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Cuba's Latin American medical school: can socially-accountable medical education make a difference?
Conner Gorry MA
After graduating more than 12,000 doctors since its founding in 1999, Cuba's Latin American Medical School (ELAM, the Spanish acronym) is tackling one of its greatest challenges to date: how to track graduates from over 65 countries and measure their impact on health outcomes and policy in their local contexts?
ELAM, with its main campus at a former naval academy on the outskirts of Havana, extends scholarships to young people from around the world-most of whom otherwise would not have the means to become doctors. The ELAM curriculum is a six-year course of study designed to graduate physicians who will provide relevant, quality care while fostering equity and improving individual and population health outcomes.[1] ELAM's framework for recruiting, educating, and retaining students is intended to reinforce these goals by:
Recruiting students from rural, remote, resource-scarce and other disadvantaged communities with the greatest health needs;
Providing full, six-year scholarships to all students;
Encouraging students to commit to practice as primary care physicians in underserved areas upon graduation;
Integrating concepts of prevention, social determinants of health, and active community partnering into curriculum design;
Using a community-based, service-learning methodology, preparing students to resolve local health problems; and
Providing post-graduate clinical, research, and continuing education opportunities.
This strategy responds directly to what The Lancet characterizes as the failure of medical education "to overcome dysfunctional and inequitable health systems because of curricula rigidities, professional silos, static pedagogy, insufficient adaptation to local contexts, and commercialism in the professions. Breakdown is especially noteworthy within primary care, in both poor and rich countries."[2] Whereas the global debate once focused on the number and distribution of health workers, this shift towards the type of training signifies deeper consideration of the relationship between medical education, population health and health systems as a whole. Furthermore, it recognizes that new solutions are needed as the global health picture becomes more complex due to the international transfer of pathogens and people; continuing brain drain from the Global South to developed countries; emerging and re-emerging diseases; and widening health disparities. Complicating this scenario even further is inequitable access to care- primary care in particular-both within and among countries. In short, fresh thinking must be applied to health professionals' education if there is to be any hope of achieving health for all and global health security.
In this vein, ELAM and a handful of other medical schools worldwide have adopted the central mandate of social accountability, developing problem- and service-based learning, participatory action research, and other linkages between medical education, health systems development and population health equity. Characterized by curricula that transfer learning from the classroom to the community while emphasizing equity, they formed a consortium in 2008 to begin strengthening their evidence base, voice and influence.
This Training for Health Equity Network (THEnet) provides a framework for such socially-accountable medical schools to share tools, data, and experience in an effort to promote the innovations needed to confront the global crisis in human resources for health. The first step to begin evaluating impact across such diverse contexts and cultures-THEnet schools are found in Australia, Africa, Asia, Europe and the Americas-is learning where, how and with whom graduates from these schools are working.
Tracking ELAM Students and Grads
Unlike the rest of the schools in THEnet, ELAM is both big and diverse. Indeed, it is the world's largest and most diverse medical school. Rector Juan Carrizo says such heterogeneity represents the institution's biggest challenge, dealing with "different customs and culture, language and habits." Yet, he says the school's strength also lies in diversity, as students live and work amongst peers from many different cultures, and lifelong relationships are built across borders.[4]
Such size and diversity obliges ELAM administrators to systematically evaluate their own policies and outcomes-from student intake and curricular content, to job placement and career continuum-in order to remain effective and relevant to the school's mission. Through information technologies, and by adapting and contributing to a social accountability evaluation framework developed by THEnet in partnership with flagship schools, ELAM is striving to better gauge its impact by tracking its graduates' trajectories.
The cornerstone of this effort is an interactive, student and graduate project called the Observatory. Built by Cuban software developers using open access technology, the Observatory is a virtual infrastructure providing school administrators a detailed picture of where, how and with whom ELAM doctors work. Comprehensive and flexible, the database is supported by a dynamic analysis package through which variables are parsed to track graduates and assess their impact on health and health policies. "Right now we're training the people necessary to make the Observatory as effective as possible," Observatory director Dr Kenia Monjes explained, "since data reliability and analysis depend first and foremost on relevant, accurate data collection."
Students are entered into the Observatory database immediately upon matriculation to begin capturing relevant information and facilitate networking among ELAM stakeholders throughout their education in Cuba, upon graduation, and beyond. Dr Monjes stressed that tracking students from the beginning provides an important tool for decision-making. For example, assessing attrition and other difficulties offers a guide to improving processes for selecting scholarship candidates, while feedback from graduates helps hone the relevance of course content.
In addition to standard fields such as graduating class and contact information, variables include: whether doctors are unemployed or working in the public or private health sector; if they are involved in social service projects; if they practice or are enrolled in postgraduate studies in their country of origin, Cuba, or a third country; what specialty they are pursuing; and their availability for postings with Cuban disaster relief teams.
The Observatory's Challenges
"The infrastructure and technology are in place and we already have over 22,000 students and graduates from 95 countries entered into the database," Dr Monjes told MEDICC Review. "But we are still struggling to find where many of these graduates are working once they leave Cuba."
The chart below illustrates some first results for neighboring Haiti, where ELAM has become the main source of newly-trained physicians.
The Observatory's first litmus test came in January 2010, when ELAM administrators sent out the call for volunteers to join Cuba's Henry Reeve Team of Medical Specialists in Disasters and Epidemics in Haiti.[5] The earthquake, which struck the country on January 12, hit close to home: not only had more than 500 young Haitians doctors already graduated from ELAM, but the tremor was felt by students at the school's Santiago campus in eastern Cuba.[6] With student support, the Observatory went into action, contacting more than 2000 ELAM-trained doctors, half of whom affirmed they were available and eager to serve.[7] Over 700 of these doctors from 27 countries eventually joined the team in Haiti, marking this the first time foreign medical graduates served alongside their Cuban colleagues in a disaster relief effort.
"The overwhelming response by graduates to volunteer in Haiti showed that these doctors were ready to put into practice the principles of social accountability that underpin their training," said Dr Monjes. The Haiti experience kick-started aggressive networking efforts by the Observatory, resulting in identification of an array of projects, organizations and experiences led by ELAM-trained doctors, some of which are described below. The Observatory, together with THEnet's evaluation framework, will allow such programs to be documented and assessed with appropriate methodology to determine their outcomes, replicability and social impact-going beyond anecdotal material to provide a sound evidence base.
From Argentina to California: Fulfilling the Mission
Two pillars of Cuban medical education, which ELAM students apply in service-learning rotations in the country's primary care system, are the neighborhood health diagnosis and the Continuous Assessment and Risk Evaluation (CARE; known as dispensarización in Spanish). Both tools are used to assess the health picture and needs of the local population to better tailor services and design strategies to improve outcomes. The first is a complete health diagnosis carried out annually by community-based health professionals; the second, conducted more often, classifies residents by chronic disease and risk factors.[8] In many of the contexts where ELAM graduates work, such needs assessments revealed a stark reality: health services were either non existent, insufficient, or inconsistent. In response, the ELAM doctors profiled below-what The Lancet refers to as "enlightened change agents"[2]-set out to put their problem-based, socially-accountable training to the test.
El Salvador: A member of ELAM's first graduating class in 2005, Dr Carlos Manuel Orantes received his MD upon completing six years of study and passing Cuba's national board exams. This degree proved a means rather than an end, however, since it allowed Dr Orantes to pursue his true passion: nephrology. Under the Cuban program, he won a scholarship to specialize at Havana's Nephrology Institute, where he developed primary research on renal disease in El Salvador for his thesis.
As a result of his initial-and disturbing-findings that chronic kidney disease (CKD) was epidemic among younger people in the Salvadoran countryside, he returned to El Salvador in 2009 to launch more in-depth research. Named Nefrolempa, the study is being conducted in the total population of various communities of the Bajo Lempa region where he grew up. Adopting the methodology applied in a similar study on Cuba's Isle of Youth[9]-the first of its kind in the world-Nefrolempa set out to establish the prevalence of CKD, identify associated risk factors and measure kidney function in the population. Results thus far reveal that over 25% of men in the region suffer from different stages of CKD, much higher rates than the global prevalence of between 10% and 16%, and among much younger people.[10] The alarm sounded.
Building on the basic tenets of a socially-accountable approach that research should be relevant, participatory, and equitable, the Nefrolempa team-comprised of 50 Salvadoran ELAM graduates and students, young students and doctors from the University of El Salvador, local leaders, and a pair of Cuban nephrologists working under the aegis of PAHO[11]-extended the study to more communities, some of the poorest in the country.
The study's results spurred the Salvadoran Ministry of Health to develop a renal health program for the country's primary care system, complemented by a national renal research program. Dr Orantes designed the former and is national coordinator of the latter. "We designed and developed an integrated primary health program for early detection of CKD, and are in the process of reorganizing services at the community level to provide appropriate care," says Dr Orantes. "Implementation of these national services requires putting the necessary human resources in place, which is ongoing through service learning and training workshops."[11]
Nefrolempa, now in its second phase, bolstered by initial data from the national programs, led the Minister of Health, Dr María Isabel Rodríguez, to designate CKD a priority health problem. "Not only El Salvador, but the entirety of Central America is suffering from a chronic kidney disease epidemic that is debilitating our population, hammering our national budgets, and exhausting our health systems," declared Dr Rodríguez at the WHO/PAHO Non-Communicable Chronic Disease regional meeting in 2011.[12] At her urging, the meeting included the CKD epidemic in its final declaration.
