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The Weekly Standard Mid-Term Summit 2014 August 14-16, 2014The Broadmoor Resort - Colorado Springs, Colorado
330-629-8230 814-653-2760703-961-9250 ext. 246
Official Webcast August 14-16, 2014
2014 Broadmoor Symposium On-Demand Webcast
This year's event again featured an all-star lineup of some of the nation's brightest conservative minds led by Weekly Standard editors Bill Kristol and Fred Barnes.And back by popular demand: Charles Krauthammer.Guests of our 2014 Broadmoor Symposium couldn't get enough of Krauthammer's unique insights. For this year's event we included even more time with the celebrated columnist and commentator the Financial Times calls the "most influential" in the nation.View this on-demand video of Kristol, Barnes, Krauthammer and others in a townhall-style discussion of the conservative agenda in 2014 and beyond. During this exclusive session, MID-TERM SUMMIT guests had the opportunity to get their questions answered by this all-star lineup.At the MID-TERM SUMMIT we also explored:2014 mid-term elections for the House and the SenateCan Hillary be stopped?Changing demographics and a changing electorateWho can win the White House in 2016?Joining Bill, Fred and Charles were Weekly Standard writers Jonathan Last and Daniel Halper, and from the Washington Examiner, writers Byron York, Michael Barone and Susan Ferrechio.The Weekly Standard's MID-TERM SUMMIT offered an excellent opportunity to meet conservatives from other parts of the country in a historic resort hotel of timeless elegance.


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This item was originally published on January 5th, 2010 at Fast Company.
In my last blog, I looked at how Batman is known globally in comics. With plans in the current DC storyline to have Batman Inc. go worldwide, I thought we'd see if this is really feasible–that is, do bats have the same connotations around the world as they do in the U.S.? And if the bat isn't the right symbol in, say, China, what animal might serve?
Batman's costume incorporates the imagery of a bat in order to frighten criminals. While brooding in his study over how to be a more effective crime fighter, Bruce Wayne saw a bat come through his window. Seeing that "criminals are a superstitious, cowardly lot," he adopted the persona of a bat in order to conceal his identity and strike fear into his adversaries. (This origin story is circa 1939, in Detective Comics.)
In Western culture, bats are unfortunately associated with darkness and evil and scary monsters like Dracula, which is too bad, because bats are totally awesome and everyone should have a bat house in their backyard. (Hate mosquitoes? Love bats.) They are undoubtedly nocturnal, which fits well with Batman's preferred MO, but I'm not so sure that even cowardly criminals will be scared by a guy in gray tights and a cape. Sticking with DC, we can see that lots of other superheroes chose animal motifs for their costumes: Hawkman, Black Canary, Robin, Raven, Catwoman, and of course Beast Boy, who can transmute into any animal.
But none of these are particularly scary. If you really wanted to strike fear into your adversaries, pick something that people actually freak out over: Spiders (oops, taken), sharks, snakes, bees, or jellyfish. (Box jellyfish poison can kill you in 4 minutes.) Admittedly, JellyFish Man would be tough to pull off. In terms of deadliest animals, mosquitoes top the list, but that costume would suck. Therefore, in the spirit of made-up superheroes, I nominate a made-up monster, the Jersey Devil. Seriously: Jersey Devil Man would be the most terrifying thing you could encounter in the streets of Gotham.
Speaking of devils, I think the Tasmanian Devil might be a much better choice for a Batman-type hero in Australian, NZ, and Tasmania, especially since Australian Aborigines believe each bat contains the life force of a human, and to kill a bat will cause the death of the one whose life force it contains. Let's look at a few more cultures:
- Chinese: The word for bat is a homophone of the word for luck, fu, so the bat is a symbol of happiness, good luck, long life, wealth, and peace. The ancient Chinese said the bat hung upside down because of its unusually heavy brains.
- Egyptian: Bat's heads were used as protective amulets.
- Macedonian: Bats' bones were worn for good luck.
- Mayan: The number 5. The Maya called the bat the destroyer of life and said it was the ruler of fire since it is an 'eater' of light. To reach the Land of Death one must pass through the House of the Bat.
- Native American: Life, water, rebirth, and fertility. In many Native American tribes bats were and are known as the bringers of rain. The trickster in some Plains and Southwestern tribes.
- Polish: Happiness and long life.
- Samoan: The war god, Sepi Malosi, will appear in the form of a bat to lead warriors into battle if he believes they will be successful and if he thinks his warriors will lose the fight, he flies towards warning them to turn back.
So, on the whole, bats are (as I said earlier) totally awesome. Here are a few alternatives.
- Australian: Aside from Tasmanian Devil Man, there could be Dingo Man (they eat babies) or Goanna Man.
- China: Owl Man. Owls were seen as birds of ill-omen.
Mayan: Owls were symbols of death and destruction, so Owl Man could work well in South America too. - India: The god Shiva is always associated with a cobra. Shiva wears a snake coiled around his upper arms and neck, symbolizing the power he has over the most deadly of creatures. How about Krait Man? A krait is an immensely poisonous snake that can get up to 7 feet long. Plus it sounds really cool.
- Africa: While it's never a good idea to generalize to an entire ginormous continent, it's a fact that hippos kill more humans in Africa than any other large animal. Hippo Man: deadly on water and land.
- Indonesia: The Komodo Dragon (Varanus komodoensis), is the largest living lizard on
the planet with its roots going all the way back to the dinosaurs. Because of their large size and fierce personalities, Komodo Dragons are surrounded by myth and legend in Indonesia. Komodo Dragon Man! - Russia: My favorite. In the myths and legends of Eastern Europe, the hedgehog enjoys considerable respect because of its amazing wisdom. Tell me this doesn't sound like Batman: "(Those) who relate everything to a single central vision, one system, less or more coherent or articulate, in terms of which they understand, think and feel–a single, universal, organizing principle in terms of which alone all that they are and say has significance." (Isaiah Berlin, in his essay "The Hedgehog and the Fox")
Yes! Hedgehog Man!

subset: commoncrawl


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Commercial Doors Repair Vaughan
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Gene Therapy Takes Center Stage at 2019 NORD Summit
With so much recent publicity surrounding gene therapy, it's no surprise that the topic was a major focus of the recent 2019 NORD Rare Diseases & Orphan Products Breakthrough Summit.
From diagnosis and clinical trial design to manufacturing, pricing strategies, and ethical concerns, gene therapy — both its high costs and limitless potential for curing diseases — generated much discussion at the Washington, D.C., event, which was organized by the National Organization for Rare Disorders (NORD) and attended by more than 900 delegates Oct. 21–22.
"On one hand, this is a splendid time to be doing what we do," said Scott Gottlieb, MD, former commissioner of the U.S. Food and Drug Administration (FDA), and now a partner at Washington-based New Enterprise Associates. "On the other hand, it's imperative that all patients have access [to these new therapies], regardless of someone's ability to afford them. Many of the treatments are so dramatic, they can quite literally alter the destiny of someone's life.
He regarded his leadership of the agency, from May 2017 to April 2019, as "a wonderful time at the FDA because we had the benefit of cures and new money as a tailwind, but also in large measure because of the opportunities before us — such as gene therapy and CRISPR — to fundamentally alter diseases."
Gottlieb's comments come toward the end of a year that saw the FDA approve the Novartis treatment Zolgensma, the first gene therapy for spinal muscular atrophy (SMA). With a price tag of $2.1 million, it's the most expensive medication in history.
"When it comes to curative therapies, it's not that we can't sustain the cost of a million-dollar therapy if it means curing a pediatric disorder. We can afford that," he said. "But what we can't afford is to let an insurance company determine your child's destiny."
