⏐ VOICES FROM THE PAST ⏐
Eliminating Racial and Ethnic Disparities in Health, SAAPHI Action Plan | Excerpted from November 12, 2000, Boston, Massachusetts; SAAPHI Annual Meeting: “From Information to Action: Prospects for Eliminating Health Disparities in African-Americans.”
CURRENT HEALTH DISPARITIES of racial/ethnic minority populations are rooted in the sociopolitical and economic history of the American society.1,2 Currently, racial/ethnic minorities in the US suffer substantially and disproportionately from adverse health conditions and have inadequate access to quality health care services, particularly African-Americans, as described in detail in Healthy People 2010.3 Over the years in the US, there have been efforts to reduce racial/ethnic disparities in health through national policy.3,4 Some of these efforts to reduce racial/ ethnic disparities in health outcomes successfully improved the nation’s health during the 20th century as evidenced by overall reductions in deaths from coronary heart disease and stroke, an increase in the number of healthy mothers and babies (e.g., in 1997 an all-time low infant mortality rate of 7.2 deaths per 1000 live births), and elimination or near elimination of a number of vaccine-preventable diseases of childhood (e.g., in 1996, 90% of young children were vaccinated with the most critical vaccines).3,5–12 The 20th century achievements resulted from efforts to reach all Americans through a variety of policies that focused on legislation, regulation,
2070 | Voices From the Past | Hasson et al.
research, and education; a voluntary change in personal lifestyles; and population-wide policies and programs that also targeted highrisk groups, including racial and ethnic minority populations.5–18 Lessons learned from 20th century achievements, particularly childhood immunizations, suggest that the following 8 activities, especially if taken together as a strategy would be effective in eliminating certain disparities in health: setting a national priority; adopting not only long-term goals but interim goals (e.g., annual or biennial); providing sufficient funding for effective programs that are tied to accountability; regularly monitoring and evaluating progress toward goals at all levels of government and the community; providing financial incentives for achievement of goals; engaging the community by forming community partnerships and encouraging participation; expanding access to quality health care services; and optimizing health care services through performance monitoring, evaluation and feedback.1,4–26 Understanding that while the overall health of Americans improved during the 20th century, racial/ethnic disparities in health have persisted and even increased for certain health outcomes despite major advances in
public health, biotechnology, and economic prosperity and wealth.3,4,21,26 “Race”-associated differences in health outcomes are routinely documented in this country, but the basis of those differences remains poorly explained. “Race” is not a biological construct that reflects innate differences,19–25 but a social construct that precisely captures the social classification of people in a “race”-conscious society and, therefore, measures the impacts of racism.21 In response to the national call for action on eliminating racial/ ethnic disparities in health, the Society for the Analysis of African-American Public Health Issues (SAAPHI) has created the following action plan. SAAPHI, a related organization of APHA, is a research-focused national public health organization with the goal to improve the health of African-Americans through research, translation of science into policy and practice, dissemination of information, and training.
Objectives 1. Identify and promote effective interventions and programs for reducing racial/ethnic health disparities. 2. Encourage dialogue, research and intervention on racism as a fundamental cause of
American Journal of Public Health | November 2014, Vol 104, No. 11
⏐ VOICES FROM THE PAST ⏐
racial/ethnic disparities in health. 3. Work on social justice to also eliminate racial/ethnic disparities in education, housing, the criminal justice system, and other opportunities to enjoy the full privilege of American citizenry. 4. Ensure that we have data sources at the national, state, local, and community levels of organization such that we have complete data to understand the current and future health status of racial/ethnic minority populations and the impact of policy and practice on racial/ethnic minority populations.
