title: Ludovico Sforza

text: Endowed, in the best years, with great charm and charisma, Ludovico acquired fame as a seducer. It is due to Francesco Guicciardini the news - probably unfounded - of his falling in love with his niece Isabella of Aragon, which would have led him to deal with his nephew so that he could not consummate the marriage. He even boasted, in 1498, that it was out of jealousy of his wife that the Marquis Francesco Gonzaga played the double game between him and the Lordship of Venice, insinuating his relationship with his sister-in-law Isabella d'Este. These rumors, spread to Venice, outraged both the Marquis and his father-in-law Ercole, who hastened to deny them. Isabella certainly always had a soft spot for Louis, and envied her sister for her fortunate marriage, wealth, and children, but it is not proven that she was actually his mistress.


title: Ludovico Sforza

text: Despite the lively love for his wife, Ludovico had lovers both before and during the wedding, like any other gentleman of the time. The first two of which we have news, such Romana and Bernardina de' Corradis, were probably of low social extraction. In July 1485 Ludovico speaks in a letter "of the pleasure that I already took a few days ago with a young Milanese, notable by blood, very honest and beautiful as much as I could have desired", sister of a Galeazzo Gallerani, and therefore identified by Léon-Gabriel Pélissier with an Isabella Gallerani, while for other historians it would already be the best known Cecilia. This last one, however, officially appeared at court only in the summer of 1489, when the ambassador Giacomo Trotti attributed the cause of a certain malaise of the Moro to the "too much coitus with one of his girls whom he took with him, very beautiful, several days ago, who goes after him everywhere, and wants her all his good and shows him every possible way". Cecilia remained at court until the first months of 1491, when she was ousted by the new Duchess Beatrice, and for some time there are no more names of lovers.


title: Ludovico Sforza

text: In February-March 1495, coinciding with the second birth of Beatrice, Ludovico had an adventure with an Isabella Trotti da Casate (friend of Isabella d'Este, who actually came to assist her sister), of which a cloying letter addressed to him is preserved, in which he laments the lack and signs "She who is for your Lordship what you do not want me to say", that is, suggesting that Louis did not want her to call herself his lover, perhaps out of respect for his wife, who moreover read his correspondence. Shortly afterwards he had to undertake the well-known relationship with Lucrezia Crivelli, already married, which caused him - as it would seem - a marriage crisis, in fact from the Anonymous Ferrarese we know that in 1496 "All his pleasure was with one of his maids, who was the damsel of his wife [...] with whom he had not slept for good months, so that he was unwanted",  while the Muralto specifies that Beatrice "was honored with great care by Ludovico, although he welcomed Lucrezia as a concubine from the Crivelli family; because of which, no matter how much the thing gnawed the bowels of his wife, love nevertheless did not stray from her".  The relationship officially lasted until the defeat of Ludovico, despite his phase of rigorous asceticism following widowhood, since Lucrezia did not follow him, but rather sought refuge with the marquises of Mantua, taking away the son they had had together and the enormous wealth accumulated thanks to their services.Uncertain is the nature of the relationship he had instead with Graziosa Maggi, another beautiful lady of Beatrice, called "Graziosa Pia" because she was the wife of Ludovico Pio di Carpi, to whom Ludovico made a generous dowry. In August 1498 he addressed a letter to her in which every word can be explained honestly, except for a sentence: "We will remind you of this alone: that you are loved by us only, thus deserving your virtues and customs". Only hypotheses can be made about the beautiful Ippolita Fioramonte, a young lady of Beatrice, who boasted, after the death of the duchess, a protection difficult to explain by Ludovico, who gave her a princely dowry.  A more genuine friendship bound him instead to women like Chiara Gonzaga, sister of the Marquis Francesco, in relation to whom someone even spoke of marriage, a misunderstanding that Ludovico hastened to clarify.


title: Ludovico Sforza

text: Speech to itself deserves the very strong bond that he had since 1483 with Galeazzo Sanseverino, who continuously covered with honors and privileges, to the point of marrying him the only daughter and appointing him regent together with his wife Beatrice. Galeazzo was a participant in all his secrets and acquired so much power in Milan that Ambassador Trotti wrote to the Duke of Ferrara: <nowiki>"</nowiki>It seems to me that this Messer Galeazzo is Duke of Milan because he can do what he wants and has what he knows how to ask and desire.<nowiki>"</nowiki>  He served his father-in-law faithfully and, although he was not as skilled in war as his brother , it was he who served as captain general of the Sforza army from 1488 until the end. It was precisely this prevarication that brought Ludovico the hatred, which later proved fatal, Gian Giacomo Trivulzio.


title: Ludovico Sforza

text: Although Philippe de Comines ascribed everything to a relationship of a filial nature, this strange friendship stimulated the evil tongues, to such an extent that Francesco Gonzaga openly accuses Galeazzo of prostitution and Guicciardini collects those voices that silence the Moro of sodomy:The practice of sodomy, according to the ancient Greek custom, was moreover widespread almost everywhere at that time, and many other powerful lords were not exempt from it. No basis has instead the hypothesis, advanced by Antonio Perria, according to which his nephew Gian Galeazzo was also "sexually slave of Ludovico".


title: Ludovico Sforza

text: Ludovico earned the nickname "Moro" as a child: this is how the crowd acclaimed him when he paraded in procession in the cities of the Duchy. "Moors" were called at the time the Africans and the Saracens, so the most obvious interpretation of this nickname is that it was due to his bronze complexion, raven hair and black eyes, as visible from many of his portraits and as confirmed by the same contemporary chronicler Gian Andrea Prato:


title: Ludovico Sforza

text: Ludovico and his court of artists are frequent subjects in the art of the nineteenth century, on the wave of romanticism; events such as the deep sorrow for the death of his wife Beatrice, the alleged poisoning of Duke Gian Galeazzo, the presence of artists of the calibre of Leonardo da Vinci, inspired painters such as Giambattista Gigola (1816-1820), Giuseppe Diotti (1823), Francesco Gonin (1845), Francesco Podesti (1846), Cherubino Cornienti (1840 and 1858), Eleanor Fortescue-Brickdale (1920).


title: Ludovico Sforza

text: To Ludovico is dedicated the Dolceriso del Moro, a typical dessert of Vigevano, whose invention is traditionally attributed to the Duchess Beatrice herself, who would have conceived it in the spring of 1491 to please her illustrious consort. It is a kind of ricotta rice pudding, closed in a shortcrust pastry wrapper and enriched with candied fruit, pine nuts, almonds and rose water. This last ingredient served – as it seems – to induce harmony, harmony and fidelity in the couple.


title: Ludovico Sforza

text: Il Moro also had a series of natural children, all legitimized, which over the years greatly enlarged the ducal family and allowed Sforza himself to cement some alliances:


title: Ludovico Sforza

text: Perhaps he also had another illegitimate son unknown to us if, as reported by Bernardino Corio, in 1496 three of his bastard sons died, namely Leo, Bianca, and a third who cannot be identified with any of the aforementioned.


title: Hair care

text: Hair care is an overall term for hygiene and cosmetology involving the hair which grows from the human scalp, and to a lesser extent facial, pubic and other body hair. Hair care routines differ according to an individual's culture and the physical characteristics of one's hair. Hair may be colored, trimmed, shaved, plucked or otherwise removed with treatments such as waxing, sugaring and threading. Hair care services are offered in salons, barbershops and day spas, and products are available commercially for home use. Laser hair removal and electrolysis are also available, though these are provided (in the US) by licensed professionals in medical offices or speciality spas.


title: Hair care

text: Care of the hair and care of the scalp skin may appear separate, but are actually intertwined because hair grows from beneath the skin. The living parts of hair (hair follicle, hair root, root sheath and sebaceous gland) are beneath the skin, while the actual hair shaft which emerges (the cuticle which covers the cortex and medulla) has no living processes. Damage or changes made to the visible hair shaft cannot be repaired by a biological process, though much can be done to manage hair and ensure that the cuticle remains intact.


title: Hair care

text: Scalp skin, just like any other skin on the body, must be kept healthy to ensure a healthy body and healthy hair production. If the scalp is cleaned regularly by those who have rough hair or have a hair-fall problem, it can result in loss of hair. However, not all scalp disorders are a result of bacterial infections. Some arise inexplicably, and often only the symptoms can be treated for management of the condition (example: dandruff). There are also bacteria that can affect the hair itself. Head lice is probably the most common hair and scalp ailment worldwide. Head lice can be removed with great attention to detail, and studies show it is not necessarily associated with poor hygiene. More recent studies reveal that head lice actually thrive in clean hair. In this way, hair washing as a term may be a bit misleading, as what is necessary in healthy hair production and maintenance is often simply cleaning the surface of the scalp skin, the way the skin all over the body requires cleaning for good hygiene.


title: Hair care

text: The sebaceous glands in human skin produce sebum, which is composed primarily of fatty acids. Sebum acts to protect hair and skin, and can inhibit the growth of microorganisms on the skin. Sebum contributes to the skin's slightly acidic natural pH somewhere between 5 and 6.8 on the pH spectrum. This oily substance gives hair moisture and shine as it travels naturally down the hair shaft, and serves as a protective substance by preventing the hair from drying out or absorbing excessive amounts of external substances. Even though sebum serves as a protective substance, too much of this oily substance can cause blockage around hair follicles. This blockage is usually from dandruff or even dead skin. As a result, "blocked or obstructed hair follicles" may prevent hair from producing. Sebum is also distributed down the hair shaft "mechanically" by brushing and combing. When sebum is present in excess, the roots of the hair can appear oily, greasy, and darker than normal, and the hair may stick together.


title: Hair care

text: Washing hair removes excess sweat and oil, as well as unwanted products from the hair and scalp. Often hair is washed as part of a shower or bathing with shampoo, a specialized surfactant. Shampoos work by applying water and shampoo to the hair. The shampoo breaks the surface tension of the water, allowing the hair to become soaked. This is known as the wetting action. The wetting action is caused by the head of the shampoo molecule attracting the water to the hair shaft. Conversely, the tail of the shampoo molecule is attracted to the grease, dirt and oil on the hair shaft. The physical action of shampooing makes the grease and dirt become an emulsion that is then rinsed away with the water. This is known as the emulsifying action. Sulfate free shampoos are less harming on color treated hair than normal shampoos that contain sulfates. Sulfates strip away natural oils as well as hair dye. Sulfates are also responsible for the foaming effect of shampoos.


