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These studies, which check my source involved thousands of people in the kamagra canada buy U.S. And Mexico, showed that the treatment also was highly effective against “Alpha,” the erectile dysfunction variant first identified in Great Britain, reports Carl Zimmer at The New York Times (6/14/21). €œNovavax plans to apply for authorization in UK, EU, India, South Korea, and possibly the U.S.,” according to an Unbiased SciPod post (6/15/21).

A 6/17/21 story by Tanya Lewis at Scientific American describes some of the incentives being offered to people for getting vaccinated against erectile dysfunction treatment — including lottery tickets, college scholarships, train tickets, firearms, cash pay-outs, cannabis joints, doughnuts, kamagra canada buy free trips, cruises, and gift certificates. €œPublic health experts use incentives all the time to get people to quit smoking, exercise more, and so on,” the story describes the director of the Health Decision Sciences Center at Massachusetts General Hospital’s general medicine division as saying. An unpublished study by the Mass General researcher suggests that incentives might effectively induce people to get a erectile dysfunction treatment, Lewis reports.

But for some people kamagra canada buy the best inducement is an opportunity to stop wearing a mask and a general return to normalcy, the story suggests. Some positive news for people who have transplanted organs and thus take immune-suppressing drugs. A third dose of a mRNA treatment against erectile dysfunction treatment provoked a stronger immune response, at least in the form of antibodies, in organ transplant patients than the standard two doses did, per various reports.

The findings, from a small study of patients who received a third dose this spring, kamagra canada buy were published 6/15/21 in Annals of Internal Medicine. The findings are “part of a broader discussion about whether and when to offer extra doses to vulnerable individuals,” writes Jennifer Couzin-Frankel at Science (6/14/21). In past studies, organ transplant patients who got a two-dose erectile dysfunction treatment were far less likely to make protective antibodies against erectile dysfunction than the general population was.

Some larger three-dose studies among people with compromised immune systems are under way, Couzin-Frankel reports kamagra canada buy. A medical oncologist at the University of Pennsylvania is not very worried about the effectiveness of erectile dysfunction treatments among people with cancer, the story states. The story then describes two recent studies of cancer patients showing that they produced antibodies against erectile dysfunction after receiving a erectile dysfunction treatment.

However, a third study found much lower antibody levels among vaccinated cancer patients than it did among their healthy family members who kamagra canada buy also were vaccinated, Couzin-Frankel reports. The Unbiased SciPod posted some helpful informational graphics about Pfizer’s ongoing studies of its erectile dysfunction treatment in children under 12 (6/11/21). The post states that dosages have been set based on initial smaller studies in children (one-third the adult dose for ages 5-11 and one-tenth the adult dose for ages 6 months to 5 years), and that researchers will enroll 4,500 children across 90 sites globally for the larger safety and effectiveness studies.

€œChildren have immune system kamagra canada buy components that are more potent compared to adults. They may not need as high a dose for protection. Age criteria are related to immune system development, not physical size,” the post states.

The results will likely become available kamagra canada buy this fall for review by the U.S. Food and Drug Administration, with a first batch — from studies in children ages 5 to 11 — expected in early September, the post states. Nearly one quarter of all people in the U.S.

Who were infected with erectile dysfunction last year, including 19% of those who never reported erectile dysfunction treatment symptoms from their , had new kamagra canada buy medical problems within a month or more of recovering from the kamagra, according to a large study covered by Pam Belluck at The New York Times (6/15/21). Belluck writes. €œThose affected were all ages, including children.

Their most kamagra canada buy common new health problems were pain, including in nerves and muscles. Breathing difficulties. High cholesterol.

Malaise and fatigue kamagra canada buy. And high blood pressure. Other issues included intestinal symptoms.

Migraines. Skin problems. Heart abnormalities.

Sleep disorders. And mental health conditions like anxiety and depression.” The study, conducted by non-profit organization FAIR Health and not formally reviewed by experts for flaws, involved evaluating electronic health-insurance records. A 6/11/21 story by Emily Anthes at The New York Times runs down some evidence-based approaches that employers can take to reduce the risk of erectile dysfunction s and other health problems as workers return to offices nationwide.

Employers should flush unused taps and other plumbing to clear any metals or Legionella bacteria colonies that accumulated, the story states. Employers also should upgrade their ventilation and fiation systems, the story states. The goal is four to six air changes per hour, the story states, which is equivalent to completely refreshing air every 10 to 15 minutes in a room.

Portable air purifiers or even “desktop level HEPA filters” can help. And continue to wash your hands routinely, for at least 20 seconds each time, advises a Northwestern University environmental microbiologist who is quoted in the story. Not solutions.

Desk shields (plexiglass barriers are a good idea in grocery stores though), foggers, fumigators, ionizers, ozone generators and other ‘air cleaning’ devices,’ the story states. In most non-medical or non-lab settings, wiping down surfaces with bleach solutions or disinfectant solutions or wipes does little to prevent erectile dysfunction transmission. Besides, inhaling these substances is harmful.

€œThe no. 1 thing is to get vaccinated,” the story quotes Joseph Allen at the Harvard School of Public Health as saying. A debate among scientists about whether erectile dysfunction spreads mainly by fallen respiratory droplets on surfaces that people touch or spreads in air hampered public health efforts to control the kamagra and to prevent deaths.

The implications for this debate were crucial, as Megan Molteni at Wired writes (5/13/21) — officials need to know whether public-health messages should focus on hand washing or on masking and isolation or both, particularly before treatments become available. The general debate is over, as you probably know — the kamagra is mostly spread in indoor air. But why did researchers disagree until recently?.

In part, it’s because the arguments against airborne erectile dysfunction all rested on an assumption that only particles smaller than 5 microns could hang in the air. Larger ones, aka droplets, fall to surfaces. But in reality, larger particles can stay afloat and behave like aerosols, many scientists and engineers have known, including aerosols expert Linsey Marr of Virginia Tech, Molteni and others have written.

Molteni’s story masterfully traces the events, conversations, and research that came to expose the “fallacy of the 5-micron boundary.” The hero of this engaging story is Katie Randall, a graduate student who specializes in detective work to figure out how bits of knowledge are passed along through published research papers over time. Guidance from the U.S. Centers for Disease Control in April stated that international and domestic travel are low-risk activities for people vaccinated against erectile dysfunction treatment (so, this does not pertain, unfortunately, to U.S.

Children under 12, for whom erectile dysfunction treatments are not yet authorized). In response to that update, Ceylan Yeginsu at The New York Times has written up answers to some of the questions that vaccinated travelers have these days (6/15/21). A summary of the answers (again, this information is all for vaccinated people in the U.S.).

1) Yes, you must still wear a mask at the airport and on flights. 2) No, you don’t have to quarantine or test if you travel domestically, unless it is required by a state or territory. 3) No, you don’t have to take a erectile dysfunction test before departure to international destinations — not for the U.S.

At least. Check for your destination. 4) Yes, you have to test, even if vaccinated, three days before you return by air to the U.S..

5) Check lists of countries that will accept people from the U.S. Under certain conditions, including some destinations in Europe and the Caribbean. Scientists at the Walter Reed Army Institute of Research in Maryland are working on a treatment that could protect us against all erectile dysfunctiones.

In this 6/9/21 podcast at Scientific American, Emily Mullins interviews Dr. Kayvon Modjarrad who is leading the effort at Walter Reed to develop a so-called universal erectile dysfunction treatment. The treatment candidate that is being tested "combines nanoparticles from a blood protein called ferritin with erectile dysfunction proteins.” (Sorry, I’m not sure what that means either.) Modjarrad says 200 different combinations of spike proteins (a type of complex molecules that are found on the surface of all erectile dysfunctiones), types of ferritin, and ways to link them eventually yielded a treatment candidate that repeatedly provoked a strong immune response against SARS-CoV-1, erectile dysfunction and three of its variants in several species of animals ranging from rodents to sharks.

The treatment now is being tested in a small group of humans. €œIf it works and is safe, it could provide a foundation for a universal erectile dysfunction treatment,” Mullin says. You might enjoy, “A lexicon for the late kamagra,” by Jay Martel for The New Yorker (6/14/21).Here is our next installment of a new pop-up podcast miniseries that takes your ears into the deep sound of nature.

Host Jacob Job, an ecologist and audiophile, brings you inches away from a multitude of creatures, great and small, amid the sonic grandeur of nature. You may not be easily able to access these places amid the kamagra, but after you take this acoustic journey, you will be longing to get back outside.Strap on some headphones, find a quiet place and prepare to experience a thunderstorm—and a lazy day of waiting that storm out—inside the Boundary Waters Canoe Area Wilderness in northern Minnesota. Catch additional episodes in the series here.Listen to the mockingbird.

This bird makes a lot of noise. He copies all sorts of other bird songs, repeating, repeating, over and over, sometimes for hours. People must have thought this behavior was vaguely insulting to other birds, else we wouldn’t have named this one the mockingbird.

But now, listen more closely. You’ll hear that this virtuoso bird isn’t just copying other species’ tunes. He’s sampling them like a DJ and transposing, bending, tweaking them into his own quite deliberate form.

We can always tell it’s a mockingbird, not because of his copying, but because of his unique and specific way of composing music out of the material he hears in the world around him. It turned out that no humans had specifically articulated what these birds were doing, so my colleagues and I decided to delve deep into the mockingbird’s process, using the analytical tools of three different disciplines at once. Biology, music and neuroscience.

Our paper, published in early May in Frontiers in Psychology, argues that the mockingbird, one of the American birds with the most complex of songs, uses musical techniques familiar to composers from many kinds of human music. Our thesis is that mockingbirds use four compositional strategies to create their melodious song. Timbre change, pitch change, stretch and squeeze.

This allows the birds to transition from one sound to the next in ways that tickle the ears of both songbirds and people. We called this overall activity morphing, a phrase more familiar in imagery but that works for audio just the same. I’m a philosopher and musician, a person who does not usually work on scientific papers.

But I have written about scientific method many times, in popular books like Why Birds Sing, Bug Music and Survival of the Beautiful. All of these works put science in the context of culture, and most deal with the music of the animal world in one way or another. Long fascinated with the compositional methods of the mockingbird, I finally decided to dig deep into his sense of form and structure.

For that I needed the help of the greatest expert on listening to these birds, Dave Gammon, professor of biology at Elon University, who has studied the large population of mockers on his campus for many years now. He knows about 20 individual singing males by name, and can identify by ear most of the species each one imitates and which sounds are not imitations at all. €¦â€œWhen you listen to a mockingbird,” he says, “they repeat an individual phrase three or four times, and then they're doing something new, and then doing something new again.” “And after you've listened to them for just a minute,” Dave adds, “you've heard 20 to 25 different song phrases and they're still pulling out new ones.

If you listened to them for 10 minutes, you might be hard pressed to recognize anything that was repeated. The diversity is huge, and it's so loud, so conspicuous. I always felt they were composing with these diverse sounds, and that the organization of their song phrases might be perceived by humans.” [embedded content] Dave also insisted that we compare these songs to human music.

As someone who’s studied a lot of ethnomusicology, I was a bit afraid to do that. Immediately opens a can of worms!. Which human music?.

But I was impressed by his examples. Beethoven’s Fifth symphony for pitch change. The Tuvan throat-singing ensemble Huun-Huur-Tu for timbre change.

And Idina Menzel from Disney's Frozen II for stretch. All we needed is an example for squeeze, so I immediately thought we needed something from hip-hop, and I was sure Kendrick Lamar’s album Damn would have something. It really had everything, and the last piece on the album, “Duckworth,” sounded more mockingbirdesque than anything we found.

It didn’t win the Pulitzer Prize in composition for nothing. Okay, we had all these cool examples. Look, mockingbirds play with sounds just like humans do.

We call what humans do music, so why can’t the birds be making music?. “It’s all fine to propose the bird is doing something,” says lead author Tina Roeske of the Max Planck Institute for Empirical Aesthetics in Frankfurt. €œBut for science, we must analyze the data to show that our assertions fit the data.” She designed the algorithms that tested the paper’s hypotheses.

The statistics support our hypotheses, and that is what it takes for something to become science." She explains her methods. €œI'm the kind of scientist who just loves the really not so sexy stuff. I really just sit in front of the computer and listen to stuff and try to recognize structure.” She continues.

€œI mean, I love when I can show that a pattern that I perceive and perhaps find beautiful is truly there. It's like finding a proof that this is real. It's not a random thing.

It's really there. Start thinking about why is it that we also have this strong, subjective response to the mockingbird’s song. And that's really interesting.

And I don't think the analysis takes away from the beauty of the song itself.” In my books, I have long argued that for humans to best understand any phenomenon, we have to combine all the different forms of knowledge at our disposal. Poetry says one thing about mockingbirds, as in Walt Whitman’s “Out of the Cradle Endlessly Rocking.” Music says another. €œListen to the Mockingbird.” Ornithology says.

Here are all the species the mockingbird copies. Neuroscience says. Look at these numbers that prove our intuitions about pitch, timbre, stretch and squeeze are correct.

Each form of human knowledge has different criteria for truth. None reduces to the others or cancels each other out. But all can be impressed by beauty in a bird’s song, albeit in different ways.

Charles Darwin knew this full well, observing in The Descent of Man that birds have a natural aesthetic sense. €œThat’s why they evolved such beautiful songs,” I told a reporter at Elon University. €œIt takes the full range of human forms of knowledge to figure out what they are up to.

Not one of us could have done this research alone." The paper, and all its data, are free to view in the open-access journal Frontiers in Psychology. And this video version demonstrates how this bird makes such special music out of the songs of so many other birds in his habitat. If we take its music more seriously, our own sense of music expands to care just a little more about the world of nature that surrounds us and made us possible in the first place.During a congressional hearing last week, Republican Representative Louie Gohmert of Texas asked a U.S.

Forest Service official if her organization or the Bureau of Land Management could change the orbit of the moon or Earth to reverse the effects of human-caused climate change. That seems like a perfectly reasonable idea, doesn’t it?. Let’s do it.

First, we must take stock of what we have—the givens in what will be our equation for moving Earth. Our planet orbits the sun at an average distance of 149.6 million kilometers, and it soaks up enough sunlight to have an average temperature of about 15 degrees Celsius. The latter figure is, however, an increase of slightly more than one degree C from Earth’s typical temperature across the past century.

In short, this world is running a low-grade fever. According to current consensus estimates, that fever is likely to get much worse if left unchecked, raising Earth’s average temperature by another one degree C by the 2060s. Such an increase would render some presently people-packed parts of the planet effectively uninhabitable and threaten the sustainability of global civilization as we know it.

Radiative equilibrium, the balance between incoming energy from the sun’s rays and energy emitted from Earth, is key to our understanding of our planet’s changing temperature, says Britt Scharringhausen, a planetary astronomer at Beloit College. It is described in the following equation, as scribbled out by Scharringhausen. Page from planetary astronomer Britt Scharringhausen’s lab notebook shows a handwritten equation for determining a planet’s radiative equilibrium (highlighted in green), which sets its effective temperature.

Credit. Britt Scharringhausen Here, Teq is Earth’s temperature, T☉ is the sun’s temperature, R☉ is the sun’s radius, X is the distance to the sun, and A is Earth’s albedo, or reflectivity.* Albedo measures how well our planet reflects solar energy, where 0 would be perfect absorption and 1 would be perfect reflection. There is a connection between climate change and albedo.

Snow and ice, for instance, have a high albedo, reflecting up to 90 percent of the sunlight that hits them back to outer space. Anthropogenic warming causes snow and ice caps to melt, which can make Earth’s albedo decrease. That, in turn, eventually leads to a higher average planetary temperature.

Some variables in this equation are changing naturally. Our star is very slowly swelling and brightening, becoming slightly larger and more luminous as it ages. Ethan Siegel, a theoretical astrophysicist and science writer, says that while it will take the sun on the order of 100 million years to increase in luminosity by 1 percent, our greenhouse-gas-emitting global civilization is projected to increase the solar energy retained by Earth by 1 percent over the next few hundred to 1,000 years.

To make Earth cooler, we need to decrease a variable on the right side of the equation. We can’t easily lower the sun’s temperature or radius—and clearly meaningful reductions to our heat-trapping, albedo-shifting greenhouse gas emissions are out of the question. So let’s take Representative Gohmert’s advice and simply increase X, the distance to the sun.

All we have to do is find a way to move all 5.972 septillion kilograms of Earth’s mass farther away from our star. Easy, right?. By Scharringhausen’s calculations, a three-degree-C decrease in temperature to counteract current and near-future anthropogenic warming would require us to move our planet an additional three million kilometers from the sun.

Using another back-of-the-envelope calculation, Scharringhausen finds that 5 x 1031 joules could push all 5,972,000,000,000,000,000,000,000 kilograms of Earth’s mass three million kilometers out from its present orbit. These numbers present challenges for Representative Gohmert’s plan because annual global electricity production is around 1019 joules, or 0.0000000000002 percent of what we’d need to move the globe. That’s also assuming we can apply all that energy to Earth at 100 percent efficiency, which, thanks to the laws of thermodynamics, is physically impossible.

Setting aside such particulars, we haven’t addressed what form this applied energy would take. There is the literal nuclear option. One method that scientists have proposed to move an asteroid is to detonate a nuclear bomb near it, Scharringhausen says.

€œIt will basically vaporize part of the asteroid, and that escaping rock vapor acts like rocket exhaust and will push the asteroid along,” she explains. Scaled up, such a mechanism could, in principle, provide enough oomph to shift a planet’s orbit. Still, it would take a billion times more nuclear explosions than we have ever set off to move Earth the required distance, or the equivalent of dropping an atomic bomb every second for 500 years, according to Geza Gyuk, director of astronomy at the Adler Planetarium in Chicago.

The strategy of constantly detonating nuclear bombs near Earth’s surface with the goal of vaporizing parts of it to act as rocket exhaust also has several drawbacks. For our purposes, the most notable deleterious effect is that the blasts themselves would heat up the planet, counteracting the stated goal of reversing global warming. A gentler option would be to siphon off the energy of other celestial objects, such as passing asteroids or comets, by engineering close planetary flybys.

