Exploring Human Potential

Positive Medicine Visions


Mike Magee

Vision I: Health Is Political

Over the past ten years, the World Health Organization and other groups have actively engaged the question “What is health?” A large part of this thought process has involved defining what health is not. It is not the health care system. It is not the reactive elimination of disease. It is not a simple commodity to be weighed against all other commodities in society. It is different from these things, and more than these things.

Health is universal and common to the people of the world, independent of geography, race, income, gender, and culture. Health is an active state of well-being that encompasses mind, body and spirit. It is the capacity to reach one’s full human potential, and, on a larger scale, a nation’s potential for development.

Dr. Gro Brundtland, former director-general of the World Health Organization, wrote in the World Health Report 2000 that “The objective of good health is twofold – goodness and fairness; goodness being the best attainable average level; and fairness, the smallest feasible differences among individuals and groups.“ 1

Today the notion that health is a preferred state of being, rather than a set of disconnected functions or services, is increasingly being embraced.

With this in mind, it becomes impossible to ignore a significant modern-day truism. Health is profoundly political. Why is this the case? For multiple reasons. Health is a collection of resources unequally distributed in society. Health’s “social determinants” such as housing, income, and employment, are critical to the accomplishment of individual, family, and community well being and are themselves politically determined. Health is recognized by many throughout the world as a fundamental right; yet it is irreparably intertwined with our economic, social, and political systems. And growth in health, health care, and health systems requires political debate and political consensus. 2

The Health World is Changing

For these reasons and more, it is entirely reasonable to acknowledge and attempt to structure in a purposeful manner the politics of health. To do so requires mention of some of the major forces shaping health worldwide. These include aging demographics, the growth of home-based caregivers, the dual burden of disease, the Internet, and consumer empowerment and activism.

In the United States, nearly 50 percent of all 60 year olds have a parent alive, and by 2050 there will be 1 million people over age 100. 3 This means the three-generation family has been supplanted by the four and five-generation family. Twenty-five percent of American homes have an elder caregiver in place, and 85 percent of them are volunteer family members. The vast majority of these caregivers are third-generation women, managing parents and grandparents on the one hand and children and grandchildren on the other. 4,5 In the United States, their focus is predominately on chronic diseases, seven of which cause 90 percent of the disability in senior populations. 6

In the developing world, the health focus remains primarily on infectious diseases, nutrition, and maternal and fetal issues, which are challenging the human and financial resources of these countries. But urbanization and the influx of tobacco and unhealthy foods are accelerating the onset of chronic diseases and creating a dual burden of disease. 7

Finally, consumer empowerment is being fueled by the Internet and supported by physicians, nurses and other caregivers. This has led to emancipation and engagement of an increasingly activist-oriented public. 8 They desire education, behavioral modification, home-based care solutions, inclusion in the health care team, and financial incentives to reward wellness. 9

The Power is Shifting

As these trends play out and the definition of health continues to evolve, we are seeing the seat of political power in health continue to shift. It will move away from paternalism toward partnership. It will move away from individual care models to team approaches. And it will move away from intervention toward prevention and health planning. It will embrace evidence-based clinical care but incorporate educational and social missions as well. It will move away from hospitals and outpatient care sites toward home settings. And it will move away from thought elites toward patients and their care teams.

Despite this shifting environment, there is a growing political disconnect between those who make health policy and those most affected by health policy. While the former continue to reinforce silos and the status quo, the latter seek broad, fundamental and comprehensive reform. Such reform might include expansion of insurance coverage, realignment of financial incentives toward prevention, increased reimbursement of physicians and nurses for team coordination that includes home health managers, support for early diagnosis and screening, and expansion of education and behavioral modification for individuals and families.

Due to its profound impact on the future of individuals, families, communities, and societies, the politics of health deserves broad debate, active public participation, and focused scholarly pursuit. Here are two suggested areas for growth. First, we need to step up consumer education empowerment. We can build on the strong success we’ve already seen with increased understanding of the scientific lexicon, organ function, and disease management. To move another step forward, we must now offer strategies and incentives in home health management, lifespan planning, and customized health system design. Second, in the area of scholarly pursuit, we must harness the best scholars in medical sociology, political sociology and political psychology, environmental science, health economics, public health, medicine, nursing, pastoral care, and bereavement, to create interdisciplinary social health leadership curricula and degrees that are equipped to manage the rapidly evolving health environment. Such a commitment will empower us to more effectively challenge outdated thinking, outdated systems, and outdated approaches to health.


1.World Health Organization. World Health Report 2000 –Health Systems: Improving Performance.

2.Bambra C, Fox D, Scott-Samuel A. Towards a politics of health. Health Promotion International. 2005;20:187-193.

3.Alliance for Aging Research. Medical Never-Never Land: Ten Reasons Why America is Not Ready for the Coming Age Boom.

4.Census 2000 Brief. The 65 years and over population: 2000.

5.Magee M. Aging – New Environments for Mature Living. Health Politics.

6.Yach D, Hawkes C, Gould CL, Hofman KJ. The global burden of chronic diseases. JAMA. 2004;291:2612=2622.

7.Action on smoking and health. Tobacco global trends.

8.Magee M. Relationship-Based Health Care in the United States, United Kingdom, Canada, Germany, South Africa and Japan. World Medical Association Annual Meeting in Helsinki, Finland. Sept. 11, 2003.

9. Nash D. Connecting with the New Health Care Consumer. New York: McGraw Hill;2000

Vision II: Home-Centered Health Care

Healthcare reform has once again surfaced as the number one domestic issue. But what is missing is an organizing vision for today’s complex and unruly healthcare landscape.

Time for Transformation

Nearly 100 percent of the assets we currently include in our definition of the healthcare system—the bricks and mortar of our hospitals and our patient offices; our human resources as embodied in our training, roles, responsibilities, and payment incentives; our educational curricula; and our continuously reengineered processes targeted at in-patient safety and efficiency—have little to offer us, in their current form, to assist in the build-out of a truly preventive healthcare system. Instead, these elements are original, or second or third, iterations of a century-old interventional care system that stubbornly survives largely in its original form because we have been unsuccessful in managing and executing the creation of a more inclusive and anticipatory healthcare system.

Prevention is grounded in education and behavioral modification. It begins before birth and extends beyond death. To be successful, a preventive healthcare system must advantage multigenerational relationships to provide multiple, repetitive inputs in real time that allow micro-adjustments in one’s daily life. Such a system demands intimately informed, highly motivated, and deeply committed individuals willing to gently prod those under their charge toward health and wellness.