Action Steps: Policy, Practice, and Advocacy 5. Urge the APHA, HHS and Congress to ensure that the current plan for targeting specific priority areas for elimination of racial/ethnic health disparities be continued, particularly in future administrations, and to expand funding to fully implement effective interventions for eliminating disparities. 6. Urge the APHA and HHS to provide a summary of effective strategies for eliminating health disparities to the public and to outline research needs for generating new strategies. 7. Engage the public health community to promote effective strategies through presentation, publication, and implementation. 8. Call on the APHA, President and the Congress of the US to endorse a National Campaign against racism. 9. Call on the APHA and Congress of the US to convene at least the Congressional Black Caucus Foundation and the National Medical Association along with the Institute of Medicine to prepare a report that summarizes current knowledge on the impacts of racism on health and
identifies points of intervention. 10. Call on the APHA and HHS to explicitly address racism as a part of its national Initiative to Eliminate Racial and Ethnic Disparities in Health. 11. Call on the APHA, Centers for Disease Control and Prevention, and National Institutes of Health to place a high priority on research on the impacts of racism on the health and well-being of the nation. 12. Call on the President and the Congress of the US to appropriate funds for investigating the impacts of racism on the health and well being of the nation. 13. Call on the President, the Congress, and the Judicial Branch of the US to recognize and promote legal redress for discrimination in health and health care. 14. Establish an African-American agenda for eliminating racial/ethnic health disparities.
Addressing the Impacts of Racism 15. Send a delegation to the International Racism Conference. 16. Join with Congress on health, law and medicine. 17. Establish a coalition that includes the medical doctors, businessmen, lawyers, public health workers, educators, psychologists, and community activists and organizations with the goal of developing and monitoring an agenda to eliminate racial and ethnic disparities in health.
References 1. Byrd WM, Clayton LA. An American Health Dilemma: A Medical history of African Americans and the Problem of Race, Beginnings to 1900. Vol 1. New York, NY: Routledge; 2000. 2. Byrd WM, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States: from 1900 to the Dawn of the New Millennium. Vol 2. New York: Routledge; 2000.
November 2014, Vol 104, No. 11 | American Journal of Public Health
3. Healthy People 2010: National Health and Promotion and Disease Prevention Objectives: conference edition in two volumes. Washington, DC: US Department of Health and Human Services; 2000. 4. Healthy People 2000: National Health Promotion and Disease Prevention. Objectives. Full report commentary. Washington, DC: US Department of Health and Human Services; 1991. 5. CDC. Ten great public health achievements, United States, 19001999. MMWR Morb Mortal Wkly Rep. 1999;48(12):241–243. 6. CDC. Decline in deaths from heart disease and stroke--United States, 19001999. MMWR Morb Mortal Wkly Rep. 1999;48(30):649–656. 7. CDC. Healthier mothers and babies. MMWR Morb Mortal Wkly Rep. 1999;48(38):849–858. 8. CDC. Impact of vaccines universally recommended for children, United States, 1900-1998. MMWR Morb Mortal Wkly Rep. 1999;48(12):243–248. 9. CDC. Motor-vehicle safety: a 20th century public health achievement. MMWR Morb Mortal Wkly Rep. 1999;48(18):369–374. 10. CDC. Vaccination coverage by race/ ethnicity and poverty level among children aged 19-35 months, United States,1997. MMWR Morb Mortal Wkly Rep. 1998;47(44):956–959. 11. CDC. January-December 1998: vaccination coverage by race/ethnicity. Available at: http//www.cdc.gov/nip/ coverage. 12. Bernier R, Orenstein W, Hutchins S. Do Vaccines Reach Those Who Most Need Them? West Sussex, England. 1994. 13. CDC. Improvements in workplace safety United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 1999;48(22):461–469. 14. CDC. Control of infectious diseases. MMWR Morb Mortal Wkly Rep. 1999;48(29):621–629. 15. CDC. Safer and healthier foods. MMWR Morb Mortal Wkly Rep. 1999;48(40):905–913. 16. CDC. Achievements in Public Health, 1900-1999. Fluoridation of drinking water to prevent dental caries. MMWR Morb Mortal Wkly Rep. 1999;48(41):933–940. 17. CDC. Tobacco use United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999;48(43):986–993. 18. CDC. Achievements in Public Health, 1900-1999. Family Planning. MMWR Morb Mortal Wkly Rep. 1999;48(47):1073–1080.
