title: Manju Warrier

text: In 2019, she made her Tamil debut with Vetrimaaran's "Asuran" opposite Dhanush.In March 2021, Warrier began filming for "Amriki Pandit", her Hindi debut opposite R. Madhavan.In 2022, Manju reunited with Biju Menon through "Lalitham Sundaram" after a gap of 20 years.


title: Manju Warrier

text: On 20 October 1998, Manju married actor Dileep at the Aluva Sri Krishna Temple. The couple have a daughter, Meenakshi. They filed for divorce in 2014 and it was granted in January 2015. Her autobiography "Sallapam" (Memories) was released in November 2014. Manju lives in Thrissur, Kerala.


title: Manju Warrier

text: She is one of the founding members of Women in Cinema Collective, the organisation for the welfare of women workers in the Malayalam film industry, although she is not an active member anymore. She was the only female actor in Kerala having a fans association and wellwishers in International level known as Manju Warrier Fans and Welfare Association International.


title: Manju Warrier

text: In a question put up in the official Facebook page of Women in Cinema Collective, 'Who is the most influential female artist in cinema?', Manju Warrier led the poll. She was featured on a list of women superstars in South Indian cinema by The News Minute and top South Indian actresses by InUth. Her characters appear on many lists featuring strong women characters in Indian Cinema.


title: Manju Warrier

text: Manju Warrier is also a professional Kuchipudi dancer, having learnt the art from Geetha Padmakumar. She actively performs in many classical dance programs and plays. Her return to stage at Guruvayur as part of the Navaratri dance festival was received with much fanfare. "I was expecting a few people, if at all; only those who would be at Guruvayoor that day. God made me very happy that day. I am grateful to him," she said to "The Hindu".


title: Manju Warrier

text: Manju Warrier is also known for her initiatives towards various social causes. She gave the inaugural speech at the National Women's Talk Festival organised by Soorya in Thiruvananthapuram on 1 January 2018. "I don't see any reason to glorify my involvement in social issues. There are a lot of people who do a lot more for society outside the limelight. Since I am known to the public, even the smallest of my deeds are projected in a big way," she said.


title: Manju Warrier

text: Apart from films, she also acts in television commercials and is a brand ambassador of Lasagu Coaching App, Kalyan Jewellers, Sony India, Meriiboy Ice Cream, Dhathri, Kitchen Treasures, ALIFF Brand Ambassador - Cinema for Women, Samsung, Ujala, Zee Keralam and myG. She has also worked as a goodwill ambassador for public awareness projects for government and private organisations, such as She - Taxi, Kudumbasree's Organic Farming, Naipunnya development program, the Kerala State Electricity Board, Pink Patrolling, Horticorp (Kerala State Horticultural Products and Development Corporation), Malayala Manorama - Kerala Can-Cancer awareness mission.


title: Death of Ayrton Senna

text: On 1 May 1994, Brazilian Formula One driver Ayrton Senna was killed after his car crashed into a concrete barrier while he was leading the 1994 San Marino Grand Prix at the Autodromo Enzo e Dino Ferrari in Italy. The previous day, Austrian driver Roland Ratzenberger had died when his car crashed during qualification for the race. His and Senna's crashes were the worst of several that took place that weekend (including a serious one involving Rubens Barrichello) and were the first fatal collisions to occur during a Formula One race meeting in 12 years and not repeated until the fatal crash of Jules Bianchi at the 2014 Japanese Grand Prix at Suzuka Circuit. This became a turning point in the safety of Formula One, prompting the implementation of new safety measures in both Formula One and the circuit, as well as the Grand Prix Drivers' Association to be reestablished. The Supreme Court of Cassation of Italy ruled that mechanical failure was the cause of the crash.


title: Death of Ayrton Senna

text: In 1994, Senna left his longtime team McLaren, which he had joined in 1988 and won three World Drivers' Championships with in 1988, 1990 and 1991, to join Williams, replacing his former teammate Alain Prost. There he was paired with Damon Hill. Williams was expected to contend for the F1 World Championship as they had in the previous two seasons with Prost and Nigel Mansell, albeit with cars that no longer had electronic aids, which had been banned for the 1994 season.


title: Death of Ayrton Senna

text: On debut for his new team during the traditional pre-season testing at Estoril, Senna said of the Williams FW16:


title: Death of Ayrton Senna

text: The problems continued as the season commenced. Senna had his worst ever start to a Formula One season, failing to finish or score points in the first two races (the Brazilian and Pacific Grands Prix), despite having taken pole in both. Benetton's Michael Schumacher was the championship leader entering the third race at Imola, with Senna trailing by 20 points.


title: Death of Ayrton Senna

text: On the Friday before the race, Senna's protégé, Rubens Barrichello, driving for the Jordan team, clipped a curb and crashed heavily at at the Variante Bassa chicane. Senna got out of his Williams car and went to the scene of the collision. Barrichello's tongue blocked his airway and emergency work done by FIA doctor Sid Watkins saved his life. Barrichello regained consciousness and found Senna looking over him. After learning Barrichello had survived, Senna returned to his car and continued his practice session.


title: Death of Ayrton Senna

text: After the session concluded, he left his car and went to the Williams motor home to attend pre-arranged interviews for the press and told the attending journalists to wait one hour while he was checking car problems with his engineer, David Brown. Following the interviews, Senna continued his work with Brown for another two hours. Once he arrived back at his hotel in Castel San Pietro, Senna reportedly telephoned his girlfriend Adriane Galisteu and broke down into tears while recounting Barrichello's crash earlier that day.


title: Death of Ayrton Senna

text: On Saturday morning, Senna set a personal best time of 1m 22.03 seconds and agreed with teammate Damon Hill that the car had improved. Having been released from the Medical Centre, Barrichello told Senna he was flying back to England to watch the race on television.


title: Death of Ayrton Senna

text: In the afternoon, the second qualifying session began and 18 minutes into the session, Simtek driver Roland Ratzenberger struck the concrete wall on the outside of the Villeneuve curve at , as a result of a suspected front wing failure. After the impact with a concrete barrier, the car bounced off and rested in the middle of that section of the track. Senna saw the replays of the collision and rushed into the pitlane to get inside a course car. When he arrived, with Ratzenberger taken into an ambulance, Senna inspected the damaged Simtek. He then attended the circuit's Medical Centre where he learnt from neurosurgeon Sid Watkins that Ratzenberger had died from injuries sustained in the accident. When the two left the centre together, Watkins told Senna that he did not have to race ever again and suggested that he withdraw from the race and go fishing with him. Senna responded by telling Watkins he could not stop racing and then went back to the Williams garage, where he summoned Patrick Head and Frank Williams, telling them of the situation and deciding to withdraw for the remainder of the qualifying session.


title: Death of Ayrton Senna

text: Reportedly, Senna retired to his motor home where he broke down in tears and collapsed onto the floor. This had concerned Williams, who asked Betise Assumpção, Senna's PR chief to arrange a meeting to discuss Senna's emotional state. Senna decided not to attend the post-qualifying press conference, leading the FIA to discuss but decide not to take disciplinary action against him. On the following day, however, race stewards called Senna out of his motor home to discuss his having commandeered a course car to visit Ratzenberger's crash site. A row ensued and Senna stormed off in disgust. The stewards decided to take no action.


title: Death of Ayrton Senna

text: On Sunday morning, Senna was the fastest in the warm-up session by nine-tenths of a second. Afterwards he saw former McLaren rival Alain Prost sitting at a table. They talked together for 30 minutes, with Senna lobbying for Prost's help to improve the sport's safety, both agreeing to meet before the Monaco Grand Prix.


title: Death of Ayrton Senna

text: Next, Senna filmed an in-car lap of Imola for French television channel TF1, where he greeted Prost now working as a presenter for that channel: "A special hello to our dear friend Alain. We all miss you, Alain." Prost said that he was amazed and very touched by the comment.


title: Death of Ayrton Senna

text: At the drivers' briefing, Senna attended along with Gerhard Berger. Since he was unwilling to speak out due to the earlier row with race officials that had left him still fraught with emotions, Senna asked Berger to raise his concerns about the pace car's presence during formation lap, which had no role other than to promote the then latest Porsche 911. At the San Marino Grand Prix, this pace car was thus made to leave the grid in advance of the Formula One cars, instead of together.


title: Death of Ayrton Senna

text: Senna then met with fellow drivers to discuss the re-establishment of a drivers' group (the Grand Prix Drivers' Association) in an attempt to increase safety in Formula One. As the most senior driver, Senna offered to take the role of leader, starting with the next race event in Monaco. Niki Lauda suggested that Senna lead the group because of his strong personality and standing in the sport, relative to the other drivers.


title: Death of Ayrton Senna

text: At the start of the race, Pedro Lamy and JJ Lehto were involved in a serious collision, spraying debris into the crowd and injuring bystanders. Track officials deployed the Opel Vectra safety car, driven by Formula Three driver Max Angelelli, to slow down the field and allow the removal of debris. The competitors proceeded behind the safety car for five laps. As the Vectra was based on a family sedan and not relatively fast, Senna had pulled alongside the Vectra to gesture to its driver to speed up; this car was subsequently regarded as inadequate for the role (due to the fact that its brakes had overheated and thus had to be driven slowly, lest itself be the cause of a crash) and a cause of the alleged drop in tyre pressures of the following Formula One cars. Before the sixth lap, David Brown told Senna via pit-to-car radio that the safety car was pulling off, and Senna acknowledged the message.


title: Death of Ayrton Senna

text: On lap 6, the race resumed and Senna immediately set a quick pace with the third-quickest lap of the race, followed by Schumacher. At the flat-out left-hander Tamburello corner, Schumacher noticed that Senna took a tight line through the curve and his car jiggled on the bumps.


title: Death of Ayrton Senna

text: On lap 7, the second lap at racing speed, Senna's car left the racing line at Tamburello, ran in a straight line off the track and struck an unprotected concrete barrier. Telemetry data recovered from the wreckage shows he entered the corner at and then braked hard, downshifting twice to slow down before impacting the wall at . The car hit the wall at a shallow angle, tearing off the right front wheel and nose cone before spinning to a halt.


