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POLICY AND PRACTICE
Le défaut de traitement en santé mentale
La brecha terapéutica en la atención de salud mental
Robert KohnI,1; Shekhar SaxenaII; Itzhak LevavIII; Benedetto SaracenoII
IBrown University Department of Psychiatry and Human Behavior, Providence, RI, USA
IIWorld Health Organization, Department of Mental Health and Substance Dependence, Geneva, Switzerland
IIIMinistry of Health, Jerusalem, Israel
Mental disorders are highly prevalent and cause considerable suffering and disease burden. To compound this public health problem, many individuals with psychiatric disorders remain untreated although effective treatments exist. We examine the extent of this treatment gap. We reviewed community-based psychiatric epidemiology studies that used standardized diagnostic instruments and included data on the percentage of individuals receiving care for schizophrenia and other non-affective psychotic disorders, major depression, dysthymia, bipolar disorder, generalized anxiety disorder (GAD), panic disorder, obsessive–compulsive disorder (OCD), and alcohol abuse or dependence. The median rates of untreated cases of these disorders were calculated across the studies. Examples of the estimation of the treatment gap for WHO regions are also presented. Thirty-seven studies had information on service utilization. The median treatment gap for schizophrenia, including other non-affective psychosis, was 32.2%. For other disorders the gap was: depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 57.3%. Alcohol abuse and dependence had the widest treatment gap at 78.1%. The treatment gap for mental disorders is universally large, though it varies across regions. It is likely that the gap reported here is an underestimate due to the unavailability of community-based data from developing countries where services are scarcer. To address this major public health challenge, WHO has adopted in 2002 a global action programme that has been endorsed by the Member States.
Keywords: Mental health services/utilization; Health services accessibility; Schizophrenia/therapy; Anxiety disorders/therapy; Mood disorders/therapy; Compulsive personality disorder/therapy; Alcoholism/therapy; Epidemiologic studies; Cost of illness; Americas; Europe (source: MeSH, NLM).
Les troubles mentaux ont une prévalence élevée et représentent une charge considérable en termes de souffrance et de maladie. De plus, de nombreuses personnes atteintes de troubles psychiques restent sans traitement alors qu'il en existe d'efficaces. Dans le présent article, nous examinons l'étendue de ce défaut de traitement. Nous avons effectué une revue des études épidémiologiques psychiatriques en population utilisant des outils de diagnostic standard et comportant des données sur le pourcentage de sujets traités pour schizophrénie et autres troubles psychotiques non affectifs, dépression majeure, dysthymie, trouble bipolaire, anxiété généralisée, trouble panique, troubles obsessionnels-compulsifs (TOC) et abus d'alcool ou dépendance alcoolique. Les taux médians d'absence de traitement de ces affections ont été calculés pour l'ensemble de ces études. L'article présente également des exemples d'estimations du défaut de traitement dans les Régions OMS. Le taux médian de défaut de traitement pour la schizophrénie, y compris les autres psychoses non affectives, était de 32,2 %. Pour les autres affections il était de : dépression 56,3 %, dysthymie 56,0 %, trouble bipolaire 50,2 %, trouble panique 55,9 %, anxiété généralisée 57,5 % et TOC 57,3 %. Il était maximal pour l'abus d'alcool et la dépendance alcoolique avec 78,1 %. Le taux de défaut de traitement des troubles mentaux est élevé partout, même s'il varie d'une région à l'autre. Il est probable que les taux rapportés ici sont en-deçà de la réalité, du fait de l'absence de données concernant les pays en développement, où les services de santé mentale sont plus rares. Pour répondre à cet important problème de santé publique, l'OMS a adopté en 2002 un programme mondial d'action, qui a été approuvé par les Etats Membres.
Mots clés: Service santé mentale/utilisation; Accessibilité service santé; Schizophrénie/thérapeutique; Etat anxiété/thérapeutique; Troubles humeur/thérapeutique; Personnalité compulsive/thérapeutique; Alcoolisme/thérapeutique; Etude analytique (Epidémiologie); Coût maladie; Amérique; Europe (source: MeSH, INSERM).
Los trastornos mentales, cuya prevalencia es muy alta, son una causa destacada de sufrimiento y morbilidad. Este problema de salud pública se ve agravado por el hecho de que muchos individuos aquejados de trastornos psiquiátricos no reciben tratamiento alguno pese a que existen intervenciones eficaces. Hemos analizado la magnitud de esa brecha terapéutica, para lo cual se han examinado estudios comunitarios de epidemiología psiquiátrica que habían usado instrumentos diagnósticos normalizados e incluían datos sobre el porcentaje de individuos que recibían atención por padecer esquizofrenia y otros trastornos psicóticos no afectivos, depresión grave, distimia, trastorno bipolar, trastorno de ansiedad generalizado, trastorno de pánico, trastorno obsesivo–compulsivo (TOC) y abuso o dependencia del alcohol. Se calcularon las tasas medianas de casos sin tratar de esos trastornos en el conjunto de todos los estudios. Se presentan asimismo ejemplos de estimaciones de la brecha terapéutica para las Regiones de la OMS. En 37 estudios se facilitaba información sobre la utilización de los servicios. La brecha terapéutica mediana para la esquizofrenia, incluidas otras psicosis no afectivas, fue del 32,2%. Las brechas medidas para los otros trastornos fueron las siguientes: depresión, 56,3%; distimia, 56,0%; trastorno bipolar, 50,2%; trastorno de pánico, 55,9%; ansiedad generalizada, 57,5%, y TOC, 57,3%. La brecha más importante fue la correspondiente al abuso y la dependencia del alcohol, 78,1%. La brecha terapéutica de los trastornos mentales es muy amplia en general, aunque varía entre las regiones. Es probable que los valores aquí presentados subestimen la realidad, debido a la falta de datos comunitarios de los países en desarrollo donde más escasean los servicios. Para afrontar este importante reto de salud pública, la OMS ha adoptado en 2002 un programa mundial de acción que ha sido respaldado por los Estados Miembros.
Palabras clave: Servicios de salud mental/utilización; Accesibilidad a los servicios de salud; Esquizofrenia/terapia; Trastornos de ansiedad/terapia; Trastornos del humor/terapia; Trastorno de personalidad compulsiva/terapia; Alcoholismo/terapia; Estudios epidemiológicos; Costo de la enfermedad; Americas; Europa (fuente: DeCS, BIREME).
The care of people with mental and brain disorders is a growing public health concern. These disorders are highly prevalent and exact a high emotional toll on individuals, families, and society. Worldwide, community-based epidemiological studies have estimated rates of lifetime prevalence of mental disorders among adults ranging from 12.2% to 48.6% and 12-month prevalence rates ranging from 8.4% to 29.1% (1). These rates do not include neurological conditions affecting the brain (1). WHO (2) has estimated that approximately 450 million individuals worldwide suffer from neuropsychiatric disorders in their lifetime.
Mental disorders are not only highly prevalent medical conditions but they are also highly disabling. Measured by years lived with disability and by premature death in disability-adjusted life years (DALYs), psychiatric and neurological conditions accounted for over 13% of the global disease burden in the year 2001 (3). When compared with 1990, the contribution of neuropsychiatric disorders is expected to increase to almost 15% by the year 2020 (4). Among individuals age 15–44, unipolar depression is the second leading contributor of DALYs, with alcohol-related disorders, schizophrenia, and bipolar disorder among the top 10 disorders. Approximately 33% of all years lived with disability (YLD) are imputed to neuropsychiatric conditions. Of the 10 leading causes of YLD in the world among individuals of all ages, four are psychiatric conditions, with unipolar depression being the leading cause (2). Among individuals between the ages of 15 and 44, panic disorder, drug use disorders, and obsessive–compulsive disorder (OCD) were included in the top 20 disorders.
In part, the excess disability due to mental disorders is a result of their early age of onset (1). The magnitude of this burden also results from the fact that only a minority of individuals with these disorders ever receive treatment in the specialized mental health care system or in the general health care system (5); initial treatment is frequently delayed for many years (6). Numerous reasons have been imputed. These include: failing to seek help because the problem is not acknowledged, perceiving that treatment is not effective, believing that the problem will go away by itself, and desiring to deal with the problem without outside help (7, 8). In addition a lack of knowledge about mental disorders and stigma remain major barriers to care (9, 10). Factors that are direct barriers to care also preclude treatment, including financial considerations (11), issues of accessibility, as well as limited availability or lack of availability of services in many countries or for some populations (12).
If disability is to be reduced, a bridging of the "treatment gap" must occur. The treatment gap represents the absolute difference between the true prevalence of a disorder and the treated proportion of individuals affected by the disorder. Alternatively, the treatment gap may be expressed as the percentage of individuals who require care but do not receive treatment. Estimating the treatment gap in a population depends on the prevalence period of the disorder, the time frame of the examination of service utilization, and the demographic representativeness of the study sample with reference to the target population. The objective of this report is to examine the extent of the treatment gap for selected mental disorders.
To examine the worldwide extent of the treatment gap the following disorders were selected: schizophrenia and non-affective psychosis, major depressive disorder, dysthymia, bipolar disorder, OCD, panic disorder, generalized anxiety disorder (GAD), and alcohol abuse and dependence. The literature review was limited to community-based epidemiological surveys of adults age 15 and older that had been published since 1980 or provided by investigators or agencies. The literature search was conducted using the search engines of medical journals, Medline and LILACS (a database of Latin American and Caribbean literature), and using key words that included the terms "psychiatric epidemiology," "prevalence" and the name of a specific disorder, and the names of commonly used diagnostic instruments. The references of book chapters and review articles on psychiatric epidemiology or service utilization were examined. We also searched abstracts from proceedings of meetings of the World Psychiatric Association section on epidemiology and the annual meeting of the American Psychiatric Association.
The studies considered used standardized data collection instruments that generated a diagnosis linked to accepted classification systems. Surveys relying on diagnostic instruments designed specifically for use only in elderly populations were not included. Data on service utilization were obtained from community-based epidemiological studies of psychiatric disorders regardless of prevalence periods. Service utilization was defined as seeking assistance from any medical or professional service provider, specialized or not, public or private. By definition, traditional healers and non-professional providers were excluded. The category of service utilization included both somatic and psychotherapeutic treatment; however, most studies did not report utilization by treatment modality, thus limiting the analysis to overall utilization. The treatment gap from each of the available studies was determined for each specific disorder.
The median and average rates of service utilization across the studies were calculated for each disorder. Using the median rate prevents outliers from having an undue influence. Adequate data were not available for all WHO regions, but examples of regional treatment gap rates were calculated. Regional treatment gap (G) calculations take into account the service utilization rate (Sc), the prevalence rate (Rc), and the population size (Pc) of each of the countries:
We estimated the population in each country of individuals age 15 and older. The latest census data by age distribution were obtained from the United Nations demographic yearbook (13). Since the last census year varied from country to country, the estimates prepared by WHO for the year 1999 were used (14). These estimates provided data only on an individual Member country's total population. To estimate the proportion of individuals aged 15 and older, data from the last census was applied to the 1999 total population estimate to obtain an approximation of each country's population as well as of regional populations.
A description of the 37 studies with data on service utilization is included in Appendix 1. The references are available in Appendix 2 (Appendix 1 and Appendix 2, web version only, available at: http://www.who.int/bulletin). The treatment gap is shown as percentage and the median and average treatment gap for each disorder is shown in Table 1. Where available, the rates of use of specialized mental health services are presented.
The median untreated rate, or treatment gap, for schizophrenia including other non-affective psychoses was 32.2%. For other disorders the gap was: major depression, 56.3%; dysthymia, 56.0%; bipolar disorder, 50.2%; panic disorder, 55.9%; GAD, 57.5%; and OCD, 59.5%. Alcohol abuse and dependence had the largest treatment gap at 78.1%. The treatment gap varied widely between countries. As an illustration, for schizophrenia the gap among young adult Jews in Israel was only 5.9%, while the rate in New Zealand in a population of 21-year-olds was 61.5%. The treatment gap in Italy was 15.9% for major depression, while studies in the United Kingdom gave an estimate of 83.9%. The treatment gap for alcohol abuse and dependence was high across all studies: Jewish-Israeli young adults had the lowest gap (49.4%) but in Mexico City among the general adult population few were in treatment (96.0%).
Service-related information from psychiatric epidemiological studies for many regions of the world was not available, so regional estimates of the treatment gap were not possible. As a result, examples of the treatment gap for major depression are presented for the Americas and the European Regions of WHO, since there is a good representation of studies across the countries in these two regions. The 12-month prevalence, or if not available, the current prevalence, were applied. When more than one study was available for a country, the most representative ones were used (those that referred to the entire sample studied). For the United States, the Epidemiological Catchment Area (ECA) and National Comorbidity Survey (NCS) prevalence and service utilization rates were averaged, as were the rates for studies done by the United Kingdom Office for National Statistics (ONS) and the Office of Population Censuses and Surveys (OPCS). For Finland and the Netherlands, studies based on the Composite International Diagnostic Interview (CIDI) were used.
The treatment gap for major depression in the WHO European Region was 45.4%, and for the Americas it was 56.9%. The average 12-month prevalence for major depression, weighting for the proportion of the population over the age of 15 were: 4.7% for the WHO European Region and 6.2% for the Americas. This suggests that in these regions there are about 31 million people and 35 million people, respectively, with major depression during a 12-month period. Of those, about 14 million in the European Region are untreated and about 20 million in the Americas are untreated. Estimates for other disorders and WHO regions are presented in Table 2.
Admittedly, the sources of data that we present are limited. Yet they seem to indicate that the treatment gap across all the psychiatric disorders examined is wide. Even for the most severe mental disorder, schizophrenia, at least one-third of individuals remain untreated.
Clearly, the rates presented here are an underestimation. There are few studies of developing countries, where services are scarce, and the studies that are available are of highly selected regions. Thus, the treatment gap for the Americas would have been higher if all of the Latin American and Caribbean countries had been represented. As an illustration, in Belize a study of the prevalence of treatment that was based on a review of each record of all health-care providers who treated mental disorders found that about 63% of individuals with schizophrenia were untreated; 89% of those with affective disorders had not been treated; and 99% of those with an anxiety disorder also had not been treated (15). The scarcity of services in much of the world where epidemiological studies are not available is highlighted by the results of the Atlas study (12). Furthermore, common psychopharmacological agents used to treat psychosis, mania, depression and anxiety are not uniformly available (Table 3). Essential psychiatric medications at the primary care level are not available in 25% of countries (12). For 70% of the world's population there is access to less than one psychiatrist per 100 000 people (12).
This review did not examine the extent to which the skills of traditional healers and non-professional providers are utilized. Unfortunately, only a small number of studies have examined this issue. The Chilean epidemiological survey, however, suggested that contrary to popular belief, traditional healers were rarely utilized for mental health problems (16). Evidence-based data are needed on the efficacy of treatment by traditional healers and non-professional providers to help us understand their role in reducing the treatment gap.
There are few epidemiological studies that provide data on service utilization based on interviews with community respondents, and in general the method of elucidating service utilization is ill-defined and not uniform. The treatment gap for specific disorders also may be underestimated because comorbidity is not accounted for in studies of service utilization protocols that do not examine disorder-specific treatment. The treatment-gap estimates do not include childhood disorders or dementia and its effects on caregivers. In addition, some of the studies were regionally based and did not account for differences in socioeconomic status and its effects on service utilization, did not include members of indigenous populations, or did not account for regional inequities within a country. Moreover, reporting that services were sought does not imply that the treatment was adequately provided or provided at all. The studies reviewed did not measure the adequacy of treatment, and therefore, may greatly overestimate the number of people who received appropriate and adequate treatment. The primary care literature illustrates the inability of general physicians to accurately identify mental disorders and their failure to provide appropriate care (17). A study conducted in the United States among hospitalized individuals with schizophrenia revealed that over half had periods of 30 days or more off medication with an average time off medication of over seven months (18). Additionally, prevalence studies that reported on treatment utilization included individuals who are in treatment but have no current psychiatric diagnosis (19). These studies may refer to people with subclinical illness or to individuals who have benefited from treatment but no longer meet diagnostic criteria for one-year prevalence. Also, there are subclinical cases that merit treatment as they are evolving (20). If this were true, these service utilization studies might be underestimating the number of individuals with a specific diagnosis who have a past-year diagnosis and who receive treatment. Conversely, perhaps not everyone who meets diagnostic criteria needs treatment.
With regard to major depression there is some evidence that the advent of antidepressants that are better tolerated has played a part in reducing the treatment gap in countries that can afford their higher costs (21). It has also increased awareness of the disorder among primary care physicians (22). As noted in our analysis, the treatment gap was lower in the WHO European Region than in the Americas; in part this may be due to the wider availability of health coverage in western European countries. In the United States, treatment for depression increased between 1987 and 1997, despite a decline in the use of psychotherapy; this has been partially credited to expanded third-party payment for medication visits (22). This example from the United States may illustrate the role financial barriers have in contributing to the treatment gap. An alternative argument is that the increased rate of antidepressant use reflects the cohort effect of major depression and the increasing prevalence of the disorder among younger individuals (21).
Failing to reduce the treatment gap has implications beyond the impact on YLD and DALYs. An increased treatment gap has indirect economic costs. In the United States absenteeism and lost productivity at work as a result of affective disorders alone cost the nation US$ 23 billion annually and there is an additional cost of US$ 8 billion associated with premature death (23). Similarly, three-quarters of the cost of alcoholism in Germany is due to indirect factors (24). Improvements in antidepressant treatment and access to care has been credited with reducing suicide rates (25). Mental illness may result in an increased risk of living in poverty, having a lower socioeconomic status, and having lower educational attainment (26). Major depression, as well as other psychiatric disorders, has been shown to impair family function (27), increase the risk of teenage childbearing (28), and increase the risk of domestic violence (29). The impact of major depression on quality of life is as great or greater than the impact of chronic medical conditions (30). Individuals who do not seek treatment may be less clinically impaired, but there is little to suggest that treated and untreated individuals differ with regard to other psychosocial factors (31). The pervasive and chronic disability associated with major depression disappears when individuals become asymptomatic (32). Schizophrenia, major depression, and alcohol use disorders also result in an increased risk of early mortality other than suicide (33).
One factor that may diminish concern about addressing the treatment gap in health-care planning is that at least some of these disorders, such as major depression and alcohol abuse and dependence, may remit without treatment. Randomized controlled studies suggest that more than 20% of individuals with major depression who are untreated achieve remission within 20 weeks (34). However, longitudinal studies on the course of major depression, in which treatment of identified patients was not controlled, point to a more pessimistic outcome. A WHO cross-national study of 439 patients with major depression followed for 10 years found that 36% were readmitted to hospital; 11% committed suicide; and more than 18% had a poor clinical outcome (35). A 15-year follow-up study of 380 individuals who had recovered from major depression noted that 85% had a relapse (36).
The outcome is less clear for alcohol abuse and dependence. Sustained periods of abstinence without treatment are not uncommon (37). Individuals who need treatment are more likely to have significant social impairment and psychiatric comorbidity (38); therefore, accessibility and availability of care for a sizeable proportion of individuals with alcoholism is always necessary. Naturalistic studies of panic disorder have found low probabilities of remission and high rates of relapse among those who remit (39); a similar finding was noted for OCD (40). People with schizophrenia who remain untreated are often more symptomatic; stay ill longer; and are more disabled than those who receive treatment (41).
The long-term psychosocial complications of psychiatric disorders suggest not only that the treatment gap must be bridged but also that the treatment lag (the time from onset of a disorder to obtaining care) must be shortened. Of those individuals who seek help for affective disorder and anxiety disorder, 40% do so in the year of onset. In contrast, the remaining 60% have a median delay of eight years (42). Absenteeism and poor family functioning may be present, among other consequences, when a current disorder is untreated. It has been shown for individuals with panic disorder that the longer the duration of illness prior to treatment, the poorer the social outcome (43) and the more protracted the course (39). The duration of untreated psychosis (DUP) varies widely across studies: in an Australian study the average DUP was 6 months (44), while in Nigeria it was 2.1 years for women (45). Some investigators have suggested that the longer treatment lag in schizophrenia may have a neurotoxic affect on the brain (46), although more recent research has brought this finding into question (47).