While there's a "real sense of excitement" about gene therapy for illnesses such as hemophilia, SMA, sickle cell disease, and Duchenne muscular dystrophy, these expensive new treatments may actually accentuate rather than reduce disparities among patients, said Steven Pearson, MD, founder and president of the Boston-based Institute for Clinical and Economic Review.
"There's a real anxiety that this wave of innovation will lead to unexpected high costs," he said. "Insurance companies are writing policies today that will exclude gene therapies. That's ridiculous. It doesn't help anybody."
Fair pricing strategies
Fair pricing strategies are badly needed to ensure that all who need future gene therapies will have access to them, regardless of the cost, said Pearson, whose independent, nonpartisan agency objectively evaluates the clinical and economic value of prescription medications.
"We could just give this to the federal government and create risk pools, but I think the private market can sort this out," he said. "A fair price should never mean that a patient should have to repeat their genetic tests every six months to show they still have the same bloody condition."
During a panel, titled "Gene Therapy: Overcoming Challenges for Both Patients and Manufacturers," pharmaceutical executives and patient advocates discussed what the coming scientific revolution means for them.
Gene therapy offers the possibility for kids with devastating conditions and severely limited life spans to live long, productive lives and fulfill their potential, said Mark Rothera, president and CEO of London-based Orchard Therapeutics, who moderated the panel.
Rothera said he's worked in rare diseases since the late 1980s, and has launched seven orphan drugs in his career.
"But I joined Orchard a few years ago because I've never seen data like this before. It's taken 20 or 30 years of work to get to this point," he said. "The whole system is geared up for chronic long-term therapy. Now we're talking about one single intervention that will deliver lifelong benefits, so the system has to welcome that and adapt to it."
The panel included Olivier Danos, PhD, senior vice president and chief scientific officer at Regenxbio; Neil Horikoshi, CEO and executive director of the Aplastic Anemia & MDS International Foundation; Stephanie Uder, vice-president of product management at Accredo; and Amy Price, outreach coordinator at the Leukodystrophy Family Forum.
"You can imagine the enormous financial and emotional toll that 24/7 care takes on moms and dads," Rothera said. "Maybe one of the parents has to give up a job to be there. Imagine if that's no longer required, because the parents have a healthy child, and can use that time and energy to look after healthy children."
Gene therapy for ADA
To that end, Orchard is focused solely on treating children with primary immune deficiencies, neurometabolic disorders, and hemoglobinopathies — most of which lack treatments today.
The company's pipeline includes Strimvelis, the first ex vivo autologous gene therapy to treat patients with severe combined immunodeficiency due to adenosine deaminase deficiency (ADA) for whom no suitable stem cell donor is available. Approved by the European Medicines Agency in 2016, Strimvelis was acquired by Orchard from GlaxoSmithKline in March 2018.
ADA affects about 15 people per year in Europe and 12 per year in the United States. Strimvelis retails for $780,000, compared to $4.25 million for 10 years of weekly enzyme replacement therapy.
"We're building a company on a global scale to bring these medicines to patients around the world as quickly as we can, but we face plenty of challenges with patient identification," Rothera said. "When you're bringing gene therapy for the first time in the world to a community that hasn't had treatment, there's been less of an effort at diagnosis."
"But time also matters," he added. "Some patients, you want to treat as early as possible before symptoms develop — so newborn screening is very important."
Rothera also noted the complicated logistics of bringing patients from all over the world to a specific hospital to receive gene therapy.
"Imagine the case of a child born with a rare disease that has been cured through one single intervention," he said. "Effectively, that child is no longer a patient — yet will need a further 15 years of follow-up. A procedure like this requires exquisite coordination. The patient's own cells become the product."
Flying abroad for gene therapy
Amy Price knows about the complicated logistics of traveling across the ocean to cure a child.
She and her husband, Brad, have three children with metachromatic leukodystrophy (MLD). The disease affects white matter in the brain, causing progressive loss of mobility and sensation as well as intellectual decline.
Their daughter, Liviana, was born in January 2008 and diagnosed with MLD in December 2010. Giovanni was born in January 2010. After genetic testing revealed that he also had the disease, the boy was accepted into a clinical trial at Italy's San Raffaele Telethon Institute for Gene Therapy in Milan. He was treated in 2011, though it was too late for Liviana, who died in 2013.
The following year, Price gave birth to triplets. One of them, Cecilia, inherited MLD and got the gene therapy in Italy at 9 months old. According to a post in the PLOS Blogs Network, the gene therapy that Giovanni and Cecilia received "adds corrected genes for the enzyme arylsulfatase A to bone marrow stem cells taken from the children. The cells are infused and migrate to the brain, where they give rise to corrected glial cells that make the necessary enzyme. Done early enough, symptoms never begin."
A psychologist, Price recently interviewed 16 families whose children — 12 with MLD — underwent gene therapy treatments, mostly between 2011 and 2016. Half of the children was American and the other half was European. Their ages ranged from 8 months to 11 years, with an average age of 3 years.
She found that the most formidable challenges for families were fear of unknown or long-term treatment outcomes; family separation; having to care for other children at the same time; social isolation; unfamiliar language or customs; and financial well-being.
"It seems like such a small thing, but if you don't have WiFi and nobody speaks your language, it's a cumulative effect," said Price, noting the emotional and physical stress of travel logistics, flying, and general exhaustion on the patients and their families.
Among her suggestions:
- Bring patient communities into the preclinical planning process.
- Understand and effectively address cultural challenges with international participants.
- Identify and work to eliminate the external stressors that impact families (lack of WiFi, social and language barriers).
- Provide effective psychological support during and after hospitalization, and connect patient to local resources.
- Provide clinical follow-up at local hospitals to eliminate the challenges of traveling.
"There is so much unknown with a new treatment, and the patients make an immeasurable and priceless sacrifice of hope," said Price. But even so, she added, "it's a life-or-death choice, and 100% [of respondents] said they would do it again."


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GTT Communications, Inc. (NYSE: GTT), the leading global cloud networking provider to multinational clients, announced today that it will sponsor and speak at the upcoming PTC'17 conference in Honolulu. PTC'17: Changing Realities will explore the evolving landscape of the global economy and regulatory environment, and present ways in which service providers can prepare for these changes.
PTC'17 will be held January 15-18 at the Hilton Waikiki Beach Resort. GTT Chief Marketing Officer Gina Nomellini will participate on a panel titled "Cloud/Networking: Digital Transformation in the Changing IT Reality," on Monday, January 16, at 3:30 p.m. The session will review the best strategies for leveraging the hybrid cloud and hybrid IT to address challenges posed by the rapidly growing digital landscape and evolving IT trends, including those relating to the Internet of Things (IoT).
"GTT is pleased to have the opportunity to participate in this discussion," said Ms. Nomellini. "As a leader in cloud networking services, GTT is committed to supporting our clients' digital transformation initiatives and to securely and privately connecting them with the applications and services they require. We look forward to meeting with other industry leaders and discussing how the right connectivity model is key to implementing cloud-based services and new technologies within the enterprise."
About GTT
GTT provides multinationals with a better way to reach the cloud through its suite of cloud networking services, including wide area networking, Internet, managed services and voice services. The company's Tier 1 IP network, ranked in the top five worldwide, connects clients to any location in the world and any application in the cloud. GTT delivers an outstanding client experience by living its core values of simplicity, speed and agility. For more information on how GTT is redefining global communications, please visit www.gtt.net.


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In July of this year five students from Northwestern University's Feinberg School of Medicine traveled to rural India as part of a unique global health program organized by Child Family Health International – CFHI, the second trip organized through their unique partnership. Funded by Northwestern's Center for Global Health we set out to learn about public health, increase our cultural competency, and develop clinical skills by participating in a four-week clinical shadowing experience across Northwest India. We rotated in different settings, from tiny villages like Patti tucked away in the foothills of the Himalayas to the bustling city of Dehradun, in both public and private healthcare sectors. During our time in the clinics, on the wards, and in the field we witnessed healthcare disparities as they are manifested between rural and urban regions, between private and public sectors, and between different socioeconomic groups. We were able to see, for cultural and economic reasons, how differently medicine is delivered half a world away.