This technique is regularly used in reverse, with great success, by spacecraft that boost their speed by passing close to a planet to steal a portion of its orbital energy. For moving our planet, the issue with the method is scale, Siegel says. The total mass of the asteroid belt is only 4 to 5 percent of that of the moon, or 0.05 to 0.06 percent of that of Earth.

Using the mass of the entire asteroid belt in flybys would migrate Earth away from the sun by less than 748,000 kilometers, or a quarter of the distance we’d need, he says. And a single off-course collision with our planet would spark destruction approaching that caused by the asteroid impact that eradicated the dinosaurs in a global mass extinction. Fortunately, we have a much more massive space rock sitting in our backyard.

The moon itself. Could we “cut” the gravitational string connecting the moon to the Earth, thereby slingshotting our planet into a wider orbit?. Not in any way that we’re capable of doing today, Siegel says, and the consequences would be disastrous.

Besides having greatly reduced tides, a moonless Earth would have much darker nights, shorter days and extreme, unpredictable seasons because of a destabilized axis of rotation. What if instead of getting rid of our natural satellite altogether, we only change its orbit around Earth?. Increasing the radius of the moon’s orbit by 10 percent would affect Earth’s own trajectory around the sun in the long term, says Matteo Ceriotti, a rocket scientist at the University of Glasgow’s James Watt School of Engineering.

We could extract and accelerate material off the moon, Ceriotti says. Using a 100-gigawatt laser, or one with about the power capacity of every single wind turbine in the U.S., it would take 300 trillion years to lift sufficient amounts of material from the lunar surface. There is always the aforementioned nuclear option, too, which could be used to move the moon rather than Earth.

Another, less messy choice would be to manually extract lunar material with conventional rockets. €œIf we were able to build a spaceport on the moon and build a rocket equivalent to SpaceX’s Falcon Heavy to lift off moon material into deep space, we would need 7 x 1016 launches,” Ceriotti says. That’s 70,000 trillion rocket launches.

For comparison, during the entirety of the space age, humankind has only managed to achieve 70,780 launches, and more than half of them did not leave Earth’s atmosphere. Humans could add a twist to the use of asteroids in the flyby idea and instead put them on a collision course with the moon, Gyuk says. We would need kilometer-sized comets to crash into the moon every second for a couple of hundred years to make a substantial difference.

Again, though, an off-course projectile could cause a planetary mass extinction event. Because of the magnitude of the change necessary to increase the Earth’s orbit, any intervention would probably need to last for many millions of years at minimum, which raises an unexpected sociological issue, Gyuk says. We don’t have precedent for planning across such vast timescales.

And in fact, no civilization in human history has endured more than a mere few thousand years. Finally, even if humans managed to alter our planet’s orbit using any of these methods, they wouldn’t be able to rest easy, Siegel says. €œIf we even somehow could make this enormous change in Earth’s orbit,” he says, “it doesn’t absolve us from the responsibility that we’ll keep needing to make this change as long as we keep increasing the greenhouse gas concentration in our atmosphere.” To my ears, that sounds like a stirring endorsement of our fossil-fuel-addicted status quo!.

We should immediately prioritize pouring all our energy into changing Earth’s orbit, starting now and lasting forever.

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As we age, our kamagra buy online canada hearing and balance naturally decline kamagra oral jelly canada. More than one in four Americans age 65 or older falls every year, the Centers for Disease Control and Prevention (CDC) reports. Even if you’re not hurt, a tumble is frightening. People tend to retreat to kamagra oral jelly canada their chairs, which sets off a bad cycle.

You move less, you become weaker, and are more likely to fall again. Here’s a simple test of your risk. Stand on one kamagra oral jelly canada leg. In a small study of women in their 70s, the chance of a hip fracture dropped by 5 percent for every second they could stand on one leg with their eyes open.

Hearing and balance. How they're kamagra oral jelly canada connected How does hearing fit in?. What you hear (and don’t hear) directly affects your balance, according to a research overview led by Anat Lubetzky, PhD, assistant professor in the Physical Therapy Department at New York University, with a team at New York Eye and Ear Infirmary. This is especially important if your balance isn’t the best.

€œMost of kamagra oral jelly canada us in the field believe that people with poor balance benefit a lot from auditory cues,” Timothy Hullar, MD, a professor of otolaryngology at Oregon Health and Science University, told me. Hearing loss increases the risk of falls I know this from experience. I have hearing loss, and I’ve fallen twice on hikes. I have kamagra oral jelly canada a bit of reputation with my hiking group.

A few years ago, I tripped on a small stone—and fell over what looked like a cliff. Once I landed, I recall a flood of relief. As I looked up at the horrified faces of my hiking companions, I kamagra oral jelly canada saw a large boulder with a sharp edge coming my way. I had dislodged it.

It was worse for them than for me. I recall thinking, “So that kamagra oral jelly canada was my life!. Maybe there is a heaven.” The rock landed on my neck and because it wasn’t my time to die, it only left a scratch. Even mild hearing loss can affect fall risk My hearing loss is mild—but that counts.

A 25-decibel hearing loss—equivalent to kamagra oral jelly canada going from normal to mild hearing loss—triples your chance of falling according to a study of people aged 40 to 69. That’s when hearing loss often first develops and you’re less likely to guard against falls. Another study, from a team at the University of Michigan, analyzed data on nearly 115,000 seniors newly diagnosed with hearing loss (but otherwise healthy). It found that 13 percent had an injury in a fall kamagra oral jelly canada within three years, compared to 7.5 percent of the general population their age.

Reasons hearing loss may increase risk of falling 1. Hearing taps your brain reserves. If you’re concentrating harder to interpret sound, you may have kamagra oral jelly canada less mental resource available for balance. "Gait and balance are things most people take for granted, but they are actually very cognitively demanding," says otologist Frank Lin, MD, PhD, from the Johns Hopkins School of Medicine.

2. Aging affects kamagra oral jelly canada both hearing and balance. Age-related hearing loss may be linked to declines in the vestibular sense, a set of receptors in your inner ear, which comes into play whenever you move your head. It’s also activated by the downward force of gravity, giving you a sense of where you are.

Your grounding kamagra oral jelly canada. If you’ve ever had an of the inner ear, you’ll recall you were dizzy. However, you don’t need to be dizzy to have vestibular issues. Some evidence suggests the vestibular sense may begin to decline at about the age of kamagra oral jelly canada 40.

More than a third of all Americans older than 40 are unable to pass a balance test—standing on foam with their eyes closed—that is linked to a higher risk of falling. (To test your balance, check out this test.) Loud low-frequency sounds (think pounding drums) may damage the inner ear, over time affecting our balance (and hearing). To be clear, age-related hearing loss and kamagra oral jelly canada inner ear problems are not the same thing and don't always occur simultaneously. €œMany people with vestibular disorders have excellent hearing and not all people with hearing loss will have vestibular weakness,” Lubetzky told me.

3. Sounds help kamagra oral jelly canada us balance. If you try to balance on one leg in a yoga class, for example, your teacher will tell you to stare at one spot. Stable sounds may work the same way, Lubetzky explained, as a kind of “auditory anchor.” But you have to hear them.

This process may be especially important if you have kamagra oral jelly canada hearing loss. For example, when people with hearing loss hear stable background sounds, their posture improves. Balance arises from the contributions of several senses. Vision, the coordination between our head and our eyes, our muscle and joint coordination—and, kamagra oral jelly canada possibly, what we hear.

4. Hearing loss is linked to mood. People may be less alert when caught up in a fog of misery or kamagra oral jelly canada anxiety. Hearing loss increases the risk of depression.

Depression is linked to more falls and those falls tend to deepen depression in another classic bad cycle. How to prevent falls kamagra oral jelly canada Keep moving. Walking, balance exercises and resistance exercises to strengthen muscles can keep seniors on their feet. You can build strength and improve your balance in as little as two 15-20 minute sessions a week, Finnish researchers report.

Staying active and exercising regularlyhelps keep your sense of balance healthy kamagra oral jelly canada. Tai-chi classes, an ancient Chinese practice, are popular among older people. An hour of tai chi from one to three times a week can cut the risk of a bad fall by half, according to a review of 10 randomized controlled trials. The National Council kamagra oral jelly canada on Aging recommends a program called “Tai Chi for arthritis” for older people.

You may feel more comfortable in a tai chi (or any kind of class) if you can easily hear the teacher and converse with other students. Or consider a water aerobics class. If you do fall, strength-training will make you less to break a kamagra oral jelly canada bone. Working out with resistance bands or weights or doing resistance exercises makes your bones denser and therefore stronger.

Squats, for example, built bone mass in a group of post-menopausal women with deteriorating bones in one study. When did kamagra oral jelly canada you have your last eye checkup?. Tint-changing lenses and bifocals are less appropriate for older people and you may need to change prescriptions. Fall proof your home.

Have you done a kamagra oral jelly canada walk-through, making sure that the bottom and top of all stairs are well-lit and the carpeting and railing secure?. Secure any loose carpeting, especially in hallways. Install grab bars near the toilet and bath or shower. The CDC kamagra oral jelly canada offers a home assessment checklist.

Consider physical therapy, if you or your older loved one have trouble walking or getting up from a chair. Do hearing aids help prevent falls?. The University of Michigan study found that a first-time hearing aid kamagra oral jelly canada cut the risk of a fall-related injury by 13 percentage points in the next three years. Research has not yet supported the idea that people are more stable when wearing hearing aids.

But it’s possible that treating sites “hearing loss (with hearing aids or other implants) will also serve as a type of 'balance aid' like a cane," says otolaryngologist Maura Cosetti, MD, co-author of the New York Eye and Ear Infirmary study. The bottom line. If you’re concerned about your balance and you have hearing kamagra oral jelly canada loss, hearing better may make a difference.The popularity of headphones and earbuds has soared—and the market is projected to grow 20 percent a year in the next five years. But there’s a problem.

Your children, teens or young adults could easily be putting their hearing at risk. Uncertain future for children's hearing During the kamagra, many kids usedheadphones to help with remote learning.Experts kamagra oral jelly canada advise parents talk to kids ​​​​aboutlistening at a safe volume and takingbreaks. Loud sounds are bad for us. As retired audiologist Jan Mayes told Healthy Hearing, if small children use headphones, they might have trouble understanding speech in noisy places as early as their teens to early twenties.

By the time these children are in their mid-40s, they might kamagra oral jelly canada be as hard of hearing as their grandparents are today, in their 70s and 80s, observes Dr. Daniel Fink, an internist and board chair of the Quiet Coalition. Hearing loss already a problem More than 1 out of every 10 kids in the US (ages 6 to 19)—and nearly 1 out of 5 of adults under 70—already have suffered permanent damage to their hearing from noise, the Centers for Disease Control and Prevention (CDC) reports. This is kamagra oral jelly canada known as noise-induced hearing loss (NIHL), which is highly preventable.

About half of the population between the ages of 12 and 35 is at risk of damaged hearing because of loud sounds, according to the World Health Organization. Headphone and earbuds play a big role in this. When researchers compared hearing exams for a large cross-section of adults in Norway at two points, 20 years apart, they confirmed that those who reported using personal kamagra oral jelly canada music devices at high volume had worse hearing. More kids with tinnitus Tinnitus—typically ringing in the ears—is an early symptom.

There’s been a “mad influx” of kids reporting the problem in the last year, said audiologist Lisa Vaughan of Cook Children's Health Care System in Fort Worth, about what her clinic has been seeing. This all adds kamagra oral jelly canada up. Noise damages hearing and leads to hearing loss and tinnitus. Meanwhile, over time, hearing loss increases your risk of social isolation, falls and accidents and, in later life, cognitive decline and depression.

How loud noises from headphones hurt your ears It can be hard to kamagra oral jelly canada know how loud is too loud when listening via headphones. On an ordinary music device, you might hear sounds as high as 94-110 dBA. Less than two minutes at 110 dBA can damage anyone’s ears. Listening to these blasts—or at more reasonable volumes but for too long—leaves its kamagra oral jelly canada mark.

It can damage the hair cells in the ears that transmit sound to the brain. It can also interrupt the connection between those cells and nerve cells, and the auditory nerve may degenerate. What parents kamagra oral jelly canada can do. Talk to your kids and keep the conversation ongoing Depending on your child’s age, explain the problem.

Even a volume they enjoy can damage their ears. It doesn’t kamagra oral jelly canada have to “hurt” to be bad for them. Also, hearing loss can come suddenly. They might not have any warning.

Have a talk about what damaged kamagra oral jelly canada hearing actually feels like. Explain that they might hear weird buzzing or ringing or other noises (tinnitus) when they’re trying to concentrate on something else—even the music they love. Tinnitus is also often accompanied by a feeling of pressure or fullness. Children sometimes think other people can hear the ringing in their ears so make sure they understand the kamagra oral jelly canada concept.

They might become sensitive to noise and have spells when everything is too loud (hyperacusis) and the clatter of dishes in another room gives them pain. If they develop hearing loss, that doesn’t just mean some sounds are softer. Explain that with hearing loss, it can be hard to understand what people are saying to you, and you can feel left out kamagra oral jelly canada in groups. You might even get laughed at.

Although hearing aids help enormously, but they don’t give you back exactly the hearing you had before, and they don’t usually entirely banish hyperacusis or tinnitus. The bottom kamagra oral jelly canada line. Listening to loud music might feel cool, but hearing loss is a big price to pay. Volume limits help, but kids often know workarounds If your child is really resistant, set up a time when he or she can talk to someone with damaged hearing.

Maybe your son is an aspiring pop kamagra oral jelly canada music star. His guitar teacher can explain that many musicians live with tinnitus and hyperacusis. Set volume limits together. You want a tween kamagra oral jelly canada or teen to be on your side.

Although a parent can set a max on the volume on both Android and iPhones, a tech-savvy child can get around them and also easily find apps online that help increase the volume even further. "Even when young, kids know how to deactivate any safe listening settings their parents might set. I sat with my kids while kamagra oral jelly canada they set [a safe max] on their own device. We talked about how obviously they could switch them off and listen unsafely if they wanted to.

It was another opportunity for us to talk about protecting their hearing health," Mayes said. Aim for below 50% volume Some headphones and earbuds advertise that they limit volume—but kamagra oral jelly canada they don’t always deliver on that promise. Also, the industry standard maximum volume, 85 dBA (equal to a lawnmower or leaf blower), isn’t a safe bet. That number comes from regulations to protect adults on the job, in factories or airports and the like.

If you don’t want your child to run the risk of hearing loss, 70 dBA would be more reasonable, a kamagra oral jelly canada 2018 WHO report and 2019 paper argued. That’s typically about 50 percent volume on your device. To help your child understand these numbers, here are the average decibel ratings of some familiar sounds. Normal conversation kamagra oral jelly canada.

50-60 dBA and 60-70 dBA with background noise or shouting Movie theater. 74-104 dBA Motorcycles and dirt bikes. 80-110 dBA Music through headphones at maximum volume, sporting events, kamagra oral jelly canada and concerts. 94-110 dBA Sirens.

110-129 dBA Fireworks show. 140-160 dBA People who use a personal audio system for more than an hour a day at more than kamagra oral jelly canada 50 percent volume for more than five years are risking their ears, Fink told Healthy Hearing. Other risks like tinnitus, hyperacusis or trouble in noisy situations can happen sooner. “The goal is to listen well below 70 dBA to give a margin of safety, especially for children's ears.

This means listening as low as comfortable below 50 percent volume setting,” kamagra oral jelly canada Mayes said. Listening breaks are a great idea Teach your children to take listening breaks. The damage from loud noise is cumulative. Even a break every hour will give the hair cells in kamagra oral jelly canada the inner ear a rest.

One strategy. A rule that they must take the headphones off if they go to the kitchen or bathroom. Consider noise-cancelling headphones, rather than earbuds. This helps reduce background volume so they're less tempted to turn up the volume to mask other sounds.

Teach your children NOT to turn up the volume in loud places. If they’re often using their headphones in noisy places a noise-cancelling model is essential. Teach your children to take listening breaks. The damage from loud noise is cumulative.

Even a break every hour will give the hair cells in the inner ear a rest.

Hearing loss increases the risk of falls I know this from experience kamagra canada buy. I have hearing loss, and I’ve fallen twice on hikes. I have a bit of reputation with my hiking group.

A few kamagra canada buy years ago, I tripped on a small stone—and fell over what looked like a cliff. Once I landed, I recall a flood of relief. As I looked up at the horrified faces of my hiking companions, I saw a large boulder with a sharp edge coming my way.

I had dislodged it kamagra canada buy. It was worse for them than for me. I recall thinking, “So that was my life!.

Maybe there is a heaven.” The rock landed on my neck and because it wasn’t my time to die, it only left a scratch kamagra canada buy. Even mild hearing loss can affect fall risk My hearing loss is mild—but that counts. A 25-decibel hearing loss—equivalent to going from normal to mild hearing loss—triples your chance of falling according to a study of people aged 40 to 69.

That’s when hearing loss kamagra canada buy often first develops and you’re less likely to guard against falls. Another study, from a team at the University of Michigan, analyzed data on nearly 115,000 seniors newly diagnosed with hearing loss (but otherwise healthy). It found that 13 percent had an injury in a fall within three years, compared to 7.5 percent of the general population their age.

Reasons hearing kamagra canada buy loss may increase risk of falling 1. Hearing taps your brain reserves. If you’re concentrating harder to interpret sound, you may have less mental resource available for balance.

"Gait and balance are things most people take for granted, but they are actually very cognitively demanding," says otologist Frank Lin, kamagra canada buy MD, PhD, from the Johns Hopkins School of Medicine. 2. Aging affects both hearing and balance.

Age-related hearing loss may kamagra canada buy be linked to declines in the vestibular sense, a set of receptors in your inner ear, which comes into play whenever you move your head. It’s also activated by the downward force of gravity, giving you a sense of where you are. Your grounding.

