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dying healed: Transforming End-of-Life Care Through Innovation
- Rosaline Mercy Adams
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1 end-of-life care dying healed: Transforming End-of-Life Care Through Innovation Sir Thomas Hughes-Hallett Professor Scott A Murray MBE Dr James Cleary, Dr Liz Grant, Dr Richard Harding, Professor Alex Jadad, Dr Mark Steedman, and Karen Taylor OBE
2 3 WISH End-of-Life Care Report 2013
3 end-of-life care dying healed: Transforming End-of-Life Care Through Innovation Sir Thomas Hughes-Hallett Professor Scott A Murray MBE Dr James Cleary, Dr Liz Grant, Dr Richard Harding, Professor Alex Jadad, Dr Mark Steedman, and Karen Taylor OBE WISH End-of-Life Care Report
4 CONTENTS 1 Foreword 3 Executive summary 6 Recommendations 7 Introduction: Understanding the challenge 9 Step 1: Make care of the dying a priority for all 16 Step 2: Reduce unnecessary suffering 22 Step 3: Improve knowledge and use data to drive innovation 29 Step 4: Maximize resources 34 Step 5: Improve skills 40 Immediate next steps 41 Appendix 44 Acknowledgments 46 References Professor The Lord Darzi Sir Thomas Hughes-Hallett 5 WISH End-of-Life Care Report 2013
5 FOREWoRD Responsible societies ensure that everyone is able to live well until they die. Like birth, death is a part of life something that no one can avoid and yet all too often death is a taboo subject. How we care for the dying is a litmus test of a good health system and a responsible society to be judged by the dignity and respect given to all people of all ages in all settings at the end of their lives. Yet the specialty of end-of-life care remains in its infancy the new kid on the clinical block. Some governments have now introduced end-of-life care strategies, but still too few health systems have embraced the reality of an ever-expanding aging population who, thanks to medical advances, live longer but whose final years with multiple long-term conditions increasingly challenge health systems. This is compounded by the demise of the extended family in so many societies (ranging from the US to China) who have been the historic caregivers to the dying. We all wish for a pain-free, dignified death. The tragic lack of available treatments, particularly opioids, in so much of the world means that a pain-free death is denied to the majority of the world s population; 90 percent of the world s morphine is used by 16 percent of the population. This is a shameful reflection on our society, revealing our historic emphasis on curative treatment while leaving the dying in pain, ignoring the inevitability of death. Health systems have to change and embrace the need to develop innovative approaches and technologies for end-of-life care. All resources in society have a role to play families, communities, health and care providers and technology. There is, however, a dearth of appropriately trained professionals. The clinical specialty of palliative care, which provides pain and symptom control, is all too rarely available. This report highlights the core issues that need to be addressed, with examples of best practices from countries that have made measurable progress, not least by embracing innovation and increasing the extent and scale of coverage. We recommend practical steps that can be taken by policy-makers to effect positive change and produce better care and better economic value. The WISH summit provides a wonderful opportunity to harness the knowledge being developed in Big Data, accountable care systems, and patient and family involvement, while learning from the obvious parallels between mental health and end-of-life care. Creating a whole system approach to end-of-life care is a must do for all countries participating in the WISH summit. Professor The Lord Darzi, PC, KBE, FRS Executive Chair of WISH, Qatar Foundation Director of Institute of Global Health Innovation, Imperial College London Sir Thomas Hughes-Hallett Executive Chair, Institute of Global Health Innovation, Imperial College London WISH End-of-Life Care Report
6 Selected End-of-Life Care Innovations Canada United Kingdom Ukraine India Tyze: A private social network that connects people around someone receiving palliative care Coordinate My Care: an electronic record that holds a patient s wishes and preferences for end-of-life care treatment Morphine availability: relaxed restrictive government regulations and allowed production of morphine tablets Kerala Community Model of Palliative Care: uses a large network of volunteers to provide essential services United States Campaigns that encourage people to talk about death and dying such as Death Over Dinner and the Conversation Project Colombia A WHO public health approach was implemented to improve opioid availability, increase awareness, and improve palliative care Nigeria The Federal Ministry of Health partnered with Treat the Pain to improve access to oral morphine through a multistep strategy Uganda Specially trained nurses are allowed to prescribe opioids and community vigilantes identify patients needing hospice care Bangladesh and Myanmar Lien Collaborative for Palliative Care: a training of trainers program that enables participants to establish palliative care services 2 WISH End-of-Life Care Report 2013
7 Executive Summary What is the Challenge? Advances in medicine, nutrition, and other factors have allowed people to live longer. Yet one aspect of life is constant. Human mortality remains 100 percent; we all eventually die. While where and when we die is regularly studied, how we die is often avoided or ignored. This has led to an unacceptable amount of unnecessary suffering worldwide during the last year of life. Each year, over 100 million people would benefit from palliative care, yet fewer than 8 percent of those in need access it. 1 This is a global tragedy, but it is one that can be effectively remedied. We recognize that different countries are at different stages of establishing endof-life care for some the creation of 24/7 community services will be the key development. For others it will be providing access to pain and symptom-controlling essential medicines and staff trained to administer them. We present a five-step strategy for improving quality of life at the end-of-life with specific examples of innovations that have proven effective at reducing unnecessary suffering and improving end-of-life care in different settings and cultures. Key Messages What: To change attitudes toward death and dying and improve services and resources, allowing people to live well and die in their communities with access to effective pain and symptom management. Why: Because caring for the dying is a fundamental responsibility of all societies and good stewardship of national resources requires an evidence-based approach to meet the ever-increasing and insupportable demands on hospital facilities. How: By identifying the solutions needed to overcome barriers to quality end-of-life care; by setting out examples of best practice from around the world in improving end-of-life care; and by making specific recommendations on how individual countries can improve their approach to caring for the dying. Understanding End-of-Life Care and Palliative Care End-of-life care helps all those with advanced, progressive, incurable illness to live as well as possible until they die. It enables the supportive and palliative care needs of both patient and family to be identified and met throughout the last phase of life and into bereavement. It includes management of pain and other symptoms and provision of psychological, social, spiritual, and practical support. 2 WISH End-of-Life Care Report