That month spent in India was an unforgettable and magnificent experience: the medicine we witnessed, the physicians and nurses we worked with, and the patients we got to interact with brought the kind of perspective to my medical education that only an actual, immersive experience that being abroad could bring. We didn't stay in hostels or hotels – we lived with Indian families in their homes or in dormitories within the hospitals.
Nothing can beat that kind of immersion; nothing can beat waking up in a tiny mountain village everyday at 5:30AM with my fellow travelers to do yoga, or getting woken up in the hospital by a nurse to aid in a delivery or assist in the emergency department. We explored palaces and temples, hiked through jungles, and sampled the multitude of sights and smells, the cacophony of sounds, and the delicious and exotic foods. India brought piece and calm to my mind and body, it gave me perspective on the doctor/patient relationship, and reminded me what medicine is really about – one component of the greater endeavor to help ameliorate human suffering in the world.
India left a lasting impression – one that no doubt will shape my medical career, but also my personal life. It left me wanting to return to the more disenfranchised parts of the world to practice medicine, it left me a with a firmer perspective and appreciation of my own upbringing, and it left me with fond memories of a country I would dearly love to visit and explore again in the future.
Jason Chodakowski
Northwestern University Feinberg School of Medicine
MD Candidate – Class of 2016


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Have astronomers finally found a moon outside our Solar System?
Astronomers believe they have discovered a Neptune-sized satellite orbiting a giant Jupiter around a Sun-like star
Using NASA's Hubble and Kepler space telescopes, astronomers have uncovered tantalising evidence for what could be the first discovery of a moon orbiting a planet outside our solar system.
This moon candidate, which is 8,000 light years from Earth in the Cygnus constellation, orbits a gas-giant planet that, in turn, orbits a star called Kepler-1625. Researchers caution that the moon hypothesis is tentative and must be confirmed by follow-up Hubble observations.
"This intriguing finding shows how NASA's missions work together to uncover incredible mysteries in our cosmos," says Thomas Zurbuchen, associate administrator of NASA's Science Mission Directorate at NASA Headquarters, Washington, D.C., United States. "If confirmed, this finding could completely shake up our understanding of how moons are formed and what they can be made of."
Since moons outside our solar system — known as exomoons — cannot be imaged directly, their presence is inferred when they pass in front of a star, momentarily dimming its light. Such an event is called a transit and has been used to detect many of the exoplanets catalogued to date.
However, exomoons are harder to detect than exoplanets because they are smaller than their companion planet, and so their transit signal is weaker when plotted on a light curve that measures the duration of the planet and the amount of momentary dimming. Exomoons also shift position with each transit because the moon is orbiting the planet.
In search of exomoons, Alex Teachey and David Kipping, astronomers at Columbia University in New York, United States, analysed data from 284 Kepler-discovered planets that were in comparatively wide orbits, longer than 30 days, around their host star. The researchers found one instance, in Kepler-1625b, of a transit signature with intriguing anomalies, suggesting the presence of a moon. "We saw little deviations and wobbles in the light curve that caught our attention," says Kipping.
Based upon their findings, the team spent 40 hours making the observations with Hubble to study the planet intensively — also using the transit method — obtaining more precise data on the dips of light. Scientists monitored the planet before and during its 19-hour transit across the face of the star. After the transit ended, Hubble detected a second and much smaller decrease in the star's brightness approximately 3.5 hours later. This small decrease is consistent with a gravitationally-bound moon trailing the planet, much like a dog following after its owner. Unfortunately, the scheduled Hubble observations ended before the complete transit of the candidate moon could be measured and its existence confirmed.
In addition to this dip in light, Hubble provided supporting evidence for the moon hypothesis by finding the planet transit occurring more than an hour earlier than predicted. This is consistent with the planet and moon orbiting a common centre of gravity that would cause the planet to wobble from its predicted location, much the way the Earth wobbles as our Moon orbits it.
The researchers note the planetary wobble could be caused by the gravitational pull of a hypothetical second planet in the system, rather than a moon. While Kepler has not detected a second planet in the system, it could be that the planet is there, but not detectable using Kepler's techniques.
"A companion moon is the simplest and most natural explanation for the second dip in the light curve and the orbit-timing deviation," Kipping explains. "It was definitely a shocking moment to see that Hubble light curve, my heart started beating a little faster and I just kept looking at that signature. But we knew our job was to keep a level head and essentially assume it was bogus, testing every conceivable way in which the data could be tricking us."
In a paper recently published in the journal Science Advances, the scientists report that the candidate moon is unusually large — potentially comparable to Neptune. Such large moons do not exist in our own solar system. The researchers say this may yield new insights into the development of planetary systems and may cause experts to revisit theories of how moons form around planets.
The moon candidate is estimated to be only 1.5 percent the mass of its companion planet, and the planet is estimated to be several times the mass of Jupiter. This mass-ratio is similar to the one between Earth and the Moon. In the case of Earth-Moon system, and the Pluto-Charon system, the moons are thought to be created through dust leftover after rocky planetary collisions. However, Kepler-1625b and its possible satellite are gaseous and not rocky, so the moon may have formed through a different process.
Researchers note that if this planet is indeed a moon, both it and its host planet lie within their star's habitable zone, where moderate temperatures allow for the existence of liquid water on any solid planetary surface. However, both bodies are considered to be gaseous and therefore unsuitable for life as we know it.
Future searches for exomoons in general will target Jupiter-sized planets that are farther from their star than Earth is from the Sun. The ideal candidate planets hosting moons are in wide orbits, with long and infrequent transit times. In this search, a moon would have been among the easiest to detect because of its large size. Currently, there are just a handful of such planets in the Kepler database. Whether future observations confirm the existence of the Kepler-1625b moon, NASA's upcoming James Webb Space Telescope will be used to find candidate moons around other planets, with much greater detail than Kepler. "We can expect to see really tiny moons with Webb," says Teachey.
Keep up to date with the latest news in All About Space – available every month for just £4.99. Alternatively you can subscribe here for a fraction of the price!


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MODESTO (AP) — A California teenager who broke off a romance with her 41-year-old high school teacher after he was arrested on suspicion of sexually abusing another girl said the couple is now back together.
Jordan Powers, 18, told KOVR-TV on Tuesday the relationship was back on, and her mother said her daughter has cut off contact with the family.
News of their reunion came the same day a California Assembly committee voted down legislation that would have made it a felony for a teacher to enter into a romantic relationship with a student even if the student is over 18.
Powers and Christopher James Hooker made national headlines when they announced their relationship in February and he said he had left his wife and children to move in with his former student at Modesto's James Enochs High School.
Both insisted on talk shows and during news interviews that they did not have any sexual contact until Powers turned 18, and police launched an investigation to determine if that was true.
During the investigation, police said they uncovered a sexual relationship that Hooker had with a 17-year-old girl in 1998. He's been charged with one count of oral copulation with a minor.
A judge has entered a not-guilty plea on Hooker's behalf, and he's currently free on bail.
After Hooker's April 6 arrest, Powers said she ended the romance and moved out of their studio apartment.
But Tammie Powers, who had launched an aggressive media campaign to shame Hooker for courting her daughter, told the Modesto Bee that he called Jordan "relentlessly" while she was out of state with her family and she eventually returned to him.
"It is awful. This is what pedophiles, predators do. They isolate them from family," said Tammie Powers, who testified before the Assembly's public safety committee that considered the teacher-student bill.