title: Death of Ayrton Senna

text: After Senna's car stopped, he was initially motionless in the cockpit. After about ten seconds, as recorded by the close-up aerial footage, his head was seen to lift to the left before returning to its original position. Thereafter he did not move again. The right front wheel had shot up upon impact and entered the cockpit, striking the right frontal area of his helmet. The violence of the wheel's impact shoved his head back against the headrest (which was already far forward from the car's impact with the wall) causing fatal skull fractures. In addition, a piece of suspension attached to the wheel had also partially penetrated his Bell M3 helmet and caused trauma to his head. Also, it appeared that a jagged piece of the upright assembly had penetrated the helmet visor just above his right eye. Senna was using a medium-sized (58 cm) M3 helmet with a new "thin" Bell visor. Any one of the three injuries would probably have killed him.


title: Death of Ayrton Senna

text: After the crash, it was immediately evident that Senna had suffered some form of injury, because his helmet was seen to be motionless and leaning slightly to the right. The subtle movement of his head in the seconds that followed raised false hopes. Moments after the crash, Angelo Orsi, a photographer and a friend of Senna, took photographs of Senna in the car after his helmet was removed and Senna being treated before marshals blocked his view. Despite receiving numerous offers, the photographs have only been seen by Orsi and the Senna family, who insisted that Orsi not publish the photographs.


title: Death of Ayrton Senna

text: Fire marshals arrived at the car and were unable to touch Senna before qualified medical personnel arrived. Senna was pulled out of the car within minutes. Television coverage from an overhead helicopter was seen around the world, as rescue workers gave Senna medical attention. Close inspection of the area in which the medical staff treated Senna revealed a considerable amount of blood on the ground, probably from the pieces of suspension and upright assembly penetrating his helmet, which had ruptured his superficial temporal artery. From visible injuries to Senna's head, it was evident to attending medical professionals that he had sustained a grave head trauma. An emergency tracheotomy was conducted alongside the track to establish a secure airway through which the medical personnel could artificially maintain his breathing. The race was stopped one minute and nine seconds after Senna's crash. Williams team manager Ian Harrison went up to race control, finding a scene where many race officials were sensing that Senna's crash had been serious. Bernie Ecclestone later arrived in race control to calm the situation.


title: Death of Ayrton Senna

text: Neurosurgeon Sid Watkins, the head of Formula One's on-track medical team, performed the on-site tracheotomy on Senna. Watkins later reported:


title: Death of Ayrton Senna

text: Watkins cleared the respiratory passages, stemmed the blood flow, replaced lost blood and immobilised the cervical area. Watkins radioed for a medical helicopter and asked the intensive care anaesthetist, Giovanni Gordini, to escort Senna to Maggiore Hospital.


title: Death of Ayrton Senna

text: During the safety car period, Érik Comas brought his Larrousse-Ford to the pit lane to correct a vibration issue caused by contact under a yellow flag on the first lap. Shortly after the helicopter landed on the racing surface, Comas left the pit area and attempted to rejoin the now red-flagged Grand Prix due to a miscommunication with his crew. The race marshals waved frantically at Comas as he approached Tamburello, since he was apparently unaware of what was taking place, and he slammed on his brakes in time to stop the Larousse and avoid a collision with the medical helicopter. When he spotted Comas approaching the accident scene, John Watson — covering the events as an analyst for EuroSport — said it was the "most ridiculous thing I've ever seen at any time in my life".


title: Death of Ayrton Senna

text: Senna's car was eventually lifted onto a truck and returned to the pit lane where officials impounded it. However, an unidentified person insisted that the black-box data carried on the car be removed. At 3:00p.m., around 28 minutes after the crash, the helicopter landed in front of the Maggiore Hospital. Doctors rushed Senna into intensive care; a brain scan confirmed the diagnosis made on the track. At 3:10p.m., Senna's heart stopped beating, doctors restarted his heart, and he was placed on a life-support machine. Senna's brother Leonardo arranged for a priest to perform the last rites which occurred at 6:15p.m. Senna's heart stopped beating again at 6:37p.m., and it was decided not to restart it. Doctor Maria Teresa Fiandri, the emergency department head physician at the hospital who was off-duty and had been watching the race live from home with her sons, immediately left for the hospital and arrived at the same time as Senna's helicopter landed. In her interview after 20 years, she confirmed that the blood loss suffered by Senna was due to a damaged superficial temporal artery and that, apart from his head injuries, Senna appeared serene and the rest of the body was intact. Fiandri became responsible for providing medical updates to the media and public that had amassed at the hospital and, at about 7:00p.m., she announced that Senna died at 6:40p.m.


title: Death of Ayrton Senna

text: It was later revealed that, as medical staff examined Senna, a furled Austrian flag was found in his car—a flag that he had intended to raise in honour of Ratzenberger if he won the race.


title: Death of Ayrton Senna

text: Some time after the race, Ian Harrison was called by an Italian lawyer informing Harrison of Senna's death and that it was being treated as a "road traffic accident". Early in the morning of 2 May, Harrison was called by another lawyer, who took him to a mortuary. Harrison declined to see Senna's body upon being asked.


title: Death of Ayrton Senna

text: Following some stability and aerodynamic issues Senna's Williams FW16 was re-engineered by Adrian Newey to provide better handling at the request of Senna and Hill. After the end of the season, the cars were significantly changed to be safer. At Imola, Tamburello was changed from a flat-out left-hander to a chicane and a slow left-hander.


title: Death of Ayrton Senna

text: Senna's death was considered by many of his Brazilian fans to be a national tragedy, and the Brazilian government declared three days of national mourning. In an exception to airline policy, Senna's coffin was allowed to be flown back to his home country not as cargo but in the passenger cabin of a Varig McDonnell Douglas MD-11 commercial jetliner to São Paulo–Guarulhos International Airport, accompanied by his younger brother, Leonardo, and close friends. Senna's coffin was covered with a large Brazilian flag.


title: Death of Ayrton Senna

text: The funeral, which took place on 5 May 1994, was broadcast live on Brazilian television and an estimated three million people lined the streets of his hometown of São Paulo. Motor racing figures who attended Senna's state funeral included Alain Prost, Gerhard Berger, Jackie Stewart, Damon Hill, Thierry Boutsen, Rubens Barrichello (Ayrton's new protégé) and Emerson Fittipaldi who were among the pallbearers. Watkins and then McLaren team coordinator Jo Ramírez did not attend as they were so grief-stricken. Senna's family did not allow Formula One Management president Bernie Ecclestone to attend, and Fédération Internationale de l'Automobile (FIA) president Max Mosley instead attended the funeral of Roland Ratzenberger which took place on 7 May 1994, in Salzburg, Austria. Mosley said in a press conference ten years later, "I went to his funeral because everyone went to Senna's. I thought it was important that somebody went to his." Senna was buried at the Morumbi Cemetery in São Paulo. His grave bears the epitaph (Nothing can separate me from God's love).


title: Death of Ayrton Senna

text: At the Tokyo headquarters of Honda, where McLaren-Honda cars were typically displayed after each race, so many floral tributes were received after Senna's death that they overwhelmed the large exhibit lobby, even though Senna was no longer driving for a Honda-powered team (Honda had pulled out of Formula One after 1992, although its tuning partner Mugen Motorsports remained in the sport to supply Team Lotus that year). Senna had a special relationship with company founder Soichiro Honda and was revered in Japan. For the next race at Monaco, the FIA decided to leave the first two grid positions empty and painted them with the colours of the Brazilian and the Austrian flags, to honour Senna and Ratzenberger.


title: Death of Ayrton Senna

text: Five-time World Champion Juan Manuel Fangio was watching the race from his home in Balcarce, Argentina. He said after the accident "I knew he was dead".


title: Death of Ayrton Senna

text: ESPN, which broadcast the San Marino Grand Prix in the United States, also carried the Winston Select 500 NASCAR Winston Cup race at Talladega Superspeedway in Talladega, Alabama later the same day. With the race under a caution period on Lap 111 and Dale Earnhardt leading, lead commentator Bob Jenkins informed the audience that Senna had died. As a tribute, the ESPN booth of Jenkins, Ned Jarrett, and Benny Parsons went silent once the green flag came back out on the next lap. The moment of silence ended after a multiple-car incident caused another caution flag period within two laps of the restart. Earnhardt went on to win the race that afternoon. Once he emerged from his car, Earnhardt spoke with ESPN's Jerry Punch in Victory Lane and extended his condolences to Senna's friends and family. Nearly seven years later, Earnhardt himself died in an incident on the last lap of the 2001 Daytona 500.


title: Death of Ayrton Senna

text: Among Senna's millions of fans was future NASCAR driver Brad Keselowski, who was ten years old at the time of Senna's death. 20 years later, Keselowski drew parallels between the deaths of Senna and Earnhardt in a piece for NASCAR's website.


title: Death of Ayrton Senna

text: In Brazil, the country's television networks spent the rest of the day interrupting their normal programming schedules to announce Senna's death and replay his last interview, given to the media on the day before the crash. Many motor racing fans gathered outside of Maggiore Hospital to pay their respects to Senna, causing major traffic jams. Fans also gathered in the Williams F1 factory in Didcot where around 200 people attended with flowers laid on the front gates of the factory.


title: Death of Ayrton Senna

text: The Italian and Brazilian press were critical of the FIA for the rule changes that were enacted for 1994. Benetton driver Schumacher called for improvements in safety. BBC Sport commentator Murray Walker called Senna's death the "blackest day for Grand Prix racing that I can remember".


title: Death of Ayrton Senna

text: Two and a half months later, following Brazil's victory over Italy in the 1994 FIFA World Cup, the Brazilian squad dedicated their World Cup victory to Senna.


title: Death of Ayrton Senna

text: On 3 May, the FIA called a meeting at the request of the Italian Automobile Club to review the events of the weekend. Later on, the governing body announced new safety measures for the next round in Monaco which included the following three changes:


title: Death of Ayrton Senna

text: On 8 May, it was reported that Federico Bendinelli, an official who worked at Imola, said Senna had inspected the Tamburello corner and declared it was "O.K." Williams ran tests on one of their rigs attempting to replicate Senna's accident from the data retrieved. They attempted to simulate a mechanical failure which had not proven conclusive.