title: Hair care

text: Shampoos have a pH of between 4 & 6. Acidic shampoos are the most common type used and maintain or improve the condition of the hair as they don't swell the hairshaft and don't strip the natural oils.


title: Vonetta McGee

text: Vonetta Lawrence McGee (January 14, 1945 – July 9, 2010) was an American actress. She debuted in the Spaghetti Western "The Great Silence" and went on to appear in blaxploitation films such as "Hammer", "Melinda", "Blacula", "Shaft in Africa", "Detroit 9000", and 1974's "Thomasine & Bushrod" alongside her then-boyfriend Max Julien. In 1975, she was Clint Eastwood's co-star in "The Eiger Sanction". She was a regular on the 1987 Universal Television situation comedy "Bustin' Loose", starring as Mimi Shaw for its only season (1987–88).


title: Vonetta McGee

text: Born in San Francisco, California, to Lawrence McGee and Alma McGee (née Scott), McGee graduated from San Francisco Polytechnic High School in 1962. She enrolled at San Francisco State University and became involved in acting groups on campus.


title: Vonetta McGee

text: McGee landed her first role in 1968, when she performed alongside Jean-Louis Trintignant and Klaus Kinski in Sergio Corbucci's Spaghetti Western "The Great Silence", and made her first released film appearance that same year as the eponymous character in the Italian comedy "Faustina", which was released before the former film. She later became well known for her parts in the 1972 Blaxploitation films "Melinda" and "Hammer". In the action thriller "Shaft in Africa" (1973), McGee took the role of Aleme, the daughter of an emir, who teaches John Shaft (Richard Roundtree) Ethiopian geography. Earlier that year she had appeared in a supporting role as an occult priestess in "The Norliss Tapes". In 1974, McGee appeared as Thomasine, alongside Max Julien as Bushrod, in the western action film "Thomasine & Bushrod", which was intended as a counterpart to the 1967 film "Bonnie and Clyde". The next year, she starred alongside Clint Eastwood in the action thriller "The Eiger Sanction" (1975). She appeared in an episode of the TV series "Starsky & Hutch" named "Black and Blue" in 1979. She appeared as Marlene, the high-energy lot manager, in the 1984 cult classic "Repo Man".


title: Vonetta McGee

text: McGee was in a live-in relationship with actor Max Julien from 1974 to 1977. They starred together in the 1974 film "Thomasine & Bushrod".


title: Vonetta McGee

text: In 1987, McGee married actor Carl Lumbly, with whom she had one child, Brandon, born in 1988. McGee died of cardiac arrest on July 9, 2010, at the age of 65.


title: Parugu

text: Parugu (), titled In the Name of Love in the UK, is a 2008 Indian Telugu-language romantic action film written and directed by Bhaskar. The film stars Allu Arjun, Sheela Kaur and Prakash Raj. The film is produced by Dil Raju on Sri Venkateswara Creations whilst Mani Sharma scored the film. Vijay K. Chakravarthy and Marthand K. Venkatesh performed the cinematography and editing of the film respectively.


title: Parugu

text: This plot follows Neelakanta (Raj) and his love for his two daughters, Subbalakshmi (Poonam Bajwa) and Meenakshi (Kaur). Subbalakshmi elopes with Errababu with the help of Krishna (Arjun). Neelakanta gets hold of Krishna to know about his daughter's whereabouts, but Krishna and Meenakshi fall for each other. The rest of the story deals with how Krishna convinces Neelakanta for their marriage.


title: Parugu

text: The film was officially launched on 15 March 2007 at Hyderabad, and the principal photography began in June 2007. The film was shot in Hyderabad, Kerala, Kodaikanal and Rajahmundry while a song was shot in Jordan. The principal photography came to an end in April 2008 though the makers planned it to complete by January 2008. The film is released worldwide on 1 May 2008.


title: Parugu

text: "Parugu" was successful at the box office, earning distributors a share of 20 crore. The film won two Nandi Awards and won a Filmfare Award South among three nominations. The film is remade in Odia as "Sanju Aau Sanjana" (2010), in Bengali as "Shedin Dekha Hoyechilo" (2010), in Nepali as "Dabab" (2013), and in Hindi as "Heropanti" (2014)"."


title: Parugu

text: Neelakanta is a revered person in the village that he resides. His daughters, Subbalakshmi and Meenakshi, are more than anything for him in the world. Subbalakshmi loves a native called Errababu, with whom she elopes on the night of her arranged marriage ceremony. Neelakanta's relative Chinnabbai suspects that Errababu's friends are involved in this, and when interrogated brutally, they reveal that two more people, Sarma from Kakinada, and Krishna from Hyderabad also may have helped the couple elope. By mistaken reference of initials in the names, P. Yagnanarayana Sarma was kidnapped from Kakinada while the original man was left untouched. At Hyderabad, a drunk Krishna is kidnapped at night near his house, who is notoriously known for being a nomad and an expert in escaping. They are imprisoned at the village's temple, and all of them plan to escape the next early morning by catching a train. While all others almost approach the train the next morning, Krishna stops when he sees Meenakshi at an Anjaneya statue and falls in love with her, though she is unaware of his presence. They all are kidnapped yet again by Neelakanta's men and are imprisoned in a small penthouse near Neelakanta's main house. Its doors remain locked, and only three windows are there where a man can see the entrance door of the main house and the nearby flooring and parking area. While his friends are horrified, Krishna is not influenced by the fact that he is in love with a village native and on eloping with her, all of them have to face big trouble from the villagers. Meanwhile, Meenakshi tries to speak with them with an intention to find out details about Subbalakshmi, and neither Krishna nor his friends can see her face because of the penthouse's style of construction.


title: Parugu

text: He asks her to help him find his love and, in return promises her to tell details about Subbalakshmi's whereabouts. The added advantage to Krishna is a set of love letters received by Subbalakshmi from Errababu, which are presently in his custody, and Meenakshi is hell bent recovering them back. Meanwhile, Krishna's friend Srinu is caught red-handed who, after execution of brutal force by Neelakanta's men, reveals that the couple is in Vishakhapatnam. There, Krishna manages to send the couple Guntur without the knowledge of Neelakanta's henchmen and later at the penthouse, he reveals he is the mastermind behind the act of Subbalakshmi eloping with Errababu, which is heard by Meenakshi, who hid there and escaped through the back door. Because of her, the truth is revealed, and Krishna too, finds out that his love is none other than Meenakshi. When Krishna and his friends are brutally tortured, he lies that the couple are in Hyderabad to save his friends. Neelakanta, Bullabbai, Chinnabbai, Meenakshi, and others go to Hyderabad with Krishna and his friends, but Krishna is unaware of the fact that Errababu and Subbalakshmi are in Hyderabad. All of them start searching for the couple, and Krishna earns the trust of Neelakanta, his henchmen, and Meenakshi by saving her from a bunch of goons who try to molest her, and she slowly starts reciprocating his love, though never confesses it. Krishna, too realizes the pain faced by Neelakanta because of Subbalakshmi's wrongdoings. The next day, Neelakanta and Krishna manage to catch Subbalakshmi and Errababu red-handed, and there, Subbalakshmi revolts against her father and threatens to file a police case on him. He leaves in dejection, and Krishna watches on. At the railway station, everyone parts ways with Neelakanta apologizing to Krishna and his friends, and invites them to Meenakshi's marriage. Meenakshi stares at Krishna, waiting to confess her love, though Krishna stands like a statue there till the train leaves.


title: Parugu

text: Seeing his son leading a lazy, dull and unexcited life against the way he lived makes Krishna's mother Yashoda send him away to bring Meenakshi as his wife. With Srinu and Sarma pressurizing him, Krishna goes with his friends to attend the marriage. While Neelakanta is afraid Meenakshi would elope with Krishna this night, Krishna confronts Neelakanta, confesses his love for Meenakshi, and assures he would not elope with her. Realizing that Meenakshi's happiness lies in Krishna's company, he lets the lovers unite that night after halting the ongoing ceremony and also plans to bring Subbalakshmi and Errababu back to the village, thus accepting them too.


title: Parugu

text: After the 2004 film "Arya", Dil Raju wanted to produce a film with Allu Arjun as the protagonist of the film and planned to select Sukumar as the director of the film. However it did not materialize. Later Bhaskar approached them with a subject which the duo accepted. Incidentally, it was the sixth film for both Allu Arjun and Dil Raju in their career. The film was officially launched on 15 March 2007 at Dil Raju's office in Hyderabad. Devi Sri Prasad was selected initially as the music director though Mani Sharma replaced him later. The film's title has been in major headlines prior to the film's release. Initially it was reported in early December 2007 that the film is titled "Romeo". In early February 2008, it was reported that the film is titled "Premikudu" which was the title of the Telugu dubbed version of Shankar's "Kadhalan". Later the titles "Enta Ghaatu Premayo", "Araku" and "Varadhi" were considered before being titled as "Parugu". In an interview, Bhaskar said that this film is based on real life characters and the scenes in the film are based on real life happenings.


title: Parugu

text: Allu Arjun was a part of the film since its initial stages. He had to shed weight he gained in course of building a six pack body for the film "Desamuduru" for this film and maintained a short hair style as he had to appear like a common middle-class man. After considering Vedhicka for the female lead, Priyamani was selected in mid-July 2007 marking her first collaboration with Allu Arjun. However, Priyamani walked out of the project and it was reported in mid-August 2007 that she would be replaced with Sheela. Her inclusion was confirmed by Puri Jagannadh who said that her performance in the film "Hello Premistara" impressed Bhaskar and Dil Raju which made them sign her for this role. Prakash Raj, who played an important role in Bhaskar's debut "Bommarillu" was signed for an equally important role in this film which the actor quoted as the best role in the film. Subbaraju was selected for an important role with negative shades. Poonam Bajwa made a crucial cameo appearance in this film. Telugu anchor Chitralekha was selected for a small supporting role. Saptagiri debuted as a comedian with this film. Regarding his casting, he said "I assisted Bommarillu Bhaskar for the film Parugu and he was impressed with my narrative skill. He offered me a role, and I received acclaim."