The practical institution of a preventive system would necessitate guiding hands and a pervasive presence, family and community linkages, and the ability to efficiently lay out lifecycle plans and execute lifespan management on the one hand, and ensure adherence to palliative treatment plans for patients with chronic disease on the other. Unfortunately, these elements are not included in what we have traditionally termed “healthcare.”

Beginning with New Technology

In the build-out of such a healthcare system, there is only one location that is both geographically identifiable and politically viable as a candidate upon which to center the program – the home.  While the home may be where the heart is, it is most certainly not currently where the health is, and in this way represents an opportune site for constructive change to take place.

General Electric (GE) recognized the “moldability” of the home when it launched its remarkable exhibit called the “Carousel of Progress” at the World Fair in New York in 1964. The GE exhibit convinced many that, by improving our toasters and refrigerators, GE had truly improved our lives. The same could be done with health.

America views homelessness as a social failure. The nation has now begun to view “healthlessness” in the same light. If we were able to leverage technology—informational technology, diagnostic and imaging technology, entertainment technology, and financial system technology to equitably re-outfit and at least partially improve the health of homes, we could efficiently re-center our healthcare system around the home.

As it turns out, others have endorsed this same strategy, and have been actively at work, albeit under the radar, to develop a wide range of product offerings for which Forrester Research forecasts will find an explosive growth market by 2015.(1)  Thousands of technology, entertainment, and financial firms are now investing in the parallel build-out of preventive home-centered health. In this effort, they are working side by side with governments and municipalities, and with major academic engineering powerhouses such as MIT (2), the University of Rochester (3), Carnegie Mellon (4), and the University of Michigan (5). What is surprising, however, is the relative lack of discussion of the patient-physician relationship, care teams, and multigenerational prevention in these groups’ home health planning visions. Rather, the emphasis has been on the use of consumer health electronics to support independence, aging at home, and chronic disease management, when the true opportunity lies in multigenerational lifecycle management. (6,7)

Moving into the Home

At the center of this vision is the home: the primary health information loop would not travel from hospital to physician’s office and back, but rather from home to care team and back to home. Informal caregivers would become fully enfranchised members of physician-led, yet nurse-directed, care teams. These family caregivers would not only be linked virtually to their multigenerational families and to their care teams, but also to other informal family caregivers, thereby effectively addressing the profound sense of isolation that comes with these roles. A wide range of secondary loops would evolve from generalist to specialist, from clinician’s office to hospital, from care team to insurer or pharmacy. But the primary loop, where data would originate and from which privacy access would be granted, would be home-centered. (8,9)

The data flowing out of the home would be rich, varied, real-time, and virtual. It would include vital signs and diagnostic and imaging results sent wirelessly to care teams.  Beyond this, the healthy home would also have ubiquitous, low cost sensors able to track motions, actions, and interactions. The data produced by these sensors would be interpreted by on-site intelligence software and measured against predicted healthy living plans.(6)  The results would be fed in a continuous stream to the care team. The feedback loop, which would be supported by a connecting interface, would consist of a human team partner communicating through a friendly interface of one’s choice—wristwatch, phone, radio, TV, or computer—a guide and companion who might remind one to bathe if you’ve forgotten; to increase fluid, to alter diet, or to exercise; to take medication or vary dosage today; to schedule a mammogram; or even to call one’s daughter as one had promised.(7)

While specific roles for physician, nurse, and other formal and informal caregivers would need to be defined, it would be possible to reorganize the workflow using a clearly defined system of incentives. For example, care teams could be reimbursed for successfully assuring the health of their patients, for managing patient databases and the appropriate sharing of that data, and for providing coaching, development and oversight of lifespan health records. Patients and their families could be rewarded with lower insurance rates for adherence to their plans for health, and meeting health outcomes.

Changing Roles

As a result of this shift, physician-led teams would be reimbursed for managing complexity.  Informal caregivers would become home health managers, rewarded with lower health insurance premiums or tax benefits for accomplishing healthy family outcomes. Nurses’ roles as coaches, educators, and behavior modifiers would expand with the full support and encouragement of physicians.

Offices would see much less traffic, as most care could be accomplished without a visit. Yet physicians and nurses would make a good living, and even have time to visit their patients, in their own homes. (10,11) Hospitals and specialists, along with their advanced diagnostics and special interventional capabilities would remain a necessity. But with the success of an anticipatory preventive health care system properly incentivized to financially reward health, one would expect these services to become more centralized and concentrated, and for less services to be required per capita. The surviving services would see higher volume and would be expected to deliver better and more uniform outcomes. (12)

This shift would require caregivers, traditionally suspicious of technology for fear that it will dehumanize their relationships with their patients, to confront their aversion to technology and embrace it. The initial steps must be to develop openness to new and innovative partnerships, and a deep commitment to advance, encourage and utilize virtual connectivity to reinforce the physician/nurse – patient relationship.

These concepts together define a new era of “health enlightenment” – a primary loop from home to care team to home; physician-nurse partnering; informal family caregiver inclusion; automated, family-centered data outflow; continual assessment and coaching feedback; advanced medical communications with elimination of discovery to clinician to patient translation gaps; and active targeting of our most vulnerable populations, whether they be elderly in Florida, rural in Montana, or poor and disabled in Tucson or West Philadelphia—are both sound and achievable if supported by transformative leadership.

Alternate Pathways

The trends that are transforming healthcare – an increase in aging populations, consumerism, the Internet, broadband reach, expansion of family caregivers, and globalization – will continue to accelerate the healthcare system toward a home-centered healthcare vision, even absent the participation of physicians, nurses and other healthcare professionals. (13) Yet without the active participation of caring doctors, nurses, and health professionals, the vision can never be truly complete.

Without the active voice of clinicians at the forefront, consumerism points toward an entirely different outcome. Knowledge and consumer involvement still rise. Financial, technology, and entertainment vendors still succeed in the creation, marketing, and sales of products that transform our homes. However, supportive relationships decline further, resulting in greater consumer isolation.

Under these circumstances, our envisioned “double-connect” to each other (technology that provides a permanent, constant connection between the people and the people caring for the people) becomes a “double-check” on each other (technology used by consumers to perform second opinions on the people and institutions with whom they traditionally shared confidence and trust).