title: Death of Ayrton Senna

text: At the next race in Monaco, retired world champion Niki Lauda announced the reformation of the Grand Prix Drivers' Association (GPDA). The representatives elected were Lauda and active drivers Michael Schumacher, Gerhard Berger and Martin Brundle. At the end of the season, the GPDA demanded the FIA improve the safety of Formula One. The FIA responded quickly and introduced changes to the regulations as follows:


title: Death of Ayrton Senna

text: Other changes included improved crash barriers, redesigned tracks and tyre barriers, higher crash safety standards, higher sills on the driver cockpit and a limit on 3-litre engines. The FIA immediately investigated the Autodromo Enzo e Dino Ferrari in Imola, and the track's signature Tamburello turn was changed into a left–right chicane as a result.


title: Death of Ayrton Senna

text: In February 1995, a 500-page report by a team of judicial investigators was handed over to Italian prosecutors which attributed Senna's crash to steering column failure caused by a pre-race adjustment.


title: Death of Ayrton Senna

text: During legal proceedings before the Italian courts on 3 March 1997, based on the expert testimony and evidence of the pathologist, Dr Cipolla, Senna's official time of death was recorded as 2:17 pm on 1 May 1994, coinciding with cerebral death under , upon Senna hitting the Tamburello wall. The FIA and Italian motorsport authorities still maintain that Senna was not killed instantly, but rather died in the hospital, where he had been rushed by helicopter after an emergency tracheotomy and IV administration were performed on the track.


title: Death of Ayrton Senna

text: There is an ongoing debate as to why Senna was not declared dead at the track. Under Italian law, collisions resulting in a fatality must be investigated for any criminal culpability. The activities that cause the fatality, such as a sporting event, must be suspended forthwith and the scene of the crash secured.


title: Death of Ayrton Senna

text: The former Director of the Oporto (Portugal) Legal Medicine Institute, Professor José Eduardo Pinto da Costa, has stated the following:


title: Death of Ayrton Senna

text: Professor José Pratas Vital, Director of the Egas Moniz Hospital in Lisbon, a neurosurgeon and Head of the Medical Staff at the Portuguese GP, offered a different opinion:


title: Death of Ayrton Senna

text: Rogério Morais Martins, creative director of Ayrton Senna Promotions (which became the Ayrton Senna Institute after Senna's death), stated that:


title: Death of Ayrton Senna

text: The Williams team was entangled for many years in Italian criminal court proceedings after prosecutors instigated manslaughter charges against key team officials. On 16 December 1997, Frank Williams and five others were acquitted of the charges, ending the threat of a boycott of Formula One in Italy. In a 381-page ruling, Judge Antonio Costanzo concluded that steering column failure was the probable cause of Senna's crash; however, there was no proof of negligence on the part of Head or Newey, or that they had designed the modifications in the first place. On 22 November 1999, an appeals court upheld the acquittals, rejecting a request from prosecutors to give one-year suspended sentences to Head and Newey. In April 2002, Senna's FW16 chassis number 02 was returned to the Williams team. The team reported that the car was in an advanced state of deterioration and was subsequently destroyed. Senna's helmet was returned to Bell, and was incinerated. The car's engine was returned to Renault, where its fate is unknown.


title: Death of Ayrton Senna

text: In January 2003, the Italian Supreme Court reopened the case, ruling that "material errors" had been made in Bologna court of appeal. On 27 May 2005, the court gave a full acquittal to Adrian Newey, while the case against Head was "timed out" under a statute of limitations. A retrial was ordered by Italy's highest court in 2005.


title: Death of Ayrton Senna

text: On 13 April 2007, the Italian Supreme Court of Cassation delivered its own verdict (number 15050) stating that: "It has been determined that the accident was caused by a steering column failure. This failure was caused by badly designed and badly executed modifications. The responsibility for this falls on Patrick Head, culpable of omitted control". However, Head was not arrested since the Italian statute of limitations for culpable homicide was 7 years and 6 months, and the verdict was pronounced 13 years after the crash.


title: Death of Ayrton Senna

text: The criminal charges had focused on the car's steering column, which was found to have sheared off at a point where a modification had been made. The prosecution alleged that the column had failed, causing the crash, and the Williams team conceded to this failure but only as caused by the crash impact. In the weeks preceding the San Marino Grand Prix, Senna reportedly had asked his team to alter the steering column in order to give him more room in the cockpit. Patrick Head and Adrian Newey satisfied Senna's request by having the FW16's existing shaft cut and extended with a smaller-diameter piece of tubing that was welded together with reinforcing plates. The modification was carried out in this manner as there was insufficient time to instead manufacture a new steering shaft in time for the race.


title: Death of Ayrton Senna

text: A 600-page technical report was submitted by the University of Bologna under Professor of Engineering Enrico Lorenzini and his team of specialists. The report concluded that fatigue cracks had developed through most of the steering column at the point where it had broken. Lorenzini stated: "It had been badly welded together about a third of the way down and couldn't stand the strain of the race. We discovered scratches on the crack in the steering rod. It seemed like the job had been done in a hurry but I can't say how long before the race. Someone had tried to smooth over the joint following the welding. I have never seen anything like it. I believe the rod was faulty and probably cracked even during the warm-up. Moments before the crash only a tiny piece was left connected and therefore the car didn't respond in the bend."


title: Death of Ayrton Senna

text: An analysis of the onboard camera video was submitted by Cineca, which tracked the movement of the steering wheel during the race. Having rotated in a fixed arc during the previous laps, during the final seconds a yellow button on the wheel moved several centimetres away from its normal trajectory, with the steering wheel tilting in its own plane, indicating a breaking steering column. Williams introduced its own video to prove the movement was normal in which David Coulthard manhandled an FW16B steering wheel, the effort required to deflect the wheel termed as "quite considerable". Michele Alboreto testified that the steering wheel movement was abnormal, stating that the video "proves that something was broken in Senna's Williams. No steering wheel moves a few centimetres."


title: Death of Ayrton Senna

text: Patrick Head, technical director of Williams, believed that Senna had made a driving error. Michael Schumacher had told him after the race that Senna's car looked 'nervous' the previous lap. Damon Hill said he is convinced that Senna made a mistake.


title: Death of Ayrton Senna

text: Adrian Newey, who designed Senna's car, said he believes a tyre puncture may have caused Senna to crash. There was debris on the track following the JJ Lehto crash. Riccardo Patrese suffered a right rear tyre failure at Tamburello during practice for the 1992 Grand Prix, yet his car (an active suspension FW14B) was seen to be spinning before even leaving the track.


title: Risperidone

text: Risperidone, sold under the brand name Risperdal among others, is an atypical antipsychotic used to treat schizophrenia and bipolar disorder. It is taken either by mouth or by injection (subcutaneous or intramuscular). The injectable versions are long-acting and last for 2–4 weeks.


title: Risperidone

text: Common side effects include movement problems, sleepiness, dizziness, trouble seeing, constipation, and increased weight. Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, an increased risk of suicide, and high blood sugar levels. In older people with psychosis as a result of dementia, it may increase the risk of death. It is unknown if it is safe for use in pregnancy. Its mechanism of action is not entirely clear, but is believed to be related to its action as a dopamine and serotonin antagonist.


title: Risperidone

text: Study of risperidone began in the late 1980s and it was approved for sale in the United States in 1993. It is on the World Health Organization's List of Essential Medicines. It is available as a generic medication. In 2020, it was the 138th most commonly prescribed medication in the United States, with more than 4million prescriptions.


title: Risperidone

text: Risperidone is mainly used for the treatment of schizophrenia, bipolar disorder, and irritability associated with autism.


title: Risperidone

text: Risperidone is effective in treating psychogenic polydipsia and the acute exacerbations of schizophrenia.


title: Risperidone

text: Studies evaluating the utility of risperidone by mouth for maintenance therapy have reached varying conclusions. A 2012 systematic review concluded that evidence is strong that risperidone is more effective than all first-generation antipsychotics other than haloperidol, but that evidence directly supporting its superiority to placebo is equivocal. A 2011 review concluded that risperidone is more effective in relapse prevention than other first- and second-generation antipsychotics with the exception of olanzapine and clozapine. A 2016 Cochrane review suggests that risperidone reduces the overall symptoms of schizophrenia, but firm conclusions are difficult to make due to very low-quality evidence. Data and information are scarce, poorly reported, and probably biased in favour of risperidone, with about half of the included trials developed by drug companies. The article raises concerns regarding the serious side effects of risperidone, such as parkinsonism. A 2011 Cochrane review compared risperidone with other atypical antipsychotics such as olanzapine for schizophrenia:


title: Risperidone

text: Long-acting injectable formulations of antipsychotic drugs provide improved compliance with therapy and reduce relapse rates relative to oral formulations. The efficacy of risperidone long-acting injection appears to be similar to that of long acting injectable forms of first generation antipsychotics.


title: Risperidone

text: Second-generation antipsychotics, including risperidone, are effective in the treatment of manic symptoms in acute manic or mixed exacerbations of bipolar disorder. In children and adolescents, risperidone may be more effective than lithium or divalproex, but has more metabolic side effects. As maintenance therapy, long-acting injectable risperidone is effective for the prevention of manic episodes but not depressive episodes. The long-acting injectable form of risperidone may be advantageous over long acting first generation antipsychotics, as it is better tolerated (fewer extrapyramidal effects) and because long acting injectable formulations of first generation antipsychotics may increase the risk of depression.


title: Risperidone

text: Compared to placebo, risperidone treatment reduces certain problematic behaviors in autistic children, including aggression toward others, self-injury, challenging behaviour, and rapid mood changes. The evidence for its efficacy appears to be greater than that for alternative pharmacological treatments. Weight gain is an important adverse effect. Some authors recommend limiting the use of risperidone and aripiprazole to those with the most challenging behavioral disturbances in order to minimize the risk of drug-induced adverse effects. Evidence for the efficacy of risperidone in autistic adolescents and young adults is less persuasive.