Opponents of the bill, including the California Federation of Teachers and American Civil Liberties Union, said it was an overreaction to an isolated case, and could violate the rights of consenting adults.


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Nearly 40 thousand Americans cast more than 300,000 votes as part of a national initiative titled: "The People's Vote: 100 Documents that Shaped America," cosponsored by the National Archives, National History Day, and U.S. News & World Report. The results of the vote were announced in a ceremony in the National Archives Rotunda on December 15, 2003. The 10 documents that received the most votes are (the percentage of votes each received is shown in parentheses):
- The Declaration of Independence (75.9 percent);
- The U.S. Constitution (69.3 percent);
- The Bill of Rights (67.9 percent);
- The Louisiana Purchase Treaty (34.3 percent);
- The Emancipation Proclamation (33.5 percent);
- The 19th Amendment to the Constitution (31.4 percent);
- The 13th Amendment to the Constitution (30.1 percent);
- The Gettysburg Address (25.4 percent);
- The Civil Rights Act (25.2 percent);
- The Social Security Act (20.9 percent).
The paper ballot included an opportunity for voters to write in documents that were not on the list of 100. The majority of those mentioned were primarily from the period after 1965, the end date for the official list of 100 milestone documents. Among the documents that received multiple votes were:
- President Reagan's "Tear down that wall" speech;
- President Bush's speech discussing the September 11 tragedy;
- Roe v. Wade Supreme Court Decision;
- Martin Luther King's "I Have a Dream" speech;
- Voters' birth certificates;
- and the Medicare Bill.
In announcing the results of "The People's Vote," Archivist of the United States John Carlin said, "'The People's Vote' is truly a unique initiative. No other project has invited Americans from all walks of life, all across the country, to voice their opinion on the documents that have shaped our history, culture, and society today. Not only did it challenge voters to really think and learn about the 100 milestone documents, but it encouraged enthusiastic debate in homes, classrooms, workplaces, and online."
Brian Duffy, editor of U.S. News & World Report said, "It was a not only a privilege to work with the experts at the National Archives and Records Administration, but an honor to be involved in this unique effort to reacquaint so many Americans with some of the most defining moments of our nation's history."
In looking forward, National History Day Executive Director Cathy Gorn said at the ceremony, "Our challenge now is to continue this exercise in understanding democracy and citizenship. Today's announcement comes at the end of a major push to engage Americans in such practice. "The People's Vote" has been both educational and fun, and it is fascinating to see which documents Americans are thinking about. But this is only the beginning of the discussion. Our task now is to continue this conversation and encourage all Americans, and especially young Americans, to meet the challenge of forming 'a more perfect union.'"
—Based on a NARA Press Release
This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. Attribution must provide author name, article title, Perspectives on History, date of publication, and a link to this page. This license applies only to the article, not to text or images used here by permission.


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- Home ›
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Files, San Antonio, Texas
Part of: i. Promotions and Bookings
Rare Books & Special Collections, Hesburgh Libraries
Our collection information is a work in progress and may be updated as new research findings emerge. If you have spotted an error, please contact Rare Books & Special Collections, Hesburgh Libraries at firstname.lastname@example.com.


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- Custom Homes
- Renovations
- Landscapes
Meet the Owner
Perhaps the best way to describe Matt is to use his own words: "I have spent the past 20 years in pursuit of combining my love for design and the perfect implementation of the built form." Past clients and colleagues gladly add descriptors of their own, such as talented, creative, honest, trustworthy, dependable, and just a really good guy. You will not find a more invested and qualified individual to guide you through the process of custom building or renovation. If you'd like specifics about Matt's past experience in the design/build field, read on.
On The Boards
If you're on Facebook or Pinterest, our On The Boards galleries contain photos of current projects with a focus on initial concept and design. With a passion for beautiful design, we consider this is the most important step in any Custom Home, Landscape, or Renovation project! Facebook Gallery, Pinterest Gallery
Curious to know what we're up to? You can follow our frequent updates on these popular social websites.


text:
Listed in alphabetical order.
CITATION FORMAT: Proceedings of the 4th International Conference on Sustainability Engineering and Science, Auckland, NZ, Nov 30 – Dec 3, 2010.
Please state whether you used the proceedings USB memory stick or include the website access page address and date of access.
- Abd Wahab, Hanani; Dr. Mike Duke; Dr. Tim Anderson; Dr. James Carson
Solar Roofing System Thermal Performance Analysis (147 kB PDF)
- Batmunkh, Narantuya; Komsun Siripun; Peerapong Jitsangiam; Hamid Nikraz
Sustainable Use of Crushed Concrete Waste as A Road Base Material (502 kB PDF)
- Brown, Craig; Prof. Stephen Legg
Achieving Transition: Lessons from Human Factors/Ergonomics (1.51 MB PDF)
- Byrd, Dr. Hugh; Dr. Michael Rehm
Changing Architecture for a Changing Climate; Unsustainable Trends in New Zealand (77 kB PDF)
- Clarke, Caleb; Lucy Preston, David Phillips, L. Fourie
You Can Teach A Young Dog New Tricks: Starting At The Beginning—Sustainable Education (617 kB PDF)
- Crul, Dr. Marcel; Ir. Jan Carel Diehl
Design for Sustainability: moving from incremental towards radical design approaches (280 kB PDF)
- Dale, Michael; Dr. Susan Krumdieck; Prof Pat Bodger
Global Energy Modelling – a biophysical approach (723 kB PDF)
- David, Laurentiu (Larry); Dr. Frantz Daniel Fistung
On the road to sustainability—the case of the Romanian transportation sector (180 kB PDF)
- Dravitzki, Vince; Tiffany Lester; Peter Cenek
Pathways to a more sustainable transport infrastructure (216 kB PDF)
- Ducker, Dan; Dr. Kepa Morgan
Bridging formal research and informal approaches to enhance civic engagement processes (75 kB PDF)
- Easton, Lois; Roman Jacques
The Eco Design Advisor Programme: Supporting the Transformation of New Zealand's Housing Stocks (171 kB PDF)
- Evangelista, Anna; Dr. Maria Estela Varua
(Un)sustainable Consumption in Australian Households: An Exploratory Study (375 kB PDF)
- Foudazi, Mrs Fahimeh; Dr. Mugendi M'Rithaa
Sustainable solutions for Cooling Systems in Residential buildings: Case study in the Western Cape Province, South Africa (760 kB PDF)
- Gamage, Gayathri Babarenda; Assoc. Prof. Carol Boyle; Dr. Ir. Ron McDowall
The Development of an Integrated Model for Assessing Sustainability of Complex Systems(149 kB PDF)
- Gaziulusoy, A. Idil; Assoc. Prof. Carol Boyle; Dr. Ir. Ron McDowall
System Innovation for Sustainability at Product Development Level: Development of a Scenario Method and a Workshop Tool (581 kB PDF)
- Giurco, Dr. Damien; Dr. Timothy Prior; Ms Leah Mason; Dr. Gavin Mudd
Peak Minerals: mapping sustainability issues at local, national and global scales (2.18 MB PDF)
- Gyamfi, Samuel; Dr. Susan Krumdieck; Dr. Larry Brackney