In short, Nefrolempa, led by Dr Orantes, has alerted health authorities to CKD as a major health problem, led to national reorganization of services to address it, and sparked further research into risk factors for CKD as it manifests in El Salvador-particularly a potential association with toxic agrochemicals-all evidence of Salvadoran ELAM graduates affecting both policy and practice.
USA: Dr Brea Bondi-Boyd, ELAM class of 2009, is the first foreign medical graduate (FMG) to have been accepted into California's Contra Costa County Family Medical Residency program in decades. A native Californian, Dr Bondi-Boyd is one of nearly 200 young people from the United States who have earned scholarships to study medicine in Cuba[13]. Once she passed her US Medical Licensing Examinations ("The Boards"), she began the residency match process. "I was well received, but found, sadly, that my idealism, volunteerism and dedication to work with poor people that I largely learned from my Cuban professors, was not the norm for most US applicants, at least not in the applicant pool I came from."[14]
Dr Bondi-Boyd's experience goes to the heart of what distinguishes the training at a socially-accountable medical school from a traditional one. According to the Evaluation Framework for Socially Accountable Health Professional Education developed by THEnet, "schools help develop the values, norms, behaviors, and worldviews held by key groups in the health system. They can influence their graduates, with potentially wide-ranging effects throughout the health system."[3]
Dr Bondi-Boyd is applying those values in practice at the public hospital where she works, but also in policy, since she was chosen as a Youth Commissioner on the Education of Health Professionals for the 21st Century Global Commission, an ongoing study published by The Lancet. Among the Commission's major findings, informed by the perspectives of Dr Bondi-Boyd and other young doctors from around the world, is that "20th century educational strategies are unfit to tackle 21st century challenges"[2]-something the ELAM and other socially accountable schools confront head on. "What's amazing about Cuban medical education is that it's based on public health, population assessment, and need: in short, it's already doing what much of the Commission recommends," said Dr Bondi-Boyd. As an ELAM graduate practicing in primary care, "I felt I could demonstrate to myself, and the US and international health communities, the possibilities of a universal health care system in low-resource settings."
Honduras: There was no electricity, school, or doctor where Dr Luther Castillo grew up in his indigenous community on the remote Honduran coast. As he walked to and from a school miles away, he was haunted by images of family and friends suffering from intestinal parasites, respiratory infections, low birthweight, and anemia. These conditions, though treatable, often resulted in worsening health and, too often, death due to lack of accessible care. He carried these images through six years of training at ELAM as he formulated a plan and organized other Honduran students to bring universal, equitable care home, to the Garifuna people of the Mosquito Coast.
In 2005, medical degree in hand, Dr Castillo returned home. The plan was ambitious: to organize the community itself to build a rural hospital staffed by other Garifuna ELAM-trained doctors in a strategic, accessible location; carry out health assessments of the surrounding population; and develop a comprehensive prevention and health promotion program. After long months of sweat equity, resources, and know-how donated by the community and international partners, the First Garifuna Community Hospital of Honduras opened in 2007 in the coastal town of Ciriboya. No small feat given the complex political and socio-economic conditions in Honduras then and now, this remote hospital amounts to a trial by fire for the principles of a socially-accountable medical education.
Five years on, the hospital is staffed 24 hours a day, seven days a week by a team of five Honduran ELAM-trained doctors who provide free emergency, internal medicine, surgery, laboratory, ultrasound, and primary care services to the surrounding population of 20,000. Another three ELAM graduates serve in a mobile capacity in the most remote communities and obstetric and dental services are provided by Cuban specialists posted to the area.[15,16] Active screening and prevention campaigns for diabetes, hypertension, sexually-transmitted infections (including HIV), breast cancer and other conditions relevant to the local health picture are carried out by these health professionals.
In addition, ELAM graduates have developed training courses for midwives, nurses and health promoters. With local Garifuna leaders, they provide guidance to these communities and are active in health promotion, such as campaigns to increase breast feeding and prevent dengue. The hospital's efforts are supported by Student Health Teams, Garifuna ELAM students who dedicate their summers to working in communities back home. For the past two years, the Ciriboya-based team has conducted active screenings for breast cancer, sickle cell anemia and diabetes. By year's end 2011, the First Garifuna Community Hospital had treated over 231,000 people, attended 1630 births, performed nearly 2500 operations and saved 140 lives.[17]
Argentina: Like their colleagues in Honduras, ELAM graduates returned to Argentina to establish permanent, accessible health services to vulnerable, underserved communities. Propuesta Tatú, founded in 2008, is an intersectoral program with health, educational and cultural components offering primary care, pediatric, obstetric and mental health services free of charge in over a dozen communities on the outskirts of Buenos Aires. A MEDICC Review site visit to the 17 de Noviembre settlement where Propuesta Tatú is headquartered revealed the destitute conditions which prompted these ELAM-trained doctors to take action. Over 25,000 people-most of them indigenous immigrants from neighboring countries-live in shanties amid open sewers and stagnant lagoons, bereft of basic utilities, the air heavy with burning plastic. "These settlements are typified by extreme poverty and have no municipal services-no gas, water, schools, and no health services," Gino Straforini, Propuesta Tatú Coordinator and father of ELAM graduate Dr Carla Straforini, told MEDICC Review. "Our project was founded based on 'A Dignified Life for All,' beginning with medical attention provided by ELAM-trained doctors," he said.
From primary care services and prevention initiatives in a single settlement, Propuesta Tatú now serves 17 similar communities, staffed by 10 ELAM graduates and a handful of locally-trained doctors (including two orthopedists) and two psychologists. Through June 2012, these doctors had treated just shy of 30,000 people, provided over 1900 orthopedic consultations, and dispensed more than 26,000 prescriptions-all free of charge. Aggressive, ongoing efforts to address local health problems include dengue and Chagas disease detection, education and treatment; total population vaccination campaigns; and prevention of food- and water-borne diseases, including cholera and parasites.[18]
The scope of Propuesta Tatú has expanded since its founding to include efforts targeting the adverse effects of social determinants on health. Food and clothing distribution, nutrition and sexual health workshops, a literacy program using the Cuban method Yo Sí Puedo (winner of the UNESCO Literacy Award), housing construction, and a summer day camps for kids, all work towards the improvement of health and wellbeing in these communities. In addition, a school for health promoters and another for trades such as carpentry, computer sciences, and welding now impart classes to young people-several of whom have applied for ELAM scholarships as a result of their experiences.
Multiplying the impact of Propuesta Tatú and building sustainable, practical relationships with municipal authorities to further improve living conditions are priorities, Dr Straforini told MEDICC Review. "One municipality has contracted Propuesta Tatú doctors to work in a primary and urgent care center and we hope to extend Propuesta Tatú to Chile soon."
Haiti: Dr Patrick Dely didn't need to wait for the ELAM Observatory to find him following the earthquake that hit Haiti on January 12, 2010. He felt the ground moving in Santiago de Cuba where he was a resident in epidemiology, and immediately began organizing other Haitian ELAM graduates to join the relief effort. Dr Dely says that while his lifelong dream of becoming a doctor had been realized thanks to an ELAM scholarship, he knew it was time to go home and give back, even though it meant interrupting his postgraduate studies.
When MEDICC Review sat down with Dr Dely amidst the rubble and tents of Port-au-Prince two months into his posting with Cuba's Henry Reeve disaster team, his dream to give back had solidified into a vision: "I want to see my country transformed, where Haitians feel proud, where children have access to health and education. Where I was born, there's no school. At age 10 or 11, kids go work in the fields or emigrate. Sometimes it makes me cry to go back there. So I started thinking, what can I do?"[19] He not only started thinking, he started acting: two years on, Dr Dely's vision to establish an intersectoral community project based on education, health and social equity is a reality.
The École Bonne Samaritaine in his hometown of Madisse in north-central Haiti is the community's only school and embodies the comprehensive approach to health Dr Dely learned in Cuba. In addition to grade school classes for 182 local children, the École Bonne Samaritaine has a health clinic, staffed by Dr Dely, which provides basic primary care for students and their families plus a school meal and nutrition program-oftentimes offering the only meal these children receive each day.
This is just the beginning, according to Dr Dely, whose immediate goals are to establish a local hospital and to plant a community garden so students are guaranteed two nutritious meals a day. "My dream is for these kids to receive some of the best education in the country. I hope to see these children happy, healthy, and learning," he said.
While he works towards that goal, Dr Dely serves as Coordinator of the Haitian Ministry of Health's Epidemiology Department, a multipartite project supported by the US Centers for Disease Control; the option to obtain specialty degrees in an in-country training program led by Cuban specialists in Haiti allowed him to finally complete his studies.