If you’ve kamagra canada buy ever had an of the inner ear, you’ll recall you were dizzy. However, you don’t need to be dizzy to have vestibular issues. Some evidence suggests the vestibular sense may begin to decline at about the age of 40.

More than a third of all Americans older than 40 are unable to pass a balance test—standing on foam with their eyes closed—that is linked to a higher risk kamagra canada buy of falling. (To test your balance, check out this test.) Loud low-frequency sounds (think pounding drums) may damage the inner ear, over time affecting our balance (and hearing). To be clear, age-related hearing loss and inner ear problems are not the same thing and don't always occur simultaneously.

€œMany people with kamagra canada buy vestibular disorders have excellent hearing and not all people with hearing loss will have vestibular weakness,” Lubetzky told me. 3. Sounds help us balance.

If you try to balance on one leg in a kamagra canada buy yoga class, for example, your teacher will tell you to stare at one spot. Stable sounds may work the same way, Lubetzky explained, as a kind of “auditory anchor.” But you have to hear them. This process may be especially important if you have hearing loss.

For example, when people with hearing loss hear kamagra canada buy stable background sounds, their posture improves. Balance arises from the contributions of several senses. Vision, the coordination between our head and our eyes, our muscle and joint coordination—and, possibly, what we hear.

4. Hearing loss is linked to mood. People may be less alert when caught up in a fog of misery or anxiety.

Hearing loss increases the risk of depression. Depression is linked to more falls and those falls tend to deepen depression in another classic bad cycle. How to prevent falls Keep moving.

Walking, balance exercises and resistance exercises to strengthen muscles can keep seniors on their feet. You can build strength and improve your balance in as little as two 15-20 minute sessions a week, Finnish researchers report. Staying active and exercising regularlyhelps keep your sense of balance healthy.

Tai-chi classes, an ancient Chinese practice, are popular among older people. An hour of tai chi from one to three times a week can cut the risk of a bad fall by half, according to a review of 10 randomized controlled trials. The National Council on Aging recommends a program called “Tai Chi for arthritis” for older people.

You may feel more comfortable in a tai chi (or any kind of class) if you can easily hear the teacher and converse with other students. Or consider a water aerobics class. If you do fall, strength-training will make you less to break a bone.

Working out with resistance bands or weights or doing resistance exercises makes your bones denser and therefore stronger. Squats, for example, built bone mass in a group of post-menopausal women with deteriorating bones in one study. When did you have your last eye checkup?.

Tint-changing lenses and bifocals are less appropriate for older people and you may need to change prescriptions. Fall proof your home. Have you done a walk-through, making sure that the bottom and top of all stairs are well-lit and the carpeting and railing secure?.

Secure any loose carpeting, especially in hallways. Install grab bars near the toilet and bath or shower. The CDC offers a home assessment checklist.

Consider physical therapy, if you or your older loved one have trouble walking or getting up from a chair. Do hearing aids help prevent falls?. The University of Michigan study found that a first-time hearing aid cut the risk of a fall-related injury by 13 percentage points in the next three years.

Research has not yet supported the idea that people are more stable when wearing hearing aids. But it’s possible that treating “hearing loss (with hearing aids or other implants) will also serve as a type of 'balance aid' like a cane," says otolaryngologist Maura Cosetti, MD, co-author of the New York Eye and Ear Infirmary study. The bottom line.

If you’re concerned about your balance and you have hearing loss, hearing better may make a difference.The popularity of headphones and earbuds has soared—and the market is projected to grow 20 percent a year in the next five years. But there’s a problem. Your children, teens or young adults could easily be putting their hearing at risk.

Uncertain future for children's hearing During the kamagra, many kids usedheadphones to help with remote learning.Experts advise parents talk to kids ​​​​aboutlistening at a safe volume and takingbreaks. Loud sounds are bad for us. As retired audiologist Jan Mayes told Healthy Hearing, if small children use headphones, they might have trouble understanding speech in noisy places as early as their teens to early twenties.

By the time these children are in their mid-40s, they might be as hard of hearing as their grandparents are today, in their 70s and 80s, observes Dr. Daniel Fink, an internist and board chair of the Quiet Coalition. Hearing loss already a problem More than 1 out of every 10 kids in the US (ages 6 to 19)—and nearly 1 out of 5 of adults under 70—already have suffered permanent damage to their hearing from noise, the Centers for Disease Control and Prevention (CDC) reports.

This is known as noise-induced hearing loss (NIHL), which is highly preventable. About half of the population between the ages of 12 and 35 is at risk of damaged hearing because of loud sounds, according to the World Health Organization. Headphone and earbuds play a big role in this.

When researchers compared hearing exams for a large cross-section of adults in Norway at two points, 20 years apart, they confirmed that those who reported using personal music devices at high volume had worse hearing. More kids with tinnitus Tinnitus—typically ringing in the ears—is an early symptom. There’s been a “mad influx” of kids reporting the problem in the last year, said audiologist Lisa Vaughan of Cook Children's Health Care System in Fort Worth, about what her clinic has been seeing.

This all adds up. Noise damages hearing and leads to hearing loss and tinnitus. Meanwhile, over time, hearing loss increases your risk of social isolation, falls and accidents and, in later life, cognitive decline and depression.

How loud noises from headphones hurt your ears It can be hard to know how loud is too loud when listening via headphones. On an ordinary music device, you might hear sounds as high as 94-110 dBA. Less than two minutes at 110 dBA can damage anyone’s ears.

Listening to these blasts—or at more reasonable volumes but for too long—leaves its mark. It can damage the hair cells in the ears that transmit sound to the brain. It can also interrupt the connection between those cells and nerve cells, and the auditory nerve may degenerate.

What parents can do. Talk to your kids and keep the conversation ongoing Depending on your child’s age, explain the problem. Even a volume they enjoy can damage their ears.

It doesn’t have to “hurt” to be bad for them. Also, hearing loss can come suddenly. They might not have any warning.

Have a talk about what damaged hearing actually feels like. Explain that they might hear weird buzzing or ringing or other noises (tinnitus) when they’re trying to concentrate on something else—even the music they love. Tinnitus is also often accompanied by a feeling of pressure or fullness.

Children sometimes think other people can hear the ringing in their ears so make sure they understand the concept. They might become sensitive to noise and have spells when everything is too loud (hyperacusis) and the clatter of dishes in another room gives them pain. If they develop hearing loss, that doesn’t just mean some sounds are softer.

Explain that with hearing loss, it can be hard to understand what people are saying to you, and you can feel left out in groups. You might even get laughed at. Although hearing aids help enormously, but they don’t give you back exactly the hearing you had before, and they don’t usually entirely banish hyperacusis or tinnitus.

The bottom line. Listening to loud music might feel cool, but hearing loss is a big price to pay. Volume limits help, but kids often know workarounds If your child is really resistant, set up a time when he or she can talk to someone with damaged hearing.

Maybe your son is an aspiring pop music star. His guitar teacher can explain that many musicians live with tinnitus and hyperacusis. Set volume limits together.

You want a tween or teen to be on your side. Although a parent can set a max on the volume on both Android and iPhones, a tech-savvy child can get around them and also easily find apps online that help increase the volume even further. "Even when young, kids know how to deactivate any safe listening settings their parents might set.

I sat with my kids while they set [a safe max] on their own device. We talked about how obviously they could switch them off and listen unsafely if they wanted to. It was another opportunity for us to talk about protecting their hearing health," Mayes said.

Aim for below 50% volume Some headphones and earbuds advertise that they limit volume—but they don’t always deliver on that promise. Also, the industry standard maximum volume, 85 dBA (equal to a lawnmower or leaf blower), isn’t a safe bet. That number comes from regulations to protect adults on the job, in factories or airports and the like.

If you don’t want your child to run the risk of hearing loss, 70 dBA would be more reasonable, a 2018 WHO report and 2019 paper argued. That’s typically about 50 percent volume on your device. To help your child understand these numbers, here are the average decibel ratings of some familiar sounds.

Normal conversation. 50-60 dBA and 60-70 dBA with background noise or shouting Movie theater. 74-104 dBA Motorcycles and dirt bikes.

80-110 dBA Music through headphones at maximum volume, sporting events, and concerts. 94-110 dBA Sirens. 110-129 dBA Fireworks show.

140-160 dBA People who use a personal audio system for more than an hour a day at more than 50 percent volume for more than five years are risking their ears, Fink told Healthy Hearing. Other risks like tinnitus, hyperacusis or trouble in noisy situations can happen sooner. “The goal is to listen well below 70 dBA to give a margin of safety, especially for children's ears.

This means listening as low as comfortable below 50 percent volume setting,” Mayes said. Listening breaks are a great idea Teach your children to take listening breaks. The damage from loud noise is cumulative.

Even a break every hour will give the hair cells in the inner ear a rest. One strategy. A rule that they must take the headphones off if they go to the kitchen or bathroom.

Consider noise-cancelling headphones, rather than earbuds. This helps reduce background volume so they're less tempted to turn up the volume to mask other sounds. Teach your children NOT to turn up the volume in loud places.

If they’re often using their headphones in noisy places a noise-cancelling model is essential. Teach your children to take listening breaks. The damage from loud noise is cumulative.

Even a break every hour will give the hair cells in the inner ear a rest. One strategy. A rule that they must take the headphones off if they go to the kitchen or bathroom.

Don’t use headphones for sleeping overnight (napping on transit might be okay at the right volume). Test your child’s hearing at least every three years. Also ask your child to report any symptoms—ringing, muffling, fluttering, thumping, sensitivity, distortion, pain— even if they don’t last.

Temporary symptoms mean they might return and become permanent. They should also report if they ever feel that they can’t understand what people are saying. “Looking for safe headphones or a safe personal audio system/personal music player/personal listening device is like looking for a safe cigarette.

You won’t find one," Fink said. "Your ears are too precious to damage with personal audio systems. People survived for millennia without a personal sound track for their lives and you can too.

What side effects may I notice from Kamagra?

Side effects that you should report to your doctor or health care professional as soon as possible:

Side effects that usually do not require medical attention (report to your doctor or health care professional if they continue or are bothersome):

This list may not describe all possible side effects.

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Credit important source cialis kamagra. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the cialis kamagra most common form of permanent alopecia in this population.

The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of cialis kamagra Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over.

The prevalence of those with fibroids was cialis kamagra compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids.

The findings translate to a cialis kamagra fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause cialis kamagra of the link between the two conditions remains unclear,” she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other cialis kamagra disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other cialis kamagra authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit.

The New England Journal of Medicine Share Fast Facts This study clears up cialis kamagra how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, cialis kamagra a new study led by Johns Hopkins Kimmel Cancer Center researchers shows.

The finding, published in the Dec. 21 New England cialis kamagra Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success in treating some types cialis kamagra of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma.

The mutational cialis kamagra burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer cialis kamagra types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data cialis kamagra on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation.

The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could cialis kamagra be explained by the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of cialis kamagra those things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, cialis kamagra a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors.

However, he explains, this cancer type is often caused by a kamagra, which seems to encourage a strong immune response despite the cancer’s lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings cialis kamagra could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried.

Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in cialis kamagra individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding cialis kamagra from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Credit. IStock Share Fast Facts New @HopkinsMedicine study finds African-American women with common form of hair loss at increased risk of uterine fibroids - Click to Tweet New study in @JAMADerm shows most common form of alopecia (hair loss) in African-American women associated with higher risks of uterine fibroids - Click to Tweet In a study of medical records gathered on hundreds of thousands of African-American women, Johns Hopkins researchers say they have evidence that women with a common form of hair loss have an increased chance of developing uterine leiomyomas, or fibroids.In a report on the research, published in the December 27 issue of JAMA Dermatology, the researchers call on physicians who treat women with central centrifugal cicatricial alopecia (CCCA) to make patients aware that they may be at increased risk for fibroids and should be screened for the condition, particularly if they have symptoms such as heavy bleeding and pain. CCCA predominantly affects black women and is the most common form of permanent alopecia in this population.

The excess scar tissue that forms as a result of this type of hair loss may also explain the higher risk for uterine fibroids, which are characterized by fibrous growths in the lining of the womb. Crystal Aguh, M.D., assistant professor of dermatology at the Johns Hopkins University School of Medicine, says the scarring associated with CCCA is similar to the scarring associated with excess fibrous tissue elsewhere in the body, a situation that may explain why women with this type of hair loss are at a higher risk for fibroids.People of African descent, she notes, are more prone to develop other disorders of abnormal scarring, termed fibroproliferative disorders, such as keloids (a type of raised scar after trauma), scleroderma (an autoimmune disorder marked by thickening of the skin as well as internal organs), some types of lupus and clogged arteries. During a four-year period from 2013-2017, the researchers analyzed patient data from the Johns Hopkins electronic medical record system (Epic) of 487,104 black women ages 18 and over.

The prevalence of those with fibroids was compared in patients with and without CCCA. Overall, the researchers found that 13.9 percent of women with CCCA also had a history of uterine fibroids compared to only 3.3 percent of black women without the condition. In absolute numbers, out of the 486,000 women who were reviewed, 16,212 had fibroids.Within that population, 447 had CCCA, of which 62 had fibroids.

The findings translate to a fivefold increased risk of uterine fibroids in women with CCCA, compared to age, sex and race matched controls. Aguh cautions that their study does not suggest any cause and effect relationship, or prove a common cause for both conditions. €œThe cause of the link between the two conditions remains unclear,” she says.

However, the association was strong enough, she adds, to recommend that physicians and patients be made aware of it. Women with this type of scarring alopecia should be screened not only for fibroids, but also for other disorders associated with excess fibrous tissue, Aguh says. An estimated 70 percent of white women and between 80 and 90 percent of African-American women will develop fibroids by age 50, according to the NIH, and while CCCA is likely underdiagnosed, some estimates report a prevalence of rates as high as 17 percent of black women having this condition.

The other authors on this paper were Ginette A. Okoye, M.D. Of Johns Hopkins and Yemisi Dina of Meharry Medical College.Credit.

The New England Journal of Medicine Share Fast Facts This study clears up how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types. - Click to Tweet The number of mutations in a tumor’s DNA is a good predictor of whether it will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors. - Click to Tweet The “mutational burden,” or the number of mutations present in a tumor’s DNA, is a good predictor of whether that cancer type will respond to a class of cancer immunotherapy drugs known as checkpoint inhibitors, a new study led by Johns Hopkins Kimmel Cancer Center researchers shows.

The finding, published in the Dec. 21 New England Journal of Medicine, could be used to guide future clinical trials for these drugs. Checkpoint inhibitors are a relatively new class of drug that helps the immune system recognize cancer by interfering with mechanisms cancer cells use to hide from immune cells.

As a result, the drugs cause the immune system to fight cancer in the same way that it would fight an . These medicines have had remarkable success in treating some types of cancers that historically have had poor prognoses, such as advanced melanoma and lung cancer. However, these therapies have had little effect on other deadly cancer types, such as pancreatic cancer and glioblastoma.

The mutational burden of certain tumor types has previously been proposed as an explanation for why certain cancers respond better than others to immune checkpoint inhibitors says study leader Mark Yarchoan, M.D., chief medical oncology fellow. Work by Dung Le, M.D., associate professor of oncology, and other researchers at the Johns Hopkins Kimmel Cancer Center and its Bloomberg~Kimmel Cancer Institute for Cancer Immunotherapy showed that colon cancers that carry a high number of mutations are more likely to respond to checkpoint inhibitors than those that have fewer mutations. However, exactly how big an effect the mutational burden has on outcomes to immune checkpoint inhibitors across many different cancer types was unclear.

To investigate this question, Yarchoan and colleagues Alexander Hopkins, Ph.D., research fellow, and Elizabeth Jaffee, M.D., co-director of the Skip Viragh Center for Pancreas Cancer Clinical Research and Patient Care and associate director of the Bloomberg~Kimmel Institute, combed the medical literature for the results of clinical trials using checkpoint inhibitors on various different types of cancer. They combined these findings with data on the mutational burden of thousands of tumor samples from patients with different tumor types. Analyzing 27 different cancer types for which both pieces of information were available, the researchers found a strong correlation.

The higher a cancer type’s mutational burden tends to be, the more likely it is to respond to checkpoint inhibitors. More than half of the differences in how well cancers responded to immune checkpoint inhibitors could be explained by the mutational burden of that cancer. €œThe idea that a tumor type with more mutations might be easier to treat than one with fewer sounds a little counterintuitive.

It’s one of those things that doesn’t sound right when you hear it,” says Hopkins. €œBut with immunotherapy, the more mutations you have, the more chances the immune system has to recognize the tumor.” Although this finding held true for the vast majority of cancer types they studied, there were some outliers in their analysis, says Yarchoan. For example, Merkel cell cancer, a rare and highly aggressive skin cancer, tends to have a moderate number of mutations yet responds extremely well to checkpoint inhibitors.

However, he explains, this cancer type is often caused by a kamagra, which seems to encourage a strong immune response despite the cancer’s lower mutational burden. In contrast, the most common type of colorectal cancer has moderate mutational burden, yet responds poorly to checkpoint inhibitors for reasons that are still unclear. Yarchoan notes that these findings could help guide clinical trials to test checkpoint inhibitors on cancer types for which these drugs haven’t yet been tried.

Future studies might also focus on finding ways to prompt cancers with low mutational burdens to behave like those with higher mutational burdens so that they will respond better to these therapies. He and his colleagues plan to extend this line of research by investigating whether mutational burden might be a good predictor of whether cancers in individual patients might respond well to this class of immunotherapy drugs. €œThe end goal is precision medicine—moving beyond what’s true for big groups of patients to see whether we can use this information to help any given patient,” he says.

Yarchoan receives funding from the Norman &. Ruth Rales Foundation and the Conquer Cancer Foundation. Through a licensing agreement with Aduro Biotech, Jaffee has the potential to receive royalties in the future..