Hasson et al. | Voices From the Past | 2071
⏐ VOICES FROM THE PAST ⏐
19. Durch JS, Bailey LA, Stoto MA, eds; Committee on Using Performance Monitoring to Improve Community Health Improving Health in a Community: A Role for Performance Monitoring. Washington, DC: Institute of Medicine; 1997. 20. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Task Force on Community Preventive Services. Am J Prev Med. 2000;18(1 suppl):92–96. 21. CDC. Status report on the childhood immunization initiative: national, state and urban area vaccination coverage levels among children 19-35 months. United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(29):657–664. 22. CDC. Status report on the childhood immunization initiative: reported cases of selected vaccine preventable diseases. United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(29):665–671. 23. Dever GE. Improving Outcomes in Public Health Practice: Strategies and Methods. Gaithersburg, MD: Aspen Publishers Inc.; 1997. 24. Fairbrother G, Hanson KL, Freidman S, Butts GC. The impact of physician bonuses enhanced fees, and feedback on childhood immunization rates. Am J Public Health. 1999;89(2):171–175. 25. Lasker RD. Medicine and Public Health: the Power of Collaboration. New York: The New York Academy of Medicine; 1997. 26. Orenstein W. Overview of immunization. Paper presented at: 32nd National Immunization Conference Proceedings, 1998; Atlanta, GA.
The Society for the Analysis of AfricanAmerican Public Health Issues (SAAPHI) | Rebecca E. Hasson, PhD, Diane L. Rowley, MD, MPH, Cheryl Blackmore Prince, PhD, MPH, Camara P. Jones, MD, MPH, PhD, and William C. Jenkins, PhD, MA, MPH
IN 1990, A MEETING JOINTLY sponsored by the Black Caucus of Health Workers (BCHW), the American College of Epidemiology, and the Centers for Disease Control and Prevention assessed the underlying causes of health status and health disparities, and whether these were the result of race or racism. From this meeting, a group of primarily African American public health researchers decided to focus on health disparities as an issue and proceeded to carry out a number of analyses that focused on the true etiologic factors for health disparities. A number of articles were published, and one organization was formed to carry on this work: Society for the Analysis for African-American Public Health Issues (SAAPHI). We document the events leading up to the formation of SAAPHI and the contributions that this society and its membership have made toward improving the overall health of African Americans in the United States.
THE JOURNEY TO ESTABLISH SAAPHI The origins of SAAPHI can be traced back to 1971, when Jackie Kennedy, a biostatistician working at Howard University, invited a few young biostatisticians to lunch with two public health
2072 | Voices From the Past | Hasson et al.
stalwarts: Paul Cornely, former medical director of Howard University School of Medicine Freedmen’s Hospital and the first African American president of the American Public Health Association (APHA), and Hildrus Poindexter, Captain in the US Public Health Service and former Head of the Community Medicine Department. The conversation centered on efforts made over the three previous decades to improve the health status of African Americans, including developing an African American public health infrastructure. These conversations continued on a weekly basis and gave birth to the idea of creating several entities to improve the health of African Americans: (1) an African American school of public health, (2) an institute to help develop public health scientists, and (3) professional organizations comprising African Americans in public health. In the following years, the ideas continued to evolve and later became a reality through the establishment of the Coalition of Public Health Programs at Historically Black Colleges and Universities (HBCUs), which currently has Public Health Programs at nine HBCUs; and the Public Health Sciences Institute at Morehouse College, which has trained more than 300 students
in epidemiology and biostatistics, and more than 50% of African American doctoral students in this field. In 1985, the Report of the Secretary’s Task Force on Black & Minority Health, under the direction of Margaret Heckler, then Secretary of the US Department of Health and Human Services (HHS) was issued. The Task Force chair described this publication as a landmark effort in analyzing and synthesizing the present state of knowledge of the major factors that contributes to the health status of Blacks, Hispanics, Asian/Pacific Islanders, and Native Americans. It represented the first time the Department of Health and Human Services has consolidated minority health issues into one report. This report should serve not only as a standard resource for department wide strategy, but as the generating force for an accelerated national assault on the persistent health disparities. . . .
Margaret Heckler wrote that it was “the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track record of ever improving health.” An informal group of African American public health professionals, many of whom became founding members of SAAPHI, studied the findings from the report and committed to making health disparities
American Journal of Public Health | November 2014, Vol 104, No. 11
Eliminating Racial and Ethnic Disparities in Health, SAAPHI Action Plan | Excerpted from November 12, 2000, Boston, Massachusetts; SAAPHI Annual Meeting: “From Information to Action: Prospects for Eliminating Health Disparities in African-Americans.”