The bright promise of health populism reverts to the dead weight of health siloism, an outmoded concept that serves no one. Technology, one way or another, will transform healthcare. If traditional leaders in healthcare are able to rise to the challenge, have the wisdom and insight to see the opportunity of technology for what it is, they will embrace traditional and new healthcare partners around a new health value proposition, and collaboratively and deliberately build-out a home-centered healthcare system. (14)

The Ideal Scenario

Beyond home health care for our aging population, home-centered health is a vision for the not-so-far-off future that would use technology, advanced information systems and a new, more team-oriented medical approach to share responsibility for efficient, high quality health fulfillment.

Ten realities would be skillfully integrated into this calm and well-organized vision of a healthy home:

1.A home health manager, previously the informal family caregiver, would be designated for each extended family.

2.Health insurance would cover nearly all Americans, and a medical information highway constructed around the patient, with caregivers integrated in, would support knowledge transfer.

3.The majority of prevention, behavioral modification, monitoring and treatment of chronic diseases would take place at home.

4.Physician-led, nurse-directed virtual health networks of home health managers would serve as community-based, 24/7, educational and emotional support teams.

5.Health care insurance premiums for families would decline due to expert performance of the home health manager, as reflected in outcome measures of family members.

6.Basic diagnostics, including blood work, imaging, vital signs, and therapeutics would be performed by the home health managers and transmitted electronically to the physician-led, nurse-directed educational network, which provides feedback, coaching, and treatment options as necessary.

7.Sophisticated customized behavioral modification tools, age adjusted for each individual, and funded in part by diagnostic and therapeutic companies that have benefited from expansion of insurance coverage and health markets, would become available.

8.Primary care office capacity would grow as nursing scope of practice expands and doctors apply their advanced knowledge, skills and leadership most effectively.  Most care would not require a visit. Physician reimbursement would  increase in acknowledgment of roles in managing clinical and educational teams and multigenerational complexity. Nursing school enrollment in all bachelor RN programs would increase in support of expanded and appropriate clinical roles as educational directors.

9.Family nutrition would be carefully planned and executed; activity levels of all five generations rise; weight goes down; cognition goes up; mental and physical well being are also up.

10.Hospitals continue to right size – they’re more specialized and safer, with better outcomes. And scientific advances have allowed customized and personalized early diagnosis and more effective treatment, making the need for hospitalization increasingly rare.


1. Forrester Research, “Healthcare Unbound: Early Self Pay Market,” July,1,2005,

2. House Research Group, Department of Architecture. Massachusetts Institute of Technology,

3. Center for Future Health. University of Rochester Medical Center,

4. B. Spice, “Enhancing Quality of Life —and Saving Billions,” Carnegie Mellon Today, December 2006,

5. M.E. Pollack, “Assisted Technology for Cognition” and “Constraint-Based Temporal Reasoning,” University of Michigan,

6. E. Dishman, “Inventing Wellness Systems for Aging in Place,” Computer. no 37 (2004):31-34.

7. D. Yach,et al., The Global Burden of Chronic Diseases: Overcoming Impediments to Prevention and Control, JAMA, no. 291, (2004):2616-2622.

8. M. Magee, The Re-Emergence of Home Health Care: A Holistic Response to Aging and Consumer Empowerment in Medicine of the Person. Chapter 13 in J Cox, Campbell AV and Fulford (eds). Medicine of the Person: Faith, Science and Values in Health Care Provision, (United Kingdom: Jessica Kingsley Publishers, 2006).

9. M. Magee, Home-Centered Health Care: The Populist Transformation of the American Health Care System. (New York: Spencer Books. 2007).

10. Personal Medical Home Tops Agenda for AAFP, Wellpoint Meeting, 20 December 2006,

11. R.B. Doherty, ACP Observer, “Can the medical home model solve health care’s woes?” American Academy of Family Physicians. 20 December 2006,

12. D. Nash, M.P. Manfredi, B. Bozarth, S. Howell, Connecting with the New Health Care Consumer, (New York: McGraw-Hill Publishing Co,2000).

13. Expert Panel, “Personal Health Records and Electronic Health Records: Navigating the Intersection,” American Medical Informatics Association, Bethesda, MD, 28-29, September, 2006.

14. M. Magee, “Qualities of enduring cross-sector partnerships in public health.” American Journal of Surgeons. No.185(2003):26-29 Sector Collaborations.pdf

Vision III: Reconnecting The Family

Aging Equals Complexity

The most pressing health demographic in the U.S. and worldwide is aging and its associated chronic burden of disease. This is not news. We have seen it coming and tried to plan for it. For decades our training schools, hospitals, certifications, insurance industry, housing industry, legal system, long term care providers and elder advocacy associations have focused on our aging populations and their unique needs and vulnerabilities.

Segmentation as a Strategy No Longer Works

In the process of appropriate focus, over a period of time, we have segmented off the over 65’s and the over 85’s from the rest of the human population. (1) This may have been appropriate in the early years, but today it hampers strategic health planning, resource allocation, and system wide organization of informal and formal family caregivers. One of the greatest challenges and opportunities in health reform today is the leveraging of virtual networks and wireless Internet technologies to reconnect the family and redefine the meaning of community. While Robert Putnam was writing “Bowling Alone” and lamenting what he perceived to be a decline in American community linkages as indicated by decreases in enrollment in bowling leagues in the 80’s and 90’s, other innovative sociologists, younger and tuned in to the web, saw a very different set of data points. (2) They saw social capital on a steep incline with nearly all the gains the result of virtual networks. (3) The question for health reformists then was “Could this be applied efficiently to reconnect an American health care system that had been deliberately sliced and diced, and segregated into self isolated professional silos?”

Rather then segment off any portion of the American family, we must now use technology and social networking to aggressively reconnect the generations to manage modern family complexity, mobility, health data and the distribution of responsibility in response as we move toward the provision of universal health care.

Today 50% of our country’s 60 year old’s have a parent alive. This means that the 4-generation family – grandparent, parent, child, grandchild – is rapidly supplanting the 3-generation family. By 2050 there will be over 1 million Americans over 100 years of age. That means that the 5-generation family – great-grandparent, grandparent, parent, child, grandchild – will have fully arrived. The challenge for our system is not simply numbers but also complexity, which is significantly more demanding when dealing with families that are four and five generations deep. (1)

Five Strategic Problems With Segmentation

A segmented approach, as numbers grow, becomes increasingly problematic. For one thing, it pits one generation against another in a “civil war of health financing”. Absent coordinated efficiencies, this creates a downward cycle with all roads leading to health rationing.