Ajanta pharma kamagra review

On 22nd September 2020 the UK Government ajanta pharma kamagra review announced new lockdown restrictions to supress the erectile dysfunction treatment kamagra, directory with some areas of England having more restrictive lockdown guidance. Students in a number of cities have been confined to their halls of residences after outbreaks of erectile dysfunction treatment and in Manchester security guards were preventing students leaving the buildings. The scientific community are, unsurprisingly, divided over the question of how far ajanta pharma kamagra review lockdowns should extend.1 Monday 21st September 2020 saw the publication of two open letter to the UK government and Chief Medical Officers. One group, Sunetra Gupta et al,2 argued for a selective lockdown targeting the most vulnerable. The other, headed by Trisha Greenhalgh, arguing that attempts to suppress the kamagra should operate across the whole community.3 As we enter what appears to be a second wave of erectile dysfunction treatment s and accompanying lockdown measures, ethical debates over the appropriateness and extent of such measures are critical.Julian Savulescu and James Cameron4 in their article on lockdown of the elderly and why this is not ageist, put forward the case that, ‘an appropriate approach may be to lift the general lockdown but implement selective isolation of the elderly.’ Their central claim is that selective isolation of the ajanta pharma kamagra review elderly is to be preferred to imposing lockdown on all members of society.

The aim of lockdown, restricting movement and key activities, is designed to reduce the number of deaths from erectile dysfunction treatment and also to prevent the healthcare system from becoming overwhelmed. As the elderly are at significantly more risk of having severe cases of erectile dysfunction treatment and therefore more likely to place demands on healthcare services, they are clearly prime candidates for lockdown measures, measures that will not only benefit them but the whole ajanta pharma kamagra review of society. This is not ageist as they point out that differential treatment is not always discrimination if there is a morally relevant reason for the differential treatment. The morally relevant reason in this case is that the elderly, and other groups who may be vulnerable to erectile dysfunction treatment, are at greater risk of adverse effects from erectile dysfunction treatment ajanta pharma kamagra review and consequently more likely to burden the heath service if they get erectile dysfunction treatment. Even if this is discrimination they claim that it would be proportionate, as it benefits both the elderly and the wider population.

Savulescu and Cameron argue that to require everyone to be lockdown is the levelling ajanta pharma kamagra review down of equality – that is. €˜In order for there to be equality, people who could be better off are made worse off in order to achieve equality.’ And in their view such levelling down is ‘morally repugnant’ and unethical.In his response to Savulescu and Cameron, Jonathan Hughes5 takes issue with their claim that general lockdown measures that affect all members of society equally are a form of levelling down of equality. Hughes argues that the claim that the levelling down of equality is always unethical can be challenged, but his main argument is that ‘the choice to maintain a general lockdown, rather than easing it for the young while maintaining it for the elderly, is not an instance of levelling down.’ For selective lockdown of the elderly to be an instance of levelling down of equality, it would have to make everyone else worse off with no additional benefit to the elderly. However, Hughes argues that a general lockdown does produce benefits or reduce burdens for the elderly and hence is not the levelling down ajanta pharma kamagra review of equality. General lockdown will result in lower levels in the wider population and thus the elderly are less likely to contract erectile dysfunction treatment.

Even during lockdown many elderly people have carers or service providers visiting them to perform caring responsibilities and with lower general rates ajanta pharma kamagra review these visits are less likely to result in the spread of . Hence, the elderly are less likely to become a burden on the health service and lower levels of will mean an easing of lockdown for everyone sooner. €˜These considerations demonstrate that maintaining a general lockdown in preference to selective lockdown of the elderly and vulnerable need not only equalise the burdens by making the young and healthy worse off, but can benefit the elderly in absolute as well as relative terms.’5As both Savulescu and Cameron, and Hughes note there is an ajanta pharma kamagra review issue of proportionality that needs to be considered. Savulescu and Cameron give three reasons why the selective lockdown of the elderly, the restriction of their liberty, is proportionate. The benefits to others ajanta pharma kamagra review are significant.

The restriction will produce benefit for the elderly. And finally, this is the option that results in the least ajanta pharma kamagra review amount of liberty restriction. Hughes also points out, as do Savulescu and Cameron, that the harms to the elderly due to lockdown might be greater than for other groups, and therefore a general lockdown could be justified on the grounds of Parfit’s Priority View, that benefiting the worse off is more important.This raises the problem of how we determine who is worse off in this scenario, as both sets of authors point out that the elderly may have fewer social networks and hence be more socially isolated and find lockdown particularly hard. Further, if they only have a limited time to live, lockdown may present a relatively greater loss. However, the young, who are facing huge disruption to their social development, their education and a curbing of their freedoms and life choices at critical junctures (ie, going to University and being away from home for the first time), ajanta pharma kamagra review may want to argue that they are much more greatly harmed than the elderly.

These potential inter-generational trade-offs need to be debated, and Stephen John argues we need to think about lockdown in terms of intergenerational justice. He argues age is ajanta pharma kamagra review a relevant categorization for discussing lockdown policies in relation to erectile dysfunction treatment, as it is generally ‘an epistemically robust category, which can be operationalized.’3 and has particular significance for the aetiology of erectile dysfunction treatment. As John observes, ‘However we approach the ethics of lockdown, we need to do ethical work in deciding how to describe the effects of lockdown in the first place. In turn, I want to suggest that this process is ajanta pharma kamagra review an important, although easily overlooked site of ethical and political contestation.’6 The effects of the erectile dysfunction treatment response on those who are likely to suffer less from the disease, the younger generation, and on those whose non-erectile dysfunction treatment healthcare has been suspended, according to some, are likely to outweigh the harms caused by erectile dysfunction treatment itself.7 Hence, describing the effects of erectile dysfunction treatment and lockdown policies is no simple task.Elsewhere in this issue the Editor’s Choice article, Protecting health privacy even when privacy8 is lost by T.J. Kasperbauer considers the ethical and regulatory issues raised by the flow and sharing of data in modern healthcare.

He points out that the predominant model of safeguarding the privacy of healthcare data is one of information control, ajanta pharma kamagra review that is an attempt to limit access to personal health data. However, limiting access has important implications for developments in healthcare such as leaning health systems and precision medicine, initiatives that require a large amount of health data. Limiting access could make many data-linkage schemes unfeasible ajanta pharma kamagra review in practice. Such uses of data have the potential to make significant contributions to improving healthcare, both in terms of developing new treatments and at an organisational level, re-designing patient pathways and utilising healthcare resources more effectively.9 As an alternative to a control view of privacy, he suggests three measures that could be instituted to enable greater sharing of data, ‘such that pervasive data sharing would not automatically entail a loss of privacy.’ These are. Data obfuscation, this is making the data obscure so it is not possible to make inferences about individuals.

Penalisation of data ajanta pharma kamagra review misuse. And transparency, making any access to our data transparent so that it discourages inappropriate data use and we can see who has accessed our data. There are trade-offs and difficulties with all these suggestions as Kasperbauer notes and although changing laws around privacy is possibly the most important and most effective of these measures it is also the most difficult.The value of big data sets rests on their size and comprehensiveness, my desire to keep my health data private and opt out of ajanta pharma kamagra review big data initiatives can comprise their success. Therefore, we need to explore ways of balancing individual concerns over privacy, with using data for the greater good, and how to address possible tensions between the two.10 How policy makers and healthcare systems will manage information privacy will be a growing issue and is another example, along with the erectile dysfunction treatment kamagra,11 of how we are increasingly thinking about ethical issues at a community, rather than an individual, level and in wider global contexts. In a more connected bioethics, concepts such as justice and more community-based values such as stewardship, solidarity and reciprocity are ajanta pharma kamagra review likely to become key tools to frame these debates.12erectile dysfunction treatment continues to dominate 2020 and is likely to be a feature of our lives for some time to come.

Given this, how should health systems respond ethically to the persistent challenges of responding to the ongoing impact of the kamagra?. Relatedly, what ethical ajanta pharma kamagra review values should underpin the resetting of health services after the initial wave, knowing that local spikes and further waves now seem inevitable?. In this editorial, we outline some of the ethical challenges confronting those running health services as they try to resume non-erectile dysfunction treatment-related services, and the downstream ethical implications these have for healthcare professionals’ day-to-day decision making. This is a ajanta pharma kamagra review phase of recovery, resumption and renewal. A form of reset for health services.1 This reset phase will define the ‘new normal' for healthcare delivery, and it offers an opportunity to reimagine and change services for the better.

There are difficulties, however, healthcare systems are already weakened by austerity and the first wave of erectile dysfunction treatment and remain under stress as the kamagra continues. The reset period is operating alongside, rather than at the end, of the kamagra and this creates difficult ethical choices.Ethical challenges of resetBalancing the greater good with individual carekamagras—and ajanta pharma kamagra review public health emergencies more generally—reinforce approaches to ethics that emphasise or derive from the interests of communities, rather than those grounded in the claims of the autonomous individual. The response has been to draw on more public health focused ethics, ‘if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual's need will give way to decisions about how to maximise overall benefit’.2 Alongside this, effective control of kamagras requires that we all adopt strategies to reduce disease transmission such as the lockdown measures instituted by governments worldwide. Individual liberties are curtailed for the greater good.Together, these factors shift the weighting of ethical concepts to emphasise the individual within a community.3 4 For many years, public health ethicists and practitioners have drawn attention to the importance of the health of the whole community5 and the broader determinants of health, including the built environment and the way that society is structured.6 7 Public health emergencies, such as erectile dysfunction treatment, demonstrate our mutual ajanta pharma kamagra review dependencies and highlight the need to prioritise the interests of the community. The difficulty of balancing these tensions between the interests of the ‘wider community’ and the patient as the ‘first concern’ has been well rehearsed.

In the ajanta pharma kamagra review reset period, how to further the public good is contested. Should health services prioritise the response to erectile dysfunction treatment. Or should we now be trying to give ajanta pharma kamagra review equal or greater priority to providing non-erectile dysfunction treatment services?. It has been argued that the response to erectile dysfunction treatment will produce much greater detrimental effects on population health than the disease itself, including the impact of those who need healthcare for non-erectile dysfunction treatment conditions not receiving treatment.8 9 Thus, in the current kamagra, how to promote the public good is by no means clear and which wider community’s interests should be prioritised needs careful ethical consideration.Attention also needs to be paid to relationships between healthcare professionals and patients, as elements of non-verbal communication are inhibited by wearing masks. The calming and reassuring gesture of touch is prohibited or distorted by the use of personal ajanta pharma kamagra review protective equipment (PPE).

And patients have to attend appointments on their own without any support, no matter how difficult or traumatic the consultation is expected to be.10 This raises important ethical questions about how the demands of control should be balanced against the need for personalised, dignified and supportive care. Responding to these competing demands can result in moral distress for healthcare professionals who feel ill-prepared or unable to pursue ethically appropriate actions.11 erectile dysfunction treatment has created new and uncertain circumstances that continue to disrupt our understandings of what ‘good care’ looks like and, in so doing, shifts the underpinning values or assumptions on which care is based, raising new ethical considerations for day-to-day decision making.Resource allocationResource allocation is a perennial problem in health systems and the persistence of erectile dysfunction treatment will magnify concerns about National Health Service (NHS) resources long after the first wave. With the suspension of many non-erectile dysfunction treatment services from March 2020 in the UK, the backlog of demand for non-erectile dysfunction treatment services has grown, and the pressures on healthcare services are even ajanta pharma kamagra review greater. At the same time, healthcare is necessarily less efficient because of erectile dysfunction treatment control precautions. Each healthcare interaction takes longer because of the time it takes ajanta pharma kamagra review to clean equipment and the treatment area, don and doff PPE, and patients cannot be left waiting in shared rooms but must be tightly scheduled.In the first wave of the kamagra, the analysis focused on resource allocation between patients with erectile dysfunction treatment.12 In this reset period, attention must now turn to how to allocate resources between those with erectile dysfunction treatment and all other patients, including those whose conditions are not life-threatening and these kinds of decisions need focused ethical scrutiny.What should be done?.

Guidance on ethical responses for the acute phase of a kamagra is readily available.13 This is not the case when considering how health systems ought to reset in the immediate aftermath of a kamagra or other public health emergency. We are at a juncture where the challenges brought on by the response to erectile dysfunction treatment are forcing the re-evaluation of traditional clinical ajanta pharma kamagra review ethical approaches. The theoretical basis is shifting to give greater weight to the interests of the community as a whole. For example, the principle of justice may need to ajanta pharma kamagra review be given greater prominence, as well as a more self-conscious and widespread inclusion of values such as solidarity and reciprocity in decision making at both individual and organisational levels.14The kamagra has also highlighted how longstanding health, housing, financial and racial inequalities interact with the erectile dysfunction treatment kamagra, exacting a disproportionate impact on those already facing disadvantage and discrimination.15 In the healthcare context, an additional dimension to this is the disproportionate impact of erectile dysfunction treatment on healthcare workers from Black, Asian and minority ethnic communities.16 As Richard Horton has argued, erectile dysfunction treatment is not a kamagra it is a syndemic. Seeing erectile dysfunction treatment as a syndemic directs the focus towards the social and biological interactions that increase someone’s susceptibility to worse health outcomes.17 Consequently, in the reset phase, ethical decision making must pay more attention to the interaction between erectile dysfunction treatment and longstanding health and socioeconomic inequalities.The speed of response necessary for the first wave of the erectile dysfunction treatment kamagra meant that decisions were made with little public scrutiny or consultation.18 But this approach cannot be justified in the reset period.

The statutory, and ethical, obligation to maintain public involvement in decisions relating to service provision was reiterated by NHS England in March 2020.19 And this obligation extends to the scrutiny of the ethical values and arguments that underpin—implicitly or explicitly—the ways that services are reconfigured and the decisions about which patients and staff will bear the costs of reconfiguration.The transition through repeated waves of erectile dysfunction treatment, while not just re-establishing but also resetting NHS services, will ajanta pharma kamagra review require new ways of thinking about how to integrate public health, organisational and systems-based approaches with clinical ethics. All health systems need to think about which ethical considerations are important in the reset period, which values and interests should take precedence, and how competing interests can and should be managed. These matters deserve more explicit consideration in ethical and practitioner literature and much wider public consultation..

On 22nd September 2020 the UK Government announced new kamagra canada buy lockdown restrictions to supress the erectile dysfunction treatment kamagra, with some areas of England having more restrictive lockdown guidance. Students in a number of cities have been confined to their halls of residences after outbreaks of erectile dysfunction treatment and in Manchester security guards were preventing students leaving the buildings. The scientific community are, unsurprisingly, divided over the kamagra canada buy question of how far lockdowns should extend.1 Monday 21st September 2020 saw the publication of two open letter to the UK government and Chief Medical Officers.

One group, Sunetra Gupta et al,2 argued for a selective lockdown targeting the most vulnerable. The other, headed by Trisha Greenhalgh, arguing that attempts to suppress the kamagra should operate across the whole community.3 As we enter what appears to be a second wave of erectile dysfunction treatment s and accompanying lockdown measures, ethical debates over the appropriateness and extent of such measures are critical.Julian Savulescu and kamagra canada buy James Cameron4 in their article on lockdown of the elderly and why this is not ageist, put forward the case that, ‘an appropriate approach may be to lift the general lockdown but implement selective isolation of the elderly.’ Their central claim is that selective isolation of the elderly is to be preferred to imposing lockdown on all members of society. The aim of lockdown, restricting movement and key activities, is designed to reduce the number of deaths from erectile dysfunction treatment and also to prevent the healthcare system from becoming overwhelmed.

As the elderly are at significantly more risk of having severe cases of erectile dysfunction treatment and therefore more likely to place demands on healthcare services, they kamagra canada buy are clearly prime candidates for lockdown measures, measures that will not only benefit them but the whole of society. This is not ageist as they point out that differential treatment is not always discrimination if there is a morally relevant reason for the differential treatment. The morally relevant reason in this case is that the elderly, and other groups who may be vulnerable to erectile dysfunction treatment, are at greater risk of adverse effects from erectile dysfunction treatment and consequently more likely to burden the heath service if they kamagra canada buy get erectile dysfunction treatment.

Even if this is discrimination they claim that it would be proportionate, as it benefits both the elderly and the wider population. Savulescu and kamagra canada buy Cameron argue that to require everyone to be lockdown is the levelling down of equality – that is. €˜In order for there to be equality, people who could be better off are made worse off in order to achieve equality.’ And in their view such levelling down is ‘morally repugnant’ and unethical.In his response to Savulescu and Cameron, Jonathan Hughes5 takes issue with their claim that general lockdown measures that affect all members of society equally are a form of levelling down of equality.

Hughes argues that the claim that the levelling down of equality is always unethical can be challenged, but his main argument is that ‘the choice to maintain a general lockdown, rather than easing it for the young while maintaining it for the elderly, is not an instance of levelling down.’ For selective lockdown of the elderly to be an instance of levelling down of equality, it would have to make everyone else worse off with no additional benefit to the elderly. However, Hughes kamagra canada buy argues that a general lockdown does produce benefits or reduce burdens for the elderly and hence is not the levelling down of equality. General lockdown will result in lower levels in the wider population and thus the elderly are less likely to contract erectile dysfunction treatment.

Even during lockdown many elderly people have carers or service providers visiting them to perform caring responsibilities and with lower general rates these visits are less likely to kamagra canada buy result in the spread of . Hence, the elderly are less likely to become a burden on the health service and lower levels of will mean an easing of lockdown for everyone sooner. €˜These considerations demonstrate that maintaining a general lockdown in preference to selective lockdown of the elderly and vulnerable kamagra canada buy need not only equalise the burdens by making the young and healthy worse off, but can benefit the elderly in absolute as well as relative terms.’5As both Savulescu and Cameron, and Hughes note there is an issue of proportionality that needs to be considered.

Savulescu and Cameron give three reasons why the selective lockdown of the elderly, the restriction of their liberty, is proportionate. The benefits to others are kamagra canada buy significant. The restriction will produce benefit for the elderly.