Pattern Recognition Residential Demand Response: An Option for Critical Peak Demand Reduction in New Zealand (294 kB PDF)
- Harrison, Frances; Dr. Maggie Lawton (presenter)
Community Advocacy for Sustainable Living (380 kB PDF)
- Havenga, Dr. Jan; Zane Simpson
Research priorities for Sustainable Branch Line Revitalisation in South Africa (1.24 MB PDF)
- Howell, Dr. Robert
Transitions to Sustainable Investment (159 kB PDF)
- Hucker, Dr. Bruce
Auckland governance reforms: political legitimacy, democratic accountability and sustainable development (257 kB PDF)
- Hughes, James; Steve Goldthorpe, Robert Perry
Carbon Futures: Reducing Emissions for the Auckland Region (732 kB PDF)
- Idrus, Shaharudin; Em. Prof. Abdul Samad Hadi, Abdul Hadi Harman Shah; Ahmad Fariz Mohamed
Non-linearity of Urban Expansion: Transition to Sustainability (463 kB PDF)
- Idrus, Shaharudin; Em. Prof. Abdul Samad Hadi; Assoc. Prof. Ahmad Fariz Mohamed; Siti Nashroh Shaari; Prof. Mazlin Mokhtar
A Malaysian Initiative in Embedding Sustainability: Sustainable School—An Environment Award (72 kB PDF)
- Kelly, Dr. Patricia
Embedding Sustainability: painless is just delay (129 kB PDF)
- Kirk, Nick; Prof. Ali Memon
Sustainable Governance of Marine Fisheries: A Socio-Ecological Embeddedness Perspective (233 kB PDF)
- Koh, Sungsoo; Assoc. Prof. Carol Boyle
Limits to growth defined by water resource, Waiheke Island case study (279 kB PDF)
- Krpo, Ana; Yasenko Krpo; Tony Miguel; Helen Chin
Urban Stormwater Runoff quality – lifecycle assessment (8.09 MB PDF)
- Krumdieck, Assoc. Prof. Susan; Montira Watcharasukarn; Shannon Page
TACA Sim: a survey for adaptability assessment (265 kB PDF)
- Krumdieck, Assoc. Prof. Susan
The Survival Spectrum: the key to Transition Engineering of Complex Systems (1.82 MB PDF)
- Lawton, Ella Susanne; Prof. Robert Vale; Prof. Brenda Vale; Dr. Maggie Lawton
The New Zealand Footprint Project: the Ecological Footprint of Kiwi Lifestyles and Urban Form (94 kB PDF)
- Longley, Dr. Ian; Gustavo Olivares
What is Sustainable Air Quality? (187 kB PDF)
- Ly, Phuong; Prof. Janis Birkeland; Assoc. Prof. Nur Demirbilek
Towards Sustainable Housing for Vietnam (1.91 MB PDF)
- Martin, Tim; Dr. Gavin Mudd
Investigation of the National Pollutant Inventory (NPI) as a Sustainability Tool (393 kB PDF)
- Mason, Dr. Ian; Dr. Shannon Page; Prof. Arthur Williamson
Transitioning to a 100% renewable electricity generation system: balancing the roles of wind generation, base-load generation and hydro storage (172 kB PDF)
- McLernon, Dr. Tim
Integrating Sustainable Development Into The Higher Education Built Environment Curriculum (158 kB PDF)
- McQuinn, Taryn; Claire Jewell
Sustainable Steelmaking: Infrastructure for the Future (197 kB PDF)
- McSaveney, Len
Towards More Sustainable Concrete (88 kB PDF)
- Mohamed, Assoc. Prof. Ahmad Fariz; Prof. Abdul Samad Hadi; Shaharudin Idrus; Assoc. Prof. Abdul Hadi Harman Shah
From the Linear to Cyclic Approach for Sustainable Waste Management in Malaysian City(221 kB PDF)
- Mohamed, Mr Muaviyath; Dr. Susan Krumdieck; Dr. Larry Brackney
Sustainable Renewable Electricity for Small Islands : A Methodology for Essential Load Matching (347 kB PDF)
- Mokhtar Azizi, Ms. Sakina; Dr. Elizabeth Fassman; Assoc. Prof. Suzanne Wilkinson
Methodology for Essential Load Matching (80 kB PDF)
- Moore, Mr. Trivess; Dr. John Morrissey; Prof. Ralph Horne
Cost benefit pathways to zero emission housing: Implications for household cash-flows in Melbourne (119 kB PDF)
- Morrissey, Dr. John; Dr. Usha Iver-Raniga; Patricia McLaughlin; Assoc. Prof. Anthony Mills
Proposal of a tiered conceptual framework for sustainable design and planning of large-scale development projects in the metropolitan context (405 kB PDF)
- Mosly, Ibrahim; Dr. Guomin (Kevin) Zhang
Study on Risk Management for the Implementation of Energy Efficient & Renewable Technologies in Green Office Buildings (273 kB PDF)
- Mudd, Dr. Gavin
The "Limits to Growth" and "Finite" Mineral Resources: Revisiting the Assumptions and Drinking From That Half-Capacity Glass (329 kB PDF)
- O'Byrne, Colin; Assoc. Prof. Penny Allan
Urban Form as a Reflection of Governance Practices (176 kB PDF)
- Olorunkiya, Joshua Olutayo; Dr. Elizabeth Fassman; Assoc. Prof. Suzanne Wilkinson
Global Thinking- Local Action: Adopting the Low Impact Design (LID) Technologies in Urban Stormwater Management (394 kB PDF)
- Olorunkiya. Joshua Olutayo; Dr. Elizabeth Fassman; Assoc. Prof. Suzanne Wilkinson
Risk as a Fundamental Barrier to Adoption of Low Impact Design Technologies (337 kB PDF)
- Paetz, Matthew
Sustainable Suburbia—Oxymoron or Realistic Goal? (168 kB PDF)
- Pearce, Asst. Prof. Annie; Asst. Prof. Yong Han Ahn
Strategic Entry Points for Sustainability in University Strategic Entry Points for Sustainability in University (171 kB PDF)
- Pearce, Asst. Prof. Annie; Assoc. Prof. Kristen Sanford-Bernhardt; Assoc. Prof. Michael Garvin
Sustainability and Capital Projects: Modeling the Emergent Property of Total Cost of Ownership (611 kB PDF)
- Pearce, Asst. Prof. Annie
Costing Sustainable Capital Projects: The Human Factor (653 kB PDF)
- Perry, Robert; Paul Chambers
Carbon Now and Carbon Futures—a systems and performance based approach to reducing GHG Emissions in the Auckland Region (519 kB PDF)
- Powell, Dr. Felicity; Dr. Abigail Harding
The renaissance of inner city living and its implications for infrastructure and services: A Wellington case study (435 kB PDF)
- Quinlivan, Paul; Shelley Quinlivan
Embedding Sustainability into School Curriculums (670 kB PDF)
- Reay, Dr. Stephen; Andrew Withell, Prof. Olaf Diegel
Design for Biodiversity: a new approach for ecologically sustainable product design? (4.57 MB PDF)
- Reay, Dr. Stephen; Andrew Withell, Prof. Olaf Diegel
How to effectively engage students with environmentally sustainable product design? (386 kB PDF)
- Rendall, Stacy; Assoc. Prof. Susan Krumdieck; Dr. Elijah Van Houten; Dr. Femke Reitsma; Dr. Shannon Page
Quantifying Transport Energy Resilience: Active Mode Accessibility (713 kB PDF)
- Robak, Anna; Assoc. Prof. Henning Bjornlund
Trade-offs between public health and environmental protection in a potable water supply context: Drinking Water Standards New Zealand vs resource consent conditions (164 kB PDF)
- Rosales-Carreón, Jesús; Prof. René Jorna; Dr. Neils Faber; Prof. Rob van Haren
Sustainability: Seeing Through The Eyes Of Farmers (116 kB PDF)
- Rule, Bridget; Assoc. Prof. Carol Boyle
Challenges for sustainable infrastructure development in small island developing states(193 kB PDF)
- Russell, John; Kevin Long
Transitions to Sustainability—Are we confident about the IPCC climate change predictions for the future? (1.39 MB PDF)
- Saito, Assoc. Prof. Osamu
Measuring lifecycle carbon footprint of a golf course and greening in the golf industry (309 kB PDF)
- Saville-Smith, Kay; Lois Easton
Market Transformation to Achieve Large Scale Uptake of Sustainable Residential Renovation in New Zealand (353 kB PDF)
- Scott, Eion; Jennifer Kerr; Rhys Taylor
Resilience in sustainability: A New Resource (1.1 MB PDF)
- Sinclair, Sarah; Louise Webster; David Woods
Rethinking sustainable infrastructure using innovation tools (197 kB PDF)
- Slason, Jonathan
Unintended Consequences of Reduced Consumption (62 kB PDF)
- Smith, Tara; Dr. Gavin Mudd
Shallow Groundwater Resources and Future Climate Change Impacts:A Comparison of the Ovens and Namoi Catchments, Eastern Australia (467 kB PDF)
- Tanner, Aaron; Dr. Brian S. McIntosh; Dr. David Widdowson
Adapting to adopt sustainability: organisational change in UK water and sewerage companies (651 kB PDF)
- van Onselen, Lenny; Dr. Kristina Lauche; Dr. Sacha Silvester; Silje Rikoll Dehli
Technology Windows in Sustainable Innovation Projects: Experiences with an Innovation Tool for Identifying Sustainable Application Domains (610 kB PDF)