8 The end-of-life is generally understood as the last year of life. 3, 4 Palliative care may start earlier and is advocated by the World Health Organization to begin alongside potentially curative care when an individual is diagnosed with a life-limiting condition. As curative options decrease and the patient approaches the last year of life, endof-life care becomes the main approach. For the purpose of this report, we focus on the needs of people of all ages, diagnoses and all cultures but do not seek to tailor individual recommendations for specific groups. A Roadmap for Action This report is a call to improve palliative and end-of-life care for all patients who need it. There is no time to waste, as ending unnecessary suffering is an achievable goal. We provide a series of recommendations in five steps as follows, backed up by innovations that can dramatically improve end-of-life care. Step 1: Make Care of the Dying a Priority for All Death and dying are taboo topics in many countries. Failing to discuss and plan for dying in advance often leads to unnecessary suffering and a difficult time for all involved. The first step to changing this attitude is to begin to normalize the inevitability of death and to advocate for the inherent right of all humanity to healthcare through their whole life and not just during their childhood or their economically productive years. Quality palliative and end-of-life care should be available to all, which requires appropriate policies, health services and trained staff. Step 2: Reduce Unnecessary Suffering Lack of accessible, affordable palliative and end-of-life care results in uncontrollable pain, breathlessness, fatigue, and other disabling symptoms that drastically reduce quality of life. Essential medicines, including opioids, are often unavailable due to lack of resources, lack of skilled healthcare staff, and fear of illicit drug use, leading to overly restrictive regulations, dose limits, and other barriers to symptom relief. Through education and supportive regulation, restrictions on opioids should be relaxed. Governments should recognize the World Health Organization s Model List of Essential Medicines and train staff to make appropriate medicines available to those in need. 5 4 WISH End-of-Life Care Report 2013
9 Step 3: Improve Knowledge and Use Data to Drive Innovation Palliative and end-of-life care research is under-resourced and under-developed across the world, resulting in lack of knowledge and data about how people die. In many countries, less than 0.5 percent of cancer research spending is devoted to understanding end-of-life. 6 In order to improve access to and quality of palliative and end-of-life care, research must become a priority. Collaboration amongst leading researchers is key to establishing a best-practice evidence base that results in highquality outcomes, and common research strategies that promote better care should be accepted and promoted. Step 4: Maximize Resources All possible resources need to be maximized to improve palliative and end-of-life care quality and availability. Care strategies need to include support for not just the dying but also families and carers. Technologies such as telehealth and mobile health will play an important role in this, along with low-cost innovations that can be adopted regardless of income status. Step 5: Improve Skills A key global challenge is the lack of doctors, nurses, pharmacists, clinical officers, community health workers, social workers and other health support workers and community volunteers with knowledge and training in palliative and end-of-life care. With early training on holistic care for the dying embedded into all health worker curricula, basic palliative care coverage can be increased. Additional skills, communication, bereavement support for family members and avoidance of overmedicalization will improve care and establish a more integrated and costeffective care system. WISH End-of-Life Care Report
10 Recommendations STEp 1: MaKe care of the dying a priority for all Produce a national strategy for end-of-life care. Include palliative and end-of-life care as part of healthcare for all diseases. Monitor the scale and need for end-of-life care locally. Sign the Prague Charter and recognize that access to palliative and end-of-life care is a human right. Set up a national initiative using online tools and innovative campaigns to encourage people to learn and communicate more about death and dying. Encourage the use of advance care directives, so that patients can make their own end-of-life wishes and expectations known beforehand, rather than under pressure at a time of crisis. Step 2: Reduce unnecessary suffering Adopt the WHO Model List of Essential Medicines and eliminate overly-restrictive. regulations banning the use of opioids for palliative and end-of-life care. Ensure essential medicines are nationally available in central medical stores, licensed appropriately, and distributed effectively through existing distribution channels where possible. Ensure the appropriate use of opioids and other essential medicines. Step 3: Improve knowledge and use data to drive innovation Invest in research and development in palliative and end-of-life care. Form partnerships between national, regional, and international palliative care organizations to carry out research and publish high-quality reports. Capitalize on knowledge gained from research outcomes to lower costs and improve care. In places where Western medicine has not been fully adopted, engage with traditional healers to improve end-of-life care. Step 4: Maximize resources Engage the local community in end-of-life care. Utilize telemedicine and technology-based innovations to improve access to end-of-life services, especially in rural and remote areas. Empower patients through better access to knowledge about end-of-life care choices and availability. Step 5: Improve skills Include palliative and end-of-life care training in all professional healthcare undergraduate and postgraduate programs. Include bereavement support in palliative and end-of-life care training programs. Share global learning to enable all countries to build palliative and end-of-life care services. Access or develop e-learning training modules for staff and volunteers. END-OF-LIFE CARE FOR ALL 6 WISH End-of-Life Care Report 2013