A second problem with generational segmentation is that it traps family learning’s and health traditions in multiple intergenerational divides. For example, the 58 year old 3rd generation mother caring for her 4th generation 82 year old mother with a fragile fracture from osteoporosis, should ideally not only be a rich source of caring (if properly supported and integrated into the health care system) but also a wise source of health information. While she is focusing on her mother’s independence, dignity and pain control, she should also be asking herself “How can I avoid becoming vulnerable to the same disease as my mother?” Her research and responses to questions of her doctors and other caregivers should tell her that silent osteoporosis exists in 52% of 3rd generation women by age 50, which is to say, she herself is vulnerable and should have a bone scan.  It should also make her aware of her own 27 year old daughter’s vulnerability since 98% of a women’s skeleton is formed by age 20. And it should also bring her 5 year old granddaughter’s activities into sharp relief since diet, exercise and health behaviors in these early years determine whether this 1st generation family member’s skeleton will be in good shape 15 years from now. Thus in a enlightened connected multi-generational family committed to each other’s health and well being, health learnings should continually and seamlessly flow down the intergenerational ladder, with the goal of constantly shrinking the entire family’s future disease burden.

A third problem inherent with a segmented family care system is that it traps informal family caregivers in a cavern of social isolation. Nearly 25% of American families have an informal family caregiver in place. Over 80% of these are family members and the vast majority are 3rd generation women, age 45 to 65. They currently labor in isolation without any formal and consistent structural, emotional or financial support. Twenty one percent of those with full time jobs resign their posts to manage the complex physical and psychological demands of their new responsibilities. If their parent has dementia, over 40% in one study are clinically depressed themselves. Many ignore their own health and become ill during this period. Some die before those for whom they are caring. They are disconnected from the formal care team and from other informal family caregivers who struggle in isolation themselves. Finally, they are often disconnected from their siblings and from children and grandchildren as the chaos, depression and complexity overwhelm them. (4)

A fourth problem associated with the artificial health segmentation of the American family is that it blocks early computer-assisted, health planning which is essential in a preventive health care system. Early planning is required to move us from intervention to prevention, and propel us ahead of the disease curve by customizing and personalizing care delivery. Academics have reinforced this point from many different angles, and highlighted the opportunity that new information technologies offer.

Dr. Edward Zigler, one of the true pioneers of Early Childhood Development, one of the founding fathers of Head Start and author of “The First Three Years and Beyond,” (5) recently made these observations at an event to honor parents, doctors and nurses involved in supporting economically disadvantaged mothers with nurturing home care services:

“For anyone who wants to know the literature, there is one really good book, probably the best book in human health in the past quarter of a century by Jack Shonkoff and Deborah Phillips titled ‘From Neurons To Neighboorhoods’. (6) The book describes among other subjects, the literature in support of early interventions that impact a baby’s brain development. Now this development, this recognition of brain plasticity, has not gone unnoticed by decision makers. The early brain research made clear that delaying interventions for poor children to Head Start beginning at age three was waiting too long. One of the interesting findings – they now have done randomized assigned outcome studies on the Early Head Start program – is that, lo and behold, the earlier you get there, particularly if you get there at pregnancy or shortly thereafter, the earlier you get to the child, the better your outcomes from the program.” (7)

Well-known medical educator and health transformer, Dr. Ralph Snyderman, Chancellor Emeritus at Duke University and head of the Duke Center for Research on Prospective Health Care recently published a classic article titled “Proposal for a new health record to support personalized, predictive, preventative and participatory medicine”, The paper challenges us all with these words, “Today’s approach to patient care and the medical record that directs and documents it is largely focused on identifying and treating the patients disease. This has resulted in a sporadic, reactive healthcare system. Shifting medicine’s focus to personalized strategic health planning will require a new approach to the patient ‘work-up’, a new relationship between the patient and the provider and a new medical record to support it.” (8)

Dr. Patricia Flatley Brennan, visionary health care leader who runs the Health Systems Lab,(9) a collaborative effort of the School of Engineering and the School of Nursing at the University of Wisconsin-Madison. Way back in 1991, seventeen years ago, Dr. Brennan published a paper called “ComputerLink: electronic support for the home caregiver.” In it, she and co-authors stated that, “Computers have become ubiquitous in contemporary society, as has the demand for home care for the elderly. Caregiving is recognized as a normal experience across the life span, and nurses must develop innovative responses to support caregivers. Computer networks offer caregivers access to a wide range of services such as communication, information, and decision support.” (10)

A fifth and final argument for family connectivity is that it allows us to better define the human resource needs for a modern health care team; better assign appropriate care teams and utilize these human resources with an eye toward multi-use for cross-generational assessments and services; and enables a more informed application of unique community resources to fill in the gaps where they exist.

Time To Get It Together

If there  was ever a time for Nursing and Medicine and Early Childhood Development leaders to join hands on behalf of patients, it’s now. And there is no better place to convene the gathering then in the American Home, and no better cause then the creation of a coordinate health system featuring intergenerational connectivity, multi-generational health planning and holistic health support. The concepts of Home Centered Health Care Transformation, Lifespan Planning Records, and the critical role that nurturing from zero to three plays in early brain development must now become cross-disciplinary and rapidly gain steam.

When virtual health networks first appeared, clinical visionaries at the time imagined an age of “telemedicine”. Dreamers thought the most pressing application would be to connecting knowledge and skills in developed nations with pressing needs in the developing world. In reality, we now understand that the true promise of innovative hardware and software combined with pervasive broadband and wireless networking is not somewhere around the world, but in our own backyards.

By reconnecting the multigenerational American family, we can plan more efficiently for health and integrate community resources. We can apply the learning’s in one generation to the benefit of other generations downstream while encouraging family caregiving to flow back up the generational ladder. We can most efficiently utilize a multi-purposed health workforce. These actions in turn make it possible to afford wellness and  prevention while maintaining our scientific and technologic progress.


1.Alliance for Aging Research. “Medical Never-Never Land: Ten Reasons Why America Is Not Ready For the Coming Age Boom.” February 2002.

2. Putnam R. Bowling Alone. 2000,

3. Magee, Marc. Civic Participation and Social Capital: A Social Network Analysis in Two American Counties, in “Social Capital: an International Research Program”. Oxford University Press. 2008.