And finally, this kamagra canada buy is the option that results in the least amount of liberty restriction. Hughes also points out, as do Savulescu and Cameron, that the harms to the elderly due to lockdown might be greater than for other groups, and therefore a general lockdown could be justified on the grounds of Parfit’s Priority View, that benefiting the worse off is more important.This raises the problem of how we determine who is worse off in this scenario, as both sets of authors point out that the elderly may have fewer social networks and hence be more socially isolated and find lockdown particularly hard. Further, if they only have a limited time to live, lockdown may present a relatively greater loss.

However, the young, who are facing huge disruption to their social development, their education and a curbing of their freedoms and life choices at critical junctures kamagra canada buy (ie, going to University and being away from home for the first time), may want to argue that they are much more greatly harmed than the elderly. These potential inter-generational trade-offs need to be debated, and Stephen John argues we need to think about lockdown in terms of intergenerational justice. He argues age is a relevant categorization for discussing lockdown policies kamagra canada buy in relation to erectile dysfunction treatment, as it is generally ‘an epistemically robust category, which can be operationalized.’3 and has particular significance for the aetiology of erectile dysfunction treatment.

As John observes, ‘However we approach the ethics of lockdown, we need to do ethical work in deciding how to describe the effects of lockdown in the first place. In turn, I want to suggest that this process is an important, kamagra canada buy although easily overlooked site of ethical and political contestation.’6 The effects of the erectile dysfunction treatment response on those who are likely to suffer less from the disease, the younger generation, and on those whose non-erectile dysfunction treatment healthcare has been suspended, according to some, are likely to outweigh the harms caused by erectile dysfunction treatment itself.7 Hence, describing the effects of erectile dysfunction treatment and lockdown policies is no simple task.Elsewhere in this issue the Editor’s Choice article, Protecting health privacy even when privacy8 is lost by T.J. Kasperbauer considers the ethical and regulatory issues raised by the flow and sharing of data in modern healthcare.

He points out that the predominant model kamagra canada buy of safeguarding the privacy of healthcare data is one of information control, that is an attempt to limit access to personal health data. However, limiting access has important implications for developments in healthcare such as leaning health systems and precision medicine, initiatives that require a large amount of health data. Limiting access could make many data-linkage schemes unfeasible in practice kamagra canada buy.

Such uses of data have the potential to make significant contributions to improving healthcare, both in terms of developing new treatments and at an organisational level, re-designing patient pathways and utilising healthcare resources more effectively.9 As an alternative to a control view of privacy, he suggests three measures that could be instituted to enable greater sharing of data, ‘such that pervasive data sharing would not automatically entail a loss of privacy.’ These are. Data obfuscation, this is making the data obscure so it is not possible to make inferences about individuals. Penalisation of data misuse kamagra canada buy.

And transparency, making any access to our data transparent so that it discourages inappropriate data use and we can see who has accessed our data. There are kamagra canada buy trade-offs and difficulties with all these suggestions as Kasperbauer notes and although changing laws around privacy is possibly the most important and most effective of these measures it is also the most difficult.The value of big data sets rests on their size and comprehensiveness, my desire to keep my health data private and opt out of big data initiatives can comprise their success. Therefore, we need to explore ways of balancing individual concerns over privacy, with using data for the greater good, and how to address possible tensions between the two.10 How policy makers and healthcare systems will manage information privacy will be a growing issue and is another example, along with the erectile dysfunction treatment kamagra,11 of how we are increasingly thinking about ethical issues at a community, rather than an individual, level and in wider global contexts.

In a more connected bioethics, concepts such as justice and more community-based values such as stewardship, solidarity and reciprocity are likely to become key tools to frame these debates.12erectile dysfunction treatment continues to dominate 2020 and is likely to kamagra canada buy be a feature of our lives for some time to come. Given this, how should health systems respond ethically to the persistent challenges of responding to the ongoing impact of the kamagra?. Relatedly, what ethical values kamagra canada buy should underpin the resetting of health services after the initial wave, knowing that local spikes and further waves now seem inevitable?.

In this editorial, we outline some of the ethical challenges confronting those running health services as they try to resume non-erectile dysfunction treatment-related services, and the downstream ethical implications these have for healthcare professionals’ day-to-day decision making. This is a phase of recovery, kamagra canada buy resumption and renewal. A form of reset for health services.1 This reset phase will define the ‘new normal' for healthcare delivery, and it offers an opportunity to reimagine and change services for the better.

There are difficulties, however, healthcare systems are already weakened by austerity and the first wave of erectile dysfunction treatment and remain under stress as the kamagra continues. The reset period is operating alongside, kamagra canada buy rather than at the end, of the kamagra and this creates difficult ethical choices.Ethical challenges of resetBalancing the greater good with individual carekamagras—and public health emergencies more generally—reinforce approaches to ethics that emphasise or derive from the interests of communities, rather than those grounded in the claims of the autonomous individual. The response has been to draw on more public health focused ethics, ‘if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual's need will give way to decisions about how to maximise overall benefit’.2 Alongside this, effective control of kamagras requires that we all adopt strategies to reduce disease transmission such as the lockdown measures instituted by governments worldwide.

Individual liberties are curtailed for the greater good.Together, these factors shift the weighting of ethical concepts to emphasise the individual within a community.3 4 For many years, public health ethicists and practitioners have drawn attention kamagra canada buy to the importance of the health of the whole community5 and the broader determinants of health, including the built environment and the way that society is structured.6 7 Public health emergencies, such as erectile dysfunction treatment, demonstrate our mutual dependencies and highlight the need to prioritise the interests of the community. The difficulty of balancing these tensions between the interests of the ‘wider community’ and the patient as the ‘first concern’ has been well rehearsed. In the reset period, how to further the kamagra canada buy public good is contested.

Should health services prioritise the response to erectile dysfunction treatment. Or should we now be trying to give equal kamagra canada buy or greater priority to providing non-erectile dysfunction treatment services?. It has been argued that the response to erectile dysfunction treatment will produce much greater detrimental effects on population health than the disease itself, including the impact of those who need healthcare for non-erectile dysfunction treatment conditions not receiving treatment.8 9 Thus, in the current kamagra, how to promote the public good is by no means clear and which wider community’s interests should be prioritised needs careful ethical consideration.Attention also needs to be paid to relationships between healthcare professionals and patients, as elements of non-verbal communication are inhibited by wearing masks.

The calming and reassuring gesture of touch is prohibited or distorted by the use of personal protective kamagra canada buy equipment (PPE). And patients have to attend appointments on their own without any support, no matter how difficult or traumatic the consultation is expected to be.10 This raises important ethical questions about how the demands of control should be balanced against the need for personalised, dignified and supportive care. Responding to these competing demands can result in moral distress for healthcare professionals who feel ill-prepared or unable to pursue ethically appropriate actions.11 erectile dysfunction treatment has created new and uncertain circumstances that continue to disrupt our understandings of what ‘good care’ looks like and, in so doing, shifts the underpinning values or assumptions on which care is based, raising new ethical considerations for day-to-day decision making.Resource allocationResource allocation is a perennial problem in health systems and the persistence of erectile dysfunction treatment will magnify concerns about National Health Service (NHS) resources long after the first wave.

With the suspension of kamagra canada buy many non-erectile dysfunction treatment services from March 2020 in the UK, the backlog of demand for non-erectile dysfunction treatment services has grown, and the pressures on healthcare services are even greater. At the same time, healthcare is necessarily less efficient because of erectile dysfunction treatment control precautions. Each healthcare interaction takes longer because of the time it takes to clean equipment and the treatment area, don and doff PPE, and patients cannot be left waiting in shared rooms but must be tightly scheduled.In the first wave of the kamagra, the analysis focused on resource allocation between patients with erectile dysfunction treatment.12 In this reset period, attention must now turn to how to allocate resources between those with erectile dysfunction treatment and all other patients, including those whose conditions are not life-threatening and kamagra canada buy these kinds of decisions need focused ethical scrutiny.What should be done?.

Guidance on ethical responses for the acute phase of a kamagra is readily available.13 This is not the case when considering how health systems ought to reset in the immediate aftermath of a kamagra or other public health emergency. We are at a juncture where the challenges brought on by kamagra canada buy the response to erectile dysfunction treatment are forcing the re-evaluation of traditional clinical ethical approaches. The theoretical basis is shifting to give greater weight to the interests of the community as a whole.

For example, the principle kamagra canada buy of justice may need to be given greater prominence, as well as a more self-conscious and widespread inclusion of values such as solidarity and reciprocity in decision making at both individual and organisational levels.14The kamagra has also highlighted how longstanding health, housing, financial and racial inequalities interact with the erectile dysfunction treatment kamagra, exacting a disproportionate impact on those already facing disadvantage and discrimination.15 In the healthcare context, an additional dimension to this is the disproportionate impact of erectile dysfunction treatment on healthcare workers from Black, Asian and minority ethnic communities.16 As Richard Horton has argued, erectile dysfunction treatment is not a kamagra it is a syndemic. Seeing erectile dysfunction treatment as a syndemic directs the focus towards the social and biological interactions that increase someone’s susceptibility to worse health outcomes.17 Consequently, in the reset phase, ethical decision making must pay more attention to the interaction between erectile dysfunction treatment and longstanding health and socioeconomic inequalities.The speed of response necessary for the first wave of the erectile dysfunction treatment kamagra meant that decisions were made with little public scrutiny or consultation.18 But this approach cannot be justified in the reset period. The statutory, and ethical, obligation to maintain public involvement in decisions relating to service provision was reiterated by NHS England in March 2020.19 And this obligation extends to the scrutiny of the ethical values and arguments that underpin—implicitly or explicitly—the ways that services are reconfigured and the decisions about which patients and staff will bear the costs of reconfiguration.The transition through repeated waves of erectile dysfunction treatment, while not just re-establishing but also resetting NHS services, will require new ways of thinking about how to integrate public health, organisational and systems-based approaches with clinical ethics kamagra canada buy.

All health systems need to think about which ethical considerations are important in the reset period, which values and interests should take precedence, and how competing interests can and should be managed. These matters deserve more explicit consideration in ethical and practitioner literature and much wider public consultation..

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L buy kamagra without a prescription buy cheap kamagra. 111-148) expanded the duties of the CBE to help in the identification of gaps in available measures and to improve the selection of measures used in health care programs. In January 2009, a competitive contract was awarded by HHS to the National Quality Forum (NQF) to fulfill requirements of section 1890 of the Act.

A second, multi-year contract buy cheap kamagra was awarded again to NQF after an open competition in 2012. A third, multi-contract was awarded again to NQF after an open competition in 2017. Section 1890(b) of the Act requires the following.

Priority Setting Process buy cheap kamagra. Formulation of a National Strategy and Priorities for Health Care Performance Measurement. The CBE must synthesize evidence and convene key stakeholders to make recommendations on an integrated national strategy and priorities for health care performance measurement in all applicable settings.

In doing so, the CBE must give priority buy cheap kamagra to measures that. (1) Address the health care provided to patients with prevalent, high-cost chronic diseases. (2) have the greatest potential for improving quality, efficiency, and patient-centered health care.

And (3) may be implemented rapidly due to existing evidence, standards of care, buy cheap kamagra or other reasons. Additionally, the CBE must take into account measures that. (1) May assist consumers and patients in making informed health care decisions.

(2) address health disparities buy cheap kamagra across groups and areas. And (3) address the continuum of care furnished by multiple providers or practitioners across multiple settings. Endorsement of Measures.

The CBE must provide for the buy cheap kamagra endorsement of standardized health care performance measures. This process must consider whether measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, responsive to variations in patient characteristics such as health status, language capabilities, race or ethnicity, and income level and are consistent across types of health care providers, including hospitals and physicians. Maintenance of CBE Endorsed Measures.

The CBE buy cheap kamagra is required to establish and implement a process to ensure that endorsed measures are updated (or retired if obsolete) as new evidence is developed. Convening Multi-Stakeholder Groups. The CBE must convene multi-stakeholder groups to provide input on.

(1) The selection of certain categories of quality and efficiency measures, from among such measures that have been endorsed by the entity and from among such measures that have not been considered for endorsement by such entity but are used or proposed to be used by the Secretary for the collection or buy cheap kamagra reporting of quality and efficiency measures. And (2) national priorities for improvement in population health and in the delivery of health care services for consideration under the national strategy. The CBE provides input on measures for use in certain specific Medicare programs, for use in programs that report performance information to the public, and for use in health care programs that are not included under the Act.

The multi-stakeholder groups provide input on quality and efficiency measures for various federal health care quality reporting and quality improvement programs including those that address certain Medicare services provided through hospices, ambulatory surgical centers, hospital inpatient and outpatient facilities, physician offices, cancer buy cheap kamagra hospitals, end stage renal disease (ESRD) facilities, inpatient rehabilitation facilities, long-term care hospitals, psychiatric hospitals, and home health care programs. Transmission of Multi-Stakeholder Input. Not later than February 1 of each year, the CBE must transmit to the Secretary the input of multi-stakeholder groups.

Annual buy cheap kamagra Report to Congress and the Secretary. Not later than March 1 of each year, the CBE is required to submit to Congress and the Secretary an annual report. The report is to describe.

The implementation of quality and efficiency measurement initiatives buy cheap kamagra and the coordination of such initiatives with quality and efficiency initiatives implemented by other payers. Recommendations on an integrated national strategy and priorities for health care performance measurement. Performance of the CBE's duties required under its contract with the Secretary.

Gaps in endorsed quality and efficiency measures, including measures that are within priority areas identified by the Secretary under the national strategy established under buy cheap kamagra section 399HH of the Public Health Service Act (National Quality Strategy), and where quality and efficiency measures are unavailable or inadequate to identify or address such gaps. Areas in which evidence is insufficient to support endorsement of quality and efficiency measures in priority areas identified by the Secretary under the National Quality Strategy, and where targeted research may address such gaps. And The convening of multi-stakeholder groups to provide input on.

(1) The selection of quality and efficiency measures from among such measures that have been endorsed by the CBE and such measures that have not been buy cheap kamagra considered for endorsement by the CBE but are used or proposed to be used by the Secretary for the collection or reporting of quality and efficiency measures. And (2) national priorities for improvement in population health and the delivery of health care services for consideration under the National Quality Strategy. Section 50206(c)(1) of the Bipartisan Budget Act of 2018 (Pub.

L. 115-123) amended section 1890(b)(5)(A) of the Act to require the CBE's annual report to Congress to include the following. (1) An itemization of financial information for the previous fiscal year ending September 30, including annual revenues of the entity, annual expenses of the entity, and a breakdown of the amount awarded per contracted task order and the specific projects funded in each task order assigned to the entity.

And (2) any updates or modifications to internal policies and procedures of the entity as they relate to the duties of the CBE including specifically identifying any modifications to the disclosure of interests and conflicts of interests for committees, work groups, task forces, and advisory panels of the entity, and information on external stakeholder participation in the duties of the entity. The statutory requirements for the CBE to annually report to Congress and the Secretary of HHS also specify that the Secretary must review and publish the CBE's annual report in the Federal Register, together with any comments of the Secretary on the report, not later than 6 months after receipt. This Federal Register notice complies with the statutory requirement for Secretarial review and publication of the CBE's annual report.

NQF submitted a report on its 2019 activities to Congress and the Secretary on March 2, 2020. The Secretary's Comments on this report are presented in section II. Of this notice, and the National Quality Forum 2019 Activities Report to Congress and the Secretary of the Department of Health and Human Services is provided, Start Printed Page 60177as submitted to HHS, in the addendum to this Federal Register notice in section III.

II. Secretarial Comments on the National Quality Forum 2019 Activities. Report to Congress and the Secretary of the Department of Health and Human Services Once again, we thank the National Quality Forum (NQF) and the many stakeholders who participate in NQF projects for helping to advance the science and utility of health care quality measurement.

As part of its annual recurring work to maintain a strong portfolio of endorsed measures for use across varied providers, settings of care, and health conditions, NQF reports that in 2019, it updated its measure portfolio by reviewing and endorsing or re-endorsing 110 measures and removing 41 measures.[] Endorsed measures address a wide range of health care topics relevant to HHS programs, including. Person- and family-centered care. Care coordination.

Palliative and end-of-life care. Cardiovascular care. Behavioral health.

Pulmonary/critical care. Perinatal care. Cancer treatment.

Patient safety. And cost and resource use. In addition to endorsing measures and maintenance of endorsed measures, NQF also worked to remove measures from the portfolio of endorsed measures for their 14 projects related to the topics discussed in the previous paragraph for a variety of reasons, such as.

Measures no longer meeting endorsement criteria. Harmonization between similar measures. Replacement of outdated measures with improved measures.

And lack of continued need for measures where providers consistently perform at the highest level.[] This continuous refinement of the measures portfolio through the measures maintenance process ensures that quality measures remain aligned with current field practices and health care goals. Measure set refinements also align with HHS initiatives, such as the Meaningful Measures Initiative at the Centers for Medicare &. Medicaid Services (CMS).

CMS is working to identify the highest priorities for quality measurement and improvement and promote patient-centered, outcome based measures that are meaningful to patients and clinicians. NQF uses its unique role as the CBE to undertake a partnership with CMS to support the Core Quality Measures Collaborative (CQMC). Convened by America's Health Insurance Plans (AHIP), the CQMC is a public-private coalition, with representation by medical associations, specialty societies, public and private payers, patient and consumer groups, purchasers, and quality collaboratives.

The CQMC aims to identify high-value, high-impact quality measures that promote better outcomes. The CQMC supports nationwide quality measure alignment between Medicare and private payers and in turn, advances the ongoing work to establish a health quality roadmap to improve reporting across programs and health systems, as referenced in the recent Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.[] To date, CQMC has convened workgroups and developed eight (8) core measure sets to be used in high impact areas, including those for the topics of primary care/accountable care organizations/person-centered medical homes, cardiology, gastroenterology, HIV/Hepatitis C, medical oncology, obstetrics/gynecology, orthopedics, and pediatrics. Recognizing the importance of public-private collaboration, the CQMC's work enhances measure alignment and reduces provider burden.