title: Parugu

text: During the film's launch, it was planned that the principal photography would commence in May 2007. It was reported in early May 2007 that the principal photography would begin in June 2007, and the technicians are yet to be finalized. In mid-August 2007, the filming continued at Kodaikanal where a song and few important scenes were shot. Later, the film's shoot continued in locales of Kerala where crucial scenes on Allu Arjun, Sheela and Prakash Raj were shot. By 29 September 2007 the film's Kerala schedule was complete by which 30% of the film's shoot was wrapped up. The next schedule started at Hyderabad in the first week of October 2007. The film's climax was shot at Kodaikanal in mid-October 2007. Later, the shooting continued in mid-November 2007 at Rajahmundry. It was estimated then that the filming would be wrapped up by January 2008. From 15 March 2008 the filming continued at Jordan where songs on Allu Arjun and Sheela were shot. Later, in an interview on 8 April 2008, Allu Arjun confirmed that 90% of the shooting is complete and the rest would be wrapped in a week.


title: Parugu

text: Mani Sharma composed the soundtrack and the background score of the film which marks his first collaboration with both Bhaskar and Allu Arjun. The film's soundtrack featured 6 songs with Sirivennela Sitaramasastri, Anantha Sreeram and Chandrabose penning 2 songs each. Bhaskar said that all the songs were situational songs in this film which drive the story forward. Hemachandra and Rahul Nambiar sang two distinct songs in the album while Kailash Kher, Saindhavi, Ranjith and Saketh were the other singers who sang the remaining songs in the soundtrack. The film's soundtrack was launched on 8 April 2008 by hosting a promotional event at Durgam Cheruvu and Chiranjeevi attended the launch as the chief guest. The lead cast & crew of the film attended the function and Chiranjeevi handed the first cassette to Prakash Raj. The film's soundtrack was marketed by Aditya Music.


title: Parugu

text: The soundtrack received positive reviews from critics. "Cinegoer.net" wrote, "Not disappointing, but not the best of Sharma. Three of the numbers stand out, including Parugulu, Yelageylaga and Hrudayam. The entire compilation is not bad, yet there is nothing unique about the sound. Still, the movie-music connection is directly proportional and considering all factors, the music is good enough, but just enough. Nothing great though" and gave it a rating of 3/5, calling it a "Reasonable Fare". "IndiaGlitz" wrote "Manisharma strives hard to make the album a musical hit and he succeeded in it. As fondly called by his fans 'Melody Brahma', Manisharma mixed melody and fast beat in right ratio to suit the taste of all classes of audiences. The audio would no doubt would become one of the chart busters."


title: Parugu

text: The film's soundtrack was a huge success with the good number of sales, and the double platinum disc celebrations were planned to be held in the first week of May 2008. The songs "Nammavemo", "Hrudayam" and "Manakanna Podiche" were chart busters. However it was held at Jayabheri Club in Hyderabad on 17 May 2008. However, the absence of Bhaskar and Mani Sharma was conspicuous. The cast and crew present were presented with the Double Platinum disc shields. Saketh won a nomination for Best Male Playback Singer – Telugu at the 56th Filmfare Awards South but lost it to Karthik who won it for the song "Nijanga Nenena" from the film "Kotha Bangaru Lokam".


title: Parugu

text: "The Hindu" wrote, "The movie is interesting and a must watch for more than one reason. The usually loud and energy effusing Arjun downplays his role and gives a heartfelt performance. Bhaskar runs a compassionate thread throughout the film even while he spends the first half of the film introducing the characters and seamlessly breaks the flow of characters with humour and minimum violence. There are a few emotionally intense, and fewer tear-jerking moments in the film, but they serve to move the character forward, but to enjoy this film, watch it without any expectation, and you will be surprised with the engaging and a racy tone of the first half and the interesting development of Prakash Raj’s character post interval." "Cinegoer.net" gave a review stating "A good narrative and a strong subject, with some humor and music added in good measure-Parugu, is another movie from Dil Raju-Bhaskar that is likeable. It may not be up to Bommarillu's standards because the subject itself has been dealt with several times before, and there is a lack of freshness. Nonetheless, the movie is a good watch, and Bhasker proves he's not a one film wonder" and rated the film 3.25/5. "Oneindia Entertainment" gave a review stating, "Till the interval bang, director Bhaskar has given the audiences an impression that he was able to overcome the second film hitch, which is haunting most of the debutante directors. But he has made mistakes inadvertently in the second half. He has failed to extract the exact emotions from the artists, and the story appears to be dragging and nagging till the climax. However, he has given a good twist in the climax and has made it a little interesting." "idlebrain.com" gave a review stating "First half is good and entertaining with nice ambiance. The movie's tempo goes down as soon as the gang shifts to Hyderabad in the second half. The climax of the film appears a little hesitant and ambiguous. The plus points of the film are the energetic performance by Allu Arjun and well made first half. On the flip side, the emotions in the second half don't work, and the movie lacks soul. We have to wait and see how this film fares at box office" and rated the film 3/5.


title: Parugu

text: "Rediff.com" wrote, "Bhaskar does well in not allowing the heroine and hero to meet face to face, thereby maintaining the suspense. The screenplay in the first half is fast paced, followed by a rather slow second half. The climax is rather tame. Bhaskar ensures that the largely rural setting of the story will go down well with the rural as well as the urban audience. One has to wait and watch if the 'Dil' Raju-Bhaskar duo can repeat the magic of Bommarillu with Parugu." Sify wrote "Producer Dil Raju and director Bhaskar, who created magic among the class and mass audiences with the film Bommarillu has failed to repeat the same in this much-hyped film with Allu Arjun. The movie just doesn’t live up to the huge expectations. It has songs that are sensationally choreographed and have excellent camerawork, but it's still a film with a plot that just doesn't work. It’s an average film at best. Don't go in expecting too much, perhaps you won't be too disappointed." "IndiaGlitz" wrote "The entire first half gave the audiences an impression that Bommarillu Bhaskar is all set to continue the magic which he did in 'Bommarillu'. However, he trembled in the second half as he doesn't know how to continue the story further. Most of the scenes are very boring, and the audiences were seen moving impatiently in their seats in the absence of enough comedy relief. Too much of emotional scenes in the second half tested the patience of audiences." "greatandhra.com" gave a review stating "This is the second film by Bommarillu Bhaskar and the next film for Allu Arjun after Desamuduru. It is obvious that the expectations of Arjun fans will be big as their hero's film hitting screens after a very long time. Dil Raju produced it, and hence Bommarillu charisma is added to it. But things didn't gel well with the expectations. The film proved to be a letdown disappointing many" and rated the film 2.5/5.


title: Parugu

text: "Parugu" was remade in Odia as "Sanju Aau Sanjana" (2010), in Bengali as "Shedin Dekha Hoyechilo" (2010), in Nepali as "Dabab" (2013) and in Hindi as "Heropanti" (2014). The film was dubbed into Malayalam under the title "Krishna" which too enjoyed similar success.


title: Peon

text: Peon (English , from the Spanish "peón" ) usually refers to a person subject to peonage: any form of wage labor, financial exploitation, coercive economic practice, or policy in which the victim or a laborer (peon) has little control over employment or economic conditions. Peon and peonage can refer to both the colonial period and post-colonial period of Latin America, as well as the period after the end of slavery in the United States, when "Black Codes" were passed to retain African-American freedmen as labor through other means.


title: Peon

text: In English, "peon" (doublet of "pawn") and "peonage" have meanings related to their Spanish etymology (foot soldier); a "peon" may be defined as a person with little authority, often assigned unskilled tasks; an underling or any person subjected to capricious or unreasonable oversight. In this sense, "peon" can be used in either a derogatory or self-effacing context.


title: Peon

text: However, the term has a historical basis and usage related to much more severe conditions of forced labor:


title: Peon

text: The Spanish conquest of Mexico and Caribbean islands included peonage; the conquistadors forced natives to work for Spanish planters and mine operators. Peonage was prevalent in Latin America, especially in the countries of Mexico, Guatemala, Ecuador and Peru. It remains an important part of social life, as among the Urarina of the Peruvian Amazon.


title: Peon

text: After the American Civil War of 1861–1865, peonage developed in the Southern United States. Poor white farmers and formerly enslaved African Americans known as freedmen, who could not afford their own land, would farm another person's land, exchanging labor for a share of the crops. This was called sharecropping and initially the benefits were mutual. The land owner would pay for the seeds and tools in exchange for a percentage of the money earned from the crop and a portion of the crop. As time passed, many landowners began to abuse this system. The landowner would force the tenant farmer or sharecropper to buy seeds and tools from the land owner's store, which often had inflated prices. As sharecroppers were often illiterate, they had to depend on the books and accounting by the landowner and his staff. Other tactics included debiting expenses against the sharecropper's profits after the crop was harvested and "miscalculating" the net profit from the harvest, thereby keeping the sharecropper in perpetual debt to the landowner. Since the tenant farmers could not offset the costs, they were forced into involuntary labor due to the debts they owed the landowner. Additionally, unpredictable or disruptive climatic conditions, such as droughts or storms, caused disruptions to seasonal plantings or harvests, which in turn, caused the tenant farmers to accrue debts with the landowners.


title: Peon

text: After the U.S. Civil War, the South passed "Black Codes", laws to control freed black slaves. Vagrancy laws were included in these Black Codes. Homeless or unemployed African Americans who were between jobs, most of whom were former slaves, were arrested and fined as vagrants. Usually lacking the resources to pay the fine, the "vagrant" was sent to county labor or hired out under the convict lease program to a private employer. The authorities also tried to restrict the movement of freedmen between rural areas and cities, to between towns.


title: Peon

text: Under such laws, local officials arbitrarily arrested tens of thousands of people and charged them with fines and court costs of their cases. Black freedmen were those most aggressively targeted. Poor whites were also arrested, but usually in much smaller numbers. White merchants, farmers, and business owners were allowed to pay these debts, and the prisoner had to work off the debt. Prisoners were leased as laborers to owners and operators of coal mines, lumber camps, brickyards, railroads, quarries, and farm plantations, with the lease revenues for their labor going to the states. The lessors were responsible for room and board of the laborers, and frequently abused them with little oversight by the state. Government officials leased imprisoned blacks and whites to small town entrepreneurs, provincial farmers, and dozens of corporations looking for cheap labor. Their labor was repeatedly bought and sold for decades, well into the 20th century, long after the official abolition of American slavery.