4. Magee M. Connecting Healthy Homes To A Preventive Health Care System. Harvard Health Policy Review. Fall, 2007.

5. Zigler et al. The First Three Years and Beyond.

6. Shonkoff JP et al. From Neurons To Neighborhoods.

7. Personal Communication. New York City. October 23, 2007

8. Snyderman R and Yoediono Z. Proposal for a new health record to support personalized, predictive, preventative and participatory medicine January 2008, Vol. 5, No. 1, Pages 47-54 , DOI 10.2217/17410541.5.1.47 (doi:10.2217/17410541.5.1.47)

9. Breenan P. Health Systems Lab, University of Wisconsin.

10. Brennan PF et al. ComputerLink: electronic support for the home caregiver. ANS Adv Nurs Sci. 1991 Jun;13(4):14-27.

Vision IV: Techmanity

Medicine and Technology

Back in 1983, Dr. John A. Benson, Jr., then President of the Board of Internal Medicine, voiced these words when questioned about technology’s impact on the patient-physician relationship. ”There is a groundswell in American medicine, this desire to encourage more ethical and humanistic concerns in physicians. After the technological progress that medicine made in the 60’s and 70’s, this is a swing of the pendulum back to the fact that we are doctors, and that we can do a lot better than we are doing now.” (1) He accurately described the mood then, and for most of the 20th century, of clinicians toward technology, a complex love-hate relationship that has rejoiced and cheered on progress, while struggling to accept and master change in a manner that would avoid driving a wedge between them and their patients. (2)

It is fair to say that, as the health consumer movement has matured over the past 25 years, and physicians have moved away from paternalism to partnerships and team based approaches to care, that outright resistance and abject fear of technology has progressed to and beyond grudging acceptance. In part the people, and the people caring for the people have developed computer skills together, pursued broadband and wireless connectivity together, and discovered the value of personalized and customized computer search engines together.

Medical Informatics Meets Consumers

As this has occurred the specialty of Medical Informatics has risen to legitimacy within the Medical hierarchy, and its leaders have reinforced the need to advantage technology and informatics in support of humanistic care. (2) One such voice is that of Warner V. Slack, who heads the Center for Clinical Computing at Harvard Medical School. No “Johnny-come-lately” to the field, his first published paper in Medical Computing appeared in the New England Journal of Medicine in 1966. (3) His book, Cybermedicine: How Computing Empowers Doctors and Patients for Better Health Care, is considered a classic, and argues, as Health Informatics expert Kevin Kawamoto, from the University of Washington has said  “Computers can be mutually beneficial for both the patient and the health care provider”. (4)

If we have managed to move as caregivers from resistance to acceptance of technology in health care, we have not moved far enough. The technology sub-committee for the National Commission for Quality Long Term Care states: “In embracing technology in Medicine, we must view it as both assistive and transformational.” (5)

Ignoring Geography

The revolutionary strength of modern information and scientific technologies is that they ignore geography. In so doing they allow us to reorient and connect beyond the limits of a range of barriers whether they be physical, social, financial or political. The danger is not in over-reaching but in under-reaching. Our vision must be sufficiently forward looking and expansive to challenge technology innovators. Where are the “killer applications” that would allow lifespan planning to move us ahead of the disease curve? How can we target technologic advances in health to first reach our citizens most at risk? How do we, in powering the health technology revolution, broaden our social contract to include universal health insurance? How do we unite the technology, entertainment, and financial sectors (previously locked out of the health care space) with the traditional health care power players, and incentivize them to work together to create a truly preventive and holistic health delivery system that is equitable, just, efficient, and uniformly reliable? How can each citizen play a role in ongoing research and innovation, and help define lifelong learning and behavioral modification as part of good citizenship? What can corporate America do to advance health information infrastructure and in “doing good,” do well financially, serving Main Street as it serves Wall Street?

Moving Beyond Acceptance

Health Information leaders of the 21st century need to be more revolutionary. Were they to achieve at their full capacity, our health care system would transform and re-center around relationship-based care, cementing the people to the people caring for the people. If we were to do that we would see improvement on 10 different fronts simultaneously: access, efficiency, team care coordination, multi-generational family linkages, inclusion of informal family care givers in the health care team, targeted interventions for vulnerable populations, informed mutual decision making, lifespan health planning, evidenced based personalized care, and palpable presence of physicians, nurses and care team members in the home.
Paul Dinsmore, in the AMA Book of Project Management said, ” … designed properly…technology can be a great gift to humanity.”(6)

We no longer can afford to simply accept technology. We must embrace techmanity for all it is worth.


1. Nelson, B. Can Doctors Learn Warmth? New York Times. September 13, 1983.

2. Shortliffe, EH. Doctors, Patients and Computers: Will Information Technology Dehumanize Health Care Delivery? Journal of the American Philosophical Society. November 12, 1992. Vol. 137 (3): 390-398.

3. Warren V. Slack Bibliography.

4. Kawamoto, K. Computer Technology in Health Care Settings. The Journal of Education, Community, and Values. May-June, 2003.

5. Magee, M. Fully Leveraging Technology to Transform Health Care. Technology Sub-Committee, NCQLTC.

6.Dinsmore, Paul C. and Jeanette Cabinis-Brewin, Eds.  AMA Handbook of Project Management,

Vision V: Lifespan Planning Record

Powering The Vision

If we allow ourselves to dream of a better health care system — one that permits us to feel connected, supported, and in control of our own health destiny — two words come to mind: information and planning.

The more information we have about our own health history and genetic profile, the smarter we can be about making health decisions and planning our health future. This requires a constantly available “record” of our changing health status. But if you switch doctors or go to a hospital for surgery, you’ll find that our nation’s health records are not even close to this ideal. They are splintered and poorly organized at best.

To their credit, doctors and hospitals have been trying to create a coordinated system of electronic records – but it falls far short of what we need. The real key to our health information future is a concept called a “Lifespan Planning Record.” This computer-based and integrated model would provide a holistic view of your health – stretching all the way back to your ancestors and projecting far forward into your future – so you will know what you can anticipate as your body ages. It helps define health as much more than the absence of illness. It’s about life fulfillment.

With Lifespan Planning, we can start to concentrate on preventive activities in health – which is just about all that the experts say must happen if we are to fix our broken health care system. It will also make our health care system safer because the information we use will be more reliable. Don Detmer, President of the American Medical Informatics Association, said it best: “Significant improvements in health care safety and quality will not be achieved for Americans without robust, secure electronic health records within a national health information infrastructure.”1

Making It Happen

Implementing Lifespan Planning Records won’t be easy. As you can imagine, there are large technological and logistical hurdles. But we can at least start to sort out what some of the issues are. Let’s have a look.