This position has permitted him to put into practice epidemiological models learned in Cuba to confront the cholera epidemic in Haiti. "Once cholera was identified, we swung into action, converting the Bonne Samaritaine school into a rehydration and treatment center," Dr Dely told MEDICC Review. Previously, patients had to travel nearly an hour to the closest center, and too many simply never made it. "We treated more than 5000 people in the four months of the worst of the epidemic. The conditions were basic, but the service was free and accessible, allowing us to save many lives."[20]
Forging Partnerships, Maximizing Impact
One common denominator each of these experiences share is they all depend upon partnerships with stakeholders, local health professionals, health system administrators, policymakers and non-governmental organizations dedicated to providing health to underserved populations. Such well-directed multilateral cooperation in public health strategies-bringing additional financial, material, intellectual or technological resources-has proved to be an efficient, cost-effective strategy to address increasingly complex global health problems and their social determinants. This is especially true in areas lacking even basic infrastructure such as electricity, potable water, garbage disposal and transportation-often the precise areas where ELAM doctors commit to work.
In Haiti, Dr Dely's school clinic is supported by Global Links, a US organization dedicated to equipping health facilities in disadvantaged and underserved areas. Donations by Global Links of basic supplies including sutures, a blood pressure unit, nebulizers and a scale, enabled the clinic to open and begin attending and monitoring the health of the Madisse population.[21] Without similar donations from Global Links, MEDICC and other organizations[22], albeit on a much larger scale, the First Garifuna Community Hospital of Honduras would not exist. Other partners including the Fraternal Organization of People of Color, and a team of US volunteers that has supported the hospital since 2006, help keep the hospital running.
Data from the Observatory and experiences gleaned by ELAM graduates serving in poor communities reveal that regional and national governments have an integral and essential partnering role to play in maximizing impact of these public service doctors. After years of providing health and other services in settlements all but ignored by local government, Propuesta Tatú has finally been invited to partner with municipal health authorities in Buenos Aires. The Nefrolempa program in El Salvador is having considerable impact in this regard, as its participatory action research stimulated reforms in policy and practice at the national level, and influenced Central American regional priorities. The support of the Salvadoran Ministry of Health, PAHO and Cuban specialists, locally-trained doctors and the communities themselves helped make this possible.
Cooperation towards policy change is practical even in countries where medical associations and/or the government itself has been hostile to these returning doctors: in Honduras, the ELAM graduates at the First Garifuna Community Hospital weathered the 2009 military coup, regrouped, and proposed to the current government that primary care be legislated as national policy. This accord was recently made law: more than 1000 primary care health posts around the country currently without doctors, are slated to be staffed by physicians and nurses, many of them predicted to be ELAM graduates.[16]
Nowhere, however, is this multilateral synergy as robust as in Haiti, where regional governments-Venezuela, Brazil, and Cuba in particular, in partnership with organizations such as MEDICC and Global Links-are working together with Haitian authorities, PAHO, local NGOs and stakeholders to build quality, sustainable and accessible public health services, heavily staffed by ELAM-trained doctors.[23]
Obstacles and Opportunities Ahead
Nevertheless, one of the biggest hurdles remains recognition of the ELAM degree in many graduates' home countries. Unlike the United States, which essentially applies the same licensing requirements to both FMGs and domestic graduates, a number of countries in the Americas, Africa and Asia-perhaps accustomed more to 'brain drain' than 'brain gain'-have no mechanism for certifying these doctors and incorporating them into the health system. This is reflected in how many ELAM graduates remain unemployed, a factor the Observatory also tracks. "This is especially troubling [since] it represents the inability of some public health systems to absorb these new doctors," says ELAM Rector Juan Carrizo. Sometimes, he says, this failure is due to "budgetary constraints, but in other cases [it] represents resistance by local medical societies to accept graduates from a different kind of medical school."[24]
This is no small challenge, since measuring the impact of ELAM-trained doctors and therefore of the school itself, depends on how these physicians perform in the systems where they serve. According to WHO, gauging progress toward socially accountable care is evaluated according to relevance, quality, cost-effectiveness and equity. Furthermore, "these values must be equally emphasized by the medical school and the health care system. Understanding the interrelationship between these values allows health planners and organizers to direct (or redirect) programmes of action."[25] These ELAM graduates are returning home with such values firmly established; but it is up to recipient countries to develop practical, sustainable and effective plans of action to incorporate them into their health systems to improve population health outcomes.
While it is beyond ELAM's purview to influence individual countries' domestic policies, mechanisms are being developed by the graduates-again with support and guidance from multilateral partners-to affect policy change. And the graduates themselves are organizing: SI-ELAM (Sociedad Internacional de Egresados de ELAM; International Society of ELAM Graduates) was constituted at the Second Meeting of ELAM Graduates held in Havana this July. SI-ELAM plans to work in cooperation with the Observatory to track policy shifts in countries with ELAM-trained doctors, as well as provide support to its members and postgraduate training in research to document and disseminate the impact of ELAM graduates' projects globally. SI-ELAM is an umbrella for national affiliates in dozens of countries, and Dr Emiliano Mariscal (ELAM class of 2005 and veteran of Propuesta Tatú in Argentina) was elected its first president.
As the world becomes ever more globalized, mobile and interdependent, solutions to problems faced by individual societies require innovative thinking and shared action. Nowhere is this more evident than in health, where preventable diseases, environmental disaster and contamination and inequities of all types (especially access to care) conspire to keep marginalized populations in a state of poor health. However, as the ELAM experience has shown, training doctors and other human resources for health is only half the battle; the other half is ensuring that those health professionals have the tools, networks, experiences, continuing education and opportunities to apply their training where it is most needed.
The ELAM Observatory is building the evidence base; beginning to measure the impact of its graduates; and informing other socially accountable medical schools and evaluation mechanisms with its unique perspective. These are the first steps to leveraging success and creating synergies with stakeholders and other partners. Already the experiences above have shown that ELAM-trained doctors can act as change agents in their communities, as well as role models for other low-income young people who dream of becoming doctors. For its part, with accurate and reliable data in hand, the Observatory will be able to tailor its research to inform continuous improvements in recruitment, curriculum, teaching methodologies and student retention. Although the impact of individuals on outcomes is difficult to measure given the multifactorial influences on health and well-being, working together, the ELAM Observatory, SI-ELAM and schools participating in TheNET are multiplying partnerships and spearheading socially accountable stewardship. By doing so, they hope to provide evidence that health for all is not only necessary but possible.
References & Notes
1. For details of the ELAM curriculum, see: Cuban Medical Education: Aiming for the Six-Star Doctor, in MEDICC Rev. 2008;10(4):5-9.
2. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp N, Evans T, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010 Dec 4;376(9756):1923-58.
3. The Training for Health Equity Network. THEnet's Social Accountability Evaluation Framework Version 1. Monograph I (1 ed.) [Internet]. Belgium: The Training for Health Equity Network; 2011 [cited 2012 Jun 20]. 28 p. Available from: http://thenetcommunity.org/files/articles/Monograph%20print%20quality%20feb%201.pdf
4. Interview with Juan Carrizo. 2008 Jul 22.
5. For details on the founding of the Henry Reeve Team, see MEDICC Rev. 2005;7(8):31-2.
6. Martínez Hernández L. Amores de campamento. Granma. 2010 Feb 15.
7. Gorry C. Once the earth stood still (part I): Cuban rehabilitation services in Haiti. MEDICC Rev. 2010 Spring;12(2):44-7.
8. Keck CW, Reed GA. The curious case of Cuba [Internet]. AJPH. 2012 [cited 2012 Jun 20];102(8):e13-e22. Available from: http://ajph.aphapublications.org/doi/full/10.2105/AJPH.2012.300822
9. Almaguer M, Herrera R. Design and methodology of the Isle of Youth community- based epidemiological study of CKD, cardio-cerebral vascular disease, hypertension, and diabetes mellitus (ISYS). MEDICC Rev. 2007;9(1):23-30.
10. Orantes CM, Herrera R, Almaguer M, Brizuela EG, Hernández CE, Bayarre H, et al. Chronic kidney disease and associated risk factors in the Bajo Lempa region of El Salvador: Neforlempa study, 2009. MEDICC Rev. 2011 Oct;13(4):14-22.
11. Interview with Carlos Manuel Orantes. 2012 Jul 13.
12. Rodríguez MI. Intervención, Consulta regional de alto nivel de las Américas contras las enfermedades crónicas no transmisibles. Mexico City. 2011 Feb 25. Spanish.