To address the treatment gap, the 2001 World health report (2) has laid out 10 recommendations (Box 1). WHO has created various scenarios that begin to address these recommendations taking into account the fact that resources vary widely among nations. Following the report, WHO adopted the Mental Health Global Action Programme (mhGAP), which intends to modify the current world situation (48) with the endorsement of all Member States (49). Although the treatment gap remains wide for mental disorders, appropriate policies, programmes and service developments may allow this divide to be bridged for the benefit of those in need, their families and communities.
Funding: This paper was supported by WHO.
Conflicts of interest: none declared.
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Submitted: 22 June 2003 – Final revised version received: 20 November 2003 – Accepted: 21 November 2003
References for prevalence studies published since 1980 that provide data on service utilization
1. Andrews G, Hall W, Teesson M, Henderson S. The mental health of Australians. Australia: Mental Health Branch, Commonwealth Department of Health and Aged Care; 1999.
2. Henderson S, Andrews G, Hall W. Australia's mental health: an overview of the general population survey. Australian and New Zealand Journal of Psychiatry 2000;34:197-205.
3. Teesson M, Hall W, Lynskey M, Degenhardt L. Alcohol- and drug-use disorders in Australia: implications of the National Survey of Mental Health and Wellbeing. Australian and New Zealand Journal of Psychiatry 2000;34:206-13.
4. Andrade LH, Lolio CA, Gentil V, Laurenti R. Epidemiologia dos trastornos mentais em uma area definida de captação da cidade de São Paulo, Brasil. [Epidemiology of mental illness in a catchement area in São Paulo, Brasil.] Revista de Psiquiatria Clinica 1999;26. In Portuguese.
5. Bland RC, Orn H, Newman SC. Lifetime prevalence of psychiatric disorders in Edmonton. Acta Psychiatrica Scandinavica 1988;77 Suppl:338:24-32.
6. Bland RC, Newman SC, Orn H. Help-seeking for psychiatric disorders. Canadian Journal of Psychiatry 1997;42:935-42.
7. Offord DR, Boyle MH, Campbell D, Goering P, Lin E, Wong M, et al. One-year prevalence of psychiatric disorder in Ontarians 15 to 64 years of age. Canadian Journal of Psychiatry 1996;41:559-63.
8. Katz SJ, Kessler RC, Frank RG, Leaf P, Lin E, Edlund M. The use of outpatient mental health services in the United States and Ontario: the impact of mental morbidity and perceived need for care. American Journal of Public Health 1997;87:1136-43.
9. Parikh SV, Lin E, Lesage AD. Mental health treatment in Ontario: selected comparisons between the primary care and specialty sectors. Canadian Journal of Psychiatry 1997;42:929-34.
10. Vicente B, Rioseco P, Saldivia S, Kohn R, Torres S. Estudio Chileno de prevalencia de patología psiquiátrica (DSM-III-R/CIDI) (ECPP). [Prevalence of psychiatric disorder in Chile.] Revista Médica de Chile 2002;130:527-36. In Spanish.
11. Cooper JE, Sartorius N. Mental disorders in China: results of the National Epidemiological Survey in 12 Areas. London: Gaskell; 1996.
12. Ran M, Xiang M, Huang M, Shan Y. Natural course of schizophrenia: 2-year follow-up study in a rural Chinese community. British Journal of Psychiatry 2001;178:154-8.
13. Dzúrová D, Smolová E, Dragomirecká E. Mental health in the sociodemographic context: results of a sample survey in the Czech Republic. Prague, Czech Republic: Univerzita Karlova; 2000. In Czechoslovakian.
14. Dragomirecká E, Baudis P, Smolová E, Dzúrová D, Holub J. Psychiatric morbidity of the population in the Czech Republic. Ceska a Slovenska Psychiatrie 2002;98:72-80. In Czechoslovakian.
15. Lehtinen V, Joukamaa M, Lahtela K, Raitasalo R, Jyrkinen E, Maatela J, et al. Prevalence of mental disorders among adults in Finland: basic results from the Mini Finland Health Survey. Acta Psychiatrica Scandinavica 1990;81:418-25.
16. Lehtinen V, Joukamaa M, Jyrkinen E, Lahtela K, Raitasalo R, Maatela J, et al. Need for mental health services of the adult population in Finland: results from the Mini Finland Health Survey. Acta Psychiatrica Scandinavica 1990;81:426-31.
17. Lindeman S, Hämäläinen J, Isometsä E, Kaprio J, Poikolainen K, Heikkinen M, et al. The 12-month prevalence and risk factors for major depressive episode in Finland: representative sample of 5993 adults. Acta Psychiatrica Scandinavica 2000;102:178-84.
18. Laukkala T, Isomestä E, Hämäläinen J, Heikkinen M, Lindeman S, Aro H. Antidepresant treatment of depression in the Finnish general population. American Journal of Psychiatry 2001;158:2077-9.
19. Lepine JP, Lellouch J, Lovell A, Teherani M, Ha C, Verdier-Taillefer MH, et al. Anxiety and depressive disorders in a French population: methodology and preliminary results. Psychiatry and Psychobiology 1989;4:267-74.
20. Wittchen HU, Nelson CB, Lachner G. Prevalence of mental disorders and psychosocial impairments in adolescents and young adults. Psychological Medicine 1998;28:109-26.
21. Padmavathi R, Rajkumar S, Srinivasan N. Schizophrenia patients who were never treated – a study in an Indian urban community. Psychological Medicine 1998;28:1113-7.
22. Levav I, Kohn R, Dohrenwend BP, Shrout PE, Skodol AD, Schwartz S, et al. An epidemiological study of mental disorders in a 10-year cohort of young adults in Israel. Psychological Medicine 1993;23:691-707.
23. Faravelli C, Guerrini Degl'Innocenti B, Aiazzi L, Incerpi G, Pallanti S. Epidemiology of mood disorders: a community survey in Florence. Journal of Affective Disorders 1990;20:135-41.
24. Faravelli C, Guerrini Degl'Innocenti B, Giardinelli L. Epidemiology of anxiety disorders in Florence. Acta Psychiatrica Scandinavica 1989;79:308-12.
25. Karam EG. The nosological status of bereavement-related depressions. British Journal of Psychiatry 1994;165:48-52.
26. Caraveo-Anduaga JJ. Epidemiologia de la morbilidad psiquiátrica en la Ciudad de México. [Epidemiology of Psychiatric Morbidity in Mexico City.] Mexico City: Instituto Mexicano de Psiquiatria; 1995. In Spanish.
27. Carvaeo-Anduaga JJ, Martinez Vélez NA, Rivera Guevara BE, Dayan AP. Prevalencia en la vida de episodios depresivos y utilización de servicios especializados. [Lifetime prevalence of depressive episode and utilization of specialized services.] Salud Mental 1997;20 Suppl:15-23. In Spanish.
28. Caraveo-Anduaga JJ, Colmenares E, Saldivar GJ. Morbilidad psiquiátrica en la ciudad de México: prevalencia y comorbilidad a lo largo de la vida. [Psychiatric morbidity in Mexico City: lifetime prevalence and comorbidity.] Salud Mental 1999;22:62-7. In Spanish.
29. Salgado de Snyder VN, Diaz-Pérez M. Los trastornos afectivos en la población rural. [Depressive disorders in a rural population.] Salud Mental 1999;22:68-74. In Spanish.
30. Beekman ATF, Deeg DJH, Braam AW, Smit JH, van Tilburg W. Consequences of major and minor depression in later life: a study of disability, well-being and service utilization. Psychological Medicine 1997;27:1397-409.
31. Bijl RV, Ravelli A, van Zessen G. Prevalence of psychiatric disorder in the general population: results of the Netherlands Mental Health Survey and Incidence Study (NEMESIS). Social Psychiatry and Psychiatric Epidemiology 1998, 33:587-95.
32. Bijl RV, Ravelli A. Psychiatric morbidity, service use, and need for care in the general population: results of the Netherlands Mental Health Survey and Incidence Study. American Journal of Public Health 2000;90:602-7.
33. Well JE, Bushnell JA, Hornblow AR, Joyce PR, Oakley-Browne MA. Christchurch psychiatric epidemiology study, part I: methodology and lifetime prevalence for specific psychiatric disorders. Australian and New Zealand Journal of Psychiatry 1989;23:315-26.
34. Hornblow AR, Bushnell JA, Wells JE, Joyce PR, Oakley-Browne MA. Christchurch psychiatric epidemiology study: use of mental health services. New Zealand Medical Journal 1990;103:415-7.
35. Newman DL, Moffitt TE, Caspi A, Magdol L, Silva PA, Stanton WR. Psychiatric disorder in a birth cohort of young adults: prevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21. Journal of Consulting and Clinical Psychology 1996;64:552-62.
36. Sandanger I, Nygård JF, Ingebrigsten G, Sørensen T, Dalgard OS. Prevalence, incidence and age at onset of psychiatric disorders in Norway. Social Psychiatry and Psychiatric Epidemiology 1999;34:570-9.
37. Angst J. Epidemiology of depression. Psychopharmacology 1992;106 Suppl:71-4S.
38. Hwu HG, Yeh EK, Chang LY. Prevalence of psychiatric disorders in Taiwan defined by the Chinese Diagnostic Interview Schedule. Acta Psychiatrica Scandinavica 1989;79:136-47.
39. Hwu HG, Yeh EK, Yeh YL, Chang LY. Alcoholism by Chinese diagnostic interview schedule: a prevalence and validity study. Acta Psychiatrica Scandinavica 1988;77:7-13.
40. Kilç C. Mental health profile of Turkey: main report. Ankara, Turkey: Ministry of Health; 1998. In Turkish.
41. Singleton N, Bumpstead R, O'Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households, 2000: the report of a survey carried out by Social Survey Division of the Office for National Statistics on behalf of the Department of Health, the Scottish Executive and the National Assembly for Wales. London: Stationery Office; 2001.
42. Meltzer H, Gill B, Petticrew M, Hinds K. OPCS surveys of psychiatric morbidity in Great Britain. Report 1: the prevalence of psychiatric morbidity among adults living in private households. London: HMSO; 1995.
43. Meltzer H, Gill B, Petticrew M, Hinds K. OPCS surveys of psychiatric morbidity in Great Britain. Report 2: physical complaints, service use and treatment of adults with psychiatric disorders. London: HMSO; 1995.
44. Ohayon MM, Priest RG, Guileminault C, Caulet M. The prevalence of depressive disorders in the United Kingdom. Biological Psychiatry 1999;45:300-7.
45. Robins LN, Regier DA, editors. Psychiatric disorders in America: the Epidemiologic Catchment Area Study. New York: Free Press; 1991.
46. Regier DA, Narrow WE, Rae DS, Manderscheid RW, Locke BZ, Goodwin FK. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry 1993;50:85-94.
47. Vega WA, Kolody B, Aguilar-Gaxiola S, Alderete E, Catalano R, Caraveo-Anduaga J. Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Archives of General Psychiatry 1998;55:771-8.
48. Vega WA, Kolody B, Aguilar-Gaxiola S, Catalano R. Gaps in service utilization by Mexican Americans with mental health problems. American Journal of Psychiatry 1999;156:928-34.
49. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Highes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 1994;51:8-19.
50. Kessler RC, Zhao S, Katz SJ, Kouzis AC, Frank RG, Edlund M, et al. Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry 1999;156:115-23.
51. Weissman MM, Myers JK, Harding PS. Psychiatric disorders in a U.S. urban community: 1975-1976. American Journal of Psychiatry 1978;135:459-62.
52. Weissman MM, Myers JK, Harding PS. Prevalence and psychiatric heterogeneity of alcoholism in a United States urban community. Journal of Studies on Alcohol 1980;41:672-81.
53. Grant BF, Harford TC. Comorbidity between DSM-IV alcohol use disorders and major depression: results of a national survey. Drug and Alcohol Dependence 1995;39:197-206.
54. Dawson DA. Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research 1996;20:771-9.
55. Alegria M, Kessler RC, Bijl R, Lin E, Heeringa SG, Takeuchi DT, et al. Comparing mental health service use data across countries. In: Andrews G, editor. Unmet need in mental health service delivery. Cambridge: Cambridge University Press; 2000. p. 97-118.
56. Canino GJ, Bird HR, Shrout PE, Rubio-Stipec M, Bravo M, Martinez R, et al. The prevalence of specific psychiatric disorders in Puerto Rico. Archives of General Psychiatry 1987;44:727-5.
57. Rubio-Stipec M, Stipec B, Canino G. Costs of schizophrenia in Puerto Rico. Journal of Mental Health Administration 1994;21:136-44.
58. Steffens DC, Skoog I, Norton MC, Hart AD, Tschanz JT, Plassman BL, et al. Prevalence of depression and its treatment in an elderly population: the Cache County study. Archives of General Psychiatry 2000;57:601-7.
59. Abas MA, Broadhead JC. Depression and anxiety among women in an urban setting in Zimbabwe. Psychological Medicine 1997;27:59-71.