title: Peon

text: Southern states and private businesses profited by this form of unpaid labor. It is estimated that at the beginning of the 20th century, up to 40% of blacks in the South were trapped in peonage. Overseers and owners often used severe physical deprivation, beatings, whippings, and other abuse as "discipline" against the workers.


title: Peon

text: After the Civil War, the Thirteenth Amendment prohibited involuntary servitude such as peonage for all but convicted criminals. Congress also passed various laws to protect the constitutional rights of Southern blacks, making those who violated such rights by conspiracy, by trespass, or in disguise, guilty of an offense punishable by ten years in prison and civil disability. Unlawful use of state law to subvert rights under the Federal Constitution was made punishable by fine or a year's imprisonment. But until the involuntary servitude was abolished by president Lyndon B. Johnson in August 6, 1966, sharecroppers in Southern states were forced to continue working to pay off old debts or to pay taxes. Southern states allowed this in order to preserve sharecropping.


title: Peon

text: Because of the Spanish tradition, peonage remained legal and widespread in the New Mexico Territory even after the Civil War. In response, Congress passed the Peonage Act of 1867 on March 2, 1867, which said: "Sec 1990. The holding of any person to service or labor under the system known as peonage is abolished and forever prohibited in the territory of New Mexico, or in any other territory or state of the United States; and all acts, laws, … made to establish, maintain, or enforce, directly or indirectly, the voluntary or involuntary service or labor of any persons as peons, in liquidation of any debt or obligation, or otherwise, are declared null and void." The current version of this statute is codified at Chapter 21-I of and makes no specific mention of New Mexico.


title: Ferrari FXX

text: The Ferrari FXX is a high-performance track-only developmental prototype built by Italian automobile manufacturer Ferrari. The FXX is based on the street-legal flagship Enzo Ferrari. Production of the FXX began in 2005.


title: Ferrari FXX

text: The FXX uses some technology demonstrated on the Enzo Ferrari and combines it with new developments from Ferrari and its suppliers. However, the car is only a part of the overall FXX program. Customers pay GB£2 million, but are only allowed to drive the car on special track days which are approved by Ferrari. After they drive the car, the owners are entitled to be debriefed by Ferrari on the car's performance. Ferrari's sister company Maserati, has developed a similar car, the MC12 Versione Corsa for this purpose with the only difference being that the owners can keep the car in their custody. Lamborghini also allows their track-day car, the Essenza SCV12, to be kept by the custody of their customers. The FXX may be stored by owners wherever they please. The caveat behind the FXX is only that Ferrari technicians must look over the car "before the car hits the track in any event or private testing session."


title: Ferrari FXX

text: The FXX, an evolution of the Enzo in essence, shares some components with the flagship car, but numerous significant developments are unique to the FXX.


title: Ferrari FXX

text: The FXX's engine is based on Enzo's, but displacement has been increased to from . Power output has been raised from the Enzo's at 7,800 rpm, to at 8,500 rpm.


title: Ferrari FXX

text: The gearbox incorporates the latest developments from Ferrari's F1 program and has a shift time of under 100 milliseconds. The brake pads were also upgraded from the Enzo. It does, however, retain the Carbon fibre-reinforced Silicon Carbide (C/SiC) ceramic composite brake discs featured on the Enzo. The tyres are custom-developed 19 inch racing slicks.


title: Ferrari FXX

text: The FXX has comprehensive data-monitoring and telemetry systems that not only allow the driver to assess their performance on the track, but also provide Ferrari technicians with valuable data to improve the car and future road-going Ferrari models.


title: Ferrari FXX

text: Ferrari has built 30 cars in total, adding one special edition to the 29 cars that were originally planned. The original 29 cars have all been sold to pre-selected past Ferrari customers. The 30th car was retained by Ferrari S.p.A. and presented to Ferrari's F1 World Champion driver, Michael Schumacher, along with an Enzo Ferrari when he retired from Formula One racing at the end of 2006 as a token of appreciation for his achievements. Schumacher's FXX differs from others in having black paintwork without stripes, having red trimmed wheels, matte rather than chrome exhaust tips, and his personal logo stitched on the racing seats.


title: Ferrari FXX

text: The owners of the FXX also participate in Ferrari's testing and brand development programs. The purpose of this particular program is to allow Ferrari's top customers exclusive access to its most up-to-date technology and to utilise their input in the development of future models.


title: Ferrari FXX

text: The model was only sold in Europe. Units can be imported, but not owned, on any other continent. A more aggressive FXX Evoluzione package was introduced in 2009 and was reported to cost €1.5 million (excluding taxes) (US$2.1 million), including the car, the crew and the services provided by Ferrari.


title: Ferrari FXX

text: The Ferrari FXX program continued until 2009 (2007-2009), with the FXX Evo. The FXX Evo was improved from the standard FXX by continually adjusting specifics to generate more power and quicker gear changes, along with reducing the car's aerodynamic drag. The V12 engine under the Evo kit generates at 9,500 rpm and enables the car to accelerate from 0 to in 2.5 seconds. Certain changes were made to the gearbox in order to reduce the shift time to 60 milliseconds per shift, a reduction of 20 milliseconds over the original FXX. The car also underwent aerodynamic changes and improvements to the traction control system were made in order to make the car more responsive around the track.


title: Les Prophéties

text: Les Prophéties (The Prophecies) is a collection of prophecies by French physician Nostradamus, the first edition of which appeared in 1555 by the publishing house Macé Bonhomme. His most famous work is a collection of poems, quatrains, united in ten sets of verses ("Centuries") of 100 quatrains each.


title: Les Prophéties

text: The first edition included three whole Centuries and 53 quatrains. The book begins with a preface, in the form of a message to his son César, followed by the Centuries themselves. The second edition was published in the same year and has minor differences from the first.


title: Les Prophéties

text: The third edition was published in 1557, and included the full text of the previous edition, supplemented by three more Centuries. The fourth edition was published two years after the death of the author, in 1568. It is the first edition to include all ten Centuries, as well as a second preface, the "Letter to King Henry II". However, quatrains 55 to 100 of the seventh Century were never completed.


title: Les Prophéties

text: The first English edition titled "The True Prophecies or Prognostications of Michael Nostradamus, Physician to Henry II. Francis II. and Charles IX. Kings of France", was published in London by Thomas Ratcliffe and Nathaniel, in the year 1672.


title: Les Prophéties

text: The predictions do not follow chronological coherence and were written combining French, Greek, Latin and Occitan. It is believed that it contains anagrams, mythological and astrological references, in a subjective language that makes comprehension difficult. Some scholars claim that this was a resource used by Nostradamus to evade the Holy Inquisition, for fear of being persecuted for heresy.


title: Les Prophéties

text: Most of the quatrains deal with disasters, and Nostradamus gained notoriety for the belief in his ability to predict the future.


title: Les Prophéties

text: The open "Letter to King Henry II of France" is his dedicatory preface to the now-missing 1558 edition of "The Propheties", as reprinted in the posthumous 1568 edition by Benoist Rigaud. After a formal introduction, it makes various claims about the sources of his inspiration and lists many cryptic prophecies (nearly all undated) that seemingly have little to do with those in the work itself.


title: Mississippi Grind

text: Mississippi Grind is a 2015 American comedy-drama film written and directed by Anna Boden and Ryan Fleck. It stars Ryan Reynolds, Ben Mendelsohn, Sienna Miller, Lio Tipton, Robin Weigert, and Alfre Woodard. The film was released by A24 on September 25, 2015.


title: Mississippi Grind

text: Gerry, a struggling gambler and real estate agent, meets Curtis, an itinerant younger gambler, at a casino in Dubuque, Iowa. Curtis buys Gerry a drink; hours later, Gerry returns the favor, leading to a night of heavy drinking.


title: Mississippi Grind

text: After an unsuccessful real estate showing, at the dog track, Gerry and Curtis win big, but Gerry gambles it away. At a bar, they drunkenly attempt to bet $1,000 on a game of pool and are kicked out. Curtis tells Gerry it's almost "Machu Picchu time" – a phrase he uses whenever he leaves town. In the parking lot, Gerry is stabbed in an attempted mugging.


title: Mississippi Grind

text: Gerry's loan shark, Sam, threatens him to pay the money he owes her. Running into Curtis, Gerry proposes a gambling trip down the Mississippi, culminating in a New Orleans poker game with a $25,000 buy-in. The game is being held by Curtis' former acquaintance, Tony Roundtree. He agrees, spotting Gerry $2,000. Before hitting the road, Gerry steals the petty cash from his office.


title: Mississippi Grind

text: Arriving in St. Louis, Curtis reunites with Simone, a prostitute. After Gerry's successful poker session on a riverboat casino, he and Curtis spend the night with Simone and fellow prostitute Vanessa. While Gerry bonds with Vanessa, Simone reminds Curtis she has been taken advantage of by a gambler before, and remains unwilling to run away with him.


title: Mississippi Grind

text: In Memphis, Gerry plays well at Texas Hold 'em but loses everything on the final "river" card. Lying to Curtis that he won $7,000, he asks to go to Little Rock to see his ex Dorothy and estranged daughter, Wendy. Wendy is at school; when Dorothy catches him stealing money, she asks him to leave.


title: Mississippi Grind

text: Curtis and Gerry go to the Tunica, Mississippi casino, where Curtis' VIP card is rejected; asking Gerry for money, he discovers his lie. Disappointed, Curtis provokes strangers in the bathroom into assaulting Gerry, who later admits to his problems with money, and his belief that Curtis is his good luck charm.


title: Mississippi Grind

text: Reaching New Orleans, they sell Gerry's car, going to a horse race, and lose almost everything on a longshot. Curtis splits their funds equally, giving Gerry $100 for a bus ticket home. But then he collects his winnings, $5000, having bet on a different horse instead. Gerry fails to talk his way into the high-stakes poker game using Curtis as his in, as Tony clearly dislikes him and gets punched in the nose. Curtis gets thumped after a pickup basketball game. Offering strangers $100 for a game, he expects them to rob him when he loses and says he has no money; to his surprise they just take the $100. Curtis then visits his mother Cherry, a cabaret performer, leaving her most of his winnings.