13. Porter C. Cuba-trained doctors making difference around the world [Internet]. Toronto Star. 2012 Jun 2. Available from: http://www.thestar.com/news/world/article/1203466-cuba-trained-doctors-making-difference-around-the-world
14. Interview with Brea Bondi-Boyd. 2012 Jul 2.
15. Dolmo C, Castillo Harry L. Brigada estudiantil por la salud: Luagu hatuadi waduheñu 2011 [unpublished monograph] .
16. Interview with Luther Castillo Harry. 2012 Jul 17.
17. Fundación Luagu Hatuadi Waduheñu. Datos históricos. Personal communication.
18. Interview with Gino Straforini. 2012 Jul 3.
19. Interview with Patrick Dely. 2010 Mar 18.
20. Interview with Patrick Dely. 2012 Jul 17.
21. Global Links. Help Haiti heal newsletter. 2011 Dec 28.
22. MEDICC [Internet]. Oakland: Medical Education Cooperation with Cuba; c2012. Opening ceremonies for first indigenous Garífuna hospital in Honduras; 2007 Dec 1 [cited 2012 Jun 20];[about 1 screen]. Available from: http://medicc.org/ns/?p=264
23. Field Notes from MEDICC [Internet]. United States: WordPress.com; c2012. Trilateral accord signed to rebuild Haitian public health system; 2010 Mar 30 [cited 2012 Jun 17];[about 2 screens]. Available from: http://mediccglobal.wordpress.com/2010/03/30/trilateral-accord-signed-to-rebuild-haitian-public-health-system/
24. Neusy AJ, Palsdottir B. Roundtable: Revisiting innovative leaders in medical education. MEDICC Rev. 2011;13(3):6-11.
25. Boelen C, Heck J. Defining and measuring the social accountability of medical schools. Geneva: World Health Organization; 1995. Report No.: WHO/ HRH/95.7.
Disclosures: MEDICC Review is published by Medical Education Cooperation with Cuba (MEDICC) mentioned in this article.


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This is an exciting weekend for Capital Region theater, especially for those who appreciate the opportunity to attend rarely produced plays. "Orlando," based on the 1928 Virginia Woolf novel, will be performed at Skidmore College in Saratoga Springs Friday through Wednesday. "The Trojan Women" has been adapted from the Greek tragedy written by Euripides for The Theatre Institute at Sage in Troy. It plays today through Sunday. In contrast to these two works based on classic literature, the Local Actors Guild of Saratoga will present "Sordid Lives" for the next two weekends. Its director calls the play "a white trash comedy with heart." 'Orlando' There is a lot of ironic humor in the gender-bending story of "Orlando," a tale about a young man who, after being the lover of a queen and later a Russian princess, one day wakes to find himself a female. The adaptation is by Sarah Ruhl, a young, very popular contemporary playwright with a quirky perspective. Kathryn Rickman is co-directing the play at Skidmore College with Jeremy Ohringer. She said they were drawn to the material because, as college seniors, the play speaks to their lives. "It's about self-discovery, facing challenges and moving onto new experiences," Rickman said. She can see why the play appeals to mature audiences as well. "It addresses love, gender and aging," Rickman said. "It speaks to the meaning of life, whatever age you are." "Orlando" will be performed at Janet Kinghorn Bernhard Theater on the Skidmore College campus at 8 p.m. Friday through Wednesday, 2 and 8 p.m. Saturday and 2 p.m. Sunday. Call 580-5439 or email@example.com
for more information or reservations. 'The Trojan Women' "The Trojan Women" may not offer insight into the meaning of life, but Leigh Strimbeck, who is directing her own adaptation of the work at Sage, has equally lofty goals for her production. "It deals with the impact of war. Specifically, about how it affects women," she said. Strimbeck has taken great liberties with Euripides' play. She sets the 3,000-year-old work in the future, and instead of Troy in Greece, it takes place on the banks of the Hudson River in Troy, N.Y. The one-act play takes place at a women's refugee center in the midst of a great energy crisis in a United States that has all but collapsed after a 10-year civil war. In the original, the conquered women of Troy are forced into various forms of slavery, but in this "feminist retelling," the tragic ending has a twist. Strimbeck said, "All of my writing is about empowering young women. With this work, I have given the play an ending that I think reflects how contemporary women would respond to the situation." The work has already generated great buzz outside the region. Next week, March 9-10, the cast will travel to New York City to participate in a festival at Phoenix Theatre, and on March 22 they will be in Great Barrington, Mass., for the Simon's Rock College Festival of Women's Writers. "The Trojan Women" plays at the Meader Little Theatre in Troy at 8 p.m. Friday and Saturday and at 2 p.m. Sunday. Call 244-2248 for more information. 'Sordid Lives' J.J Buechner, who directs and plays a lead role in "Sordid Lives" for the Local Actors Guild of Saratoga, calls the work "pure entertainment" but says the work is, at times, "surprisingly sentimental." He's quick to add, though, "There are 10 times more laughs than there are serious moments." The work is perhaps best known as a cult film and maybe even as a short-lived television series. Or, more likely, it's not well-known at all. It revolves around a Texas family gathering at the funeral of its matriarch, who died in a motel room tripping over her married lover's wooden legs. At the heart of the dark comedy is a mother coming to grips with one son being openly gay and her acceptance of another son who is in a mental institution because he insists he is Tammy Wynette. They are the tip of the crazy character iceberg. "Yes, it is a totally crazy family, which makes the mother's eventual acceptance of her sons so sweet," Buechner said. "It's a very funny play about unconditional love." "Sordid Lives" will be at the Saratoga Arts Center, 320 Broadway in Saratoga Springs. Performances are scheduled for 2 and 8 p.m. this Saturday and Saturday, March 9; and 7:30 p.m. this Sunday and Sunday, March 10. Call 393-3496 for more information.

subset: commoncrawl


text:
Electromagnetic fields
Wiley, Jul 24, 1986 - Science - 587 pages
This revised edition provides patient guidance in its clear and organized presentation of problems. It is rich in variety, large in number and provides very careful treatment of relativity. One outstanding feature is the inclusion of simple, standard examples demonstrated in different methods that will allow students to enhance and understand their calculating abilities. There are over 145 worked examples; virtually all of the standard problems are included.
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angle assume axes axis becomes bound charge boundary conditions bounding surface calculate capacitance cavity charge density charge distribution charge q circuit conducting conductor const constant corresponding Coulomb's law current density curve cylinder dielectric dipole direction displacement distance divergence theorem electric field electromagnetic electrostatic energy equal equipotential evaluate example Exercise expression field point flux free charge function given illustrated in Figure induction infinitely long integral integrand Laplace's equation line charge located Lorentz transformation magnetic magnitude Maxwell's equations normal component obtained origin parallel plate capacitor particle perpendicular point charge polarized position vector potential difference quadrupole quantities rectangular coordinates region result satisfy scalar potential shown in Figure situation solenoid solution sphere of radius spherical surface charge surface charge density surface integral tangential components theorem total charge vacuum vector potential velocity volume write written xy plane zero


text:
Cursos de español para ti
Mejora tu español rápidamente.
También Erasmus +
¿Organizas un viaje de grupo?
Resolvemos todo para que el viaje sea un éxito
Cursos de profes ELE
¡Sigue formándote!
También Erasmus+
Toledo, ciudad Patrimonio de la Humanidad, resume mejor que ninguna otra la historia de España.
Toledo es una ciudad llena de encanto, es un monumento en sí misma ya que posee una de las concentraciones de arte más grandiosas de Europa. Además es un mercado vivo de artesanía y gastronomía: sus espadas, damasquinos, vinos, quesos y mazapán son únicos y todos los días ogrece interesantes actividades para disfrutar de nuestra cultura.
La variedad de nombres con los que se la reconoce a través de tiempo, muestra su importancia histórica; es Tierra de El Quijote, capital de la España Visigoda, Ciudad de las Tres Culturas, Jerusalén de Occidente, urbe medieval, metrópoli de esoterismo, Catedral Primada de España, enclave Sefardí, laberinto árabe, inspiración de El Greco, Ciudad Imperial, reino de leyendas…
Toledo es, en resumen, una explosión de cultura.
Toledo está situado en el centro de España a sólo 71 Km. de Madrid y 80 del aeropuerto internacional de Barajas.
Esto le proporciona un acceso privilegiado a los principales medios de comunicación del país ya que la mayoría de los transportes se organizan de forma radial desde la capital. Otras ciudades españolas que podrás visitar son Córdoba, Valencia, Granada, Salamanca, Barcelona, Santiago de Compostela…
Toledo se comunica con Madrid tanto por carretera como por tren. Existe una red de autobuses con salidas cada treinta minutos que une ambas ciudades; el trayecto dura 50 minutos aproximadamente. Un tren de alta velocidad hace posible el recorrido en tan sólo 25 minutos.
- ¿Qué puedo visitar en Toledo?
Información útil de Toledo y actualidad de la ciudad
Ciudades Patrimonio de la Humanidad de España
- ¿Qué hay hoy en la ciudad?
¿Cómo puedo llegar a Toledo?
Tren: www.renfe.com
Bus: www.alsa.es
- ¿Qué puedo ver en la región?
Posted by Talia S. ()
on August 2015
I also had Isabel as a teacher for several classes and she was equally as helpful as Cristina. I can't say enough good things about the teachers in Aula Toledo.
Maite was also wonderful. She was very accommodating, even when we had to change our class time due to a conflict with work schedules and she always made me feel entirely welcome in the school. She also speaks English, which at the start for me, was entirely necessary when discussing times for lessons and overall details but by the end we were able to speak mainly in Spanish.
I can't recommend this school highly enough. I thoroughly enjoyed my time there and would go back again in a heartbeat if I was still living in Toledo. (Which is a beautiful city itself.) I had a fantastic experience in this school.
Posted by Maria H. (Toledo - Spain)
on July 2015 - Spain
Posted by Susan H. (Houston - USA)
on July 2015 - USA
Posted by Emily J. ()
on June 2015
Posted by Annie B. (Paris - France)
on June 2015 - France
My teacher, Cristina, was fantastic. She provided great material to work with and I feel she has helped me immensely with my Spanish.