domain: medical


text:
(Due to certain 'technical issues', I'm having to keep the name as 'False Birth' on the front.)
A psychological, story-focused game about the last remaining human, and his search for meaning in a post-apocalyptic world.
(If the controls are different for you, just configure them from the general options tab.)
(I want to mention them here so you play the game fully prepared to encounter them. The reason these haven't been fixed is because... I couldn't fix them. They're all... mostly... small bugs, that can easily be overlooked. )
(It's a VERY biased review. I just beta-tested my game, playing it dozens of time over and over again...)
It's trash. It's high quality, genuine GARBAGE! I can't play this pile of poop anymore! (T_T)
Sadly, I have to play it a few more times, make a recording of it all, and then use it to make a trailer...
It's torture, I tell you.
The dialogue is mediocre. Sure it's clear, and properly tells the story. But it's just... if you ask me to read all the dialogue in a playthrough... I'd be VERY embarrassed to do so. It doesn't sound like something anyone would actually say.
The graphics are decent for an RPG Maker game, and that's been so much of my priority, that the game suffers on the performance side. (And hence unfortunately, a huge chunk of people may not be able to play this on their potatoes... even if the potatoes are on steroids.)
The sound of the game is AWESOME! Because... I didn't make any of the music. I just... put them in there... and had them played in the... background, yeah...
(It's so bad, that you need to tell your friends about it!)
"Hey if it's so bad, why are you publishing it?" ... because, it's taking space on my computer, so I thought this was the right place to archive it. (I'm a very moral human being; I do not permanently kill data.)
So, how did I come to make this game? I published my last game at around 16th November-2018 (title: False Awakening Ep 2) and at the time, Indie Game Making Contest (IGMC) was going on. I had 15 days to make a game for it, and I figured I should participate and cook up a small videogame.
I literally spent the first week trying to write a short story for the game. And... I failed, miserably. I had an idea on what the story was going to be, but couldn't actualize the series of events in a way that the story would be engaging. And so in due time, I realized that I couldn't write 'short' stories with the skills I had, and that I needed to first learn the 'how' of it.
I realized that and didn't act on it immediately, because certain opportunities came my way (as a result of publishing my last game) that took up few of my next days.
With that, since the contest was almost over and I had nothing prepared on my plate, I figured I should just skip it. Starting December 2018, I went through some lectures and videos on writing short stories, and finished writing the script till the 4th (of December.) In just a week, I completed the first half of the game.
Since the game was super short, (10 minutes of total playthrough) I thought I shouldn't put in any option to save. At the same time, since the game had scenarios where the player can hit gameover, and would have to start over from the beginning, there was an issue that the game can become too repetitive. (For those who get a gameover a few times.)
So I figured I could counter that by randomizing certain features for the first half, so that the game would feel less repetitive. With that, I ended up randomizing a few more things than I planned, which forced me to add more to the script. (Because everything that was happening, needed to make sense in the scope of the story.)
20 days after finishing my initial script, the first half of my game was fully completed. After that, I got busy with some family stuff, that took up my next 23-25 days. (I couldn't concentrate on my game during this period.)
Come 20th January 2019, and I was able to start working on my game again. Going through the script after around a month, I realized that the events in the story weren't dramatic enough. So as I worked towards making each cutscene in the game, I added 'dramatic elements' to the story at every opportunity I got, so that there would be more weight to it.
In my initial script, I had thought up a choice-system, but when I added it in the game, it felt too bland. Which prompted me to make alternate endings for the game. (Called 'false endings'.) So, I had to go back to the writing board, and add more layers to the story, and write more dialogue.
When I was done doing that, I had to somehow foreshadow the second half of the game, in the first half. Which means that I had to add dialogue to the first half and... then the overall story became much more powerful. (And the game became two...err- five times longer. XD )
It's been around 30 days since 20th January-2019, and I'm finally done with the game! (HUZZAHHHH!!!)
That brings the total development time to around 1 month 20 days. (Excluding the 7 days I 'tried' writing a short story, but couldn't because I didn't know how to.)
Well, that's all, I suppose. Thank you for reading! (Unless you didn't... which is completely okay because I'm mentally numb after beta-testing my game a dozen times. And instead of being unproductive, I happen to have ended up typing all this...)
The complete credits (with links) are mentioned in a document right beside the .exe file, and inside the game. (I'm skipping from mentioning them here... because the list is a bit long.)
~THAT would be SO awesome! Go right ahead!
~Want to play more games like this one? Well, you can head over to my patreon page and contribute to their development!
As you finish playing the game, please do be sure to comment and let me know! Even just a message saying, "Ey! Playd yo gaym bruv." would mean A LOT!
And should you choose to leave a review, then that's even better!