11 Introduction: Understanding the Challenge You matter because you are you, and you matter to the end of your life. We will do all we can not only to help you die peacefully, but also to live until you die. Dame Cicely Saunders, founder of the modern palliative care movement ( ) In 2013, more than 55 million people will die throughout the world. 7 The majority of these deaths, approximately 44 million, will occur in low- and middle-income countries (LMICs) where end-of-life care is rarely high-quality and is often completely unavailable. Apart from people who die suddenly between 20 percent and 40 percent of all deaths, depending on the country 7 all people, no matter who they are or where they die, would benefit from receiving some form of end-of-life care. Such care includes optimizing the quality of life remaining, and supporting the patient, carers, and family in ensuring that the patient s death is as painless and dignified as possible. This report is a call to action: high-quality end-of-life care should be available to all who need it. 8 End-of-life care is intrinsically linked to palliative care. Patients diagnosed with lifelimiting conditions may need palliative care for many years before death, but palliative care does not signal the end of all curative treatments. Rather, within a continuum of holistic care, such care can work alongside active interventions to treat and alleviate symptoms. Where good palliative care is implemented, a reduction in ineffective, distressing and invasive curative treatments often occurs, 9 and as the last phase of life approaches and curative options reduce, end-of-life care enables patients to live as well as possible until they die. Currently, however, end-of-life care is provided mainly to those with advanced cancer, often too late to be very effective For many people, regardless of income level, high-quality end-of-life care is simply not available Figure 1: Worldwide palliative care development. 21 WISH End-of-Life Care Report
12 Improving access to end-of-life care must begin by improving palliative care across the world. Few countries incorporate palliative care strategies into their overall healthcare policy. Lynch et al recently categorized palliative care development in 234 countries, ranging from those with no known hospice/palliative care activity to those with services with advanced integration into mainstream healthcare (Figure 1). 21 In 2011, 136 of the world s countries (58 percent) had one or more palliative care service, a 9 percent increase since 2006, with the most notable increases in service arriving in parts of Africa. However, only 20 (8.5 percent) countries have integrated their palliative care effectively into the wider health care system to enable greater access to all citizens. This clearly leaves much room for improvement in making palliative and end-of-life care accessible to all who need it. We believe that this is a global tragedy and that access to palliative and end-oflife care is a human right for every person and a benchmark for the development of a nation. Crucial Facts About Death - Human mortality remains 100 percent; we all eventually die. HOW we die is up to us million people need palliative care each year only 8 million people have access to it percent of the world s morphine is used by 16 percent of the population. 8 WISH End-of-Life Care Report 2013
13 Step 1: Make Care of the Dying a Priority for All Unfortunately in end-of-life care, we do not have a vocal constituency: The dead are no longer here to speak, the dying often cannot speak, and the bereaved are often too overcome by their loss to speak. Professor Harvey Chochinov, University of Manitoba, Canada Figure 2: Access to palliative and end-of-life care is a human right that should be available to all individuals. This core declaration is supported by five fundamental principles of how to die well, surrounded by a continuum of people and support structures. VOLUNTEERS CHARITIES FAMILY BEREAVEMENT SUPPORT HOSPICES Supports the individual and family Is not to be feared or ignored Access to Palliative and End-of-Life Care is a Human Right Allows people to live and die with dignity Causes no unnecessary suffering Neither hastens nor postpones death CARERS CARE PRODUCTS SPECIALIST PALLIATIVE GENERALIST HEALTH & SOCIAL CARE STAFF Accept Access to Palliative and End-of-Life Care is a Human Right and Adopt Policies that Prioritize End-of-Life Care, Including an End-of-Life Care National Strategy While reducing untimely and preventable deaths is a well-established global health priority, improving the quality of life of those who are dying has been largely ignored. Palliative care is seldom recognized as a major health issue, and death, although inevitable, is often unmentioned. More than 100 million people would annually benefit WISH End-of-Life Care Report
14 from palliative care (including family and carers who need help and assistance in caring). However, less than 8 percent of those who would benefit from palliative care are able to access it. 1 Policy-makers and clinicians, struggling with limited resources, are engaged in developing strategies and actions that prioritize and tackle illnesses where they can save lives. Thus, even in many high-income countries, end-of-life care is left to the charitable and voluntary sector, who have to champion its importance and provide the majority of the required funding. 22 Dying is seen as a sign of the failure of the health system to successfully cure. Yet, dying is an inevitable outcome of living, thus supporting all policy-makers and clinicians to enable people to die well is an essential duty of a caring and civilized society. The first step to achieving this aim is international recognition of palliative and endof-life care as a human right (Figure 2). Despite growing international pressure in this direction, many countries still shy away from it, setting palliative and end-of-life care low on their list of priorities. 8,23,24 One of the primary tasks facing international palliative care organizations is to continue their advocacy for a change of attitude within national healthcare systems. A leading advocate of good practice in this area is the European Association for Palliative Care (EAPC), which has published a series of white papers covering standards and norms in palliative care, outcome assessment, and palliative care for patients with dementia Along with other organizations, EAPC has been active in producing and promoting a range of other initiatives, most recently The Prague Charter (Table 1), a document that advocates the recognition of palliative care as a human right. Table 1: The Prague Charter The Prague Charter urges governments to relieve suffering and ensure the right to palliative care. In recognizing and celebrating palliative care as a human right, the Prague Charter maintains that palliative care should be part of all governments fundamental health policy and should be available to everyone. A copy of the Prague Charter can be found in Appendix WISH End-of-Life Care Report 2013