I stayed with a host family and I thoroughly enjoyed my stay.
A well-run school with dedicated staff that truly care about their students. I highly recommend this school, it will surpass your expectations!
Posted by Patrick D. (Ireland)
on May 2015 - Ireland
Posted by Julia T. (Singen - Germany)
on November 2014 - Germany
Posted by Norbert M. (Cologne - Germany)
on September 2014 - Germany
Posted by Brian B. (Weimar - Germany)
on August 2014 - Germany
Posted by Kelly D. (Providence - USA)
on March 2014 - USA
Posted by Marge P. ()
on December 2013
I was extremely lucky to practice Spanish every day and evening with my hosts, and to receive such excellent tuition in a small, professional and friendly language school.
I would recommend it to anyone!
Posted by Jilly B. (London - United Kingdom)
on October 2013 - United Kingdom
Posted by Cynthia S. (Boston - USA)
on September 2013 - USA
Posted by Rhonda D. (Brooklyn - USA)
on September 2013 - USA
As this is probably not the standard program for a language course, I asked for individual classes and of course for staying in a host family.
Both turned out to be just perfect.
The teachers at the school put a course together for me, which fit perfectly my level and abilities. Now I only have to use all what I learned there.
And my host family - well it was like visiting an old friend!
Finally, the city. Well I guess I don't have to tell you what a beautiful city it is and how important it once was for our European culture. And it is really convenient to reach from Madrid airport. It is always worth a visit, but "living" in this city for a whole week (the house of my host family was in the old town 10 minutes away from the school) is a completely different story. Every morning on the way to school I could explore other parts of the town. My absolute favorite was San Roman, located very close to the school, but not for the museum but for the frescos!
So, if you want to learn or improve your Spanish and you have some interest for culture - don't wait to book your language trip to Aula Toledo.
Posted by Stephan p. a. S. (Gentofte - Denmark)
on August 2013 - Denmark
I found the classes quite challenging (being placed in the B2) group but really beneficial- I feel as if my standard of speaking and listening in Spanish have significantly improved since taking the week long course.
I would highly recommend Aula Toledo to anyone wishing to practise their Spanish given the high standard of teaching and the friendly atmosphere of the school.
Posted by Tasha D. (Milton Keynes - United Kingdom)
on August 2013 - United Kingdom
The class sizes were perfect for studying a language, with plenty of time dedicated to conversation and practice. There were also activities outside of class that were really fun and engaging, like movie nights, games, and tours around Toledo (now one of my favorite cities). One thing I was able to do through the school was schedule meet-ups with native Spanish speakers to practice my Spanish outside of class. Aula Toledo's director, Maite, is incredibly helpful and definitely wants each student to enjoy and take advantage of the experience as much as possible.
I highly recommend Aula Toledo, and I can't wait to visit again someday!
Posted by Sonya V. (USA)
on August 2013 - USA
I think Toledo is a great choice to learn Spanish. It's a beautiful small town, very rich culturally and ideal for those who would like to be at a quieter place.
Posted by Danillo S. (Sao Paulo - Brazil)
on July 2013 - Brazil
Posted by Hlynur J. (Iceland)
on June 2013 - Iceland
Posted by Pekka V. (Finland)
on June 2013 - Finland
The team at Aula Toledo provides professional tuition for any level/need and caters for any age group. I studied Spanish some 30 years ago to A level equivalence in France. Within one week, I achieved more than in many months of evening adult classes in England (obviously, catering more for the English)
Outside the classroom, Maite went out of her way to make sure my time way used in a constructive manner in this very cultural and historical city, I also joined a guided tour and took part in a couple of language exchanges.
My stay with a local resident was also very pleasant and very beneficial.
Overall a very good experience.
Thanks to Maite, Cristina F and Cristina L
Posted by Francoise S. (Leighton Buzzard - United Kingdom)
on March 2013 - United Kingdom
Here are some thoughts I've came back to the Swiss Alps with:
- There still are generous, lively, positive, responsive people out there and it is so good to meet/work with them;
- It is incredible how much one can learn within a short period of time when the teacher is good;
- How come didn't I know Toledo before?
Thanks again to the whole team and hugs to Maite,
Posted by Pierre-yves C. (Lausanne - Switzerland)
on January 2013 - Switzerland
Even before having arrived I could experience the good service of the school as Maite, the school's director, answered all my emails quickly and gave me necessary information, e.g. about transport. On my first day Maite took us on a tour of the city which was helpful to receive important information about the city and to get some orientation in Toledo.
My classes were well organized and effective and the content of the course was adjusted exactly to our requirements. Due to the commitment of our teacher Cristina we enjoyed every minute, but at the same time our language skills improved considerably. I had interrupted my Spanish education for several years, but because of the intensive training with Cristina I could reach the old level within short time and even improved my language capacity.
Apart from school and homework we had time to discover Toledo with its interesting historic and cultural background. I shared a nice apartment with a friend very close to the school in the heart of the city.
I enjoyed the friendly atmosphere at Aula Toledo and the excellent language training. It was a great experience there and if possible once again I will come back.
Posted by Katrin B. (Germany)
on November 2012 - Germany
Posted by Takuma F. (Salamanca - Spain)
on October 2012 - Spain
Posted by Karen B. (Ann Arbor, MI – USA) on August 2012 – USA
I had a great family stay as well. I had a couple of personal problems that I needed to deal with and both my host family and Maite were extremely helpful in straightening them out. You really can't ask for more in a language school! I would concur with all of the other five star reviews!
Posted by Karen B. (Ann Arbor, MI - USA)
on August 2012 - USA
Maite also takes particular care in choosing home stay arrangements for her students and placements are excellently matched to the individual's tastes and interests. Having had a few bad home stay experiences this was something I particularly appreciated. My home stay could not have been better and I count my stay in Toledo as one of the best experiences of my life. Aula Toledo is nothing like your usual "pump them through" language school and I'll be heading back as soon as I can.
John C. Wellington, New Zealand
Posted by John C. (Wellington - New Zealand)
on April 2012 - New Zealand
Posted by Wayne C. (Salado - USA)
on February 2012 - USA
Posted by Darryl B. (USA)
on January 2012 - USA
Even if I had to work quite hard doing the exercises in the evenings because of my poor knowledge of Spanish, it was FUN! And most delightful was to notice how much you can learn in a week when teaching and learning materials are on high level.
The spirit of AULA TOLEDO was free and easy, friendly and jovial, so it is no wonder I enjoyed my school week very much.
Toledo itself is a charming city with a special atmosphere and has lots to offer. So it would be a great choice to travel to Toledo to study Spanish at AULA TOLEDO and have an opportunity to enjoy the city of Toledo.
Leena Saikkonen from Finland
Posted by Leena S. (Savitaipale - Finland)
on November 2011 - Finland
Posted by Elizabeth H. (USA)
on September 2011 - USA
soy un chico italiano y he transcurrido 2 semanas en Toledo.Cualquier adjetivo para hablar de esta experiencia serìa desperdiciado.El casco antiguo de Toledo es una cosa ùnica en todo el mundo. El curso es muy ùtil y combina mucha conversaciòn con la justa parte de gramatica. Los profesores son amables,preparados y te ayudan para cualquiera cosa. La directriz es extraordinaria y disponible para cualquira cosa, y si hay un problema te ayuda sin duda. Si queréis disfrutar en todo Espana desde el idioma hasta la comida os aconsejo alojar en familia como yo. Mi familia fue muy acogedora y ahora la echo de menos.:-) Id sin vacilaciones no os arrepentiréis. Ah y Madrid està a media hora con el tren. Adìos
Posted by Juan L. (Italy)
on August 2011 - Italy
Wonderful time in Toledo!
Hello, I spent a wonderful time in Toledo! The two weeks organized by Aula Toledo were so rich! First, I wanted to go to Toledo, because it is a very old and culturally interesting town. The old part of Toledo (el casco) is very nice and you can visit a lot of sites (old Roman bath, mosque, synagogue, churches, cathedral, museum of El Greco and so much more… and there are so nice bars and restaurants).
Then, I looked for a language school and found Aula Toledo. Although I organized my time in Toledo very spontaneously, Maite López, the director of Aula Toledo, was very committed and found a host family in a few days. The contact (e-mail) was very reliable I always got help and answers very quickly. The Premium Intensive course (24 hours/week) was very helpful to improve the knowledge of Spanish language. The main focus was communication, but our teachers were always ready to revise grammatical problems etc. if we wanted to do it. Our group was very small: 4 students and one teacher, so we always had the opportunity to talk and our teachers found good and varied occasions to speak about. They were very interested in our persons, our lands…They are humorous people and had a very good sense of what every student wanted to learn and was able to do. We enjoyed the time together!
After school I lived in a Spanish family, so nice! They gave me the opportunity to become integrated into their family and were so open to me. They showed me interesting sites and gave me some good advice what to do. And they spent a lot of time with me. So I had another good occasion to talk and to learn about the Spanish culture. And it was a wonderful human experience.