domain: game


text:
Former Bengals receiver Marvin Jones is expected to be a fixture in Detroit's transition into the post-Calvin Johnson era.
(AP File Photo)
ALLEN PARK -- For the first time in his career, Matthew Stafford won't have the greatest receiver in Detroit Lions history at his disposal.
This is going to take some getting used to.
And that process is already under way.
The key piece, obviously, is Marvin Jones. He was the No. 1 free-agent receiver in the league, and his acquisition was made to help mitigate the loss of Calvin Johnson.
Jones has been spending time with his new teammates to try to build some chemistry before the start of the season. That includes hanging out at tight end Eric Ebron's house to play basketball and watch the NBA playoffs.
"You just get to know the guys -- talk to everybody," Jones said last week at the "Taste of the Lions" event at Ford Field. "I'll say, the camaraderie we have here with the Lions is great. It was great in Cincinnati, and I'm glad it's great here as well. Everybody's together."
Jones also has gotten in some reps on the field with his new quarterback. The work has been primitive, with no defense to work against, but that activity will ramp up this week with the start of OTAs on Tuesday.
Detroit also will practice on Wednesday and Thursday before breaking for the weekend.
"It's going great (with Stafford)," Jones said. "I mean, we've had a little over a month to get some camaraderie between the quarterbacks and the wide receivers, and everything is going good. We've been going hard. It all shows in what we're doing this offseason."
The Lions offense is expected to change fairly dramatically this offseason. It was always going to evolve under Jim Bob Cooter, but Johnson's retirement has ramped things up even more.
Now Detroit is transitioning from an offense that was predicated on a true No. 1 wideout, to one that is tailored for a more diversified distribution to guys such as Jones, Golden Tate, Theo Riddick and Ebron.
"We haven't even practiced yet," Jones said. "We've been throwing routes against air and stuff like that, but it'll start to pick up when we start getting defenses on us and stuff like that.
"It'll take some time, but it's going great right now."

domain: news


text:
This post contains affiliate links.
Guinea pigs are one of humanity’s favorite pets. As small animals go, guinea pigs have quite specific dietary requirements. One question that is often asked is whether or not it is safe to feed your guinea pig dog food.
It is not safe to feed guinea pigs dog food. They are obligate herbivores, meaning that they need to eat plants to stay healthy and can’t process meat. They also need a lot of vitamin C, which is not in dog food. They should eat a mixture of hay, guinea pig pellets, and fresh fruits or vegetables.
Now you know that dog food is not a safe part of a guinea pig’s diet. Read on to find out why that is and what you should feed your piggie to keep them safe and healthy.
Here are some reasons why guinea pigs cannot eat dog food:
Similar to humans, guinea pigs are not capable of vitamin C production. That means that they need to eat foods that contain the vitamin in order to keep healthy. Dogs produce their own vitamin C, so food designed for dogs is unlikely to contain any of the vitamins.
For the same reason, rabbit food cannot make up a large part of a guinea pig’s diet. Without vitamin C, guinea pigs quickly develop scurvy, which could be fatal!
It is worth noting that vitamin C depletes over time. If you are feeding your pet guinea pig pellets as a small part of their diet (as you should), make sure to throw out any remaining pellets after a few months. If the vitamin C in the pellets has deplete#d, but you don’t know it, you could be giving your pig a deficiency!
It is also worth noting that a pregnant or sick guinea pig can require up to 5 times as much vitamin C as your average pig! Here are some foods you can give your pig to make sure they are getting enough of this vital vitamin:
- Red peppers are a great way for your guinea pig to get vitamin C. Your pig can safely eat red bell peppers as frequently as every day. Green and yellow peppers are also safe but do not contain as much vitamin C.
- Leafy greens should be a pretty big part of your guinea pig’s feed. Romaine lettuce, parsley, cabbage, spinach, kale, cilantro and others are all good sources of vitamin C. Your guinea pig should get 2 or 3 leaves of plants like this every day. Try to mix it up for better nutrition!
- Fruits and vegetables like cucumbers, broccoli, cauliflower, strawberries, carrots and tomatoes should be sparingly given since they contain quite a lot of sugar as well as vitamin C that can cause diabetes or cataracts.
Guinea pigs are adapted to eating plants, and so are unable to digest meat in any form. Dogs are carnivores, so their food is packed with processed meat. For that reason, if a guinea pig eats dog food, it can make them very ill. Hay is a vital part of a guinea pig’s diet since the fiber it contains is what allows the guinea pig’s digestive system to function properly.
Here are some reasons why guinea pigs can’t eat meat:
- Feeding dog food, or any other kind of meat, to your guinea pig will damage their digestive system and may even cause a total GI block!
- Meat has no nutritional benefit to a guinea pig; they do not need protein, fat, or calories. Plus, there is no fiber, which is necessary for proper guinea pig digestion.
- Guinea pigs do not have the enzymes or acids required to break down the meat. Even if they needed the nutrients in meat, they wouldn’t be able to get them by eating meat!
When you give any animal food that they are not adapted to eat, it will negatively affect their health. While eucalyptus is fine for koalas, for example, it would make you very sick!
Here are some of the effects meat could have on your guinea pig’s health:
- High cholesterol: Guinea pigs are prone to heart disease. Similar to humans, there is a link between the cholesterol in their diets and their heart health. Eating any sort of meat raises a guinea pig’s cholesterol.
- Obesity: Also similar to humans, a guinea pig with a high-calorie diet will put on weight. This can put serious pressure on the pig’s organs, also leading to heart disease.
- Heart disease: Saturated fats are bad for the same reasons outlined above—guinea pigs do not have a digestive system that is set up for them. Feeding them a diet that is high in these fats could make heart disease more likely.
Now that we’ve discussed the various ways dog food and other meat products can affect guinea pig’s health. Let’s move on to the right way to feed a guinea pig. I have already hinted above at what kind of foods your pig needs, but let’s get more specific.
Here are some tips on guinea pigs’ diet, which will keep your furry buddy fit and healthy:
This is the most important part of any pig’s diet. Your guinea pig should have constant access to hay. Timothy hay, grass hay, and orchard grass are all great choices. Legume hays like alfalfa and clover are high in calcium, protein, and calories, so should not be the main part of your guinea pig’s diet unless they are pregnant or growing.
Guinea pigs need a constant supply of hay to chew on because their teeth never stop growing. Without the wear and tear that comes with constantly munching on fibrous hay, the guinea pig’s teeth can grow crooked and make it difficult for them to eat.
As mentioned above, leafy greens are a great way to keep your guinea pig’s vitamin C at a safe level. It is worth noting that iceberg lettuce does not have any nutritional value for guinea pigs, although other leafy lettuces do. Kale, rocket, marigold, rosemary, dill, and parsley are all healthy additions to your pig’s diet. 2 to 3 leaves per day should be enough!
Fruit is a tricky one. There is some disagreement about whether it is good to give a guinea pig the odd bit of fruit as a treat. On the one hand, it is a great vitamin C source, and the pigs love eating it.
On the other hand, fruits are high in sugar, so feeding it to your guinea pig could cause them to develop diabetes or cataracts. If you are going to give your pig fruit a few times a week, apples (with the seeds taken out) and mango are good choices.
Vegetables like cauliflower, broccoli, cabbage, and brussels sprouts are also recommended as part of a guinea pig’s diet. Again, you should only give them these a few times a week. They are a great source of vitamin C but are no replacement for the hay that should make up about 80% of your guinea pig’s diet.
The short and sweet answer to the question posed in the title of this piece is no; guinea pigs can not eat dog food. Not only can they not digest it properly, but it could also cause serious health problems like heart disease or a GI block.
Give your pigs an unlimited supply of hay, a few leafy greens a day, and some fruit and veg, and they will be happy and healthy. I hope that helps!
- Can Deer Eat Dog Food? What You Need To Know
- Can Rats Eat Dog Food? What You Need to Know
- Can a Cat Eat Dog Food? Is It Safe?
- Can Rabbits Eat Dry Dog Food? My Opinion
- Can Sugar Gliders Eat Dog Food? Is It Safe?
- Can Fish Eat Dog Food? Is It Safe?
- ASPCA: Guinea Pig Care
- Dog Food Advisor: Do Dogs Need Vitamin C In Their Diet?
- Exotic Direct: What Can Guinea Pigs Eat?
- Ferm Up: What Does Gram-Positive Mean?
- Hutch and Cage: Can Guinea Pigs Eat Meat? Facts and Risks
- Illinois University College of Veterinary Medicine: Housing and Feeding Your Guinea Pig
- Journal of Animal Health and Behavioural Science: The Effects of Diet On Anatomy, Physiology, and Health In Guinea Pigs
- Mom.com: Acceptable Food For Guinea Pigs
- NCBI: Nutrient Requirements of Laboratory Animals – Nutrient Requirements of Guinea Pigs
- Online Guinea Pig Care: Can Guinea Pigs Eat Dog Food?
- Palmerstown Vets: How To Take Care of Your Pet Guinea Pig
- PDSA: Your Guinea Pig’s Diet
- PetCo: What Can Guinea Pigs Eat?
- Pet Educate: Can Guinea Pigs Eat Meat? (What Owners Need To Know)
- Pet Life Buzz: Feeding Guinea Pig: A Guide From Vet
- Pet Stop: Feeding Your Guinea Pig
- RSPCA: What Should I Feed My Guinea Pigs?
- Small Pet Select: 15 Things Guinea Pigs Shouldn’t Eat
- The Spruce Pets: Feeding Guinea Pigs
- VCA Hospitals: Feeding Guinea Pigs
- WikiHow: How To Feed Guinea Pigs Vitamin C
- Zooplus: The Digestive System Of Guinea Pigs
- Britannica: Orchard grass
- Small Pet Select: Hay, Fresh and Fragrant
- Mayo Clinic: Intestinal obstruction
- Lumen Learning: Herbivores, Carnivores, and Omnivores
- American Academy of Ophthalmology: What Are Cataracts?
- NIDDK: What Is Diabetes?
- Better Health: Scurvy
Mrdogfood.com is a participant in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising fees by advertising and linking to Amazon.com. We also participate in other affiliate programs which compensate us for referring traffic.