title: Risperidone

text: While antipsychotic medications such as risperidone have a slight benefit in people with dementia, they have been linked to higher incidence of death and stroke. Because of this increased risk of death, treatment of dementia-related psychosis with risperidone is not FDA approved and carries a black box warning. However many other jurisdictions regularly use it to control severe aggression and psychosis in those with dementia when other non-pharmacological interventions have failed and their pharmaceutical regulators have approved its use in this population.


title: Risperidone

text: Risperidone has shown promise in treating therapy-resistant obsessive-compulsive disorder, when serotonin reuptake inhibitors alone are not sufficient.


title: Risperidone

text: Risperidone has proven to be effective in treatment with Attention deficit hyperactivity disorder especially in cases of aggression or with another mental condition.


title: Risperidone

text: Risperidone has not demonstrated a benefit in the treatment of eating disorders or personality disorders, except for limited evidence in schizotypal personality disorder.


title: Risperidone

text: Available forms of risperidone include tablet, oral dissolving tablet, oral solution, and powder and solvent for suspension for injection.


title: Risperidone

text: Common side effects include movement problems, sleepiness, dizziness, trouble seeing, constipation, and increased weight. About 9 to 20% of people gained more than 7% of the baseline weight depending on the dose. Serious side effects may include the potentially permanent movement disorder tardive dyskinesia, as well as neuroleptic malignant syndrome, an increased risk of suicide, and high blood sugar levels. In older people with psychosis as a result of dementia, it may increase the risk of death.


title: Risperidone

text: While atypical antipsychotics appear to have a lower rate of movement problems as compared to typical antipsychotics, risperidone has a high risk of movement problems among the atypicals. Atypical antipsychotics, however, are associated with a greater amount of weight gain and other metabolic side effects.


title: Risperidone

text: The British National Formulary recommends a gradual withdrawal when discontinuing antipsychotic treatment to avoid acute withdrawal syndrome or rapid relapse. Some have argued the additional somatic and psychiatric symptoms associated with dopaminergic super-sensitivity, including dyskinesia and acute psychosis, are common features of withdrawal in individuals treated with neuroleptics. This has led some to suggest the withdrawal process might itself be schizomimetic, producing schizophrenia-like symptoms even in previously healthy patients, indicating a possible pharmacological origin of mental illness in a yet unknown percentage of patients currently and previously treated with antipsychotics. This question is unresolved, and remains a highly controversial issue among professionals in the medical and mental health communities, as well as the public.


title: Risperidone

text: Risperidone has been classified as a "qualitatively atypical" antipsychotic agent with a relatively low incidence of extrapyramidal side effects (when given at low doses) that has more pronounced serotonin antagonism than dopamine antagonism. Risperidone contains the functional groups of benzisoxazole and piperidine as part of its molecular structure. Although not a butyrophenone, it was developed with the structures of benperidol and ketanserin as a basis. It has actions at several 5-HT (serotonin) receptor subtypes. These are 5-HT, linked to weight gain, 5-HT, linked to its antipsychotic action and relief of some of the extrapyramidal side effects experienced with the typical neuroleptics.


title: Risperidone

text: It has been found that -amino acid oxidase, the enzyme that catalyses the breakdown of -amino acids (e.g. -alanine and -serine — the neurotransmitters) is inhibited by risperidone.


title: Risperidone

text: Dopamine receptors: This drug is an antagonist of the D (D, and D) as well as the D family (D, D and D) receptors, with 70-fold selectivity for the D family. It has "tight binding" properties, which means it has a long half-life. Like other antipsychotics, risperidone blocks the mesolimbic pathway, the prefrontal cortex limbic pathway, and the tuberoinfundibular pathway in the central nervous system. Risperidone may induce extrapyramidal side effects, akathisia and tremors, associated with diminished dopaminergic activity in the striatum. It can also cause sexual side effects, galactorrhoea, infertility, gynecomastia and, with chronic use reduced bone mineral density leading to breaks, all of which are associated with increased prolactin secretion.


title: Risperidone

text: Serotonin receptors: Its action at these receptor, mediated through an exceptionally strong 5ht/D ratio, is to prevent the drugs potential causing extrapyramidal side effects, like the reference substance clozapine. This strong binding affinity and through this a possibly competitive activation of specific brain regions led mice to alleviate amphetamininduced antagonism of dopaminereceptors with administration of long-acting risperidone.


title: Risperidone

text: However, these findings could only be regarded neurological, not psychological, as in one study conducted with monkeys, risperidone even increases the choice of methamphetamine over food.


title: Risperidone

text: Alpha α adrenergic receptors: This action accounts for the orthostatic hypotensive effects and perhaps some of the sedating effects of risperidone.


title: Risperidone

text: Alpha α adrenergic receptors: Risperidone's action at these receptors may cause greater positive, negative, affective, and cognitive symptom control.


title: Risperidone

text: Histamine H receptors: effects on these receptors account for its sedation and reduction in vigilance. This may also lead to drowsiness and weight gain.


title: Risperidone

text: Voltage-gated sodium channels: Because it accumulates in synaptic vesicles, Risperidone inhibits voltage-gated sodium channels at clinically used concentrations.


title: Risperidone

text: Risperidone undergoes hepatic metabolism and renal excretion. Lower doses are recommended for patients with severe liver and kidney disease. The active metabolite of risperidone, paliperidone, is also used as an antipsychotic.


title: Risperidone

text: Risperidone was approved by the United States Food and Drug Administration (FDA) in 1993 for the treatment of schizophrenia. In 2003, the FDA approved risperidone for the short-term treatment of the mixed and manic states associated with bipolar disorder. In 2006, the FDA approved risperidone for the treatment of irritability in autistic children and adolescents. The FDA's decision was based in part on a study of autistic people with severe and enduring problems of violent meltdowns, aggression, and self-injury; risperidone is not recommended for autistic people with mild aggression and explosive behavior without an enduring pattern. On 22 August 2007, risperidone was approved as the only drug agent available for treatment of schizophrenia in youths, ages 13–17; it was also approved that same day for treatment of bipolar disorder in youths and children, ages 10–17, joining lithium.


title: Risperidone

text: On 16 December 2021, the Committee for Medicinal Products for Human Use (CHMP) of the European Medicines Agency (EMA) adopted a positive opinion, recommending the granting of a marketing authorization for the medicinal product Okedi, intended for the treatment of schizophrenia in adults for whom tolerability and effectiveness has been established with oral risperidone. The applicant for this medicinal product is Laboratorios Farmacéuticos Rovi, S.A. Risperidone was approved for medical use in the European Union in February 2022.


title: Risperidone

text: Janssen's patent on risperidone expired on 29 December 2003, opening the market for cheaper generic versions from other companies, and Janssen's exclusive marketing rights expired on 29 June 2004 (the result of a pediatric extension). It is available under many brand names worldwide.


title: Risperidone

text: On 11 April 2012, Johnson & Johnson (J&J) and its subsidiary Janssen Pharmaceuticals Inc. were fined $1.2 billion by Judge Timothy Davis Fox of the Sixth Division of the Sixth Judicial Circuit of the U.S. state of Arkansas. The jury found the companies had downplayed multiple risks associated with risperidone. The verdict was later reversed by the Arkansas state supreme court.


title: Risperidone

text: In August 2012, Johnson & Johnson agreed to pay $181 million to 36 U.S. states in order to settle claims that it had promoted risperidone and paliperidone for off-label uses including for dementia, anger management, and anxiety.


title: Risperidone

text: In November 2013, J&J was fined $2.2 billion for illegally marketing risperidone for use in people with dementia.


title: Risperidone

text: In 2015, Steven Brill posted a 15-part investigative journalism piece on J&J in "The Huffington Post", called "America's most admired lawbreaker", which was focused on J&J's marketing of risperidone.


title: Risperidone

text: J&J has faced numerous civil lawsuits on behalf of children who were prescribed risperidone who grew breasts (a condition called gynecomastia); as of July 2016 there were about 1,500 cases in Pennsylvania state court in Philadelphia, and there had been a February 2015 verdict against J&J with $2.5 million awarded to a man from Alabama, a $1.75 million verdict against J&J that November, and in 2016 a $70 million verdict against J&J. In October 2019, a jury awarded a Pennsylvania man $8 billion in a verdict against J&J.


title: Risperidone

text: Brand names include Risperdal, Risperdal Consta, Risperdal M-Tab, Risperdal Quicklets, Risperlet, Okedi, and Perseris.


title: Ophthalmology

text: Ophthalmology ( ) is a surgical subspecialty within medicine that deals with the diagnosis and treatment of eye disorders.


title: Ophthalmology

text: An ophthalmologist is a physician who undergoes subspecialty training in medical and surgical eye care. Following a medical degree, a doctor specialising in ophthalmology must pursue additional postgraduate residency training specific to that field. This may include a one-year integrated internship that involves more general medical training in other fields such as internal medicine or general surgery. Following residency, additional specialty training (or fellowship) may be sought in a particular aspect of eye pathology.


title: Ophthalmology

text: Ophthalmologists prescribe medications to treat eye diseases, implement laser therapy, and perform surgery when needed. Ophthalmologists provide both primary and specialty eye care - medical and surgical. Most ophthalmologists participate in academic research on eye diseases at some point in their training and many include research as part of their career.


title: Ophthalmology

text: Ophthalmology has always been at the forefront of medical research with a long history of advancement and innovation in eye care.


title: Ophthalmology

text: Following are examples of examination methods performed during an eye examination that enables diagnosis


title: Ophthalmology

text: Optical coherence tomography (OCT) is a medical technological platform used to assess ocular structures. The information is then used by physicians to assess staging of pathological processes and confirm clinical diagnoses. Subsequent OCT scans are used to assess the efficacy of managing diabetic retinopathy, age-related macular degeneration, and glaucoma.


title: Ophthalmology

text: Optical coherence tomography angiography (OCTA) and Fluorescein angiography to visualize the vascular networks of the retina and choroid.