15 Establishing palliative care as a human right will require some effort on the part of national governments. Countries need to formulate and publish their own national strategies for quality palliative and end-of-life care. In 2008, the UK published the document End of Life Care Strategy: Promoting High-quality Care for all Adults at the End of Life. Each year since, the Department of Health has published an annual report on progress achieved in implementing the strategy. The stated goal of the document was to set out a policy strategy for ensuring that everyone attains a good death. This good death was defined as: being treated as an individual, with dignity and respect; being without pain and other symptoms; being in familiar surroundings; and being in the company of close family and/or friends. The document should act as an incentive to other countries to formulate and publish their own strategies, which would in turn raise the profile of end-of-life care in the eyes of the world. Recommendations for policy-makers: Produce a national strategy for end-of-life care. Include palliative and end-of-life care as part of healthcare for all diseases. Monitor the scale and need for palliative and end-of-life care locally. Sign the Prague Charter and recognize that access to palliative and end-of-life care is a human right. WISH End-of-Life Care Report
16 Table 2: Integrating palliative and end-of-life care into public health Case Study: Colombia A Public Health Model developed by the WHO was implemented in Colombia to increase awareness about palliative and end-of-life care, include palliative and end-of-life care as a component of care in legislation, and improve opioid availability. In November 2007, a national workshop was organized and attended by pain and palliative care specialists from all over Colombia to identify barriers and possible solutions to opioid availability, inform regulators about the challenges physicians identify in the prescription process, and inform physicians about the limitations that regulators face. Following the workshop, the following recommendations were delivered to the Ministry of Health: 1. Modify a national policy to guarantee availability of opioid analgesics 24 hours a day/7 days a week in the capital cities of the 10 main states in Colombia. 2. Involve and engage the health maintenance organizations in order to inform them of the results of the workshop so that they can incorporate strategies in their quality improvement process to improve opioid accessibility. 3. Form an advisory group of pain and palliative care clinicians to help the National Drug Authority in the identification of essential medicines and in the development of estimates of controlled medications to submit to the International Narcotics Control Board. 4. Require Regional Hospitals to provide opioid medication for outpatients. Following the workshop, aspects of palliative care improved in Colombia. A new regulation mandated all 32 states in Colombia have at least one place where opioids are guaranteed to be in stock. Consequently, from 2006 to 2009, the sale of morphine increased 42 percent and the sale of hydromorphone increased 195 percent nationwide. A course on Pain and Palliative Care was established at the Universidad de la Sabana and made mandatory for all undergraduate students in the school of medicine. These improvements in opioid availability and education are evidence that the WHO Public Health Model can be crucial in the development of palliative care, and Colombia should continue to prioritize palliative and end-oflife care to see further improvements. Start The Public Talking About Death and Dying Changing government policy is only one step in making care of the dying a priority for all. Quality end-of-life care must also be built from the ground up. In some cultures, talking openly about death and dying is considered disrespectful and can lead to despair and even accelerate the process of dying. For many people, death is simply too distressing to contemplate and is therefore ignored or avoided Here anonymity can be an advantage, and in some countries, innovative online tools have become a welcome resource for information about end-of-life care (Table 3). 12 WISH End-of-Life Care Report 2013
17 Table 3: Online Tools That Promote Quality End-of-Life Care Dying Matters, England, United Kingdom Good Life, Good Death, Good Grief, Scotland, United Kingdom Grassroots groups have launched a number of campaigns aimed at encouraging people to initiate conversations about death with their family members and close friends. The objective is to lessen anxiety that typically accompanies such conversations. In particular, people are encouraged to talk about these topics before they are actually needed, and in familiar surroundings, such as at the dinner table, rather than somewhere that is felt to be threatening, such as a hospital intensive-care unit (Table 4). Table 4: Campaigns that Encourage People to Talk About Death and Dying Death Over Dinner, United States The Conversation Project, United States Recommendation for policy-makers: Set up a national initiative using online tools and innovative campaigns to encourage people to learn and communicate more about death and dying. WISH End-of-Life Care Report
18 Plan for the Future The experience of dying can accentuate cultural, religious and social differences between carers, providers, and patients, and needs to be sensibly and sensitively approached in end-of-life care. Patients, even when they suspect they are dying, are often shielded from the knowledge that their condition has been diagnosed as terminal. Families, carers and health professionals are all likely to want to avoid raising the subject of death. This can lead to a failure to acknowledge the possibility of death and to discuss and plan for it in a way that respects the patient s and family s wishes. Research has shown that, when plans have been made beforehand, patients usually die where and in the way they would wish. When no such plans are in place, there is little opportunity to determine the patient s wishes and preferences: patients are rushed into hospital, and their last days are dominated by medical supervision, or worse still they are left to die unsupported and in pain. 32 Recently, various tools have been developed to better prepare patients and families for the process of dying. Advance healthcare directives are instructions given by patients beforehand, specifying how they want matters treated if they are no longer able to make independent decisions owing to illness or incapacity (Table 5). They allow patients to maintain a sense of control over daily life, 33 and it is clear that an advance care directive, if designed and implemented effectively, can contribute significantly to improving patient experiences at the end-of-life (Table 6). 34 Table 5: Advance Care Directives Five Wishes, United States MyDirectives, United States Coordinate My Care, London, United Kingdom 14 WISH End-of-Life Care Report 2013