CURRENT HEALTH DISPARITIES of racial/ethnic minority populations are rooted in the sociopolitical and economic history of the American society.1,2 Currently, racial/ethnic minorities in the US suffer substantially and disproportionately from adverse health conditions and have inadequate access to quality health care services, particularly African-Americans, as described in detail in Healthy People 2010.3 Over the years in the US, there have been efforts to reduce racial/ethnic disparities in health through national policy.3,4 Some of these efforts to reduce racial/ ethnic disparities in health outcomes successfully improved the nation’s health during the 20th century as evidenced by overall reductions in deaths from coronary heart disease and stroke, an increase in the number of healthy mothers and babies (e.g., in 1997 an all-time low infant mortality rate of 7.2 deaths per 1000 live births), and elimination or near elimination of a number of vaccine-preventable diseases of childhood (e.g., in 1996, 90% of young children were vaccinated with the most critical vaccines).3,5–12 The 20th century achievements resulted from efforts to reach all Americans through a variety of policies that focused on legislation, regulation,
2070 | Voices From the Past | Hasson et al.
research, and education; a voluntary change in personal lifestyles; and population-wide policies and programs that also targeted highrisk groups, including racial and ethnic minority populations.5–18 Lessons learned from 20th century achievements, particularly childhood immunizations, suggest that the following 8 activities, especially if taken together as a strategy would be effective in eliminating certain disparities in health: setting a national priority; adopting not only long-term goals but interim goals (e.g., annual or biennial); providing sufficient funding for effective programs that are tied to accountability; regularly monitoring and evaluating progress toward goals at all levels of government and the community; providing financial incentives for achievement of goals; engaging the community by forming community partnerships and encouraging participation; expanding access to quality health care services; and optimizing health care services through performance monitoring, evaluation and feedback.1,4–26 Understanding that while the overall health of Americans improved during the 20th century, racial/ethnic disparities in health have persisted and even increased for certain health outcomes despite major advances in
public health, biotechnology, and economic prosperity and wealth.3,4,21,26 “Race”-associated differences in health outcomes are routinely documented in this country, but the basis of those differences remains poorly explained. “Race” is not a biological construct that reflects innate differences,19–25 but a social construct that precisely captures the social classification of people in a “race”-conscious society and, therefore, measures the impacts of racism.21 In response to the national call for action on eliminating racial/ ethnic disparities in health, the Society for the Analysis of African-American Public Health Issues (SAAPHI) has created the following action plan. SAAPHI, a related organization of APHA, is a research-focused national public health organization with the goal to improve the health of African-Americans through research, translation of science into policy and practice, dissemination of information, and training.
Objectives 1. Identify and promote effective interventions and programs for reducing racial/ethnic health disparities. 2. Encourage dialogue, research and intervention on racism as a fundamental cause of
American Journal of Public Health | November 2014, Vol 104, No. 11
⏐ VOICES FROM THE PAST ⏐
racial/ethnic disparities in health. 3. Work on social justice to also eliminate racial/ethnic disparities in education, housing, the criminal justice system, and other opportunities to enjoy the full privilege of American citizenry. 4. Ensure that we have data sources at the national, state, local, and community levels of organization such that we have complete data to understand the current and future health status of racial/ethnic minority populations and the impact of policy and practice on racial/ethnic minority populations.
Action Steps: Policy, Practice, and Advocacy 5. Urge the APHA, HHS and Congress to ensure that the current plan for targeting specific priority areas for elimination of racial/ethnic health disparities be continued, particularly in future administrations, and to expand funding to fully implement effective interventions for eliminating disparities. 6. Urge the APHA and HHS to provide a summary of effective strategies for eliminating health disparities to the public and to outline research needs for generating new strategies. 7. Engage the public health community to promote effective strategies through presentation, publication, and implementation. 8. Call on the APHA, President and the Congress of the US to endorse a National Campaign against racism. 9. Call on the APHA and Congress of the US to convene at least the Congressional Black Caucus Foundation and the National Medical Association along with the Institute of Medicine to prepare a report that summarizes current knowledge on the impacts of racism on health and
identifies points of intervention. 10. Call on the APHA and HHS to explicitly address racism as a part of its national Initiative to Eliminate Racial and Ethnic Disparities in Health. 11. Call on the APHA, Centers for Disease Control and Prevention, and National Institutes of Health to place a high priority on research on the impacts of racism on the health and well-being of the nation. 12. Call on the President and the Congress of the US to appropriate funds for investigating the impacts of racism on the health and well being of the nation. 13. Call on the President, the Congress, and the Judicial Branch of the US to recognize and promote legal redress for discrimination in health and health care. 14. Establish an African-American agenda for eliminating racial/ethnic health disparities.