title: Ophthalmology

text: Electroretinography (ERG) measures the electrical responses of various cell types in the retina, including the photoreceptors (rods and cones), inner retinal cells (bipolar and amacrine cells), and the ganglion cells.


title: Ophthalmology

text: Electrooculography (EOG) is a technique for measuring the corneo-retinal standing potential that exists between the front and the back of the human eye. The resulting signal is called the electrooculogram. Primary applications are in ophthalmological diagnosis and in recording eye movements.


title: Ophthalmology

text: Visual field testing to detect dysfunction in central and peripheral vision which may be caused by various medical conditions such as glaucoma, stroke, pituitary disease, brain tumours or other neurological deficits.


title: Ophthalmology

text: Corneal topography is a non-invasive medical imaging technique for mapping the anterior curvature of the cornea, the outer structure of the eye.


title: Ophthalmology

text: Eye surgery, also known as ocular surgery, is surgery performed on the eye or its adnexa by an ophthalmologist. The eye is a fragile organ, and requires extreme care before, during, and after a surgical procedure. An eye surgeon is responsible for selecting the appropriate surgical procedure for the patient and for taking the necessary safety precautions.


title: Ophthalmology

text: Ophthalmology includes subspecialities that deal either with certain diseases or diseases of certain parts of the eye. Some of them are:


title: Ophthalmology

text: Medical retina and vitreo-retinal surgery sometimes are combined and together they are called posterior segment subspecialisation


title: Ophthalmology

text: The Greek roots of the word ophthalmology are ὀφθαλμός (, "eye") and -λoγία (-, "study, discourse"), i.e., "the study of eyes". The discipline applies to all animal eyes, whether human or not, since the practice and procedures are quite similar with respect to disease processes, although there are differences in the anatomy or disease prevalence.


title: Ophthalmology

text: Prior to Hippocrates, physicians largely based their anatomical conceptions of the eye on speculation, rather than empiricism. They recognized the sclera and transparent cornea running flushly as the outer coating of the eye, with an inner layer with pupil, and a fluid at the centre. It was believed, by Alcamaeon (fifth century BC) and others, that this fluid was the medium of vision and flowed from the eye to the brain by a tube. Aristotle advanced such ideas with empiricism. He dissected the eyes of animals, and discovering three layers (not two), found that the fluid was of a constant consistency with the lens forming (or congealing) after death, and the surrounding layers were seen to be juxtaposed. He and his contemporaries further put forth the existence of three tubes leading from the eye, not one. One tube from each eye met within the skull.


title: Ophthalmology

text: The Greek physician Rufus of Ephesus (first century AD) recognised a more modern concept of the eye, with conjunctiva, extending as a fourth epithelial layer over the eye. Rufus was the first to recognise a two-chambered eye, with one chamber from cornea to lens (filled with water), the other from lens to retina (filled with a substance resembling egg whites).


title: Ophthalmology

text: Celsus the Greek philosopher of the second century AD gave a detailed description of cataract surgery by the couching method.


title: Ophthalmology

text: The Greek physician Galen (second century AD) remedied some mistaken descriptions, including about the curvature of the cornea and lens, the nature of the optic nerve, and the existence of a posterior chamber. Although this model was a roughly correct modern model of the eye, it contained errors. Still, it was not advanced upon again until after Vesalius. A ciliary body was then discovered and the sclera, retina, choroid, and cornea were seen to meet at the same point. The two chambers were seen to hold the same fluid, as well as the lens being attached to the choroid. Galen continued the notion of a central canal, but he dissected the optic nerve and saw that it was solid. He mistakenly counted seven optical muscles, one too many. He also knew of the tear ducts.


title: Ophthalmology

text: The Indian surgeon Sushruta wrote the "Sushruta Samhita" in Sanskrit in approximately the sixth century BC, which describes 76 ocular diseases (of these, 51 surgical) as well as several ophthalmological surgical instruments and techniques. His description of cataract surgery was compatible with the method of couching. He has been described as one of the first cataract surgeons.


title: Ophthalmology

text: Medieval Islamic Arabic and Persian scientists (unlike their classical predecessors) considered it normal to combine theory and practice, including the crafting of precise instruments, and therefore, found it natural to combine the study of the eye with the practical application of that knowledge. Hunayn ibn Ishaq, and others beginning with the medieval Arabic period, taught that the crystalline lens is in the exact center of the eye. This idea was propagated until the end of the 1500s.


title: Ophthalmology

text: Ibn al-Haytham (Alhazen), in his Book of Optics explained that vision occurs when light lands on an object, bounces off, and is directed to one's eyes.


title: Ophthalmology

text: Ibn al-Nafis, an Arabic native of Damascus, wrote a large textbook, "The Polished Book on Experimental Ophthalmology", divided into two parts, "On the Theory of Ophthalmology" and "Simple and Compounded Ophthalmic Drugs".


title: Ophthalmology

text: Avicenna wrote in his Canon "rescheth", which means "retiformis", and Gerard of Cremona translated this at approximately 1150 into the new term "retina".


title: Ophthalmology

text: In the seventeenth and eighteenth centuries, hand lenses were used by Malpighi, microscopes by Leeuwenhoek, preparations for fixing the eye for study by Ruysch, and later the freezing of the eye by Petit. This allowed for detailed study of the eye and an advanced model. Some mistakes persisted, such as: why the pupil changed size (seen to be vessels of the iris filling with blood), the existence of the posterior chamber, and the nature of the retina. Unaware of their functions, Leeuwenhoek noted the existence of photoreceptors, however, they were not properly described until Gottfried Reinhold Treviranus in 1834.


title: Ophthalmology

text: Approximately 1750, Jacques Daviel advocated a new treatment for cataract by extraction instead of the traditional method of couching. Georg Joseph Beer (1763–1821) was an Austrian ophthalmologist and leader of the First Viennese School of Medicine. He introduced a flap operation for treatment of cataract (Beer's operation), as well as having popularized the instrument used to perform the surgery (Beer's knife).


title: Ophthalmology

text: In North America, indigenous healers treated some eye diseases by rubbing or scraping the eyes or eyelids.


title: Ophthalmology

text: The first ophthalmic surgeon in Great Britain was John Freke, appointed to the position by the governors of St. Bartholomew's Hospital in 1727. A major breakthrough came with the appointment of Baron de Wenzel (1724–90), a German who became the oculist to King George III of Great Britain in 1772. His skill at removing cataracts legitimized the field. The first dedicated ophthalmic hospital opened in 1805 in London; it is now called Moorfields Eye Hospital. Clinical developments at Moorfields and the founding of the Institute of Ophthalmology (now part of the University College London) by Sir Stewart Duke-Elder established the site as the largest eye hospital in the world and a nexus for ophthalmic research.


title: Ophthalmology

text: In Berlin, ophthalmologist Albrecht von Graefe introduced iridectomy as a treatment for glaucoma and improved cataract surgery, he is also considered the founding father of the German Ophthalmological Society.


title: Ophthalmology

text: Numerous ophthalmologists fled Germany after 1933 as the Nazis began to persecute those of Jewish descent. A representative leader was Joseph Igersheimer (1879–1965), best known for his discoveries with arsphenamine for the treatment of syphilis. He fled to Turkey in 1933. As one of eight emigrant directors in the Faculty of Medicine at the University of Istanbul, he built a modern clinic and trained students. In 1939, he went to the United States, becoming a professor at Tufts University. German ophthalmologist, Gerhard Meyer-Schwickerath is widely credited with developing the predecessor of laser coagulation, photocoagulation.


title: Ophthalmology

text: In 1946, Igersheimer conducted the first experiments on light coagulation. In 1949, he performed the first successful treatment of a retinal detachment with a light beam (light coagulation) with a self-constructed device on the roof of the ophthalmic clinic at the University of Hamburg-Eppendorf.


title: Ophthalmology

text: Polish ophthalmology dates to the thirteenth century. The Polish Ophthalmological Society was founded in 1911. A representative leader was Adam Zamenhof (1888–1940), who introduced certain diagnostic, surgical, and nonsurgical eye-care procedures. He was executed by the German Nazis in 1940.


title: Ophthalmology

text: Zofia Falkowska (1915–93) head of the Faculty and Clinic of Ophthalmology in Warsaw from 1963 to 1976, was the first to use lasers in her practice.


title: Ophthalmology

text: The prominent physicists of the late nineteenth and early twentieth centuries included Ernst Abbe (1840–1905), a co-owner of at the Zeiss Jena factories in Germany, where he developed numerous optical instruments. Hermann von Helmholtz (1821-1894) was a polymath who made contributions to many fields of science and invented the ophthalmoscope in 1851. They both made theoretical calculations on image formation in optical systems and also had studied the optics of the eye.


title: Ophthalmology

text: Ophthalmologists are physicians (MD/DO in the U.S. or MBBS in the UK and elsewhere or DO/DOMS/DNB, who typically complete an undergraduate degree, general medical school, followed by a residency in ophthalmology. Ophthalmologists typically perform optical, medical and surgical eye care.


title: Ophthalmology

text: In Australia and New Zealand, the FRACO or FRANZCO is the equivalent postgraduate specialist qualification. The structured training system takes place over five years of postgraduate training. Overseas-trained ophthalmologists are assessed using the pathway published on the RANZCO website. Those who have completed their formal training in the UK and have the CCST or CCT, usually are deemed to be comparable.


title: Ophthalmology

text: In Bangladesh to be an ophthalmologist the basic degree is an MBBS. Then they have to obtain a postgraduate degree or diploma in an ophthalmology specialty. In Bangladesh, these are diploma in ophthalmology, diploma in community ophthalmology, fellow or member of the College of Physicians and Surgeons in ophthalmology, and Master of Science in ophthalmology.


title: Ophthalmology

text: In Canada, after medical school an ophthalmology residency is undertaken. The residency typically lasts five years, which culminates in fellowship of the Royal College of Surgeons of Canada (FRCSC). Subspecialty training is undertaken by approximately 30% of fellows (FRCSC) in a variety of fields from anterior segment, cornea, glaucoma, vision rehabilitation, uveitis, oculoplastics, medical and surgical retina, ocular oncology, Ocular pathology, or neuro-ophthalmology. Approximately 35 vacancies open per year for ophthalmology residency training in all of Canada. These numbers fluctuate per year, ranging from 30 to 37 spots. Of these, up to ten spots are at French-speaking universities in Quebec. At the end of the five years, the graduating ophthalmologist must pass the oral and written portions of the Royal College exam in either English or French.