The first thing you should know is that some of health care’s most important players are spending significant time on the question of record-keeping — from the American Medical Informatics Association to The Robert Wood Johnson Foundation to the Agency for Healthcare Research and Quality.2

Much of the challenge for groups like these is in determining how to build a system around what is, essentially, a moving target. Which parts of the plan should be derived from technology of the present, technology of the future, and technology from the distant future?

To adequately address those questions, let’s look at the trends. First, longer life spans are moving us from three generation families to four and five generation families – with more complicated health management needs.3 Second, the health consumer movement is in full swing, with consumers carving out a more empowered role and demanding reform.4 And third, information technology is advancing to provide new linkages between patient and caregiver and mind-boggling possibilities for data storage and exchange.5

As these trends intersect, they are rapidly changing the very drawing board that is being used to plan for a new national health record system. Over the last decade, the discussion about health care records has focused on electronic medical records — or EMRs — and aspired to improve accuracy and efficiency by converting paper-based systems used by doctors, nurses and hospitals to electronic formats.6 That’s a worthy goal. But as leaders diligently began this conversion, the environment began to shift under foot – thanks largely to our three intersecting trends.

In fact, by 2005 it had become quite clear to many leaders in the field that “The Record” properly resided with the patient from whom health data emerged, and that the data that flowed through the hands of hospitals, doctors and nurses was only a part of the overall picture. Thus the concept of a “Personal Health Record” is gradually subsuming the vision of an Electronic Medical Record.7

This is a good development. The Personal Health Record combines data, knowledge and software tools, which help patients become participants in their health care. But if we are truly to anticipate where health care trends are taking us, even this is not enough.

An Integrated Long-Term Plan

It is now clear that in a truly preventive system, “health” is not a collection of late-stage, reactive interventions. That kind of thinking will soon be a relic of the past.8 Rather, health should be defined as a life fully lived – hopeful, productive, fulfilling, rewarding and manageable. The determinants of such a life begin before birth, embedded in the healthful behaviors of ones’ future parents, and they extend beyond death to ones’ survivors.

Considering this broader view of health, the right concept for our health record system should be a Lifespan Planning Record — or LPR. The LPR for a single individual born today could extend out at least 120 years. It would include all of the baseline medical information needed by patients, and much more. It would consider economic, social, educational, and spiritual goals and milestones as well as medical and scientific objectives.

Born today, the newborn child’s plan would already be inhabited with a great deal of data. Some reasonable compilation of the records of parents, grandparents and siblings would be represented. Future diagnostic and preventive therapeutic measures, based on familial information, would be flagged on the timeline. Print, video and graphic information from other accessible intelligence databases would be seamlessly interwoven for easy use by the people caring for each other and this new global citizen.

As time passes, this “Living Record” would flexibly grow and adjust to assist informed decision making, preventive behavior and full and complete human development.9 Where will the knowledge come from? Patients, obviously, will need to contribute to the personal side of the record. On the health and science side it will emerge from three electronic data sources: the Clinical Research Data space, the Continuing Professional Development data space, and the Continuing Consumer Education data space. These data sources will desegregate and converge to allow integrated use of the information they contain, by the people, the people caring for the people, and investigators searching for new solutions to today’s unresolved problems.10

Obviously, many issues will need to be sorted out – not the least of which are confidentiality, patient privacy, and control over records. But the bottom line is that as quickly as the Electronic Medical Record is being subsumed by the Personal Health Record, the Personal Health Record is now being subsumed by the need for a Lifespan Planning Record – because that’s the best way to move us toward a preventive care system.


1.Detmer DE. “Getting to a ‘Smarter’ Health Information System: Legislative Proposals to Promote the Adoption of Electronic Health Records (EHRs).” Testimony Before the Committee on Energy and Commerce, Subcommittee on Health. March 16, 2006.

2.Expert Panel. “Personal Health Records and Electronic Health Records: Navigating the Intersection.” Bethesda, Maryland. September 28-29, 2006.

3.Alliance for Aging Research. “Medical Never-Never Land: Ten Reasons Why America Is Not Ready For the Coming Age Boom.” February 2002. Available at:

4.Nash D, Manfredi MP, Bozarth B, Howell S. Connecting with the New Health Care Consumer. McGraw-Hill Publishing Co; 1st edition (January 15, 2000). New York.

5.Dishman E. Inventing Wireless Systems for Aging in Place. Computer. 2004;37:31-34.

6.Hillestad R. Can Electronic Medical Record Systems Transform Health Care? Health Affairs. 2005;24”1103-1117.

7.Tang PC, Ash JS, Bates DW, Overage JM, Sands DZ. Personal Health Records: Definitions, Benefits, and Strategies for Overcoming Barriers to Adoption. J Am Med Inform Assoc. 2006;13:121-126.

8. Magee M. Health Politics: Power, Populism and Health. Spencer Books. 2005. New York.

9. Magee M. The Re-Emergence of Home Health Care: A Holistic Response to Aging and Consumer Empowerment in Medicine of the Person. John Cox. Alastair V Campbell and Bill Fulford (eds). Jessica Kingsley Publishers, UK.

10. Magee M. “Turning Silos to Vapor: How the New Health Populism Will Transform Medicine as We Know It.” Speech to the American Medical Association Presidents’ Forum. March 12, 2006. Washington DC.

Vision VI: Collapsing Databases

Three Databases Going Virtual

Three enormous health databases are in the process of going virtual or electronic. The first of these is the Clinical Research Database or CRD. On the back end of the Vioxx withdrawal, conflict of interest concerns, and legitimate health consumer desires for early access to discovery information, major research databases are moving toward open transparency. For better or worse, the public will soon have ready access to the vast majority of positive and negative results of studies at the time of completion. These results will be electronic and readily transferable, far and wide. (1,2)

The second database is the Continuing Medical Education or CME database. It, too, is going electronic. In fact, projections are that 50% of all U.S. CME will be electronic by 2016, and eCME has been demonstrated to be effective. It is likely that within ten years, the vast majority of CME will be virtual and will be applied in real time rather than in episodic segments. Handheld devices are increasingly standard medical equipment in caring encounters, providing immediate database support to the patient/physician relationship during the evaluative and joint decision making process. This allows experts to quite confidently predict that in a preventive health care system where information is overwhelmingly the dominant health care product, CME will be inter-changeable and indecipherable from the care itself. (3)

And this brings us to the third database, CCE or Continuing Consumer Education. The consumer movement continues to evolve from educational empowerment to active engagement and inclusion in the health care team. 80% of Internet users in 2010 accessed health information on the web. (4) Patients and their families will increasingly demand access to the same hand-held hardware and information software that the other care team members are using. This will help avoid any confusion that might arise from multitracked information and accelerate the need for simple and well- designed educational products. By using the same devices and educational platforms, issues of standards and problems of incompatibility that might compromise the primary “home to care team to home” loop will melt away.