title: Mississippi Grind

text: At a casino, Gerry bets the last of his money first on a slot machine then on roulette and wins. Curtis arrives at Gerry's blackjack table and loses his remaining money, but Gerry shares his chips. Their winnings continue to grow as they play craps, and Curtis calls Simone, who proclaims his love for her. Convinced they cannot lose, Gerry and Curtis bet their entire $285,000.


title: Mississippi Grind

text: Over an expensive dinner, Gerry and Curtis discuss their plans, having won a half-million dollars. Curtis wants a white Cadillac but when asked repeatedly all Gerry can come up with is he wants to do something nice for his daughter.


title: Mississippi Grind

text: In the morning, Curtis finds Gerry has gone, leaving his half of the money with a note: "It's Machu Picchu time". Curtis flirts with the hotel clerk; asked if he is going anywhere special, he replies, "Peru", offering to take her with him.


title: Mississippi Grind

text: In the final scene, Gerry buys back his car from the dealer he sold it to, telling the man he "got lucky." Sitting in his own car again, he turns it on and hears the gambling tips CD he left in the stereo. As the CD describes the mark of a confident player (sitting back, relaxed shoulders), Gerry's slouching posture transforms into a confident one and an American flag can be seen reflected upside down in the windshield.


title: Mississippi Grind

text: On August 15, 2012, Jake Gyllenhaal was in talks to join Anna Boden and Ryan Fleck on their gambling project; the duo would direct the film "Mississippi Grind" penned by themselves. On January 7, 2013, Ben Mendelsohn joined the cast of the film to star opposite Gyllenhaal. On February 1, 2013, it was announced that Panorama Media would produce the road trip drama "Mississippi Grind", with Electric City Entertainment producing. On June 27, 2013, Ryan Reynolds joined the cast of the film to play the lead as a gambler, replacing Gyllenhaal in the cast. On November 6, 2013, Sienna Miller agreed to a starring role in the film alongside Reynolds and Mendelsohn, with production to start in January 2014 in New Orleans. On January 8, 2014, there was a casting call for extras to film some scenes at Mobile Greyhound Park in Mobile. On January 27, 2014, Lio Tipton signed on to the film.


title: Mississippi Grind

text: Principal photography began on January 19, 2014 in Mobile, Alabama and went on through March 2014. The shooting was also done in New Orleans and Baton Rouge, Louisiana. On February 4, Reynolds and Miller were spotted filming scenes on the Mississippi River. On March 11, 2014, the crews were spotted filming scenes at Mobile Greyhound Park in Mobile.


title: Mississippi Grind

text: The film had its world premiere at the Sundance Film Festival on January 24, 2015. On January 28, 2015, A24 and DirecTV Cinema had acquired distribution rights to the film. The film went onto premiere at the Karlovy Vary International Film Festival on July 4, 2015. and Melbourne International Film Festival on August 1, 2015. The film was released through DirecTV Cinema on August 13, 2015, before being released in a limited release on September 25, 2015. It was scheduled to be released on video on demand on October 13, 2015. It was selected to be screened in the Gala Presentations section of the 2015 Toronto International Film Festival.


title: Mississippi Grind

text: On Rotten Tomatoes, the film holds an approval rating of 91% based on reviews from 119 critics, with an average rating of 7.3/10. The website's critics consensus reads, "Well-acted and steeped in Southern atmosphere, "Mississippi Grind" is a road movie and addiction drama that transcends each of its well-worn genres."


title: Mississippi Grind

text: Metacritic, which uses a weighted average, assigns a score of 77 out of 100 based on 27 critics, indicating "generally favorable reviews".


title: Antimicrobial spectrum

text: The antimicrobial spectrum of an antibiotic means the range of microorganisms it can kill or inhibit. Antibiotics can be divided into broad-spectrum antibiotics, extended-spectrum antibiotics and narrow-spectrum antibiotics based on their spectrum of activity. Detailedly, broad-spectrum antibiotics can kill or inhibit a wide range of microorganisms; extended-spectrum antibiotic can kill or inhibit Gram positive bacteria and some Gram negative bacteria; narrow-spectrum antibiotic can only kill or inhibit limited species of bacteria.


title: Antimicrobial spectrum

text: The antimicrobial spectrum of an antibiotic can be determined by testing its antimicrobial activity against a wide range of microbes "in vitro ". Nonetheless, the range of microorganisms which an antibiotic can kill or inhibit "in vivo" may not always be the same as the antimicrobial spectrum based on data collected in vitro.


title: Antimicrobial spectrum

text: Narrow-spectrum antibiotics have low propensity to induce bacterial resistance and are less likely to disrupt the microbiome (normal microflora). On the other hand, indiscriminate use of broad-spectrum antibiotics may not only induce the development of bacterial resistance and promote the emergence of multidrug-resistant organisms, but also cause off-target effects due to dysbiosis. They may also have side effects, such as diarrhea or rash. Generally, a broad antibiotic has more clinical indications, and therefore are more widely used. The Healthcare Infection Control Practices Advisory Committee (HICPAC) recommends the use of narrow-spectrum antibiotics whenever possible.


title: Handy Manny

text: Handy Manny is a CGI-animated children's television series that premiered with its first two episodes consecutively on Saturday, September 16, 2006, originally as part of Disney Channel's Playhouse Disney block. On Valentine's Day 2011, the series moved to the Disney Junior block, which served as Playhouse Disney's replacement.


title: Handy Manny

text: The titular character (as well as his counterpart from old Sheetrock Hills) are both voiced by Wilmer Valderrama. The show was created by Roger Bollen and Marilyn Sadler, and developed for TV by Rick Gitelson. The show's animation was produced by Canada-based Nelvana, and features the additional voice talents of Dee Bradley Baker, Tom Kenny, Fred Stoller, Nika Futterman, Kath Soucie, Carlos Alazraqui, Grey DeLisle, and Nancy Truman. The theme song is performed by Los Lobos.


title: Handy Manny

text: The series is set in the fictional town of Sheetrock Hills where the titular character, Manny (whose full name is Manuel Esteves Garcia III), owns a repair shop where he works with his anthropomorphic talking tools. It is unknown exactly where this town is located, but there are a multitude of Spanish speaking residents within it and the town is surrounded by tropical plants and ocean water (as seen in the Main Title Theme of every episode and as well as seen sometimes during the end of them). This would place Sheetrock Hills in Ventura County in California, as the hills seen in the Main Title Themes are similar to the Simi Hills mountains of Ventura County as well as Los Angeles County, California. Whether this was a coincidence or done on purpose is unknown. Most thirty-minute episodes contain two stories. They typically begin with Manny and the tools interacting in Manny's repair shop. While there, someone, usually needing something repaired or assembled, calls Manny, who answers, "Hola, Handy Manny's Repair Shop. You break it..." and then the Tools shout "We fix it!" After hearing who needs help where, Manny and the Tools sing "Hop Up, Jump In" while the Tools hop into his tool box. In each episode (except for Uncle Manny, the only episode where Mr. Lopart isn't seen at all) when Manny and the Tools leave for the repair, they see Mr. Lopart with his pet cat Fluffy in front of (or inside) his candy store. Mr. Lopart would try to do something on his own without any prior experience. Manny offers him to help but Mr. Lopart says that he doesn't need any help, after Manny and the Tools leave the item Mr. Lopart was building would malfunction and cause a mess. Once Manny and the tools arrive at the repair site, they collaborate on the best way to fix the broken item. Manny then goes to Kelly's hardware store where she almost always has the item that they need. Once they have the items needed for the repair, they go back to the work-site and sing "Fix It Right" while performing the repairs. In each episode, the item is fixed.


title: Handy Manny

text: As of August 22, 2018, all of the series' episodes are available on YouTube and Google Play to watch (some episodes were released on August 19 and August 22, and the rest were all released on August 20). In addition, excerpts of the show have been made available on YouTube accounts of Disney's international TV Channels such as Disney Junior UK and Disney Channel Africa. The series was made available on Disney+ on November 12, 2019.


title: Handy Manny

text: The series not only aired Spanish-Dubbed versions of its episodes on the "Disney Junior en Univision" sub-block on Univision's Planeta U block (weekends from May 31, 2014 to May 26, 2018), but also aired Russian-Dubbed versions of its episode on Disney Channel Russia's "Recognition Disney" (later "Disney Recognition") block, and also Hebrew-Dubbed versions of its episodes on Hop! Channel, all alongside Mickey Mouse Clubhouse (the block on Disney Channel Russia had the exact same logos as Playhouse Disney (with the exception of the block using the former branding) and Disney Junior (with the exception of the block using the latter branding). When the series was released on Disney+, several dubbed versions (whose languages were derived from Latin) were made available. Languages of these dubs include (but might not be limited to) Spanish, European and Brazilian Portuguese, Norwegian, French, Dutch, Danish and Swedish.


title: Preventive healthcare

text: Preventive healthcare, or prophylaxis, consists of measures taken for the purposes of disease prevention. Disease and disability are affected by environmental factors, genetic predisposition, disease agents, and lifestyle choices, and are dynamic processes which begin before individuals realize they are affected. Disease prevention relies on anticipatory actions that can be categorized as primal, primary, secondary, and tertiary prevention.


title: Preventive healthcare

text: Each year, millions of people die of preventable deaths. A 2004 study showed that about half of all deaths in the United States in 2000 were due to preventable behaviors and exposures. Leading causes included cardiovascular disease, chronic respiratory disease, unintentional injuries, diabetes, and certain infectious diseases. This same study estimates that 400,000 people die each year in the United States due to poor diet and a sedentary lifestyle. According to estimates made by the World Health Organization (WHO), about 55 million people died worldwide in 2011, two thirds of this group from non-communicable diseases, including cancer, diabetes, and chronic cardiovascular and lung diseases. This is an increase from the year 2000, during which 60% of deaths were attributed to these diseases.