domain: food


text:
A False Claims Act lawsuit filed by a whistleblower and resulting investigation of those claims has led to the arrest of a New York City-area cardiologist, neurologist, and several others on charges of health care fraud, identity theft, and making false statements, among other things, as well as civil allegations that they defrauded Medicare, Medicaid, and private health insurance companies.
Preet Bharara, the U.S. Attorney for the Southern District of New York, and other federal officials announced the charges March 1, saying that the defendants’ wrongdoing spanned 12 years starting in 2003 and cost taxpayers and private insurers more than $50 million. The U.S. government said it would seek treble damages under the False Claims Act, meaning that the defendants could be on the hook for $150 million.
The Department of Justice (DOJ) determined a board-certified interventional cardiologist who was the president and owner of City Medical Associates, a cardiology and neurology clinic based in Bayside, New York, orchestrated the massive health care fraud scheme, the complaint alleges.
Also participating in the scheme were others employed by City Medical Associates, the U.S. alleges, including the doctor’s nephew, brother, City Medical Associates employees, and a board-certified neurologist with his own practice in Westchester, New York.
The U.S. accuses the defendants of making false representations to insurance providers, including providers paid through Medicaid and Medicare, about the medical condition of patients in order to obtain preauthorization for medical tests and procedures
The U.S. also alleges the defendants submitted false claims to insurance providers for tests and procedures that were not performed or were not medically unnecessary, as well as for drugs and other items that were never used or provided.
Additionally, the defendants paid “exorbitant kickbacks” to local primary care medical offices in exchange for profitable referrals, federal prosecutors contend.
The defendants also accessed the electronic health records of patients at a particular Long Island hospital without authorization in order to identify patients that could be recruited to City Medical Associates, the U.S. alleges.
“As alleged, these defendants that included a cardiologist and neurologist ran a medical practice that for years bilked public health care programs and private insurance companies of more than $50 million,” Bharara said. “Thanks to the hard work of federal and state investigators, this fraud has been revealed and the alleged perpetrators forced to face the consequences of their actions.”

domain: law


WVU needed Smith's record day
MORGANTOWN, W.Va. -- When quarterback Geno Smith and the rest of the West Virginia offense stop to think about how they rewrote the school record book in their Big 12 debut, let's hope they remember that they wouldn't have done so without Nick Florence and the Baylor offense.
A generation ago, Affirmed won the 1978 Triple Crown because Alydar pushed him in all three races. Magic had Larry. Jack Nicklaus had Tom Watson. And on Saturday, Smith and the No. 9 Mountaineers put up video ...
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Breakthrough is moving its headquarters from downtown Green Bay to the Titletown District adjacent to Lambeau Field.
The company, which helps shippers cut their logistics costs, said it will occupy almost two whole floors of the office building under construction at the west end of the Titletown area. It hopes to move 90 employees later this fall.
The announcement comes a little more than one year after Breakthrough confirmed it no longer planned to build an $8 million headquarters building in Green Bay’s Shipyard redevelopment area.
The Titletown District is the “perfect place” for Breakthrough to grow its workforce and provide “a unique, elevated experience” for visiting clients, said Doug Mueller, Breakthrough’s president and CEO, in a news release.
The company also announced it will vacate some of its downtown office space, but will maintain its Technology and Innovation Center, located above Backstage at the Meyer.
Breakthrough’s current headquarters on South Washington Street will become the new home for the Greater Green Bay Community Foundation.

domain: economics


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Retired Caryville Police Chief Bill Widener, who served the department for 23 years, died overnight at his home.
Widener, who resided in Jacksboro, had recently undergone heart surgery. His wife reported his death.
Caryville Police Chief Stephanie Smith said Widener launched his career at the department on Nov. 26, 1986. He retired June 30, 2010.
Smith said Caryville police units will participate in the funeral once arrangements are made. She said the agency’s seven officers also will honor Widener by wearing a strip of black cloth over their badges.
“He hired me on as a patrol officer and then promoted me to detective,” Smith said. She has been chief for six months.
“He was not your everyday, ordinary chief of police. He was your friend, a good shoulder to lean on, compassionate and loved by so many.
“He always had a joke about something. You enjoyed your job even though the stresses of the job are more than most can comprehend.”
For Smith, memories of Widener will bring one thought: “He was my friend,” she said.
More details as they develop online and in Thursday’s News Sentinel.


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And in most cases, the cause is the lack of healthy, happy relationship.
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Fabulously lucky are those Ukrainian people who were born here, grew up and succeeded to arrange their work and personal life.
Probably we can say the same about any capital of any country of the world.
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Use the links to jump ahead to the area that strikes your fancy and find the top gay dating networks for you.

domain: sociology


NORWICH – Having recently been named the new overseer of the summertime farmers market in downtown Norwich, the Norwich Business Improvement District (BID) is moving ahead with plans to make this year's market more viable for local consumers.
Since being given authority over the market by the Chenango County Board of Supervisors last month, the Bullthistle Farmers Market Committee, a subsidiary of the Business Improvement District, has been soliciting new vendors and ideas to improve the downtown market. The Bullthistle Farmers Market, formerly the Chenango County Farmers Market, is a fresh start to an old tradition, said BID Administrator Ann Coe.
“We're really working to get more participation this year and to get more people downtown,” said Coe. “It's going to be a new and improved market.”
The Bullthistle Farmers Market will consist of produce and craft vendors, and live entertainment each week. From musicians to cooking demonstrations to fitness instruction, the goal is to have a more diverse market to draw people in, said Coe. The agency is presently seeking local talent to participate.


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I Will Okay Restructuring Bill If Passed, Says Buhari
President Muhammadu Buhari on Thursday said he would give his approval to any amendments to the 1999 Constitution on restructuring.
Buhari spoke when the National Executive of the Ijaw National Congress (INC), led by Prof Benjamin Okaba, visited him at the Presidential Villa in Abuja.
On calls for restructuring, the President noted that the National Assembly, whose responsibility it is to amend the constitution, had concluded regional consultations.
“As soon as they finalise the process, necessary action would not be delayed on my part,” he said.
President Buhari had at the weekend in a message at the Kudirat Abiola Sabon Gari Peace Foundation in Zaria, Kaduna State, said he was not going to assent to the clamored amendment to the 1999 Constitution on restructuring.
He said: “Those who are discussing restructuring, my question is, what are you going to restructure?
“If you ask many Nigerians what they are going to restructure, you will find out that they have nothing to talk about.
“Some of them have not even studied the 1999 Constitution. The 1999 Constitution is almost 70 to 80 per cent 1979 Constitution.”
Responding to other requests by the INC, the President said the creation of two additional states and more local government areas for the Ijaw are to be handled by the National Assembly.
He praised the INC leadership for affirming its belief in a united Nigeria.
A statement by presidential spokesman, Garba Shehu, quoted the President as saying: “Make sure that we keep working together to keep this country a united, indivisible entity so that we can tackle our problems together and overcome our challenges together.”


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The comfortable Super 8 Kings Mountain Hotel is a great place in a metropolitan area of Kings Mountain. Super 8 Kings Mountain Hotel has been welcoming guests to its non-smoking rooms since 1975.
The property lies within 26.6 km from Uptown/Business District and Daniel Stowe Botanical Gardens. A 30-minute walk to the center of Kings Mountain.
The hotel allows quick access to a national park and lakes.
Charlotte Douglas airport can be reached in 40 minutes by car from Super 8 Kings Mountain Hotel.
There are 60 rooms including king room and double room in Super 8 Kings Mountain Hotel, offering a breathtaking view of the park along with a seating area, a private safe, a writing desk, a closet and complimentary wireless internet. Guests will enjoy views of Mountain State Park from their rooms. They also comprise en suite bathrooms appointed with a Jacuzzi, a shower and complimentary toiletries.
Eat & Drink
The restaurant serves Mexican dishes. Serving an array of dishes, Mc Donald's and Big E's BBQ are just 300 meters away.
The hotel offers a vending machine, a lift and free self parking along with a meeting room, a business center and a photocopier to fulfill the needs of all travelers.
Wireless internet is available in the entire hotel for free.
Free public parking is possible on site.