CMS awarded NQF a 3-year contract in September 2018 to support the CQMC's work to update and expand the core sets.

A third, multi-contract was awarded again to NQF after an open competition in who can buy kamagra online 2017 kamagra canada buy. Section 1890(b) of the Act requires the following. Priority Setting Process.

Formulation of a National Strategy kamagra canada buy and Priorities for Health Care Performance Measurement. The CBE must synthesize evidence and convene key stakeholders to make recommendations on an integrated national strategy and priorities for health care performance measurement in all applicable settings. In doing so, the CBE must give priority to measures that.

(1) Address the health care provided to patients kamagra canada buy with prevalent, high-cost chronic diseases. (2) have the greatest potential for improving quality, efficiency, and patient-centered health care. And (3) may be implemented rapidly due to existing evidence, standards of care, or other reasons.

Additionally, the CBE must take into account measures that kamagra canada buy. (1) May assist consumers and patients in making informed health care decisions. (2) address health disparities across groups and areas.

And (3) address the kamagra canada buy continuum of care furnished by multiple providers or practitioners across multiple settings. Endorsement of Measures. The CBE must provide for the endorsement of standardized health care performance measures.

This process must consider whether measures are evidence-based, reliable, valid, verifiable, relevant to enhanced health outcomes, actionable at the caregiver level, feasible to collect and report, responsive kamagra canada buy to variations in patient characteristics such as health status, language capabilities, race or ethnicity, and income level and are consistent across types of health care providers, including hospitals and physicians. Maintenance of CBE Endorsed Measures. The CBE is required to establish and implement a process to ensure that endorsed measures are updated (or retired if obsolete) as new evidence is developed.

Convening kamagra canada buy Multi-Stakeholder Groups. The CBE must convene multi-stakeholder groups to provide input on. (1) The selection of certain categories of quality and efficiency measures, from among such measures that have been endorsed by the entity and from among such measures that have not been considered for endorsement by such entity but are used or proposed to be used by the Secretary for the collection or reporting of quality and efficiency measures.

And (2) national priorities for improvement in population health and in the kamagra canada buy delivery of health care services for consideration under the national strategy. The CBE provides input on measures for use in certain specific Medicare programs, for use in programs that report performance information to the public, and for use in health care programs that are not included under the Act. The multi-stakeholder groups provide input on quality and efficiency measures for various federal health care quality reporting and quality improvement programs including those that address certain Medicare services provided through hospices, ambulatory surgical centers, hospital inpatient and outpatient facilities, physician offices, cancer hospitals, end stage renal disease (ESRD) facilities, inpatient rehabilitation facilities, long-term care hospitals, psychiatric hospitals, and home health care programs.

Transmission of kamagra canada buy Multi-Stakeholder Input. Not later than February 1 of each year, the CBE must transmit to the Secretary the input of multi-stakeholder groups. Annual Report to Congress and the Secretary.

Not later than March 1 of each year, the CBE is kamagra canada buy required to submit to Congress and the Secretary an annual report. The report is to describe. The implementation of quality and efficiency measurement initiatives and the coordination of such initiatives with quality and efficiency initiatives implemented by other payers.

Recommendations on an integrated national strategy and priorities for health care performance measurement kamagra canada buy. Performance of the CBE's duties required under its contract with the Secretary. Gaps in endorsed quality and efficiency measures, including measures that are within priority areas identified by the Secretary under the national strategy established under section 399HH of the Public Health Service Act (National Quality Strategy), and where quality and efficiency measures are unavailable or inadequate to identify or address such gaps.

Areas in which evidence is insufficient to support endorsement of quality and efficiency measures in priority areas identified by the Secretary under the National kamagra canada buy Quality Strategy, and where targeted research may address such gaps. And The convening of multi-stakeholder groups to provide input on. (1) The selection of quality and efficiency measures from among such measures that have been endorsed by the CBE and such measures that have not been considered for endorsement by the CBE but are used or proposed to be used by the Secretary for the collection or reporting of quality and efficiency measures.

And (2) national priorities for improvement in population kamagra canada buy health and the delivery of health care services for consideration under the National Quality Strategy. Section 50206(c)(1) of the Bipartisan Budget Act of 2018 (Pub. L.

115-123) amended section 1890(b)(5)(A) kamagra canada buy of the Act to require the CBE's annual report to Congress to include the following. (1) An itemization of financial information for the previous fiscal year ending September 30, including annual revenues of the entity, annual expenses of the entity, and a breakdown of the amount awarded per contracted task order and the specific projects funded in each task order assigned to the entity. And (2) any updates or modifications to internal policies and procedures of the entity as they relate to the duties of the CBE including specifically identifying any modifications to the disclosure of interests and conflicts of interests for committees, work groups, task forces, and advisory panels of the entity, and information on external stakeholder participation in the duties of the entity.

The statutory requirements for the CBE to annually report to Congress and the Secretary of HHS also specify that the Secretary must review and publish the CBE's annual report in the Federal Register, together with any comments of the Secretary on the report, kamagra canada buy not later than 6 months after receipt. This Federal Register notice complies with the statutory requirement for Secretarial review and publication of the CBE's annual report. NQF submitted a report on its 2019 activities to Congress and the Secretary on March 2, 2020.

The Secretary's Comments kamagra canada buy on this report are presented in section II. Of this notice, and the National Quality Forum 2019 Activities Report to Congress and the Secretary of the Department of Health and Human Services is provided, Start Printed Page 60177as submitted to HHS, in the addendum to this Federal Register notice in section III. II.

Secretarial Comments on the kamagra canada buy National Quality Forum 2019 Activities. Report to Congress and the Secretary of the Department of Health and Human Services Once again, we thank the National Quality Forum (NQF) and the many stakeholders who participate in NQF projects for helping to advance the science and utility of health care quality measurement. As part of its annual recurring work to maintain a strong portfolio of endorsed measures for use across varied providers, settings of care, and health conditions, NQF reports that in 2019, it updated its measure portfolio by reviewing and endorsing or re-endorsing 110 measures and removing 41 measures.[] Endorsed measures address a wide range of health care topics relevant to HHS programs, including.

Person- and kamagra canada buy family-centered care. Care coordination. Palliative and end-of-life care.

Cardiovascular care kamagra canada buy. Behavioral health. Pulmonary/critical care.

Perinatal care kamagra canada buy. Cancer treatment. Patient safety.

And cost and kamagra canada buy resource use. In addition to endorsing measures and maintenance of endorsed measures, NQF also worked to remove measures from the portfolio of endorsed measures for their 14 projects related to the topics discussed in the previous paragraph for a variety of reasons, such as. Measures no longer meeting endorsement criteria.

Harmonization between kamagra canada buy similar measures. Replacement of outdated measures with improved measures. And lack of continued need for measures where providers consistently perform at the highest level.[] This continuous refinement of the measures portfolio through the measures maintenance process ensures that quality measures remain aligned with current field practices and health care goals.

Measure set refinements also align with HHS initiatives, such as the Meaningful Measures Initiative at the Centers for Medicare kamagra canada buy &. Medicaid Services (CMS). CMS is working to identify the highest priorities for quality measurement and improvement and promote patient-centered, outcome based measures that are meaningful to patients and clinicians.

NQF uses its unique kamagra canada buy role as the CBE to undertake a partnership with CMS to support the Core Quality Measures Collaborative (CQMC). Convened by America's Health Insurance Plans (AHIP), the CQMC is a public-private coalition, with representation by medical associations, specialty societies, public and private payers, patient and consumer groups, purchasers, and quality collaboratives. The CQMC aims to identify high-value, high-impact quality measures that promote better outcomes.

The CQMC supports nationwide quality measure alignment between Medicare and private payers and in turn, advances the ongoing work to establish a health quality roadmap to improve kamagra canada buy reporting across programs and health systems, as referenced in the recent Executive Order on Improving Price and Quality Transparency in American Healthcare to Put Patients First.[] To date, CQMC has convened workgroups and developed eight (8) core measure sets to be used in high impact areas, including those for the topics of primary care/accountable care organizations/person-centered medical homes, cardiology, gastroenterology, HIV/Hepatitis C, medical oncology, obstetrics/gynecology, orthopedics, and pediatrics. Recognizing the importance of public-private collaboration, the CQMC's work enhances measure alignment and reduces provider burden. CMS awarded NQF a 3-year contract in September 2018 to support the CQMC's work to update and expand the core sets.

In 2019, NQF convened all of the eight CQMC workgroups to update the core sets and discuss maintenance of the core sets. In addition, NQF updated and finalized the principles for selecting measures for existing and new core sets, based on the input of the workgroups. During the same period, NQF also developed the approaches for prioritizing the topics or areas for potential new core sets.

Through its partnership with NQF, CMS has contributed to the CQMC by making sure that the core sets drive innovation, reflect evidence-based care, and are meaningful to all stakeholders.

Goedkoopste kamagra

About This TrackerThis tracker provides the number of confirmed cases and deaths from novel erectile dysfunction by country, the trend in confirmed case and death counts by goedkoopste kamagra country, and a global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) erectile dysfunction Resource Center’s erectile dysfunction treatment Map and the World Health Organization’s (WHO) erectile dysfunction Disease (erectile dysfunction treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About erectile dysfunction treatment erectile dysfunctionIn late 2019, a new erectile dysfunction emerged in central China goedkoopste kamagra to cause disease in humans.

Cases of this disease, known as erectile dysfunction treatment, have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the kamagra represents a public health emergency of international concern, and on January 31, 2020, goedkoopste kamagra the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.Key PointsOn January 23, 2017, President Donald Trump reinstated and expanded the Mexico City Policy via presidential memorandum, renaming it “Protecting Life in Global Health Assistance.” This explainer provides an overview of the policy, including its history, changes over time, and current application.First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines and has now been in effect for 19 of the past 34 years.The policy requires foreign non-governmental organizations (NGOs) to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S.

Funds) as a condition of receiving goedkoopste kamagra U.S. Government global family planning assistance and, as of Jan. 23, 2017, goedkoopste kamagra most other U.S.

Global health assistance.The Trump administration’s application of the policy extends to the vast majority of U.S. Bilateral global health assistance, including funding goedkoopste kamagra for HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs. This marks a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounts for approximately $600 million of that total).Additionally, as a result of a March 2019 policy announcement and subsequent information released in June 2019, the policy, for the first time, prohibits foreign NGOs who accept the policy from providing any financial support using any source of funds and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning.

This greatly extends goedkoopste kamagra its reach to other areas of U.S. Development assistance beyond global health and to other non-U.S. Funding streams.More recently, in September 2020, a proposed rule goedkoopste kamagra to extend the policy to contracts was published.

If finalized, it would greatly extend the reach of the policy beyond grants and cooperative agreements to also include contracts.KFF analyses have found that:more than half of the countries in which the U.S. Provides bilateral global health assistance allow for legal abortion in goedkoopste kamagra at least one case not permitted by the policy (analysis). Andhad the expanded policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy (analysis).What is the Mexico City Policy?.

The Mexico City goedkoopste kamagra Policy is a U.S. Government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. Funds) as a condition goedkoopste kamagra of receiving U.S.

Global family planning assistance and, as of Jan. 23, 2017, goedkoopste kamagra most other U.S. Global health assistance.The policy was first announced by the Reagan administration at the 2nd International Conference on Population, which was held in Mexico City, Mexico, on August 6-14, 1984 (hence its name.

See Box goedkoopste kamagra 1). Under the Trump administration, the policy has been renamed “Protecting Life in Global Health Assistance” (PLGHA). Among opponents, it is also known goedkoopste kamagra as the “Global Gag Rule,” because among other activities, it prohibits foreign NGOs from using any funds (including non-U.S.

Funds) to provide information about abortion as a method of family planning and to lobby a foreign government to legalize abortion. €œ[T]he United States does not consider abortion an acceptable goedkoopste kamagra element of family planning programs and will no longer contribute to those of which it is a part. €¦[T]he United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations.”When first instituted in 1984, the Mexico City Policy marked an expansion of existing legislative restrictions that already prohibited U.S.

Funding for goedkoopste kamagra abortion internationally, with some exceptions (see below). Prior to the policy, foreign NGOs could use non-U.S. Funds to engage in certain voluntary abortion-related activities as long as they maintained segregated accounts for goedkoopste kamagra any U.S.

Money received, but after the Mexico City Policy was in place, they were no longer permitted to do so if they wanted to receive U.S. Family planning assistance.The Trump administration’s application of the policy to the vast majority of U.S goedkoopste kamagra. Bilateral global health assistance, including funding for HIV under the U.S.

President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, malaria, nutrition, and other programs, marks goedkoopste kamagra a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total). The Administration’s more recent extension of the policy to include any financial support (health or otherwise) provided by foreign NGOs for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning is likely to encompass significant additional funding.When has it been in effect?. The Mexico City Policy has been in effect for 19 of the past 34 years, primarily through executive action, and has been instated, rescinded, and reinstated by presidential administrations along party lines (see Table 1).The policy was first instituted in 1984 (taking effect in 1985) by President Ronald Reagan and continued to be in effect through President George H.W.

Bush’s administration goedkoopste kamagra. It was rescinded by President Bill Clinton in 1993 (although it was reinstated legislatively for one year during his second term. See below) goedkoopste kamagra.

The policy was reinstated by President George W. Bush in goedkoopste kamagra 2001 and then rescinded by President Barack Obama in 2009. It is currently in effect, having been reinstated by President Trump in 2017.

YearsIn Effect? goedkoopste kamagra. Presidential Administration (Party Affiliation)Executive (E) or Congressional (C) Action?. 1985-1989YesReagan (R)E1989-1993YesBush (R)E1993-1999 Sept.NoClinton (D)E1999 Oct.-2000 Sept.Yes*Clinton (D)C2000 Oct.-2001NoClinton (D)E2001-2009YesBush (R)E2009-2017NoObama goedkoopste kamagra (D)E2017-presentYesTrump (R)ENOTES.

Shaded blue indicate periods when policy was in effect. * There was a temporary, one-year legislative imposition of the policy, which included a portion of the restrictions in effect in other years and an goedkoopste kamagra option for the president to waive these restrictions in part. However, if the waiver option was exercised (for no more than $15 million in family planning assistance), then $12.5 million of this funding would be transferred to maternal and child health assistance.

The president did exercise goedkoopste kamagra the waiver option.SOURCES. €œPolicy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. Bill Clinton goedkoopste kamagra Administration, “Subject.

AID Family Planning Grants/Mexico City Policy,” Memorandum for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives, https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html. FY 2000 Consolidated Appropriations goedkoopste kamagra Act, P.L. 106-113.

George W goedkoopste kamagra. Bush Administration, “Subject. Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, goedkoopste kamagra January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html.

€œSubject. Restoration of the Mexico goedkoopste kamagra City Policy,” Memorandum for the Administrator of the United States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy. George W.

Bush Administration, goedkoopste kamagra “Subject. Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html. Barack Obama Administration, “Mexico City Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, goedkoopste kamagra Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning.

White House, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policy.How is it instituted (and goedkoopste kamagra rescinded)?. The Mexico City Policy has, for the most part, been instituted or rescinded through executive branch action (typically via presidential memoranda).

While Congress has the ability to institute the policy through legislation, this goedkoopste kamagra has happened only once in the past. A modified version of the policy was briefly applied by Congress during President Clinton’s last year in office as part of a broader arrangement to pay the U.S. Debt to goedkoopste kamagra the United Nations.

(At that time, President Clinton was able to partially waive the policy’s restrictions.) Other attempts to institute the policy through legislation have not been enacted into law, nor have legislative attempts to overturn the policy. See Table 1.Who goedkoopste kamagra does the policy apply to?. The policy, when in effect, applies to foreign NGOs as a condition for receiving U.S.

Family planning support and, now, other global health assistance, either directly (as the main – or prime – recipient of U.S. Funding) or indirectly (as a recipient goedkoopste kamagra of U.S. Funding through an agreement with the prime recipient.

Referred to goedkoopste kamagra as a sub-recipient). Specifically, a foreign NGO “recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities.”Foreign NGOs include:international NGOs that are based outside the U.S.,regional NGOs that are based outside the U.S., andlocal NGOs in assisted countries.U.S. NGOs, while not directly subject to the goedkoopste kamagra Mexico City Policy, must also agree to ensure that they do not provide funding to any foreign NGO sub-recipients unless those sub-recipients have first certified adherence to the policy.

Specifically, a U.S. NGO “recipient (A) agrees that it will not furnish health assistance under this award to goedkoopste kamagra any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning in foreign countries. And (B) further agrees to require that such sub-recipients do not provide financial support to any other foreign non-governmental organization that conducts such activities.”As in the past, the current policy does not apply to funding provided by the U.S.

Government to foreign governments (national or sub-national), public international organizations, and other goedkoopste kamagra multilateral entities, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the treatment Alliance. However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy. See “What goedkoopste kamagra is ‘financial support’?.

€ below.To what assistance does it apply?. In the past, foreign NGOs have been required goedkoopste kamagra to adhere to the Mexico City Policy – when it was in effect – as a condition of receiving support through certain U.S. International funding streams.

Family planning goedkoopste kamagra assistance through the U.S. Agency for International Development (USAID) and, beginning in 2003, family planning assistance through the U.S. Department of goedkoopste kamagra State.

