in critical care while allowing the primary physicians “to care for their individual patients without facing a conflict of interest,” in the words of the proposal.Birkhead said it’s impossible to know whether those charged with the tough decisions will follow the guidelines when the crisis comes.”To have any protocol that says you’re going to take people off a ventilator is difficult to contemplate,” he said. “So the question whether healthcare workers will accept this is hard to answer ahead of time. But I think people will rise to a crisis.”No preference for healthcare workersSome issues were more controversial than others as the guidelines were hammered out. One was “whether there would be priority access for healthcare workers and other first responders,” said Powell. “The group has proposed that there not be prioritized access for healthcare workers. Once you’re a critically ill patient, it doesn’t matter what you do for a living.”The panel found several reasons not to prioritize healthcare workers. For one, “health care workers sick enough to require ventilators are unlikely to regain health and return to service during the pandemic,” the proposal says.Powell adds that the group of people who would risk exposure and do crucial work in a pandemic is large and hard to define, ranging from doctors and nurses to workers who clean the intensive care unit and emergency medical technicians, who in rural areas are often part-time volunteers.”If you use up all those people you might run out of ventilators before you got to anyone else in the community, including children,” she said. “That’s unappealing,” particularly in light of some evidence that children and adolescents may be particularly at risk for death from avian flu.Powell said another controversial issue was how to deal with patients in chronic care facilities, including those who are chronic ventilator users. “We proposed that people in chronic care facilities be offered a different standard,” she said. “To be in a chronic care facility, by definition, you’re stable, you’re not acutely ill. . . . We thought it was important to offer a haven for some of our most vulnerable chronically ill patients.”If the same clinical criteria were applied to people in chronic and acute care facilities, the proposal says, “the result might be the sudden and fatal extubation of stable, long-term ventilator-dependent patients in chronic care facilities.” This might allow more people to survive, but it would “make victims of the disabled.”How to handle patients on kidney dialysis also generated some debate, according to Birkhead and Powell. The panel decided to include renal failure as an exclusion criterion, on the ground that “renal failure will increase the probability of mortality in those who also now require a ventilator,” said Powell. “In addition, the need for dialysis creates an additional demand for nursing support, which is also a scarce resource.”But some panel members disagreed, pointing out “that the bridge therapy of dialysis puts end stage renal failure into a different and more hopeful category than liver or lung failure,” she added.A question on which the committee disagreed was what sort of process should be used to review the allocation decisions. A review process is needed to ensure consistency and justice in application of the criteria, but the participants “disagreed about whether a real-time or retrospective form of review would better serve the goal of providing a just and workable triage system,” the report says.The Ontario pandemic plan calls for a system in which triage decisions can be appealed, but that approach might cause unworkable delays and trigger “explosive debate during a time of scarce manpower and other resources,” the New York document states. An alternative, it says, is to conduct a daily retrospective review of all triage decisions, which would help ensure correct and consistent use of the guidelines but would not allow intervention in individual decisions.An effective liability shield?Acknowledging that ventilator rationing would be likely to trigger lawsuits, the proposal says that guidelines issued by the NYSDOH “would provide strong evidence for an acceptable standard of care during the dire circumstances of a pandemic.” However, it adds, there is no guarantee that a court would accept this view. Only legislation would provide certain protection.The state health department has authority to issue regulations concerning standards of care during a pandemic, but turning the guidelines into regulations would create complications. For one, state law bars the health department from regulating physician practice, the document says. Another is the likelihood of causing unforeseen harmful consequences, given that the guidelines will not have been tested in practice.”If you put something in a regulation or law, you really have to specify all the details, and in doing that you really lose some of your flexibility,” said Powell. “You wouldn’t be able to change a regulation as rapidly as you could something that would come out in the context of recommendations.”Comments invitedThe NYSDOH has publicized the proposal via many avenues, starting by posting it on the department’s Web site. The plan has been sent to state emergency preparedness coordinators, the Association of State and Territorial Health Officials, certain medical societies, advocacy groups for people with disabilities, hospital associations, the National Kidney Foundation, and state and county health officials in New York. The department also ran a satellite video conference with hospitals around the state and briefed hospital officials in New York City.”We’re very explicitly putting this out for public comment. We want to be sure people have ample opportunity for input,” Birkhead said. The panel is asking for comments by the end of May.Powell said a number of other states are considering the problem of ventilator allocation, but she was not aware of any other state that has published recommendations.So far the response to the proposal has been positive, but some have asked for various clarifications, according to Powell. “Many facilities observe, quite correctly, that the document doesn’t take you all the way to the level of detail of how you would operationalize it in your particular facility,” she said. “So there’s more work to be done.”Happily the feedback overall is positive. We’re getting a lot of comments, so we’re trying to incorporate those and make it better.”See also:NYSDOH proposal for allocation of ventilators in a pandemic (52 pages)Frequently asked questions on the proposalAccess to the Ontario Health Plan for a Pandemic
Read also: Indonesian stocks fall to 4-year low following Wall Street crashIndonesia announced on Monday a US$2.34 billion trade surplus in February despite disrupted trade activities in China amid the spread of the coronavirus disease. The figure is the first surplus in four months and the highest since September 2011.On the same day, the government announced a rise in confirmed COVID-19 infections to 134, with five deaths and eight recoveries.Separately, Institute for Development of Economics and Finance (Indef) economist Bhima Yudhistira said the US Federal Reserve’s move to cut its interest rates to near zero and its quantitative easing policy also affected the rupiah as market players panicked over the prospect of global economic growth. “Moreover, the dollar index has also strengthened 1.72 percent over the past week, signaling that the currency is considered a safe haven by market players as the global economy is shadowed by the possibility of imminent recession,” he said.Read also: COVID-19 pandemic looms over Indonesia’s record-high trade surplusForeign investors dumped around Rp 480 billion (US$31.86 million) worth of stocks during Monday morning trade. They recorded more than Rp 8 trillion in net sell so far this year.Last week, Bank Indonesia (BI) revealed foreign outflows of around Rp 31.76 trillion in government bonds and Rp 4.87 trillion in Indonesian shares since January, as investors flee to safe-haven assets. In its effort to stabilize the rupiah, the central bank has bought Rp 130 trillion in government debt papers since January, of which around Rp 110 trillion has been spent since COVID-19 spread outside China in late January.“We are committed to remaining in the market to stabilize the rupiah by selling dollars as cash or domestic non-deliverables forward,” BI Governor Perry Warjiyo said recently.Topics : The rupiah fell to below the psychological level of Rp 15,000 per US dollar on Tuesday as the greenback strengthened amid investors’ fears over the spread of COVID-19.The currency depreciated 0.83 percent to Rp 15,057 against the greenback at 11:40 a.m. in Jakarta, touching a level unseen since October 2018. The Bank Indonesia (BI) Jakarta Interspot Dollar Rate (JISDOR) stood at Rp 15,083 to a dollar on Tuesday.“Market players are not responding to the trade balance announcement as they are focusing on observing the government’s effort to tackle the spread of the coronavirus, which needs to be handled seriously,” TRFX Garuda Berjangka director Ibrahim wrote in a research note on Monday.