title: Preventive healthcare

text: Preventive healthcare is especially important given the worldwide rise in prevalence of chronic diseases and deaths from these diseases. There are many methods for prevention of disease. One of them is prevention of teenage smoking through information giving. It is recommended that adults and children aim to visit their doctor for regular check-ups, even if they feel healthy, to perform disease screening, identify risk factors for disease, discuss tips for a healthy and balanced lifestyle, stay up to date with immunizations and boosters, and maintain a good relationship with a healthcare provider. In pediatrics, some common examples of primary prevention are encouraging parents to turn down the temperature of their home water heater in order to avoid scalding burns, encouraging children to wear bicycle helmets, and suggesting that people use the Air Quality Index (AQI) to check the level of pollution in the outside air before engaging in sporting activities. Some common disease screenings include checking for hypertension (high blood pressure), hyperglycemia (high blood sugar, a risk factor for diabetes mellitus), hypercholesterolemia (high blood cholesterol), screening for colon cancer, depression, HIV and other common types of sexually transmitted disease such as chlamydia, syphilis, and gonorrhea, mammography (to screen for breast cancer), colorectal cancer screening, a Pap test (to check for cervical cancer), and screening for osteoporosis. Genetic testing can also be performed to screen for mutations that cause genetic disorders or predisposition to certain diseases such as breast or ovarian cancer. However, these measures are not affordable for every individual and the cost effectiveness of preventive healthcare is still a topic of debate.


title: Preventive healthcare

text: Preventive healthcare strategies are described as taking place at the primal, primary, secondary, and tertiary prevention levels.


title: Preventive healthcare

text: Although advocated as preventive medicine in the early twentieth century by Sara Josephine Baker, in the 1940s, Hugh R. Leavell and E. Gurney Clark coined the term primary prevention. They worked at the Harvard and Columbia University Schools of Public Health, respectively, and later expanded the levels to include secondary and tertiary prevention. Goldston (1987) notes that these levels might be better described as "prevention, treatment, and rehabilitation", although the terms primary, secondary, and tertiary prevention are still in use today. The concept of primal prevention has been created much more recently, in relation to the new developments in molecular biology over the last fifty years, more particularly in epigenetics, which point to the paramount importance of environmental conditions, both physical and affective, on the organism during its fetal and newborn life, or so-called primal period of life.


title: Preventive healthcare

text: Primal prevention is health promotion "par excellence". New knowledge in molecular biology, in particular epigenetics, points to how much affective as well as physical environment during fetal and newborn life may determine adult health. This way of promoting health consists mainly in providing future parents with pertinent, unbiased information on primal health and supporting them during their child's primal period of life (i.e., "from conception to first anniversary" according to definition by the Primal Health Research Centre, London). This includes adequate parental leave, ideally for both parents, with kin caregiving and financial help where needed.


title: Preventive healthcare

text: Primordial prevention refers to all measures designed to prevent the development of risk factors in the first place, early in life, and even preconception, as Ruth A. Etzel has described it "all population-level actions and measures that inhibit the emergence and establishment of adverse environmental, economic, and social conditions". This could be reducing air pollution or prohibiting endocrine-disrupting chemicals in food-handling equipment and food contact materials.


title: Preventive healthcare

text: Primary prevention consists of traditional health promotion and "specific protection". Health promotion activities include prevention strategies such as health education and lifestyle medicine, and are current, non-clinical life choices such as eating nutritious meals and exercising often, that prevent lifestyle-related medical conditions, improve the quality of life, and create a sense of overall well-being. Preventing disease and creating overall well-being prolongs life expectancy. Health-promotional activities do not target a specific disease or condition but rather promote health and well-being on a very general level. On the other hand, specific protection targets a type or group of diseases and complements the goals of health promotion.


title: Preventive healthcare

text: The 2011 National Health Interview Survey performed by the Centers for Disease Control was the first national survey to include questions about ability to pay for food. Difficulty with paying for food, medicine, or both is a problem facing 1 out of 3 Americans. If better food options were available through food banks, soup kitchens, and other resources for low-income people, obesity and the chronic conditions that come along with it would be better controlled. A food desert is an area with restricted access to healthy foods due to a lack of supermarkets within a reasonable distance. These are often low-income neighborhoods with the majority of residents lacking transportation. There have been several grassroots movements since 1995 to encourage urban gardening, using vacant lots to grow food cultivated by local residents. Mobile fresh markets are another resource for residents in a "food desert", which are specially outfitted buses bringing affordable fresh fruits and vegetables to low-income neighborhoods.


title: Preventive healthcare

text: It has been proposed that healthy longevity diets are included in standard healthcare as switching from a "typical Western diet" could often extend life by a decade.


title: Preventive healthcare

text: Specific protective measures such as water purification, sewage treatment, and the development of personal hygienic routines, such as regular hand-washing, safe sex to prevent sexually transmitted infections, became mainstream upon the discovery of infectious disease agents and have decreased the rates of communicable diseases which are spread in unsanitary conditions.


title: Preventive healthcare

text: Scientific advancements in genetics have contributed to the knowledge of hereditary diseases and have facilitated progress in specific protective measures in individuals who are carriers of a disease gene or have an increased predisposition to a specific disease. Genetic testing has allowed physicians to make quicker and more accurate diagnoses and has allowed for tailored treatments or personalized medicine.


title: Preventive healthcare

text: Water, including drinking water, is also monitored in many cases for securing health. There also is some monitoring of air pollution. In many cases, environmental standards such as via maximum pollution levels, regulation of chemicals, occupational hygiene requirements or consumer protection regulations establish some protection in combination with the monitoring.


title: Preventive healthcare

text: Preventative measures like vaccines and medical screenings are also important. Using PPE properly and getting the recommended vaccines and screenings can help decrease the spread of respiratory diseases, protecting the healthcare workers as well as their patients.


title: Preventive healthcare

text: Secondary prevention deals with latent diseases and attempts to prevent an asymptomatic disease from progressing to symptomatic disease. Certain diseases can be classified as primary or secondary. This depends on definitions of what constitutes a disease, though, in general, primary prevention addresses the root cause of a disease or injury whereas secondary prevention aims to detect and treat a disease early on. Secondary prevention consists of "early diagnosis and prompt treatment" to contain the disease and prevent its spread to other individuals, and "disability limitation" to prevent potential future complications and disabilities from the disease. Early diagnosis and prompt treatment for a syphilis patient would include a course of antibiotics to destroy the pathogen and screening and treatment of any infants born to syphilitic mothers. Disability limitation for syphilitic patients includes continued check-ups on the heart, cerebrospinal fluid, and central nervous system of patients to curb any damaging effects such as blindness or paralysis.


title: Preventive healthcare

text: Finally, tertiary prevention attempts to reduce the damage caused by symptomatic disease by focusing on mental, physical, and social rehabilitation. Unlike secondary prevention, which aims to prevent disability, the objective of tertiary prevention is to maximize the remaining capabilities and functions of an already disabled patient. Goals of tertiary prevention include: preventing pain and damage, halting progression and complications from disease, and restoring the health and functions of the individuals affected by disease. For syphilitic patients, rehabilitation includes measures to prevent complete disability from the disease, such as implementing work-place adjustments for the blind and paralyzed or providing counseling to restore normal daily functions to the greatest extent possible.


title: Preventive healthcare

text: The general use of machinery that has adequate ventilation and airflow is suggested for these patients in order to halt progression and complications of disease. A study conducted in nursing homes to prevent diseases concluded that the use of evaporative humidifiers to maintain the indoor humidity within the range 40–60% can reduce respiratory risk. Certain diseases thrive in different humidities, so the use of the humidifiers can help kill the particles of diseases.


title: Preventive healthcare

text: The leading preventable cause of death in the United States is tobacco; however, poor diet and lack of exercise may soon surpass tobacco as a leading cause of death. These behaviors are modifiable and public health and prevention efforts could make a difference to reduce these deaths.


title: Preventive healthcare

text: The leading causes of preventable death worldwide share similar trends to the United States. There are a few differences between the two, such as malnutrition, pollution, and unsafe sanitation, that reflect health disparities between the developing and developed world.


title: Preventive healthcare

text: However, several of the leading causes of death – or underlying contributors to earlier death – may not be included as "preventable" causes of death. A study concluded that pollution was "responsible for approximately 9 million deaths per year" in 2019. And another study concluded that the global mean loss of life expectancy (a measure similar to years of potential life lost) from air pollution in 2015 was 2.9 years, substantially more than, for example, 0.3 years from all forms of direct violence, albeit a significant fraction of the LLE is considered to be unavoidable (such as pollution from some natural wildfires).<ref name="10.1093/cvr/cvaa025"></ref>


title: Preventive healthcare

text: A landmark study conducted by the World Health Organization and the International Labour Organization found that exposure to long working hours is the occupational risk factor with the largest attributable burden of disease, i.e. an estimated 745,000 fatalities from ischemic heart disease and stroke events in 2016. With this study, prevention of exposure to long working hours has emerged as a priority for prevention healthcare in workplace settings.


title: Preventive healthcare

text: In 2010, 7.6 million children died before reaching the age of 5. While this is a decrease from 9.6 million in 2000, it was still far from the fourth Millennium Development Goal to decrease child mortality by two-thirds by 2015. Of these deaths, about 64% were due to infection including diarrhea, pneumonia, and malaria. About 40% of these deaths occurred in neonates (children ages 1–28 days) due to pre-term birth complications. The highest number of child deaths occurred in Africa and Southeast Asia. As of 2015 in Africa, almost no progress has been made in reducing neonatal death since 1990. In 2010, India, Nigeria, Democratic Republic of the Congo, Pakistan, and China contributed to almost 50% of global child deaths. Targeting efforts in these countries is essential to reducing the global child death rate.


title: Preventive healthcare

text: Child mortality is caused by factors including poverty, environmental hazards, and lack of maternal education. In 2003, the World Health Organization created a list of interventions in the following table that were judged economically and operationally "feasible," based on the healthcare resources and infrastructure in 42 nations that contribute to 90% of all infant and child deaths. The table indicates how many infant and child deaths could have been prevented in 2000, assuming universal healthcare coverage.