- Vickers, Jeff; Assoc. Prof. Carol Boyle
Design for Sustainable Development: A Framework for Sustainable Product Development and its Application to Earthmoving Equipment (676 kB PDF)
- Weng, Zhehan; Dr. Gavin M. Mudd; Assoc. Prof. Carol Boyle
Projecting the Full Pollutant Cycle from Coal Utilisation to 2050: Understanding the Global Environmental Implications (130 kB PDF)
- Williamson, Prof. Arthur; Dr. Ian Mason
Transitions in transit: future options for transport energy in New Zealand (174 kB PDF)
- Wolfgramm, Dr. Rachel
Creating leadership in transition to sustainability societies: Reflections from the Universitas 21 Sustainability Project (177 kB PDF)
- Young, Damian
Can catchment management can be delivered for the Auckland Super City watersheds and achieve sustainability (270 kB PDF)
- Zahedi, Assoc. Prof. Ahmad
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OCEAN CITY – Plans to scuttle a retired U.S. Navy destroyer as part of a three-state artificial reef system 30 miles from the Ocean City Inlet are inching closer to becoming a reality this week as final preparations and inspections are being conducted on the vessel that could be sunk before the end of October.
The decommissioned U.S.S. Arthur W. Radford will be featured in a three-state cooperative artificial reef project that includes Maryland, Delaware and New Jersey, along with the U.S. Navy. The 563-foot Radford has been stored all summer in the Navy's Philadelphia shipyard where it is being prepared for its ultimate home at the bottom of the ocean off the mid-Atlantic coast.
Preliminary plans called for the vessel to be sunk on a permitted artificial reef site named "DelJerseyLand" in honor of the three states participating in the project in late summer, but the sinking has been delayed as the vessel undergoes final preparations and inspections. The ship is in the final stages of the process to strip and clean it in order to make it environmentally viable as a future artificial site.
The Maryland Artificial Reef Initiative (MARI) has partnered with similar agencies in Delaware and New Jersey to first acquire the decommissioned Radford and then prepare it for sinking off the mid-Atlantic coast in an area equidistant from the three states.
Maryland Artificial Reef Coordinator Erik Zlokovitz said this week the exact date of the sinking has been difficult to pin down, although the plan is on track for mid- to late October.
"The date of the sinking would be mid- to late October at the earliest," he said. "We cannot schedule the date until we meet with the EPA and work out the schedule for the final PCB inspection."
Zlokovitz said the final date would depend largely on the approval of the EPA. After the vessel is cleared for sinking, the exact date will likely depend on weather and sea conditions and other logistics involved with the massive undertaking.
"If we are not in compliance with EPA procedures and don't have all the documentation, we may have to delay the sinking in order to come into compliance," he said. "I am on standby to attend a meeting with EPA to discuss PCB cleaning procedures and final prep work and should know more about a final sinking date after that meeting."
The already-permitted site is equidistant from each state's major Atlantic port at about 32 miles east-northeast of the Ocean City Inlet, 28 miles southeast of the Indian River Inlet in Delaware and 34 miles southeast of Cape May, N.J. Following a final inspection and clearance to proceed, likely some time later this month, the Radford will be towed down the Delaware River and out to sea over the permitted reef site. It will remain over the permitted reef site for several days while its hull is strategically sliced open to allow for a methodical sinking by flooding its many compartments.
The 536-foot Radford will become the largest warship ever sunk as part of an artificial reef site on the East Coast. The 910-foot former aircraft carrier Oriskany was sunk in the Gulf of Mexico off the coast of Pensacola, Fla. in 2006, becoming the largest warship ever sunk expressly for the purpose.
The retired Radford would be sunk in about 130 feet of water and would create a vertical profile from the sea floor of about 70 feet, along with its 560-foot-plus length. It was launched in 1975 and commissioned in 1977. Twenty-eight years later it was decommissioned and now sits in a Philadelphia shipyard awaiting its fate. The ship was made available to all Gulf and Atlantic states in May 2008, but the Navy received only the application from the tri-state group including Maryland.


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Assessing care for patients with TB/HIV/STI infections in a rural district in KwaZulu-Natal
Health Systems Research Unit, Medical Research Council, Tygerberg, W Cape
Marian Loveday, M Phil (Maternal & Child Health)
School of Public Health, University of the Western Cape, Bellville
Vera Scott, MB ChB, DCH, MPH
Feroza Amien, BCh D, MCh D (Community Dentistry)
TB/HIV Care Association, Cape Town
Jenny McLoughlin, BCur (Nursing)
School of Public Health and Family Medicine, University of Cape Town
Virginia Zweigenthal, MB ChB, DTM&H, DPH, FCPHM (SA)
Corresponding author: M Loveday (firstname.lastname@example.com)
Setting. Despite the prioritisation of TB, HIV and STI programmes in South Africa, service targets are not achieved, have had little effect, and the magnitude of the epidemics continues to escalate.
Objective. To report on a participatory quality improvement intervention designed to evaluate these priority programmes in primary health care (PHC) clinics in a rural district in KwaZulu-Natal.
Methods. A participatory quality improvement intervention with district health managers, PHC supervisors and researchers was used to modify a TB/HIV/STI audit tool for use in a rural area, conduct a district-wide clinic audit, assess performance, set targets and develop plans to address the problems identified.
Results. We highlight weaknesses in training and support of staff at PHC clinics, pharmaceutical and laboratory failures, and inadequate monitoring of patients as contributing to poor TB, HIV and STI service implementation. In the 25 facilities audited, 71% of the clinical staff had received no training in TB diagnosis and management, and 46% of the facilities were visited monthly by a PHC supervisor. Eighty per cent of the facilities experienced non-availability of essential drugs and supplies; polymerase chain reaction (PCR) results were not documented for 54% of specimens assessed, and the mean length of time between eligibility for ART and starting treatment was 47 days.
Conclusion. Through a participatory approach, a TB/HIV/STI audit tool was successfully adapted and implemented in a rural district. It yielded information enabling managers to identify obstacles to TB, HIV and STI service implementation and develop plans to address these. The audit can be used by the district to monitor priority services at a primary level.
S Afr Med J 2011;101:887-890.
South Africa has a high infectious disease burden with concomitant HIV and TB epidemics and high rates of sexually transmitted infections (STIs). In 2009, KwaZulu-Natal had the highest TB notification rate in the country, with 1 163 cases per 100 000 population, in a setting where 80% of all TB patients are HIV-positive, and the 17% HIV prevalence in 15 - 49-year-olds was among the highest in the world.1 , 2
Expenditure on primary level services in South Africa has increased from investment in infrastructure and human resources, yet the health services have been ineffective in reducing the caseload and incidence of the TB, HIV and STI epidemics.