Two Translation Gaps

Three large growing databases – CRD, CME, CCE – have gone virtual and are widely accessible. What remains are two translation gaps. (5) The first is between CRD and CME, and it ensures that discoveries will take many years to penetrate and inform clinical practice. If, for example, a study reveals that it is safer and better for mother and child to provide epidural anesthesia at 2 cm rather than 5 cm dilation, and that doing so not only does not increase Csection rates but ensures safer, more comfortable labor and better Apgar scores for the baby, under our past system, this knowledge transfer to practice would be a multiyear affair. With virtual CRD and CME, there exists the ability to collapse those databases upon each other and almost immediately affect practice behavior changes coincident with a new discovery.

If CRD and CME will collapse upon each other, CME and CCE will in many ways become one and the same. Thus, the frantic efforts to develop Personal Health Records on the one hand and Electronic Medical Records on the other are already raising entrepreneurial eyebrows. Are these not, after all, one and the same? Does not all clinical data originate with the people? Do they not loan this data to the people in whom they have the greatest trust and confidence – their physicians, nurses, and other caregivers? And if our records are one and the same, should we not also use the same informational resources to support our joint decision-making? Wouldn’t this be the best way to help us stay on the same page and avoid any chance of miscalculation, misinformation, or mistake?

Information Domination

As we move from intervention to prevention, health care will be information dominated product or service, and this product will be anchored by three massive, collapsing databases – discovery (CRD), medical (CME) and consumer (CCE) – with primary ownership residing where the data originated, with the people, and provided primarily to the people caring for the people.

Killer applications that allow health care to move from intervention to prevention to strategic health planning will emerge on the consumer side with health care professionals moving toward the people to support confidence, trust and relationship building. By utilizing the same software, information will double connect the people to the people caring for the people, rather then serving as a double check on each other.


1. Greener M. Drug Safety On Trial. EMBO Reports. 2005.

2. PhRMA Statement Supporting Enhanced Transparency. Aug. 2, 2010

3. Harris JM. The growth, characteristics, and future of online CME. The Journal of Continuing Education in The Health Professions

4. Fox S. Health Digital Divide. Pew Research Center. Feb. 1, 2011.

5. Haynes B and Haines A. Getting research findings into practice: Barriers and bridges to evidence based clinical practice. BMJ 1998; 317: 273,1998

Vision VII: The Planetary Patient

Pursuing Potential

If health is defined today as the capacity to reach one’s full human potential, our environment – including the quality and availablility of water, air, soil, and plant and animal life are critical determinants of human health. For too long health professionals have considered the planetary patient as beyond their domain. In reality, it is the health of this patient that provides the basis for all other health endeavors. In embracing and caring for this “patient”, we learn that integrated solutions, forward thinking, wise prioritization and investment, and careful governance are essential to the future well being of our human population. In caring for the planet, we are instructed and guided on how best to care for each other. But in reality, improving the health of our planetary patient requires changes in human behavior. Changing behavior is both a function of the message and the messenger. And studies consistently affirm that their is are no more powerful messengers in society – when it comes confidence and trust – then physicians and nurses. We must ask ourselves then, how much progress could be made if care professionals were fully educated and engaged in environmental health and applied the social capital of their relationship with the people to fuel societal behavioral change?

Consider Water

There is no better example of this principle then water. In the vastness of the planets’ oceans and the pureness of its rivers lies the very basis of life itself,”1 states a United Nations healthy waters study. One might think, since 70 percent of the earth is covered by water, why should we worry about running out of it? Here are the facts: 97 percent of the earth’s water is salt water. Only 3 percent is pure and most of that is trapped in glaciers, icebergs and snow. Only 1 percent of the earth’s water is both fresh and available either on the surface or in underground aquifers.2

As Dr. Kerstin Leitner of the World Health Organization has noted, “We’re not running out of water; we’re running out of fresh water.”3 Why is this the case? Let’s start from the beginning. Human beings are critically dependent on water for life. Seventy percent of the human body is water. An average human consumes 2.3 liters of water a day – a half a liter goes to sweat, .3 liters is released through respiration, and 1.5 liters is excreted as waste. If we lose 1 percent of water, we become thirsty. If we lose 5 percent, a mild fever develops. Lose 10 percent, we’re immobilized. And if we lose 12 percent, we die.2

As critical as water is to life itself, one-sixth of the planet’s human population, some 1.1 billion people, lack reliable access to clean water.4,5 The source points of all water are complex, interdependent, and fragile. The oceans’ seawater is 80 times as dense as air and provides many species with complete support, including nutrition and reproductive needs. The oceans support the growth of 50 billion tons of living creatures per year. They deliver 90 million metric tons of fish to humans each year. They also annually absorb 8 billion tons of carbon dioxide, acting as a safeguard against global warming. The sea provides a secure environment for biologic cells, it’s a chemical buffer, a good solvent, and a barrier against severe external temperature gradients.6

Feeding the oceans are streams, river basins, lakes and wetlands, which join together to form hundreds of distinct watersheds. These networks cover 45 percent of the Earth’s land and nourish locations that support 60 percent of our global population. The coexistence of these watersheds and human populations has created growing challenges. 261 of these watersheds cross two or more countries’ jurisdictional boundaries. The Nile crosses nine countries; the Danube 13; and the Mississippi passes through 31 states.1,6,7 Poor management and policy upstream invariably means trouble downstream. Raw sewage, pollutants from unregulated industry, poor land management, and agricultural runoff all contribute, at times irreversibly, to the growing water crisis.4

Between mountaintop and sea, water suffers at every turn. To begin with, 40 percent of the world’s population, some 2.5 billion people, lack access to proper sanitation. In Bangladesh, 60 percent have no access to bathrooms.2 Human waste, joined by agricultural and industrial waste, easily finds its way into surface and underground water. With pollution comes disease, accessed through unhealthy behaviors. For example, in Varanasi, India, a sacred site on the Ganges River, 60,000 people bathe in the polluted waters each day.2 Infected water and lack of public health education both contribute to 4 billion cases of diarrhea a year worldwide, which results in 2.2 million deaths, mostly among young children. In fact, these deaths represent approximately 15 percent of all deaths of children under five in developing countries.5