title: Ophthalmology

text: In India, after completing MBBS degree, postgraduate study in ophthalmology is required. The degrees are doctor of medicine, master of surgery, diploma in ophthalmic medicine and surgery, and diplomate of national board. The concurrent training and work experience are in the form of a junior residency at a medical college, eye hospital, or institution under the supervision of experienced faculty. Further work experience in the form of fellowship, registrar, or senior resident refines the skills of these eye surgeons. All members of the India Ophthalmologist Society and various state-level ophthalmologist societies hold regular conferences and actively promote continuing medical education.


title: Ophthalmology

text: In Nepal, to become an ophthalmologist, three years of postgraduate study is required after completing an MBBS degree. The postgraduate degree in ophthalmology is called medical doctor in ophthalmology. Currently, this degree is provided by Tilganga Institute of Ophthalmology, Tilganga, Kathmandu, BPKLCO, Institute of Medicine, TU, Kathmandu, BP Koirala Institute of Health Sciences, Dharan, Kathmandu University, Dhulikhel, and National Academy of Medical Science, Kathmandu. A few Nepalese citizens also study this subject in Bangladesh, China, India, Pakistan, and other countries. All graduates have to pass the Nepal Medical Council Licensing Exam to become a registered ophthalmologists in Nepal. The concurrent residency training is in the form of a PG student (resident) at a medical college, eye hospital, or institution according to the degree providing university's rules and regulations. Nepal Ophthalmic Society holds regular conferences and actively promotes continuing medical education.


title: Ophthalmology

text: In Ireland, the Royal College of Surgeons of Ireland grants membership (MRCSI (Ophth)) and fellowship (FRCSI (Ophth)) qualifications in conjunction with the Irish College of Ophthalmologists. Total postgraduate training involves an intern year, a minimum of three years of basic surgical training, and a further 4.5 years of higher surgical training. Clinical training takes place within public, Health Service Executive-funded hospitals in Dublin, Sligo, Limerick, Galway, Waterford, and Cork. A minimum of 8.5 years of training is required before eligibility to work in consultant posts. Some trainees take extra time to obtain MSc, MD or PhD degrees and to undertake clinical fellowships in the UK, Australia, and the United States.


title: Ophthalmology

text: In Pakistan, after MBBS, a four-year full-time residency program leads to an exit-level FCPS examination in ophthalmology, held under the auspices of the College of Physicians and Surgeons, Pakistan. The tough examination is assessed by both highly qualified Pakistani and eminent international ophthalmic consultants. As a prerequisite to the final examinations, an intermediate module, an optics and refraction module, and a dissertation written on a research project carried out under supervision is also assessed.


title: Ophthalmology

text: Moreover, a two-and-a-half-year residency program leads to an MCPS while a two-year training of DOMS is also being offered. For candidates in the military, a stringent two-year graded course, with quarterly assessments, is held under Armed Forces Post Graduate Medical Institute in Rawalpindi.


title: Ophthalmology

text: The M.S. in ophthalmology is also one of the specialty programs. In addition to programs for physicians, various diplomas and degrees for allied eyecare personnel are also being offered to produce competent optometrists, orthoptists, ophthalmic nurses, ophthalmic technologists, and ophthalmic technicians in this field. These programs are being offered, notably by the College of Ophthalmology and Allied Vision Sciences, in Lahore and the Pakistan Institute of Community Ophthalmology in Peshawar. Subspecialty fellowships also are being offered in the fields of pediatric ophthalmology and vitreoretinal ophthalmology. King Edward Medical University, Al Shifa Trust Eye Hospital Rawalpindi, and Al- Ibrahim Eye Hospital Karachi also have started a degree program in this field.


title: Ophthalmology

text: In the Philippines, Ophthalmology is considered a medical specialty that uses medicine and surgery to treat diseases of the eye. There is only one professional organization in the country that is duly recognized by the PMA and the PCS: the Philippine Academy of Ophthalmology (PAO). PAO and the state-standard Philippine Board of Ophthalmology (PBO) regulates ophthalmology residency programs and board certification. To become a general ophthalmologist in the Philippines, a candidate must have completed a doctor of medicine degree (MD) or its equivalent (e.g. MBBS), have completed an internship in Medicine, have passed the physician licensure exam, and have completed residency training at a hospital accredited by the Philippine Board of Ophthalmology (accrediting arm of PAO). Attainment of board certification in ophthalmology from the PBO is essential in acquiring privileges in most major health institutions. Graduates of residency programs can receive further training in ophthalmology subspecialties, such as neuro-ophthalmology, retina, etc. by completing a fellowship program that varies in length depending on each program's requirements.


title: Ophthalmology

text: In the United Kingdom, three colleges grant postgraduate degrees in ophthalmology. The Royal College of Ophthalmologists (RCOphth) and the Royal College of Surgeons of Edinburgh grant MRCOphth/FRCOphth and MRCSEd/FRCSEd, (although membership is no longer a prerequisite for fellowship), the Royal College of Glasgow grants FRCS. Postgraduate work as a specialist registrar and one of these degrees is required for specialization in eye diseases. Such clinical work is within the NHS, with supplementary private work for some consultants.


title: Ophthalmology

text: Only 2.3 ophthalmologists exist per 100,000 population in the UK – fewer "pro rata" than in any nations in the European Union.


title: Ophthalmology

text: Ophthalmologists typically complete four years of undergraduate studies, four years of medical school and four years of eye-specific training (residency). Some pursue additional training, known as a fellowship - typically one to two years. Ophthalmologists are physicians who specialize in the eye and related structures. They perform medical and surgical eye care and may also write prescriptions for corrective lenses. They often manage late stage eye disease, which typically involves surgery.


title: Ophthalmology

text: Ophthalmologists must complete the requirements of continuing medical education to maintain licensure and for recertification.


title: Ophthalmology

text: The following is a list of physicians who have significantly contributed to the field of ophthalmology:


title: Maggie Siff

text: Maggie Siff (born June 21, 1974) is an American actress. Her most notable television roles have included department store heiress Rachel Menken Katz on the AMC drama "Mad Men", Dr. Tara Knowles on the FX drama "Sons of Anarchy" for which she was twice nominated for the Critics' Choice Television Award for Best Supporting Actress in a Drama Series, and psychiatrist Wendy Rhoades on the Showtime series "Billions".


title: Maggie Siff

text: She has also had roles in the films "Push" (2009) as Teresa Stowe, and "Leaves of Grass" (2010) as Rabbi Renannah Zimmerman. She starred in indie film "A Woman, a Part" (2016) and had a minor role in the drama film "One Percent More Humid" (2017). She is the television spokesperson for the robo-advisor service Betterment.


title: Maggie Siff

text: Siff is an alumna of The Bronx High School of Science and of Bryn Mawr College, where she majored in English and graduated in 1996. She later completed an M.F.A. in acting at New York University's Tisch School of the Arts. Shortly after graduating, Siff also worked as a temp at a hedge fund, an experience she drew on for her role in "Billions".


title: Maggie Siff

text: Siff worked extensively in regional theater before acting in television. She won a Barrymore Award for Excellence in Theater in 1998 for her work in Henrik Ibsen's "Ghosts" at Lantern Theater Company.


title: Maggie Siff

text: Born to a father of Ashkenazi Jewish descent who was also a stage actor, Siff has stated that she feels “culturally Jewish because of how and where I grew up."


title: Maggie Siff

text: Siff started appearing in television series in 2004. She appeared as an Alcoholics Anonymous speaker during an episode of "Rescue Me" in Season 2. She also had roles on "", "Grey's Anatomy", and "Law & Order".


title: Maggie Siff

text: She played Rachel Menken Katz on the series "Mad Men" from 2007 to 2008, which earned her a nomination, along with the rest of the cast, for a Screen Actors Guild Award for Outstanding Performance by an Ensemble in a Drama Series. She also appeared in a small role as a burn victim on "Nip/Tuck" during that time, before being cast as Dr. Tara Knowles on "Sons of Anarchy" in 2008.


title: Maggie Siff

text: She has appeared in such films as "Then She Found Me" (2007) as Lily, "Push" as a psychic surgeon (called a Stitch) named Teresa Stowe, sent to help Nick (played by Chris Evans), "Funny People" (2009) as Rachel, "Leaves of Grass" (2010) as Rabbi Renannah Zimmerman, and "Concussion" (2013) as Sam Bennet. She appears in the 2016 Showtime series "Billions". She starred in an independent indie film called "A Woman, A Part" (2016) as well as "One Percent More Humid" (2017).


title: Maggie Siff

text: Starting in 2018, she has been serving as the television spokesperson for Betterment, an online investment service.


title: Maggie Siff

text: In 2020, Siff provided the voice for the titular subject of "Polly Platt: The Invisible Woman", over the course of a season of Karina Longworth’s film history podcast "You Must Remember This."


title: Maggie Siff

text: In October 2013, Siff announced that she was expecting her first child with husband, Paul Ratliff, whom she married in 2012. Siff gave birth to a daughter, Lucy.


title: Affordable Care Act

text: The Affordable Care Act (ACA), formally known as the Patient Protection and Affordable Care Act and colloquially known as Obamacare, is a landmark U.S. federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the enactment of Medicare and Medicaid in 1965.


title: Affordable Care Act

text: The ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After it went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.


title: Affordable Care Act

text: The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to changes to individual insurance markets. Both received new spending, funded through a combination of new taxes and cuts to Medicare provider rates and Medicare Advantage. Several Congressional Budget Office (CBO) reports said that overall these provisions reduced the budget deficit, that repealing ACA would increase the deficit, and that the law reduced income inequality by taxing primarily the top 1% to fund roughly $600 in benefits on average to families in the bottom 40% of the income distribution.