Addressing the Impacts of Racism 15. Send a delegation to the International Racism Conference. 16. Join with Congress on health, law and medicine. 17. Establish a coalition that includes the medical doctors, businessmen, lawyers, public health workers, educators, psychologists, and community activists and organizations with the goal of developing and monitoring an agenda to eliminate racial and ethnic disparities in health.
References 1. Byrd WM, Clayton LA. An American Health Dilemma: A Medical history of African Americans and the Problem of Race, Beginnings to 1900. Vol 1. New York, NY: Routledge; 2000. 2. Byrd WM, Clayton LA. An American Health Dilemma: Race, Medicine, and Health Care in the United States: from 1900 to the Dawn of the New Millennium. Vol 2. New York: Routledge; 2000.
November 2014, Vol 104, No. 11 | American Journal of Public Health
3. Healthy People 2010: National Health and Promotion and Disease Prevention Objectives: conference edition in two volumes. Washington, DC: US Department of Health and Human Services; 2000. 4. Healthy People 2000: National Health Promotion and Disease Prevention. Objectives. Full report commentary. Washington, DC: US Department of Health and Human Services; 1991. 5. CDC. Ten great public health achievements, United States, 19001999. MMWR Morb Mortal Wkly Rep. 1999;48(12):241–243. 6. CDC. Decline in deaths from heart disease and stroke--United States, 19001999. MMWR Morb Mortal Wkly Rep. 1999;48(30):649–656. 7. CDC. Healthier mothers and babies. MMWR Morb Mortal Wkly Rep. 1999;48(38):849–858. 8. CDC. Impact of vaccines universally recommended for children, United States, 1900-1998. MMWR Morb Mortal Wkly Rep. 1999;48(12):243–248. 9. CDC. Motor-vehicle safety: a 20th century public health achievement. MMWR Morb Mortal Wkly Rep. 1999;48(18):369–374. 10. CDC. Vaccination coverage by race/ ethnicity and poverty level among children aged 19-35 months, United States,1997. MMWR Morb Mortal Wkly Rep. 1998;47(44):956–959. 11. CDC. January-December 1998: vaccination coverage by race/ethnicity. Available at: http//www.cdc.gov/nip/ coverage. 12. Bernier R, Orenstein W, Hutchins S. Do Vaccines Reach Those Who Most Need Them? West Sussex, England. 1994. 13. CDC. Improvements in workplace safety United States, 1990-1999. MMWR Morb Mortal Wkly Rep. 1999;48(22):461–469. 14. CDC. Control of infectious diseases. MMWR Morb Mortal Wkly Rep. 1999;48(29):621–629. 15. CDC. Safer and healthier foods. MMWR Morb Mortal Wkly Rep. 1999;48(40):905–913. 16. CDC. Achievements in Public Health, 1900-1999. Fluoridation of drinking water to prevent dental caries. MMWR Morb Mortal Wkly Rep. 1999;48(41):933–940. 17. CDC. Tobacco use United States, 1900-1999. MMWR Morb Mortal Wkly Rep. 1999;48(43):986–993. 18. CDC. Achievements in Public Health, 1900-1999. Family Planning. MMWR Morb Mortal Wkly Rep. 1999;48(47):1073–1080.