19 Table 6: Coordinate My Care helps Londoners die in their place of preference with the care they desire Case Study: Where we die Location of death % London National Preference Hospital Hospital/specialist palliative carecentre 5 Care home Home Source: England, Wales and Scotland (2000); Telephone survey; Priorities and preferences for end-of-life care in England, Wales and Scotland (2003); Telephone Survey NCHPCS/Cicely Saunders Foundation; National statistics (2003), London Health Observatory (2005) Despite a strong preference to die at home (57 percent), only 20 percent of Londoners actually die in the comfort of their own bed. Instead, 66 percent of people die in hospital. In order to reduce hospital deaths and allow people to die at their place of preference, the Government developed an End-of-Life Care Strategy that included setting up Electronic Palliative Care Coordination Systems (EPaCCs) for patients approaching the end-of-life, including Coordinate My Care. Patients wishes were documented through the Coordinate My Care program that, after a two-year pilot study, went live across London in the spring of Currently there are 8,030 CMC records, and 2,548 of these patients have died. Of the patients who have died with a Coordinate My Care plan in place, 79 percent have died in their place of preference, and 81 percent of patients have died outside of the hospital setting. In the summer of 2014, access to Coordinate My Care will be made easier through the introduction of a mobile app that patients can use to update their wishes. Recommendation for policy-makers: Encourage the use of advance care directives, so that patients can make their own end-of-life wishes and expectations known beforehand, rather than under pressure at a time of crisis. WISH End-of-Life Care Report
20 Step 2: Reduce Unnecessary Suffering No one should die in the torture of pain when the drugs to stop that pain are available and so affordable Living pain-free especially but not only during our last period of life is a right that can be met even in the poorest of settings. Professor Felicia Knaul, Harvard University, USA The most important practical issue facing end-of-life care providers is the availability of painkilling drugs or, more often, the lack of them. This remains a significant international challenge. For many people who are dying, access to pain relief is a basic requirement. In 2013, over seven million people will die of HIV or cancers in moderate to severe pain, and nearly three million of them will have no access to pain relief. 7 The lack of basic medication in many parts of the world causes huge suffering, not just for the dying themselves but also for their carers and families, who are left feeling helpless in the face of this suffering. Pain and other symptom control is the basis of all palliative and end-of-life care, and the availability of opioids (morphine and its equivalents) is fundamental to quality palliative and end-of-life care. But across the world, an estimated five billion people lack access to opioids, largely because of concerns about illicit drug use and trafficking. 7 Despite long-standing efforts to ensure wider access to opioids for the control of pain at the end-of-life, major disparities exist among the countries of the world (Figure 3). Figure 3: Worldwide opioid consumption. The morphine equivalence metric is used to compare aggregate consumption of multiple opioids used to treat moderate to severe pain. 16 WISH End-of-Life Care Report 2013
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Page 1 AFRICAN UNION UNION AFRICAINE UNIÃO AFRICANA Addis Ababa, ETHIOPIA P. O. Box 3243 Telephone 251-11-5517 700 Fax 251-11-5517 844 website: www. africa-union.org 5 th SESSION OF THE AU CONFERENCE OFMore information
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shows: was a lost fan, but it's over
music: mumford & sons and augustana lately
2: iced coffee
3: my phone
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|Gay, Man, Single, 6' 2", Average build
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|Never smokes, Drinks socially, Doesn't do drugs, Might want kids, Pisces
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Registration for students in all Vandalia schools will beheld from 10 a.m.-6 p.m. on Tuesday, Aug. 9, and from 8 a.m.-3 p.m. on Wednesday, Aug. 10, at Vandalia Junior High School.
St. Elmo
• Aug. 1 – 10 a.m.-6 p.m.
• Aug. 2 – 10 a.m.-6 p.m.
• Aug. 1 – 6-8 p.m. – Seventh-grade orientation/registration for all seventh-grade students and parents.
Rylee Suzanne Sasse
Levi and Bre Sasse of Vandalia are the parents of a girl born at 9:55 a.m. on Friday, June 3, 2011, at Greenville Regional Hospital in Greenville.
Michelle Berger and Caleb Miller, both of Brownstown, have announced their engagement and upcoming wedding.
Dennis and Evelyn Meseke of Shobonier will celebrate their 60th wedding anniversary on Monday, Aug. 1.
Harry Hutchison, president and CEO of National Bank, recently announced that Joe Schaal has joined National Bank at Greenville as the Greenville area business development officer.
Two employees of Dr. Kevin Childers recently passed milestone dates in their employment at Eye Care of Vandalia. Flanking Childers are administrative assistant Katrina Wollerman, left, 20 years, and optometric technician Twila FInley, right, 25 years.
Vandalia Mayor Rick Gottman gave a mid-year update on the city's financial condition and its economic development efforts at the July 6 monthly meeting of the Vandalia Chamber of Commerce.
When the new County Market sign went up on the front of Harmon's Market IGA earlier this month, it marked the beginning of many changes for the Vandalia grocery store.
Tools for School, a program that provides free school supplies for Fayette County students in need, will be in operation at First Presbyterian Church in Vandalia on the following dates and times:
• Wednesday, Aug. 10 – 9 a.m.-7 p.m.
•Thursday, Aug. 11 – 9 a.m.-7 p.m.
• Friday, Aug. 12 – 9 a.m.-3 p.m.
• Saturday, Aug. 13 – 9 a.m.-noon.