Between 2002 and 2009, a TB/HIV/STI service evaluation tool was developed in the Western Cape to promote integration between these services and to rationalise supervisory tools in use at a facility level. In an urban area with good infrastructural support, the tool successfully identified problems and, if used regularly, could improve service delivery.3 It was adapted for rural areas, to account for differences in service delivery operations and priorities.
We describe the adaptation of the urban audit tool to assess and support effective TB/HIV/STI services at primary care level in a rural South African district, and to provide the results of the first audit in which its relevance and usefulness in a rural setting were tested.
Primary health care (PHC) services are nurse-driven and, in rural areas where a small population is served, one professional nurse in a small facility may provide the only health care in a vast geographical area with no support from a doctor. Clinic nurses become responsible for diagnosing and managing TB, HIV and STIs, providing acute curative services and attending to chronic conditions such as hypertension.
An economically and infrastructurally poor rural district in KwaZulu-Natal was selected as the setting for adaptation and piloting the tool. The residents are among the most socio-economically deprived in the country, with limited or no access to piped water.4 Impassable roads in the rainy season and inadequate communication networks result in remote clinics having no communication with the district hospital or district office for weeks. Limited managerial and infrastructural capacity, staff attrition and delays in filling key managerial and clinical posts hinder the performance of public health services. For example, the TB cure rate of 62% falls far short of the national target of 85%.4 The district is not named as its conditions are similar to those in many rural districts of South Africa.
The audit tool explores six domains of effective programme delivery: access, availability, capacity, continuity of care, quality and integrated care adapted from a UNAIDS/UNICEF5 framework evaluating Prevention of Mother to Child Transmission (PMTCT) programmes.3
TB/HIV/STI programmes at PHC level comprise HIV counselling and testing (HCT), HIV care prior to the commencement of antiretroviral therapy (pre-ART), ART care, TB management, and evaluation of STI treatment. Facility requirements necessary for HIV/TB/STI programme delivery are assessed. Tracer indicators assess the implementation of the key programme components. Measures of effectiveness allow managers to infer programme performance within conditions.3
Data collection tools include a review of routine data, facility manager interview, checklist for equipment and supplies, register reviews and a series of folder reviews. All data collected verbally had to be verified by written documentation.
Factors considered in the adaptation of the rural tool
The local district management team and relevant programme managers participated in adapting the tool for a rural setting by ensuring that: (i) the information generated was relevant and addressed the needs of the district, (ii) identified indicators were measureable and (iii) that the tool could become part of the routine supervision, monitoring and evaluation process of the district.
The functionality of laboratory and pharmaceutical services was highlighted for rural service delivery as they are affected by obstacles such as impassable roads, irregular transport and limited communication. Facility-held laboratory registers and pharmaceutical records were reviewed. Laboratory services were evaluated by calculating turn-around-time (TAT) for certain tests and the percentage of missing test results. TAT is the length of time from the collection of a specimen until the result is given to the patient. Targets agreed to by the National Health Laboratory Service have been set by the TB and HIV programmes.
Functional recall systems which trace defaulters and recall patients with abnormal results are essential in the management of infectious diseases. For the audit, this system needed to meet three criteria: (i) responsibility for recall is allocated to a specific person, (ii) a patient identification system for those requiring recall that is implemented regularly, and (iii) documentation of outcomes of attempts to recall patients.
A single tracer indicator 'adequacy of clinic preparedness' was introduced to represent a summary of different components of infrastructural availability for programme implementation (Table I illustrates this for HIV services). Clinics were considered to be prepared for programme implementation if all components were available daily for the three months prior to the audit. Adequate training for staff was based on attendance of provincial training courses.
The urban tool relied on clinic-based folder reviews to assess quality, continuity and integration of care. In rural areas, patient-held records are often used to ensure continuity of care in a mobile population. Facility-held records are brief and, in the case of assessing STI treatment, the only information available was from the daily attendance register. Only two indicators of quality of STI care could therefore be assessed: the percentages of patients with a specific syndromic diagnosis, and receiving the correct drug regimen. There was no documentation at a facility level of patients attending HCT. However, TB, pre-ART and ART care were documented using folder reviews. Programme register folder numbers were randomly selected from a pre-determined time period and the corresponding patient notes located and reviewed.
The audit process
Given the clinic numbers, distances between them and limited time available, not all clinics in the district were audited. Purposive sampling was used in 20 (80%) of the clinics selected to ensure that all clinics with a high burden of TB/HIV/STI disease or rendering ART services were selected. To ensure each of the sub-districts were equally represented, 5 (20%) clinics were identified using convenience sampling.
District level staff and facility managers forming audit teams were trained to use the evaluation tools. At each clinic, facility managers were interviewed, observations conducted, and the daily attendance register together with 10 HIV, ART and TB folders reviewed. Teams received daily support from 2 local researchers.
Data were checked by the audit team and corrected in discussion with data collectors. Routine data extracted from the District Health Information System (DHIS) supplemented the facility audits. EXCEL (version 3) was used to capture data and generate results. The 6 key domains of effectiveness were used as a framework for the analysis. Missing data were excluded from the analysis.
The audit results were presented to the district management and audit teams, and the process, appropriateness and usefulness of the audit evaluated. Obstacles at a district and facility level were identified, and plans to address these formulated.
Twenty-five clinics (57% of PHC health facilities in the district) were reviewed, 52 consulting rooms and 32 counselling rooms were inspected, and 569 records were sampled.
The PHC utilisation rate measures the average number of visits per person to a PHC facility over a year. This rate per person for the district in 2007/2008 was 1.7; the national average is 2.2 and the national target 2.5.
Twenty-one per cent of the patients initiated on ART had a CD4 count <50. Cornell et al. found that 28% of clients had a starting CD4 count <50.6 Neither sample is representative, but both suggest that access to ART is not acceptable. A patient's eligibility for ART depends on their CD4 count. The mean TAT for CD4 counts was 14 days (range 6 - 60), although the national target is 6 days (Table II).
Effective service delivery in the facilities audited was compromised by inadequate infrastructure (Table I); 80% (20/25) of facilities reported non-availability of key drugs and supplies in the 6 months before the audit, and 64% (16/25) had no stock control mechanisms for essential drugs and supplies.
The district had no doctors supporting PHCs. The only facilities visited by doctors were ART sites attached to hospitals where ART was initiated. One remote facility had no professional nurse at the time of the audit. The training of clinical staff (N=128) to deliver PHC services and treat patients with TB, HIV or STIs was inadequate (Fig. 1), with only 29% (37/128) and 21% (27/128) of the staff respectively trained to deliver TB and ART services. In 4 (16%) clinics, no staff were trained in the management of TB and, in a further 3 clinics, no staff were trained in the management of patients with STIs. Staff with appropriate training were not necessarily deployed to an area where this training was utilised. In one sub-district, although 8 professional nurses were trained in ART management, only one was working at an ART site.
Forty-four per cent (11/25) of the facilities were visited monthly by a PHC supervisor; visits by the TB and HIV co-ordinators were less frequent, with none having visited in the previous quarter.
Continuity of care
Three aspects of continuity of care were monitored during the audit: laboratory service support, recall mechanisms, and recording and reporting systems.
Laboratory service support was measured using TAT and missing results. Although the average TATs for the different tests were acceptable for a rural area, for each test there were facilities where the TATs were unacceptable – up to 90 days (Table II). Results were often not documented in folders, e.g. in 54% of the specimens sent for HIV diagnosis using polymerase chain reaction (PCR), results were not noted in either the patient's folder or the register.