domain: travel


SYML Collaborates With Elbow Singer Guy Garvey On Haunting New Single “Lost Myself”
September 28, 2022 BY Jason Currell
Progressive singer, songwriter, and producer Brian Fennell aka SYML returns to unveil his haunting new single “Lost Myself,” featuring Elbow frontman Guy Garvey.
Fennell, a longtime fan of the venerable British quartet, reached out to the singer to see if he’d lend his voice to the song. Garvey not only agreed to join Fennell on the song, he reworked his verse, bringing his unique perspective to the final recording.
Accompanied by a stunning new video, the additional visuals tell the story of Brian meeting Guy for the first time in London, having previously worked the track together remotely.
Speaking about the new offering, SYML said, “I’ve been a fan of Guy and Elbow since their album Cast of Thousands got stuck in my car’s CD player when I was in college. It would always come on glaringly loud whenever I started my car. I got to tell him this story when we were shooting the video for Lost Myself and had a good laugh. Singing with Guy feels like having a good conversation over a pint. Familiar and warm.”
While Guy Garvey added, “I was hooked by Brian’s emotionally fluent beautiful songwriting and very flattered to be asked to join him on this song. I also discovered that he’s a lovely bloke and a great laugh. Can’t wait until our next day out.”
SYML released his self-titled debut album in 2019, which included the platinum-selling song ‘“Where’s My Love.” YML is Welsh for ‘simple’ and pronounced ‘sim-muhl’. With over 1 billion streams, his music has connected with the world for its honest songwriting and emotive voice. Born and raised in Seattle, Fennell studied piano at university and became a self-taught producer, programmer, and guitarist. His music has been featured in countless movies, TV series and ad campaigns including Netflix’s original series ‘Behind Her Eyes’ which featured his version of Mr. Sandman as the title track.
His music has a sacred quality, themes tap into the instincts that drive us to places of sanctuary, whether that be a place or person. “It comes back to your identity of being human; throughout time we’ve shared the same drive,” he explains. His own upbringing – interwoven with experiences of abandonment, adoption, loss, grief and love – is what drives him to question how connections between people shape us as individuals.
“We have this awesome capability to be conscious and know what it is to be here”. This outlook helped him process the death of his adoptive father in 2021, as well as be there for his friends and family. It transpired in his haunting, grief-stricken EP ’DIM’, written and released during that year.
Having supported Dermot Kennedy on his most recent US tour, in late 2021 SYML embarked on an extensive US and European headline tour taking in some of the world’s most beautiful churches in support of his live album ‘Sacred Spaces’. From sold out shows at London’s iconic Union Chapel to Paris’s Café de la Danse to Amsterdam’s Het Zonnehuis the tour took him full circle back to where it was all recorded at St. Mark’s Cathedral.
Lots more to come from SYML in 2022.


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From the Delta County Independent (Kathy Browning):
On Oct. 21, volunteers worked on a half-mile of the easement. Tamarisk, Russian olive and Siberian elm were cut out and stumps of the invasives were treated with herbicide. Tamarisk and Russian olive were introduced in the 19th century as ornamentals. Tamarisk is now seen as a problem as it out-competes native plants for moisture and displaces them along river eco-systems in the West.
Webb Callicutt, Delta County weed coordinator, trained volunteers on how to apply the herbicide.
Rosa Brey of the Colorado Canyons Association explained why it was partnering on this project. “We are a Grand Junction based group and are looking to expand our membership and our volunteer base in Delta and Montrose counties,” Brey said. “The other reason we are involved is because this river flows into the Gunnison which flows through several of our conservation areas. So if we can get tamarisk eradicated on the upstream sections of the river, then there will be fewer seeds that will flow down the river and down into the conservation areas.”


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In recent years, the integration of Environmental, Social, and Governance (ESG) factors into business operations and supply chains has gained significant momentum. ESG considerations go beyond traditional sustainability metrics and focus on a company's impact on the environment, society, financials, and its corporate governance.
Combining ESG and financial data has become a powerful approach for businesses looking to drive sustainable growth, enhance corporate reputation, and uplift their financial profitability. This article explores the value of harmonising ESG and financials and the benefits it brings to businesses and stakeholders alike.
Enhanced Risk Management and Long-Term Resilience
Integrating ESG metrics with financial metrics enables a comprehensive assessment of a company's risk profile. By identifying potential environmental and social risks, businesses are able to implement proactive measures to mitigate them. This proactive approach not only safeguards against financial losses but also enhances long-term resilience by addressing issues that could impact business continuity.
Attracting Responsible Investment
In recent years, responsible investing has experienced a surge in popularity as investors increasingly prioritise sustainability and ethical practices. Businesses with robust ESG performance are more likely to attract responsible investment, as they are perceived as better equipped to weather, environmental and social challenges. Aligning ESG and financials allows businesses to effectively communicate their sustainability efforts, opening doors to a broader pool of investors who value sustainable practices.
Strengthening Stakeholder Trust and Brand Reputation
ESG-conscious consumers and other external stakeholders are placing higher expectations on companies to act ethically and transparently. By integrating ESG and financial reporting, organisations demonstrate their commitment to responsible business practices. This alignment fosters trust among customers, employees, suppliers, and communities, bolstering brand reputation and loyalty.
Cost Reduction and Efficiency Gains
Unique Excellence has focussed on this aspect, as we have seen how combining ESG with an organisation's financials increases efficient resource management. By accurately analysing ESG performance alongside financials, businesses are able to identify opportunities for cost reduction, waste minimisation, and energy efficiency. Such optimisation doesn't only benefits the bottom-line but also reduces the organisation's ecological footprint, positioning it as an environmentally conscious entity.
Compliance with Evolving Regulations
Governments and regulatory bodies worldwide are increasingly mandating ESG disclosures. By integrating ESG and financial reporting, businesses are able to streamline their compliance efforts and stay ahead of emerging regulatory requirements. Proactively addressing ESG obligations helps businesses avoid potential penalties and reputational damage resulting from non-compliance.
Talent Attraction and Retention
The "modern workforce" seeks purpose-driven organisations that prioritise social and environmental impact. Businesses that emphasise ESG values and demonstrate a commitment to sustainability are more likely to attract and retain top talent. Aligning ESG and financial practices positions an organisation as an employer of choice for individuals who seek to contribute to a greater cause.
One of the main reasons why Unique Excellence has introduced ESG Custodian is based on the substantial value of combining ESG and financials. This goes beyond merely ticking boxes for sustainability reporting. It is a strategic imperative that fosters long-term success on an organisation's financials, while creating a positive impact on society and the environment.
Over the years we have worked across Food & Beverage, Health & Wellness and Medical Supplies to make some real impact. Included are some of the examples that assist our clients and potential clients to see the importance of an ESG Custodian solution, incl.;
Waste Reduction in Food Production: A leading food manufacturer reduced food waste by 30% through improved inventory management, better packaging design, and optimised production schedules. This resulted in an annual cost savings of approximately US$3 million.
Renewable Energy Integration: A global beverage company integrated solar panels into its warehouse and distribution centers, reducing energy costs by 40%. This translated to an annual savings of US$2.5 million and a reduction of 5,000 tons of CO2 emissions.
Supplier Collaboration for Efficiency: A well-known health and wellness business collaborated closely with its suppliers and customers to streamline the end-to-end S&OP processes, reducing lead times by 20%. This led to a 15% reduction in inventory carrying costs (storage, waste, energy, etc.) creating a AUD$1.8 million increase in cash flow.
Circular Packaging Design: A medical supplies manufacturer re-designed its product packaging to be reusable and recyclable. This move not only reduced packaging costs by 25%, saving US$1.2 million annually, but also enhanced the brand's eco-friendly image.
Water Conservation in Production: A global beer company implemented water- and energy-efficient practices in its production facilities, reducing water consumption by 25%, and energy consumption by 35%. This saved US$17 million annually and contributed to local water and energy conservation efforts.
Reverse Logistics Optimization: A global food and beverage business optimised its reverse logistics operations, reclaiming valuable materials from returned products. This generated an additional revenue stream of AUD$1.5 million annually.
Integrating ESG considerations into financial decision-making through scenario analysis empowers business leaders to seize opportunities, manage risks, attract responsible investment, and build trust among internal and external stakeholders.
Embracing financial and environmental sustainability through our ESG Custodian solution, as a core tenet, paves the way for a brighter and more sustainable future for both businesses and the global community.

domain: literature


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Just PROSHOWing Off Some Fave Lumia 1020 Pictures
The Nokia Lumia devices are not just all work, although you can see the good work that can be done with these phones in my last post. No, today I discovered the ProShow app for making slideshow videos out of you still pictures. Here’s my first one!
Lumia 1020 Photo Roundup
It’s been a while since I’ve done a entry that’s just about photography on the Lumia 1020. It’s not that I’ve stopped taking photos, but I’ve settled into a posting them in a places with a built in photographic community. You can regularly find my pictures on my Flickr account and my Phonetogaphs Blog and in the Fhotoroom community.
The picture above is one of my favorites from this device. I love the contrasts of color and texture.
OK, let’s dive into some more…

domain: artistic


text: Actor/singer Connie Stevens was born Concetta Rosalie Ann Ingolia on August 8, 1938, in Brooklyn, NY. Coming from a highly musical family (both her parents were jazz musicians and her brother was a drummer), the up-and-coming singer changed her last name to Stevens after her father's stage name (Teddy Stevens). At the age of 16, she was singing in her first group, the Three Debs. By the late '50s, Stevens had co-launched a singing and acting career, signing with Warner Bros. and issuing her debut album, Conchetta, in 1958 and acting in several movies and TV series (Young and Dangerous, Rock-a-Bye Baby, etc.). Stevens continued on with her musical career throughout the '60s, landing two big hit singles -- a duet with actor Ed "Kookie" Burns on "Kookie Kookie (Lend Me Your Comb)" and the number one 1961 hit "Sixteen Reasons"; but it was her role as Cricket Blake in the popular TV series Hawaiian Eye that made Stevens famous. It was also during the '60s that Stevens married singer Eddie Fisher, and although the marriage would only last two years (from 1967 through 1969), Stevens and Fisher would have two daughters together, future actress Joely Fisher and future actress/singer Tricia Leigh Fisher.