The program is open to all students in need in grades K-12.
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Despite pressure from the new Administration, the Chilean Congress has still not passed a resolution for a Biotechnology Framework. Progress in the short term does not look very promising, especially in the area of labeling.
THIS REPORT CONTAINS ASSESSMENTS OF COMMODITY AND TRADE ISSUES MADE BY USDA STAFF AND NOT NECESSARILY STATEMENTS OF OFFICIAL U.S. GOVERNMENT POLICY Required Report - public distribution Date: 7/15/2011 GAIN Report Number: CI1021 Chile Agricultural Biotechnology Annual Biotechnology situation in Chile Approved By: Rachel Bickford, Agricultural Attaché Prepared By: Nelson Ramirez, Agricultural Specialist Report Highlights: Despite pressure from the new Administration, the Chilean Congress has still not passed a resolution for a Biotechnology Framework. Progress in the short term does not look very promising, especially in the area of labeling. Section I. Executive Summary: Under the current Chilean regulations, Chile can only propagate transgenic seeds for export. In food products, all events must be registered with the Ministry of Health, and the product must be label only if substantially different from their conventional counterpart. Despite two bills introduced in Congress to regulate biotechnology, one of them requiring mandatory labeling and the other to creating a biotechnology framework, the Bachelet administration, which ended this past March, did not move forward to adopt this technology. The new Piñera Administration, especially Minister Galilea, the Minister of Agriculture, is seen as enthusiastic to push forward on passing the Biotechnology Regulatory Framework that has been stuck in Congress for the past seven years. The Minister wants Chilean farmers to be able to benefit from this technology. Three years ago, then Senator Galilea was the intellectual author of the proposed framework to extend the use of transgenic crops in Chile. Commercially, Chile could be a consumer of transgenic sugar beets, corn, alfalfa, and soybeans (if the salmon industry were to lift its self-imposed ban on the use of biotech feeds), to name a few crops. Although not widely publicized, Chile has begun to do landmark research in ?orphan? crops (non-bulk commodities), such as salmon, pine, stone fruit, apples, and grapes. As part of the government?s efforts to increase research and development using funds received from copper mining royalties, Conicyt/FIA/Corfo manage the funds and establish consortiums to do biotech research. As with many developing countries, the majority of research funds come from the public sector. In 2009 the Government announced a number of programs and affiliations with different universities in the U.S., Australia and Canada to promote technology transfer and postgraduate degrees with the purpose of increasing research and development. Section II. Plant Biotechnology Trade and Production: Does Chile commercially produce any biotechnology crops? Chile does not produce any GM crops for sale domestically. However, Chile has propagated transgenic seeds under strict field controls for re-export for more than a decade. In 2007 Monsanto introduced the GM soybean into Chile and planted two thousand hectares and the ammount has increased over the years. Are there any biotechnology crops under development in your country that will be on the market in the coming year? There are no biotechnology crops developed in Chile that could be on the market in the coming year. Does the country import biotechnology crops/products? Yes. Chile imports soybeans and corn for use in animal feed. Does Chile import biotechnology crops/products or planting seeds? Yes, planting seeds propagate and re-export, not to consume in country. Is the country a food aid recipient or likely to be a food aid recipient in the near future? No, Chile is a major agricultural exporting country. Does Chile produce any biotechnology crops that were developed outside of the United States and have not passed through the U.S. regulatory system? No. Section III. Plant Biotechnology Policy: a) i. Chile does not have a biotechnology framework in place, only the reproduction of seeds to be re- exported is allowed under strict control from the Agricultural and Livestock Service (SAG) of the Ministry of Agriculture. Resolution 1523 from 2001 regulates this process. ii. Chile signed the Cartagena Protocol on Biosafety, but has not ratified it yet. Nor has Chile established an adventitious presence level for imports yet. iii. There have been many comments from this new Administration regarding the need to regulate as Chilean farmers are not benefiting from this technology. It seems that they understand that at the double standard farmers are facing, when they can propagate GM seeds for export and then must import soybeans and corn for feed at a higher price. There is some will to move forward with a regulatory system. This is a change from the previous Administration. An aspect of this change is that many of the new appointees come from the private sector, and so they have an idea of how the country can benefit from new technologies. b) Again, only the reproduction of seeds to be re exported is allowed in Chile, field trials are allowed but are treated the same way, under strict controls from (SAG); there are no crops authorized to be commercialized in the country. Unfortunately this year was not possible to obtain the official information on the authorized crops as the information was declared sensible. c) Chile allows field trials which are treated the same as the production of seeds, this year was not possible to obtain the official information as it was declare sensible. d) The Ministry of Agriculture treats stacked events in field trials and reproduction of seeds as if it was a single event. The Ministry of Health, on the other hand, regulates the imports and the domestic production of food products; and requires all events to be registered in the Chile, but if they have been registered before with FDA the process is faster, on stacked events they require the registrations of all events. e) No additional registration is required f) There currently are no specific rules on the subject of coexistence, but Resolution 1523 of 2001 introduced a traceability system and documentation requirements for all seeds and the fields where they are planted. As part of the process for every field trial approval, biosafety measures are established, such as physical isolation from sexually compatible species and post harvest management. g) The Ministry of Health only requires labeling of the product when the biotechnology-derived ingredient has different characteristics than the conventional product. h) Chile signed the Cartagena Protocol on Biosafety, but has not ratified it yet. There are no visible intentions on ratifying the Protocol in the near future. i) As Chile is an agricultural export based economy, with agricultural exports accounting for 15% of GDP, these reservations have prompted Chile to take a cautionary approach on biotech issues and play a muted role in international fora such as APEC, MERCOSUR, and OAS, as well as UN and WTO organizations such as FAO, CODEX, and the International Plant Protection Convention (IPPC). However, with a strong