title: Affordable Care Act

text: The act largely retained the existing structure of Medicare, Medicaid, and the employer market, but individual markets were radically overhauled. Insurers were made to accept all applicants without charging based on preexisting conditions or demographic status (except age). To combat the resultant adverse selection, the act mandated that individuals buy insurance (or pay a fine/tax) and that insurers cover a list of "essential health benefits".


title: Affordable Care Act

text: Before and after enactment the ACA faced strong political opposition, calls for repeal and legal challenges. In "National Federation of Independent Business v. Sebelius", the Supreme Court ruled that states could choose not to participate in the law's Medicaid expansion, but upheld the law as a whole. The federal health insurance exchange, HealthCare.gov, faced major technical problems at the beginning of its rollout in 2013. Polls initially found that a plurality of Americans opposed the act, although its individual provisions were generally more popular. By 2017, the law had majority support. President Donald Trump rescinded the federal tax penalty for violating the individual mandate through the Tax Cuts and Jobs Act of 2017, starting in 2019. This raised questions about whether the ACA was still constitutional. In June 2021, the Supreme Court upheld the ACA for the third time in "California v. Texas".


title: Affordable Care Act

text: ACA amended the Public Health Service Act of 1944 and inserted new provisions on affordable care into Title 42 of the United States Code. The individual insurance market was radically overhauled, and many of the law's regulations applied specifically to this market, while the structure of Medicare, Medicaid, and the employer market were largely retained. Some regulations applied to the employer market, and the law also made delivery system changes that affected most of the health care system.


title: Affordable Care Act

text: All new individual major medical health insurance policies sold to individuals and families faced new requirements. The requirements took effect on January 1, 2014. They include:


title: Affordable Care Act

text: The individual mandate required everyone to have insurance or pay a penalty. The mandate and limits on open enrollment were designed to avoid the insurance death spiral, minimize the free rider problem and prevent the healthcare system from succumbing to adverse selection.


title: Affordable Care Act

text: The mandate was intended to increase the size and diversity of the insured population, including more young and healthy participants to broaden the risk pool, spreading costs.


title: Affordable Care Act

text: The Tax Cuts and Jobs Act of 2017, reduced to 0 the fine/tax for violating the individual mandate, starting in 2019.


title: Affordable Care Act

text: ACA mandated that health insurance exchanges be provided for each state. The exchanges are regulated, largely online marketplaces, administered by either federal or state governments, where individuals, families and small businesses can purchase private insurance plans. Exchanges first offered insurance for 2014. Some exchanges also provide access to Medicaid.


title: Affordable Care Act

text: States that set up their own exchanges have some discretion on standards and prices. For example, states approve plans for sale, and thereby influence (through negotiations) prices. They can impose additional coverage requirements—such as abortion. Alternatively, states can make the federal government responsible for operating their exchanges.


title: Affordable Care Act

text: Individuals whose household incomes are between 100% and 400% of the federal poverty level (FPL) are eligible to receive federal subsidies for premiums for policies purchased on an ACA exchange, provided they are not eligible for Medicare, Medicaid, the Children's Health Insurance Program, or other forms of public assistance health coverage, and do not have access to affordable coverage (no more than 9.86% of income for the employee's coverage) through their own or a family member's employer. Households below the federal poverty level are not eligible to receive these subsidies. Lawful Residents and some other legally present immigrants whose household income is below 100% FPL and are not otherwise eligible for Medicaid are eligible for subsidies if they meet all other eligibility requirements. Married people must file taxes jointly to receive subsidies. Enrollees must have U.S. citizenship or proof of legal residency to obtain a subsidy.


title: Affordable Care Act

text: The subsidies for an ACA plan purchased on an exchange stop at 400% of the federal poverty level (FPL). According to the Kaiser Foundation, this results in a sharp "discontinuity of treatment" at 400% FPL, which is sometimes called the "subsidy cliff". After-subsidy premiums for the second lowest cost silver plan (SCLSP) just below the cliff are 9.86% of income in 2019.


title: Affordable Care Act

text: The amount of subsidy is sufficient to reduce the premium for the second-lowest-cost silver plan (SCLSP) on an exchange cost a sliding-scale percentage of income. The percentage is based on the percent of federal poverty level (FPL) for the household, and varies slightly from year to year. In 2019, it ranged from 2.08% of income (100%-133% FPL) to 9.86% of income (300%-400% FPL). The subsidy can be used for any plan available on the exchange, but not catastrophic plans. The subsidy may not exceed the premium for the purchased plan.


title: Affordable Care Act

text: As written, ACA mandated that insurers reduce copayments and deductibles for ACA exchange enrollees earning less than 250% of the FPL. Medicaid recipients were not eligible for the reductions.


title: Affordable Care Act

text: So-called cost-sharing reduction (CSR) subsidies were to be paid to insurance companies to fund the reductions. During 2017, approximately $7 billion in CSR subsidies were to be paid, versus $34 billion for premium tax credits.


title: Affordable Care Act

text: The latter was defined as mandatory spending that does not require an annual Congressional appropriation. CSR payments were not explicitly defined as mandatory. This led to litigation and disruption later.


title: Affordable Care Act

text: ACA implemented multiple approaches to helping mitigate the disruptions to insurers that came with its many changes.


title: Affordable Care Act

text: The risk-corridor program was a temporary risk management device. It was intended to encourage reluctant insurers into ACA insurance market from 2014 to 2016. For those years the Department of Health and Human Services (DHHS) would cover some of the losses for insurers whose plans performed worse than they expected. Loss-making insurers would receive payments paid for in part by profit-making insurers. Similar risk corridors had been established for the Medicare prescription drug benefit.


title: Affordable Care Act

text: Many insurers initially offered exchange plans. However, the program did not pay for itself as planned, losing up to $8.3 billion for 2014 and 2015. Authorization had to be given so DHHS could pay insurers from "general government revenues". However, the Consolidated Appropriations Act, 2014 (H.R. 3547) stated that no funds "could be used for risk-corridor payments". leaving the government in a potential breach of contract with insurers who offered qualified health plans.


title: Affordable Care Act

text: Several insurers sued the government at the United States Court of Federal Claims to recover the funds believed owed to them under the Risk Corridors program. While several were summarily closed, in the case of "Moda Health v the United States", Moda Health won a $214-million judgment in February 2017. Federal Claims judge Thomas C. Wheeler stated, "the Government made a promise in the risk corridors program that it has yet to fulfill. Today, the court directs the Government to fulfill that promise. After all, to say to [Moda], 'The joke is on you. You shouldn't have trusted us,' is hardly worthy of our great government." Moda Health's case was appealed by the government to the United States Court of Appeals for the Federal Circuit along with the appeals of the other insurers; here, the Federal Circuit reversed the Moda Health ruling and ruled across all the cases in favor of the government, that the appropriations riders ceded the government from paying out remain money due to the insurers. The Supreme Court reversed this ruling in the consolidated case, "Maine Community Health Options v. United States", reaffirming as with Judge Wheeler that the government had a responsibility to pay those funds under the ACA and the use of riders to de-obligate its from those payments was illegal.


title: Affordable Care Act

text: The temporary reinsurance program is meant to stabilize premiums by reducing the incentive for insurers to raise premiums due to concerns about higher-risk enrollees. Reinsurance was based on retrospective costs rather than prospective risk evaluations. Reinsurance was available from 2014 through 2016.


title: Affordable Care Act

text: Risk adjustment involves transferring funds from plans with lower-risk enrollees to plans with higher-risk enrollees. It was intended to encourage insurers to compete based on value and efficiency rather than by attracting healthier enrollees. Of the three risk management programs, only risk adjustment was permanent. Plans with low actuarial risk compensate plans with high actuarial risk.


title: Affordable Care Act

text: ACA revised and expanded Medicaid eligibility starting in 2014. All U.S. citizens and legal residents with income up to 133% of the poverty line, including adults without dependent children, would qualify for coverage in any state that participated in the Medicaid program. The federal government was to pay 100% of the increased cost in 2014, 2015 and 2016; 95% in 2017, 94% in 2018, 93% in 2019, and 90% in 2020 and all subsequent years. A 5% "income disregard" made the effective income eligibility limit for Medicaid 138% of the poverty level. However, the Supreme Court ruled in "NFIB v. Sebelius" that this provision of ACA was coercive, and that states could choose to continue at pre-ACA eligibility levels.


title: Affordable Care Act

text: Medicare reimbursements were reduced to insurers and drug companies for private Medicare Advantage policies that the Government Accountability Office and Medicare Payment Advisory Commission found to be excessively costly relative to standard Medicare; and to hospitals that failed standards of efficiency and care.


title: Affordable Care Act

text: Income from self-employment and wages of single individuals in excess of $200,000 annually are subjected to an additional tax of 0.9%. The threshold amount is $250,000 for a married couple filing jointly (threshold applies to their total compensation), or $125,000 for a married person filing separately.


title: Affordable Care Act

text: In ACA's companion legislation, the Health Care and Education Reconciliation Act of 2010, an additional tax of 3.8% was applied to unearned income, specifically the lesser of net investment income and the amount by which adjusted gross income exceeds the above income limits.


title: Affordable Care Act

text: ACA included an excise tax of 40% ("Cadillac tax") on total employer premium spending in excess of specified dollar amounts (initially $10,200 for single coverage and $27,500 for family coverage) indexed to inflation. This tax was originally scheduled to take effect in 2018, but was delayed until 2020 by the Consolidated Appropriations Act, 2016 and again to 2022. Excise taxes totaling $3 billion were levied on importers and manufacturers of prescription drugs. An excise tax of 2.3% on medical devices and a 10% excise tax on indoor tanning services were applied as well. The tax was repealed in late 2019.


title: Affordable Care Act

text: Dependents were permitted to remain on their parents' insurance plan until their 26th birthday, including dependents who no longer lived with their parents, are not a dependent on a parent's tax return, are no longer a student, or are married.


title: Affordable Care Act

text: Businesses that employ fifty or more people but do not offer health insurance to their full-time employees are assessed additional tax if the government has subsidized a full-time employee's healthcare through tax deductions or other means. This is commonly known as the employer mandate. This provision was included to encourage employers to continue providing insurance once the exchanges began operating.