Thank you so much!
ent a wonderful
Posted by Veronika T. (Husum - Germany)
on August 2011 - Germany
2 amazing weeks in Toledo
I spend 2 amazing weeks in Toledo. I was basically looking for something serious and fun. I read so many reviews and understood that many "schools" do not actually deliver what is required to master a language.
Aula Toledo is first all a real school with talented teachers. They really sense the needs of a student and how to help him progress effectively. The program is clear and you can really notice the improvement quickly. I will also recommend a minimum of 2 weeks to really get the maximum of it.
The school is as well amazing, very stylish and you can really feel after a while at home.
I took the option to stay in a family. Everything was great and I salute the two of them as they were really kind and down to earth. They welcomed me not only as a guest but also as a friend. That makes the experience even richer.
Toledo? A great city full of history with amazing food and fun!
I highly recommend this school and strongly believe they should deserve much more credit as I can really see the improvement! Be part of the adventure and go to Aula Toledo!!!
Posted by Aymeric B. (London - United Kingdom)
on June 2011 - United Kingdom
Toledo is a wonderful city
I studied 2 weeks in Aula Toledo and the whole experience was just great!
Toledo is a wonderful city, every corner is picture-worthy, and it has a unique and incredibly rich history. To illustrate this, the walls of the room where I lived were made of stones from the wisigoth and Arabic eras and there was a roman cistern in my closet!
I've studied in a few language schools and I can tell that the service, the whole registration process, is the best I've encountered. You really feel like you are welcomed. My host family waited for me at the train station and Maite toured with me in the city showing me the main points of interests, restaurants and bars (they are surprisingly many).
The courses themselves are great too. They are centered on conversation, but of course, all the important aspects are covered (grammar, audition, tricks to learn verbs, slang etc.), and meanwhile you learn a lot about Spanish culture. My teacher, Chus, adapted rapidly to my level.
As I said, I lived in a family, wonderful and kind people. The room was perfect (my own bathroom!) and food was fantastic. I practiced a lot with them and it was a real immersion. I made a lot of progress there!
My two weeks in Toledo were certainly the highlights of my trip in Spain and I just wished I had stayed longer!!
Posted by Maxim L. (Montreal - Canada)
on May 2011 - Canada
Todo perfecto
La ciudad es fantástica y da la impresión de vivir en siglos pasados pero con las comodidades modernas. La comida está muy rica y la gente muy agradable. Por suerte no se habla mucho inglés todavía.
En cuanto a la escuela, el sitio, el ambiente, los docentes, todo perfecto. Me gustó el contenido del curso. Me gustó también la honestidad de la escuela. Por ejemplo, cuando dicen 4 horas, son 4, no 3.30. Cuando hacen una semana de 3 días por causa de vacaciones, no hacen pagar 5 días. Cuando dicen que no se fuma en la casa, no se fuma, no es que se fuma en la ventana con la mitad del humo volviendo dentro de la casa como lo experimenté la semana siguiente en otra ciudad.
Bueno, solo cosas positivas. Yo seguro que volveré (si me aceptan).
Posted by Lam C. (France)
on May 2011 - France
A.C. Reino Unido
The teachers could not have been more dedicated and helpful and always consulted with me closely over my needs, objectives and topics that interest me , ensuring that every class was highly productive and enjoyable. They also gave me very useful feedback and lots of resources for further study.
Apart from the classes I also appreciated the opportunity to explore the beautiful city of Toledo in more depth and learn and experience so much more than I could have done during a short touristic visit ."
Posted by A.C (UK)
on October 2018
Excellent school! I recommend it!!!
Posted by Rita R. (Italy)
on October 2018
Fantastic School
Posted by Charlie Y. (UK)
on September 2018
Esperienza indescrivibile
Posted by Mattia D. (Italy)
on July 2017
Great Experience!
Posted by Durban L. (USA)
on July 2016
Great week in Toledo and at Aula Toledo
Posted by Perkes K.
on June 2016
Totalmente recomendado!!
Posted by Ryan L.
on January 2016
Not like other schools
We've all experienced other language schools. Schools where lazy teachers run through the programme with weary indifference. Schools where the accommodation is basic and the food miserable. Where your host family is disengaged and conversation limited or non-existent.
Aula Toledo is none of these things. The teachers are enthusiastic and present their classes with imagination and flair. The host families provide excellent accommodation and engage enthusiastically with students. The school provides the perfect environment for learning Spanish.
I have now spent two study periods of over a month at Aula Toledo and each has been a marvellous experience. My Spanish has improved dramatically and I have formed lasting friendships with my host families.
There is no better place to learn Spanish.
John Cryer (Wellington, New Zealand)


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|March 16, 2013, 12:02 AM
Senior Member
Join Date: February 25, 2013
Location: Broward County, Florida
Posts: 2,957
Can you use a suppressor with a concealed/car gun?
I was just reading a thread about shooting without hearing protection and the kind of damage it can do in an emergency situation. I found myself wondering if you can carry a concealed weapon with a suppressor (that is, if you could manage to conceal it) or on one that you keep in your car to protect your hearing and the hearing of those around you.
My question isn't necessarily if it would be practical, just legal.
|March 16, 2013, 12:28 AM
Senior Member
Join Date: May 25, 1999
Location: Too close to Houston
Posts: 4,196
It would be legal where I live. You would only have to keep a copy of the tax stamp with you.
Proud member of the NRA and Texas State Rifle Association. Registered and active voter.
|March 16, 2013, 08:58 AM
Senior Member
Join Date: March 5, 2009
Location: Uh-Hi-O
Posts: 2,644
I can't speak for states outside Ohio. In Oh there are no laws saying you can't.
My P226 with the Trident9 on it is about as long as my forearm. Not concealable at all. I have seen some of those micro 9mm cans like the Nano. They add enough length that a Glock 26 becomes longer than a 17 Long slide.
HOWEVER one must remember that sometimes a defensive shooting can land the shooter in court, be that criminal or civil. With that in mind, remember that 99.5% of the population still think that silencers are only for assassins. Your muzzle mounted hearing protection could land you in hot water.
The "can I use my NFA weapon for defense" question has come up a million times before this. It has been beaten to death on the internets.
PLEASE don't drag the "castle doctrine" in to this. It is not a iron clad guarantee that you can shoot someone and get away with it.
PLEASE don't pull out that tired old "judged by twelve carried by six" line. You may have a conversation that goes something like
(prosecutor)"Why did you have a suppressor mounted on your pistol?"
(you)"I wanted to protect my hearing."
(prosecutor)"So, you are telling the ladies and gentlemen of the jury that when you left your house that morning, you so fully expected that you would be shooting someone that day, you brought along hearing protection? You brought along with your loaded handgun a device designed to muffle and conceal the report of a gunshot. The prosecution rests, Your Honor."
Now don't get me wrong, if someone were to kick in my back door right now they would be met by my suppressed 9mm. That said, I won't be carrying it as my primary defensive arm when I go out into the world.
rant off.
"9mm has a very long history of being a pointy little bullet moving quickly" --Sevens
|March 16, 2013, 05:27 PM
Senior Member
Join Date: February 25, 2013
Location: Broward County, Florida
Posts: 2,957
I had the same thought as to what it would look like if used for self defense for that reason. I figured the whole machine pistol thing had been considered but I wasn't sure about the use of suppressors.
|March 16, 2013, 07:29 PM
Senior Member
Join Date: August 22, 2008
Location: las vegas, NV
Posts: 409
the use of a suppressor or full auto firearm in a defensive shooting being a factor is likely just as over blown as the use of hand loaded ammunition or customized trigger pulls. If it's a good shoot the tools involved are irrelevant; if its a bad shoot, then you're up the creek anyways.
|March 16, 2013, 08:59 PM
Senior Member
Join Date: September 25, 2012
Location: ohio
Posts: 145
^^^ this. Although the fearful will never look at it that way
Due to several differences of opinion with staff, I am choosing to no longer do business on this forum. Everyone that has a pending order will need to contact me via email at [email protected] Thanks,
|March 19, 2013, 07:25 AM
Senior Member
Join Date: November 20, 2008
Posts: 10,879
I would rather deal with using a full-auto machine gun for SD than a suppressor. At least there is some precedent where full-auto was used and the shooting was justifiable. See Beckwith Incident.
|March 19, 2013, 09:03 AM
Join Date: July 28, 2010
Location: Arkansas
Posts: 8,089
This whole "a good shoot is a good shoot" business is hogwash. The reality of a SD shooting is that "a good shoot may be a good shoot, or it may be a good shoot after the police, the prosecuting attorney, the judge, and a jury, or maybe several, decide that it is a good shoot." If one doesn't take possible jury perception into account, then one has looked at an imcomplete picture of the legal landscape.
With that said, I am unaware of any law in my State (Arkansas) that would prohibit me from using a suppressor in a car gun. I do not know what the laws of the OPs State say on the matter, though. I also must admit to not having researched the laws on the federal level, but I'm unaware of any federal law that would prohibit concealing or carrying in a vehicle a suppressed firearm, presuming that all of the legal niceties (tax stamp, etc) are met.