regulatory system and a greater investment in the technology, Chile could become an important developing country spokesman in the above-mentioned venues. j) Until the discussion on the framework to regulate biotechnology-related issues is finished, we cannot say that there are any trade barriers. It will be clearer once the discussion begins since the labeling issue is very sensible. k) Congress approved the ratification of UPOV 91, it was ratified by the Constitutional Court and is waiting for the signature of the President. Section IV. Plant Biotechnology Marketing Issues: The agricultural export sector remains concerned about the trade implications of this technology. They view the issue from the perspective of how will the uses of transgenic affect Chile?s ?natural? image. They argue that currently there are few benefits for the products in which Chile has a competitive advantage (horticultural crops, salmon and forestry). Section V. Plant Biotechnology Capacity Building and Outreach: a) U.S. Government or USDA funded capacity building or outreach activities: Post, in conjunction with the International Life Sciences Institute, has submitted a request for State funds to fund travel of experts to Chile to increase dialogue among interested parties. Past biotechnology activities in Chile include: In 2011, FAS in collaboration with Asia Biobusiness, IICA and the Chilean Ministry of Agriculture organized a two days Risk Communication Workshop that had the participation of all the Ministries that in some way or another will have to address the public to clarify misleading information or just speak about biotechnology. The Minister of Agriculture, Jose Antonio Galilea opened the event. In 2010, FAS and the State Department organized a seminar to address how Agricultural Biotechnology can help the region address climate change issues. Post has included Argentina and Peru to make it a regional activity. Two speakers from the U.S. will participate of this seminar. In 2009, with the participation of two U.S. speakers, post organized a biotechnology workshop focused on the international regulatory framework putting emphasis on the regulations in the U.S. This workshop was intended for law makers, universities government and research centers. Interact with the centers of biotechnology of the University of Talca, the Catholic University and University of Concepcion. Every year USDA funds the participation of several Chilean government officials to different APEC Agricultural Biotechnology related activities. For example: Funded the participation of Dr. Ralph Scorza as speaker at the Red Bio Agricultural biotechnology Conference organized in Viña del Mar, Chile in October, 2007. Organized a biotechnology/IPR seminar with the participation of high level government officials and agencies, June 7, 2007, that included the participation of Clive James (ISAA) and Karen Hauda (U.S. Patent and Trade Mark Office) as main speakers. Sponsor the participation of the one member of the Chilean delegation to the APEC High Level Policy Dialogue on Agricultural Biotechnology (HLPDAB) held in Canberra, Australia, 2007. Embassy Science Fellowship program with the participation of a USDA/ARS scientist for two months in Chile from May-July 2006. Ministry of Agriculture Official was sent to a training course in the Philippines in June 2006 on Commercializing biotech crops. The U.S. Government participated in the Tenth APEC Research, Development and Extension of Agricultural Biotechnology (RDEAB) hosted by Chile in November 2005, Post organized a reverse CODEL to the U.S. to learn about the U.S. regulatory System for Biotech products in July 2005; We sponsored a Chilean expert to attend the APEC Seminar: ?Creating a Positive Investment Environment for Agricultural Biotechnology?, in Malaysia in Dec 04; we organized a panel of experts to address the Chilean Agriculture and Health Committees in Oct 04; we sent the President of the Small Farmers Cooperative Confederation to a farmer-to- farmer training program in Honduras in Aug-Sept 04; we sponsored two participants to attend the Michigan State biotechnology short course in August 2004; we hosted a visit to the U.S. of a team of Ministry of Health officials tasked with gathering information about other countries biotech regulations in Mar-Apr 04; we coordinated between the Einstein Institute for Science, Health and the Courts (EINSHAC) and the Chilean Judicial Institute to provide technical training to the judiciary regarding biotechnology in civil, criminal and family cases in Mar 04; we organized the HLPDAB in Chile, in Feb 04 and funded the participation of 22 representatives from APEC emerging markets to attend, as well as nine speakers. b) Country specific needs or strategies for Chile. Post?s strategies on biotechnology have focused in two main areas over the past 7 years; one of them is the regulatory aspect of the issue and the other is providing science base information. The main objective regarding regulation is to have Chile adopt a framework that is science based and that does not impose trade barriers; to accomplish this goal we have taken congressmen to the U.S. so they can get knowledge in situ of the regulatory process of biotechnology in the U.S. they met with all the regulatory agencies and growers to have a better understanding of the benefits of this technology so they can develop a regulatory system. One of the participants of the group was one of senators that drafted the framework that is being discussed in Congress. We will continue focusing on the necessity that Chile adopts a science base regulatory framework as this is the key stone to begin trade. We have organized and, we will continue organize biotechnology seminars with universities and researches with the participation of U.S. scientist and speakers; we believe that the more information we provide, the better the public will be informed, and fears about biotech products will be eliminated. Section VI. Animal Biotechnology: I. Development and Use: No genetic engineering in animals is being used in Chile. II. Regulation b) There is no regulation in place; the discussion will start when they begin to review the proposed framework in Congress. c) We believe that regarding genetic engineered animals the government entities that might have a role will be The Ministry of Health in all issues concerning human health and food safety; the Ministry of Agriculture through its SAG office in issues concerning animal health and the new created Environmental Ministry in issues related to the environment. d) The current draft framework introduced to the Congress only deals with vegetables, animals have not yet been considered in any of the proposals. III. Stakeholder/Public Opinion The issue of GMO animals has not been on the table of public discussion, even at a government level the only concern for the moment are the vegetable GMO, I believe the discussion will begin after the framework for vegetables is approved. At the moment animals have not been mentioned. IV. International Organizations: GMO animals have not been considered by Chile in any International discussion. V. Outreach, Needs and Strategies: a) The main strategy is to monitor what happens with the discussion and provide as much science base information as possible when the discussion begins.