title: Affordable Care Act

text: The act includes delivery system reforms intended to constrain costs and improve quality. These include Medicare payment changes to discourage hospital-acquired conditions and readmissions, bundled payment initiatives, the Center for Medicare and Medicaid Innovation, the Independent Payment Advisory Board, and accountable care organizations.


title: Affordable Care Act

text: Health care cost/quality initiatives included incentives to reduce hospital infections, adopt electronic medical records, and to coordinate care and prioritize quality over quantity.


title: Affordable Care Act

text: Medicare switched from fee-for-service to bundled payments. A single payment was to be paid to a hospital and a physician group for a defined episode of care (such as a hip replacement) rather than separate payments to individual service providers.


title: Affordable Care Act

text: The Medicare Shared Savings Program (MSSP) was established by section 3022 of the Affordable Care Act. It is the program by which an accountable care organization interacts with the federal government, and by which accountable care organizations can be created. It is a fee-for-service model.


title: Affordable Care Act

text: The Act allowed the creation of accountable care organizations (ACOs), which are groups of doctors, hospitals and other providers that commit to give coordinated care to Medicare patients. ACOs were allowed to continue using fee-for-service billing. They receive bonus payments from the government for minimizing costs while achieving quality benchmarks that emphasize prevention and mitigation of chronic disease. Missing cost or quality benchmarks subjected them to penalties.


title: Affordable Care Act

text: Unlike health maintenance organizations, ACO patients are not required to obtain all care from the ACO. Also, unlike HMOs, ACOs must achieve quality-of-care goals.


title: Affordable Care Act

text: Medicare Part D participants received a 50% discount on brand name drugs purchased after exhausting their initial coverage and before reaching the catastrophic-coverage threshold. By 2020, the "doughnut hole" would be completely filled.


title: Affordable Care Act

text: From 2017 onwards, states can apply for a "waiver for state innovation" which allows them to conduct experiments that meet certain criteria. To obtain a waiver, a state must pass legislation setting up an alternative health system that provides insurance at least as comprehensive and as affordable as ACA, covers at least as many residents and does not increase the federal deficit. These states can escape some of ACA's central requirements, including the individual and employer mandates and the provision of an insurance exchange. The state would receive compensation equal to the aggregate amount of any federal subsidies and tax credits for which its residents and employers would have been eligible under ACA, if they cannot be paid under the state plan.


title: Affordable Care Act

text: The Community Living Assistance Services and Supports Act (or CLASS Act) established a voluntary and public long-term care insurance option for employees, The program was abolished as impractical without ever having taken effect.


title: Affordable Care Act

text: Consumer Operated and Oriented Plans (CO-OP), member-governed non-profit insurers, could start providing health care coverage, based on a 5-year federal loan. As of 2017, only four of the original 23 co-ops were still in operation.


title: Affordable Care Act

text: Nutrition labeling requirements officially took effect in 2010, but implementation was delayed, and they actually took effect on May 7, 2018.


title: Affordable Care Act

text: ACA followed a long series of unsuccessful attempts by one party or the other to pass major insurance reforms. Innovations were limited to health savings accounts (2003), medical savings accounts (1996) or flexible spending accounts, which increased insurance options, but did not materially expand coverage. Health care was a major factor in multiple elections, but until 2009, neither party had the votes to overcome the other's opposition.


title: Affordable Care Act

text: The concept of an individual mandate goes back to at least 1989, when The Heritage Foundation, a conservative think-tank, proposed an individual mandate as an alternative to single-payer health care. It was championed for a time by conservative economists and Republican senators as a market-based approach to healthcare reform on the basis of individual responsibility and avoidance of free rider problems. Specifically, because the 1986 Emergency Medical Treatment and Active Labor Act (EMTALA) requires any hospital participating in Medicare (nearly all do) to provide emergency care to anyone who needs it, the government often indirectly bore the cost of those without the ability to pay.


title: Affordable Care Act

text: President Bill Clinton proposed a major healthcare reform bill in 1993 that ultimately failed. Clinton negotiated a compromise with the 105th Congress to instead enact the State Children's Health Insurance Program (SCHIP) in 1997. The failed Clinton plan included a mandate for employers to provide health insurance to all employees through a regulated marketplace of health maintenance organizations. Republican senators proposed an alternative that would have required individuals, but not employers, to buy insurance.


title: Affordable Care Act

text: The 1993 Republican Health Equity and Access Reform Today (HEART) Act, contained a "universal coverage" requirement with a penalty for noncompliance—an individual mandate—as well as subsidies to be used in state-based 'purchasing groups'. Advocates included prominent Republican senators such as John Chafee, Orrin Hatch, Chuck Grassley, Bob Bennett and Kit Bond. The 1994 Republican Consumer Choice Health Security Act, initially contained an individual mandate with a penalty provision; however, author Don Nickles subsequently removed the mandate, stating, "government should not compel people to buy health insurance". At the time of these proposals, Republicans did not raise constitutional issues; Mark Pauly, who helped develop a proposal that included an individual mandate for George H. W. Bush, remarked, "I don't remember that being raised at all. The way it was viewed by the Congressional Budget Office in 1994 was, effectively, as a tax."


title: Affordable Care Act

text: In 2006, an insurance expansion bill was enacted at the state level in Massachusetts. The bill contained both an individual mandate and an insurance exchange. Republican Governor Mitt Romney vetoed the mandate, but after Democrats overrode his veto, he signed it into law. Romney's implementation of the 'Health Connector' exchange and individual mandate in Massachusetts was at first lauded by Republicans. During Romney's 2008 presidential campaign, Senator Jim DeMint praised Romney's ability to "take some good conservative ideas, like private health insurance, and apply them to the need to have everyone insured". Romney said of the individual mandate: "I'm proud of what we've done. If Massachusetts succeeds in implementing it, then that will be the model for the nation."


title: Affordable Care Act

text: In 2007 Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which featured an individual mandate and state-based, regulated insurance markets called "State Health Help Agencies". The bill attracted bipartisan support, but died in committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 healthcare debate.


title: Affordable Care Act

text: By 2008 many Democrats were considering this approach as the basis for healthcare reform. Experts said the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill and that it took ideas from the Massachusetts reforms.


title: Affordable Care Act

text: A driving force behind Obama's healthcare reform was Peter Orszag, Director of the Office of Management and Budget. Obama called Orszag his "healthcare czar" because of his knowledge of healthcare reform. Orszag had previously been director of the Congressional Budget Office, and under his leadership the agency had focused on using cost analysis to create an affordable and effective approach to health care reform. Orszag claimed that healthcare reform became Obama's top agenda item because he wanted it to be his legacy. According to an article by Ryan Lizza in "The New Yorker", the core of "the Obama budget is Orszag's belief [in]...a government empowered with research on the most effective medical treatments". Obama bet "his presidency on Orszag's thesis of comparative effectiveness." Orszag's policies were influenced by an article in "The Annals of Internal Medicine" co-authored by Elliott S. Fisher, David Wennberg and others. The article presented strong evidence based on the co-authors' research that numerous procedures, therapies and tests were being delivered with scant evidence of their medical value. If those procedures and tests could be eliminated, this evidence suggested, medical costs might provide the savings to give healthcare to the uninsured population. After reading a "The New Yorker" article that used the "Dartmouth findings" to compare two counties in Texas with enormous variations in Medicare costs using hard data, Obama directed that his entire staff read it. More than anything else, the Dartmouth data intrigued Obama since it gave him an academic rationale for reshaping medicine.


title: Affordable Care Act

text: The concept of comparing the effectiveness of healthcare options based on hard data ("comparative effectiveness" and "evidence-based medicine") was pioneered by John E. Wennberg, founder of The Dartmouth Institute, co-founder of The Foundation for Informed Medical Decision Making and senior advisor to Health Dialog Inc., a venture that he and his researchers created to help insurers implement the Dartmouth findings.


title: Affordable Care Act

text: Healthcare reform was a major topic during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, Hillary Clinton and the eventual nominee, Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton's proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's proposal provided a subsidy without a mandate.


title: Affordable Care Act

text: During the general election, Obama said fixing healthcare would be one of his top four priorities as president. Obama and his opponent, Senator John McCain, both proposed health insurance reforms, though their plans differed. McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018 at a higher cost.


title: Affordable Care Act

text: Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform. By July, a series of bills were approved by committees within the House of Representatives. On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a proposal. This group—in particular, Democrats Max Baucus, Jeff Bingaman and Kent Conrad, along with Republicans Mike Enzi, Chuck Grassley and Olympia Snowe—met for more than 60 hours, and the principles they discussed, in conjunction with the other committees, became the foundation of a Senate bill.


title: Affordable Care Act

text: Congressional Democrats and health policy experts, such as MIT economics professor Jonathan Gruber and David Cutler, argued that guaranteed issue would require both community rating and an individual mandate to ensure that adverse selection and/or "free riding" would not result in an insurance "death spiral". They chose this approach after concluding that filibuster-proof support in the Senate was not present for more progressive plans such as single-payer. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate Majority Leaders Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell—the bill's drafters hoped to garner the necessary votes.


title: Affordable Care Act

text: However, following the incorporation of an individual mandate into the proposal, Republicans threatened to filibuster any bill that contained it. Senate Minority Leader Mitch McConnell, who led the Republican response, concluded Republicans should not support the bill.


title: Affordable Care Act

text: Republican senators, including those who had supported earlier proposals with a similar mandate, began to describe the mandate as "unconstitutional". Journalist Ezra Klein wrote in "The New Yorker", "a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition."


title: Affordable Care Act

text: The reform attracted attention from lobbyists, including deals between lobby groups and the advocates to win the support of groups who had opposed past proposals.


title: Affordable Care Act

text: During the August 2009 summer congressional recess, many members went back to their districts and held town hall meetings on the proposals. The nascent Tea Party movement organized protests and many conservative groups and individuals attended the meetings to oppose the proposed reforms. Threats were made against members of Congress over the course of the debate.


title: Affordable Care Act

text: In September 2009 Obama delivered another speech to a joint session of Congress supporting the negotiations. On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.