OP, take a look at your own State laws or consult an attorney licensed in your jurisdiction and familiar with NFA laws. Those are your best options. Consulting a bunch of well-meaning, but ultimately unlicensed, individuals whose credentials and knowledge you really cannot verify is not the best move in light of the possible penalties that could be involved.
I'm a lawyer, but I'm not your lawyer. If you need some honest-to-goodness legal advice, go buy some.
|March 19, 2013, 01:18 PM
Senior Member
Join Date: February 25, 2013
Location: Broward County, Florida
Posts: 2,957
Spats, thanks for the advice, but I was just looking for an answer for kicks rather than legal advice. I'm 3 years from being able to own a suppressor legally anyways and if I decided to keep one on a weapon for self defense I'd do the research necessary. Prison doesn't sound like a fun place.
|March 19, 2013, 01:26 PM
Join Date: July 28, 2010
Location: Arkansas
Posts: 8,089
Getting a heads-up for kicks is fine, especially if you start the research well in advance, as you have. Just don't rely on us to know the particulars of your state law, especially if we don't know your state.
I'm a lawyer, but I'm not your lawyer. If you need some honest-to-goodness legal advice, go buy some.
|March 21, 2013, 07:59 PM
Senior Member
Join Date: March 17, 1999
Posts: 24,383
Silencers (suppressors if you must) were regulated under the NFA in the first place because Congress was convinced they were ""sneaky" and not in the image of good, clean living Americans, only of dirty foreign assassins. (Yes, those terms were used in the debates.)
Those ideas and images still remain and can still be used to influence a jury. I agree that the "good shoot" business is nonsense. We are no longer in the Wild West (if such existed outside "dime novels"). Anyone who kills or seriously injures another person, even in his own home, is not going to be congratulated and stood to drinks by the local sheriff. NOT going to happen, so get over that idea fast.
Jim K
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- Summary
After more than 45 years of producing extraordinary copper pans, the Ruffoni family began channeling its craftsmanship into clad stainless-steel cookware of the same exceptional quality. This versatile saucepan is adorned with a silver-plated, cast-brass knob shaped like an artichoke and carrot.
- 3 1/2-qt. cap.
- Alternating layers of stainless steel and aluminum transfer heat efficiently, eliminating hot spots.
- Hand-hammered exterior with a unique serial number inscribed on the bottom.
- Solid stainless-steel handle and lid.
- Knob is hand cast in brass and plated in silver by a Milanese silversmith.
- Ideal for use on any type of cooktop, including induction.
- Handsome enough for oven-to-table presentation.
- Made in Italy.
- Dimensions & More Info
- 7 3/4" diam., 4 1/4" high.
- 3 1/2-qt. cap.
- 4 lb. 1 oz. with lid.
- Made in Italy.
- Use & Care
- Ideal for use on any type of cooktop, including induction.
- Oven safe to 500°F.
- Use wood, plastic or heat-resistant nylon tools to avoid scratching the stainless-steel lining
- Do not use knives, sharp kitchen tools or an electric hand mixer in your cookware, as they may scratch lining.
- Allow pan to cool before washing.
- The pan and lid are dishwasher safe.
- Hand-wash removable knob.
- Avoid using steel wool, steel scouring pads or harsh detergents.
- To remove stubborn food residue, fill cookware with small amount of water and place over low heat until food is softened and easily removed.
- Cookware may discolor if not completely cleaned before reheating. To remove discolored areas, rub with a cloth dampened with lemon juice or white vinegar, or use a high-quality nonabrasive stainless-steel cleaner.
- Shipping
Shipping Information
UPS can deliver most in-stock items within 3–5 business days. UPS is unable to deliver to P.O. boxes.
Shipping Rates
The shipping rate varies depending on your order total and shipping destination. View Shipping Options and Charges.
Next Day Delivery
For an additional charge of $26 per address, we can expedite delivery to most destinations. This service is not available for some oversize items, items shipped directly from the supplier (including perishable and custom-manufactured items), out-of-stock items and items to be shipped outside the contiguous 48 states.
Orders received by 9:00 p.m. ET Monday through Thursday will arrive the next business day; orders placed Friday through Sunday will arrive on the following Tuesday.
Return Policy
At Williams Sonoma, we take great pride in the quality and craftsmanship of our products. Attention to design, materials, safety and construction are our priority. Upon receipt, please inspect your purchase and notify us of any damage; we will arrange for a prompt replacement.
If within 30 days, you are dissatisfied for any reason, you may return your purchase for a refund of the merchandise value. An original receipt or gift receipt is required for all returns and exchanges. Returns with a gift receipt will be refunded in the form of a Merchandise Credit for the amount indicated on the gift receipt. Returns with original receipt will be refunded in the original form of payment, cash and check refunds over $100 will be issued as a company check (may take 14 business days from time of request).
For all cutlery returns (knife sets, single knives, cutting boards, knife sharpeners and knife storage), please contact us at 888.922.4108 to initiate the return.
We cannot accept returns on monogrammed, personalized, special-order items, custom upholstery, food, items shipped direct from the vendor or on items damaged through normal wear and tear. Final sale items ending in .97 or .99 cannot be returned.
Made to Order and Final Sale Furniture items are non-returnable and cannot be cancelled once the order is placed.
For returns of items purchased from your Williams Sonoma Gift Registry, we will gladly provide a refund or exchange for the merchandise within 90 days of your event or within 90 days of purchase, whichever date is later. View Full Returns Policy.
- More about Ruffoni
Ruffoni was founded in 1962 in Omegna, Italy, a beautiful lakeside town at the base of the Alps that's known for its tradition of metalworking and coppersmiths. The Ruffoni family preserves this history in its private collection and museum, which showcases antique copper cookware and early copper-production processes. The company's skilled artisans still use many of these time-tested, hands-on techniques to craft heirloom-quality cookware as beautiful as it is functional. From hand-hammered exteriors to decorative molded handles and knobs, the famous Italian attention to design shines in every piece.
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Rated 1 out of 5 by Myrtie from disappointing Beautiful to look at, yes. My daughter reports that the handle over heats. I also noticed that the finial silver wore off after only a few uses. Would never buy again.Date published: 2015-08-14Rated 5 out of 5 by DanielRay from My Favorite Pot for Daily Use I use my Ruffino Opus Prima Hammered Stainless-Steel Saucepan daily for making oatmeal, sauces, and other food. It is easy to clean and a beautiful appealing Stainless-Steel Saucepan. I have collected 5 pieces of Ruffino Opus Prima Hammered Stainless-Steel products and plan to get all of them. I must say that I am very pleased with this product... Thanks for a quaility, beautiful, useful saucepan Ruffino...Date published: 2015-07-12Rated 5 out of 5 by flyingpig from A workhorse & gorgeous, too! This is my 7th piece of these & I LOVE them for all aspects of cooking & serving. They are top notch & as an added bonus, they are just gorgeous & the focal point of my kitchen display!Date published: 2013-11-12Rated 5 out of 5 by Kelsey1838 from Beautiful And Functional Cookware Who knew that cooking could not only be functional but beautiful. These pans cook evenly and are a breeze to clean - while at the same time looking elegant and lovely while on the stove. The one drawback on these and other newer pans is that that knobs on the lids transmit the heat from cooking, so you will need to use a pothodler - but that is true on any number of pans today. The quality of the product is superb.Date published: 2013-04-01


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Even if many transactions were bolstered by cut-rate lease deals and other incentives last month, with 13,497 units rolling out of dealerships through the end of August, the Chevrolet Volt "extended range electric" sedan is outselling about half of all cars marketed in the U.S.
If indeed the Volt is a "failure," as some of its critics have contended, we're sure there's several auto executives out there that would like many of their slower-selling models to suffer the same fate.
Now to be fair, the industry's top performers were responsible for far more sales over the first eight months of the year than the Volt could register in a decade at its current pace. Among passenger cars, the Toyota Camry leads the pack with 280,536 deliveries through the end of August (not counting 30,587 Camry Hybrid models). The Ford F150 pickup truck did even better with a phenomenal 408,656 units, albeit with sales bolstered by considerable cash rebates.
Still, the Volt's 133rd-place ranking placed it ahead of industry stalwarts like the Audi A6, BMW 7-Series, Porsche Cayenne and Mercedes-Benz S-Class, and it outsold most hybrids including the Toyota Prius plug-in, Honda Civic, Kia Optima, Toyota Highlander and Lexus RX 450h. Sure, the big-money incentives helped kick start sales last month, but the more Volts GM gets into consumers' hands will closer the car and its advanced technology will approach the mainstream. It took Toyota many years to become profitable with the Prius, and the company took heat investing big bucks to develop its hybrid technology back in the late 1990's when gas cost about a dollar a gallon.
Now of course, as it is in the National Football League, one great game does not ensure a Super Bowl victory, and it doesn't help that General Motors' executives were, shall we say, overly optimistic with the Volt's initial sales projections, but it does look like the Volt may finally be finding a niche for itself. Or at least one that's stronger than, say, any of the well-regarded sports cars it's handily outselling this year like the Chevrolet Corvette, Porsche 911 and BMW 6 Series. If GM can figure out how to attract a steady stream of customers without having to slap a thick wad of cash on the Volt's hood, so much the better.