In the 2003 memorandum announcing the policy’s expansion to include the Department of State, President Bush stated that the policy did not apply to funding for global HIV/AIDS programs and that multilateral organizations that are associations of governments are not included among “foreign NGOs.”The current policy, reinstated in 2017, applies to the vast majority of U.S. Bilateral global health goedkoopste kamagra assistance furnished by all agencies and departments. “Assistance” includes “the provision of funds, commodities, equipment, or other in-kind global health assistance.” Specifically, the expanded policy applies to nearly all bilateral global health assistance, including.

family planning and reproductive healthfor the first time:maternal and child health (including household-level water, sanitation, and hygiene (WASH))nutritionHIV under PEPFARtuberculosismalaria under the President’s Malaria Initiative (PMI)neglected tropical diseasesglobal health securitycertain types of research activitiesThe policy applies to the assistance described goedkoopste kamagra above that is appropriated directly to three agencies and departments. USAID. The Department of State, including the Office of the Global AIDS Coordinator, which oversees and goedkoopste kamagra coordinates U.S.

Global HIV funding under PEPFAR. And for the first time, the Department of Defense goedkoopste kamagra (DoD). When such funding is transferred to another agency, including the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), it remains subject to the policy, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly.The policy applies to three types of funding agreements for such assistance.

Grants. Cooperative agreements. And, for the first time, contracts, pending necessary rule-making that would be needed to do so (a proposed rule to accomplish this was published in September 2020).The policy does not apply to U.S.

Assistance for. Water supply and sanitation activities, which is usually focused on infrastructure and systems. Humanitarian assistance, including activities related to migration and refugee assistance activities as well as disaster and humanitarian relief activities.

The American Schools and Hospitals Abroad (ASHA) program. And Food for Peace (FFP). However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy.

See “What is ‘financial support’?. € below.What activities are prohibited?. The policy prohibits foreign NGOs that receive U.S.

Family planning assistance and, now, most other U.S. Bilateral global health assistance from using funds from any source (including non-U.S. Funds) to “perform or actively promote abortion as a method of family planning.” In addition to providing abortions with non-U.S.

Funds, restricted activities also include the following:providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e., engaging in lobbying), andconducting public information campaigns about abortion as a method of family planning.The prohibition of these activities are why the policy has been referred to by its critics as the “Global Gag Rule.”Additionally, for the first time, the policy prohibits foreign NGOs from providing any financial support with any source of funds (including non-U.S. Funding) and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning. See “What is “financial support?.

€ below.The policy, however, does not prohibit foreign NGOs from:providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the mother or resulted from incest or rape. Andresponding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information).In addition, the expanded policy does not apply to healthcare providers who have an affirmative duty required under local law to provide counseling about and referrals for abortion as a method of family planning.Does it restrict direct U.S. Funding for abortion overseas?.

U.S. Funding for abortion is already restricted under several provisions of the law. Specifically, before the Mexico City Policy was first announced in 1984, U.S.

Law already prohibited the use of U.S. Aid:to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act). Andto lobby for or against abortion (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).Then, shortly after the policy was announced in 1984, the Kemp-Kasten Amendment was passed in 1985, prohibiting the use of U.S.

Aid to fund any organization or program, as determined by the president, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it is now included in annual appropriations).Before the Mexico City Policy, U.S. Aid recipients could use non-U.S. Funds to engage in certain abortion-related activities but were required to maintain segregated accounts for U.S.

Assistance. The Mexico City Policy reversed this practice. No longer were foreign NGOs allowed to use non-U.S.

Funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive U.S. Family planning funds.Does the policy prohibit post-abortion care?. The Mexico City Policy does not restrict the provision of post-abortion care, which is a supported activity of U.S.

Family planning assistance. Whether or not the Mexico City Policy is in effect, recipients of U.S. Family planning assistance are allowed to use U.S.

And non-U.S. Funding to support post-abortion care, no matter the circumstances of the abortion (whether it was legal or illegal).What has been the impact of the policy?. Several studies have looked at the impact of the policy.

A 2011 quantitative analysis by Bendavid, et. Al, found a strong association between the Mexico City Policy and abortion rates in sub-Saharan Africa. This study was recently updated to include several more years of data, again identifying a strong association.

Specifically, the updated study found that during periods when the policy was in place, abortion rates rose by 40% in countries with high exposure to the Mexico City Policy compared to those with low exposure, while the use of modern contraceptives declined by 14% and pregnancies increased by 12% in high exposure compared to low exposure countries. In other words, it found patterns that “strengthen the case for the role played by the policy” in “a substantial increase in abortions across sub-Saharan Africa among women affected by the U.S. Mexico City Policy … [and] a corresponding decline in the use of modern contraception and increase in pregnancies,” likely because foreign NGOs that declined U.S.

Funding as a result of the Mexico City Policy – often key providers of women’s health services in these areas – had fewer resources to support family planning services, particularly contraceptives. Increased access to and use of contraception have been shown to be key to preventing unintended pregnancies and thereby reducing abortion, including unsafe abortion. The study also found patterns that “suggest that the effects of the policy are reversible” when the policy is not in place.Additionally, there has been anecdotal evidence and qualitative data on the impact of the policy, when it has been in force in the past, on the work of organizations that have chosen not to agree to the policy and, therefore, forgo U.S.

Funding that had previously supported their activities. For example, they have reported that they have fewer resources to support family planning and reproductive health services, including family planning counseling, contraceptive commodities, condoms, and reproductive cancer screenings.While it is likely too early to assess the full effects of the current policy on NGOs and the individuals they serve, as the policy is applied on a rolling basis as new funding agreements or modifications to existing agreements are made, some early data are available. Several early qualitative and quantitative studies have been released, and at least one long-term, quantitative assessment is underway.

Additionally, an official assessment by the U.S. Department of State on implementation during the first six months of the policy has been released (see below). This review acknowledged that it took “place early in the policy’s implementation, when affected U.S.

Government departments and agencies have added a significant portion of the funding affected by the policy to grants and cooperative agreements only recently [i.e., after the period the review examined]. A follow-on analysis would allow an opportunity to address one of the primary concerns presented in feedback from third-party stakeholder organizations, namely that six months is insufficient time to gauge the impacts of” the policy.Nonetheless, it is already clear that the reinstated and expanded version of the policy applies to a much greater amount of U.S. Global health assistance, and greater number of foreign NGOs, across many program areas.

KFF has found that more than half (37) of the 64 countries that received U.S. Bilateral global health assistance in FY 2016 allow for legal abortion in at least one case not permitted by the policy and that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy. In addition, at least 469 U.S.

NGOs that received U.S. Global health assistance during this period would have been required to ensure that their foreign NGO sub-recipients were in compliance. Additional foreign NGOs are likely to be impacted by the policy due to the revised interpretation of “financial support” announced in March 2019 and implemented beginning June 2019.

See “What is ‘financial support’?. € below.A report released in March 2020 by the U.S. Government Accountability Office (GAO) provided new information on the number of projects (awards) and NGOs affected.

It found that from May 2017 through FY 2018:the policy had been applied to over 1,300 global health projects, with the vast majority of these through USAID and CDC, andNGOs declined to accept the policy in 54 instances, totaling $153 million in declined funding – specifically, seven prime awards amounting to $102 million and 47 sub-awards amounting to $51 million (more than two-thirds of sub-awards were intended for Africa) – across USAID and CDC. The Department of State and DoD did not identify any instances where NGOs declined to accept the policy conditions.What have the U.S. Government’s reviews of the policy found?.

The U.S. Government has published two reviews of the policy to date, with the first examining the initial six months of the policy released in February 2018 and the second examining the first 18 months of the policy released in August 2020.First ReviewIn February 2018, the Department of State announced the findings of an initial six-month review of implementation of the policy through the end of FY 2017 (September 2017). The report directed agencies to provide greater support for improving understanding of implementation among affected organizations and provided guidance to clarify terms included in standard provisions of grants and cooperative agreements.

In the six-month review report, the Department of State report identified a number of “actions” for implementing agencies, such as a need for:more central and field-based training and implementation tools,a clearer explanation of termination of awards for NGOs found to be in violation of the policy, anda clarification of “financial support,” which was not defined in the standard provisions (see “What is financial support?. € below).The six month review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2017 (see Table 2). U.S.

Agency or DepartmentPolicy Implementation DateOverall # of Grants and Cooperative Agreements with Global Health Assistance FundingOf Overall #:(From the Policy Implementation Date through 9/30/2017)# That Received New Funding and Accepted Policy# That Received New Funding and Declined to Accept Policy^# That Had Not Received New Funding YetUSAIDMay 15, 20175804193158State*May 15, 2017142108034HHS+May 31, 20174991600339DoDMay 15, 20177742134TOTAL12987294565NOTES. * reflects PEPFAR funding implemented through the Department of State. Other departments and agencies implement the majority of PEPFAR funding.

+ At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2017, USAID reported it was aware of three centrally funded prime partners, and 12 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards. DoD reported that one DoD partner, a U.S.

NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that no HHS partners declined to agree.SOURCES. KFF analysis of data from Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb.

6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Second ReviewOn August 17, 2020, the Department of State released its second review of the policy, updating its initial six-month review (as an action item in the six-month review report, the department stated it would “conduct a further review of implementation of the policy by December 15, 2018, when more extensive experience will enable a more thorough examination of the benefits and challenges”). The long-anticipated review, which examines the period from May 2017 through September 2018, found:the awards declined spanned a variety of program areas, including family planning and reproductive health (FP/RH), HIV and AIDS (HIV/AIDS), maternal and child health (MCH), tuberculosis (TB), and nutrition, in addition to cross-cutting awards;the awards declined spanned geographic areas but many were for activities in sub-Saharan Africa;agencies and departments made efforts to transition projects to another implementer in order to minimize disruption. Butnevertheless, among USAID awards involving health service delivery where prime and sub-award recipients declined to accept the policy, gaps or disruptions in service delivery were sometimes reported.The second review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2018 (see Table 3).

U.S. Agency or DepartmentPolicy Implementation Date# of Grants and Cooperative Agreements with Global Health Assistance Funding# of Prime Awardees That Declined to Accept Policy^USAIDMay 15, 20174866State*May 15, 20173350HHS+May 31, 20174661DoDMay 15, 2017531TOTAL13408NOTES. * reflects PEPFAR funding implemented through the Department of State.

Other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2018, USAID reported it was aware of six centrally funded prime partners, and 47 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards.

DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that one HHS partner declined to agree.SOURCES.

KFF analysis of data from Department of State, “Review of the Implementation of the Protecting Life in Global Health Assistance Policy ,” report, Aug. 17, 2020, https://www.state.gov/wp-content/uploads/2020/08/PLGHA-2019-Review-Final-8.17.2020-508.pdf, and Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Additionally, the review reports that 47 sub-awardees, all under USAID awards, declined to accept the policy.

It is important to note that the review also states that information on sub-awards is not systematically collected by departments and agencies and that DoD was not able to collect information on sub-awards.What is “financial support”?. In February 2018, in the initial six-month review issued when Secretary of State Tillerson led the department, the Department of State report included an “action” statement to clarify the definition of “financial support” as used in the standard provisions for grants and cooperative agreements. At issue was whether it applied more narrowly to certain funding provided by foreign NGOs (i.e., funding other than U.S.

Global health funding) to other foreign NGOs specifically for the purpose of performing or actively promoting abortion as a method of family planning or if it applied more broadly to certain funding provided by foreign NGOs to other foreign NGOs for any purpose, if that foreign NGO happened to perform or actively promote abortion as a method of family planning. The State Department clarified that it was the more narrow interpretation.However, on March 26, 2019, Secretary of State Pompeo reversed this interpretation, announcing further “refinements” to the policy to clarify that it applied to the broader definition of financial support. Specifically, under the policy, U.S.-supported foreign NGOs agree to not provide any financial support (global health-related as well as other support), no matter the source of funds, to any other foreign NGO that performs or actively promotes abortion as a method of family planning.

In June 2019, USAID provided additional information to reflect this broader interpretation of the standard provisions.This marks the first time the policy has been applied this broadly, as it can now affect funding provided by other donors (such as other governments and foundations) and non-global health funding provided by the U.S. Government for a wide range of purposes if this funding is first provided to foreign NGOs who have accepted the policy (as recipients of U.S. Global health assistance) that then in turn provide that donor or U.S.

Non global health funding for any purpose to foreign NGOs that perform or actively promote abortion as a method of family planning. For example, under the prior interpretation, a foreign NGO recipient of U.S. Global health funding could not provide any non-U.S.

Funding to another foreign NGO to perform or actively promote abortion as a method of family planning but could provide funding for other activities, such as education, even if the foreign NGO carried out prohibited activities. Under the broader interpretation, a foreign NGO could not provide any non-U.S. Funding for any activity to a foreign NGO that carried out prohibited activities.

Similarly, while under the prior interpretation a foreign NGO recipient of U.S. Global health funding could provide other U.S. Funding (such as humanitarian assistance) to another foreign NGO for non-prohibited activities, even if the foreign NGO carried out prohibited activities, now under the broader interpretation, it could not do so.What are the next steps in implementing the expanded policy?.

The policy went into effect in May 2017 (see Table 2), although it is applied on a rolling basis, as new funding agreements and modifications to existing agreements occur. While it applies to all grants and cooperative agreements, the Trump administration has indicated that it intends the policy to apply to contracts, which would require a rule-making process (it began this process by publishing a proposed rule in September 2020)..

About This TrackerThis tracker provides the number of confirmed cases and deaths from novel erectile dysfunction by country, the trend kamagra canada buy in confirmed case and death counts by country, and Cialis online a global map showing which countries have confirmed cases and deaths. The data are drawn from the Johns Hopkins University (JHU) erectile dysfunction Resource Center’s erectile dysfunction treatment Map and the World Health Organization’s (WHO) erectile dysfunction Disease (erectile dysfunction treatment-2019) situation reports.This tracker will be updated regularly, as new data are released.Related Content. About erectile dysfunction treatment erectile dysfunctionIn late 2019, a new erectile dysfunction emerged in central China to cause disease kamagra canada buy in humans.

Cases of this disease, known as erectile dysfunction treatment, have since been reported across around the globe. On January 30, 2020, the World Health Organization (WHO) declared the kamagra canada buy kamagra represents a public health emergency of international concern, and on January 31, 2020, the U.S. Department of Health and Human Services declared it to be a health emergency for the United States.Key PointsOn January 23, 2017, President Donald Trump reinstated and expanded the Mexico City Policy via presidential memorandum, renaming it “Protecting Life in Global Health Assistance.” This explainer provides an overview of the policy, including its history, changes over time, and current application.First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines and has now been in effect for 19 of the past 34 years.The policy requires foreign non-governmental organizations (NGOs) to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S.

Funds) as a condition of kamagra canada buy receiving U.S. Government global family planning assistance and, as of Jan. 23, 2017, kamagra canada buy most other U.S.

Global health assistance.The Trump administration’s application of the policy extends to the vast majority of U.S. Bilateral global health assistance, including funding for HIV under PEPFAR, maternal and child health, malaria, nutrition, and other programs kamagra canada buy. This marks a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounts for approximately $600 million of that total).Additionally, as a result of a March 2019 policy announcement and subsequent information released in June 2019, the policy, for the first time, prohibits foreign NGOs who accept the policy from providing any financial support using any source of funds and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning.

This greatly extends its reach to other areas of kamagra canada buy U.S. Development assistance beyond global health and to other non-U.S. Funding streams.More kamagra canada buy recently, in September 2020, a proposed rule to extend the policy to contracts was published.

If finalized, it would greatly extend the reach of the policy beyond grants and cooperative agreements to also include contracts.KFF analyses have found that:more than half of the countries in which the U.S. Provides bilateral global health assistance allow for legal abortion in at least one kamagra canada buy case not permitted by the policy (analysis). Andhad the expanded policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy (analysis).What is the Mexico City Policy?.

The Mexico City Policy is kamagra canada buy a U.S. Government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. Funds) as a kamagra canada buy condition of receiving U.S.

Global family planning assistance and, as of Jan. 23, 2017, most other kamagra canada buy U.S. Global health assistance.The policy was first announced by the Reagan administration at the 2nd International Conference on Population, which was held in Mexico City, Mexico, on August 6-14, 1984 (hence its name.

See Box 1) kamagra canada buy. Under the Trump administration, the policy has been renamed “Protecting Life in Global Health Assistance” (PLGHA). Among opponents, it is also known as the “Global Gag Rule,” because among other activities, it prohibits foreign NGOs kamagra canada buy from using any funds (including non-U.S.

Funds) to provide information about abortion as a method of family planning and to lobby a foreign government to legalize abortion. €œ[T]he United States does not consider abortion an kamagra canada buy acceptable element of family planning programs and will no longer contribute to those of which it is a part. €¦[T]he United States will no longer contribute to separate nongovernmental organizations which perform or actively promote abortion as a method of family planning in other nations.”When first instituted in 1984, the Mexico City Policy marked an expansion of existing legislative restrictions that already prohibited U.S.

Funding for abortion internationally, with some exceptions kamagra canada buy (see below). Prior to the policy, foreign NGOs could use non-U.S. Funds to engage in certain voluntary abortion-related activities as long as kamagra canada buy they maintained segregated accounts for any U.S.

Money received, but after the Mexico City Policy was in place, they were no longer permitted to do so if they wanted to receive U.S. Family planning assistance.The Trump administration’s application kamagra canada buy of the policy to the vast majority of U.S. Bilateral global health assistance, including funding for HIV under the U.S.

President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, malaria, nutrition, and other programs, marks a significant expansion of its scope, potentially encompassing kamagra canada buy $7.3 billion in FY 2020, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total). The Administration’s more recent extension of the policy to include any financial support (health or otherwise) provided by foreign NGOs for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning is likely to encompass significant additional funding.When has it been in effect?. The Mexico City Policy has been in effect for 19 of the past 34 years, primarily through executive action, and has been instated, rescinded, and reinstated by presidential administrations along party lines (see Table 1).The policy was first instituted in 1984 (taking effect in 1985) by President Ronald Reagan and continued to be in effect through President George H.W.

Bush’s administration kamagra canada buy. It was rescinded by President Bill Clinton in 1993 (although it was reinstated legislatively for one year during his second term. See below) kamagra canada buy.