domain: celebrity


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Our bespoke Engineering Oversight System (EOS) allows you to receive real-time installation information that will assist you with the day-to-day running of a project, so we can report to you on a wide array of metrics.
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Our dedicated on-site installation teams provide an effective and efficient service. They focus on the requirements of our customers, while maintaining high standards in order to complete projects in a professional and timely manner.
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Ph.D., Associate ProfessorSchool of Materials Science and Engineering, Tsinghua UniversityPhone: +86-10-62794616Fax: +86-10-62794616E-mail: email@example.com
1997, Ph.D., Xi’an Jiaotong University, China1993, M.S., Xi’an Jiaotong University, China1990, B.S., Harbin Institute of Technology, China
2006-, Associate Professor, Tsinghua University, China2002-2005, Research Officer, University of Wales Swansea, UK2000-2002, Postdoctoral Researcher, Tsinghua University, China1998-2000, Postdoctoral Researcher, University of Science and Technology Beijing, China
2007-, Member of the Minerals, Metals and Materials Society (TMS)
1. High integrity and near net shape casting technology for lightweight metal alloys2. Squeeze casting process of aluminum and magnesium alloys and macro and microscopic modeling of the process3. Multi-scale and multi-discipline modeling and computation of solidification and casting processes4. Heavy steel casting process and microstructure prediction5. Through-process modeling and integrated computational materials engineering
1. Modeling and simulation on eutectics and precipitates in squeeze casting magnesium alloys by coupling thermodynamic and kinetic computation, National Natural Science Foundation of China, Grant No. 51175291, Duration 2012-2015.2. Macro-, micro- and nano-scale modeling on the microstructure evolution in alloy solidification under unsteady pressure condition, National Natural Science Foundation of China, Grant No. 50875143, Duration 2009-2011.3. Modeling and simulation on thermomechanical and transport phenomena in squeeze casting process of light metal alloys, National Natural Science Foundation of China, Grant No. 50675113, Duration 2007-2009.4. Magnesium front end research and development (MFERD), a Canada-China-USA collaborative research and development project, Task 9: integrated computational materials engineering (ICME), Ministry of Science and Technology of China, Duration 2007-2013.5. Fundamental research on magnesium squeeze casting, General Motors Global Research and Development Center, Duration 2011-2013.
2009, 1st-class Award for Excellent Undergraduate Class Advisor, Tsinghua University, China
Patents and Software
1. Zhiqiang Han, Xiaoran Huang, Yanda Li, and Jinxi Li, A method and dieset for measuring temperature inside casing during squeeze casting process, China Patent, ZL201010249074.02. Zhiqiang Han, Baicheng Liu, and Liang Huo, A computer software for simulating microstructure of cast magnesium alloys, Registered at the National Copyright Administration of China, Reg. No. 2010SRBJ34233. Zhiqiang Han, Baicheng Liu, and Bin Su, A computer software for simulating microstructure of heavy steel castings, Registered at the National Copyright Administration of China, Reg. No. 2011SR048538
1. Guomin Han, Zhiqiang Han, Alan A. Luo, Anil K. Sachdev, and Baicheng Liu, A phase field model for simulating the precipitation of multi-variant β-Mg17Al12 in Mg–Al based alloys, Scripta Materialia, Vol.68, No.9, 691-694 (2013)2. Bin Su, Zhiqiang Han, and Baicheng Liu, Cellular automaton modeling of austenite nucleation and growth in hypoeutectoid steel during heating process, ISIJ International, Vol.53, No.3, 527–534 (2013)3. Zhiqiang Han, Xiaoran Huang, Alan A. Luo, Anil K. Sachdev, and Baicheng Liu, A quantitative model for describing crystal nucleation in pressurized solidification during squeeze casting, Scripta Materialia, Vol.66, No.5, 215-218 (2012)4. Guomin Han, Zhiqiang Han, Liang Huo, Junpeng Duan, Xunming Zhu, and Baicheng Liu, Microstructure simulation and mechanical property prediction of magnesium alloy casting considering solid solution and aging process, Acta Metallurgica Sinica, Vol.48, No.3, 363-370 (2012)5. Xiaoran Huang, Zhiqiang Han, and Baicheng Liu, Study on the effect of pressure on the equilibrium and stability of the solid-liquid interface in solidification of binary alloys, Science China E, Vol.54, No.2, 479-483 (2011)6. Bin Su, Zhiqiang Han, Yongrang Zhao, Bingzhen Shen, Lianzhen Zhang, and Baicheng Liu, Cellular automaton modeling of phase transformation in ASTM A216 WCA cast steel during solidification and cooling process, Acta Metallurgica Sinica, Vol.47, No.11, 1388-1395 (2011)7. Zhiqiang Han, Jinxi Li, Wen Yang, Haidong Zhao, and Baicheng Liu, Modeling and simulation on microporosity formed during squeeze casting of aluminum alloy, Acta Metallurgica Sinica, Vol.47, No.1, 7-16 (2011)8. Liang Huo, Zhiqiang Han, and Baicheng Liu, Modeling and simulation of microstructure evolution of cast magnesium alloys using cellular automaton method based on two sets of mesh, Acta Metallurgica Sinica, Vol.45, No.12, 1414-1420 (2009)9. Zhiqiang Han, Wei Zhu, and Baicheng Liu, Thermomechanical modeling of solidification process of squeeze casting I. Mathematic model and solution methodology, Acta Metallurgica Sinica, Vol.45, No.3, 356-362 (2009)10. Wei Zhu, Zhiqiang Han, and Baicheng Liu, Thermomechanical modeling of solidification process of squeeze casting II. Numerical simulation and experimental validation, Acta Metallurgica Sinica, Vol.45, No.3, 363-368 (2009)
Copyright © 2020 School of Materials Science and Engineering, Tsinghua University All Rights Reserved.


State officials pulled back on their effort Friday to secure a crucial green light for the Delta tunnels project, all but ensuring that the controversial plan to re-engineer the West Coast’s largest estuary will remain in limbo after Gov. Jerry Brown leaves office.
Facing a likely defeat, the Department of Water Resources withdrew its petition to the Delta Stewardship Council to have the project deemed in compliance with what’s known as the the Delta Plan, a set of policy goals, mandated by state law, that put protection and restoration of the fragile Sacramento-San Joaquin Delta estuary’s eco-system on an equal footing with more reliable water supplies.
Without the council’s green light, the $16.7 billion project, known officially as California WaterFix, can’t go forward.
As a consequence, regulatory approval for WaterFix almost certainly won’t be completed before Brown’s term as governor runs out this year. Brown has championed the project for years, but his successor, Gov.-elect Gavin Newsom, has taken a more lukewarm attitude toward WaterFix and has said it might have to be scaled back to one tunnel instead of two.
The decision by DWR Director Karla Nemeth was hailed as a victory, at least in the short term, for opponents of the project, which is designed to overhaul how Northern California river water gets delivered through the Delta to farms and cities in the southern half of the state.
“Now they have to go back to the drawing board and prepare a new certificate,” said Kelley Taber, a Sacramento lawyer who represents several local governments that are fighting the project.
Taber said it isn’t clear how long that will take, but “it’s hard to see how these issues could be fixed quickly.”
But DWR expressed confidence the project was not imperiled.
“WaterFix will continue to move forward,” DWR spokeswoman Erin Mellon said in an email. “We will work with the Delta Stewardship Council to resolve issues related to Delta Plan interpretation and plan to submit a revised certification.”
An obscure state agency formed in 2009, the Delta Stewardship Council was set to vote Dec. 20 on whether the tunnels project complies with the Delta Plan.
But it was clear that the Stewardship Council wasn’t likely to go along with the state’s application. The council’s staff on Nov. 15 said the Brown administration hadn’t proven that the south-state water agencies have done enough to reduce their reliance on Delta water shipments, as the Delta Plan mandates. The staff also criticized DWR for not using updated analysis of how climate change would affect tunnels operations, and it said the project poses major “conflicts with land uses in existing Delta communities.”
At a council meeting in November, board Chairman Randy Fiorini ripped the Brown administration for “political expediency” and rushing the application before it was ready.
In her letter to Fiorini, Nemeth defended the petition but said her agency “appreciates that there are unresolved issues” regarding the project.
Tunnels backers acknowledged it was a setback, but they hoped not a major one.
“I hope it’s just a time issue, like a fix-it ticket,” said Jeff Kightlinger, general manager for the Metropolitan Water District of Southern California, the massive Los Angeles urban water agency that’s WaterFix’s biggest booster. “Rather than fight it and appeal it, I figured, let’s just pull it back we’ll get that more information to them and move forward. ... We’ve been working on this over a decade. A few months isn’t going to kill anything.”
Metropolitan agreed in April to bankroll $10.8 billion of WaterFix’s total cost, breathing new life into a project that was sputtering because of funding shortfalls. South-of-Delta water agencies are supposed to pay for the entire project.
The withdrawal comes as the tunnels project falls under attack from other quarters.
Environmentalists, who are generally opposed to the tunnels, say the Trump administration is threatening to withhold support for WaterFix unless California officials agree to significant changes in how water is shipped through the Delta. The Trump administration is trying to streamline environmental rules that sometimes interfere with Delta pumping operations — which means billions of gallons of water sometimes bypass the delivery pumps and flows out to the ocean, leaving less water for the farmers and cities.
The state and federal government pumps, located at the south end of the Delta, are so powerful that they can cause the river channels in the south Delta to run backward, causing endangered smelt and winter-run Chinook salmon to migrate toward the pumps and predatory fish that gather to eat them at the intakes.
The tunnels, a pair of 35-mile-long underground pipes, are designed to bring some of the water from the Sacramento River near Courtland south of Sacramento directly to the pumping stations.The pumps then wouldn’t have to churn so hard, tamping down the “reverse flow” problem and allowing water deliveries to proceed with fewer problems for the fish.
Environmentalists, however, say the tunnels would actually worsen the Delta’s ecosystem and deprive the region’s farmers of much of the fresh water they need to grow grapes, corn and other crops.
“Today is a good day for the Delta and California,” said Barbara Barrigan-Parrilla of Restore the Delta, a tunnels opponent. “But it’s not over yet.”