title: Preventive healthcare

text: Obesity is a major risk factor for a wide variety of conditions including cardiovascular diseases, hypertension, certain cancers, and type 2 diabetes. In order to prevent obesity, it is recommended that individuals adhere to a consistent exercise regimen as well as a nutritious and balanced diet. A healthy individual should aim for acquiring 10% of their energy from proteins, 15-20% from fat, and over 50% from complex carbohydrates, while avoiding alcohol as well as foods high in fat, salt, and sugar. Sedentary adults should aim for at least half an hour of moderate-level daily physical activity and eventually increase to include at least 20 minutes of intense exercise, three times a week. Preventive health care offers many benefits to those that chose to participate in taking an active role in the culture. The medical system in our society is geared toward curing acute symptoms of disease after the fact that they have brought us into the emergency room. An ongoing epidemic within American culture is the prevalence of obesity. Healthy eating and regular exercise play a significant role in reducing an individual's risk for type 2 diabetes. A 2008 study concluded that about 23.6 million people in the United States had diabetes, including 5.7 million that had not been diagnosed. 90 to 95 percent of people with diabetes have type 2 diabetes. Diabetes is the main cause of kidney failure, limb amputation, and new-onset blindness in American adults.


title: Preventive healthcare

text: Sexually transmitted infections (STIs), such as syphilis and HIV, are common but preventable with safe-sex practices. STIs can be asymptomatic, or cause a range of symptoms. Preventive measures for STIs are called prophylactics. The term especially applies to the use of condoms, which are highly effective at preventing disease, but also to other devices meant to prevent STIs, such as dental dams and latex gloves. Other means for preventing STIs include education on how to use condoms or other such barrier devices, testing partners before having unprotected sex, receiving regular STI screenings, to both receive treatment and prevent spreading STIs to partners, and, specifically for HIV, regularly taking prophylactic antiretroviral drugs, such as Truvada. Post-exposure prophylaxis, started within 72 hours (optimally less than 1 hour) after exposure to high-risk fluids, can also protect against HIV transmission.


title: Preventive healthcare

text: Genetically modified mosquitoes are being used in developing countries to control malaria. This approach has been subject to objections and controversy.


title: Preventive healthcare

text: Thrombosis is a serious circulatory disease affecting thousands, usually older persons undergoing surgical procedures, women taking oral contraceptives and travelers. The consequences of thrombosis can be heart attacks and strokes. Prevention can include exercise, anti-embolism stockings, pneumatic devices, and pharmacological treatments.


title: Preventive healthcare

text: In recent years, cancer has become a global problem. Low and middle income countries share a majority of the cancer burden largely due to exposure to carcinogens resulting from industrialization and globalization. However, primary prevention of cancer and knowledge of cancer risk factors can reduce over one third of all cancer cases. Primary prevention of cancer can also prevent other diseases, both communicable and non-communicable, that share common risk factors with cancer.


title: Preventive healthcare

text: Lung cancer is the leading cause of cancer-related deaths in the United States and Europe and is a major cause of death in other countries. Tobacco is an environmental carcinogen and the major underlying cause of lung cancer. Between 25% and 40% of all cancer deaths and about 90% of lung cancer cases are associated with tobacco use. Other carcinogens include asbestos and radioactive materials. Both smoking and second-hand exposure from other smokers can lead to lung cancer and eventually death.


title: Preventive healthcare

text: Prevention of tobacco use is paramount to prevention of lung cancer. Individual, community, and statewide interventions can prevent or cease tobacco use. 90% of adults in the U.S. who have ever smoked did so prior to the age of 20. In-school prevention/educational programs, as well as counseling resources, can help prevent and cease adolescent smoking. Other cessation techniques include group support programs, nicotine replacement therapy (NRT), hypnosis, and self-motivated behavioral change. Studies have shown long term success rates (>1 year) of 20% for hypnosis and 10%-20% for group therapy.


title: Preventive healthcare

text: Cancer screening programs serve as effective sources of secondary prevention. The Mayo Clinic, Johns Hopkins, and Memorial Sloan-Kettering hospitals conducted annual x-ray screenings and sputum cytology tests and found that lung cancer was detected at higher rates, earlier stages, and had more favorable treatment outcomes, which supports widespread investment in such programs.


title: Preventive healthcare

text: Legislation can also affect smoking prevention and cessation. In 1992, Massachusetts (United States) voters passed a bill adding an extra 25 cent tax to each pack of cigarettes, despite intense lobbying and $7.3 million spent by the tobacco industry to oppose this bill. Tax revenue goes toward tobacco education and control programs and has led to a decline of tobacco use in the state.


title: Preventive healthcare

text: Lung cancer and tobacco smoking are increasing worldwide, especially in China. China is responsible for about one-third of the global consumption and production of tobacco products. Tobacco control policies have been ineffective as China is home to 350 million regular smokers and 750 million passive smokers and the annual death toll is over 1 million. Recommended actions to reduce tobacco use include decreasing tobacco supply, increasing tobacco taxes, widespread educational campaigns, decreasing advertising from the tobacco industry, and increasing tobacco cessation support resources. In Wuhan, China, a 1998 school-based program implemented an anti-tobacco curriculum for adolescents and reduced the number of regular smokers, though it did not significantly decrease the number of adolescents who initiated smoking. This program was therefore effective in secondary but not primary prevention and shows that school-based programs have the potential to reduce tobacco use.


title: Preventive healthcare

text: Skin cancer is the most common cancer in the United States. The most lethal form of skin cancer, melanoma, leads to over 50,000 annual deaths in the United States. Childhood prevention is particularly important because a significant portion of ultraviolet radiation exposure from the sun occurs during childhood and adolescence and can subsequently lead to skin cancer in adulthood. Furthermore, childhood prevention can lead to the development of healthy habits that continue to prevent cancer for a lifetime.


title: Preventive healthcare

text: The Centers for Disease Control and Prevention (CDC) recommends several primary prevention methods including: limiting sun exposure between 10 AM and 4 PM, when the sun is strongest, wearing tighter-weave natural cotton clothing, wide-brim hats, and sunglasses as protective covers, using sunscreens that protect against both UV-A and UV-B rays, and avoiding tanning salons. Sunscreen should be reapplied after sweating, exposure to water (through swimming for example) or after several hours of sun exposure. Since skin cancer is very preventable, the CDC recommends school-level prevention programs including preventive curricula, family involvement, participation and support from the school's health services, and partnership with community, state, and national agencies and organizations to keep children away from excessive UV radiation exposure.


title: Preventive healthcare

text: Most skin cancer and sun protection data comes from Australia and the United States. An international study reported that Australians tended to demonstrate higher knowledge of sun protection and skin cancer knowledge, compared to other countries. Of children, adolescents, and adults, sunscreen was the most commonly used skin protection. However, many adolescents purposely used sunscreen with a low sun protection factor (SPF) in order to get a tan. Various Australian studies have shown that many adults failed to use sunscreen correctly; many applied sunscreen well after their initial sun exposure and/or failed to reapply when necessary. A 2002 case-control study in Brazil showed that only 3% of case participants and 11% of control participants used sunscreen with SPF >15.


title: Preventive healthcare

text: Cervical cancer ranks among the top three most common cancers among women in Latin America, sub-Saharan Africa, and parts of Asia. Cervical cytology screening aims to detect abnormal lesions in the cervix so that women can undergo treatment prior to the development of cancer. Given that high quality screening and follow-up care has been shown to reduce cervical cancer rates by up to 80%, most developed countries now encourage sexually active women to undergo a Pap test every 3–5 years. Finland and Iceland have developed effective organized programs with routine monitoring and have managed to significantly reduce cervical cancer mortality while using fewer resources than unorganized, opportunistic programs such as those in the United States or Canada.


title: Preventive healthcare

text: In developing nations in Latin America, such as Chile, Colombia, Costa Rica, and Cuba, both public and privately organized programs have offered women routine cytological screening since the 1970s. However, these efforts have not resulted in a significant change in cervical cancer incidence or mortality in these nations. This is likely due to low quality, inefficient testing. However, Puerto Rico, which has offered early screening since the 1960s, has witnessed almost a 50% decline in cervical cancer incidence and almost a four-fold decrease in mortality between 1950 and 1990. Brazil, Peru, India, and several high-risk nations in sub-Saharan Africa which lack organized screening programs, have a high incidence of cervical cancer.


title: Preventive healthcare

text: Colorectal cancer is globally the second most common cancer in women and the third-most common in men, and the fourth most common cause of cancer death after lung, stomach, and liver cancer, having caused 715,000 deaths in 2010.


title: Preventive healthcare

text: It is also highly preventable; about 80 percent of colorectal cancers begin as benign growths, commonly called polyps, which can be easily detected and removed during a colonoscopy. Other methods of screening for polyps and cancers include fecal occult blood testing. Lifestyle changes that may reduce the risk of colorectal cancer include increasing consumption of whole grains, fruits and vegetables, and reducing consumption of red meat.


title: Preventive healthcare

text: Access to healthcare and preventive health services is unequal, as is the quality of care received. A study conducted by the Agency for Healthcare Research and Quality (AHRQ) revealed health disparities in the United States. In the United States, elderly adults (>65 years old) received worse care and had less access to care than their younger counterparts. The same trends are seen when comparing all racial minorities (black, Hispanic, Asian) to white patients, and low-income people to high-income people. Common barriers to accessing and utilizing healthcare resources included lack of income and education, language barriers, and lack of health insurance. Minorities were less likely than whites to possess health insurance, as were individuals who completed less education. These disparities made it more difficult for the disadvantaged groups to have regular access to a primary care provider, receive immunizations, or receive other types of medical care. Additionally, uninsured people tend to not seek care until their diseases progress to chronic and serious states and they are also more likely to forgo necessary tests, treatments, and filling prescription medications.


title: Preventive healthcare

text: These sorts of disparities and barriers exist worldwide as well. Often, there are decades of gaps in life expectancy between developing and developed countries. For example, Japan has an average life expectancy that is 36 years greater than that in Malawi. Low-income countries also tend to have fewer physicians than high-income countries. In Nigeria and Myanmar, there are fewer than 4 physicians per 100,000 people while Norway and Switzerland have a ratio that is ten-fold higher. Common barriers worldwide include lack of availability of health services and healthcare providers in the region, great physical distance between the home and health service facilities, high transportation costs, high treatment costs, and social norms and stigma toward accessing certain health services.


title: Preventive healthcare

text: With lifestyle factors such as diet and exercise rising to the top of preventable death statistics, the economics of healthy lifestyle is a growing concern. There is little question that positive lifestyle choices provide an investment in health throughout life. To gauge success, traditional measures such as the quality years of life method (QALY), show great value. However, that method does not account for the cost of chronic conditions or future lost earnings because of poor health.