The policy was reinstated by President George W. Bush in 2001 and then rescinded by President Barack Obama kamagra canada buy in 2009. It is currently in effect, having been reinstated by President Trump in 2017.

YearsIn Effect? kamagra canada buy. Presidential Administration (Party Affiliation)Executive (E) or Congressional (C) Action?. 1985-1989YesReagan (R)E1989-1993YesBush (R)E1993-1999 Sept.NoClinton (D)E1999 kamagra canada buy Oct.-2000 Sept.Yes*Clinton (D)C2000 Oct.-2001NoClinton (D)E2001-2009YesBush (R)E2009-2017NoObama (D)E2017-presentYesTrump (R)ENOTES.

Shaded blue indicate periods when policy was in effect. * There was kamagra canada buy a temporary, one-year legislative imposition of the policy, which included a portion of the restrictions in effect in other years and an option for the president to waive these restrictions in part. However, if the waiver option was exercised (for no more than $15 million in family planning assistance), then $12.5 million of this funding would be transferred to maternal and child health assistance.

The president did kamagra canada buy exercise the waiver option.SOURCES. €œPolicy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. Bill Clinton kamagra canada buy Administration, “Subject.

AID Family Planning Grants/Mexico City Policy,” Memorandum for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives, https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html. FY 2000 Consolidated kamagra canada buy Appropriations Act, P.L. 106-113.

George W kamagra canada buy. Bush Administration, “Subject. Restoration of the Mexico City Policy,” Memorandum for kamagra canada buy the Administrator of the United States Agency for International Development, January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html.

€œSubject. Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United kamagra canada buy States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy. George W.

Bush Administration, “Subject kamagra canada buy. Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html. Barack Obama Administration, “Mexico City kamagra canada buy Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning.

White House, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, https://www.whitehouse.gov/the-press-office/2017/01/23/presidential-memorandum-regarding-mexico-city-policy.How is it instituted kamagra canada buy (and rescinded)?. The Mexico City Policy has, for the most part, been instituted or rescinded through executive branch action (typically via presidential memoranda).

While Congress has kamagra canada buy the ability to institute the policy through legislation, this has happened only once in the past. A modified version of the policy was briefly applied by Congress during President Clinton’s last year in office as part of a broader arrangement to pay the U.S. Debt to the kamagra canada buy United Nations.

(At that time, President Clinton was able to partially waive the policy’s restrictions.) Other attempts to institute the policy through legislation have not been enacted into law, nor have legislative attempts to overturn the policy. See Table kamagra canada buy 1.Who does the policy apply to?. The policy, when in effect, applies to foreign NGOs as a condition for receiving U.S.

Family planning support and, now, other global health assistance, either directly (as the main – or prime – recipient of U.S. Funding) or kamagra canada buy indirectly (as a recipient of U.S. Funding through an agreement with the prime recipient.

Referred to as a sub-recipient) kamagra canada buy. Specifically, a foreign NGO “recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities.”Foreign NGOs include:international NGOs that are based outside the U.S.,regional NGOs that are based outside the U.S., andlocal NGOs in assisted countries.U.S. NGOs, while not directly subject to the Mexico City Policy, must also agree to ensure that they do not provide funding to any foreign NGO sub-recipients unless those sub-recipients have first certified kamagra canada buy adherence to the policy.

Specifically, a U.S. NGO “recipient (A) agrees that it will not furnish health assistance under this award to any foreign non-governmental organization that performs or kamagra canada buy actively promotes abortion as a method of family planning in foreign countries. And (B) further agrees to require that such sub-recipients do not provide financial support to any other foreign non-governmental organization that conducts such activities.”As in the past, the current policy does not apply to funding provided by the U.S.

Government to foreign governments (national or sub-national), public international organizations, and other multilateral entities, such as the Global kamagra canada buy Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the treatment Alliance. However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy. See “What kamagra canada buy is ‘financial support’?.

€ below.To what assistance does it apply?. In the past, foreign NGOs have been required to adhere to the Mexico City Policy – when it was in kamagra canada buy effect – as a condition of receiving support through certain U.S. International funding streams.

Family planning assistance through the U.S kamagra canada buy. Agency for International Development (USAID) and, beginning in 2003, family planning assistance through the U.S. Department of kamagra canada buy State.

In the 2003 memorandum announcing the policy’s expansion to include the Department of State, President Bush stated that the policy did not apply to funding for global HIV/AIDS programs and that multilateral organizations that are associations of governments are not included among “foreign NGOs.”The current policy, reinstated in 2017, applies to the vast majority of U.S. Bilateral global health assistance furnished by all kamagra canada buy agencies and departments. “Assistance” includes “the provision of funds, commodities, equipment, or other in-kind global health assistance.” Specifically, the expanded policy applies to nearly all bilateral global health assistance, including.

family planning kamagra canada buy and reproductive healthfor the first time:maternal and child health (including household-level water, sanitation, and hygiene (WASH))nutritionHIV under PEPFARtuberculosismalaria under the President’s Malaria Initiative (PMI)neglected tropical diseasesglobal health securitycertain types of research activitiesThe policy applies to the assistance described above that is appropriated directly to three agencies and departments. USAID. The Department of State, including kamagra canada buy the Office of the Global AIDS Coordinator, which oversees and coordinates U.S.

Global HIV funding under PEPFAR. And for kamagra canada buy the first time, the Department of Defense (DoD). When such funding is transferred to another agency, including the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), it remains subject to the policy, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly.The policy applies to three types of funding agreements for such assistance.

Grants. Cooperative agreements. And, for the first time, contracts, pending necessary rule-making that would be needed to do so (a proposed rule to accomplish this was published in September 2020).The policy does not apply to U.S.

Assistance for. Water supply and sanitation activities, which is usually focused on infrastructure and systems. Humanitarian assistance, including activities related to migration and refugee assistance activities as well as disaster and humanitarian relief activities.

The American Schools and Hospitals Abroad (ASHA) program. And Food for Peace (FFP). However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy.

See “What is ‘financial support’?. € below.What activities are prohibited?. The policy prohibits foreign NGOs that receive U.S.

Family planning assistance and, now, most other U.S. Bilateral global health assistance from using funds from any source (including non-U.S. Funds) to “perform or actively promote abortion as a method of family planning.” In addition to providing abortions with non-U.S.

Funds, restricted activities also include the following:providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e., engaging in lobbying), andconducting public information campaigns about abortion as a method of family planning.The prohibition of these activities are why the policy has been referred to by its critics as the “Global Gag Rule.”Additionally, for the first time, the policy prohibits foreign NGOs from providing any financial support with any source of funds (including non-U.S. Funding) and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning. See “What is “financial support?.

€ below.The policy, however, does not prohibit foreign NGOs from:providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the mother or resulted from incest or rape. Andresponding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information).In addition, the expanded policy does not apply to healthcare providers who have an affirmative duty required under local law to provide counseling about and referrals for abortion as a method of family planning.Does it restrict direct U.S. Funding for abortion overseas?.

U.S. Funding for abortion is already restricted under several provisions of the law. Specifically, before the Mexico City Policy was first announced in 1984, U.S.

Law already prohibited the use of U.S. Aid:to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act). Andto lobby for or against abortion (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).Then, shortly after the policy was announced in 1984, the Kemp-Kasten Amendment was passed in 1985, prohibiting the use of U.S.

Aid to fund any organization or program, as determined by the president, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it is now included in annual appropriations).Before the Mexico City Policy, U.S. Aid recipients could use non-U.S. Funds to engage in certain abortion-related activities but were required to maintain segregated accounts for U.S.

Assistance. The Mexico City Policy reversed this practice. No longer were foreign NGOs allowed to use non-U.S.

Funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive U.S. Family planning funds.Does the policy prohibit post-abortion care?. The Mexico City Policy does not restrict the provision of post-abortion care, which is a supported activity of U.S.

Family planning assistance. Whether or not the Mexico City Policy is in effect, recipients of U.S. Family planning assistance are allowed to use U.S.

And non-U.S. Funding to support post-abortion care, no matter the circumstances of the abortion (whether it was legal or illegal).What has been the impact of the policy?. Several studies have looked at the impact of the policy.

A 2011 quantitative analysis by Bendavid, et. Al, found a strong association between the Mexico City Policy and abortion rates in sub-Saharan Africa. This study was recently updated to include several more years of data, again identifying a strong association.

Specifically, the updated study found that during periods when the policy was in place, abortion rates rose by 40% in countries with high exposure to the Mexico City Policy compared to those with low exposure, while the use of modern contraceptives declined by 14% and pregnancies increased by 12% in high exposure compared to low exposure countries. In other words, it found patterns that “strengthen the case for the role played by the policy” in “a substantial increase in abortions across sub-Saharan Africa among women affected by the U.S. Mexico City Policy … [and] a corresponding decline in the use of modern contraception and increase in pregnancies,” likely because foreign NGOs that declined U.S.

Funding as a result of the Mexico City Policy – often key providers of women’s health services in these areas – had fewer resources to support family planning services, particularly contraceptives. Increased access to and use of contraception have been shown to be key to preventing unintended pregnancies and thereby reducing abortion, including unsafe abortion. The study also found patterns that “suggest that the effects of the policy are reversible” when the policy is not in place.Additionally, there has been anecdotal evidence and qualitative data on the impact of the policy, when it has been in force in the past, on the work of organizations that have chosen not to agree to the policy and, therefore, forgo U.S.

Funding that had previously supported their activities. For example, they have reported that they have fewer resources to support family planning and reproductive health services, including family planning counseling, contraceptive commodities, condoms, and reproductive cancer screenings.While it is likely too early to assess the full effects of the current policy on NGOs and the individuals they serve, as the policy is applied on a rolling basis as new funding agreements or modifications to existing agreements are made, some early data are available. Several early qualitative and quantitative studies have been released, and at least one long-term, quantitative assessment is underway.

Additionally, an official assessment by the U.S. Department of State on implementation during the first six months of the policy has been released (see below). This review acknowledged that it took “place early in the policy’s implementation, when affected U.S.

Government departments and agencies have added a significant portion of the funding affected by the policy to grants and cooperative agreements only recently [i.e., after the period the review examined]. A follow-on analysis would allow an opportunity to address one of the primary concerns presented in feedback from third-party stakeholder organizations, namely that six months is insufficient time to gauge the impacts of” the policy.Nonetheless, it is already clear that the reinstated and expanded version of the policy applies to a much greater amount of U.S. Global health assistance, and greater number of foreign NGOs, across many program areas.

KFF has found that more than half (37) of the 64 countries that received U.S. Bilateral global health assistance in FY 2016 allow for legal abortion in at least one case not permitted by the policy and that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy. In addition, at least 469 U.S.

NGOs that received U.S. Global health assistance during this period would have been required to ensure that their foreign NGO sub-recipients were in compliance. Additional foreign NGOs are likely to be impacted by the policy due to the revised interpretation of “financial support” announced in March 2019 and implemented beginning June 2019.

See “What is ‘financial support’?. € below.A report released in March 2020 by the U.S. Government Accountability Office (GAO) provided new information on the number of projects (awards) and NGOs affected.

It found that from May 2017 through FY 2018:the policy had been applied to over 1,300 global health projects, with the vast majority of these through USAID and CDC, andNGOs declined to accept the policy in 54 instances, totaling $153 million in declined funding – specifically, seven prime awards amounting to $102 million and 47 sub-awards amounting to $51 million (more than two-thirds of sub-awards were intended for Africa) – across USAID and CDC. The Department of State and DoD did not identify any instances where NGOs declined to accept the policy conditions.What have the U.S. Government’s reviews of the policy found?.

The U.S. Government has published two reviews of the policy to date, with the first examining the initial six months of the policy released in February 2018 and the second examining the first 18 months of the policy released in August 2020.First ReviewIn February 2018, the Department of State announced the findings of an initial six-month review of implementation of the policy through the end of FY 2017 (September 2017). The report directed agencies to provide greater support for improving understanding of implementation among affected organizations and provided guidance to clarify terms included in standard provisions of grants and cooperative agreements.

In the six-month review report, the Department of State report identified a number of “actions” for implementing agencies, such as a need for:more central and field-based training and implementation tools,a clearer explanation of termination of awards for NGOs found to be in violation of the policy, anda clarification of “financial support,” which was not defined in the standard provisions (see “What is financial support?. € below).The six month review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2017 (see Table 2). U.S.

Agency or DepartmentPolicy Implementation DateOverall # of Grants and Cooperative Agreements with Global Health Assistance FundingOf Overall #:(From the Policy Implementation Date through 9/30/2017)# That Received New Funding and Accepted Policy# That Received New Funding and Declined to Accept Policy^# That Had Not Received New Funding YetUSAIDMay 15, 20175804193158State*May 15, 2017142108034HHS+May 31, 20174991600339DoDMay 15, 20177742134TOTAL12987294565NOTES. * reflects PEPFAR funding implemented through the Department of State. Other departments and agencies implement the majority of PEPFAR funding.

+ At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2017, USAID reported it was aware of three centrally funded prime partners, and 12 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards. DoD reported that one DoD partner, a U.S.

NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that no HHS partners declined to agree.SOURCES. KFF analysis of data from Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb.

6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Second ReviewOn August 17, 2020, the Department of State released its second review of the policy, updating its initial six-month review (as an action item in the six-month review report, the department stated it would “conduct a further review of implementation of the policy by December 15, 2018, when more extensive experience will enable a more thorough examination of the benefits and challenges”). The long-anticipated review, which examines the period from May 2017 through September 2018, found:the awards declined spanned a variety of program areas, including family planning and reproductive health (FP/RH), HIV and AIDS (HIV/AIDS), maternal and child health (MCH), tuberculosis (TB), and nutrition, in addition to cross-cutting awards;the awards declined spanned geographic areas but many were for activities in sub-Saharan Africa;agencies and departments made efforts to transition projects to another implementer in order to minimize disruption. Butnevertheless, among USAID awards involving health service delivery where prime and sub-award recipients declined to accept the policy, gaps or disruptions in service delivery were sometimes reported.The second review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2018 (see Table 3).

U.S. Agency or DepartmentPolicy Implementation Date# of Grants and Cooperative Agreements with Global Health Assistance Funding# of Prime Awardees That Declined to Accept Policy^USAIDMay 15, 20174866State*May 15, 20173350HHS+May 31, 20174661DoDMay 15, 2017531TOTAL13408NOTES. * reflects PEPFAR funding implemented through the Department of State.

Other departments and agencies implement the majority of PEPFAR funding. + At HHS agencies, only certain assistance funding transferred from USAID, State, and DoD are subject to the policy. ^ As of September 30, 2018, USAID reported it was aware of six centrally funded prime partners, and 47 sub-awardee implementing partners, that declined to agree to the Protecting Life in Global Health Assistance (PLGHA) terms in their awards.

DoD reported that one DoD partner, a U.S. NGO, declined to agree in one country but accepted the PLGHA standard provision in other countries. And HHS reported that one HHS partner declined to agree.SOURCES.

KFF analysis of data from Department of State, “Review of the Implementation of the Protecting Life in Global Health Assistance Policy ,” report, Aug. 17, 2020, https://www.state.gov/wp-content/uploads/2020/08/PLGHA-2019-Review-Final-8.17.2020-508.pdf, and Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://www.state.gov/protecting-life-in-global-health-assistance-six-month-review/.Additionally, the review reports that 47 sub-awardees, all under USAID awards, declined to accept the policy.

It is important to note that the review also states that information on sub-awards is not systematically collected by departments and agencies and that DoD was not able to collect information on sub-awards.What is “financial support”?. In February 2018, in the initial six-month review issued when Secretary of State Tillerson led the department, the Department of State report included an “action” statement to clarify the definition of “financial support” as used in the standard provisions for grants and cooperative agreements. At issue was whether it applied more narrowly to certain funding provided by foreign NGOs (i.e., funding other than U.S.

Global health funding) to other foreign NGOs specifically for the purpose of performing or actively promoting abortion as a method of family planning or if it applied more broadly to certain funding provided by foreign NGOs to other foreign NGOs for any purpose, if that foreign NGO happened to perform or actively promote abortion as a method of family planning. The State Department clarified that it was the more narrow interpretation.However, on March 26, 2019, Secretary of State Pompeo reversed this interpretation, announcing further “refinements” to the policy to clarify that it applied to the broader definition of financial support. Specifically, under the policy, U.S.-supported foreign NGOs agree to not provide any financial support (global health-related as well as other support), no matter the source of funds, to any other foreign NGO that performs or actively promotes abortion as a method of family planning.

In June 2019, USAID provided additional information to reflect this broader interpretation of the standard provisions.This marks the first time the policy has been applied this broadly, as it can now affect funding provided by other donors (such as other governments and foundations) and non-global health funding provided by the U.S. Government for a wide range of purposes if this funding is first provided to foreign NGOs who have accepted the policy (as recipients of U.S. Global health assistance) that then in turn provide that donor or U.S.

Non global health funding for any purpose to foreign NGOs that perform or actively promote abortion as a method of family planning. For example, under the prior interpretation, a foreign NGO recipient of U.S. Global health funding could not provide any non-U.S.

Funding to another foreign NGO to perform or actively promote abortion as a method of family planning but could provide funding for other activities, such as education, even if the foreign NGO carried out prohibited activities. Under the broader interpretation, a foreign NGO could not provide any non-U.S. Funding for any activity to a foreign NGO that carried out prohibited activities.

Similarly, while under the prior interpretation a foreign NGO recipient of U.S. Global health funding could provide other U.S. Funding (such as humanitarian assistance) to another foreign NGO for non-prohibited activities, even if the foreign NGO carried out prohibited activities, now under the broader interpretation, it could not do so.What are the next steps in implementing the expanded policy?.

The policy went into effect in May 2017 (see Table 2), although it is applied on a rolling basis, as new funding agreements and modifications to existing agreements occur. While it applies to all grants and cooperative agreements, the Trump administration has indicated that it intends the policy to apply to contracts, which would require a rule-making process (it began this process by publishing a proposed rule in September 2020)..