Source: GM-Volt.com via GreenCarReports.com; 2012 sales rankings: GoodCarBadCar.net


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It was approximately 3:30 Thursday morning when Red Sox general manager Ben Cherington came to an agreement on a trade that would send ace lefthander Jon Lester and outfielder Jonny Gomes to the Oakland Athletics.
It was just the start of an unprecedented series of moves for the Red Sox, making for one of the most dizzying days in team history.
The last-place Red Sox tore apart the team that won the World Series last fall, trading Lester, Gomes, shortstop Stephen Drew, righthander John Lackey, and lefthanded reliever Andrew Miller to teams in playoff contention.
The return was significant. Oakland sent All-Star outfielder Yoenis Cespedes to the Sox. The St. Louis Cardinals traded outfielder Allen Craig and righthander Joe Kelly in return for Lackey.
The Yankees, who had not made a trade with the Sox since 1997, dealt infielder Kelly Johnson for Drew, and the Baltimore Orioles received Miller in exchange for promising 21-year-old lefthander Eduardo Rodriguez.
The deal involving Drew came only 30 minutes before the 4 p.m. deadline for trades.
"I think everybody is stunned," said Gomes as he drove away from Fenway Park in his red pickup truck.
RELATED | Shaughnessy: Just what are the Red Sox up to?
The 48-60 Red Sox, hopelessly out of contention a year after winning it all, have fully turned their attention to next season with 54 games to play.
"We had to find a way to take advantage of the unfortunate position we were in and try to kick-start a little bit building the next team," said Cherington, who said he didn't sleep for two days plotting all the moves.
Of the 25 players who were on the playoff roster last season, only 14 are still with the organization. Seven have been traded, four of them on Thursday.
Cespedes and Craig are expected to be in the lineup for Friday night's game against the Yankees, and Kelly will join the rotation next week.
Rookie Xander Bogaerts is being moved back to shortstop and Will Middlebrooks is returning from the minors to play third. Those moves were what motivated the trade of Drew.
A team that on Wednesday had a strong rotation and a weak offense now has a pitching staff loaded with unproven talent but a much-improved offensive attack.
'There's nothing sort of celebratory about this.'
Cespedes is the centerpiece. The 28-year-old from Cuba is an athletic and exciting player with a flair for dramatic plays. He has 17 home runs this season, three more than the Red Sox had out of their entire set of outfielders.
"A really powerful, dynamic player in his prime who fits in our ballpark in the outfield. We'll probably take a look at him in right field and see sort of how he looks out there," Cherington said.
RELATED:Trade deadline day recap: Who's here, who's gone
Cespedes, who is signed through the 2015 season, was second in the American League Rookie of the Year voting in 2012 but has seen his batting average, on-base percentage, and slugging percentage drop since.
Still, his power potential made the deal work. Cespedes represented a better player than the Red Sox were likely to find in the free-agent market this winter.
"We're excited to have him. He's someone clearly we don't have," Cherington said. "That did become a priority for us to see if we could get a little bit of a jump start on adding to the offense at the deadline."
Lester, 30, leaves the Red Sox at the top of his game, having gone 10-7 with a 2.52 earned run average in 21 starts. His 149 strikeouts are sixth in the American League and he is fifth in ERA.
Lester joins an Oakland team that is in first place in the American League West and has the best record in baseball. After helping lead the Red Sox to a World Series title, he has a chance to repeat that accomplishment with his new team. Lester gives Oakland a formidable rotation that includes Jeff Samardzija, Sonny Gray, and Scott Kazmir.
RELATED | Cafardo: Revamping offense was Red Sox' priority
Lester was a favorite in the organization, a homegrown talent who beat lymphoma early in his career to help win two World Series. He was 110-63 over parts of nine seasons with the Red Sox. He is ninth in team history in wins, fourth in starts, and fourth in strikeouts with 1,386. Only Roger Clemens, Tim Wakefield, and Pedro Martinez had more.
"Tough decision with people who have meant a lot to the Red Sox who I've known for a long time and done great things for the organization. So you start thinking about that and that's hard," Cherington said.
Lester will be a free agent after the season and has said he would be agreeable to returning to Boston. One aspect of the trade that appealed to the Red Sox was the knowledge that the Athletics were unlikely to retain Lester and that he would become available.
Watch: Ben Cherington on Jon Lester contract talks
Ben Cherington says Jon Lester contract talks "just didn't happen enough"
"He's an Oakland A right now. I don't think it's right for me to talk about that other than to say, looking back, that we certainly had a desire to engage on a contract conversation with him and that conversation just didn't happen enough for whatever reason," Cherington said.
Gomes, a platoon outfielder, had a big impact on the 2013 World Series champion Red Sox but was hitting .234 with six home runs and 32 RBIs this season. He returns to Oakland, where he played in 2012.
"There's a spot in my house forever for my Red Sox jersey. Scooped up some Red Sox dirt to take that home," Gomes said. "That [World Series] ring, that ring's a lifer. I was fortunate to have the opportunity to wear that uniform."
The 30-year-old Craig has played primarily right field and first base on his career. He is having a down season, hitting .237 with seven homers and 44 RBI for the Cardinals. But Craig hit .312 with an .864 OPS and 46 home runs from 2011-13.
Cherington said that dealing Lackey along with Lester required getting a starter pitcher in return and Kelly fit the criteria. The Cardinals also received minor league lefthander Corey Littrell and $1.75 million.
Watch: Ben Cherington on Red Sox trades
Red Sox general manager Ben Cherington on today's trades
Once that deal was finished, the Sox turned to trading Miller. His 2.34 ERA over 50 appearances and 14.7 strikeouts per nine innings had created a demand. He was on the team last year, but was injured and could not play in the postseason.
"We had more calls on Andrew Miller than any other player on our team. Every contender in baseball pretty much called us on Andrew Miller because he fits for everyone," Cherington said.
Miller also will be a free agent after the season and said he "absolutely" would consider a return to Boston.
"It's exciting. I get a chance to pitch for a team that could go to to the playoffs," he said. "I didn't want to leave here but if I have to go, I'm glad it's to a team like that."
RELATED:How other big Red Sox deadline deals worked out
The trade of Drew came last. It was essentially a salary dump as the Red Sox will save approximately $2.8 million. They sent the Yankees $500,000 and took on Johnson, a utility player on the disabled list.
Drew left the Red Sox as a free agent after the Series, went unsigned, and returned in May. He hit .176 in 39 games.
"In retrospect, that move didn't work out the way we wanted it to. Now it's an opportunity to move [Bogaerts] back and use the rest of the year to let him play and we'll see where we are," Cherington said.
In what has been a bad year for the Sox, Thursday may have been a day that changes the fortunes of the team. The Red Sox remade the roster after finishing in last place in 2012 and went on to win the Series. Now they're starting over again.
"There's nothing sort of celebratory about this. These moves are made because collectively as an organization we haven't performed well enough," Cherington said.
Related coverage:
• Dan Shaughnessy: Just what are the Red Sox up to?
• Nick Cafardo: Revamping offense was Red Sox' priority
• Trade deadline day recap: Who's here, who's gone
• How other big Red Sox deadline deals worked firstname.lastname@example.com. Follow him on Twitter @PeteAbe.


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Server Outage
The server that runs this website went offline without notice yesterday. We don't know why and we've had no contact from our server host. We do have complete backups, no data has been lost. We've started to restore services and the outstanding service will be reinstated as time permits over the holiday period.
We will update this page as services come back online.
What is the impact?
This services are currently down, listed in order of restore priority
ml.mate-desktop.org- The mailing lists, which are rarely used.
forums.mate-desktop.org- The forums, which we started shutting down earlier in the year and are locked.
What has been restored?
- http://www.mate-desktop.org - This website
- http://pub.mate-desktop.org - Where you can find the tarballs of MATE Desktop releases.
- http://wiki.mate-desktop.org - The developer wiki.
- http://git.mate-desktop.org - This is a mirror of the MATE Desktop GitHub.
- http://planet.mate-desktop.org - The MATE Desktop planet.
mail.mate-desktop.org- Mail server for developers.
21st December
- Bytemark offer to sponsor MATE Desktop hosting to help us overcome the server outage with our previous provider.
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22nd December
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23nd December
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2nd January
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We apologise for any inconvenience this may have caused.


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Elevate your favorite recipes with these pantry essentials.Shop Now
For the Cinnamon-Honey Dressing, mix lemon juice, honey, sea salt and roasted cinnamon in small bowl. Slowly whisk in 6 tablespoons of the oil. Set aside.
Mix plum preserves and water in small bowl. Set aside. Mix Applewood Rub and lemon peel. Thread shrimp onto skewers. Brush with remaining 1 tablespoon oil. Coat with Rub mixture.
Grill shrimp skewers over medium heat 4 to 5 minutes per side or just until shrimp turn pink, brushing occasionally with plum preserves mixture. Grill plums 1 to 2 minutes or until grill marks appear, turning frequently and brushing with 2 tablespoons of the Dressing.
To serve, divide salad greens among 6 plates. Top each with shrimp, plums, raspberries and bacon. Serve with remaining Cinnamon-Honey Dressing.