Hasson et al. | Voices From the Past | 2071
⏐ VOICES FROM THE PAST ⏐
19. Durch JS, Bailey LA, Stoto MA, eds; Committee on Using Performance Monitoring to Improve Community Health Improving Health in a Community: A Role for Performance Monitoring. Washington, DC: Institute of Medicine; 1997. 20. Recommendations regarding interventions to improve vaccination coverage in children, adolescents, and adults. Task Force on Community Preventive Services. Am J Prev Med. 2000;18(1 suppl):92–96. 21. CDC. Status report on the childhood immunization initiative: national, state and urban area vaccination coverage levels among children 19-35 months. United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(29):657–664. 22. CDC. Status report on the childhood immunization initiative: reported cases of selected vaccine preventable diseases. United States, 1996. MMWR Morb Mortal Wkly Rep. 1997;46(29):665–671. 23. Dever GE. Improving Outcomes in Public Health Practice: Strategies and Methods. Gaithersburg, MD: Aspen Publishers Inc.; 1997. 24. Fairbrother G, Hanson KL, Freidman S, Butts GC. The impact of physician bonuses enhanced fees, and feedback on childhood immunization rates. Am J Public Health. 1999;89(2):171–175. 25. Lasker RD. Medicine and Public Health: the Power of Collaboration. New York: The New York Academy of Medicine; 1997. 26. Orenstein W. Overview of immunization. Paper presented at: 32nd National Immunization Conference Proceedings, 1998; Atlanta, GA.
The Society for the Analysis of AfricanAmerican Public Health Issues (SAAPHI) | Rebecca E. Hasson, PhD, Diane L. Rowley, MD, MPH, Cheryl Blackmore Prince, PhD, MPH, Camara P. Jones, MD, MPH, PhD, and William C. Jenkins, PhD, MA, MPH
IN 1990, A MEETING JOINTLY sponsored by the Black Caucus of Health Workers (BCHW), the American College of Epidemiology, and the Centers for Disease Control and Prevention assessed the underlying causes of health status and health disparities, and whether these were the result of race or racism. From this meeting, a group of primarily African American public health researchers decided to focus on health disparities as an issue and proceeded to carry out a number of analyses that focused on the true etiologic factors for health disparities. A number of articles were published, and one organization was formed to carry on this work: Society for the Analysis for African-American Public Health Issues (SAAPHI). We document the events leading up to the formation of SAAPHI and the contributions that this society and its membership have made toward improving the overall health of African Americans in the United States.
THE JOURNEY TO ESTABLISH SAAPHI The origins of SAAPHI can be traced back to 1971, when Jackie Kennedy, a biostatistician working at Howard University, invited a few young biostatisticians to lunch with two public health
2072 | Voices From the Past | Hasson et al.
stalwarts: Paul Cornely, former medical director of Howard University School of Medicine Freedmen’s Hospital and the first African American president of the American Public Health Association (APHA), and Hildrus Poindexter, Captain in the US Public Health Service and former Head of the Community Medicine Department. The conversation centered on efforts made over the three previous decades to improve the health status of African Americans, including developing an African American public health infrastructure. These conversations continued on a weekly basis and gave birth to the idea of creating several entities to improve the health of African Americans: (1) an African American school of public health, (2) an institute to help develop public health scientists, and (3) professional organizations comprising African Americans in public health. In the following years, the ideas continued to evolve and later became a reality through the establishment of the Coalition of Public Health Programs at Historically Black Colleges and Universities (HBCUs), which currently has Public Health Programs at nine HBCUs; and the Public Health Sciences Institute at Morehouse College, which has trained more than 300 students
in epidemiology and biostatistics, and more than 50% of African American doctoral students in this field. In 1985, the Report of the Secretary’s Task Force on Black & Minority Health, under the direction of Margaret Heckler, then Secretary of the US Department of Health and Human Services (HHS) was issued. The Task Force chair described this publication as a landmark effort in analyzing and synthesizing the present state of knowledge of the major factors that contributes to the health status of Blacks, Hispanics, Asian/Pacific Islanders, and Native Americans. It represented the first time the Department of Health and Human Services has consolidated minority health issues into one report. This report should serve not only as a standard resource for department wide strategy, but as the generating force for an accelerated national assault on the persistent health disparities. . . .
Margaret Heckler wrote that it was “the beginning of the end of the health disparity that has, for so long, cast a shadow on the otherwise splendid American track record of ever improving health.” An informal group of African American public health professionals, many of whom became founding members of SAAPHI, studied the findings from the report and committed to making health disparities
American Journal of Public Health | November 2014, Vol 104, No. 11