Over 50% of facilities had functional recall systems, with 72% (18/25) having systems to recall TB suspects and defaulters, 52% (13/25) with systems for patients with CD4 <200, and 56% (14/25) with systems for HIV-positive infants. In the third of the facilities that had no recall systems, the length of time between diagnosis and the start of treatment was longest and the TB defaulter rate highest.
A functional filing system is a prerequisite for optimal recording and reporting but, in some clinics, up to 15% (7/47) of the folders requested for review could not be retrieved from the filing system.
Quality of care
Quality of care was measured by assessing whether management guidelines were appropriately followed. One hundred and twenty-eight ART folders were reviewed and, although adherence of patients on ART was assessed and addressed in 95% (121/128), only 74% (93/125) had had a CD4 count done in the last 6 months, as specified in the protocol.
To determine the quality of care received by TB patients, 230 folders were reviewed; 96% (221/230) were correctly categorised and 91% (210/230) were started on the correct regimen. However, only 72% (157/217) had their sputum results documented in their folder.
A review of 205 HIV-positive patients not yet on ART found that 68% (126/185) were screened for STIs, but only 35% (25/72) were then managed according to standard treatment guidelines. Among the patients on ART, 47% (60/127) were screened for STIs over a 3-month period, and 57% (34/60) of these were managed appropriately. Of the TB patients, 18% (34/187) were screened for STIs, but none was managed appropriately. For the 3 months reviewed, the contraceptive needs of 53% (108/205) of the pre-ART patients, 39% (83/214) of the TB patients and 67% (81/121) of the patients on ART were assessed.
Published articles have described the key role of health systems in effective primary care service delivery, the impact of dysfunctional health systems on achieving the Millennium Development Goals and the need for health system strengthening across different programmes.7 A failing health system may worsen an epidemic.8 This service evaluation, adapted and used in a rural setting, identified key health system factors needing strengthening at district and facility level to improve the effectiveness of TB, HIV and STI services.
The participatory approach and framework used for this study effectively identified obstacles to TB, HIV and STI programmes in a rural South African district. Including district and facility level staff in the audit teams enabled staff to assess their own practice, and exposure to other facilities facilitated a peer review process enabling managers to compare and learn from one another. Similar observations were reported after the development of the STI quality-assessment instrument which informed this study.9
Routinely collected data are often underutilised by district and facility level managers as they can be incomplete or inaccurate.10 , 11 We used routine information and a facility audit monitored health service effectiveness and informed decisions stimulating staff to improve data quality and completeness.
Without population-based planning and monitoring of services, poor access is often not identified, or is underestimated. A strength of this evaluation tool is highlighting access to different health service components. PHC utilisation was low and, when patients did present, diagnosis was delayed owing to long TATs and delays in initiating treatment with drugs not always being available – 44% of the facilities had had a stock-out of TB drugs in the last 6 months. This is particularly concerning for TB where rapid case detection and treatment are essential to limit its transmission. Where ART sites do not render TB or STI services but refer to the nearest PHC clinic, access, integration of services and holistic care are undermined.12 The importance of HIV and TB service integration was highlighted in the December 2009 South African government announcements regarding revisions to HIV treatment. While we recognise the complexity of TB and HIV service delivery, there is an opportunity to rework service delivery, optimise health care delivery and develop quality improvement systems for patients co-infected with TB and HIV.13 The recent initiative by the Department of Health to 're-engineer PHC services' underlines this opportunity.
In this audit, clinic performance varied and was affected by the sub-district location, the extent of recent staff attrition and training, and the level of supervision. In some facilities, staff were not adequately trained in general PHC and TB/HIV/STI services, a finding similar to a study in another rural KwaZulu-Natal district where less than a third of clinic staff were trained in PMTCT, HIV and infant feeding and 46% in HIV counselling and testing.11 Owing to the ongoing loss of staff from rural areas, training must be prioritised. In-service training at a facility level is effective.14 Regular, careful supervision improves the quality of services significantly15 and, although it is not feasible for TB and HIV co-ordinators to visit every facility in large rural districts, facilities that have a high burden of disease or problems with programme implementation should be supported regularly.
The poor quality of care that we documented has been confirmed by other studies for patients with a disease requiring ongoing treatment.16 Problems identified – the unavailability of key drugs, equipment and supplies undermining service delivery – reveal inadequacies in facility and district level management skills and priorities. Facility managers supported by the district team have a critical role in addressing these problems and ensuring that quality and continuity of care in their facilities are regularly reviewed and addressed. Innovations such as the audit tool and process are valuable as they engage managers and their staff in a quality improvement process, generate local data for problem analysis and lead to local managerial action.
Inadequate stewardship, leadership and management at all levels of the South African health system affect the implementation of health services.17 Although TB cure rate is only one indicator, in an equally poor district with an even higher TB/HIV disease burden in the same province, committed leadership and good district management improved programme outcome indicators and resulted in a district 81% TB cure rate.4
This study was limited in its assessment of the effectiveness of HIV/TB/STI services as it only assessed the facility component and not the important community-based aspect. It was conducted in one district only and was time-consuming (each facility audit took 4 hours). Other programme components such as non-communicable diseases, women, and maternal and child care could be added to the evaluation. These would increase the efficiency of the process and avoid the inevitable competition for scarce managerial and time resources that separate programme evaluations bring, and so foster health systems strengthening.
The rural evaluation tool developed is feasible and relevant and identifies constraints to effective TB/HIV/STI service delivery that can be addressed at district and facility level. We identified aspects of availability, capacity and continuity of care as hindering effective service delivery: key drugs, stocks and equipment were not available; capacity of staff was compromised by inadequate training and supervision; and continuity of care was hindered by poor laboratory support and no recall system. Strengthening district services is a key component of the 're-engineering of PHC services', and an annual audit is recommended as part of a district quality improvement process to promote effective TB, HIV and STI service delivery.
Acknowledgements. The authors thank the South African National Department of Health for providing financial support for this study, and the district management team, especially Mrs Radebe and Mrs Khwela for their commitment to this process of improving the PMTCT programme. ML was employed and funded by the Medical Research Council of South Africa. VS and FA were employed and funded by the University of the Western Cape. JM was employed and funded by the University of the Western Cape and TB HIV Care, South Africa. VZ was employed by the University of Cape Town. The funding bodies had no influence on the study design, data collection, analysis or interpretation of data, writing of the manuscript or the decision to submit the manuscript for publication.
Authors' contributions. ML, VS, JM, FA and VZ participated in the design of the study. ML and JM adapted the evaluation tool, conducted the training, and co-ordinated and implemented the study. ML, VS, FA and VZ helped to draft the manuscript. All authors read and approved the final manuscript.
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Accepted 15 August 2011.
Table I. Percentage of facilities equipped to provide TB/HIV/STI services ( N =25) |
Aspects of preparedness |
Guidelines |
18 (72%) |
19 (76%) |
13 (52%) |
17 (68%) |
Stationery |
24 (96%) |
24 (96%) |
18 (72%) |
20 (80%) |
Equipment |
15 (60%) |
5 (20%) |
18 (72%) |
Stocks |
13 (52%) |
13 (52%) |
6 (24%) |
19 (76%) |
Drugs |
11 (44%) |
4 (16%) |
14 (56%) |
Table II. Indicators measuring laboratory service support at a district level |
Laboratory test |
Mean turnaround time (days) |
Range (days) |
National target (days) |
Missing results N (%) |
Sputum microscopy |
5 |
2 - 14 |
2 |
1 197 (10%) |
Sputum culture |
44 |
21 - 90 |
42 - 56 |
87 (24%) |
32 |
4 - 90 |
42 |
162 (54%) |
Elisa |
9.3 |
7 - 21 |
14 |
20 (25%) |
14 |
6 - 60 |
6 |
678 (21%) |
PCR = polymerase chain reaction. |
Fig. 1. Percentage of clinical staff trained in different components of PHC services.
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