While demand for fresh water is increasing, our limited supply is further diminished by waste and ignorance. The World Health Organization standards state that 75 liters of water per day is necessary to protect against household disease, and 50 liters is necessary for basic sanitation.4 But individual consumption around the world varies widely. A member of the Masai tribe in Africa survives on approximately 4 liters per day, while a typical resident of Los Angeles uses 500 liters per day.2

But individuals are small consumers compared to agriculture. Farmers use 70 percent of all fresh water. Using standard irrigation, 50 percent never gets to the roots of plants. With newer drip technologies, 90 percent is well utilized. Increasingly, we will have to think of food in water terms. For example, a typical ton of wheat is really 1,000 tons of water with sun and soil thrown in. 4Industry is the next largest water consumer. Yet, only 10 percent of the water that industries use actually ends up in products. Ninety percent is discarded, often permanently fouled and on its way downstream.2

On the demand side, the world’s population of more than 6 billion is due to double by 2050. And the imbalance of supply and demand for water is especially acute in certain regions. For example, the Middle East has only .9 percent of the Earth’s fresh water but 5 percent of the world’s population. By 2020, more than 50 nations will have severe water shortages, and by 2025, more than a dozen nations will face a severe need for water from a hostile neighbor.2

Ensuring healthy waters requires wise policy and grassroots activation of health care and governmental leaders. The Aral Sea debacle is a useful cautionary tale. In the 1950s, Khrushchev diverted two Russian rivers to supply profitable cotton fields in the region. Using open-ditch irrigation, 80 percent of the water was lost to evaporation and seepage. Over the next few decades, the Aral Sea shrunk to half its size, salinity rose, and fish died. Sixty thousand citizens living off the sea were impacted immediately. With the passage of time, dust from the sea’s contaminated seabed, picked up by winds, spread across the globe, was ingested by penguins in the Antarctic, and deposited on Himalayan peaks where the salt caused early melting of snow. One ill-advised policy choice created a lasting negative impact around the world.2,8

Integration with Energy and Global Warming

Water policy is also inseparable from management of global warming and the pursuit of energy independence. In a 2006 EPA webinar, Don Elder, water expert and President of the River Network said, “Only the healthiest watersheds will be resilient enough to support the full range of life in the face of climate change…The 2007 Intergovernmental Panel on Climate Change predicts a 4 to 5 degree rise in temperature, and an 11 to 23 inch rise in sea levels by the end of the century.” 9,10 To water experts like Mr. Elder, climate change spells the worst of both worlds; more frequent and severe storms in the wet seasons, leading to floods and disasters, and more lengthy and profound droughts in the dry seasons. As Hurricane Katrina and the tsunami in Indonesia have made clear, human security in both the developing and developed world is fragile in the face of climate related water bourne disasters. Yet the solutions are within grasp if we take an integrated approach. Elder emphasizes that the fastest way to save energy is to save water. He says: “Saving energy by saving water beats ethanol by a mile because it doesn’t compete with food and has no carbon footprint; and beats new technology plans for carbon capture in energy plants because we know it will work, it’s ready to go and would save energy immediately. Saving energy by saving water will keep coal and oil in the ground, carbon out of the air, water in our streams, and money in our pockets.” 9,10

So water is energy. But will saving water be possible and how would we go about it? Experts says we’ll do it by conservation, efficiency and reuse. Conservation is a matter of adjusting our habits, and efficiency is about using new hardware. Neither adjusting habits, nor changing hardware, as it turns out, involves much hardship. Less than one third of the water we use needs to be pure. Said another way, two thirds of the water we consume is used to flush toilets, water lawns and the like. In the future, as we replace appliances and water systems, we’ll be going to systems that reuse and recycle. So for example the water you use to shower will be able to be used to flush a toilet. The water captured by your roof drains, instead of running off, will be available to water plants. The incentives to be smart about water use will increase. Think tiered pricing. Basic amounts will be priced low because water is a human right, essential for survival. Tier two will be priced higher for discretionary use, causing you to think conservation. Tier three will be priced much higher to discourage waste. Technology will help – like new toilets with a double flush to choose from- small flush for liquid, large flush for solid. 26% of the water used by the average American family goes down the toilet – literally. Rainwater harvest is beginning to appear, in homes and in buildings. The new Bank of America tower, on its ceiling footprint in New York City, captures 100% of rainwater and directs it inside for use. Home rain harvesting could meet 20% of home use consumption needs. 9,10

An Environmental Platform for Health Professionals

If the planetary patient is now a responsibility of physicians, nurses and other health care professionals, what are the cornerstones of care of this patient? First, we recognize that clean and accessible water, air and soil are fundamental human rights. Second,  efficiency and conservation of these limited resources is a shared responsibility of the people and the people caring for the people. Third, technology should be utilized to expand access and conserve resources. Fourth, these resources should be utilized as close to site as possible. Fifth, private and public resources must be applied in a sustained manner for technology, training, and infrastructure growth. Sixth, enforce wise integrated environmental health  policy. Seventh, focus special attention on agriculture and industrial consumption of natural resources. Finally, emphasize environmental education utilizing health sites and health professionals’ influence to accomplish meaningful behavioral change.7


1.Protecting International Waters: Sustaining Livelihoods. United Nations Development Programme. Available at:

2.Swanson P. Water: The Drop of Life. 2001. Northword Press, Minnetonka, Minnesota.

3.Leitner K. Personal communication, October 15, 2004.

4.Water for Health: WHO’s Guidelines for Drinking-Water Quality. Geneva, World Health Organization, 2004. Available at:

5.Global Water Supply and Sanitation Assessment 2000 Report. Geneva, World Health Organization, 2000.

6.Kenchington RA. Managing marine environments: an introduction to issues of sustainability, conservation, planning and implementation. In: Conserving marine environments: out of site out of mind. Pat Hutchings and Dan Lunney (eds.). 2003. Royal Zoological Society of New South Wales. Mosman, NSW Australia.

7.From Source Water to Drinking Water. Workshop Summary. Institute of Medicine, 2004.

8.Hidalgo L. Aral Sea poison dust danger. BBC News. February 18, 2000.

9.Don Elder named Clean Water Act Hero.

10.EPA. “Water, Energy and Climate Change”. Webinar. Don Elder.


Show Buttons
Hide Buttons