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How to Create solid water for miniature dioramas and models
You can paint your plaster blue and coat it with a gloss, but there are easier ways to make artificial water for miniature dioramas, architectural models and war game terrain. Easy Water is a product made up of small plastic pellets that need to be melted and poured onto the model. You cannot use this on styrofoam, obviously. This instructional video provides some alternative methods for creating water effects on miniature dioramas.


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Author | exchange4media News Service | Monday, Jun 10,2002 7:23 AM
Advertising and sales promotion expenditure of Hindustan Lever (HLL) soared to a record Rs 823.82 crore during the year ended December 2001.
In the previous fiscal, the company had spend Rs 696.58 crore. The spending on advertisement sales promotion, which is up 18.27 per cent in 2001 considered to be on a higher side as FMCG companies are facing acute demand recession.
The fierce competition among all personal care companies, particularly to maintain the market shares in shampoo, toothpaste, detergent bath-soaps and hair-dye, has compelled HLL to go for large ad spending.
The higher spending on advertisement has, however, not instrumental to increase the sales/ad spend ratio of HLL.
The company generated sales of Rs 13.32 on a rupee spend on advertisement and sales promotion. The current ratio has been the lowest last five years. In 1999, the company had net sales of Rs 13.75 on a rupee spending on advertisement and sales promotion.
The company had sales/advertisement ratio of 16.20 times in 1997. The ratio dropped to 14.17 times in 1998 and moved up to 15.22 times in 2000.
HLL's spending on advertisement and sales promotion rose 141 per cent or Rs 341.87 crore since December 1997. The company's sales during the period rose 40 per cent or by Rs 3,164 crore.
Though, HLL's sales to advertisement rate drop considerably, the net profit advertisement ratio moved up considerably. In 2001, the spending on advertising accounted for 50.19 per cent of the net profit. In 2000, ad spend accounted for 53.17 per cent of the net profit and in 1998 it was 68.96 per cent of the net profit.
The company's advertisement spend accounted for 83.06 per cent in 1997.


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President Obama said today he wants Congress to vote on his proposed jobs bill this month.
"I'm very much looking forward to seeing Congress debate this bill, pass it, get it to my desk so we can start putting hundreds of thousands and millions of Americans back to work," Obama told reporters before a Cabinet meeting at the White House today.
The president, grappling with a 9.1% unemployment rate, has been traveling the country on behalf of the $447 billion American Jobs Act since he unveiled in a speech to Congress on Sept. 8.
No votes are currently scheduled in either the Republican-run House or the Democratic Senate.
Senate Minority Leader Mitch McConnell, R-Ky., and other Republicans note that some Senate Democrats are uncomfortable with the size of the $447 billion proposal, as well as Obama's plan to finance it with higher taxes on high-earners.
Obama said he plans to meet soon with both Democratic and Republican congressional leaders about moving the jobs bill forward.
The proposal emphasizes new public works projects, particularly roads, bridges and other infrastructure. The jobs bill also includes new tax breaks for potential employers and their workers, as well as financial assistance to state and local governments to help keep teachers, police officers and firefighters on the job.
Perhaps as as inducement to congressional Republicans, Obama also said he would soon make an announcement about submitting proposed free trade agreements with South Korea, Panama and Colombia to the Senate.
Senate Republicans have long backed free trade agreements with those countries, saying they will help create American jobs.
Obama also said he has asked his Cabinet to "look at what we can do administratively to accelerate job growth over the next several months."
"I will be continuing to put as much pressure as I can bring to bear on my administration and our agencies to do everything we can without Congress' help,"Obama said. "But ultimately they (members of Congress) have got to do the right thing for the American people."
David's journalism career spans three decades, including coverage of five presidential elections, the Oklahoma City bombing, the 2000 Florida presidential recount and the 9/11 terrorist attacks. He has covered the White House for USA TODAY since 2005. His interests include history, politics, books, movies and college football -- not necessarily in that order. More about David
Follow the Oval on Twitter: @The Oval, @djusatoday.
Also contributing to the Oval: Richard Wolf @richardjwolf; Aamer Madhani @AamerISmad


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Marine Weather
Eastern Bass Strait Marine Weather Overview
|Swell height
|Districts with warnings
|Observed wind
most recent warnings
Eastern Bass Strait Current Conditions
Weather News
Dry winter exacerbated by frost over growing regions
Winter has made itself felt in recent days over the southeastern inland but not in the form of rain bearing cold fronts.
Canberra's cold, dry start to winter
Canberra is known for its cold weather, although this winter has been even colder - and drier - than usual.
Late-week frost covers eastern Australia
It's a frosty end to the week across much of eastern and southeast Australia, with parts of four states experiencing their lowest temperature in two years this morning.


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