title: Preventive healthcare

text: Developing future economic models that would guide both private and public investments as well as drive future policy to evaluate the efficacy of positive lifestyle choices on health is a major topic for economists globally. Americans spend over three trillion a year on health care but have a higher rate of infant mortality, shorter life expectancies, and a higher rate of diabetes than other high-income nations because of negative lifestyle choices. Despite these large costs, very little is spent on prevention for lifestyle-caused conditions in comparison. In 2016, the "Journal of the American Medical Association" estimated that $101 billion was spent in 2013 on the preventable disease of diabetes, and another $88 billion was spent on heart disease. In an effort to encourage healthy lifestyle choices, as of 2010 workplace wellness programs were on the rise but the economics and effectiveness data were continuing to evolve and develop.


title: Preventive healthcare

text: Health insurance coverage impacts lifestyle choices, even intermittent loss of coverage had negative effects on healthy choices in the U.S. The repeal of the Affordable Care Act (ACA) could significantly impact coverage for many Americans as well as "The Prevention and Public Health Fund" which is the U.S. first and only mandatory funding stream dedicated to improving public health including counseling on lifestyle prevention issues, such as weight management, alcohol use, and treatment for depression.


title: Preventive healthcare

text: Because in the U.S. chronic illnesses predominate as a cause of death and pathways for treating chronic illnesses are complex and multifaceted, prevention is a best practice approach to chronic disease when possible. In many cases, prevention requires mapping complex pathways to determine the ideal point for intervention. Cost-effectiveness of prevention is achievable, but impacted by the length of time it takes to see effects/outcomes of intervention. This makes prevention efforts difficult to fund—particularly in strained financial contexts. Prevention potentially creates other costs as well, due to extending the lifespan and thereby increasing opportunities for illness. In order to assess the cost-effectiveness of prevention, the cost of the preventive measure, savings from avoiding morbidity, and the cost from extending the lifespan need to be considered. Life extension costs become smaller when accounting for savings from postponing the last year of life, which makes up a large fraction of lifetime medical expenditures and becomes cheaper with age. Prevention leads to savings only if the cost of the preventive measure is less than the savings from avoiding morbidity net of the cost of extending the life span. In order to establish reliable economics of prevention for illnesses that are complicated in origin, knowing how best to assess prevention efforts, i.e. developing useful measures and appropriate scope, is required.


title: Preventive healthcare

text: There is no general consensus as to whether or not preventive healthcare measures are cost-effective, but they increase the quality of life dramatically. There are varying views on what constitutes a "good investment." Some argue that preventive health measures should save more money than they cost, when factoring in treatment costs in the absence of such measures. Others have argued in favor of "good value" or conferring significant health benefits even if the measures do not save money. Furthermore, preventive health services are often described as one entity though they comprise a myriad of different services, each of which can individually lead to net costs, savings, or neither. Greater differentiation of these services is necessary to fully understand both the financial and health effects.


title: Preventive healthcare

text: A 2010 study reported that in the United States, vaccinating children, cessation of smoking, daily prophylactic use of aspirin, and screening of breast and colorectal cancers had the most potential to prevent premature death. Preventive health measures that resulted in savings included vaccinating children and adults, smoking cessation, daily use of aspirin, and screening for issues with alcoholism, obesity, and vision failure. These authors estimated that if usage of these services in the United States increased to 90% of the population, there would be net savings of $3.7 billion, which comprised only about -0.2% of the total 2006 United States healthcare expenditure. Despite the potential for decreasing healthcare spending, utilization of healthcare resources in the United States still remains low, especially among Latinos and African-Americans. Overall, preventive services are difficult to implement because healthcare providers have limited time with patients and must integrate a variety of preventive health measures from different sources.


title: Preventive healthcare

text: While these specific services bring about small net savings, not every preventive health measure saves more than it costs. A 1970s study showed that preventing heart attacks by treating hypertension early on with drugs actually did not save money in the long run. The money saved by evading treatment from heart attack and stroke only amounted to about a quarter of the cost of the drugs. Similarly, it was found that the cost of drugs or dietary changes to decrease high blood cholesterol exceeded the cost of subsequent heart disease treatment. Due to these findings, some argue that rather than focusing healthcare reform efforts exclusively on preventive care, the interventions that bring about the highest level of health should be prioritized.


title: Preventive healthcare

text: In 2008, Cohen "et al." outlined a few arguments made by skeptics of preventive healthcare. Many argue that preventive measures only cost less than future treatment when the proportion of the population that would become ill in the absence of prevention is fairly large. The Diabetes Prevention Program Research Group conducted a 2012 study evaluating the costs and benefits in quality-adjusted life-years or QALYs of lifestyle changes versus taking the drug metformin. They found that neither method brought about financial savings, but were cost-effective nonetheless because they brought about an increase in QALYs. In addition to scrutinizing costs, preventive healthcare skeptics also examine efficiency of interventions. They argue that while many treatments of existing diseases involve use of advanced equipment and technology, in some cases, this is a more efficient use of resources than attempts to prevent the disease. Cohen suggested that the preventive measures most worth exploring and investing in are those that could benefit a large portion of the population to bring about cumulative and widespread health benefits at a reasonable cost.


title: Preventive healthcare

text: There are at least four nationally implemented childhood obesity interventions in the United States: the Sugar-Sweetened Beverage excise tax (SSB), the TV AD program, active physical education (Active PE) policies, and early care and education (ECE) policies. They each have similar goals of reducing childhood obesity. The effects of these interventions on BMI have been studied, and the cost-effectiveness analysis (CEA) has led to a better understanding of projected cost reductions and improved health outcomes. The Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) was conducted to evaluate and compare the CEA of these four interventions.


title: Preventive healthcare

text: Gortmaker, S.L. "et al." (2015) states: "The four initial interventions were selected by the investigators to represent a broad range of nationally scalable strategies to reduce childhood obesity using a mix of both policy and programmatic strategies... 1. an excise tax of $0.01 per ounce of sweetened beverages, applied nationally and administered at the state level (SSB), 2. elimination of the tax deductibility of advertising costs of TV advertisements for "nutritionally poor" foods and beverages seen by children and adolescents (TV AD), 3. state policy requiring all public elementary schools in which physical education (PE) is currently provided to devote ≥50% of PE class time to moderate and vigorous physical activity (Active PE), and 4. state policy to make early child educational settings healthier by increasing physical activity, improving nutrition, and reducing screen time (ECE)." The CHOICES found that SSB, TV AD, and ECE led to net cost savings. Both SSB and TV AD increased quality adjusted life years and produced yearly tax revenue of 12.5 billion U.S. dollars and 80 million U.S. dollars, respectively.


title: Preventive healthcare

text: As of 2009, the cost-effectiveness of preventive care is a highly debated topic. While some economists argue that preventive care is valuable and potentially cost saving, others believe it is an inefficient waste of resources. Preventive care is composed of a variety of clinical services and programs including annual doctor's check-ups, annual immunizations, and wellness programs; recent models show that these simple interventions can have significant economic impacts.


title: Preventive healthcare

text: Research on preventive care addresses the question of whether it is cost saving or cost effective and whether there is an economics evidence base for health promotion and disease prevention. The need for and interest in preventive care is driven by the imperative to reduce health care costs while improving quality of care and the patient experience. Preventive care can lead to improved health outcomes and cost savings potential. Services such as health assessments/screenings, prenatal care, and telehealth and telemedicine can reduce morbidity or mortality with low cost or cost savings. Specifically, health assessments/screenings have cost savings potential, with varied cost-effectiveness based on screening and assessment type. Inadequate prenatal care can lead to an increased risk of prematurity, stillbirth, and infant death. Time is the ultimate resource and preventive care can help mitigate the time costs. Telehealth and telemedicine is one option that has gained consumer interest, acceptance, and confidence and can improve quality of care and patient satisfaction.


title: Preventive healthcare

text: There are benefits and trade-offs when considering investment in preventive care versus other types of clinical services. Preventive care can be a good investment as supported by the evidence base and can drive population health management objectives. The concepts of cost saving and cost-effectiveness are different and both are relevant to preventive care. Preventive care that may not save money may still provide health benefits; thus, there is a need to compare interventions relative to impact on health and cost.


title: Preventive healthcare

text: Preventive care transcends demographics and is applicable to people of every age. The Health Capital Theory underpins the importance of preventive care across the lifecycle and provides a framework for understanding the variances in health and health care that are experienced. It treats health as a stock that provides direct utility. Health depreciates with age and the aging process can be countered through health investments. The theory further supports that individuals demand good health, that the demand for health investment is a derived demand (i.e. investment is health is due to the underlying demand for good health), and the efficiency of the health investment process increases with knowledge (i.e. it is assumed that the more educated are more efficient consumers and producers of health).


title: Preventive healthcare

text: The prevalence elasticity of demand for prevention can also provide insights into the economics. Demand for preventive care can alter the prevalence rate of a given disease and further reduce or even reverse any further growth of prevalence. Reduction in prevalence subsequently leads to reduction in costs. There are a number of organizations and policy actions that are relevant when discussing the economics of preventive care services. The evidence base, viewpoints, and policy briefs from the Robert Wood Johnson Foundation, the Organisation for Economic Co-operation and Development (OECD), and efforts by the U.S. Preventive Services Task Force (USPSTF) all provide examples that improve the health and well-being of populations (e.g. preventive health assessments/screenings, prenatal care, and telehealth/telemedicine). The Affordable Care Act (ACA) has major influence on the provision of preventive care services, although it is currently under heavy scrutiny and review by the new administration. According to the Centers for Disease Control and Prevention (CDC), the ACA makes preventive care affordable and accessible through mandatory coverage of preventive services without a deductible, copayment, coinsurance, or other cost sharing.


title: Preventive healthcare

text: The U.S. Preventive Services Task Force (USPSTF), a panel of national experts in prevention and evidence-based medicine, works to improve health of Americans by making evidence-based recommendations about clinical preventive services. They do not consider the cost of a preventive service when determining a recommendation. Each year, the organization delivers a report to Congress that identifies critical evidence gaps in research and recommends priority areas for further review.